2.1: Massage Therapy: An Evidence-Based Framework

Massage therapists want to help people, and part of our approach requires having a clear message of who we are and the value we offer. Adopting an evidence-based framework offers a solution, as it can provide a cohesive message of our nature and value. An evidence-based framework is an interdisciplinary approach to clinical practice used throughout healthcare. By adopting this approach, massage therapists will ensure that healthcare professionals consider the complex interplay between physiological and psychological factors that massage therapy affects.

Treatment approaches in massage therapy may vary, but each therapeutic encounter involves some overlapping principles. This book highlights the main principles of an evidence-based framework for massage therapy using recent scientific research.

Affective Touch: Therapeutic massage is a source of safety, comfort, and relief

Socially appropriate interpersonal touch has been shown to stimulate the release of neurochemicals (endogenous opioids and oxytocin) associated with relaxation and pain relief (Chen et al., 2020; Rapaport et al., 2012; Vigotsky et al., 2015; Walker et al., 2017). Massage therapy has been shown to influence cortisol levels, but the effect is small and, in most cases not clinically significant (Moyer et al., 2004; Moyer et al., 2011). In general, a reassuring therapeutic encounter, in which a patient is provided with compassionate touch, provides the patient with a safety message. This can result in reduced physiological and behavioral reactivity to stressors and improved mood/affect.

“We will experience pain when our credible evidence of danger related to our body is greater than our credible evidence of safety related to our body. Equally we won’t have pain when our credible evidence of safety is greater than our credible evidence of danger”- Lorimer Moseley

Contextual Factors: A person-centered clinical experience enchances the natural healing capacity of the body

It has long been known that the way a clinician presents both themselves and their treatment, is tied to health-related outcomes – this is known as the contextual factors of a therapeutic encounter (Rossettini et al., 2018). Creating an environment for healing involves providing a person-centered clinical experience that embraces the placebo response and the natural healing capacity of the body (Ellingsen et al., 2020; Kaptchuk et al., 2020)

In essence, behaviors and interactions with patients facilitate a relaxation response that will help to influence health-related outcomes; the magnitude of a response is influenced by expectation, learning processes, personality traits, and mindset (Rossettini et al., 2020).

“By definition, CFs (Contextual Factors) are physical, psychological and social elements that characterize the therapeutic encounter with the patient. CFs are actively interpreted by the patient and are capable of eliciting expectations, memories and emotions that in turn can influence the health-related outcome, producing placebo or nocebo effects.” – Rossettini et al., 2018

Mechanical Factors: Therapeutic massage influences tissue and cell physiology

Researchers have investigated the effect of soft-tissue massage on cellular signaling and tissue remodeling; this is referred to as mechanotherapy. Geoffrey Bove a researcher at the University of New England has conducted research examining the effect of modelled manual therapy on repetitive motion disorders and the development of fibrosis. One study published in The Journal of Neurological Sciences showed soft-tissue massage prevented the deposition of collagen and transforming growth factor beta-1 (TGF beta 1) in the nerves and connective tissues of the forearm (Bove et al., 2016). This was recently followed up by a study published in the prestigious journal Pain showing that by attenuating the inflammatory response (with modelled massage) in the early stages of an injury, they were able to prevent the development of neural fibrosis (Bove et al., 2019).

Research demonstrated that massage therapy (effleurage in particular) has a modest effect on local circulation and perfusion both in the massaged limb and in the contralateral limb (Monteiro Rodrigues et al., 2020). Furthermore, a recent joint research effort between Timothy Butterfield of the University of Kentucky and researchers at Colorado State University demonstrated that modelled massage enhanced satellite cell numbers (Miller et al., 2018; Hunt et al., 2019). This was in addition to earlier research from Butterfield and his collaborators at the University of Kentucky, which proposes the idea that mechanical stimulation prompts a phenotype change of pro-inflammatory M¹ macrophages into anti-inflammatory M² macrophages (Waters-Banker et al., 2014). Taken together the increase in satellite cell numbers and reduction in inflammatory signaling may improve the body’s ability to respond to subsequent rehabilitation (Van Pelt et al., 2021).

Neurological Factors: Therapeutic massage stimulates specialized sensory receptors

Therapeutic massage is processed by specialized sensory receptors located in cutaneous and subcutaneous structures. Specialized mechanoreceptors located in cutaneous and subcutaneous structures are what informs the body about the type of touch they are receiving, there are five major types of mechanoreceptors that massage therapists should be aware of:

• Two of these are located in the superficial layers of the skin: Merkel cells and Meissner corpuscles.
• Two receptors, Pacinian corpuscle and Ruffini endings, are found in the subcutaneous and deeper tissue layers.
• The fifth type of mechanoreceptor are the recently discovered C-tactile fibers that play a specific role in transmitting the pleasurable properties of touch (they also play a role in affective touch mentioned prior).

Massage therapy is a form of peripheral somatosensory stimulation that can modulate the activity of neuro-immune (peripheral, cortical, subcortical) processes correlated with the experience of pain. Through a process of gently stretching muscles, neurovascular structures and investing fascia nociceptive processing associated with tissue damage (actual or perceived) is modifiable in such a way that the pain subsides. Preferential sites for stimulation are associated with areas rich in specialized sensory receptors such as Merkel cells, Meissner corpuscles (superficial layers of the skin), Pacinian corpuscles, Ruffini endings (joint capsules & subcutaneous tissue) and C-tactile fibers which play a role in the singling of affective aspects of human touch.

Building of Effective Patient-Provider Relationships

Massage therapy is a form of peripheral somatosensory stimulation that can modulate the activity of neuro-immune (peripheral, cortical, subcortical) processes correlated with the experience of pain (Bialosky et al., 2018). By activating ascending and descending inhibitory systems, massage therapy may be able to mitigate the transition, amplification and development of chronic pain.

Massage therapy is a clinically-oriented healthcare option that can improve quality of life for patients with a variety of conditions. The responses to massage therapy are multifactorial, even if the mechanisms of action have not yet been fully elucidated. There is evidence that in terms of clinical responses to massage therapy affective touch, contextual factors, mechanical factors, and neurological factors are likely to play a role.

How Manual Therapy Works - From Physiotutors

Key Takeaways

With respect to the multidisciplinary treatment of musculoskeletal disorders massage therapy has a desirable safety profile and it is a health care option that is effective, economical, and accessible. Understanding the basic science behind massage therapy and the guiding principles of adaptability enables massage therapists to think flexibly about what is going on, both in terms of specific and nonspecific effects. Based on available evidence the best way to describe the effects of massage therapy, is not in a single unified response, but as a collection of interconnected adaptive responses within the nervous system and soft tissue structures. A biopsychosocial framework of health and wellness helps put into context the interconnected and multidirectional interaction between physiology, thoughts, emotions, behaviors, culture, and beliefs. In terms of clinical responses to massage therapy there are a couple of proposed mechanisms of action, including but not limited to: affective touch, contextual factors, mechanical factors, and neurological factors.

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