Altered Skin Colour And Circulation, Result Of Massage Or Nervous System?


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):

  1. Increase circulation.
  2. Decrease SNS firing.
  3. 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. 

Sport Massage 

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 by 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. 


Home Care Plans: Instructions Vs. Adherence

I remember going to physiotherapy when I was in high school and having my exercises prescribed to me for my knee pain. I was instructed to do them every day, which I think I may have managed to do for about a week. Past that, they tapered down to as little as once per week only, followed by lies to my physio about doing them regularly.

Was I just a bad client? Maybe.  Let’s fast-forward a decade or so, though.

When I began my career as an Athletic Therapist, I would instruct my patients along the same lines. Do the exercises every single day in order to get better. It’s the standard I wanted and, if nothing else, it would make the clients exercise to some extent.

But my method didn’t work.

Adherence to my instructions was poor and my clients had a difficult time getting better. Truth, maybe there are “bad clients” out there, but at some point, you have to look at the coach rather than the players. Which brings us to the key error so common to many of our practices:

“I tell my clients to do their exercises every single day knowing that they won’t, but at least, then, they’ll do them every other day.”

Does this sound familiar?

As health practitioners, we’re used to working with patients who are only partially or completely non-compliant when it comes to their exercise rehab. As a result, we become accustomed to “tricks” in order to get them to exercise and be able to recover.

However, if you’ve used the above trick in the past, I’m sorry to say that you’re terribly misguided. (As I was.)

Let’s consider that by saying this, we’re raising the expectations for a patient to what is, for all intents and purposes, an unrealistic level. (If it was realistic, then we wouldn’t be assuming failure on the client’s part.) Now ask yourself, have unrealistic expectations ever proven to be a formula for success?

We know this to not work with raising children or dieting, so why in the world do we assume this to be effective when it comes to rehab?

Poor exercise adherence has been shown to be, in large part, due to anxiety regarding the process and an expectation of failure. Think about it; if we’re told that we absolutely need to do 100% to recover, but we know we won’t achieve that 100%, are we going to be motivated to do 50% in hopes that it will be enough? Not likely!

More likely, the guilt of not adhering completely will derail the behaviour change altogether.

So, I’m sorry, there is no easy and effective “trick” such as simply telling a patient to perform a mile while expecting an inch. Instead, actual investment in coaching patients through their exercise barriers is required.

Such coaching techniques include:

  • Helping them understand the starting process and develop a feeling of control
  • Understanding their hesitations regarding exercise
  • Finding exercise and time routines that work with their lifestyles
  • Making small changes at a time
  • Developing relapse expectation and management

So, let’s look into how we can take those points and put them into action with our patients.


As clinical professionals trying to induce behavioural changes, we need to ensure our patients have a thorough understanding of the recovery process and the importance of exercise. With this understanding, clients will develop a feeling of control over their recovery and become motivated by being able to see the direct benefit of their actions.

Exploring Barriers

If a patient has barriers to physical activity, you’re allowed to dig a little bit to understand them for yourself.

Perhaps it’s that anxiety about the process, which education will address. Maybe it’s a time constraint or limited equipment-availability, which signals the need to carefully strategize with their plan. The patient could simply hate the idea of exercising, and so you might have to come up with something that does not necessarily feel like formal exercise.

Discussing these obstacles with your patient will let them know you’re investing time and energy in creating the right plan for them and create trust between the two of you.

Which brings us to…

Individualizing Their Routine

If you have a go-to-patient that is hyped and happy to set aside 30 minutes per day and run through all of their rehab homework daily, then great. For the rest, we need to explore different methods.

For some patients, requesting their rehab exercises to be done every 2-3 days might be the realistic and attainable option. You can also consider programming them as a warm-up before working out, sports, or even just going out to walk, which is great for those with perceived time-restrictions.

Split-routines are an effective method as well, especially when it comes to combatting boredom or monotony. If you have six exercises you want your patient to do, try splitting them into three on one day and three on the other.

Finally, for those who are averse to traditional exercise, in general, you might have to be a bit more creative and find movements that are fun or don’t resemble the “work” of a workout. What I find beneficial is simply reintroducing the activities that patients want to do upon recovery as graded-exposure therapy.

Throughout all this, though, let’s remember to make small changes to lifestyle at a time. As we know, gradual modifications are much more successful in the long-term than massive overhauls.

Develop A Relapse Plan

Finally, it’s crucial we create somewhat of a risk-management plan with our clients.

A lot of things can potentially derail an individual’s adherence to change. Missing a day or two of exercise might demotivate someone from continuing further. A relapse of pain might be the clincher that causes a patient to give up and think they failed. Even simple life events might throw a wedge into the ability for someone to focus on their health.

In these cases, I drive home the point that relapses and derails are likely to happen. By predicting the possibility, we can create methods of coping and moving on. Let a patient know that it’s ok if they miss a day or even a week of exercise and that they’ll continue to reap the benefits as soon as they get back on the horse.

Pain relapses should be normalized as an expected event, and if the patient can use it as a learning opportunity rather than as a sign of a failed recovery. Like with anything we do in life, recovery will involve ups, downs, and plateaus to work around.

In truth, this ability to work with a client to create longer-term habits and adherence is something that many fitness professionals commonly excel at over medical ones. Personal trainers know that it’s an easy way to lose their client by telling them to do cardio six times per week or that they need to work out for three hours per day. Bringing those expectations back down to a realistic level and adjusting their plans as the client changes are the sure-fire way to success. Cookie-cutting a method for motivating that person to exercise is as bad as cookie-cutting the program itself. We have a duty to individualize our patients routine which includes the frequency basis on which it’s performed. And don’t expect failure; aim for success.

Why Do Isometrics Work So Well?


A question I often get asked is “Why do isometrics work well to isolate pain?” I started adding isometrics to improve pain during motion and pain and end range with active and passive testing.

They work great! Forget “muscle energy technique” and other theories. They are too mechanical. I go over the reason why isometrics work well as a compliment to manual therapy and repeated loading strategies.

5 Tissue Loading Progressions To Help With Hip Pain

Not too long ago we went over the different phases of tissue healing and how to start properly loading the tissues to promote healing and help get our patients stronger. This is ALWAYS a great way to reinforce the manual therapy you do with your patients on the table and can also be a way to start the treatment.

If someone comes in who is having some S.I. Joint pain, Glute pain, or just pain in the posterior hip, in general, this is a good way to start getting them moving again. Quite often when a patient is dealing with pain, they become afraid to move because they associate pain with the movement.

This is where doing a solid intake interview (remember to rule out red flags) is important to listen to your patient and let them be heard regarding their pain. All too often patients feel like no one will actually listen to them and rush to get into a treatment, rather than listening to what they are fearful about, or acknowledging that their pain is real.

However, if you can get the person into a different plane of movement and apply some graded exposure techniques you’ll find they become less fearful and start to move more. Even if the movement is just a minor increase each time, it can make a huge difference for the patient. 

This video shows just one way to do some graded exposure, but I would encourage you to try some different movements to instil that feeling of safety with your patients. Remember, pain is a protection mechanism and sometimes we just need to send signals to the brain to show that movements are safe again.

Once you’ve done some treatment, this is a way to start loading the tissue.

During the acute phase (the first 24-48 hours) these isometrics would be most appropriate. As you can see there is some movement as the patient loads and pushes up into the glute bridge, but once they are there have them hold the contraction at the top of the range for 20-45 seconds (depending on their tolerance) and gradually add a little bit more time to the contraction as they build strength. 

Once your patient can confidently do the exercises in the video above, see if they can handle doing the same exercise, one hip at a time.

These are still an isometric load, we’re just building more strength on each side by removing the assistance of the opposite hip. 

Once the patient can do the single leg isometric exercises, you can start to add more difficulty by using an eccentric load, as they are now in the proliferative phase of healing and it’s safe to start adding more load.

In this case, we are going to provide stability for the patient by coming up into the bridge using both hips, but then applying the eccentric load to only one side. This way if the patient is feeling weak or unable to do a full range, the opposite hip is there to provide safety in case the movement feels like it’s too much at any point. 

Now as we progress hopefully your patient is going through the ranges in a more pain-free movement as you’ve been doing great treatments and appropriately loading the tissue.

If by their third or fourth visit they can do the above eccentric exercises, you can start to apply concentric loads. By this point they have probably reached the remodelling phase of healing, so we can start to be a little more aggressive, but still need to stay within the patient’s pain tolerance. 


  • Remember that your patient may be fearful of movement due to their experiences with pain, this is where using graded exposure to the movement is the most beneficial.
  • Encourage the patient that movement is a good thing, even if they are a bit sore from it the next day. If they haven’t been moving for a while, some discomfort the next day will be normal, just like going to the gym for the first time after a long absence.
  • As important as your communication with the patient is, their communication and feedback are far more important, listen to their concerns and address them appropriately.
  • Educate on how a little bit of pain during movement is okay, just remind them not to overdo it.

4 Tissue Loading Progressions To Help With Knee Pain

We have discussed therapeutic exercise/movement many times on this blog before.

Not too long ago we went over the different phases of healing and discussed appropriate measures to take in loading tissues to help with healing. Movement is a great way to reinforce the manual therapy you help your patient with while they’re on the table, so we encourage you to start making a practice of tissue loading and movement once they’re off of it.

After you’ve done your interview and concluded it is safe to begin loading (which you can read about here), here are some progressions for the knee you can do right in your treatment room. These are good for someone with anterior knee pain, a quad contusion, patellar tendinopathy, or a quad strain. 

If the injury is more severe like a ligament tear, more specific interventions and movements should be chosen.

In the acute stage, (the first 24-48 hours) these isometric exercises (joint angle doesn’t change during contraction) would be appropriate. You’ll notice there is some movement to get into a bent knee, but then the contraction is actually a hold with the knee kept bent. 


When your patient comes in for their second treatment, you can start to progress the movement as you are now in the proliferative phase of healing.

In this case, you can progress to an eccentric load, but make sure to stay within the patient’s pain tolerance.  A little bit of discomfort is okay, but we don’t want to aggravate the injury by causing any significant pain.

Hopefully, by this point, your patient is getting into more pain-free movement because you’ve been doing lots of great treatment and also getting them to load the tissue. 

So, if they could do the above eccentric movements by the third or fourth visit, you can progress them to concentric movements as they have probably progressed to the remodelling phase of healing.

Here is a final progression you can try if your patient is up for it.

Plyometrics! It may take a bit of encouragement to get them to try, but if they can do this, it’s a great progressive load for athletes who may be on a return to play rehab scenario or a return to work for an injured worker.

If the patient has any balance issues, it might be best to avoid this until they regain more strength and their balance has improved. 


  • Make sure you are monitoring the area for swelling, redness, and heat, or anything else that could indicate chronic inflammation.
  • Encourage the patient to move, they may be apprehensive to start a loading program.
  • Communication is essential both for the instructions you give, and the feedback you get from the patient.
  • Educate them on how a little bit of pain and discomfort is okay during the movement, they just don’t want to overdo it.

10 Evidence Based Reasons Why You & Your Patients Should Exercise

Exercise is great, we know this, right?

Well, sort of.

Many people know exercise is good for us on a general level, but the question is, do they know it’s right for them on an individual level and is it the right fix for their problem?

This is an entirely different proposition, applying that general information to the person. This idea that these things are good for us can be quite vague, one of those things we may have glanced over in a newspaper or half-hearted on the news whilst eating our corn flakes.

People also build up ideas about what is the correct treatment for them. This can be from their own in-depth research on the internet (right!), what they have picked up from friends and family or from previous treatment with a therapist. This can lead to some pretty strong ideas about what should and perhaps should not be done to help them.

These beliefs don’t always align with the best available data we have about interventions. A prime example of this is the belief that exercise risks outweigh the benefits with back pain (55% of folk in New Zealand). This stat was taken from this Darlow paper in 2016 HERE. 

We know that exercise can be effective with back pain, certainly not a magic bullet, but one of the best things we have at our disposable within a comprehensive treatment plan, especially as it is low cost and low risk too.

Beliefs And Expectations

Our beliefs drive our expectations and actions. Predicted expectations are gaining weight as a prognostic factor in recovery over the past decade. They may influence my participation and behaviour in a treatment plan that will ultimately affect the outcome.  If I don’t believe in something I am much less likely to do it.

How can we combat this? Well, in my opinion, the best tool we have is good quality information we can use to combat the beliefs that may hold people back. A key to start affecting beliefs, again, in my opinion, is not to challenge too firmly, but inform people using well-evidenced information. One of my favourite one-liners is “That’s what we used to think but we are learning new things all the time, the latest research suggests…”

Here are some small tidbits of information that we can use to start informing our patients and clients about the role of exercise in pain AND health, which of course ultimately affects pain too!

Remember that giving people information is really designed to change behaviour rather than just show how smart you are so monitoring what happens is pretty important.

1. Exercise Is One Of The Best Evidence-Based Interventions We Have For MSK Pain

This paper HERE from 2017 in PLOS one shows moderate to strong effectiveness of exercise as an intervention for many MSK issues. This is in contrast to the belief that things need to be zapped, needled or popped back into place.

My therapist only gave me some exercises. Yep. Because they followed the evidence!

2. Exercise Won’t Make Your Body Worse

So many people see the body as a bit of machinery. The more it works the more the parts need replacing. Is this true? Absolutely NOT. The body is an organic organism that adapts both positively and negatively to stimulus. The more active we are (within reason) the stronger we become. The less active, well…

A classic common belief is that our intervertebral discs wear out the more we use them. This classic study from Battie HERE (2009) looked at twins to determine the major contributors to disc degeneration. They suggest that the “commonly held view that disc degeneration is primarily a result of ageing and ‘wear and tear’ from mechanical insults and injuries, was not supported by this series of studies”.

This study HERE from 2017 found that if you have a rotator cuff tear, the tear getting worse did not appear to be simply related to activity levels. In fact, they suggest pain development is actually associated with LOWER activity levels. If I had a pound for every time it has been suggested to me that running damages the knees then I would be a rich man. A study of marathon runners HERE showed that they had LESS meniscal abnormalities than non-runners.

3. Exercise Might Actually Make The Discs In Your Back Healthier!

Two recent studies have shown a POSITIVE effect of activity on intervertebral discs. Firstly this study HERE from 2017 showed that MORE vigorous activity was associated with BETTER disc health on MRI. Secondly, in this paper from 2016 HERE. Runners were shown to have intervertebral discs that had increase hypertrophy compared to the non-athletic group. The authors suggest that running actually strengthens the discs, whether we can infer a causal relationship here is unclear but this goes against activity causing wear and tear which is a common belief.

4. Activity Is A Pain Killer

This study HERE showed that older adults who were MORE active also had better endogenous pain inhibitory mechanisms when their conditioned pain modulation (CPM) was tested. Simply put, this means the more active the better their natural pain-killing mechanisms were. Which of course is super cool.

5. Exercise Is An Anti Inflammatory

This study HERE showed that regular physical activity caused an increase in interleukin -10 which is an anti-inflammatory cytokine that can reduce nociceptor sensitisation.

Now the caveat here is this study was performed in an animal population but as we know that there are associations between inactivity and both acute and chronic pain in humans it is a linked that potentially needs to be better explored.

6. Lack Of Exercise Is Associated With Chronic Pain

This large study HERE looked at the relationship between recreational exercise and chronic pain. Both older and younger folk were studied and the researchers found that for both groups exercise participation was associated with reduced chronic pain. A relationship was also present for the frequency, duration and intensity of that exercise.

7. Lack Of Exercise As A Major Cause Of Chronic Diseases

This comprehensive paper HERE makes a case for a lack of exercise being a primary prevention against 35 chronic conditions suffered by us poor humans. This goes beyond what most of us involved in the musculoskeletal field would have to deal with but also shows the importance of exercise for systemic health too.

8. It’s Involved In Mental Health As Well

We are understanding more and more that the mind and the body cannot really be separated. Physical health and mental health are interlinked in the human being and guess what…..exercise plays a role in improving mental health too. This paper HERE explores the mechanisms that may relate to mental health and exercise.

This randomised control trial looked at aerobic exercise and a variety of measures of psychological health HERE. The authors found significant group differences that favoured the exercise group.

9. You Want To Live Longer Right?

Strength training in this paper HERE was found to have a significant association with decreased mortality in adults over 65. But only a minority of this age group actually meet the current guidelines.

10. Have A Healthier Heart

This prospective study of 15 years duration HERE found that physical activity was a predictor of cardiovascular disease.

Summing Up

There are a whole bunch of others studies that relate to these topics but I just picked a few. I think it demonstrates that physical activity and exercise have an effect on us on a number of different levels, from the heart to the head to pain as well.

  • Do it
  • Do it
  • Do it
  • Do it