Deep massage and our perceptions of pain

Do you think of deep tissue work as someone using their elbow on you to reach deep layers of muscles, or having tissues stripped, or adhesions broken up? Do you equate 'working deeply' with physical depth and the idea of being fixed? Are you a member of the ‘no pain, no gain’ club?

I ask these questions because there is still a powerful idea which circulates through the world of bodywork that long-term changes can be made to the body in a single session of bodywork as long as enough ‘good pain’ is inflicted on the body. Muscles can be forced to let go by pressing hard, tissues stripped with force, adhesions broken up by using lots of pressure, and stiff joints made more open by moving them to places that hurt. “Pain is good”, I hear people say, “It must be working if it hurts”, “If you don’t make it hurt, it won’t get better”.

Change does not happen quickly
I want to address the fact that change does not happen quickly in the human body. We can't rebalance anything as if we were turning a screw or replacing a spring. The human body is far to complex an organism for this. Change never happens in a single session, and certainly not without the nervous system being fully 'on board'. We can't force anything in the body to do anything it does not want to do. We cannot force tension away by pushing it with physical force.

Bodywork is about restoring balance to the body, a process that involves the therapist and the client working together. Homeostasis is the state of balance that the brain spends most of its time trying to achieve, by regulating hormones, heart rate, breathing, digestion, sleep etc.,

Pain and dysfunction can be considered states of imbalance. Often, we end up with chronic pain through years of repetitive movements, which have irritated structures and increased tension in our soft tissues. If we view chronic pain as something to be fixed, then we can easily get trapped in thinking that we have to work as deeply as physically possible in order to get rid of it.

The Good, The Bad and The Ugly
The myth persists that deep massage should be painful. I want to feel good pain, I hear people say. The paradox of good pain is that human beings experience widely variable pain tolerances and prefer different amounts of pressure, so what’s good for one person is probably bad for another.

Some people seek out good pain (a strange, potent sensory paradox) either consciously or unconsciously when they go for bodywork. This good pain can be intense, or painful but desired because of some belief, an actual biological relief or a belief that there is a relief. Bad pain is unpleasant but usually manageable and safe-tolerated to a point; it’s probably ok. But ugly pain is dangerous physically and neurologically, and will cause a ‘fight or flight’ reaction in your body. It should be avoided at all costs.

Brutal massages might be appreciated or even helpful, but most people can’t tell the difference between the kind of pain that might be a necessary part of therapy and ugly pain that is just abusive and dangerous. And therein lies part of the problem.

Painful massage can work
Breaking news…..painful massage can work because it is a high-intensity stimulus that competes with other pain. Yep, by causing more pain, the body forgets about the pain it was originally thinking about and the brain is duped into thinking that the body feels better. Sometimes this works as a result of provoking different nociceptors (specialised sensory neurons that detect potentially harmful stimuli, like pressure and transmit this information to the central nervous system, where it can be perceived as pain) through working with superficial structures like fascia or trigger points. Other times it can be as a result of attacking tissues directly, say through leaning into a muscle spasm and asking the client to breathe into it. The client may get up and feel much better, but this is almost always the result of the body releasing endorphins when the pituitary gland says, “enough is enough”.

In both cases, the crash that comes afterwards can be truly spectacular. A sudden extreme reduction in muscle tone is often followed by reflexive tightening, which can be a precursor to spasms. A loss of pain sensitivity as a result of the release of the endorphins means that when the sensitivity returns, it's even more unpleasant, creating an environment for everything to spasm again. On top of this, painful massages will damage the body's tissues. In some cases, people end up feeling like they have the flu or a fever or develop bruised skin. There is nothing good about any bodywork which ultimately makes you feel worse than you were to begin with.

Working deeply without pain
So if we want to work deeply, we need to step back and think about how the body works. You may have heard me say, ‘I don’t fix people, I create the space for change’. It sounds a bit fanciful, I know, but the truth is that the body is exceptionally good at finding homeostasis given the right inputs. Let me suggest a different way of thinking about working deeply, one in which the body and mind are given lots of different stimuli, by the use of different types of touch, movement and positioning. What could the brain, which is in charge of EVERYTHING, make of this information? Might it do what it does best, and return the body to homeostasis?

The adaptation of ‘normal’
Let’s think about someone with chronic upper back pain. They may be a desk worker, a hairdresser or a chef. They spend upwards of 8 hours a day standing or sitting in the same position. Their body has adapted itself to this position, and the brain has come to think of it as ‘normal’. Their body receives inputs daily, such as ‘my upper back has to be hunched like this, cause this is my new reality. I might be trapped under a building or trying to roll a boulder up a hill. I’ll just try to make the best of this situation'. Interestingly, their brain doesn’t link their chronic upper back pain with their daily work. The outcome of this is that their upper back gets really bent and strong.

While the body tries to adapt as best it can, the brain and spinal cord (the central nervous system) might think that something is very seriously wrong. The brain sees those tense, strained Rhomboids as endangered because they are in a semi-permanent or permanent state of pain. The brain might then send out signals to cause spasms in an attempt to prevent further pain.

Central Sensitisation and top-down processing
So, how do we work deeply with a body when it’s got stuck and is in pain? How do we convince the brain that the normal it thinks is normal isn’t?

This is where we need to look at central sensitisation and top-down processing. These processes help us to understand concepts like why we feel pain. The central nervous system (CNS) is great at listening. Neurologically, when it senses pain, it turns up the dial so it can hear all the inputs from our pain sensors - this is called central sensitisation - the process of the brain and spinal cord amplifying stimuli that might otherwise be filtered out. It can be great in situations like when we use a joint that has hurt in the past or walk on broken glass. It makes sense, right? And it helps to prevent us from harming ourselves, but it can cause a problem if the CNS listens too hard. Sometimes, the CNS decides that because it once noticed your shoulder hurting during a specific movement, any little twinge in that same shoulder might be dangerous.

This is where the CNS becomes dysfunctional, and the consequent pain can be hard to deal with. Normal inputs are coming from the peripheral nervous system, but they cause pain. You have no tissue damage in your shoulder, but it hurts like hell when you move it. This situation comes about when the brain and the spinal cord decide there’s an emergency based on a past crisis. So even though you have no injury, you feel pain. It's a miserable place to be, and a lot of people get stuck here, in pain with no injury, unable to move how they want to and unsure of what to do. This is where bodywork comes in!

Deep massage that works with the CNS
Deep massage is profound work. It's focused work. It is work where the therapist and the client work together. It’s respectful of the whole person and attentive to their needs and wants. It works with the CNS to present it with new hypotheses about the body and the world. It turns down the dial on sensitivity and helps the brain emerge from the state of emergency it got itself into. We do this by:

Using a thorough, informed contact. If you have shoulder pain, your therapist should interact with your shoulder and all the structures that surround it in a variety of ways. They should work you seated, on your back, on your front and on your side, making the contact 3D in every possible way. This contact is part of a two-way process and not simply a technique that is done to you.

Pacing. Slowing down, exploring, and taking time are all super important. If an area is tight, it needs focused attention and a variety of different ‘inputs’ for the brain to process. The brain needs time to absorb this new information. It is a process. It takes time.

Sensitivity. Rather than lots of pressure, the pressure needs to be right. Too much and the body will often reflexively tighten up, not enough, and it feels like nothing is happening, and there won’t be enough input for the brain to register that something can change. What is acceptable pressure for one person may not be for someone else, so the therapist-client partnership is important in establishing what feels ok and what pushes the client into a place where they feel pain.

At the end of the day, the nervous system isn’t picky about what gets done; it cares about thorough work done at a sensible pace, where there are lots of different stimuli happening. Your body and mind will respond a whole heap better if deep work is done in a way that respects your pain threshold and doesn’t cause you more pain. In my book, there’s no valid reason to cause a client pain in the attempt to heal their pain. We need to work with the nervous system and the brain when we want to work deeply. That is where the magic lies.