Introduction
Massage is a commonly used manual intervention in physiotherapy, rehabilitation, and health promotion. Contemporary understanding of massage is based on an integrated approach that includes both mechanical effects in tissues and neurophysiological responses (including pain modulation and regulation of the autonomic nervous system) (Keter et al., 2025). In clinical practice, massage should be treated as a purposeful therapeutic intervention, the effectiveness of which depends on appropriate stimulus selection, dosage, the therapeutic context, and individual patient characteristics.
From an evidence-based perspective, overly simplified explanations should be avoided—particularly those that reduce the effects of massage solely to “removal of metabolic by-products” or “muscle cleansing.” Instead, massage should be described as a complex form of stimulation that can influence symptoms and function through both local tissue-related mechanisms and processes occurring within the central nervous system (Crawford et al., 2016; Keter et al., 2025).
1. Mechanical effects: influence on tissues and fluid dynamics
Massage involves the application of mechanical stimuli such as compression, stretching, and shear forces to soft tissues. These stimuli may influence:
- Local circulation and tissue temperature
- Muscle and fascia tone as well as viscoelastic properties of the myofascial system
- The distribution of interstitial fluids and venous/lymphatic flow (Keter et al., 2025)
It is important to emphasize that the effects of massage are not limited to superficial layers only. Appropriately selected techniques (including deep-tissue techniques) may also influence deeper structures, modifying tissue tone, tissue tolerance, and mechanical conditions within the myofascial system. From a clinical perspective, it is more accurate to describe massage as supporting regulation of the local tissue environment (e.g., mechanical loading, fluid dynamics, inflammatory response and recovery processes) rather than as “flushing out metabolites” (Keter et al., 2025).
2. Neurophysiological mechanisms: pain modulation and autonomic responses
A significant portion of the clinical effects of massage may result from sensory modulation and neurophysiological responses. Touch, pressure, and stretching activate mechanoreceptors and interoceptive systems, which can influence pain perception through:
- Mechanisms of segmental pain inhibition (the so-called “pain gate”)
- Activation of descending inhibitory pathways
- Changes in central processing of nociceptive input (Keter et al., 2025)
Contemporary models of manual therapy emphasize that the analgesic effects of massage often arise primarily from central and neurophysiological mechanisms rather than solely from local mechanical changes in tissues (Keter et al., 2025). This means that massage can be a particularly effective therapeutic tool when pain and increased muscle tone are protective, reflexive, or maintained by heightened excitability of the nervous system. Massage may also reduce stress-related arousal and influence autonomic activity, promoting relaxation and improving overall well-being (Crawford et al., 2016; Keter et al., 2025).
3. Movement restrictions and modern interpretation of “barriers”
In classical descriptions of manual therapy, the term “barriers” was commonly used. In modern evidence-based practice, more precise clinical terminology is recommended. Movement restrictions may be described as:
- Reduced range of motion (ROM)
- Reduced tissue tolerance (pain, guarding, irritability)
- Impaired gliding between structures (muscles, fascia, neural tissues)
- Changes in motor control and movement strategies (Keter et al., 2025)
Movement capacity results from dynamic interaction between joints, muscles, fascia, the nervous system, and psychosocial factors. Selection of massage techniques should be clinically justified and matched to the underlying mechanism of dysfunction, rather than based on a schematic assumption that every tissue-related problem requires “relaxation” (Chimenti et al., 2018).
4. The role of therapeutic context and safety
In manual therapy, the therapeutic context plays a crucial role: communication, a sense of safety, trust, and patient expectations. These factors may modify the body’s response to manual stimulation. Therefore, massage should not be seen solely as a mechanical technique, but as a clinical intervention whose effects arise from the interaction between physical stimulation and psychophysiological processes (Keter et al., 2025).
5. Post-treatment responses and clinical safety
In some patients, post-treatment responses may occur after massage, particularly following the first session or after more intensive treatment. Most commonly, these include:
- Tissue tenderness
- Temporary increase in symptoms
- Fatigue, malaise, or a sense of “heaviness,
- Short-term changes in general well-being
The patient should be informed about these possibilities, which increases their sense of control and reduces the risk of discontinuing therapy out of fear of adverse effects. In cases of excessive or atypical reactions, the therapist should reduce the dosage (duration, intensity, technique) or temporarily modify the treatment plan.
Special caution is recommended in patients with:
- Uncontrolled hypertension or serious cardiovascular disease
- Advanced osteoporosis
- Significant neurological disorders
- Acute inflammatory conditions or infections
- Other conditions that increase the risk of complications during manual therapy
Massage can be applied safely and effectively in clinical practice provided that the patient is appropriately assessed, techniques are selected carefully, and the therapist accounts for nervous system reactivity and overall health status (Crawford et al., 2016; Liao et al., 2016; Vijayakumar et al., 2024).