Deep massage and our perceptions of pain

Do you think of deep tissue work as someone using their elbow to reach deep layers of muscle, stripping tissues or breaking up adhesions? 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 belief circulating within the world of bodywork that long-term change can be achieved in a single session, provided enough “good pain” is inflicted. Muscles can be forced to let go through pressure, tissues can be stripped with force, adhesions can be broken up, and stiff joints can be pushed into painful ranges in the hope that this will create lasting change. “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.”

This narrative is persistent. It is also deeply misleading.

Change does not happen quickly

Change does not happen quickly in the human body. We cannot rebalance it as though we were turning a screw or replacing a spring. The body is far too complex an organism for such mechanical thinking. Lasting change rarely happens in a single session, and certainly not without the nervous system being fully on board. We cannot force the body to do something it does not perceive as safe.

Bodywork is about restoring balance, a process that involves collaboration between therapist and client. The body constantly strives for homeostasis, the dynamic equilibrium the brain regulates through hormones, heart rate, breathing, digestion and sleep (Guyton and Hall, 2016). Pain and dysfunction can be understood as states of imbalance within this system.

Chronic pain often develops gradually through repetitive movements and sustained postures that irritate tissues and increase muscular tension. Pain science has shown that pain is not simply a reflection of tissue damage, but an output of the nervous system influenced by context, memory and perception (Butler and Moseley, 2013).

The Good, The Bad and The Ugly

The myth persists that deep massage should be painful. Human beings have widely varying pain tolerances and preferences for pressure. What feels therapeutic to one person may feel threatening to another. When pain crosses a certain threshold, the sympathetic nervous system becomes dominant, and the body moves into protection mode (Sapolsky, 2004). In that state, genuine relaxation and long-term change are unlikely. Brutal massages may sometimes be appreciated, but many people struggle to distinguish between therapeutic intensity and genuinely harmful stimulation.

But painful massage can work

Painful massage can appear to work because it introduces a high-intensity stimulus that competes with existing pain. Mechanisms such as descending pain modulation explain how one painful input can temporarily dampen another (Tracey and Mantyh, 2007). Intense stimulation can also trigger the release of endorphins, the body’s endogenous opioids, which reduce pain perception (Fields, 2004). However, this relief is often temporary and may be followed by increased sensitivity. Excessive pressure can also cause tissue irritation and inflammatory responses.

Working deeply without pain

If we truly want to work deeply, we must reconsider what depth means. Depth does not necessarily equate to pressure. It can refer to depth of attention, depth of nervous system engagement and depth of therapeutic relationship. The brain constructs the experience of pain and constantly updates its internal model of the body (Butler and Moseley, 2013). Through varied, safe and collaborative touch, the nervous system may reduce protective output and restore ease.

The adaptation of ‘normal’

Sustained postures and repetitive work can lead the body to adapt to certain positions, which the brain then interprets as normal. Over time, persistent tension may lead to protective responses such as spasms. The nervous system adapts based on repeated inputs. When pain persists, the brain may increase protective output in an attempt to guard perceived vulnerability.

Central Sensitisation and top-down processing

Central sensitisation refers to amplification of neural signalling within the central nervous system, leading to hypersensitivity (Woolf, 2011). In this state, normal stimuli can be experienced as painful. The central nervous system is protective by design, but problems arise when sensitivity persists beyond tissue healing (Butler and Moseley, 2013).

Deep massage that works with the CNS

Deep massage, when skilfully applied, works with the nervous system rather than against it. It introduces meaningful, non-threatening sensory input that may reduce protective output and modulate sensitivity. Depth is not about how hard we press. It is about how deeply we engage the nervous system in a collaborative process of change.

References

Butler, D.S. and Moseley, G.L., 2013. Explain Pain. 2nd ed. Adelaide: NOI Group Publications.

Fields, H.L., 2004. State-dependent opioid control of pain. Nature Reviews Neuroscience, 5(7), pp.565–575.

Guyton, A.C. and Hall, J.E., 2016. Textbook of Medical Physiology. 13th ed. Philadelphia: Elsevier.

Sapolsky, R.M., 2004. Why Zebras Don’t Get Ulcers. 3rd ed. New York: Henry Holt.

Tracey, I. and Mantyh, P.W., 2007. The cerebral signature for pain perception and its modulation. Neuron, 55(3), pp.377–391.

Woolf, C.J., 2011. Central sensitization: Implications for the diagnosis and treatment of pain. Pain, 152(3 Suppl), pp.S2–S15.