You may have noticed that my blog posts have been sporadically timed over the past couple of months, and I have been entirely absent for three weeks. Like everyone else, I am disheartened over our current political situation, but that alone is not the reason for my silence. (You all still have to show up to work … I am still supposed to write my blog!) Rather, I have been taking a little time to integrate old and new ideas about the field of massage, as it pertains specifically to those clients who see me for pain relief. As I continue to research, it has become clear to me that we are experiencing a fundamental paradigm shift in the way we conceive of pain. The structural model explains imbalances in the body, but it is not always sufficient to explain pain. This shift has been happening in other disciplines over the last couple of decades, but massage has been slow to catch on. Leaders in massage research have recently begun discussing pain science and its effects on massage therapy principles, and over the last six months I have been digging into the reading and trying to figure out my place within the entire framework.
The most basic massage school education (mandated by the state of Texas) covers muscles, joints and fascia. Pain is understood to be related to tight muscles, adhesions in fascia, or trigger points that need releasing. It is a starting point, a fairly simplistic stimulus-response type of model which many have argued is outdated. In my case, I was lucky to have a mentor who introduced me to the nervous system as an alternative mechanism for understanding pain. The first time he mentioned that when it comes to pain, massage therapists are not working on muscles but rather working on the nervous system, my brain lit up. Relaxed nerves then relax the muscles, not the other way around. I have written much about the nervous system and how I work with it in my practice in this blog.
However, recent pain science has revealed that pain is a little more complicated than understanding where specific nerves lie within the body and where they might be impinged. It’s more than just general relaxation of the nervous system (although this still really does wonders). Pain is often multifactorial and can have as much to do with heightened sensitivity in the brain and the clients own beliefs about their pain as anything going on in the tissues themselves. The body is a complex ecosystem. There are many cases in which clients report pain and there is no clear correlation between past or present tissue damage and the sensations being reported. Equally confusing is the very common opposite case in which healthy pain-free individuals present with clear tissue damage. For example, at least 40% of healthy individuals reporting no back pain are said to have bulging disks. In other words, I could have one and yet I have no back pain. It makes it very difficult to then say with confidence to someone with a bulging disk and back pain that the pain is definitively caused by the disk. The bulging disk is not insignificant, but some other factor coupled with the disk was necessary to trigger the pain. In these cases, an explanation focusing on tissue level intervention is not enough. The same could be said for “tight rhomboids” or any other tissue dysfunction more appropriate to a massage therapist’s scope of practice. As a discipline, massage therapy often jumps erroneously from correlation to causation. In reality, when two conditions exist we can not be sure that one condition caused the other or if two conditions happen to be present at the same time due to some third unexplored factor or a combination of factors. Again, structure and function are significant but we are still not clear as to how significant a role they play in certain types of chronic pain. It is easy to see how this might throw a massage therapist into a temporary existential crisis!
However, it is not necessary to toss out the massage “baby” with the proverbial bathwater. The issue is not whether or not massage “works”; I have seen its profound effects as both a giver and receiver of massage. The trick is that the mechanisms massage therapists use to explain how it works might not be exactly accurate, or at best are only part of the story. I read a very comforting blog post by one of my favorite massage educators and writers, Whitney Lowe, about his own wrestling with this paradigm shift. He explained that to understand pain, bodyworkers must have a good understanding not only of biomechanics, but of neuroscience, physiology, psychology, trauma and many other areas. The explanation is now much more complicated, but it is not necessary to dismiss all of the clinical experience that has shown us that massage therapy is impactful. Lowe writes, “I’m excited about looking at massage therapy in a new way, but also I am not willing to jettison the aspects of our work that change people’s lives and help them relieve their discomfort on a daily basis”. My sentiments exactly!
Neuroscience education is a big part of the paradigm shift, which is essentially helping clients understand their own pain (but this means we have to understand the basic principles first). According to neuroscientist Adriaan Louw, pain is produced by the brain based on the perception of threat. In other words, clients’ thoughts and beliefs contribute to their pain experience considerably. Massage therapy can find a place within this framework. In my practice, this is most evident in prenatal massage and labor. Helping a woman to manage her anxiety surrounding the labor is key to coping with the pain. The difficulty is battling the lack of confidence in her own body which is implanted from the onset by the current medical paradigm of birthing. Once a woman truly believes that she – not the doctor – is capable of birthing the baby, everything changes. Practicing body awareness and active relaxation techniques during prenatal massage sessions makes the pain more manageable during labor, partly because mom’s perception is different. For my many non-pregnant clients, instilling confidence in their body’s innate ability to heal is fundamental. On a subconscious level, it is important to understand proprioception and the body’s neuromuscular signaling in hopes of reframing the body’s perception of threat.
When discussing my thoughts with my mentor, he validated my explorations and then gave me some excellent advice: “Keep researching. Do what you do best. Just don’t tell stories about why it works if you are not sure they are true.” So, while I continue to try to better understand the neurophysiology as well as the psychological mechanisms of pain, I will lean into the gifts I know I can share through massage. All of the tenets are still there and are still valid. I create a safe space for my clients and offer them my full presence and quality of touch. I encourage body awareness and the development of a mind-body connection so each client can hopefully access her inner healing powers. I treat each client as a whole person, not a pelvis or a knee. And I fully embrace that in some ways the human body is still a mystery even while I am trying to figure it all out.
Confronting the Challenges of a Major Paradigm Shift, Whitney Lowe
Therapeutic Neuroscience Education, Adriaan Louw
Five Myths and Truths about Massage Therapy, Tracy Walton
Reconciling Biomechanics with Pain Science, Greg Lehman
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