by Dr. Stan Dawson, DC
Deep Tissue massage and Swedish massage are the two most commonly requested massage techniques. You can assume that a client who requests Deep Tissue wants a massage that is not focused only on relaxation. She wants you to work deeply enough to make a difference in her level of discomfort and possibly also her overall posture and wellbeing. She wants you to work through the layers of her muscles to get to the deep, sore places that Swedish massage alone does not effectively relieve. Her focus is probably on results rather than relaxation. She may or may not know precisely what Deep Tissue is, and she may have a potentially dangerous misconception that it is okay to work deeper than is physiologically appropriate. Some people seem not to understand that it is possible to work too deep. Causing more pain is not the key to results. So, before you begin the session, I suggest that you ask your client what she means by Deep Tissue. This question will start a discussion in which you will be able to use the information contained in the rest of this paper. To make this easier for you, I will begin with an explanation of how the term Deep Tissue evolved, and what it has developed into. I will focus on the nature of the tight, sore places therapists were attempting to resolve and will advise you on how to handle the discussion you will be having with your client.
Historically, Deep Tissue evolved (in the 1960s and 70s) as slower, deeper, harder Swedish. The Deep Tissue practitioner uses Swedish strokes, but applies them at a slower pace with more pressure; at times using elbows, knuckles, fists and forearms to work harder without hurting the therapist’s hands and wrists in the process of applying more pressure on the client’s tissues. Deep Tissue was created as a response to the inability of pure Swedish massage to relieve the deep, sore places in muscles that do not simply go away by getting someone relaxed. In its original (limited) form, it failed to do much more than Swedish massage for the deep, sore places in muscles. Simply working slower, deeper and harder does not create a significantly different effect than Swedish technique already does. It also runs the risk of causing the person to guard and brace themselves to cope with the additional pain caused by the harder pressure. Unfortunately, it is common for the client to feel quite sore after a Deep Tissue session for up to several days.
To the uneducated client, it feels like the massage therapist is getting down to where the problem lies, and she is. However, the question becomes, “Are you being effective simply by virtue of reaching the correct level in the layers of muscles?” The answer is: It is not how deep you go, but how you go deep. Once you find the level of the problem in the layers of muscle tissue, what matters is how the tissue will be restored to normal. In its original form, Deep Tissue failed to resolve most of the problems that Swedish had already failed to solve. Consequently, serious therapists were left needing to look deeper into the nature of the tight, sore places they wanted to relieve and how to accomplish that goal.
State of the art research on the nature of the painful problems massage therapists are presented with suggests several possibilities. The main possibilities are: lack of blood flow to the tissues (ischemia), muscle spasms, trigger points in muscles and fascia, myofascial involvement like adhesions, poor posture and its complications, nerve entrapments, subluxations, abnormal joint dynamics, nerve impingements, nerve irritations, and muscle tone problems brought on by electrolyte imbalances, especially involving calcium, magnesium or potassium. Research also shows that unresolved mental and emotional issues can contribute to the creation of deep, sore muscle problems as can energetic imbalances best addressed by working on acupuncture points and meridians. It turns out that Deep Tissue, as originally conceived, fails to address any of these possible factors in a systematic way.
Over the past 40-50 years, Western bodywork has evolved considerably. Ray Nimmo, Bonnie Pruden, and Janet Travell have expounded on the nature of “trigger points” and how to release them. Ida Rolf developed the theory of involvement in the myofascial system playing a key role in pain and posture in the body. Chiropractors and Osteopaths have developed techniques that address subluxations, abnormal joint dynamics and a host of musculoskeletal conditions. Occupational therapists have advanced our understanding of the role of the modulation of the nervous system in autism, learning disabilities and many neurological issues. Chiropractors, osteopaths and massage therapists have advanced our understanding of the possibility of cranial manipulation and complementary bodywork techniques helping to integrate neurological function not only in the brain and spinal cord but also throughout the entire system. Biomechanical research has shown the role of the musculoskeletal system in nerve irritation and entrapment, as well as the limited possibility of nerve entrapment from skeletal misalignments. Nutrition, psychotherapy, and acupuncture have also proven helpful in treating myofascial and musculoskeletal conditions.
For the serious massage therapist, the main options beyond Swedish massage are Neuromuscular Therapy to address ischemic muscle tissue and muscle tone; myofascial manipulation to address fascial length; Muscle Energy Techniques to address joint dynamics, fascial organization and muscle tone; lymphatic drainage massage to address lymph flow; craniosacral techniques to address CSF flow problems; and Asian techniques like acupressure, shiatsu, Polarity Therapy or Reflexology to address energetic blockages and imbalances. Active and passive stretching techniques also contribute to relieving serious issues. A combination of all these techniques can be applied to address pain and other symptoms as well as posture and structural integrity. Structural balance enhances overall health, moving us toward optimal health.
Modern Deep Tissue as presented by Don Scheumann in his textbook, The Balanced Body, states that Deep Tissue technique integrates NMT, myofascial, Swedish, cross fiber, Deep Tissue, Polarity and Shiatsu into an integrated system of massage. It is a good idea to create an integrated system of massage that uses a combination of effective techniques aimed at using whatever works for a particular case, and he has done just that. His system does not include Muscle Energy Techniques which are very effective, yet gentle and safe. It is just confusing to call such an integrated system: Deep Tissue. Deep Tissue is one of the six techniques combined into Scheumann’s integrated system, but he then calls the whole system – Deep Tissue. Unless massage schools use his textbook, what they teach as Deep Tissue is probably something completely different from Scheumann’s version of Deep Tissue. Consequently, some practitioners, who were trained years ago, mean slower, harder, deeper Swedish when they say they do
Deep Tissue. More recently, therapists from schools that use Scheumann’s book mean his integrated version of Deep Tissue. Other therapists, who attended a school that uses a different textbook, teach something different. Yet, all of them claim to do Deep Tissue. Consequently, it is imperative that you ask your client what they mean by Deep Tissue. It could be perceived as several different things by different people. You should not assume you know which version they mean, or even if they know what Deep Tissue actually is.
Modern Deep Tissue has evolved to a system that integrates a combination of Eastern and Western techniques to address pain, posture, fascial length, muscle tone and, potentially, overall wellness. It is now no longer a failed technique like the original form of Deep Tissue. In its modern form, it is performed with awareness of how deep is “too deep,” with awareness of mind/body issues that can result in “emotional release,” and with attention to sophisticated principles of physiology. When utilized by a knowledgeable practitioner, Deep Tissue is an effective technique that integrates NMT, Myofascial Release, Polarity Therapy, energy work and stretching into the Deep Tissue session. This version is similar to the system taught at ASHA, School of Massage (my school), but it does not include METs, and it emphasizes Deep Tissue as the foundation technique rather than the gentler and more effective NMT. What ASHA students do should be considered “advanced Deep Tissue,” because NMT is more effective than Deep Tissue (original form) in releasing the deep, sore places in muscles and is less painful to receive.
ASHA trained therapists know that their work goes as deeply into the body as any system of bodywork possibly could. As a client explains what she means by Deep Tissue, look for the sense that she is interested in pain relief or something more substantial than relaxation. Listen to see what she means by Deep Tissue. Is she describing slow, deep, hard Swedish or some type of integrated massage? Does she know and describe what techniques are parts of what she thinks Deep Tissue is? Once you know what she means by Deep Tissue, you should assure her that your work will address her goals, and that you do an integrated version of Deep Tissue and not the older version of Deep Tissue. Do not try to convince her before you start the session that what you do is better than what she is used to receiving. You are more likely to get into a debate or a power struggle with someone who thinks they know better than you what Deep Tissue is or what works for them. Don’t go there. Focus on reassuring them that you do deep work. Let the work speak for itself, and coach them up a little toward what you know if the opportunity presents itself. Look for her to open the discussion of the differences between what you are doing and what she is used to receiving. Try to educate her but avoid mental conflict with an opinionated client. If she insists that you should be working deeper to be effective with her, try to explain the physiology of your technique. If she remains unsatisfied and you feel that what she wants does not match the pressures that you are comfortable working at, simply suggest that she may be happier working with someone whose range of pressure is greater than you are comfortable using. You know classmates or colleagues whose natural pressure is harder than yours. Send her to one of them. More often than not, the results you get with a superior technique will win over your client to the type of work you do.
Handling a request for Deep Tissue massage will occur frequently in your career as a massage therapist, especially because it is requested so often. Now you know how Deep Tissue evolved into what it is today. You also understand how to begin a conversation that will help you avoid some problems that are likely to occur because of the confusion about what Deep Tissue actually is.
Stan Dawson, DC is Co-owner and Executive Director of ASHA, School of Massage in suburban Atlanta. Dr. Dawson is a pioneer in the field of holistic health. He started the first holistic health center in the southeast in 1978. He is on the Board of Directors of the Alliance for Massage Therapy Education. He is also on the Education Work Group (EWG) for the Academic Consortium for Complementary and Alternative Health Care. The EWG is developing a course to train health care practitioners from both conventional medicine and complementary health care to work as a team. He is passionate about the role of touch, the value of soft tissue work and changing the focus of the health care system from treating illness to creating wellness.
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