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).


Neuromodulation

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).


Neurodynamics 

“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).


Mechanotherapy

"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.
https://www.ncbi.nlm.nih.gov/pubmed/27497646

Best, T. M., & Crawford, S. K. (2017). Massage and postexercise recovery: The science is emerging. British Journal of Sports Medicine.
https://www.ncbi.nlm.nih.gov/pubmed/27797730

Best, T.M., Gharaibeh, B., Huard, J. (2013). Stem cells, angiogenesis and muscle healing: a potential role in massage therapies? Br J Sports Med.
https://www.ncbi.nlm.nih.gov/pubmed/23197410

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.
https://www.ncbi.nlm.nih.gov/pubmed/28459190

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. 
https://www.ncbi.nlm.nih.gov/pubmed/19027342

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.
https://www.ncbi.nlm.nih.gov/pubmed/26401979 (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.
https://www.ncbi.nlm.nih.gov/pubmed/26810536

Chaitow, L. (2016). Dosage and manual therapies – Can we translate science into practice? Journal of Bodywork and Movement Therapies.
https://www.ncbi.nlm.nih.gov/pubmed/27210835

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.
https://www.ncbi.nlm.nih.gov/pubmed/25288713

Chen, L., Michalsen, A. (2017). Management of chronic pain using complementary and integrative medicine. BMJ.
https://www.ncbi.nlm.nih.gov/pubmed/28438745

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.
http://www.ncbi.nlm.nih.gov/pubmed/22301554
*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.
https://www.ncbi.nlm.nih.gov/pubmed/27013961 (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.
http://www.ncbi.nlm.nih.gov/pubmed/26700270

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.
https://www.ncbi.nlm.nih.gov/pubmed/26779092

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.
https://www.ncbi.nlm.nih.gov/pubmed/25487283

Field, T. (2016). Massage therapy research review. Complementary Therapies in Clinical Practice.
https://www.ncbi.nlm.nih.gov/pubmed/27502797

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.
https://www.ncbi.nlm.nih.gov/pubmed/25789756 (Open Access)

Fryer, G. (2017). Integrating osteopathic approaches based on biopsychosocial therapeutic mechanisms. International Journal of Osteopathic Medicine.
http://www.journalofosteopathicmedicine.com/article/S1746-0689(17)30031-7/fulltext

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.
http://www.ncbi.nlm.nih.gov/pubmed/26917940 (OPEN ACCESS)

Ji, R.R., Chamessian, A., Zhang, Y.Q. (2016). Pain regulation by non-neuronal cells and inflammation. Science.
https://www.ncbi.nlm.nih.gov/pubmed/27811267

Louw, A., Zimney, K., Puentedura, E.J., Diener, I. (2016). The efficacy of pain neuroscience education on musculoskeletal pain: A systematic review of the literature. Physiother Theory Pract.
https://www.ncbi.nlm.nih.gov/pubmed/27351541

Louw, A., Nijs, J., Puentedura, E. (2017). A clinical perspective on a pain neuroscience education approach to manual therapy. Journal of Manual & Manipulative Therapy.
http://www.tandfonline.com/doi/abs/10.1080/10669817.2017.1323699?journalCode=yjmt20

Mancini, F., Nash, T., Iannetti, G.D., Haggard, P. (2014). Pain relief by touch: a quantitative approach. Pain.
https://www.ncbi.nlm.nih.gov/pubmed/24361816

McGlone, F., Wessberg, J., Olausson, H. (2014). Discriminative and affective touch: sensing and feeling. Neuron.
https://www.ncbi.nlm.nih.gov/pubmed/24853935

Mancini, F., Beaumont, A., Hu, L., Haggard, P., & Iannetti, G. D. (2015). Touch inhibits subcortical and cortical nociceptive responses. Pain.
https://www.ncbi.nlm.nih.gov/pubmed/26058037

McGlone, F., Cerritelli, F., Walker, S., Esteves, J. (2016). The role of gentle touch in perinatal osteopathic manual therapy. Neurosci Biobehav Rev.
https://www.ncbi.nlm.nih.gov/pubmed/27845175

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.
https://www.ncbi.nlm.nih.gov/pubmed/24622769

Melzack, R. & Wall, P.D. (1965). Pain mechanisms: a new theory. Science.
http://www.ncbi.nlm.nih.gov/pubmed/5320816

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.
https://www.ncbi.nlm.nih.gov/pubmed/22975226

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.
https://www.ncbi.nlm.nih.gov/pubmed/28442987 (OPEN ACCESS)

Moyer, C.A., Rounds, J., Hannum, J.W. (2004). A meta-analysis of massage therapy research. Psychol Bull.
https://www.ncbi.nlm.nih.gov/pubmed/14717648

Nelson, N.L. (2015). Massage therapy: understanding the mechanisms of action on blood pressure. A scoping review. J Am Soc Hypertens.
https://www.ncbi.nlm.nih.gov/pubmed/26324746

Newell, D., Lothe, L.R., Raven, T.J. (2017). Contextually Aided Recovery (CARe): a scientific theory for innate healing. Chiropr Man Therap.
https://www.ncbi.nlm.nih.gov/pubmed/28289539

Nummenmaa, L., Tuominen, L., Dunbar, R., ... Sams, M. (2016). Social touch modulates endogenous μ-opioid system activity in humans. Neuroimage.
https://www.ncbi.nlm.nih.gov/pubmed/27238727

Parravicini, G., Bergna, A., (2017). Biological effects of direct and indirect manipulation of the fascial system. Narrative review. Journal of Bodywork & Movement Therapies.
https://www.ncbi.nlm.nih.gov/pubmed/28532888

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.
https://www.ncbi.nlm.nih.gov/pubmed/25887644

Poppendieck, W., Wegmann, M., Ferrauti, A., Kellmann, M., Pfeiffer, M., Meyer, T. (2016). Massage and Performance Recovery: A Meta-Analytical Review. Sports Med.
https://www.ncbi.nlm.nih.gov/pubmed/26744335

Rabey, M., Hall, T., Hebron, C., Palsson, T.S., Christensen, S.W., Moloney, N. (2017). Reconceptualising manual therapy skills in contemporary practice. Musculoskeletal Science and Practice.
https://www.ncbi.nlm.nih.gov/pubmed/2828624

Rapaport, M.H., Schettler, P., Bresee, C. (2012). A preliminary study of the effects of repeated massage on hypothalamic-pituitary-adrenal and immune function in healthy individuals: a study of mechanisms of action and dosage. J Altern Complement Med.
https://www.ncbi.nlm.nih.gov/pubmed/22775448

Sawynok, J. (2016). Adenosine receptor targets for pain. Neuroscience.
https://www.ncbi.nlm.nih.gov/pubmed/26500181

Sliz, D., Smith, A., Wiebking, C., Northoff, G., Hayley, S. (2012). Neural correlates of a single-session massage treatment. Brain Imaging Behav.
https://www.ncbi.nlm.nih.gov/pubmed/22261925 (OPEN ACCESS)

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.
https://www.ncbi.nlm.nih.gov/pubmed/19340540

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. 
https://www.ncbi.nlm.nih.gov/pubmed/26637643 (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.
https://www.ncbi.nlm.nih.gov/pubmed/20046617 (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. 
https://www.ncbi.nlm.nih.gov/pubmed/26788367 (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.
https://www.ncbi.nlm.nih.gov/pubmed/28162847

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)
https://www.ncbi.nlm.nih.gov/pubmed/24641083

Zein-Hammoud, M., & Standley, P. R. (2015). Modeled Osteopathic Manipulative Treatments: A Review of Their in Vitro Effects on Fibroblast Tissue Preparations. JAOA.
https://www.ncbi.nlm.nih.gov/pubmed/26214822