Responses to Massage Therapy are Multifactorial

What is Massage Therapy

Massage therapy is a clinically-oriented multi-modal approach based on a biopsychosocial model and on the three pillars of evidence based practice. 

Physicians, now more than ever, are recommending conservative evidence based treatment including massage, acupuncture and exercise as part of a multi-modal approach for patients suffering from low back pain, headaches, anxiety and stress.

Why Does Massage Therapy Work

As part of the evolution of the profession is important to have a working knowledge of the myriad of mechanisms of action that may be at play.

The mechanism by which massage therapy alleviates pain and improves function is not clear, biological factors (physiology), psychological (i.e. thoughts, emotions, and behaviors) and social (i.e. culture, and beleifs) factors play a significant role in the experience and reduction of pain. In terms of clinical responses to massage therapy there are a couple of proposed mechanisms of action: 

Contextually Aided Recovery

The way we present ourselves and present our techniques is tied to clinical outcomes, the magnitude of a response may be influenced by mood, expectation, and conditioning (Bialosky et al. 2017).


Massage has an affect on peripheral and central processes - input from large sensory neurons may prevent the spinal cord from amplifying nociceptive signaling (Bishop et al. 2015, Vigotsky et al. 2015).

Nervous system regulated by touch (social grooming) helps modulate the activity of neural circuits important for maintaining resting state. This reduced physiological and behavioural reactivity to stressors results in improved mood/affect (Ellingsen et al. 2016, Moyer et al. 2004, Walker et al. 2017).

An Increase in Parasympathetic Activity

Studies have demonstrated an increase in parasympathetic activity following local compression of triggerpoints. This alteration within the autonomic nervous system result in changes to regional perfusion (Takamoto et al. 2009Morikawa et al. 2017 ). It is proposed that improved perfusion and oxygen delivery to the muscle, encourages the removal of cellular exudates and drainage of metabolic waste (Moraska et al. 2013).


“A clinical concept that uses movement (1) to assess increased mechanosensitivity of the nervous system; and (2) to restore the altered homeostasis in and around the nervous system.” (2015) Grieve's Modern Musculoskeletal Physiotherapy.

Attenuating intraneural edema - Massage therapy may diminish intraneural edema by mobilizing neural tubes “the use of repetitive motion, neural mobilization techniques may promote a healthy nerve environment by improving axonal transport and blood flow, and reducing detrimental chemical and mechanical components resulting from intraneural edema” (Gilbert et al. 2015).


"Any intervention that introduces mechanical forces with the goal of altering molecular pathways and inducing a cellular response that  enhances tissue growth, modeling, remodeling, or repair.” (Thompson et al. 2016)

  • The skin, adipose tissue, and fascia are not isolated; rather, they form 1 block of layered tissue on a base of muscle and bone." Soft tissue treatments often engage the skin and underlying tissues. (Chaudhry et al. 2014).The application of appropriate shear force and pressure impart a mechanical stimulus that may attenuate tissue levels of TGF-β1. (Bove et al. 2016).  
  • Mechanical stimulation can trigger fibroblasts to express pro-/anti-inflammatory cytokines respectively (Zein-Hammoud et al. 2015).
  • Research also suggests that the application of massage induces a phenotype change, prompting the transition of M1 macrophages into the M2 macrophages which play a role in tissue remodeling, immune regulation and efficient phagocytic activity. (Waters-Banker et al. 2014).

More to Explore

Begovic, H., Zhou, G., Schuster, S., & Zheng, Y. (2016). The neuromotor effects of transverse friction massage. Manual Therapy.

Best, T. M., & Crawford, S. K. (2017). Massage and postexercise recovery: The science is emerging. British Journal of Sports Medicine.

Best, T.M., Gharaibeh, B., Huard, J. (2013). Stem cells, angiogenesis and muscle healing: a potential role in massage therapies? Br J Sports Med.

Bialosky, J.E., Bishop, M.D., Penza, C.W. (2017). Placebo Mechanisms of Manual Therapy: A Sheep in Wolf's Clothing? J Orthop Sports Phys Ther.

Bialosky, J. E., Bishop, M. D., Price, D. D., Robinson, M. E., & George, S. Z. (2009). The mechanisms of manual therapy in the treatment of musculoskeletal pain: A comprehensive model. Manual Therapy.

Bishop, M. D., Torres-Cueco, R., Gay, C. W., Lluch-Girbés, E., Beneciuk, J. M., & Bialosky, J. E. (2015). What effect can manual therapy have on a patient's pain experience? Pain Management. (OPEN ACCESS)

Bove, G., Harris, M., Zhao, H., & Barbe, M. (2016). Manual therapy as an effective treatment for fibrosis in a rat model of upper extremity overuse injury. Journal of the Neurological Sciences.

Chaitow, L. (2016). Dosage and manual therapies – Can we translate science into practice? Journal of Bodywork and Movement Therapies.

Chaudhry, H., Bukiet, B., Ji, Z., Stecco, A., & Findley, T. (2014). Deformations Experienced in the Human Skin, Adipose Tissue, and Fascia in Osteopathic Manipulative Medicine. JAOA.

Chen, L., Michalsen, A. (2017). Management of chronic pain using complementary and integrative medicine. BMJ.

Crane, J., Ogborn, D., Cupido, C., Melov, S., Hubbard, A., Bourgeois, J., & Tarnopolsky, M. (2012). Massage Therapy Attenuates Inflammatory Signaling After Exercise-Induced Muscle Damage. Science Translational Medicine.
*This is the first research to show that massage can reduce pro-inflammatory cytokines, the reductions in some of the inflammatory signalling pathways may also influence pain and muscle soreness sensation

D'alessandro, G., Cerritelli, F., & Cortelli, P. (2016). Sensitization and Interoception as Key Neurological Concepts in Osteopathy and Other Manual Medicines. Frontiers in Neuroscience. (Open Access)

Dunn, S. L., & Olmedo, M. L. (2016). Mechanotransduction: Relevance to Physical Therapist Practice--Understanding Our Ability to Affect Genetic Expression Through Mechanical Forces. Physical Therapy.

Ellingsen, D., Leknes, S., Løseth, G., Wessberg, J., & Olausson, H. (2016). The Neurobiology Shaping Affective Touch: Expectation, Motivation, and Meaning in the Multisensory Context. Frontiers in Psychology.

Eriksson Crommert, M., Lacourpaille, L., Heales, L.J., Tucker, K., Hug, F. (2015). Massage induces an immediate, albeit short-term, reduction in muscle stiffness. Scand J Med Sci Sports.

Field, T. (2016). Massage therapy research review. Complementary Therapies in Clinical Practice.

Foster, E., Wildner, H., Tudeau, L., Haueter, S., Ralvenius, W., Jegen, M., . . . Zeilhofer, H. (2015). Targeted Ablation, Silencing, and Activation Establish Glycinergic Dorsal Horn Neurons as Key Components of a Spinal Gate for Pain and Itch. Neuron. (Open Access)

Fryer, G. (2017). Integrating osteopathic approaches based on biopsychosocial therapeutic mechanisms. International Journal of Osteopathic Medicine.

Gilbert, K. K., James, C. R., Apte, G., Brown, C., Sizer, P. S., Brismée, J., & Smith, M. P. (2015). Effects of simulated neural mobilization on fluid movement in cadaveric peripheral nerve sections: Implications for the treatment of neuropathic pain and dysfunction. Journal of Manual & Manipulative Therapy. (OPEN ACCESS)

Ji, R.R., Chamessian, A., Zhang, Y.Q. (2016). Pain regulation by non-neuronal cells and inflammation. Science.

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Louw, A., Nijs, J., Puentedura, E. (2017). A clinical perspective on a pain neuroscience education approach to manual therapy. Journal of Manual & Manipulative Therapy.

Mancini, F., Nash, T., Iannetti, G.D., Haggard, P. (2014). Pain relief by touch: a quantitative approach. Pain.

McGlone, F., Wessberg, J., Olausson, H. (2014). Discriminative and affective touch: sensing and feeling. Neuron.

Mancini, F., Beaumont, A., Hu, L., Haggard, P., & Iannetti, G. D. (2015). Touch inhibits subcortical and cortical nociceptive responses. Pain.

McGlone, F., Cerritelli, F., Walker, S., Esteves, J. (2016). The role of gentle touch in perinatal osteopathic manual therapy. Neurosci Biobehav Rev.

Mcpartland, J. M., Guy, G. W., & Marzo, V. D. (2014). Care and Feeding of the Endocannabinoid System: A Systematic Review of Potential Clinical Interventions that Upregulate the Endocannabinoid System. PLoS ONE.

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Moraska, A.F., Hickner, R.C., Kohrt, W.M., Brewer, A. (2013). Changes in blood flow and cellular metabolism at a myofascial trigger point with trigger point release (ischemic compression): A proof-of-principle pilot study. Arch Phys Med Rehabil.

Morikawa, Y., Takamoto, K., Nishimaru, H., Taguchi, T., Urakawa, S., Sakai, S., Ono, T., Nishijo, H. (2017). Compression at Myofascial Trigger Point on Chronic Neck Pain Provides  Pain Relief through the Prefrontal Cortex and Autonomic Nervous System: A Pilot Study. Front Neurosci. (OPEN ACCESS)

Moyer, C.A., Rounds, J., Hannum, J.W. (2004). A meta-analysis of massage therapy research. Psychol Bull.

Nelson, N.L. (2015). Massage therapy: understanding the mechanisms of action on blood pressure. A scoping review. J Am Soc Hypertens.

Newell, D., Lothe, L.R., Raven, T.J. (2017). Contextually Aided Recovery (CARe): a scientific theory for innate healing. Chiropr Man Therap.

Nummenmaa, L., Tuominen, L., Dunbar, R., ... Sams, M. (2016). Social touch modulates endogenous μ-opioid system activity in humans. Neuroimage.

Parravicini, G., Bergna, A., (2017). Biological effects of direct and indirect manipulation of the fascial system. Narrative review. Journal of Bodywork & Movement Therapies.

Pelletier, R., Higgins, J., & Bourbonnais, D. (2015). Is neuroplasticity in the central nervous system the missing link to our understanding of chronic musculoskeletal disorders? BMC Musculoskeletal Disorders.

Poppendieck, W., Wegmann, M., Ferrauti, A., Kellmann, M., Pfeiffer, M., Meyer, T. (2016). Massage and Performance Recovery: A Meta-Analytical Review. Sports Med.

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Takamoto, K., Sakai, S., Hori, E., Urakawa, S., Umeno, K., Ono, T., Nishijo, H. (2009). Compression on trigger points in the leg muscle increases parasympathetic nervous activity based on heart rate variability. J Physiol Sci.

Thompson, W. R., Scott, A., Loghmani, M. T., Ward, S. R., & Warden, S. J. (2016). Understanding Mechanobiology: Physical Therapists as a Force in Mechanotherapy and Musculoskeletal Regenerative Rehabilitation. Physical Therapy. (OPEN ACCESS)

Vairo, G.L., Miller, S.J., McBrier, N.M., Buckley, W.E. (2009). Systematic review of efficacy for manual lymphatic drainage techniques in sports medicine and rehabilitation: an evidence-based practice approach. J Man Manip Ther. (Open Access)

Vigotsky, A. D., & Bruhns, R. P. (2015). The Role of Descending Modulation in Manual Therapy and Its Analgesic Implications: A Narrative Review. Pain Research and Treatment. (OPEN ACCESS)

Walker, S.C., Trotter, P.D., Swaney, W.T., Marshall, A., Mcglone, F.P. (2017). C-tactile afferents: Cutaneous mediators of oxytocin release during affiliative tactile interactions?  Neuropeptides.

Waters-Banker, C., Dupont-Versteegden, E. E., Kitzman, P. H., & Butterfield, T. A. (2014). Investigating the Mechanisms of Massage Efficacy: The Role of Mechanical Immunomodulation. Journal of Athletic Training. (OPEN ACCESS)

Zein-Hammoud, M., & Standley, P. R. (2015). Modeled Osteopathic Manipulative Treatments: A Review of Their in Vitro Effects on Fibroblast Tissue Preparations. JAOA.