I recently attended the excellent online conference ‘Therapy Live’. One of the talks that really got me thinking was ‘Manual Therapy Justifications’ with Matt Scarsbrook. Matt was talking about this in relation to pelvic health but I realised it could be applied to my practice as a Sports Therapist.
From the first day of my sports massage course around eight years ago, I struggled to believe that using only my hands, outside the body, I am able to increase circulation, breakdown scar tissue and knots in muscles, reduce pain, increase range of motion etc etc etc .
But then we practiced on each other.
And I saw it work.
The areas of my back that had felt tight before the practical sessions no longer felt tight and I could see improvements in those that I practiced on.
Ok so I know it works, but how does it work? I had finished my sport and exercise science degree - so I had a pretty detailed understanding of anatomy and physiology. And I couldn’t understand how rubbing the skin, and even the deep tissue techniques could influence physiological structures of muscles and other tissues.
While studying for my Sports Therapy Masters we were taught how simply manipulating the muscles with our hands we can impact physiological processes; increasing blood flow and changing fibre properties. When I graduated I went on to work in sport and daily I would see manual therapy treatments including massage cause instant improvements in players symptoms, range, strength and ability to train and play.
I am totally for evidence based practice, and I know that systematic reviews and scientific literature continue to find no strong evidence of the benefits of sports massage and continue to oppose a specific biomechanical mechanism of efficacy. Yet, everyday I see it work. Now, I am by no means suggesting that this should be the sole treatment, rehabilitation and exercise programmes are the gold standard for a reason. However a treatment that makes you feel immediately better is a great way to get people started on these programmes. It can help those who are stuck in a cycle of fear-avoidance due to pain, break that cycle and start moving again. Therefore I fully support the idea of using the two approaches together and although those therapists who choose not to use manual therapy are doing so with the best of intentions; if it is more comfortable for you to squat after I have ‘released’ your glute, then quite frankly, I’m gonna do it.
So, why am I telling you all of this? One of the points that Matt made wonderfully in his talk was that we need to stop suggesting to those we treat that we can influence the physiology of their tissues as this may result in them feeling reliant upon passive treatments from a therapist. That you need us to change the underlying processes of the body in order for you to see results. We need to tell people that what we are actually doing is helping them move more easily and therefore engage more fully in the exercise programme and ‘make themselves better’.
So if during your sports massage - or other form of manual therapy, I am not changing your tissues how are we actually bringing about the changes that we see. Well, it’s all about the brain. There’s some quite complicated neuroscience involved and I’m not gonna pretend to explain it all fully, but I am going to attempt to give you a brief overview.
Any changes to the tissues during manual therapy are neurological, not physiological. And they occur via biofeedback. Biofeedback is a complex of systems within the body used to regulate things such as temperature and insulin levels among other things. For example when we detect that we are cold, signals from the brain will be sent that stimulate a reaction such as shivering in an attempt to return our body to an ideal temperature. When a therapist applies targeted pressure to a muscle, the nervous system sends a message to the brain, which then sends a signal to the muscle causing it to relax. We have not altered the physiology of that muscle, we haven’t untangled or broken down any fibres but we have influenced the way the brain causes that muscle to behave.
Massage has also been shown to reduce the perception of pain, increase mood and increase the perception of recovery post exercise. This again occurs via the nervous system with changes in the brain visible on MRI during and after treatment. The deep pressure applied during massage has been shown to elicit the same changes in the brain as a soft stroking touch hence the calming effect.
So while sports massage itself won’t ‘fix’ you, it can make you feel great and allow you to participate fully in a programme to help you ‘fix’ yourself.
As a final note, while many clinical studies fail to support the efficacy of manual therapy - the gold standard for determining whether a treatment has been effective is patient self report. So if you feel better, well I’d say that means it’s worked!
Davis HL, Alabed S, Chico TJA, Effect of sports massage on performance and recovery: a systematic review and meta-analysis BMJ Open Sport & Exercise Medicine 2020;6:e000614. doi: 10.1136/bmjsem-2019-000614
Bialosky JE, Beneciuk JM, Bishop MD, Coronado RA, Penza CW, Simon CB, George, SZ, Unraveling the Mechanisms of Manual Therapy: Modeling an Approach, Journal of Orthopaedic & Sports Physical Therapy, 2017, 48:1 p 8-18
Hunt ER, Baez SE, Olson AD, Butterfield TA, Dupont-Versteegden, Using Massage to Combat Fear-Avoidance and the Pain Tension Cycle, International Journal of Athletic Therapy and Training, 2018, 24:5 p198-201
Case LK, Liljencrantz J, McCall MV, Bradson M, Necaise A, Justin T, Olaisson H, Wang B, Bushnell C, Pleasant Deep Pressure: Expanding the Social Touch Hypothesis, Neuroscience, 2020
Cameron W. MacDonald, Peter G Osmotherly & Darren a Rivett (2020) COVID-19 wash your hands but don’t erase them from our profession – considerations on manual therapy past and present, Journal of Manual & Manipulative Therapy, 28:3, 127-131, DOI: 10.1080/10669817.2020.1766845
Reuchert B (2020) Does the Therapist’s Sex Affect the Psychological Effects of Sports Massage? - A Quasi-Experimental Study. Brain Sciences, 10(6) p. 376