When Wendi White first experienced functional pain, her sensitivity to touch was so intense that she thought she had cancer.
Jenny Baltazar remembers being frustrated not only by the intensity of her initial discomfort from functional pain, but also by the runaround she experienced from health care providers.
“People thought it was in my head,” Baltazar recalls.
Doctors prescribed a series of medications to help Tina Miccio deal with her functional pain, but Miccio’s condition didn’t improve.
All three women ultimately benefited from massage therapy, and all three now are licensed massage therapists with extensive experience in helping others work through their own struggles with functional pain.
Functional pain is an umbrella term used to describe a series of conditions that lack an obvious organic origin or etiology, including fibromyalgia, myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS) and irritable bowel syndrome (IBS). And while the conditions under the functional pain umbrella are much more widely acknowledged than when Baltazar first sought treatment decades ago, they remain perplexing to researchers.
Yet there have been advances. A 2020 study in the Journal of Clinical Medicine,1 for example, showed a strong link between fibromyalgia and mitochondrial dysfunction, linking fibromyalgia to decreased concentrations of metabolic substances such as adenosine triphosphate (ATP). And researchers are also beginning to see a greater relationship among the different functional-pain conditions, according to a report in BJA Education.2
“There has been a paradigm shift in the understanding” of functional pain, the report’s authors noted. “The old model of multiple discrete chronic pain conditions is being replaced by a more overarching, although no less complex, state of central sensitivity syndrome.”
Another area of emerging consensus around functional pain is that massage can help. A study in PLoS One,3 for example, found that massage therapy had “beneficial immediate effects on improving pain, anxiety and depression” in patients with fibromyalgia.
One reason could be that functional-pain conditions are often marked by improper muscle contraction and relaxation, and massage can bring relief to muscles that otherwise struggle to relax. ATP, for example, plays a key role in enabling muscles to contract and release,4 so the decreased amounts observed in fibromyalgia patients means they struggle to relax their muscles naturally.
The idea that massage can help restore function in those cases resonates with White, LMT, a board-certified massage therapist who practices in Hanover, PA.
“Some of my clients couldn’t even walk up steps when they first were diagnosed,” White says. “Massage has enabled them to manage their functional pain issues to the point where they are able to live a normal life.”
That’s not to say that massage is a standalone cure for functional pain—it’s not. But as part of a broader care regimen that includes other practices, such as nutrition and stress management, massage can play a crucial role in helping people bring their functional pain under control.
Clients in Distress: Take Your Time, Go Easy and Communicate
Functional pain can involve musculoskeletal irritation and acute sensitivity, which means massage therapists must proceed carefully when a client first comes to them in the midst of a flare-up. That means the massage therapist’s standard intake process takes on special importance.
“You have good days and bad days—days where you feel like you need more pressure or a harder massage, and days when you need everything to be gentle and soft,” says Miccio, LMT, a board-certified massage therapist based in Bradenton, FL.
She recommends keeping especially thorough notes on clients experiencing functional pain, beginning with a history form that her clients fill out prior to their first massage. From there, she records any symptoms, injuries or complaints that the client mentions at each session, as well as any information about that day’s massage session.
“It’s important to really pay attention to what the client is saying, and then customize your massage based on that,” Miccio says.
In cases where clients are experiencing a flare, Baltazar recommends starting away from the primary tender points.
“I’ll start with the feet, because even though there are lots of nerve endings, there are also many layers of skin—which means it can be an area where there’s more tolerance of pressure,” says Baltazar, an LMT licensed in New York, who now operates an integrative health coaching business in West Stockbridge, MA, called Wild Blossom Coaching. “Sometimes you can also start with general relaxation massage, but for people with fibromyalgia that can almost be too stimulating—you’re looking for a place to give firm pressure but nothing that’s too deep. You’re just trying to help their body decompress.”
It’s also essential to check in frequently with clients to gauge their pain level. Pain thresholds and sensitivity can vary substantially from day to day for people with chronic pain, and massage therapists have to keep tabs on how their clients are feeling in the moment.
One caveat there: Use caution if a client dealing with functional pain asks for a massage that includes substantial pressure. Massage therapists are trained to value deep-tissue work, and it can—eventually—play an important role in providing relief from functional pain. But there’s also the danger of triggering or exacerbating a flare.
Instead, it’s best to proceed with “a lighter touch and a broader stroke,” says White. “Start out light, maybe even with lymph massage, because the body responds very well to that when the person is at that acute phase. It relaxes their body and then you can move on from there.”
Addressing Common Functional-pain Conditions on Your Table
The different conditions that fall under the umbrella of functional pain can have unique presentations that call for different approaches. For example, clients suffering from three of the most common functional-pain conditions—fibromyalgia, IBS and ME/CFS—each require a different approach.
IBS: Inflammatory bowel syndrome can present in very different ways, one in which people feel intestinal blockage or constipation, and others where they tend toward diarrhea or acid reflux. A client who is feeling blocked may benefit from gentle abdominal massage, done in a circular motion around the base of the ribcage and lower abdominal area. That sort of massage can be helpful in warming the area and helping it to relax and loosen, Baltazar says. However, clients can also benefit from work done away from the abdomen—specifically, the feet.
Massaging the feet “stimulates the parasympathetic response, and their nervous system can relax. And that can make a huge difference—I’ve had people report that an hour later they got home and were able to go to the bathroom,” says Baltazar.
And of course, with clients whose IBS leans toward diarrhea or acid reflux, it’s best to stay away from working the abdomen directly, or to apply heat anywhere on the body.
Fibromyalgia: As clients suffering from fibromyalgia slowly improve from the intense pain and sensitivity of a flare, it’s helpful to gradually apply more pressure—but only with a broad, flat-hand stroke, says White.
“Never dig with your thumbs, fingers or elbows on someone with fibromyalgia. Just go deeper with your palm and lean in to get that pressure,” she says. “At first, you’re just gliding across the tissue, and the next time you can try to go a little deeper into the muscle. If someone is coming to you regularly and really needs deep work [and isn’t in a place of high sensitivity], then you can go all the way down to the bone—but still with a flat hand.”
When massage therapists work directly on the tender points of clients with fibromyalgia, White says it’s also important to watch the clock. She’s careful never to work on a tender area for more than 10 minutes to prevent the massage from sparking a flare.
ME/CFS: People suffering from chronic fatigue syndrome can be so mentally frayed and deprived of quality rest that Baltazar cautions massage therapists take care to ensure that their clients are exhibiting the agency needed to be able to receive a massage—something that generally can be gleaned during the intake process prior to beginning a massage.
Once that bar is cleared, clients with ME/CFS often respond well to deep-tissue Swedish massage and hot-stone massage, says Baltazar. Soft-tissue massage along the spine and respiratory muscles also can be helpful to calm the nervous system.
Baltazar also recommends craniosacral therapy, which “opens up their nervous system and allows it to go into more of a calm state and shifts them into parasympathetic response, which can be helpful not only for chronic fatigue but any sort of chronic pain.”
People suffering from functional pain are forced to deal with sometimes-debilitating discomfort, as well as the frustration of having to contend with a condition that has no clear medical cause, and often a murky set of treatment options. The good news is that massage is emerging as a critical means of gaining relief from the symptoms of functional pain, and offering clients a path to reclaiming control of their lives.
Massage Therapy Journal
Massage and Chronic Pain
1. Gerdle, B, et al (2020). "Evidence of Mitochondrial Dysfunction in Fibromyalgia: Deviating Muscle Energy Metabolism Detected Using Microdialysis and Magnetic Resonance." Journal of Clinical Medicine. 9(11).
2. Crabtree, D, Ganty, P. (2016). "Common Functional Pain Syndromes." BJA Education. 6(10).
3. Li, Y, et al (2014). "Massage Therapy for Fibromyalgia: A Systematic Review and Meta-Analysis of Randomized Controlled Trials." PLoS One 9(2)