Deep tissue massage uses a variety of techniques (including direct myofascial release, frictioning, positional release and trigger point work) to lengthen, loosen and unstick stiff and painful areas, such as the low back or shoulders. A structurally-based strategy is used to discover the problem patterns "written" in the muscles and fascia, and create improvement through hands on work and facilitating body awareness.
Pain is often a result of imbalance between overactive and weakened muscles, an imbalance created by posture and repetitive activity or injury. When we engage in repetitive activities counter to the design of a body intended to be running through the savanna (e.g. sitting motionless for hours in chairs staring at screens and driving cars), some muscles become overactive and shortened, while others weaken and begin to atrophy.
The weakened muscles are unable to "fight back" effectively against the pull of the overactive muscles, and will "knot" in self-defense. The fascia wrapping and interpenetrating the distressed muscles shortens and becomes stickier causing nearby muscles to be drawn into the disfunction.
The weak muscles cry out in pain, but it is the overactive muscles that need to be lengthened and released.
Investing an entire bodywork session into lengthening the weakened muscles will only make the imbalance worse, even though that's where the client is feeling the pain. That's why its so important to work with a plan and not just randomly release knots. Anatomical knowledge and experience with disfunction patterns is needed to direct work where it will improve rather than exacerbate the situation.
Lineage of Crossed Syndromes work in Massage Therapy
Dr. Vladimir Janda (1923-2002), the "Father of Czech Rehabilitation", discovered and defined "crossed syndromes", maps of typical alternating patterns of tightness and weakness (click here to see a diagram).
"By using Janda's classification, clinicians can begin to predict patterns of tightness and weakness in the sensorimotor system's attempt to reach homeostasis. Janda noted that these changes in muscular tone create a muscle imbalance, which leads to movement dysfunction. Muscles prone to tightness generally have a "lowered irritability threshold" and are readily activated with any movement, thus creating abnormal movement patterns. These imbalances and movement dysfunctions may have direct effect on joint surfaces, thus potentially leading to joint degeneration. In some cases, joint degeneration may be a direct source of pain, but the actual cause of pain is often secondary to muscle imbalance. Therefore, clinicians should find and treat the cause of the pain rather than focus on the source of the pain." (Source)Janda's work was hidden behind the iron curtain and not well known to practitioners in the West until after the fall of the USSR. Erik Dalton encountered his work in 1992 and developed manual therapy protocols informed by Janda's work in addition to his own studies with Ida Rolf, manipulative osteopaths, and self healing from a serious neck injury. His method is called Myoskeletal Alignment Techniques. "The Myoskeletal method simplifies assessment of painful ... conditions by looking for A.R.T. = Asymmetry, Restriction of motion, and Tissue texture abnormality. " I have been reading Dalton's work and studying his DVDs for some time, and was finally able to take a hands on workshop with him in October 2010.
The body is a continuous tension network, a tensegrity structure, that suspends floating compression elements (bones) in a geometric relationship to each other. The word "tensegrity," coined by Buckminster Fuller, means that the integrity depends on the balance between tension and compression, between "push" and "pull." Unlike rigid frameworks, tensegrity structures are extremely lightweight, resilient, and designed to withstand stress by distributing strain evenly to all parts of the structure simultaneously.
Fascia is the organ that does this. It is in essence an organ of pattern. The fascial network is what gives the body its three-dimensional shape and determines its boundaries. A change in one part is distributed throughout. Disturb any part of the pattern and whole pattern can change (for good or ill).
Myofascial release is a used to release tension stored in the fascia. Fascia is literally one piece of connective tissue that lines the body cavities, and surrounds all the muscles, organs, bones, vessels, and nerves, somewhat like a large piece of shrinkwrap. Where the fascia wrapping a muscle attaches to the bone, it is called a tendon. Fascia that simply connects two bones together is called a ligament. Because fascia tightens and shortens in response to trauma, repetitive stress and lack of movement, it can painfully restrict joint movement and blood flow. Repeated trauma can create adhesions where the fascia become stuck together, thereby creating further restriction. The techniques used in myofascial release break up fascial adhesions and change tension relationships.
My own style of myofascial release is informed by a number of different therapeutic approaches. Fairly early in my massage career, I took a workshop with John F Barnes and studied the first level of his style of indirect myofascial release. During the next year I attended study group sessions (led by one of his TAs) with other massage therapists applying techniques from that style of work. My work has since evolved in a different direction. Although I do sometimes use decompression work from the Barnes style, the type of myofascial release I usually do today is direct myofascial release, one of the techniques borrowed from Rolfing into deep tissue massage. My stroke is also influenced by my experience of Fijian massage that I learned from Lolita Knight, Tom Myers' Anatomy Trains and explanations of Tensegrity, and my experience studying Taiji. Taiji is a traditional form of fascial remodeling (as well as a martial art). I am in the process of becoming a certified Taiji instructor in Evidence Based TaijiTM. In addition to Taiji, I have also studied Yoga, another traditional form of fascial remodeling, for several years.
Finally, if you are a geek like me, you'll like this article by T.E. Flemons The Geometry of Anatomy - the Bones of Tensegrity
Sometimes known as "fold and hold" or strain/counterstrain, in this technique, pain is relieved by passively putting the joint in the position of greatest comfort, leaving it there for 90 seconds, and then passively and slowly returning it to its normal position. Putting the joint in the exact opposite position from the one that causes pain will relax the contractive force that is causing the pain. The technique is very gentle and effective
Definition: "A myofascial trigger point is defined as "a hyperirritable spot, usually within a taut band of skeletal muscle or in the muscle fascia, that is painful on compression and that can give rise to characteristic referred pain, tenderness, and autonomic phenomena." It is an area of local ischemia (restriction in blood supply).
This is the conventional explanation. In other words, trigger points are "knots" and are responsible for a lot of pain. As Paul Ingraham states, "That small patch of knotted muscle is stagnant and swampy, literally clenching off its own blood supply, a vicious cycle called 'metabolic crisis.'". When the trigger points are released, the muscle is able to elongate to its proper length and pain is relieved. The "knot" is often not where the pain is felt, so it is important for the therapist to understand "referral patterns" to know where to look for the trigger points. They can be caused by a variety of factors including accidents, over-use or under-use of muscles, ergonomic imbalances in the home or workplace, or structural imbalances in the body.
Another explanation says that MPS symptoms do not arise from taut myofascial trigger point bands, but instead from peripheral nerve pain at motor end plates. Unfortunately, the science is still out on why such good anecdotal results have arisen over the years from trigger point techniques, or if what the conventional explanation describes even exists.
The technique used to release a trigger point is known as ischemic compression. Basically it means that when the point is found, it is pressed for approximately 8 seconds during which time it releases, with a sensation akin to melting. The technique is briefly painful during the compression, but never excruciating. It should always be a "good hurt".
- The Biology of Trigger Points: What they are, what they do, and when and why they occur
- Clair Davies describes the phenomenon of trigger points
- Quick Q&A on Myofascial Pain presents the concept of Trigger Points (TrPs) named for their ability to refer pain to distant areas of the body where they may manifest as everything from headaches to carpal tunnel syndrome. The current estimate is that some 85% of the time, where you feel a pain is not where it's coming from. (Round Earth Publishing)
- Common Diagnoses with Possible Muscular Components (Round Earth Publishing)
- What Types of Dysfunctions Respond To Clinical Massage? (holisticonline.com)
- Save Yourself from Myofascial Pain Syndrome! by Paul Ingraham
- Trigger Point Therapy by Boris Prilutsky (mentions the controversy about whether taut bands or peripheral nerve pain at the motor end plate cause myofascial pain symptoms)
- Paul Ingraham - Perfect Spots
- Trigger Point Technologies (tpmassageball.com)
- Sports Injury Clinic
- NISMAT Physical Therapy Corner
- Massage Magazine: Assess and Address
- MyoRehab articles on conditions aided by Myofascial Trigger Point Therapy
- Round Earth Publishing - Myofascial Pain
- The Visible Body - General Anatomy Images
Tendon/Ligament Issues - Frictioning Work
Trouble does not only occur in muscles. It can also occur in the tendon where the muscle attaches to the bone. For overuse conditions such as tendinosis (collagen degeneration resulting from excessive load on collagen), taking the load off is important. Any techniques that act to relax what a muscle that seems to be shortened will help reduce the load on the tendon. In addition, cross-fiber frictioning and myofascial spreading strokes are believed to break up collagen cross-linking and reduce fibrosis.
[Click here to see illustrations of what a tendon is supposed to look like; a tendon with tendinitis; and a tendon with tendinosis.]
Directly stimulating the tendon can be done through cross-fiber friction. Frictioning begins the process of activating its fibroblasts and synthesizing significant quantities of new collagen fibers. While it might seem that rest would give an injured tendon an opportunity to heal, it might also give a tendon suffering from tendonosis a chance to degenerate further. For more information, see this article from Running Research News.
Tendon and ligament injuries take much longer to heal than muscle injuries. If icing and rest have not improved things after two weeks, tendinosis is a reasonable bet. While most injuries occur where muscles and tendons join (the musculotendinous complex), and respond well to massage, if you have an injury that is not healing on its own, it might be a good idea to get a sports medicine physician involved, as other conditions might be involved. For instance, although it's rare, it is possible for muscles and tendons to actually tear away from the bone (called an avulsion).
What about Deep Tissue Massage?
I've described this style of massage as "Deep Tissue Massage" because its a term that people use when they are looking for something other than stress management and relaxation from their massage. Unfortunately, this term has so many different meanings between different massage therapists, it is effectively meaningless (its most accepted meaning today is that it costs $10 more at a spa). So just to be sure we're on the same page, here's my interpretation of the term.
In your body, muscles are built up in layers, some of which are superficial and some of which are deep. For instance in the area of your rear pelvis, you have superficial gluteus maximus, and deep piriformis. Deep Tissue means massage that is intended to obtain tension balancing and release in whatever layer of soft tissue needs restriction, whether deep or shallow, requiring techniques that do more than glide over the top surface of the body. I use the amount of pressure required to achieve the desired therapeutic effect. I prefer precision over force. I do tend to enter deeper layers very slowly and at an oblique angle to minimize pain and frequently use myofascial lifting strokes in addition to compressive and frictioning strokes. Historically, use of the term seems to have arisen when some massage therapists at Esalen began studying Rolfing (a modality that uses direct myofascial release).
Art Riggs wrote a wonderful 3 part article (from a therapist's perspective) on deep tissue:
- Deep Tissue Massage : Part 1 - The Tools
- Deep Tissue Massage: Part 2 - Stroke Intention
- Deep Tissue Massage: Part 3 - Body Positioning
An Evolving Understanding
This page is due for a revision... The work is constantly evolving, as is my understanding of what's happening. Watch my Facebook page for up to date information about pain science and bodywork.
Intense is OK but Painful is Not
There is a fashion in bodywork right now for very painful aggressive massages. That's not what this is. I don't think that causing outright pain is helpful. Over the years, I've learned that better results arise from staying below the pain threshold when engaging a restriction in soft tissue. (Note that a soft tissue "restriction" is a convenient perception. It is just as likely to be some kind of brain-based pattern as an actual "adhesion" or literal gluing.)
I use the gentlest methods possible that will be effective. Think of a stuck drawer on a fragile antique dresser. To get the drawer out, it works better not to yank but to wiggle it free, sensing all the edges of the restriction and working them free little by little. It takes more time, but there is much less danger of causing damage. In a soft tissue restriction, the nervous system is aware that the restriction is being engaged with this kind of approach, but does not go into alarm. Most people would describe this feeling as "intense". I will remind you throughout the session to tell me if it is ever painful so that I tread more slowly and carefully. It doesn't matter if you "can take it"... if you want someone to hurt you, you need to find a different therapist. Longer lasting results will arise from staying below the pain threshold.
Even the kind of careful deep work that I do is not right for everyone. If you are in a state of physical exhaustion from chronic pain, this type of work is usually too much stress for the body to deal with and is thus counterproductive to receive. The more indirect approach in my Gentle Pain Calming massage would be more appropriate for conditions involving pain flares. If 15 minutes of exercise leads to crippling pain three days later, as happens in some conditions, Targeted Knotwork is definitely not a good choice to receive. I never want to see a client left in that kind of pain afterwards. If you have any history of bad reactions from bodywork or exercise, please do let me know the details so that more appropriate techniques can be selected for your session.
Targeted Knotwork is not simply a deep Swedish massage. It is not about maintaining a constant rhythm and pace or putting you to sleep. It is NOT intended to be a full body massage. If there's a system of restrictions that is causing you pain right now, that system needs to be understood and unraveled. For most people, 60 minutes is insufficient to treat a system AND provide structured touch front and back and top to bottom. I do offer Fijian Barefoot Massage if you are simply looking to receive all-over deep pressure in a full body massage.
Tools I Sometimes Use
In addition to my hands, I sometimes use tools. Bamboo cho sticks for providing broad pressure, and NMT bars for pinpoint accuracy of delivering pressure.
I may use a silicone cup (which is much gentler than the pumped vacuum cups) to clean up superficial restrictions.
Example Variants for Targeted Knotwork Sessions
If your body is not accustomed to massage or strenuous exercise, it is better to start with a shorter session of 30 minutes and work up to longer sessions. Be aware that the body tends to receive deep bodywork similarly to exercise, and just as a new weight lifting program can lead to delayed onset muscle soreness, your body might react in the same way to deep tissue massage.
The Studio Helix Approach
If you have a chronic pain condition, realize that massage on its own is a passive modality. It can be very effective in immediately reducing pain, but for lasting results, weakened muscles need to be strengthened, and repetitive activities that are causing imbalance need to be addressed. In other words, it's a great tool for creating an opening for being able to take a more active role. Studio Helix, where my practice is located, specializes in designing customized programs based on sound anatomical engineering practice that include massage where it will be optimally effective, and exercise where it will be most effective.