For the whole decade I was a massage therapist, the most frequently discussed questions in my office was “the pressure question.” How much is enough? How deep is too deep? Should deep tissue massage be painful?
There’s rarely any justification for extremely painful massage, unless it clearly produces a better result than gentler treatment — which is rarely clear!1 It is possible that a few “brutal” deep tissue massages could do the trick where gentler treatment would fail — but there is no way to know this in advance, and massage is expensive stuff. If you’re going to gamble on a treatment, gamble on cheaper and less painful ones.
The reason the Pressure Question exists is that it’s hard for patients to tell the difference between nasty pain that might be a necessary part of therapy, and ugly pain that is just abusive. Not everything that hurts is therapeutic, but not every therapeutic procedure painless! How can we tell if an intense massage technique is therapeutic or not?
On my client intake form, I asked clients why they left their last massage therapist. The results, after several years of doing that…
|20%||not intense enough!|
|20%||unfocussed or wrong focus|
People vote with their feet, and it seems clear that many people have been dissatisfied with the pressure they’ve received during massage. They do not like their massage to be too painful… or too fluffy, regardless of whether or not they think it works.3People vote with their feet & they do not like their massage to be too painful… or too fluffy.
People also clearly don’t like their preferences to be ignored. Many of these clients, whether they wanted less pressure or more, have told me that massage therapists should ask about the pressure, to find out what each person wants. So there is one point, above all, that I would like to make about pressure…
It fascinates me just how different people can be in this regard. Pressure that would be quite comfortable for one person would certainly cause severe pain and emotional distress in another, and probably even injury.4
These differences can also occur between body parts. Pressures that worked well on the back can prove to be disastrously intense in the lower legs. And pressure tolerance changes with time: pressures that seemed fine on Tuesday can be brutal on Friday.
All of this highlights the necessity of massage therapy that is:
That is, regardless of all other considerations, a massage therapist must talk to you about pressure, respect your preferences (they are more important than any treatment ideology), and be careful about stumbling into areas that need much less pressure (for comfort) or much more pressure (for satisfaction). Far too many therapists make the mistake of setting a “default” pressure for a client early on, and then using roughly that much pressure everywhere.
And if therapy isn’t communicative, respectful, and cautious? If the pressure feels wrong to you again and again?
A reader told me this alarming story by email, a typical example of unpleasantly intense massage therapy:
My massage therapist has been doing massages for 30 years. He is really aggressive. I thought that I was going to die. The pain was so intense that I honestly feel that it was worse than having children. When the massage was complete, I felt relaxed. When I got home I felt exhausted, like I had been in a major accident. Truthfully I feel like crap. I ache from head to toe, what the heck is this? I feel absolutely horrible. I had a bath before bed and it did help somewhat. But this morning I still feel like hell …
an anonymous reader
It’s tough to be assertive with a therapist like that! How much luck do you think most new clients would have telling an “aggressive” 30-year veteran of massage therapy to “ease up, please”? The trouble with most therapists like this is that they are set in their ways and are not communicative, respectful, or cautious.
You’d hope this sort of thing would be rare, but it’s not. Readers regularly tell me about massage therapists who do not ask them what they want, who dismiss their patients’ concerns about pressure, and who ignore signs that their clients are in pain. They display a “doctor knows best” arrogance — ironic for an alternative health care professional — imposing their own idea of the “right” intensity.
If you have the misfortune of hiring such a therapist, and you are not a natural masochist — hey, everyone’s different! — then by all means find another therapist. Be a consumer and shop around. Painfully intense massage therapy may be regrettably common, but it is by no means the only kind available. There are therapists who do it right.5
The Answer to the Pressure question begins with three flavours of pain…
Painful experiences on the massage table can be divided into three familiar categories: the good, the bad, and the ugly. Here’s a summary of each, and then I’ll go into much more detail.
Good pain. In massage, there is a curious phenomenon widely known as “good pain.” It arises from a sensory contradiction between the sensitivity to pressure and the “instinctive” sense that the pressure is also a source of relief. So pressure can be an intense sensation that just feels right somehow. It’s strong, but it’s welcome. Good pains are usually dull and aching, and are often described as a “sweet” aching. The best good pain may be such a relief that “pain” isn’t even really the right word.
Bad pain. Bad pain comes with no obvious, immediate benefits. If there is anything good about it, there is no way to tell from the sensation at the time. Bad pains are usually sharp, burning, or hot. Such pain is usually caused by excessive but harmless pressure. As bad as it feels, it probably won’t hurt you — maybe a little bruising — but there’s also a good chance that it won’t be therapeutic either. The big question about bad pain is whether or not it is ever justified.
Ugly pain. This is a type of pain in massage therapy that is, by my definition, never okay. Ugly pain is often caused by things that aren’t likely to offer even a delayed benefit, and may even be dangerous.
Ugly pain in massage therapy is, by my definition, never okay. Ugly pain is often caused by things that are not going to offer even minimal, delayed benefits, and may even be dangerous. It’s important to be able to spot ugly pain for what it is and completely eliminate it from any therapy you’re receiving. What kinds of handling may cause “ugly” pain?
“Ugly” pain is inflicted only by careless, incompetent therapists. Ugly pain should simply never happen. Yet it does happen, and a shocking number of therapists will actually attempt to justify it or minimize the concern.
For instance, many poorly trained therapists do not know the endangerment sites, and will carelessly dig their thumbs into that hollow between your jaw and your ear, where there are exposed nerve bundles and salivary glands that can really smart when poked.6There are massage therapists who seem to believe that any painful sensation is simply part of the process & if they poked you in the eye they would call it “ocular release therapy.”
Another alarmingly common example is the sensation of skin tearing. This has been inflicted on me personally on at least three occasions, and not by poorly trained therapists — quite the opposite, the perpetrators were all well-trained massage therapists doing a kind of “fascial release” therapy that they clearly thought of as an “advanced” technique.7
This may come as a surprise, but in fact there is no therapeutic benefit to stretching skin so hard that it feels like it is going to tear! And it is a completely different and uglier sensation than how fascial stretching can feel and should feel (more like a good massage). When I complained about this (politely), the therapists made no distinction between skin-tearing and fascial stretching, and more or less tried to tell me that I was objecting to perfectly good therapy. Needless to say, I never returned to those therapists.
There are massage therapists who seem to believe that any painful sensation is simply part of the process, and if they poked you in the eye they would call it “ocular release therapy.”
Ugly pain can be a sign of real dangers, one more obvious than the other:
Consequently, ugly pain in massage therapy is all too common and tragic. I cringe to think how many people have been abused this way. If you have a therapist you suspect of carelessly or deliberately inflicting ugly pain, just say no!
For more information about the potential hazards of intense manual therapy, see What Could Possibly Go Wrong With Massage? Rare but real adverse effects of massage therapy, especially “deep tissue” massage.
Now, let’s move on to “bad” pain.
Bad pain in massage comes with no obvious benefits — it hurts, but without being obviously dangerous or beneficial. The benefits may be subtle, or delayed… or nonexistent.
Once again, the Pressure Question is basically about whether or not bad pain is ever justified. If unpleasant pain is therapeutic, then I would call it “bad pain” — unpleasant, but worthwhile. If it’s not therapeutic, and you are paying to experience pain with no benefit, then it should be considered ugly pain — both unpleasant and pointless!
But how do you know?
For starters, you bear in mind the things described above that tend to cause ugly pain, and you avoid that kind of therapy like the plague. Then you look for some clues that painful pressure is okay. Here are at least three reasons why unpleasantly intense pressure might be therapeutic — “bad pain,” but not ugly. In each of these situations, it might be acceptable to tolerate sensations so intense and painful that the only thing about them that is pleasant is the part where it stops.
Myofascial trigger points — muscle knots — are a ubiquitous muscular dysfunction, causing most of the aches, pains and stiffness in the world, and complicating virtually every other injury and disease process. A lot of massage is focussed on them, directly or indirectly. Massage may be helpful because it relieves the symptoms of muscle knots, or even unties them. (No, not literally.)
One theory is that muscle knots may be caused by something that goes wrong at the “motor end plate” — where a nerve ending attaches to a muscle cell.9 We don’t know why this happens, or what exactly goes wrong, but there is circumstantial evidence that motor end plates are the “point” in trigger point. That evidence is too complex and controversial to review properly here. It is explored in detail in my book. Some research has suggested that it may actually be possible to physically destroy the motor end plate with strong massage, thereby inactivating the trigger point.10 When it regrows — these are microscopic structures, it doesn’t take them long to heal — the trigger point may be gone.
It’s just a theory: no one knows if this is actually effective.11 However, it may explain why so many massage patients report a “gets a bit worse before it gets much better” response to quite painful treatments: motor end plates are (painfully) destroyed by strong pressures, and then that tissue is quite sensitive and a bit weak as it heals over a day or two … and then you finally feel much better after that!
Maybe. But I repeat, no one really knows — and there is also good evidence that intense pressures, which cause a fight-or-flight reaction in your nervous system, almost certainly can aggravate trigger points. There are dozen variables that could affect which of these two ideas might be more relevant to a given person on a particular day.
The best we can say is that there is some reason to believe that painful pressures on muscles might be therapeutic for some people some of the time. Pretty decisive, eh? This is why it drives me nutters that so many therapists insist that strong pressures are “essential” to achieve “a complete release.” It really isn’t possible to know! It really does depend! Why would anyone pretend to “know”?
Somatoemotional release. Mental and emotional context is a major factor in how we experience pain. Painful sensations are unusually good at stimulating catharsis — the expression of strong or repressed emotion. — because physical pain often strongly “resonates” with emotional pain.12 For instance, the pain of an injury may blur together with the emotional frustrations of functional limits and rehab. That’s a basic example, and much more complex interactions between emotional and physical pain are obviously possible. Whether it is the clear goal of therapy, or simply a natural side benefit, experiencing very strong sensations can certainly be a meaningful part of a personal growth process “just” by changing your sense of yourself, how it feels to be in your skin, and perhaps bumping you out of some other sensory rut.13
Flushing. If massage can “improve” any tissue — unknown — one way it might do it is through simple hydraulics: physically pumping tissue fluids around, and/or stimulating the circulation of blood and lymph. I won’t get into the evidence about it here. Suffice it to say that it might be true, and if it’s true then it may not much matter if the process is uncomfortable. While gentler massage may feel pleasant and satisfying, it is possible that more biological benefits can only be achieved hydraulically — whether it’s comfortable or not. This is even more plausible because of trigger points: it’s likely that the tissue fluids of a trigger point are quite polluted with waste metabolites, and the need for flushing is greater, but it’s especially uncomfortable to squish those polluted patches of tissue.
Connective tissue stimulation. A lot of therapists are keen on stretching connective tissues — tendons, ligaments, and layers of Saran wrap-like tissue called “fascia.” I’m not a huge fan of this style, but certainly it’s a way of generating many potent and novel sensations, which may be inherently valuable to us — another form of touch. Although “improving” the fascia itself is implausible and unproven, perhaps fascial manipulations affect bodies indirectly, just as a sailboat is affected by pulling on its rigging. People have written whole books full of speculation along these lines. So, as long as the sensations are not like skin tearing (that’s an ugly pain for sure), you might choose to tolerate this kind of massage if it seems to be helping you.
In massage therapy, so much can be achieved while inflicting only good pain on patients that bad pain must be justified by vivid, quick, and somewhat lasting benefits — which is a high bar to clear. All health care practices must be justified by benefits. As risk and pain and expense increase, the benefits must also. There is simply no point in tolerating — and paying for — painful treatment without an obvious return on the investment.
Good pain is an interesting subject because it’s a contradiction that somehow manages to make perfect sense when you experience it. The sensation is unique and distinctive, but it doesn’t have its own word.
And it comes from inside of people. Therapists have not imposed the idea of good pain on patients the way that they have imposed many other common therapy ideas. Even massage newbies recognize the sensory paradox clearly. It’s always fun and interesting to listen to an inexperienced patient discovering good pain …
Oooh, wow … oh, that’s sensitive … but it’s good … but it’s definitely pain … but it’s definitely good …
typical patient discovering “good pain”
The contradiction between the good and bad parts of pain can be strong. Good pain may involve an undeniably nasty or gross or sickening compenent, a truly unpleasant quality, and yet still be accompanied by a distinct sense of relief, like an itch being scratched.
No one really knows how a painful massage can also feel so good at the same time. This is a sensory phenomenon mostly beyond the reach of science — not entirely14 — all we can do is speculate. A main question is whether good pain is good because we expect to relief to follow pain, or because positive and negative qualities are being produced simultaneously. My bet is on the latter.
But the relief model is certainly tempting. There are many painful-but-relieving analogies in medicine and biology.15 That’s similar to what good pain in massage feels like, but it’s not the same: no one thinks that lancing a boil or popping a shoulder joint back in is anything but painful while it’s happening.16 And we can’t necessarily take the good pain sensation at face value and assume it means there’s actually going to be a positive outcome. Brains are not all-knowing. Sometimes they see danger where there is none, and sometimes they see help where there is none.
A satisfying sensation doesn’t necessarily imply successful treatment, unfortunately. Scratching mosquito bites feels great…but it’s not helping them! Trigger points may be like mosquito bites: it may feel terrific to massage those mysterious sensitive spots in soft tissue, but it may not be doing much to actually “release” or resolve them. It may be a purely sensory experience, the satisfaction of dealing with an “itch” that we cannot easily reach on our own.
Regardless of what hurts so good…The referred pain phenomenon basically just makes trigger point release feel bigger, more important.
Referred pain spreads the goodness. Undoubtedly another reason that massage pain can feel good is the phenomenon of referred sensation. If you stimulate internal tissues anywhere in the body, muscle or otherwise, the brain really has trouble telling quite where the sensation is coming from. When you press hard enough on your muscles, particularly on sensitive trigger points, the pain is often experienced as though it originated from a much broader area.
Referred pain basically just makes trigger point stimulation feel bigger, more important. Press on a small spot … feel it down your entire arm. Wow! Impressive! Even though it’s just a thumb on a trigger point, it feels as though that “itch” is being scratched throughout an entire region. Referred pain amplifies the good pain effect — or the bad pain effect, if the pressure is too intense!
I am a science writer, former massage therapist, and I was the assistant editor at ScienceBasedMedicine.org for several years. I have had my share of injuries and pain challenges as a runner and ultimate player. My wife and I live in downtown Vancouver, Canada. See my full bio and qualifications, or my blog, Writerly. You might run into me on Facebook or Twitter.