We massage therapists are taught a lot about muscles. We also study bones, joints, ligaments, tendons, fascia. We learn a little about physiology, about other systems of the body, and some lip service is paid to the role of the nervous system in the relaxation response and to how the brain mediates the changes brought about by massage. But mostly we pay attention to muscles. We talk about which muscles are tight, find “knots” in them, and “release” them by pushing into them and/or stretching them with our hands, fingers, forearms, and elbows.
For many years, I studied and assisted at seminars about myofascial trigger points, tender points that, when pushed into, will refer pain or other sensations elsewhere. It was believed that they existed in muscles and though much wasn’t known about them, our approach was to locate them, push into them, and somehow this would alleviate the pain that they seemed to be associated with. We weren’t sure exactly how direct pressure created this change. At first the “Gate Theory” was proposed to be the mechanism by which this change came about. [note: scroll down the page on that link to find the segment on the Gate Theory.] Later, it was suggested that TPs were the result of damaged endplates at the neuromuscular junction and that our pressure destroyed them and caused the body to rebuild or repair them. That explanation always troubled me a bit. For one thing, sometimes it didn’t take all that much pressure for a TP to be calmed. For another, I just didn’t like the idea that I was destroying structures in the body. However, there were no better explanations and digital pressure on TPs seemed to work well enough often enough. I accepted that we just didn’t know how it worked and left it at that.
But I still believed that I was pushing into muscle tissue and that somehow that pressure on muscle did something to muscle fibers to release contracture and reduce pain.
Over time, more questions were raised. Gross anatomy class brought me face to face with evidence that challenged my assumptions about our ability to “touch” certain muscles. One of the most obvious was the piriformis. Most of it lies inaccessible beneath the sacrum. Through dissection, I saw that only a small tip of it is exposed beyond the sacrum. In addition, what little of it is exposed is deep within the hip, covered by several inches of adipose tissue on even the most slender of individuals, not to mention the skin covering it all. Was it really possible that we could push into the tip of a muscle that was covered either by bone or several inches of padding plus skin? This didn’t make sense but I didn’t dwell on it. After all, it felt like we could do that so I didn’t think about it too much.
The role of the nervous system
My Russian Massage teacher Zhenya Kurashova Wine was the first person I heard explain how massage works. She explained about the nervous system and how nerves went to the skin. She explained how mechanoreceptors at nerve endings in or below the skin sensed heat, cold, vibration, pressure, and that when we touched the skin with massage, our stimulation of these mechanoreceptors sent signals to the brain. The brain took in this information and decided how to respond to it. If the brain liked our touch, it would relax the body. It might dilate blood vessels, slow the breathing, relax muscles. If it did not like our touch, it might contract the muscles and constrict blood vessels. It was important, she told us, to create a positive experience for the nervous system rather than to create pain.
Meanwhile, I learned about Hilton’s Law in NMT seminars. Hilton observed that a nerve that innervates a joint usually also innervates the muscles around the joint and the skin lying over the muscles of that joint. The significance of this to us was that the application of heat or ice to the skin was said to have an effect on deeper muscle tissues through the nerves in the skin being stimulated by the heat or the cold. Although the heat or cold may may create the sensation that it penetrates deep into the muscles, the sensation of depth is an illusion. Later this would help me understand how what we think we feel may not be an accurate reflection of what is actually happening and might also provide an explanation for the sensation of affecting deep muscles when it just seemed implausible.
About a year and a half ago I began meeting some manual pain therapists who rejected the notion that pushing into irritated tissue was the best way to get rid of musculoskeletal pain. They challenged the assumption that we can “touch” muscles. They pointed out the obvious: we can only touch the skin. Well, yes, I thought, but we can push through the skin into the muscle tissue below it, can’t we? They also pointed out something that took me back to what my teacher had said long ago about how massage works: when we touch our clients with massage or any other manual therapy, it is through stimulating mechanoreceptors in the skin that change is created via the brain.
A change in thinking
It took some time for these ideas to sink in but slowly I began to see that not only did they make sense, but it explained the questions that had been in the back of my mind for many years. Perhaps when someone pressed their elbow into my hip, the sensation of penetrating deep enough to affect this tiny portion of piriformis muscle lying underneath several inches of fat padding was actually a sensory illusion. How could pressure diffused by skin and several inches of padding destroy endplates deep below? Maybe it wasn’t the pressure to muscle fibers themselves, maybe it was pressure to the mechanoreceptors in the skin.
This could also explain why pushing on what we thought of as the edge of a muscle, rather than smack in the middle of its belly, might have an effect. It would also account for why sometimes one didn’t need all that much pressure to calm some trigger points.
When I thought about how my touch stimulated mechanoreceptors in the skin, things made more sense. Most mechanoreceptors are in or just below the skin. There are some in deeper tissues but in order for us to “reach” those deeper receptors we still have to push into the skin where we are stimulating many more receptors. There’s no way to get past them without stimulating them.
Slowly, my thinking has changed. I’ve come to doubt that when we push into the body that we are doing what we think we are doing. I know it feels as if we are pushing into muscle and that it feels like pressure on muscle tissue creates the change, but I doubt it. I suspect the sensation is probably an illusion.
Our brain is good at creating illusions
Our brain can easily create very convincing illusions. The rubber hand experiment has shown that people can easily begin to feel as if a rubber hand is their own hand, even while knowing it is not.
Recently, I had an experience of an illusion that felt very, very real. I was in a seminar and we were practicing a technique. I was lying on a table, face down, with my arm hanging off the table. A therapist was applying very gentle traction to the skin of my arm and holding it for several minutes. My arm was stationary and I could feel my hand lightly touching her knee, which gave me a point of reference. About a minute into this practice, I began to have the sensation that the therapist was moving my arm in a spiraling motion and that my arm was bobbing as if it were floating on a wave. I knew that, in fact, my arm was stationary and I could feel my hand continued to touch the therapist’s knee, yet this sensory hallucination persisted and felt very real. It was a pleasant sensation and I enjoyed watching my brain play tricks on me.
As massage therapists, both we and our clients have sensory experiences for which we have explanations. Our explanations may or may not be accurate. As we learn more about how the body actually works, we adapt our thinking and our explanations to what we learn. Our methods may achieve particular results but the way in which those results come about may not happen the way we think they do. When we understand how the body works, technique rises out of that understanding.
Are we really doing what we think we are doing?
I have come to doubt that we touch muscles in the way that we think we do or that pressing into muscles does what we think it does. However, this has not upset me. Thinking about the nervous system, about the skin, and about how our contact with our client’s skin speaks directly to their brain has opened up an entirely new world to me. I heard it first from Deane Juhan in his book Job’s Body: “The skin is the surface of the brain.” I’m starting to understand what that means.