Everyone knows the cliches. “Working out the knots.” “Hurts so good.” “The harder the better.” They’ve endured as long as massage therapy itself, sometimes branding the practice with a reputation for deep, high-intensity pressure. And while certain physiological symptoms can no doubt benefit from a deeper, exertive massage, could a lighter, softer experience be more beneficial in more circumstances?
A Certain Kind of Touch
Matthew Tomasino, LMT, will never forget the day his residential-facility employer in Greenwich, CT, resumed his massage therapy services after the quarantine necessitated by the pandemic in 2020 was lifted. Like many massage therapists, Tomasino had gone a long time without seeing any clients, and he was nervous about reconnecting. Compounding his anxiety was the fact that this facility specialized in memory care. “People here live with conditions like Alzheimer’s, dementia and Parkinson’s, and many of them are extremely wary of physical touch,” he says. “Going back after a year felt like starting from zero.”
The first to greet Tomasino that day was an 87-year-old man with Parkinson’s who had taken two years to consent to a massage. “Many of these folks were brought up in the 1940s and 50s, when touch was taboo, and now they’re dealing with the spatial distortion that comes with these kinds of neurodegenerative diseases,” Tomasino says. “That day, though, he looked right at me and said, ‘It’s you!’”
Tomasino prides himself for his warm, approachable personality. But that’s not, in his opinion, what prompted the man’s recognition. “I attribute it all to touch,” he says.
Gentle touch, specifically, is what Tomasino credits, and there exists a growing movement and increasing research to support him. A study published in the February 2019 issue of Developmental Cognitive Neuroscience found “slow, gentle stroking” of infants in their first weeks of life supported brain development.1 That same year, Complementary Medicine Research reported pain relief, relaxation and improved well-being in geriatric patients who received four weeks of “soft, gentle touch.”2
What is “Gentle”?
To Tomasino, “gentle massage” can include many things. “I’ll often start by simply holding their hand or placing a palm to their forehead,” he says. “Then, if they’re comfortable with it, I’ll lightly brush or stroke their back.”
The implication seems clear, but without an objective, measurable definition, “gentle” will not be the same for all clients or massage therapists.
Virginia-based Healwell advocates for a broader role for massage therapists in health care and trains massage therapists to provide care safely and effectively. As Healwell’s education director,
Rebecca Sturgeon, LMT, considers bridging those language gaps critical to the organization’s mission. Their No. 1 tool? The Massage Therapy Pressure Scale. Introduced in 2002 by author and massage therapist Tracy Walton, the pressure scale is an objective measure of force applied to tissue. It plots all massage across five levels of pressure, with “Level 1” denoting an application so light the hands barely contact the skin and “Level 5” representing the highest-possible hand-to-body pressure—a manipulation of the deepest layers of tissue, muscle, blood vessels and fascia.
“It’s a way to orient students and health care professionals so that you don’t have the frustrating experience of saying, ‘We’re going to work lightly,’ only to discover their interpretation of lightly is completely different from yours,” says Sturgeon, who, along with Janet Penny, RMT, authored the 2021 textbook Oncology Massage: An Integrative Approach to Cancer Care. “It’s so much easier to instead say, ‘That’s not a Level 1, because these are the tissues you are moving around.’”
What Does It Look Like?
In this framework, most practitioners equate “gentle massage” with a Level 1 or 2 on the pressure scale. Here, therapists use zero body weight and a strictly-
for-contouring hand pressure to enact the very slightest movement of the most superficial layers of skin and tissue.
The Massage Therapy Pressure Scale makes minimal mention of specific technique, relying instead on an adaption of all modalities according to the appropriate level of pressure. “We’re not here to teach you a new way to massage; we’re here to teach you how to scale your existing methods,” Sturgeon says. “Under this definition, for example, it could be possible to affect a trigger point application at a Level 1 pressure.”
Integrative Touch founder Shay Beider, LMT, MPH, agrees with Sturgeon’s interpretation and takes it a step further. “Gentle touch can be applied both physically and as an ethos,” Beider says. “It encompasses the way you enter a room, the way you present yourself, the way you speak to a person and the way you gain their consent.”
Pediatric consent is a crucial component of the Integrative Touch curriculum Beider has spent more than 20 years refining. “We use a team-based model when working hands-on with children, as we never want one child left alone in a room with an adult during therapy,” she says. “And we teach every child that every adult needs permission to touch them. That’s something that’s going to serve them well beyond a single massage session.”
The same goes for clients on the opposite end of the age spectrum. “So many of these people get handled, with no one ever asking permission,” Tomasino says. “I find that looking deep into their eyes and asking for their consent goes a long way toward not only making them feel safe but also acknowledging their integrity.”
When Gentle Is Mandatory
“The ornery part of me asks, ‘Why isn’t all massage gentle?’ Gentle massage is beneficial for all humans, whereas a Level 4 or 5 is not,” Sturgeon says.
Few would argue with her assessment—that a light touch is essentially, universally appropriate. That said, there are certain populations for whom a light touch is especially appropriate, if not mandatory. Those include children, the elderly and anyone ill or medically fragile. Researchers from University of Arizona and Banner Children’s Hospital have determined Beider’s Integrative Touch therapies result in a 62 percent reduction in children’s anxiety, 60 percent reduction in pain and a 52 percent improvement in global well-being.3
Consent and psychological considerations aside, children must also be treated according to their immaturely developed nervous and musculoskeletal systems. “Many children simply cannot tolerate what we generally consider a formal massage,” Beider says. “Their pressure tolerance is in proportion to their physical size and muscle tension, both of which are significantly less than that of adults.”
Though larger in frame, elderly clients’ deteriorating tissue and bone mass require an equally gentle touch. “You could break a bone or tear tissue,” Tomasino says. “You have to be careful.”
The more medical contradictions a client possesses, the more that gentle massage shifts from being just “beneficial” to “non-negotiable.” Lymphedema risk is one of the only circumstances to which Sturgeon assigns a specific technique. “If you use an overly heavy pressure or stroke in a direction against the lymphatic system, the danger is that you might overload the system and trigger it.”
Patients with known or suspected blood clots, (a common side effect of surgery and certain chemotherapies), necessitate extreme caution to avoid dislodging them. “In many cases, you’re not going past a Level 1, and you’re not doing any circulatory strokes at all,” Sturgeon says. “Your hands aren’t really moving at all.”
Finally, there is palliative care massage, which requires the lightest touch of all.
Whether applying every time or to these cases only, one rule of thumb stands reliable among the rest when discussing gentle massage. “One of the things I teach is to always err on the side of being gentle—you can’t go wrong by doing that, because you can always work in more,” Beider says. “But you can go wrong by overdoing it. It’s hard to go back from that.”
1. “Neural Correlates of Gentle Skin Stroking in Early Infancy,” Developmental Cognitive Neuroscience.
2. “Implementation of Intentional Touch for Geriatric Patients with Chronic Pain: A Qualitative Pilot Study,” Complementary Medicine Research.
3. “Program Outcomes,” Integrative Touch.