This is one of those topics that inevitably comes up on a regular basis.
The last time I taught our course on pain science and therapeutic exercise, there was some resistance to the idea that massage therapy does not increase circulation and last week there were some big discussions on the topic on one of the massage groups on facebook.
This was a harsh reality for me when I realized we don’t have any effect on circulation and I remember the day in college when I started to question it (I’d love to say it was because I was some sort of forward-thinking genius, but I digress). I was working with a hockey team and one of the players had an episode in the summer which required him to be on blood thinners. I was super worried that if I did any massage I’d have an adverse effect on him, so I approached one of my teachers to ask if massage was contraindicated and what I should do as I was worried about the increase of circulation with his condition.
My teacher simply looked at me and said: “you’re not going to increase his circulation any more than him playing hockey!”
It was like a light bulb of astonishment went off, I wish I had a picture of my face.
Now, surely that story can be taken anecdotally if you choose to, so the question will remain: “what does the research say?”
Heart Rate And The SNS
I remember in college while working in the student clinic, part of each treatment we had to develop three goals prior to treatment to be reviewed by one of the clinic supervisors.
Most of the time my goals would look something like this (they got more specific as school progressed):
- Increase circulation.
- Decrease SNS firing.
- Patient education.
I think the reasoning behind “decreasing the sympathetic nervous system firing” was more to just a way of saying we calmed the patient’s stressors down and essentially helped them relax. As we know the SNS is responsible for our “fight or flight” response, which is essentially used when we are scared because we’re being chased by a bear or something. In order to have a “fight or flight” response, it would require our heart to start pumping hard and feed blood to the necessary parts of our body to get us moving and run from the said bear.
One of the assessment tools we would use to prove whether we actually had an effect on the patients SNS was to check their pulse before and after treatment to see if there was a change. Inevitably their pulse rate would be slower post-treatment than it was prior to treatment, thus justifying how we “relaxed” our patient.
So how in the world did I think I could simultaneously increase circulation, while both decreasing sympathetic nervous system activity? My assessment was literally proving me wrong. The sad part is I only thought of this example last week, at no point during my education did I ever question this, I just habitually put them as goals.
One thing we know for sure (and we’ve written about it before, you can read it here), is that massage therapy can help with hypertension and actually decreasing blood pressure. Some articles argue this entirely depends on the type and depth of massage technique used. One study showed using trigger point therapy and sports massage actually increased BP, however, the article wisely ackn0wledged this was due to the pain caused during a trigger point treatment. In this case, the treatment would be causing a sympathetic nervous system reaction to withdraw from pain, thus temporarily increasing blood pressure.
With everything we know about modern pain science and the knowledge around old theory of trigger point therapy, I hope we aren’t going in and causing pain with our patients anymore, as we know it’s not effective. In turn, it’s also not a technique we should use to fight the argument about an increase in circulation. As far as sports massage causing an increase, we’ll get to that in a bit.
In the sport massage world, there has been a long time practice of using tapotement techniques to help with warm-up and increase blood flow before a competition.
While this can be an effective way of helping an athlete warm-up, there is probably more of a psychological aspect to it than anything about bringing circulation to a specific body part or tissue (this may be part of the reason that a typical warm-up involving exercise is always recommended before seeing a therapist to assist with warmup).
There is also the argument about doing a “leg flush” post-competition to help clear out lactic acid as part of recovery.
While there are several studies showing that blood flow is increased with massage (to help prove the above theories), most of the methods used to try and prove this theory wasn’t very reliable. However, more recent studies have shown that massage has little effect on arterial blood flow.
There were theories that reported a 50% increase in circulation after a vigorous massage, but later studies (which used somewhat unreliable measurement tools) showed not only smaller increases, but some showed no increase at all.
The above-cited study actually did tests post-exercise to see if massage would still have any effect when it comes to circulation. They used one group who would take regular rest post-exercise and one group who would receive massage. There was no significant difference between the two groups on femoral artery blood flow and massage performed on the quadriceps.
So what does this tell us? The only real way to increase blood flow is through movement and exercise. As our friend Alice Sanvito stated in a forum not too long ago: “If we mean there is more blood to an area, we run into another problem. The circulatory system is a closed-loop. There is a relatively fixed amount of blood. If more blood is shunted to one area, then there must be less blood somewhere else.”
The body would not let this happen, so we cannot actually alter circulation to bring more or less to any area of the body, without significant injury, which would result in shock, or blood loss.
Changes In Skin Colour
The question came up, “if we don’t increase circulation why does the skin go red!?”
Great question!, so I had to do some research on that as well.
We have all seen it in our clinic, we work on a specific area of the body and the skin changes color and gets a little bit pink, or maybe even red. Well, there are two possible mechanisms at work here, either the friction created doing, say, an effleurage stroke is irritating the skin, or a change in temperature from touch is the culprit. What about the clients you treat where the skin doesn’t change colour? Does this mean the massage is having less of an effect on them?
Well, studies show that skin friction can increase heating which causes hyperemia in the local massaged area. But the same thing happens when I put a cold pack on my arm and isn’t cold actually supposed to cause vasodilation and a decrease in circulation?
While there is a minor increase in blood flow to the capillaries of the skin, the increase in blood flow has been measured and shows that the amount is so arbitrary, there is no way it is being diverted away from local musculature. So, while this is p0ssibly a minor increase to the skin, we can’t assume we are increasing circulation to the muscle because the skin is changing colour.
As we mentioned before, what about those clients whose skin colour doesn’t change? Does this mean there is something wrong with their circulatory system, and we aren’t influencing circulation to that area? I’d venture to say no, it probably has more to do with skin sensitivity, or it’s a true measure of how minimal the circulation increase actually is.
Our friend Alice Sanvito also made a stellar point about this:
“What were we taught about the sympathetic and parasympathetic nervous systems? The sympathetic “fight or flight” nervous system diverts blood away from the skin and internal organs and towards the muscles. The parasympathetic “rest and digest” nervous system diverts blood away from the muscles and towards the internal organs and the skin. Since massage tends to relax people, it is probably safe to assume it is downregulating the sympathetic nervous system.”
Like it has been with so many other things in our career, we really have to take a step back sometimes and critically look at the things we were taught. This has been a huge learning curve for me during my career, but there is also a refreshing side to being able to give honest and logical answers to patients. While we may encounter arguments from others on these points, it’s important to keep educating ourselves and others to stay on top of current research and evidence-based practice. We’ve said it before on this blog in regards to circulation, there’s more of an increase happening by your patient walking into your clinic and getting on your table than from anything that happens during the treatment. And you know what? That’s okay because what you are doing for them on the table is FAR more important than worrying about increasing their circulation.