In the beginning… there was massage. Thousands of years old, this discipline has been used to soothe tired muscles, promote healing and even as a pathway to meditation and enlightenment.
This is a difficult post to write and research, because the more I read, the less, apparently, I know. Which is rather disheartening. After learning how varied, inconclusive and downright contradictory the clinically researched evidence is, I feel a bit uncertain when once again I settle a patient down and start to feel my way across the landscape of their back.
And yet, I do feel things that correspond to my patient’s discomfort. I do ask them to differentiate between tenderness from ‘just me prodding’ and ‘their pain’ and they can do this with certainty. I do navigate lumps, bumps, cords and hollows that in my experience stimulate fairly consistent reactions. I do get gasps of “how did you find exactly the right spot?!”
Then, afterwards, they do say they feel better, lighter, eased, in less pain than before. Surely not all of them can just be being polite? The one thing I know is I can’t pretend to know for sure – but then even Socrates said that “the most important thing to know is that we know nothing”. So the following is an attempt to introduce some of the complexities of massage, and to reassure you that an unclear answer is the most honest one. Again as Socrates said: “I cannot teach anybody anything, I can only make them think”.
Before We Begin…
People are often surprised by how different they can feel – not necessarily during, but after their treatment. They expect that once they’re walking out of my clinic that the ordeal is over, that the body is better. And they do feel better, though a few have wryly asked ‘is that just because I’ve been lying down for 30 minutes?’. I can only put on my religious-awe expression and agree – in the business of settling down pain and neural irritability, good therapists will use all the tools they can get: not just the lying down, but (in my clinic, at least) the soft, clean, not battered-and-lumpy pillows, the calming turquoise wall, the scented air, the bubble of the little fish tank and the striking orange shapes flickering within. The rustling trees that flicker in the windows, the ever watchful church tower across the way. These things aren’t just for your benefit – they form the space I like to spend time in, that puts me in the best frame of mind. I am ever-increasingly of the belief that we are part of our environment and the more harmony the better. It’s not meant to con anyone, just tune into their comfort zone. But the Healing Crisis has just begun…
The difficult thing here is, evidence for the ‘healing crisis’ is in short supply. An unsatisfying scour of Dr Google’s offerings provides only links to homeopathic websites and colloquial opinions from ‘Doctors’ in the US, proclaiming that, essentially, sometimes you will feel worse before you get better. Symptoms can range from fatigue and increased urination, to fever and sickness after a medical or therapeutic intervention. Admittedly, it does sound a rather convenient excuse for any adverse effects of treatment doesn’t it? The closest I can find is The Jarisch–Herxheimer Reaction, related to inflammation after use of antibiotics for, amongst other things, syphilis. It is suggested that it is the body’s reaction to the toxins produced or released by dying bacteria, and the attempts of the body to deal with and remove these toxins. And yet… many of my patients have returned to tell me things that sound like these symptoms. Reports run along the lines of:
“I felt amazing straight after the treatment, relaxed, calm, and my pain had gone / significantly reduced. Then the next day I felt so stiff / felt like I was coming down with a cold! But that eased a day or so later and I felt so much better than before I came to see you.”
I severely doubt that I am killing any bacteria by my massage techniques, and sincerely hope that you do not have syphilis, but consider the following:
Contrary to commonly held beliefs that massage ‘detoxifies’ your body, in using massage I may even be increasing ‘toxin’ levels, with your kind permission… I use the word ‘toxin’ very loosely, as again it is not clear what exactly causes a sensation of stiffness after exercise or injury, except to say that it almost certainly is NOT lactic acid. A stiff, tender area is currently thought to be an area of tissue that has had its circulation restricted (not cut off!). The cells here will continue to metabolise and create waste products, but the lymph vessels that help to carry away waste are restricted or congested, as the lymphatic system doesn’t have its own ‘pump’ such as the heart but relies on its own tiny contractions and the movement of the tissues around it to get it flowing. So the waste products hang around, which affects the local chemical balance and has been suggested causes the tenderness we feel in random places that can seem unrelated to our shoulder aches. If massage can start to get the local circulation moving, shown in the red skin and warmth produced, then it is reasonable to explain any minor, temporary adverse effects by suggesting that there is some mild inflammation and stimulation of bodily responses. Rather like the roar of an old engine before it settles into a purr, the lymph (and therefore immune) system is getting a little revving up. So massage can increase the toxins circulating in your body and the body may react in a noticeable way to then process these. That’s why I usually also suggest drinking plenty of water and getting to bed early that night – to give your body the best chance of processing all those changes to the greatest effect.
Please note: water itself is NOT a detoxifier, but seeing as every chemical reaction in our body takes place in a fluid medium, it can’t hurt to oil the engine.
Why does it happen to some people and not others? I could give you a few suggestions, mostly related to their existing health, wellbeing and attitude to their recovery, but the short answer is, nobody could tell you for sure.
What does Massage Actually Do – Can I Make You Better?
Shown to calm the nervous system, suggested to stimulate the lymph and reported by the vast majority of patients to have a significant beneficial effect, massage nevertheless is still hotly debated as research digs deeper into the nature and behaviour of tissues, nerves and body systems.
Even some therapists question the benefits of a ‘skilled’ professional, asking why the untrained touch of a partner can have ‘better’ effects than a paid session. There’s no doubt that the benefits are at least in part subjective, but then in some trials placebos have been shown to have a positive effect in up to 40% of subjects. This is no hokum: if our brain perceives that it is good, then in many cases it will be good.
Again, in the interests of honesty, I can’t claim that for sure that I know what I’m doing to your body. I would rather direct you to a well written, engaging and well researched article by Canadian science writer Paul Ingraham, who has dedicated far more time than me to these and other questions.
However to intrigue you with the latest research, there is thinking that suggests that for all the kneading and pounding that patients often request, that physical punishment actually has no direct effect on actually ‘lengthening’ or ‘de-knotting’ the muscles at all. The theory is much along the lines that massage settles down the nervous system using touch and which then allows the tissues to ‘relax’, ‘let go’ and, perhaps more clinically put, re-establish homeostasis both chemically and neurally. By ‘settling down the nervous system’ I mean stimulating the parasympathetic nervous response – that part of our neural organisation that calms breathing, subdues adrenaline, promotes digestion and feelings of relaxation. If you think of the many unfortunate souls out there with high- or low-tone dysfunction (cerbral palsy, motor neurone disease, for example) this makes sense – it is the brain and its messages to the body that dictate how tense or relaxed our tissues can be. Perhaps massage serves to re-establish disused message pathway, and promote harmony again.
I have also had to re-educate some who come to me asking for a pummelling, and who believe the ‘No Pain No Gain’ mantra. It is often unavoidable to work on tender areas without, well, some tenderness. However, I am in no way out to damage any tissues or to create an anticipation of pain that will hotwire the fight or flight system for action – exactly the opposite effect I am trying to achieve. Some people are more sensitive than others: there’s no correct value or negative judgement associated with that, and certainly I have learnt a lot from my patients’ reactions. Perhaps a key moment with one of my most ‘wussy’ clients (absolutely his words, not mine!) was when he looked up at me with eyes filled with earnestness, and said “I can handle the pain, if only you could do it slowly!” Ever since, I have made sure wherever possible to take time approaching the tender areas, to allow the brain and body to adjust and prepare, and I and my patients have so far reaped the benefits.
How Long Will Effects Last? Massage as a Start
Well now, I can confidently say that this is down to individual circumstances, and I can honestly say that it can be a powerful tool if you choose to use it. Don’t get me wrong, I absolutely love seeing my patients sitting opposite me keen to book in their next session but somehow feeling all fuzzy headed and unable to find words quickly because they are too relaxed. But the next stage is up to them, up to you. If you go back and do exactly all the things that caused that tension in the first place, my hard work and weary thumbs may have given you a few days’ relief, a week probably at best. For example, do you sit like any of these people..? Forty hours a week..?
Here is not the place for all the fascinating facts about posture, I will save that for another blog, but I firmly believe that the ease you feel after a massage is a short opportunity, a brief window of time where you can start to make things different, with or without advice and exercises from your physio. A time to begin new ways of thinking and moving, that can lead to a significant change in your lifestyle and consequently your life. I kid you not, patients who have cracked on and reveled in their new-found freedom of movement have not looked back, and it’s honestly with a glowing feeling inside that I hear of their progress: “I am now on the road to recovery, gaining strength, flexibility and most importantly, confidence in my back. Now pain free, I am again participating in sporting activities, something that I had given up due to the after effects [of a fractured vertebra]” (NB, back pain patient). I’m not quoting a patient to boast (though I am VERY pleased!), but as a true example of how massage has not made, but begun a lasting change to this man’s life. The rest has been all down to him.
Shall We Begin?
So massage, to me, is magic. Though of course as a physio I want to know THE ANSWER, I also kind of like the uncertainty: like the Loch Ness Monster, I love to believe in the possibilities of amazing things. I love the sense of wonder as science gradually pieces things together, things that the Ancients might snort derisively at and say “Pfft, we’ve known that for centuries!” partly because, I fancy, they were in more harmony with their bodies in the first place. I am always pleased when people ask me these questions because I know it is again a start, a tiny turning point in the way they understand and appreciate their own wonderful workings.