Pain and the Mind's Response

Understanding of how pain works can help massage therapists better meet their clients' needs.

By Michelle Vallet, May 23, 2017

You have a massage therapy client who comes to you in pain. Perhaps they have arthritis or maybe they injured themselves during a workout. There’s no question you believe that massage therapy can help them manage, if not completely alleviate, their pain. And as recent research is suggesting, you’d be right.

Pain is complex. Having a basic understanding of how pain works—the role sensitization plays and how the brain informs pain, for example—can give massage therapists both a better understanding of the needs of their clients and the ways in which massage therapy can help.

What is Pain?

The answer to the question seems obvious, but pain is more nuanced than we might first think. Doug Nelson, a massage therapist and president of NMT Midwest in Champaign, Illinois, first learned that when taking a deeper dive into the science of pain. “The more I explored the science, the richer and more complex the subject of pain became,” he remembers. “Perhaps most surprising to me was the way it changed how I practiced.”

A basic definition of pain offered by The International Association for the Study of Pain is the following: “An unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage.”

That and is important, according to Nelson. “Notice the use of the word and, not or,” he explains. “Emotion plays an enormous role in pain. Pain is not just a sensory experience.” In other words, he says, how you think about pain is important.

“One of the important concepts that has become very clear over the years is that pain is not a stimulus,” Nelson explains. “The experience of pain revolves not just around what you feel; it is largely about what you think the pain means.”

Nelson uses a minor wrist injury he had a few years ago as an example of how this works: “My brain immediately went down the rabbit hole of ‘I won’t be able to see clients, my office will fall apart, then I’ll lose my house, my wife will resent supporting me …’” he says. “By the time I saw my physician a few days later, I imagined myself just short of being homeless and destitute.”

But guess what happened when the doctor diagnosed a minor ligament injury? “I walked out of his office in a lot less pain and was much relieved emotionally,” Nelson says. “Yet, the doctor did nothing and gave me nothing except the knowledge that this was a solvable problem.”

The truth is we’ve probably all had this very same experience, an illness or injury that feels huge—a sore throat we’re sure is strep, joint pain we’re certain is arthritis—and then when we’re told it’s not what we’ve imagined, suddenly we don’t feel quite as bad.

Pain Mechanisms

You can’t think about how pain works without acknowledging the role sensitization plays. “Neuroceptors called nociceptors are always on the lookout for noxious stimuli that might pose a threat to the system,” Nelson says. “If they become too sensitive, they react to innocuous stimuli as though they were a threat.”

Nelson likens this to a house that has a faulty alarm system that keeps going off even when there is no sign of an intruder. “In the body, nociceptors learn to fire faster to be more protective,” he says. “Unfortunately, they are now misinterpreting normal sensations as noxious and the cycle continues to escalate.” This is peripheral sensitization, Nelson says.

When the periphery continuously pings the central nervous system, a condition called central sensitization can occur. “When the central nervous system is under a barrage of inputs from the periphery, it too can become overly stimulated and sensitized,” Nelson explains. “A clinical example of this condition is fibromyalgia.” The difference with central sensitization is that because the stimulation starts centrally and streams down the nervous system, effects are felt in both extremities equally. “You cannot have fibromyalgia on just one side of the body,” Nelson says.

Peripheral and central sensitivity don’t necessarily work independently, however. “It is quite common to have a bidirectional movement of these inputs, which can escalate and make things far worse,” Nelson says.

How does that work exactly? Nelson explains: “Peripheral sensitivity sends information to the brain that something might possibly be wrong in an area, let’s call it zone ‘F,’” he says. “If that input continues, then the central nervous system turns up the ‘sensitivity dial’ to be on higher alert and might also tell the neighboring peripheral zones ‘E’ and ‘G’ to be on alert, as well. As more and more peripheral areas increase their sensitivity, more input is going to be streaming back to the central nervous system, which will increase central sensitization.”

Acute + Chronic Pain

The two main divisions of pain are acute and chronic, though many subcategories exist. When thinking of how to distinguish the two, Nelson considers this question: Is the source of the pain still present?

“In acute pain, the source of the pain is present,” he says. For example, Nelson says, think about what happens when you step on something sharp when you’re barefoot. “If there is tissue damage, the pain will limit your activity to prevent more damage, enforce rest to encourage healing and perhaps teach you a lesson about where you should and should not walk barefoot,” he says.

When pain is considered chronic, however, the original source of pain might not be present, though the pain is still there. “Nerves in the area of injury become oversensitive and respond to normal stimuli as though they were a threat,” Nelson explains. “Movement patterns remain altered, and often movement is limited.”

Here’s where things can get tricky. Remember, the role of acute pain can be protective, alerting you to injury and forcing down time so you can heal. When those same mechanisms continue to fire long term, however, the results can be disastrous, according to Nelson. “This is not unlike the world of stress research,” he explains. “Temporary spikes in stress levels activate our immune system and make us stronger. Unrelenting stress, however, has the opposite effect and depresses our immune function over time.”

How Massage Therapy Can Help Pain

Nelson sees real value in massage therapy even as he understands that pain can be a complex issue. “It is my strong belief that massage therapy is uniquely positioned in so many ways to help people in pain,” he says.

Think back to conditions that involve central sensitization, like Nelson’s example of fibromyalgia. Remember that pain—especially chronic pain—can be caused by oversensitive nociceptors that respond to normal stimuli as a threat and keep pinging the central nervous system from the periphery, which responds in kind by becoming oversensitized itself.

This means that pain can occur both with and without stimulus. Clifford J. Woolf touches on this when, as part of his own research, he describes some of the early scientific evidence on central sensitization and pain.

“However, after the discovery of central sensitization, it became clear that a noxious stimulus, while sufficient, was not necessary to produce pain. If the gain of neurons in the ‘pain pathway’ in the CNS was increased, they could now begin to be activated by low threshold, innocuous inputs,” he explains. “In consequence, pain could in these circumstances become the equivalent of an illusory perception, a sensation that has the exact quality of that evoked by a real noxious stimulus, but which occurs in the absence of such an injurious stimulus.”1

So one distinct benefit massage therapy offers, Nelson says, is that massage therapists can often replicate the pain the client is experiencing, which can be huge for them. “This validation is extremely important,” he adds.

Touch is important, too, Nelson notes, which is borne out in some of the most recent research on the efficacy of massage therapy for pain. A recent collaborative meta-analysis of research on massage therapy for pain conducted by the Samueli Institute concluded that based on evidence, massage therapy can provide significant improvement for pain, anxiety and health-related quality of life for those looking to manage their pain. This same meta-analysis also found that based on the evidence, massage therapy was effective for reducing pain intensity/severity and anxiety in patients undergoing surgical procedures.2

Another recent study on the effects of massage therapy on pain in rheumatoid arthritis (RA) patients found that adults with RA may feel a decrease in pain, as well as greater grip strength and range of motion in wrists and large upper joints, after receiving regular moderatepressure massage during a four-week period.3

Additionally, the American College of Physicians just released guidelines recommending massage therapy, as well as therapies such as yoga and exercise, for low back pain. These guidelines analyzed more than 150 studies on low back pain treatments, and nonpharmacological approaches such as massage therapy are preferred.

Related: Massage Therapy as an Alternative to Opioids

Pain is one of the main reasons that people seek massage therapy, whether it’s because of injury or a primary symptom of chronic disease. As a massage therapist, you are in a great position to help. Having a basic understanding of how pain works will give you a better understanding of how massage therapy can help—which benefits both you and your clients.


1. Woolf CJ. “Central sensitization: Implications for the diagnosis and treatment of pain.” Pain. 2011 Mar; 152: S2–15.

2. Crawford C, Boyd C, Paat CF, Price A, Xenakis L, Yang E, Zhang W. “The impact of massage therapy on function in pain populations—A systematic review and meta-analysis of randomized controlled trials.” Pain Med. 2016 May 10.

3. Field T, Diego M, Delgado J, Garcia D, Funk CG. “Rheumatoid arthritis in upper limbs benefits from moderate pressure massage therapy. Complementary Therapies in Clinical Practice. 2013 May;19(2):101–3.