--- So how can massage contribute to physiotherapy recovery? ---

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. This article will indicate the difference between the two pathways and where they might overlap.

Physiotherapists have a duty to diagnose patients based on clinical reasoning. They do this by asking questions about your condition and performing specific tests, in order to recognise patterns, which associate with different pain syndromes. For example they 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 to plan appropriate treatment. Physiotherapists then conduct treatment based on a variety of clinical considerations, but in Bahrain (and this is a generalisation) treatments are mostly based on the core aspects of physiotherapy alone. A view persists that massage assistance to healing may be considered as a secondary objective to patient care. However, the two principles can work in harmony providing great benefit.

The physiotherapist will prescribe a course of treatment but, by integrating massage into a patient’s rehabilitative programme, recovery rates have been proved more pronounced. So how does massage help the journey to recovery?  After all, massage is viewed by many as a ‘relaxation’ pursuit, as a ‘spa treatment’ for pleasure…. The truth is that therapeutic massage, as a clinical treatment, forms a serious and medically proven aid to recovery from injury or trauma.

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. The physiotherapist may concentrate on specific areas of concern such as torn ligaments or a skeletal problem while massage may greatly assist the healing process by addressing the soft tissue areas surrounding the core problem – helping relax locked up muscle tissue, holistically calming the whole body and easing stress and tension. By doing so, massage therapy contributes greatly to overall recovery.

Massage techniques

There are many different massage techniques. Here are some examples of what you might expect:

The most traditional type of massage uses 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, stretching or other prescribes activities.

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 therapist 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.

Different types of massage may be used 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.

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 a massage therapist 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
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
-r educed migraines and tension headaches
- improved functioning of the immune system

In Conclusion:

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 in order to be of lasting benefit.