What’s the right amount of pressure to apply to your muscles in massage therapy and self-massage?

One of the most frequently discussed concerns about massage therapy in my office is “the pressure question.” How much is enough? How deep is too deep? Should deep tissue massage be painful? On my client intake form, I ask clients why they left their last massage therapist. Here is a summary of the results from my first several years in business:

Why people “fired” their massage therapists
55% too intense
20% not intense enough
20% unfocussed or wrong focus
5% other

People vote with their feet, and it seems clear from the results of this informal poll I’ve been taking that many people have been disastisfied with the pressure they’ve received during massage. They do not like their massage to be painful … or too fluffy!

People probably have that preference regardless of whether or not they think the style works. And they 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 …

People are different.

Really, really different. It often 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 possibly even injury!

These differences can also occur between body parts, for instance. 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:

  • communicative
  • respectful
  • attentive

And if it’s not?

Be assertive!

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 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 “aggressive” therapists is that they are notcommunicative, respectful or attentive, pretty much by definition.

If you have the misfortune of working with 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 is regrettably common, but it is by no means the only kind available.

The good, the bad, and the ugly

Painful experiences on the massage table can be divided into three familiar categories: the good, the bad, and the ugly. Good pain is intense but somehow welcome, a paradoxical feeling, and probably what you mostly want out of therapy. Bad pain has no component of goodness in it, but is not necessarily incompatible with therapy. Ugly pain is particularl extreme and a bad idea in every way. Let’s look at them in a little more detail.

Good pain. In massage, there is such a thing as “good pain.” It arises from a sensory contradiction between the sensitivity caused by various types of muscle problems, and the instinctive sense that pressure is a source of relief from some of it — from trigger points (muscle knots) in particular. So pressure can be an intense sensation that just feels rightsomehow. It’s strong, but it’s welcome. Good pains are usually dull and aching. It is often described as a “sweet” ache. The best good pain may be such a relief that really the onlybadthing about it is just that it is breathtakingly intense. The worst may be truly unpleasant: more like having to vomit to relieve a stomach ache!

Bad pain. Bad pain comes with no apparent benefits. If there is anything good about it, there is no way to tell from the sensation. 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. Let’s look at ugly pain

Ugly pain

Let’s deal with the subject of ugly pain first, because it’s important to completely eliminate it from therapy. Once you’ve got a clearer idea of what kind of pain is totally unacceptable, it’s easier to wrap your head around the other kinds of pain. So, what kinds of situations involve “ugly” pain?

  • fingernail digging or skin tearing sensations, very common in “fascial release” therapy
  • nerve pinching or gland compression in one of the body’s “endangerment zones,” vulnerable spots where sensitive tissue is exposed
  • disturbing infected or inflamed tissue
  • truly excessive pressure or overstretch that is simply way over your personal pain threshold for that day, location or situation

“Ugly” pain is something 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 — and, no, they do not get the slightest benefit from being mangled. There are no trigger points there! Yet that therapist may well put out a “no pain, no gain” message or try to justify it as a crucial part of treating jaw tension, which is simply ridiculous. Jaw tension is treated by treating the jaw muscles, not the salivary glands!

Another alarmingly common example is the sensation of skin tearing. This has been inflicted on me personally on three occasions by well-trained therapists who thought they were doing fascial therapy. However, there is no likely therapeutic benefit to stretching the 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). Needless to say, I never returned to those therapists.

There also seem to be therapists who believe that any painful sensation is simply part of the process, and if they poked you in the eye that would be “ocular release therapy.”

Ugly pain can be a sign of real dangers, one more obvious than the other:

  1. Direct injury.
  2. Sensory injury. A painful, alarming experience can actually dial up pain sensitivity — even long term.

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! Now, let’s move on to “bad” pain.

More about bad pain, and when it might be justifiable

The reason for the Pressure Question 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 simply abusive. How do you know if a particular intense massage technique is therapeutic or not? If it is therapeutic, then we 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. Now we’ll try to learn 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.

Motor end plate destruction. 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. Most massage is focussed on them, directly or indirectly. To the extent that massage therapy is an effective and evidence-based form of therapy, it tends to be so because it relieves the symptoms of muscle knots.

Thanks to quite recent research (see Simons), we now know that muscle knots are caused by something that goes wrong at the “motor end plate” — where a nerve ending attaches to a muscle cell. We don’t know why this happens, or what exactly goeswrong, but we do know that if you paralyze the motor end plate (with botox, say), the trigger point completely vanishes. The motor end plates are unquestionably the immediate cause of the problem.

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 (see Danneskiold-Samsoe). When it regrows — these are microscopic structures, it doesn’t take them long to heal — the trigger point may be gone.

To the extent that massage therapy is effective, it is effective because it relieves the symptoms of muscle knots

No one knows for sure if this is actually effective. However, it could explain why so many massage patients experience a “gets worse before it gets better” response to quite painful treatments: motor end plates are painfully destroyed by strong pressures, the 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 aggravatetrigger points. There are dozen variables that could affect which of these two theories alone might be more relevant to a given person on a particular day … and there are most assuredly other factors, other theories, that we don’t yet know anything about.

Therefore, the most we can know is that there is some reason to believe that painful pressures on muscles might be therapeutic forsome people, some of the time. Pretty decisive, eh? This is why it kind of drives me nuts 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. And the final decision has to be up to you.

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 these techniques, not so much because I don’t think it works, but just because I think trigger point therapy works much better — much more bang for my patients’ buck. However, I can imagine a number of reasons why intense manipulations of connective tissue might be therapeutic. 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.

Somatoemotional release. Mental and emotional context is an important part of how we perceive pain. Undeniably painful sensations can help to stimulate cathartic emotional releases (and I’m assuming here that emotional releases are valuable). Physical pain can strongly resonate with emotional pain. Often the two experiences are intimately related: for instance, the pain of an injury may be interwoven with the emotional frustrations of rehabilitation. That is quite a rudimentary 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 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.

Sometimes regular massage therapy involves a bit of this kind of thing. And when it does, “bad” pain may be justified … but, again,only if you feel there is a net gain.

The choice is yours

All health care practices must be justified by clear benefits. As risk increases, the benefit must get even clearer. So much can be achieved inflicting only good pain on patients that bad pain must be justified by extremely vivid, quick, and somewhat lasting benefits — anything less than that, and you should definitely consider shopping around for another massage therapist. There is simply no point in tolerating — and paying for — truly painful treatment without a good reason.

But you should never tolerate bad pain unless there are clear signs of therapeutic benefits within three appointments. A persistent lack of results should make you question any kind of therapy, of course, but especially a very painful therapy.

More about this whole “good pain” business

Good pain is an interesting subject because it’s a contradiction that somehow manages to make perfect sense when you experience it.

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 quite 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 client discovering “good pain”

The contradiction between the good and bad parts of pain can be very 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.

So, how can a painful pain be so good? What’s going on? It’s all about trigger points. The secret to pain’s goodness — like so much else about massage therapy — probably mostly lies in the nature of trigger points, or muscle knots. They are an “itch” that we cannot easily “scratch” on our own. In particular, we try to stretch them out, and it usually doesn’t work all that well. They are probably 80% of the reason why a good massage is both intense … and an intense relief.

Trigger points are fairly well-defined physiologically. We know what they are, and we know where they live. They are essentially a miniature spasm, a small patch of a muscle tissue that is super-clenched. They are common, and responsible for most of the garden variety aches and pains of humanity, ranging from mild to crippling. And we know that they can, sometimes, be relieved simply by “ironing them out” with skillful thumbs.

When you press on a trigger point, it’s going to feel painful because it’s a swampy little patch of muscle in metabolic overdrive, its sensory nerve endings bathed in junk molecules. But it’s also going to feel like a relief to have any of that problem taken away! As discussed above, relief from trigger points may occur simply through crushing and destroying the cellular machinery of it. But there are numerous other possible mechanisms, such as a tiny, localized stretching of the spasm — a miniature version of what you do when you stretch out a big leg muscle to ease a charlie horse. Another likely mechanism is that the pressure squishes stagnant tissue fluids out of the spot, allowing them to be replaced by fresh circulation.

Referred pain spreads the goodness. Undoubtedly another reason that massage pain can be 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 wherethe sensation is coming from. The net effect of this is that, when you press hard enough on your muscles, particularly on sensitive trigger points, the pain is often experienced throughout a much wider area.

There are many important clinical implications of this interesting neurology, but as far as the good pain thing goes, it basically just makes trigger point release 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 essentially amplifies the good pain effect — or the bad pain effect, if the pressure is too intense!

The referred pain phenomenon basically just makes trigger point release feel bigger, more important.

Security

Feeling safe is critical to the experience of good pain. Tiny differences in trust and comfort can make the difference between an intense pain being good or bad. Much of the “goodness” of good pain comes from mental context, from knowing that a pain is not dangerous or pointless, that it will not increase suddenly, or anything else yucky or shocking. In fact, when therapists tell patients “no pain, no gain,” this is often just a clumsy and mostly ineffective way of trying to make the pain seem safe and reasonable and less bad — but there are much (much) better ways to do that, and the “no pain, no gain” rationalization is almost always a cover-up for sloppy technique.

This is why it is so important, especially for chronic pain sufferers, to find a massage therapist who is curious and concerned about your sensory experience and responsive when you ask for pressure changes.

About Paul Ingraham

 I am a science writer, former massage therapist, and assistant editor of Science-Based Medicine. 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 and Google, but mostly Twitter.