Massage Pressure – the bad

More about bad pain, and when it might be justifiable

The reason for the Pressure Question is that it’s hard for patients to tell the difference between nasty pain that might be a necessary part of therapy, and ugly pain that is simply abusive. How do you know if a particular intense massage technique is therapeutic or not? If it is therapeutic, then we would call it “bad pain” — unpleasant, but worthwhile. If it’s not therapeutic, and you are paying to experience pain with no benefit, then it should be considered ugly pain — both unpleasant and pointless!

But how do you know?

For starters, you bear in mind the things described above that tend to cause ugly pain, and you avoid that kind of therapy. Now we’ll try to learn some clues that painful pressure is okay. Here are at least three reasons why unpleasantly intense pressure might be therapeutic — “bad pain,” but not ugly. In each of these situations, it might be acceptable to tolerate sensations so intense and painful that the only thing about them that is pleasant is the part where it stops.

Motor end plate destruction. Myofascial trigger points — muscle knots — are a ubiquitous muscular dysfunction, causing most of the aches, pains and stiffness in the world, and complicating virtually every other injury and disease process. Most massage is focussed on them, directly or indirectly. To the extent that massage therapy is an effective and evidence-based form of therapy, it tends to be so because it relieves the symptoms of muscle knots.

Thanks to quite recent research (see Simons), we now know that muscle knots are caused by something that goes wrong at the “motor end plate” — where a nerve ending attaches to a muscle cell. We don’t know why this happens, or what exactly goeswrong, but we do know that if you paralyze the motor end plate (with botox, say), the trigger point completely vanishes. The motor end plates are unquestionably the immediate cause of the problem.

Some research has suggested that it may actually be possible to physically destroy the motor end plate with strong massage, thereby inactivating the trigger point (see Danneskiold-Samsoe). When it regrows — these are microscopic structures, it doesn’t take them long to heal — the trigger point may be gone.

To the extent that massage therapy is effective, it is effective because it relieves the symptoms of muscle knots

No one knows for sure if this is actually effective. However, it could explain why so many massage patients experience a “gets worse before it gets better” response to quite painful treatments: motor end plates are painfully destroyed by strong pressures, the tissue is quite sensitive and a bit weak as it heals over a day or two … and then you finally feel much better after that!

Maybe. But I repeat, no one really knows — and there is also good evidence that intense pressures, which cause a fight-or-flight reaction in your nervous system, almost certainly can aggravate trigger points. There are dozen variables that could affect which of these two theories alone might be more relevant to a given person on a particular day … and there are most assuredly other factors, other theories, that we don’t yet know anything about.

Therefore, the most we can know is that there is some reason to believe that painful pressures on muscles might be therapeutic for some people, some of the time. Pretty decisive, eh? This is why it kind of drives me nuts that so many therapists insist that strong pressures are “essential” to achieve “a complete release.” It really isn’t possible to know. It really does depend. And the final decision has to be up to you.

Connective tissue stimulation. A lot of therapists are keen on stretching connective tissues — tendons, ligaments, and layers of Saran wrap-like tissue called “fascia.” I’m not a huge fan of these techniques, not so much because I don’t think it works, but just because I think trigger point therapy works much better — much more bang for my patients’ buck. However, I can imagine a number of reasons why intense manipulations of connective tissue might be therapeutic. So, as long as the sensations are not like skin tearing (that’s an ugly pain for sure), you might choose to tolerate this kind of massage if it seems to be helping you.

Somatoemotional release. Mental and emotional context is an important part of how we perceive pain. Undeniably painful sensations can help to stimulate cathartic emotional releases (and I’m assuming here that emotional releases are valuable). Physical pain can strongly resonate with emotional pain. Often the two experiences are intimately related: for instance, the pain of an injury may be interwoven with the emotional frustrations of rehabilitation. That is quite a rudimentary example, and much more complex interactions between emotional and physical pain are obviously possible. Whether it is the clear goal of therapy, or simply a natural side benefit, experiencing strong sensations can certainly be a meaningful part of a personal growth process “just” by changing your sense of yourself, how it feels to be in your skin, and perhaps bumping you out of some other sensory rut.

Sometimes regular massage therapy involves a bit of this kind of thing. And when it does, “bad” pain may be justified … but, again, only if you feel there is a net gain.

The choice is yours

All health care practices must be justified by clear benefits. As risk increases, the benefit must get even clearer. So much can be achieved inflicting only good pain on patients that bad pain must be justified by extremely vivid, quick, and somewhat lasting benefits — anything less than that, and you should definitely consider shopping around for another massage therapist. There is simply no point in tolerating — and paying for — truly painful treatment without a good reason.

But you should never tolerate bad pain unless there are clear signs of therapeutic benefits within three appointments. A persistent lack of results should make you question any kind of therapy, of course, but especially a very painful therapy.


Excerpt taken from Paul Ingraham -