Reframing Pain, Reframing Massage

It is a very human desire to want pain gone, and one of the agents of elimination we often turn to is a massage therapist.

For acute inflammatory pain, say from an injury, it does indeed go away once the injury has healed. Further, those who are highly active and get regular delayed onset muscle soreness (DOMs) there is the benefit of more mobility and increased removal of lactic acid after massage.

Have you noticed, however, that with chronic pain (that you might have had for months or years) the more you focus on it and try to get rid of it the worse it can get?

The solution is to see this chronic, or more accurately 'persistent' pain within the broader context of your life and beliefs. Whilst this might be the last thing you want, if you accept it, you will discover that pain is, in fact, something of gift from your neural system.

David Butler and Lorimer Mosely (2015) describe this reframing in terms of moving from active to passive coping:

Passive coping:

  • Waiting for someone to ‘fix your pain’
  • Letting someone else take control
  • Doing nothing to help yourself
  • Avoiding activity
  • Believing activity will make you worse
  • Only taking pills
  • Hoping your pain will just disappear

Reframe to active coping:

  • Finding out more about the problem
  • Making plans
  • Exploring different ways to move
  • Improving your fitness
  • Working with a supporting clinician
  • Eating better
  • Learning to face unchangeable 'Danger in Me' patterns

Moseley and Butler (2015, pg35)

Myotherapy, at least in its origins, and indeed many passive therapies, are based in notions that have very little scientific validity today. The original premise of Myotherapy is that trigger points in the body could be identified and released. Although trigger points and their treatment are bread-and-butter for many myo- and massage therapists, they are now on very tenuous evidential ground.

For Myofascial Release or Rolfing there was the belief that adhesions in fascia can cause postural deformity and these could be remodeled by strong massage. These ideas have been significantly invalidated by practitioners in the field itself.

For pain that comes from a grumbly tendon (normally when it is more painful under weight bearing) offering only massage will prevent the client getting on with the active tendon rehabilitation that is required.

Further, given the passive-to-active trajectory described above, massage may delay people's acceptance, and the slow, brave work to reframe the pain. This is why an evidence-based Myotherapy session need not include massage at all and will get onto the nuts and bolts of pain reframing pain in a larger psychological, social and movement context.

So if biomechanical explanations have been largely discredited and evidence-based Myotherapy is moving in the direction of movement and pain education, should we be bothering with massage at all?

It seems unlikely massage is going to go away for the treatment of pain. Further, many enjoy giving and receiving passive therapies. So what are the ways we can reframe massage itself in the context of the pain science literature? Here are some ideas:

  • The first is to frame the massage or passive technique within the broader context of pain education, and make explicit the limits of massage to our clients. We should be equipped with the skills of pain education or 'know what we don't know' and ensure our clients are appropriately referred.
  • Massage can be a beneficial 'Safety in Me' (SIM) activity. It should really be enjoyable and create a sense of being nurtured and supported. Effleurage or Swedish type massage is better for producing dopamine and happy neurotransmitters than stronger techniques. In a busy life many seek massage to support the activation of their parasympathetic (rest, digest) nervous system. My clinical observations with parasympathetic monitoring suggests massage is best accompanied by day-today mindfulness practice and breath awareness.
  • Therapists should be careful with the language they use to avoid adding Danger in Me (DIM) signals. Terms like 'stiff', 'frozen', 'syndrome' might serve for rebookings but don't benefit pain education goals. We should instead encourage safety messaging like 'strong', 'malleable', 'responsive', 'bio-plastic'. See Moseley and Butler (2015, 2017).
  • Massage can modify our pain experience. A systematic review of different modalities found most stronger approaches have a 'descending modulation' effect. Without going into detail, we are, in a sense, internally reframing the pain as a pleasurable experience and thus do not associate it as a threat thereby decreasing the danger signalling. Many clients crave this 'good pain' experience. I'm not entirely sure about the ethics of this practice as for some clients it can border on clinical masochism. Despite my reticence I doubt strong massage will lose popularity. Again we need to be transparent about the limits of the approach in the context of broader pain reframing.
  • After Greg Lehman and others, we can use specific therapy techniques to demonstrate the effect of cognition on pain. If we use a technique to relieve pain, we should make it clear that most of the relief came from the belief the patient had that the particular technique was relevant and worked. This belief, however, is associated with the 'expert therapist' fixing the problem and is not owned by the patient. It is far better longer term if the the therapist lets the cat out of the bag and admits the technique was a placebo. This can help the patient own the power of belief and use it on an ongoing basis in their life.
  • Last, but certainly not least, is the growing interest in body-work modalities and manual therapy as brain or 'cortical' remapping tools. When we injure ourselves in a particular movement we can have residual pain patterns associated with that movement, and also poorer representation of that part of the body in the brain (specifically the somatosensory centers of the cortex). This reduced representation is also noted in those with arthritis and other chronic pain conditions and is exacerbated with age. Research is scant on the effect of manual therapy on tactile acuity although studies employing acupuncture are useful. Researchers noted that the positive effect of acupuncture on pain (sham or genuine) may indeed relate to the cortical remapping effect. Requesting specific feedback from the patient on tactile perception improved the pain relief over not requesting feedback. The authors note that needle insertion is most likely not necessary for this effect. So even if the the patient is not physically active they are actively involved in the sensory training and cortical remapping. In theory there is no limit to the use and benefit of different tactile sensations for cortical remapping as long as a direct and nuanced feedback relationship exists between the stimulus and the perception.

To conclude passive therapies still have numerous roles within the 'pain education paradigm'. We need, however, to be transparent about what we are doing with different approaches so that we are supporting clients in the broader pain reframing project and not substituting a 'dead end' solution.

Non web references

Moseley, G. L., & Butler, D. S. (2017). Explain pain supercharged: The clinician's manual. SA: Noigroup

Moseley, G.L., &, Butler, D.S (2015) Adelaide, The Explain Pain Handbook: Protectometer. SA:  Noigroup

Andrew D. Vigotsky and Ryan P. Bruhns (2015), “The Role of Descending Modulation in Manual Therapy and Its Analgesic Implications: A Narrative Review,” Pain Research and Treatment, vol. 2015,

Wallwork, S. B., Bellan, V., & Moseley, G. L. (2017). Applying Current Concepts in Pain-Related Brain Science to Dance Rehabilitation. Journal of Dance Medicine and Science21(1), 13-23. 

The receptive fields or 'resolution' of the body are a highly variable as demonstrated by the two-point discrimination test. Perhaps working with average and distorted resolution will become common practice for manual therapists?

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