During the course of attending massage school at A New Beginning School of Massage, students are given a number of assignments that requiring research and writing. Some of these assignments result in very insightful and  well thought out information and  decision-making outcomes. I am happy to share some of their assignments for you to enjoy.

Massage therapy is a budding industry, bringing in $12.1 billion dollars in 2015 alone in the United States (AMTA, 2016). Despite being widely accepted among the general population, it is still relatively new as an accepted part of the health industry in the Western world. Part of the reason is due to lack of scientific evidence indicating the benefits of massage. However, that does not suggest that massage is not beneficial. Many studies show its positive effects on overall wellness, but they may not be of the highest scientific rigor regarding studies. Unfortunately, research in the massage realm is difficult due to the nature of the therapy itself.

Types of research found in the massage profession are case reports, pilot studies, randomized controlled trials, and meta-analyses. In my opinion, case reports are individual incidences and should not be taken as a fundamental understanding of massage outcomes. When many case studies claim the same outcome, only then does it warrant a larger study to provide evidence for, or to disprove, that effect. Even pilot studies should be applied carefully. Though randomized controlled trials are the gold standard in the scientific community, they are extremely difficult to set up in the massage world. Meta-analyses are the highest level of research to look to, but, unfortunately, many suggest there are not enough studies or not enough evidence currently to create generalizations about massage topics. With this knowledge, pilot studies  can be looked at to determine validity of research, keeping in mind that staying up with the most current research becomes even more important. To determine clinical significance, there must be statistical significance. Statistical significance means that the study showed what happened in the test was a real effect and not something that happened by chance.

Research is important in the massage profession. Period. Research is vital for massage to be taken more seriously in the health field. For instance, oncology massage has taken a complete change from being totally shunned to being encouraged in cancer patients in a rather short amount of time, due to scientific research. On the other hand, many people seek out massage for the therapeutic, relaxing, and temporary relieving benefits of massage, and do not need any convincing that massage is beneficial. It is not necessary for a relaxation massage business to function, but having a practice grounded in research can only be beneficial - especially to recommend certain modalities and treatments on an individual basis. A therapist will not only gain client trust by being scientifically backed, the client will benefit from the enhanced and focused treatments stemming from massage research.

So, does deep tissue massage need to be painful to be effective? First, what is deemed "effective" in massage? Does modest, temporary relief from pain in muscles count as effective? Or must it produce long-term effects to be considered as such? As mentioned earlier, regardless of massage's research-proven effects, temporarily reducing stress and relieving muscular pain are worth it for clients that come back to the table again and again. From this perspective, I believe even short term effects are noteworthy. There is a small selection of research on massage pressure that can be assessed.

One such article of research is "Effects of Patterns of Pressure Application on Resting Electromyography During Massage," by Langdon Roberts, in which various levels of pressure were applied to muscles during rest to each participant. They received three levels of pressure in ascending or descending order on their rectus femoris muscle. Surface electromyography (EMG) was used to measure activity levels of the muscle at baseline and after each pressure level was applied. Interestingly, EMG readings did not change significantly between ascending readings, meaning the muscle stayed relaxed. Yet during descending readings, EMG readings did vary significantly "with the largest variation, an increase of 235%, noted between baseline activity and activity after deep pressure" (Roberts, 2011). This finding suggests that light- to moderate-pressure massage is necessary, before deeper pressure, to maintain relaxation in muscles. Chronic pain syndromes cause elevated nerve reflexes, and increasing pressure variation is a possible mechanism of chronic pain relief by massage therapy. This study shows that it is not beneficial to start out with deep pressure; it causes severely enhanced muscle activity which is not the desired effect. The approach of gradually increasing pressure, as currently practiced by many massage therapists, may have more therapeutic benefit that applying deep pressure with little or no warm-up.

Research showing the effects of moderate-pressure massage are also beneficial for disproving the "no pain, no gain" approach to massage. One research analysis tells all in its title, "Moderate Pressure is Essential for Massage Therapy Effects." The abstract claims that, when moderate pressure is applied, "growth and development are enhanced in infants and stress is reduced in adults," showing that painful massage is not necessary for effective massage (Field at al., 2010). Moderate pressure is preferred for beneficial effects.

Another study, looking at massage effects on rheumatoid arthritis, showed similar results. Each of 42 volunteers were randomly assigned to a light- or moderate-pressure group. A therapist massaged their arm weekly for one month and taught each participant at-home self-massage techniques. As a result, "by the end of the one month period, the moderate pressure massage group had less pain, greater grip strength and greater range of motion in their wrist and large upper joints (Field et al., 2013)."

A review of moderate pressure massage studies contributes several positive effects of moderate pressure including the aforementioned growth in infants, reduced pain in rheumatoid arthritis, and included several more benefits from increased attention and immune function, to decreased pain in fibromyalgia. Moderate pressure massage, as compared to light pressure, reduces anxiety, depression, decreased cortisol levels (the stress hormone) and showed a relaxation response by changed EEG patterns. Moderate massage also stimulates multiple brain regions involving stress and emotional regulation, measured by functional magnetic resonance. However, the author states that, unfortunately, these studies still need to be peer-reviewed and more research is needed to identify the "underlying neurophysiological and biochemical mechanism associated with moderate pressure massage (Field, 2014)."

Pain is a protective mechanism in the body used to alert the brain of harmful stimuli, either actually or potentially, injuring the body. Pain can produce, not only physical but also emotional, responses. Painful pressure would mostly be described as an acute pain - temporary, and without lasting effects. However, reaching this state is the opposite effect of the overall intention of massage therapy. The body reacts to pain by becoming unrelaxed and potentially sending an immune response to that area of the body (The Gale Group, 2008).

Not only is painful massage unnecessary for beneficial effects, it may also be harmful. One case report observes an isolated incident in which a spinal accessory nerve was injured by deep tissue massage, causing droopy shoulder and scapular winging in the individual. In this case, not only was deep tissue massage not effective, it broke the first ethical rule of massage - do no harm (Aksoy, 2009).

Each person's body is unique to touch, and a pressure that may be painfully deep to one may not even feel of therapeutic value to another. What is it about pain that makes so many people believe this myth that massage must be painful? To compare massage to yoga and stretching, there is a level of sensation that feels intense but still feels "oh so good." Once the pressure or stretch is released, there is a sigh of relief that that movement is over, and the body falls into a more relaxed state. It feels like something good has been accomplished. This is what I would say the threshold of pressure that I am comfortable with giving during a massage session for those clients that do prefer deep pressure. Once the deep pressure makes the body go into the protective zone, that is not ok. I never want to bruise or harm a client or make their body less accepting to my touch.

In conclusion; no, deep tissue massage does not need to be painful to be effective. In fact, painful massage is less effective. The body tenses up into a protective mode, not allowing the tissues to relax to accept the works that the therapist is doing to aid in stress relief and hypertension. Using what the studies show, one can use moderate pressure to be effective and should also work from lighter to heavier pressure. As far as my own practice goes, I will use this information to apply proper therapeutic pressure. I am one of those people that typically likes especially deep pressure on my shoulders and lower back, at the threshold between intense pressure and pain. To note an especially deep pressure massage I recently received by another student, specifically deep forearm pressure applied too heavily on the calves, I tensed up. I did not enjoy it, I was brought out of my relaxed state, and my body was left bruised for a week. I will definitely carry that experience with me as I massage clients in the future. After reviewing these research findings, and having my own experience with painful pressure, my expectations in each massage I personally receive have changed. In class massages, I initially felt frustrated when the other student was not going deep enough for me. Now, with the understanding that moderate pressure is effective, I can simply relax with the understanding that a moderate-pressure massage is still working on my body's tension and stress. I have also massaged many people who prefer deep pressure already in my internship alone. I hope to steer people out of their sensation - based pressure needs and inform them that what they think they want may not necessarily provide the best outcome. I plan to listen to my client's needs regarding pressure, but also educate them about the research by communicating individually, and through my own posts on social media and my website. I will make sure to work superficial to moderate pressure and use deep pressure only if necessary, making sure to never reach a painful level. Pressure and sensation change from person to person, so I plan to check in regularly, during each massage, about pressure, making sure I never inflict pain. In all, I am happy with the question I chose to research, and am somewhat satisfied with the research I found. I wish there was more research to extract from and I am looking forward to staying current on the topic regarding pain, pressure, and effective massage.

Works Cited:

Aksoy, A., Schrader, S., Ali, M., Borovansky, J., & Ross, M. (2009, November). Spinal Accessory Neuropathy Associated with Deep Tissue Massage: A Case Report. (Abstract). Archives of Physical Medicine and Rehabilitation, 90(11), 1969-1972. doi:10.1016/j.apmr.2009.06.015.

Field, T. (2014, November). Massage Therapy Research Review (Abstract). Complementary Therapies in Clinical Practice, 20(4), 224-229. doi:10.1016/j.ctcp.2014.07.002

Field, T., Diego, M., Delgado, J., Garcia, D., & Funk, C. (2013, May). Rheumatoid Arthritis in Upper Limbs Benefits from Moderate Pressure Massage Therapy. (Abstract). Complementary Therapies in Clinical Practice, 19(2), 101-103. doi:10.1016/j.ctcp.2012.12.001.

Field, T., Diego, M., & Hernandez-Reif, M. (2010, April 19). Moderate Pressure is Essential for Massage Therapy Effects (Abstract). International Journal of Neuroscience, 120(5), 381-385. doi:10.3109/00207450903579475.

Industry fact Sheet. (2016, February). Retrieved April 20, 2016, from https://www.amtamassage.org/infocenter/economic_industry-fact-sheet.html

Paul Ingraham. (2016, May 13). Massage Pressure: How Deep is Too Deep? Retrieved October 05, 2016, from https://www.painscience.com/articles/pressure-question.php

The Gale Group, Inc. (2008). Pain | definition of pain by Medical dictionary. Retrieved October 05, 2016, from http://medical-dictionary.thefreedictionary.com/pain

Roberts, L. (2011. March 30). Effects of Patterns of Pressure Application on Resting Electromyography During Massage. Int J Ther Massage Bodywork, 4(1), 4-11. Retrieved April 29, 2016, from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3088531/#_ffn_sectitle