This chapter will focus on understanding and justifying massage as a treatment approach for pain management. Current research will be analyzed to support the premise that massage is a valuable intervention for pain management.

In review of Chapter 1, pain is usually described as acute or short term and as chronic or long term. Acute pain arises from sudden injury to the structures of the body (e.g. skin, muscles, viscera). The intensity of pain is usually proportional to the extent of tissue damage. The sympathetic nervous system is activated, resulting in an increase in the heart rate, pulse, respirations, and blood pressure. This also causes nausea, diaphoresis, dilated pupils, and elevated glucose. Continuing or persistent pain results from ongoing tissue damage or from chemicals released by the surrounding cells during the initial trauma (e.g. a crushing injury). The intensity diminishes as the stimulus is removed or tissue repair and healing take place. Acute pain serves an important protective physiologic purpose that warns of potential or actual tissue damage. Chronic pain has slower onset and lasts longer than 3 months beyond the healing process. Chronic pain does not relate to an injury or provide physiologic value. Depending upon the underlying etiology, it is often subdivided into malignant (cancer) or nonmalignant (causes other than cancer) pain. It may arise from visceral organs, muscular and connective tissue, or neurologic causes such as diabetic neuropathy, trigeminal neuralgia, or amputation. As chronic pain progresses, especially poorly treated pain, other physical and emotional factors come into play affecting almost every aspect of a patient’s life – physical, mental, social, financial, and spiritual – causing additional stress, anger, chronic fatigue, and depression. Whereas pain has always been viewed as a symptom of a disease or a condition, chronic pain and its harmful physiologic effects are being looked upon as a disease itself.

As presented in Chapter 1, pain is caused by the stimulation of nociceptors. These receptors are usually stimulated by chemicals such as substance P, bradykinin, and histamine, which excite the nerve endings. Pain is elicited by three different classes of stimuli: mechanical, chemical, and thermal. Soft tissue pain is caused by the chemicals released from illness, injury, or from mechanical irritation caused by cumulative stress, microinflammation, or extreme heat or cold. Emotional or psychological stress, called autonomic disturbances, can cause pain by causing hypertonic muscles and shifts in fluid flow affecting oxygen and nutrient delivery and waste removal.

Within the spinal cord, the messages can also change. Other sensations may overpower and diminish the pain signals. This is called counterirritation or hyperstimulation analgesia. Again, massage is an effective intervention to create counterirritation or hyperstimulation analgesia to suppress pain sensation. The question becomes, is there sufficient research to support massage as evidence based and best practice intervention?

We do not totally understand how massage therapy causes physiological change but researchers are beginning to uncover evidence that explains the value of the treatment. The focus of this text is massage therapy as an intervention for pain management. Much of the research has targeted pain reduction as an outcome. If massage can be considered a valid intervention then it must somehow influence pain production and perception. Additionally massage would work to reduce the source of the pain, such as to reduce nerve impingement, or modulate the transmission of pain signaling, or affect the pain tolerance, or activate or support the pain modulation neurochemical system of the body.

Treatment modalities in interdisciplinary pain management may include:

Massage therapy needs to function to interface with one or more of these four points.

The most commonly used complementary modalities in the research are:

If adaptation failure is the primary cause of pain then whatever treatment is offered should achieve one of three things:

Since healing, or recovery, is a self-generated function (cuts heal, broken bones mend, etc.) the important element in any treatment choice is that it should be safe, should not add to the load, and should hopefully help recovery to be more rapidly achieved, and if not more rapidly, more comfortably.

Massage seems well able to offer a number of these features, with education and rehabilitation exercises doing the rest in most cases.

Research is mixed for the efficacy of massage for pain. Generally massage for pain management was not found to be a definitive treatment on its own but was supportive of many other interventions either enhancing effects or managing side effects of other treatments. Massage was found to be generally safe. Some benefits of massage related to other conditions such as low back or neck pain can be logically applied to pain in general. Other researchers have looked at massage for pain in general and others delved into the general benefits of massage.

Based on a search using the terms massage, massage therapy and pain, the following is presented. Since research is an evolving process the studies and conclusions presented can be either confirmed or questioned and the massage professional needs to remain current with advances in the understanding of the benefits of massage. The search process for this text involved mainly Internet search using ScienceDirect, PubMed and Google Scholar. Representative studies, especially meta-analyses, were analyzed and the findings of some of these reports appear next.

When looking at any treatment, safety is a primary concern, i.e. do no harm. If harm is possible, then the benefits of receiving massage must exceed the potential for harm. A summary of a review of massage safety by Ernst (2006) concludes that massage is generally safe (Box 2.1). Massage is not entirely risk free. However, serious adverse effects are rare. The majority of adverse effects from massage were associated with aggressive types of manual massage or massage delivered by untrained individuals. Serious adverse effects were associated mostly with massage techniques other than ‘Swedish’(classic) massage.

Information provided by Moyer and others (2006) indicates that massage is effective as a treatment in some instances but they did not investigate why. The ‘why massage works’ remains elusive but there are reoccurring findings indicating possible physiologic mechanisms for massage benefit. One study by Field and her associates (2005) is particularly relevant for the topic of this text since it deals with serotonin, which is associated with the body pain modulation mechanisms. In the other studies (2004) Diego speaks of how massage needs to be applied with sufficient compressive force to stimulate antiarousal response and that massage that is considered light can be arousing (Moyer 2006).

Massage therapy appears to affect anxiety levels (Fig. 2.1). The therapeutic relationship established between massage therapist and client is similar to psychotherapy: a treatment that relies on communication and therapeutic relationship to provide effects. It is possible that massage effects related to the affective category are related to the therapeutic relationship (Fellowes 2004, Moyer 2006). As described it is common to find a correlation between stress, anxiety, depression, and pain. According to Hanley et al (2003) despite very strong patient preference for therapeutic massage, it did not show any benefits over either a relaxation tape used in the surgery or a relaxation tape used at home. This study indicates that massage is effective but no more effective than other relaxation interventions.

Figure 2.1 General adaptation syndrome (GAS).

A key is that people liked massage, which is important in compliance with treatment. Muller-Oerlinghausen et al (2004) concluded that slow-stroke massage is suitable for adjuvant intervention for depression and is readily accepted by very ill patients. Currin and Meister (2008) found that reduction in oncology patient distress was observed regardless of gender, age, ethnicity, or cancer type and therefore supported massage therapy for hospitalized oncology patients as a means of enhancing their course of treatment. Sturgeon et al (2009) found that therapeutic massage shows potential benefits for reducing breast cancer treatment side effects of chemotherapy and radiation and improving perceived quality of life and overall functioning.

Mechanical effects related to massage benefits

Massage benefits appear to be related to mechanical forces applied to soft tissue which:

• alter pliability in connective tissue

• stimulate neuro signaling in fascia

• create changes in circulation

• stimulate changes in motor tone of muscles.

Let’s look at each of these areas. As presented later in this text, massage methods apply mechanical forces to the soft tissue. According to Langevin and Sherman (2007) pain related fear leads to a cycle of decreased movement, connective tissue remodeling, inflammation and nervous system sensitization which combine into a cycle resulting in further decreased mobility. The mechanisms of a variety of treatments such as massage may reverse these abnormalities by applying mechanical forces to soft tissues. Based on a tensegrity principle, direct or indirect connections between fascia or muscles which stretch the aponeurosis or intermuscular septum may allow the transfer of tension over long distances. Massage applied in such a way to deform the soft tissue has an effect on electrical (EMG) and mechanical (MMG) activities of a muscle lying distant, but indirectly connected to, the massaged muscle. It was concluded that there was an electrical as well as a mechanical response of muscle connected indirectly by structural elements with the muscle being massaged, indicating an application for the tensegrity principle in massage therapy and influence on adverse muscle tension by massaging another distant muscle (Kassolik et al 2009).

Figure 2.2 Crisis intervention model.

(Redrawn from Aguilera 1998.)

Day et al (2009) found that deep muscular fascia design supports the premise that the myofascial system is a three-dimensional continuum, including the epimysium and the retinacula. Dr Carla Stecco and Dr Antonio Stecco have carried out extensive research into the anatomy and histology of the fascia via dissection of unembalmed cadavers. This technique presents a complete biomechanical model that assists in deciphering the role of fascia in musculoskeletal disorders.

The mainstay of this manual technique lies in the identification of a specific, localized area of the fascia in connection with a specific limited movement. Once a limited or painful movement is identified, then a specific point on the fascia is implicated and, through the appropriate manipulation of this precise part of the fascia, movement can be restored. These dissections have enhanced the pre-existing biomechanical model already elaborated by Luigi Stecco (2004, 2009) by providing new histological and anatomical data.

While part of the fascia is anchored to bone, part is also always free to slide.

Fascia is formed by undulated collagen fibers and elastic fibers arranged in distinct layers, and within each layer the fibers are aligned in a different direction. Due to its undulated collagen fibers, fascia can be stretched and, thanks to its elastic fibers, it can then return to its original resting state. Subcutaneous connective tissue forms a very elastic, sliding membrane essential for thermal regulation, metabolic exchanges, and the protection of vessels and nerves, whereas the deep fascia envelops the muscles, and surrounds a muscle’s aponeurosis up to where it inserts into bone.

It is hypothesized that the richly innervated fascia could be maintained in a resting state of tension due to the different muscular fibers that insert into it. Due to this optimal resting state, or basal tension, of the fascia, the free nerve endings and receptors within the fascial tissue are primed to perceive any variation in tension and, therefore, any movement of the body, whenever it occurs (Stecco et al 2007).

Deep fascia is effectively an ideal structure for perceiving and, consequently, assisting in organizing movements. Whenever a body part moves in any given direction in space there is a myofascial, tensional rearrangement within the corresponding fascia. Afferents embedded within the fascia are stimulated, producing accurate directional information. Any impediment in the gliding of the fascia could alter afferent input resulting in incoherent movement.

It is hypothesized that fascia is involved in proprioception and peripheral motor control in strict collaboration with the CNS.

The method used in the Stecco studies involves a deep kneading of muscular fascia at specific points, termed centers of coordination (cc) and centers of fusion (cf), along myofascial sequences, diagonals, and spirals, and is called fascial manipulation technique. Visual analogue scale (VAS) measurement of pain administered prior to the first session and after the third session was compared with a follow-up evaluation at 3 months. Results suggested that the application of fascial manipulation technique may be effective in reducing pain in chronic situations (Pedrelli et al 2009).

Box 2.3 Interview of Luigi Stecco

Fascial Manipulation© is a manual therapy that has been developed by Luigi Stecco, an Italian physiotherapist from the north of Italy. This method has evolved over the last 30 years through study and practice in the treatment of a vast caseload of musculoskeletal problems.

In the fascia, there are different Centres of Coordination that, incidentally, often coincide with acupuncture points. These centres are probably involved in the coordination of joint movements. When, or if, they become ‘desensitized’, pain results in the associated joint. In order to re-balance the various body structures the densifications need to be slowly dissolved. Not by chance, manipulation of the fascia can play a role in preventing dysfunction.

http://www.fascialmanipulation.com/Portals/0/Curingthefascia.pdf

Curing the fascia. Interview of Luigi Stecco by Massimo Ilari. Published April 2003, Vita & Salute magazine. Translation: Julie Ann Day

Recent studies suggest that cyclic stretching of fibroblasts contributes to antifibrotic processes of wound healing by reducing connective tissue growth factor (CTGF) production (Kanazawa et al 2009). Robert Schleip (2003) indicates that fascia is imbedded with sensory mechanoreceptors, making fascia a sensory organ, and free nerve endings which respond to mechanical force stimulation. The intrafascial mechanoreceptors consist of four groups:

1. Golgi organs, which are found mostly in myotendinous junctions.

2. Large Pacini corpuscles, which respond to rapid changes in pressure.

3. Smaller and more longitudinal Ruffini organs, which do not adapt quickly to pressure.

4. Interstitial myofascial receptors.

Schleip (2006) indicates soft tissue strain involves a stimulation of intrafascial mechanoreceptors. This stimulation leads to an input to the central nervous system, altering the tone of motor units associated with the tissue. Combined with Ruffini organs and interstitial receptors, it can trigger changes in the autonomic nervous system.

The European Fascia Group (Schleip et al 2006) found that when fascia is stretched there are longitudinal relaxation changes in the collagen fibers and the water is squeezed out. Fascia seems to adapt with very complex and dynamic water changes to mechanical stimuli and the matrix reacts in smooth muscle-like contraction and relaxation responses of the whole tissue due to the sponge effect of fascia, like squeezing and refilling effects in the semiliquid ground substance.

Dr Leon Chaitow (2009) indicates that key fascia related topics are:

• The presence of contractile smooth muscle cells (SMCs/myofibroblasts) that are embedded in most connective tissues. For example, SMCs have been located widely in connective tissues including cartilage, ligaments, spinal discs, and lumbodorsal fascia (Ahluwalia 2001, Hastreite et al 2001). The extracellular matrix (ECM) plays a key role in the transmission of forces generated by the organism (e.g. muscle contraction) or externally applied (e.g. gravity, or by means of manually applied therapy).

• Cell-matrix adhesion sites appear to host a ‘mechanosensory switch’ as they transmit forces from the ECM to the cytoskeleton, and vice versa, triggering internal signals following mechanical stimulation, such as occurs in manual therapy (Chen & Ingber 1999). There appear to be forms of communication within the fascial matrix, for example caused by tugging in the mucopolysaccharides, created by twisting acupuncture needles (Langevin et al 2005).

German researchers, Robert Schleip et al (2005), note that:

The ability of fascia to contract is further demonstrated by the widespread existence of pathological fascial contractures. Probably, the most well known example is Dupuytren disease (palmar fibromatosis), which is known to be mediated by the proliferation and contractile activity of myofibroblasts. Lesser known is the existence of similar contractures in other fascial tissues which are also driven by contractile myofibroblasts, e.g. plantar fibromatosis, Peyronies disease (induratio penis plastica), club foot, or – much more commonly – in the frozen shoulder with its documented connective tissue contractures. Given the widespread existence of such strong pathological chronic contractures, it seems likely that minor degrees of fascial contractures might exist among normal, healthy people and have some influence on biomechanical behavior.

The behavior of water that interacts with protein in the human body is becoming clearer. Professor Martin Gruebele of the University of Illinois explains:

Water in our bodies has different physical properties from ordinary bulk water, because of the presence of proteins and other biomolecules. Proteins change the properties of water to perform particular tasks in different parts of our cells … Water can be viewed as a ‘designer fluid’ in living cells.

http://www.biocompare.com/News/NewsStory/239323/NewsStory.html Retrieved December 17, 2009.

Sommer and Zhu (2008) note that interfascial water plays a key part in what is termed ‘protein folding,’ the process necessary for cells to form their characteristic shapes – and that nanocrystals are a part of this process – and that these are influenced by light:

In the course of a systematic exploration of interfascial water layers on solids we discovered microtornadoes, found a complementary explanation to the surface conductivity on hydrogenated diamond, and arrived at a practical method to repair elastin degeneration, using light.

A leading researcher in this field, Pollack (2006), has shown that water can at times demonstrate a tendency to behave in a crystalline manner. He has discussed interfascial water in living cells known as vicinal water. Interfascial water exhibits structural organizations that differ from what is termed ‘bulk’ water. This vicinal water seems to be influenced by structural properties that make up the cell. In discussion of one example of this, in relation to the water in a temporomandibular joint, Pollack says:

The combined data from three different methods lead to the conclusion that all or almost all of the water in the intact disc is bound water and does not have properties consistent with free or bulk water.

Pollack also says:

If you want to understand what happens in any system – be it biological, or physical, or chemical, or oceanographic, or atmospheric, or whatever – it doesn’t matter, anything involving water, you really have to know the behavior of this special kind of gel-like water, which dominates.

Several years ago Klingler and Schleip (2004) showed that the water content of fascia partially determines its stiffness, and that stretching, or compression, of fascia (as occurs during almost all manual therapies) causes water to be extruded (like a sponge) – making the tissues more pliable and supple. After a while the water is taken up again and stiffness returns, but in the meantime structures can be mobilized and stretched more effectively and comfortably than when were they still densely packed with water.

• Klingler et al measured wet and dry fresh human fascia, and found that during an isometric stretch, water is extruded, refilling during a subsequent rest period.

• As water extrudes during stretching, temporary relaxation occurs in the longitudinal arrangement of the collagen fibers.

• If the strain is moderate, and there are no micro-injuries, water soaks back into the tissue until it swells, becoming stiffer than before.

All this suggests that much manual therapy, and the tissue responses experienced, may relate to sponge-like squeezing and refilling effects in the semi-liquid ground substance, with its water binding glycosaminoglycans and proteoglycans.

Muscle energy technique-like contractions and stretches almost certainly have similar effects on the water content of connective tissue, as do myofascial release methods and the multiple force-loading elements of massage.

Most people nowadays are aware that acupuncture points in TCM are thought of as being linked along invisible lines (meridians) that apparently connect anatomical areas and organs, and along which energy (chi) is thought to travel. Obstructions to this flow, leading to areas of congestion or deficiency, are seen as contributing to health problems, and can be relieved by appropriate needle application (or manual treatment of the points – as in shiatsu). Please forgive this simplistic outline of what is in fact a far more complex theoretical construction, but it may help in my attempt to eventually get to the ‘wow’ moments from Vermont and outer space, below.

Apart from the hundreds of ‘official’ acupuncture points, lying on these meridian maps/lines, another class of acupuncture point has always fascinated me. This is the so-called Ah shi point. Ah shi points are areas that become spontaneously tender/painful in response to local problems (strain, draughts, etc.). They become ‘eligible’ for treatment in acupuncture (needles or acupressure) when they are sensitive. Now anyone who knows very much about Simons, Travell and Simons’ (1999) work on trigger points might be forgiven for thinking that these points sound like those points … if you see what I mean?

Since we already know that approximately 80% of the main trigger point sites lie on points located on the meridian maps (Wall & Melzack 1990), the conjunction of these two areas of study (TCM/acupuncture points and myofascial trigger points) should not come as a surprise. Indeed, many experts believe that trigger points and acupuncture points are the same phenomenon (Kawakita et al 2002). Whether this is so or not, it suggests that in trying to understand trigger points better, we need to pay attention to research that tries to explain the processes of acupuncture, and the structural aspects of these invisible points.

Dr Langevin and her research colleagues have helped to clarify the situation, having shown that acupuncture points, and many of the effects of acupuncture, seem to relate to the fact that most of these localized ‘points’ lie directly over areas where there is a fascial cleavage, where sheets of fascia diverge to separate, surround, and support different muscle bundles (Langevin et al 2001).

It seems that the meridians may, in fact, be fascial pathways. This is not too surprising, since we know the fascial network represents one continuum from the internal cranial reciprocal tension membranes to the plantar fascia of the feet. Now we know that acupuncture points (and it seems the majority of trigger points) are structurally situated in connective tissue, but how does application of a needle or pressure in one part of the fascia translate to distant sites? How does the fascia communicate with other parts of the body?

Well, the Vermont researchers have also shown that connective tissue is a sophisticated communication system, of as yet unknown potential:

‘Loose’ connective tissue forms a network extending throughout the body including subcutaneous and interstitial connective tissues. The existence of a cellular network of fibroblasts within loose connective tissue may have considerable significance as it may support yet unknown body-wide cellular signaling systems …Our findings indicate that soft tissue fibroblasts form an extensively interconnected cellular network, suggesting they may have important, and so far unsuspected integrative functions at the level of the whole body. (Langevin et al 2004)

Author’s note: Research information summarized in this article has been drawn from content in the 2nd edition of my book, Clinical Applications of Neuromuscular Techniques: Volume 1 (Churchill Livingstone, 2001).

To understand how this signaling system works we need to be aware of the role of integrins – tiny projections emerging from each cell, that act like mini-transmitters and receivers. What Helene Langevin and her colleagues are now showing is that when deformation of cells and tissues occurs – such as that which happens to all of us when areas of the body are chronically shortened, crowded, compressed, stretched, or twisted due to age, disease, trauma, or progressive adaptation – the cells cannot function or communicate normally, or even demonstrate normal gene expression. And consider, from the bodyworker’s point of view, the reverse of that scenario. When we normalize tissues that are tense/tight/deformed/compressed by means of massage, stretching, mobilizing, etc., we are not just normalizing the biomechanical aspects of the function of those tissues – so that, for example, the shoulder or elbow or neck or whatever ‘feels’ better – we are also improving internal cellular function, enhancing cellular communication and gene expression. If that’s not a ‘wow’ I don’t know what is!

The Amazing Fascial Web, Leon Chaitow

The observation of Langevin et al (2005) is:

The dynamic, cytoskeleton-dependent responses of fibroblasts to changes in tissue length demonstrated in this study have important implications for our understanding of normal movement and posture, as well as therapies using mechanical stimulation of connective tissue including physical therapy, massage and acupuncture. (Langevin et al 2005)

Consider the connections I have attempted to put together in this brief communication regarding different elements of our understanding of how the body works:

1. The fascial cleavage planes seem to have a great deal to do with where acupuncture points (and many or most trigger points) are situated.

2. Cells communicate via (among other methods) mini-projections (integrins) that are capable of becoming deformed and distorted though age, overuse, misuse, abuse, and disuse (and loss of gravity!), with negative effects on cellular (and therefore tissue) function, including communication, nutrition, and reproduction (gene expression).

3. The function of tissues, down to the cellular level, can be enhanced by appropriate massage, bodywork, movement, and manipulation (and, it seems, by acupuncture).

Our work can really change the way the body works, and not just on the mechanical level. We influence emotion, the mind, the nervous system, immune function, and now we know that we also influence the way cells communicate and nourish themselves.

What type of methods influence fascia?

Any form of application that deforms the tissue and incorporates a stretching technique influences fascia. Fascia is a thin tissue that covers all the organs of the body. This tissue covers every muscle and every fiber within each muscle. All muscle stretching is, therefore, actually stretching of the fascia and the muscle, the myofascial unit. Injury to this tissue and subsequent healing can result in changes in the force distribution through the fascial network. Based on tensegrity structure, strain, shortening, and shape change in the tissue can cause pain and stiffness in areas of the body distant from the original injury site.

Fischer et al (2009) confirmed the interconnectedness of body areas with a study that suggests that temporomandibular joint dysfunction plays an important role in the restriction of hip motion experienced by patients with complex regional pain syndrome, which indicated a connectedness between these two regions of the body.

Various fascial techniques contain the same components. The therapist finds the area of tightness (better described as bind) and a light stretch (better called tension force) is applied to the tight area. The tension on the tissue is maintained for up to 30 seconds until softening occurs. Then the therapist moves to the next area of binding tissue and repeats constantly, sustaining bind and moving in multiple directions. The process is repeated until the area is fully softened. Then, the next area is addressed.

Circulation is also affected by massage. Castro-Sánchez et al (2009) found that connective tissue massage improves blood circulation in the lower limbs of type 2 diabetic patients at stage I or II-a and may be useful to slow the progression of peripheral artery disease. A different study lead by Castro-Sánchez indicated that a combined program of exercise and massage improves arterial blood pressure and ankle brachial index values in type 2 diabetics with peripheral arterial disease. Walton (2008) investigated efficacy of myofascial release techniques in the treatment of primary Raynaud’s phenomenon and found that releasing restricted fascia using myofascial techniques may influence the duration and severity of the vasospastic episodes.

Arroyo-Morales et al (2008) found that massage reduces EMG amplitude and vigor when applied as a passive recovery technique after a high-intensity exercise protocol. Massage may induce a transient loss of muscle strength or a change in the muscle fiber tension–length relationship, influenced by alterations of muscle function and a psychological state of relaxation.