by Dr. Ross Turchaninov

Phoenix, AZ

 

          Dear readers, if you are practicing the clinical aspects of massage therapy, we invite you to carefully analyze the information in this and the following articles. It carries great value for any health professional engaged in somatic rehabilitation.

          Let us consider a patient with lower back pain as an example. Two fundamental questions arise:

  1. The patient experiences severe lower back pain. Where is the pain actually located?
  2. The same patient presents with a lateral tilt of the trunk. Why does this occur?

 

          From article to article, from class to class, and from treatment room to treatment room, many educators and therapists treat local symptoms—such as pain in the lower back, lateral tilt, or shoulder elevation—as the primary therapeutic targets. However, this is narrow clinical thinking that reduces the effectiveness of treatment, especially in chronic pain and dysfunction, where multiple secondary abnormalities develop over time.

          If proper therapy is not provided, these secondary symptoms eventually dominate the clinical picture. They can mislead therapists into treating the consequences while the original trigger remains hidden under layers of the brain’s compensatory reactions.

            The discussion in this article is based on two fundamental scientific models of pain formation:

  • Gate-Control Theory of Pain (Melzack and Wall)
  • Neuromatrix Theory of Pain (Melzack and Katz)

 

          Before continuing, we recommend reviewing SOMI’s earlier publications on these models from a massage therapy perspective.

Gate-control Theory of Pain: Medical Massage Courses & Certification | Science of Massage Institute » HOW MASSAGE HEALS THE BODY: CLINICAL APPLICATION OF GATE CONTROL AND NEUROMATRIX THEORIES OF PAIN

Neuromatrix Theory of Pain: Medical Massage Courses & Certification | Science of Massage Institute » HOW MASSAGE HEALS BODY. PART IV PHENOMENON OF PAIN AND MASSAGE THERAPY: NEUROMATRIX THEORY

 

PHENOMENON OF PAIN

          Pain is a highly complex physiological, psychological, and even philosophical phenomenon. For humans, it is both a curse and a blessing. While it devastates us physically and emotionally, it also saves lives by preventing dangerous actions.

          The human body processes pain through two distinct systems, and each has its own network of specialized receptors located in the tissues and organs:

  • a fast pain-analyzing system, responsible for acute, sharp pain perception;
  • a slow pain-analyzing system, responsible for dull, lower-intensity, chronic pain.

 

          Importantly, pain does not reside in the lower back—or any other local area—by itself. Pain is a creation of the brain. Symptoms such as pain, numbness, or burning are generated centrally, based on information received from pathologically altered peripheral receptors. This is a pathophysiological fact.

          Thus, dysfunction of peripheral receptors in soft tissues and internal organs is the direct trigger for pain and other pathological sensations. A well-trained therapist understands that while working on soft tissues locally (draining interstitial edema, releasing fascial adhesions, etc.), they are also resetting the function of peripheral receptors and, through them, recalibrating the patient’s sensory and motor cortex. That will eventually stop the brain from further re-printing the pain pattern.

          This is the reflex mechanism of Medical Massage (MM), which must be combined with local work on the affected tissues. The reflex mechanism of MM provides long-term stability of clinical results. Addressing symptoms only at the local level with a single modality is like trying to fly with one wing. Please remember that the ultimate goal of our therapy is to target the patient’s brain, and we achieve this through the peripheral receptors located in the affected soft tissues.

 

LAYERS OF SOFT TISSUE AND DISTRIBUTION OF RECEPTORS

          There are four primary soft tissue layers in the human body:

  1. Skin
  2. Fascia
  3. Skeletal muscles
  4. Periosteum

 

Fig. 1 illustrates the typical arrangement of the soft tissues in the human body using the posterior leg as an example.

Fig. 1. Soft Tissue Arrangement

A – Skin;  B – Subcutaneous Tissue;  C – Superficial Fascia with fibrotic bridges;  D – Superficial muscle (gastrocnemius m.);  E – Deep Fascia with fibrotic bridges;  F – Deep Skeletal Muscle (soleus m.);  G – line of fibrotic bridges;  H – Perisoteum;  I – Bone (tibia and fibula)

          Each layer is unique in structure, function, innervation, circulation, and—most importantly—the distribution of peripheral receptors, including nociceptors (pain receptors). Let’s review peripheral receptors in the soft tissues, which constantly feed the brain with necessary data.

 

Skin

          The skin contains the richest and most complex network of peripheral receptors, allowing the brain to interpret the environment and respond appropriately. Fig. 2 summarizes peripheral receptors located in the skin.

Fig. 2. Peripheral Receptors in the Skin

Fascia

          Fascia is also richly innervated. In addition to the receptors found in skin, the fascia contains:

  • Interstitial receptors are the ends of sensory nerves that innervate fascia. They monitor fascial tension and stretch. Interstitial receptors are predominantly located in the deep fascia, which separates muscle layers. For example, the deep fascia that separates the gastrocnemius and soleus muscles or the trapezius and rhomboid muscles. The full function of interstitial receptors is still being examined by scientists. Fig. 3 illustrates the sensory innervation of the superficial fascia.
Fig 3. Sensory innervation of superficial fascia (Fede et al., 2022)

a – adipose tissue

c – connective tissue of superficial fascia

v – vessel supplies the fascia

small arrows – sensory nerves innervating the fascia

       Interstitial receptors link fascial and muscular dysfunction to the Autonomic Nervous System (ANS). Thus, their activation can trigger autonomic responses, such as blood pressure fluctuations, nausea, sweating, or rapid, shallow breathing. ANS imbalance additionally sensitizes the brain to nociceptive input, amplifying pain perception.

  • Chemoreception. Fascia doesn’t have classic form of chemoreceptors which respond to local biochemical changes. However, fascia contains an abundant accumulation of mast cells, and their activation alters local pH, releases cytokines during local inflammation, participates in tissue repair, and forms an initial immune defense barrier. Their activation further sensitizes nociceptors and enhances pain generation. Fig. 4 illustrates the distribution of mast cells in the fascia.
Fig. 4. Distribution of mast cells (dark blue dots) in fascia (Zhang et al., 2019)

Skeletal Muscles

Two key receptor groups govern muscle function:

  • Muscle spindle receptors, located in the muscle belly they monitor changes in muscle length and stretch. They are critical for muscle coordination and posture. In dysfunction, they start to send incorrect data to the motor cortex, confusing the brain and deepening the dysfunction. Fig. 5 illustrates the position and cross-section of skeletal muscles with the muscle spindle receptor.

Fig. 5. Muscle Spindle receptors (Embryology Tutorial)

a – position of muscle spindle receptors in the muscle bellies between myofibrils

b – cross-section of skeletal muscle with the muscle spindle receptors surrounded by a capsule

  • Golgi tendon organ receptors, located at muscle–tendon junctions, detect tension and act as inhibitory receptors. We are engaging them commonly during passive stretching to induce relaxation. The sensory fibers of the receptor weave between the tendon’s collagen fibers. Fig. 6 illustrates the position and structure of the Golgi Tendon Organ receptor.

Fig. 6. Golgi Tendon Organ receptor in the tendinous part of the muscle

 

Periosteum

          The periosteum has relatively few receptors overall but is densely populated with nociceptors. The intense pain a bone fracture patient feels is not due to the bone itself (which lacks nociceptors) but to damage of the thin periosteum surrounding it. Periositeum also has Meissner’s Corpuscle receptors, which detect vibration.

 

CLINICAL IMPLICATIONS

          The varied receptor distribution in each soft tissue layer underscores the necessity of treating each layer individually. Treating soft tissue as a single bulk structure is ineffective and ultimately a dead end in somatic rehabilitation.

Effective therapy requires that the therapist:

  • accurately evaluate the tissue layers involved,
  • understand receptor distribution and function in those tissues, and
  • select appropriate techniques and modalities for each layer.

          No single method — whether Neuromuscular Therapy, Trigger Point Therapy, or Myofascial Release — is sufficient on its own. Each has value in a specific clinical niche. Stable and lasting results come only from their thoughtful integration.

          Thus, therapists must look beyond local pain and structural changes. The true therapeutic goal is the patient’s brain. By restoring the function of peripheral receptors in skin, fascia, muscles, and periosteum, we gradually reduce central pain perception.

          This integrative, receptor-based approach is the foundation of Medical Massage, which is a treatment concept rather than an individual modality, as mistakenly presented. Medical Massage combines scientifically validated and clinically tested methods to address each layer of soft tissue individually and systematically according to the needs of each individual patient.

 

NEXT IN Part II

          In the following article, we will examine the mechanisms of acute and chronic pain, the development of structural abnormalities, and how Medical Massage addresses them effectively.

 

REFERENCES

Fede C., Petrelli L., Winfried C., Neuhuber F., Tiengo C., Biz C., De Caro R., Schleip R., Stecco C. Innervation of human superficial fascia. Front. Neuroanat., Vol. 16, 2022

Melzack R. (1990) Phantom Limbs and The Concept of Neuromatrix. Trend Neurosci.. 13:88-92.

Melzack, R., Katz, J. (2013). Pain. Wiley Interdisciplinary Reviews: Cognitive Science, 4(1):1-15, Jan/Feb., 2013

Melzack R., Wall P.D. Pain Mechanisms: A New Theory. Science. Nov. 1965, 150(3699): 971-979

Zhang D., Dong Y., Zhang Y., Su X., Chen T., Zhang Y., Wu B., Guoheng X. Spatial distribution and correlation of adipocytes and mast cells in superficial fascia in rats. Histochemistry and Cell Biology,  2019, 152(6):1-13


Category: Medical Massage

Tags: