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From scratching an itch to picking a scab

Paul Ingraham ARCHIVEDMicroblog posts are archived and rarely updated. In contrast, most long-form articles on PainScience.com are updated regularly over the years.

I’ve observed this pattern in people’s stories about massage, and I’ve experienced it myself a few times: feeling better when you finally give up on massage. Self-massage specifically: rubbing, foam rollers and balls, vibrating massage tools, and so on. I call it the “back-off effect.” Here’s how it seems to go:

  1. Symptoms of chronic pain and stiffness inspire self-massage, and at first it seems like the Best Thing Ever. There are some excellent early results, sometimes almost miraculous. For a while, it may even seem like the problem is solved. But it often isn’t.
  2. The problem persists despite the promising start. Maybe it feels like it’s being controlled better, because self-treatment keeps taking the “edge” off, and thank goodness for small mercies. But it becomes apparent that nothing is really being solved, and so…
  3. The ante gets upped. Moar release, moar! Harder! Twice a day instead of once every other day! Better tools! And then self-treatment becomes entrenched as a ritual that feels necessary — things would be so much worse without it! — but progress has become elusive. Sometimes people up the ante more than others, until eventually…
  4. Tedium sets in and the ritual gets neglected. Or it’s blocked by other events, like travel or a family crisis. And then something surprising happens…
  5. When the self-treatment finally stops, the symptoms improve markedly, sometimes even finally resolving completely!

Wish I had a buck for every time I’ve heard some version of that story. I’ve been noticing it for years, and was reminded to finally write about it when a good friend of mine reported his own version of it recently. I’ve speculated about the cause many times.

What explains the back-off effect? From itching scratching to scab picking

The most obvious explanation is that it’s all about sensory modulation. One likely reason self-massage seems so helpful to begin with is that it’s a refreshing, reassuring, and hopeful sensory input, inherently satisfying, “scratching an itch.” But it’s mostly a trivial palliative effect that eases pain temporarily and ultimately solves nothing, fails to treat the cause (with some possible exceptions, but we won’t get into that here, or I’ll need a lot more space). There’s a phase of ramping up the intensity as you try to recapture those early wins, and then a transition to overstimulation and irritation: scratching an itch so hard for so long that the scratching becomes more of a problem than the itch.

At that point, we need a new metaphor: “picking at a scab.”

Eventually we back off for one reason or another, and then feel better for that. And that can be temporary, because the underlying problem still hasn’t been solved!

Or maybe it has. Maybe the underlying condition actually just finally gets over itself, as most do — good ol’ regression to the mean, which never gets the credit it deserves for so many recoveries. Instead, it’s usually whatever therapy we’re investing in at the time that gets the credit. And sometimes even “backing off” gets that credit! (I discuss regression to the mean and the “darkest before dawn” effect in detail in The Power of Barking.)

Phase 3 insanity: getting carried away

Upping the self-massage ante so far that you actually hurt yourself is another obvious explanation for the back-off effect. Massage is generally quite safe, but things can go wrong, and self-massage can be the riskiest of all.

In phase 3 of the pattern described above, when people are trying to recapture the early victories of their self-release effort, some people respond by upping the ante once or twice before giving up, while others just don’t seem to know when to quit, and a few of those get really get carried away and start to do damage. From the earliest days of this website, I have begged readers to exercise common sense and caution with their self-massage efforts, but I still get email from people who clearly have different “common sense” than I do.

A recent case in point: fellow rubs his putative trigger points so hard for so long he breaks the skin and gets two infections at two sites. Please, never massage so intensely that you start damaging your skin. You are way past the limits of reasonable precautions at that point!

Just for a little extra colour, this reader also wanted to know if the infections were caused by “toxins” emerging from trigger points like pollutants oozing out of a landfill. Nope! That is extremely wrong. If there are “toxins” in trigger points (sore spots) in any sense, it’s relatively subtle metabolic wastes, which do not ooze to the surface, or cause infections. Infections are caused by microorganisms.

While hurting yourself is indeed a good explanation for why stopping would feel good, it’s also not the real story here: it’s less interesting and less common than whatever’s usually going on with the back-off effect.

Does the back-off effect happen with professional massage?

The back-off effect mainly seems to be in the domain of self-massage. It almost certainly occurs to some degree with pro massage, but I’ve never heard stories about that. The odds of getting into overzealous persistence must be quite a bit lower, probably just because it’s just too expensive to keep going without clear benefits. It’s also too expensive for the frequency that is probably required to get into that “scab picking” phase. As it is, the massage frequency that people can actually afford tends to result in every massage feeling like the first: blissful but temporary symptom relief! That might inspire self-massage efforts, but professional massage itself has never appeared to be the driver of the back-off effect in any stories I’ve heard.

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