It is not uncommon for clients to present for a physiotherapy assessment expecting to have some form of massage. Whilst massage may definitely form part of a patient’s treatment programme, if you have an injury or pain syndrome, it is important for your physiotherapist to assess your problem first and formulate a diagnosis on which to base your treatment plan. Clients who are not in pain may of course wish to skip this step and head straight to one of our massage therapists. This blog will indicate the difference between the two pathways and where they might overlap.
Chartered physiotherapists have a duty to diagnose patients based on clinical reasoning. We do this by asking lots of questions about your condition and performing specific tests in order to recognise patterns which we associate with different pain syndromes. For example we can make an informed clinical decision if your lower back pain is predominately muscular or more likely to be coming from a disc or joint. This helps us to determine an estimated recovery time and plan appropriate treatment. In particular, when we deal with insurance companies we must show that we are using the most evidence based techniques to get you better in the shortest time. It also means that we can justify referring you onto a specialist or for further investigations if your condition seems more serious or you do not recover as we had expected.
Physiotherapists have long used massage therapy as one of their manual therapy techniques. Massage describes techniques where a therapist manually manipulates the soft tissues of the body. For thousands of years massage has been a treatment of choice for people in pain.
At Little Venice Pilates, our massage therapists will still perform a certain level of assessment in order to determine how their massage techniques can best help you. If they feel there is an underlying problem, they may suggest you consider a more in depth assessment with a physiotherapist. This helps to ensure any serious pathology is picked up as well as helping you to gain the maximum benefit from your massage experience.
There are many different massage techniques. Here are some examples of what you might expect:
• Swedish massage is the most traditional type of massage, using long strokes, kneading, deep circular movement and tapping. This sort of massage can be invigorating whether you are in pain or not. If you are not experiencing any specific pain or problem, your massage therapist may go deeper with some techniques. Many clients enjoy a deep massage but it can cause some temporary aching afterwards. If you have pain already the massage should respect this and ease rather than create discomfort.
• Myofascial trigger point therapy focuses directly on the points that cause you pain when they are pressed. The pain can refer to a larger area, which often corresponds with patients symptoms, in a dysfunction. Whilst research is difficult to find proving the effectiveness of this treatment, the patients themselves often understand this approach best. They can feel that the therapist is working directly on the painful area and there is often immediate relief. How long it lasts may depend on what else happens in the treatment session and afterwards-home exercise, Pilates, posture work etc.
• Essential oils are used in aromatherapy massage, which may promote additional relaxation and stress release. Whilst there is no hard evidence for the effectiveness of aromatherapy there is little doubt that they add to the sense of relaxation and wellbeing.
• Myofascial release techniques are very gentle techniques which attempt to manipulate the fascia, a connective tissue, enveloping muscles and tendons, lying just underneath the skin. This sort of massage is relatively new and is much lighter than a traditional massage. Your physiotherapist might use a technique like this if you are particularly sensitive, for example in fibromyalgia, a chronic pain condition, where alterations in the way the brain processes pain can create discomfort with all but the lightest touch.
• Lymphatic drainage is a type of massage used to reduce swelling. It is often used after surgery to reduce lymphodeama in breast cancer patients. However it could also be used for more acute swelling such as from a sprained ankle.
• Friction massage was traditionally used to help tendon healing. It tends to be very painful and other types of treatment such as taping and offloading are often preferred and found to be more clinically effective
Massage within your physiotherapy treatment session
Your physiotherapist will use massage in your session where it is the appropriate treatment choice. It might be used as a method of lengthening certain muscle groups. For example, a long distance runner with an Achilles problem presenting with tight calf muscles. Massage of the lower leg muscles is helpful to relieve pain and promote a return to exercise. Alternatively a patient with acute neck pain who is unable to turn their head may benefit from massage to relax the neck muscles preventing movement.
A physiotherapist must justify, through clinical reasoning, that massage is the most appropriate use of treatment time. Therefore in some cases, whilst massage might feel beneficial, it may not be the best choice of treatment to aid your recovery. For example, evidence indicates that massage alone will not resolve chronic back pain. Therapeutic exercise such as Pilates is a far better tool to use according to research. That doesn’t mean that massage is not enjoyable if you have back pain. In these situations you may find that additional sessions with a massage therapist complement the rehabilitation work you are doing with your physiotherapist.
The role of the massage therapist
Clients often find sessions with a massage therapist are a helpful addition to a stretching or Pilates programme. After finishing a course of physiotherapy for an injury some clients choose to keep up regular massages with one of our massage therapists in the same way that they keep up a Pilates programme or a self management programme of exercises. This will be effective in maintaining health and fitness and preventing further problems.
Both a systematic review in 2008 and a clinical trial in 2011 concluded that massage may be helpful for subacute and chronic back pain, with some effects lasting up to 6 months. (Furlan et al 2008, Cherkin et al 2011). A 2012 study indicated that massage may also help with pain due to osteoarthritis of the knee (Perlman et al 2012). Whilst the research does not support massage as the sole treatment choice for these common problems, it is suggesting that it may have an important role. Pain is so often a barrier to exercise, whereas exercise has known links to improved outcomes in chronic pain. From my 15 years of clinical experience I have found combining massage with exercise therapy such as Pilates in the initial stages of a treatment plan is an excellent way to improve wellbeing and reduce pain levels in order to improve motivation and maintain exercise goals.
Perhaps the most significant finding in massage research is the positive effect on depression and anxiety (Sherman et al 2010). These can be significant influencing factors in chronic pain and so the importance of massage here should not be overlooked.
Smaller studies indicating the following additional benefits from massage:
-improved sleep patterns
-reduced bloating and mood swings in PMS
-reduced migraines and tension headaches
-improved functioning of the immune system
Massage has important positive effects on wellbeing as well as being a recognised useful tool to relieve some symptoms of chronic pain. The benefits of massage are mostly short term and most of the evidence suggests you need to keep getting the massages for the benefits to continue. If you are in pain it is important to have a proper diagnosis for a condition with a Physiotherapist or Osteopath. After you have been diagnosed the therapist can explain how massage might benefit your condition. Since the effects of massage are short lived it should nearly always be combined with other treatment, in particular therapeutic exercise such as Pilates in order to be of lasting benefit.
Written By Nikki Richards MPHTY(Sports) BSc(hons)Physio MCSP
Little Venice Pilates and Physiotherapy, 28 Bristol Gardens, London W9 2JQ – Massage in Little Venice, Maida Vale, St John’s Wood, Paddington
Cherkin DC, Sherman KJ, Kahn J, et al. A comparison of the effects of 2 types of massage and usual care on chronic low back pain: a randomized, controlled trial. Annals of Internal Medicine. 2011;155(1):1-9
Furlan AD, Imamura M, Dryden T, Irvin E. Massage for low-back pain. Cochrane Database Syst Rev. 2008;(4):CD001929. PubMed #18843627. PainSci #55772.
Perlman AI, Ali A, Njike VY, et al. Massage therapy for osteoarthritis of the knee: a randomized dose findingtrial. PLoS One. 2012;7(2):e30248.
Sherman KJ, Ludman EJ, Cook AJ, et al. Effectiveness of therapeutic massage for generalized anxiety disorder: a randomized controlled trial. Depression and Anxiety. 2010;27(5):441-450