MorePainMoreGain

Press hard. Stretch it. Crack it. Now more. I can take it - more pain, more gain. These are the common, basic maxims of massage and manual therapy, i.e., bodywork. They reflect the idea that increased input creates increased output. If your back is sore and tight, with your ribs crackling at the vertebrae with each breath, the prescription would seem to be to lengthen those tissues. Pull on a leg until the segments of the spine, anchored to the pelvis, strain against their ligamentous bindings and give way, allowing the breath to return with ease. Twist the thorax until it yields another degree. Place an elbow on the ropey, overworked muscles of the paraspinal gutters, and after the pain comes the euphoria of release. 

We have treated the human body like this for thousands of years. Modalities of bodywork have been passed down through a lineage of practitioners whose work operates within this instinctual mode. Across continents and time, the application of therapeutic force to the human body is a constant. And it works. Input does create output, and modern physiology has an explanation for why. Pain modulation and tension change are neurological responses provoked by alternative stimuli. Replacing what we perceive as pain (nociception) with pressure or a stretch will likely decrease the perception of that pain. Not always - chronic pain, nociplastic sensitization, often evades these approaches. But generally speaking, the human instinct to press on a banged elbow or rub a sore foot, codified in traditional approaches to bodywork, is real and physiological. 

But I wonder - is it necessary? 

Structural approaches to bodywork - “press it, stretch it, crack it” - are helpful and effective. Despite mostly low-quality evidence, dozens of meta-analyses show some effect in reducing pain for patients receiving manual therapy interventions. Not every therapist will achieve an outcome for every patient, and not every patient or condition is amenable to treatment. Usually, some relief is possible. And sometimes it hurts, but then it feels better. The effect is also evident anecdotally. You’ve probably had a massage before - tight shoulders, headaches, whatever ails you - and walked out feeling looser, maybe a little euphoric. Perhaps, in that process of relief, you encountered exquisite pain as the therapist pressed on an inflamed transverse process and asked you to breathe. As you count to 30, the pain subsides. Your headache abates. We wouldn’t have been doing this for millennia if we didn’t think there was some benefit. 

The question is, is that pain, that force, that pressure and pull actually required to achieve an effect? Indirect approaches to manual therapy offer an alternative. Indirect techniques are contrasted with direct techniques (press, stretch, crack) by their avoidance of the restrictive barrier. Rather than stretching the tissues to the end of their range, we shorten them. 

Take strain/counterstrain. A tender point in a well-used hamstring is poked - provoked - and identified. The heel is flexed at the knee towards the pelvis, and a hand is applied to the now-soft muscle and skin - a listening hand. The counting starts. The hand feels the muscles begin to shift. Perhaps they recede towards the ischial tuberosity or rotate gently towards the ITB. The hand follows the motion. Ninety seconds later, the leg is unfurled, and the point is once again provoked as the therapist enquires with a curious, probing index finger. The tender spot is gone, and the hamstring is looser than it was when we started. No pressure or pain was required. No stretch was applied. And the outcome is therapeutic. 

Physiology offers some insights into the function of these techniques. For some, like counterstrain, there are at least four theoretical models. For others, like craniosacral therapy, there are rationales, but they evade simple description and don’t align with allopathic dogma. What all indirect approaches have in common is their capacity to reduce pain with less input. Less is more. People stand from the treatment table and feel relief. But they have not suffered to achieve it. 

I use indirect techniques all the time in my work. A good therapist has multiple tools. I also stretch, and I also press. I don’t crack, but I will when I’m an osteopath. I use indirect techniques judiciously when a client is receptive to their potential. Not all people can endure the still, quiet time of waiting for an effect. Such is the power of the lineage of manual therapy in the cultural imagination. Maximalism reigns supreme. I ask - does your body really require that?

You might be surprised to know that it doesn’t.