Practical Science on Movement and Pain

The Monday Effect, or Why Your Massage Lasted Only Two Days

Monday, Monday
Every other day of the week is fine. Yeah

Here’s a common frustration for therapists of all kinds (and their clients.) After a session, whether it’s massage, chiropractic, a Feldenkrais movement lesson, Rolfing, osteopathy, whatever, the client feels great, as if there has been a major progress. Pain is reduced, coordination improves, movement feels easier, lighter, more efficient. And then, two days later, things are pretty much back to normal. Of course this doesn’t always happen, but I’m sure it is a familiar situation for many therapists. I know one (ex) chiropractor who called it the parking lot effect, because his clients looked great when they left his table but were already degenerating by the time they reached their cars. I’ve always been very curious about this and have wondered why. Although I don’t have any definite answers, perhaps this has something to do with what neuroscientist Alvaro Pascal Leon called the Monday Effect.

The Monday effect

Pascal used transcranial magnetic stimulation (TMS) to look at the brains of subjects in the process of learning to read Braille. The subjects studied Braille five days a week, two hours a day. The TMS revealed that the parts of the brain devoted to sensing the reading fingers grew bigger than the parts for sensing the non-reading fingers. Further, these parts, called maps, got even bigger as the students’ reading got faster. This makes sense – if you want better sensation in your fingers, you might want more brain area devoted to the task of sensing. The interesting part was the pattern of progress and regression in map growth.

Pascal noticed that map growth regressed during each weekend when practice did not occur. Specifically, the maps he measured on Friday showed dramatic expansion as a result of five days of practice, but by Monday the maps were returning to their baseline size. This happened for about six months, then the pattern changed. Now the Friday maps grew slower, and the weekend regressions were less, so that the Monday maps were starting to grow. The growth of the Monday maps leveled off at ten months. At this point the students took two months off. When they returned their maps suffered no regression – their size was unchanged.

The stages of learning

The fact that the Braille skills eventually became permanent after some threshold of practice is consistent with conventional motor learning theory, which observes that the process of learning a physical skill proceeds in stages. First, in what is called the cognitive stage, performance of the skill requires great mental effort and conscious attention. After enough practice, performance of the skill eventually becomes “automatic”, it requires almost no conscious attention or effort at all. Imagine the first time you drove a car. You really had to pay attention to exactly what you were doing – where to put the right foot, the left foot, etc. After a while, these skills become automatic, freeing your conscious brain to perform other activities while driving, such as talking on a cell phone, enjoying a delicious beverage, texting, or offering helpful suggestions to other drivers with appropriate hand gestures. And, not only does the skill become automatic, it becomes relatively permanent, i.e. not something you will ever forget how to do, like riding a bike.

So the fact that Pascal’s Braille students eventually reached a larger map size that was stable during layoffs is not surprising. But why did the changes evaporate each weekend for the first six months? Why was there a Monday effect? Pascal explained the results in the following way. The great initial improvements that occurred by Friday were the result of strengthening existing neuronal connections in the brain, as opposed to growing new connections. This process is quick but temporary. The improvements that remained on Mondays were long-term changes that required the formation of new neuronal linkages. This process is more time consuming but has greater permanence. The pattern should be easy to recognize because we have all experienced numerous examples in real life.

When we cram for a test, we can quickly accumulate great amounts of knowledge sufficient to pass the test, but the information will soon be forgotten. The maps were only temporary. On the other hand, any skill that we develop to the expert level, such as fluency in a language, or mastery of an instrument or sport will always be there to some extent. Even after years of neglect, the foundation will remain, and the prior level of skill can be recovered fairly easily with just a little brushing up. The maps are fairly permanent.

So what does this have to do with therapy?

As readers of this blog know, I believe that many problems with chronic pain or physical performance are related to problems with the body maps. For example, as seen above, good coordination or movement skill depends on good body maps. Moving without pain and accurately sensing what is going on in the body is also very much of a skill. In fact, research shows that confusion in the brain’s sensory maps can lead to pain and that correcting such confusion can reduce pain.

Based on these ideas, I believe that a significant portion of the benefit seen in most therapies, whether movement oriented or hands on, is a result of making beneficial changes in the maps. (If you are lost at this point maybe it would help to click on the links above for some background.) In other words, if you feel better after a massage session or a yoga class, one important reason is that your maps have been altered for the better. If you feel back to normal a few days later, perhaps this is akin to the Monday effect – the map changes were only temporary. So does this mean you need to do some form of therapy every day for six months to see a lasting benefit? I think the answer depends on whether your improvement requires learning totally new skills or just brushing up on or modifying old ones. I’ll use two opposite examples from either end of the spectrum to explain.

Brushing up versus starting over

Imagine someone who sustains a major injury to their body such as an amputation, or broken bone, or major soft tissue scar that substantially changes the structure of the body and makes certain old movement patterns simply impossible. It is obvious that this person needs to learn some new movement skills from scratch. This means building new maps, and this takes time and effort comparable to learning a new language or instrument. We can expect that the rehab process may take a long time, and might involve many set backs or Monday effects on the way.

On the other hand, imagine a healthy and athletic person who has developed some back pain following recovery from a sprained ankle. Perhaps the back pain was caused by some faulty movement or sensory habits (sensory motor amnesia) that developed during the process of protecting the ankle while it was healing. Maybe all that he needs is a reminder of the old healthy sensory motor patterns that he used successfully for years, but then put on hold for a month or two while the ankle healed. In other words, this person already has the maps needed for a pain free back, he just needs to brush up on them a little. For this person, it is not unreasonable to hope that he could be cured with just one movement or massage session, or any other stimulus that reminds him of the capabilities of his old self. He will not necessarily have a Monday effect, because the maps are already there.

Of course, most clients fall somewhere in between these two extremes. We might expect that any one person will have a variety of issues, some of which can be resolved with a little brushing up, others that will require some new skill building. Most people who do not regularly move their bodies through a full range of options will get a little rusty with certain sensory/movement skills. These smudged maps might be easily clarified with appropriate movement or bodywork. Improving these rusty spots is like grabbing some low hanging fruit – it accounts for the easy successes that have permanent effects.

At the same time, the average person will also probably have some pain or movement defects that are not so easily fixed. The bodies we live in are always changing their structure day by day – sometimes suddenly from a traumatic accident but always gradually from the aging process – muscles get weaker, bones and cartilege get rougher, discs bulge, rotator cuffs tear, connective tissue gets scarred and stiff. As I stated in an earlier post, it is very possible and even likely that these structural problems will not result in pain, but this will depend on the brain’s ability to start sensing and moving the altered body parts in at least slightly different ways. In other words, a changing body requires changes and updates to existing movement and sensory skills. Hopefully the body changes happen gradually, and you make frequent minor updates. But if the brain maps don’t keep up with the body structure for whatever reason, either because of a long layoff from skilled movement and sensation, or because of a traumatic injury, you might end up with a major disconnect between body and brain that requires some real work to be cured. For example if you haven’t thrown a baseball for twenty years, you probably won’t find your old technique useful or safe anymore. The old maps for throwing are now useless – you need to build a whole new set of throwing maps before you can throw safely again.

So what can we do with this information? First, prevent map confusion – keep moving so that your brain is always up to date on how to move and sense the ever-changing body. Second, brush up on old skills. This is the low hanging fruit. Maybe you can get some quick and easy benefits by remembering how to use some maps that are already in place. Some good options for curing sensory motor amnesia might be the Feldenkrais Method, Z-Health, martial arts, yoga or some bodywork. Third, if these things don’t work, build some new maps. This might take some time and effort, in the form of frequent movement practice like one of the above or a daily sensory practice like meditation or just mindfulness.

Fourth, be aware of what is perhaps the most challenging problem in regard to chronic pain and the remapping process. I have been talking about how to build new maps and skills, but not about how to dismantle old maps. What if you spend so much time moving and sensing in a painful way that the painful pattern becomes an ingrained habit? The bad habit now has its own well-established map in long-term storage. The painful pattern will compete with any new healthier skills you try to substitute. The problem now is not just one of how to learn new skills, it is how to unlearn old ones. And that’s a big problem that requires real patience. Perhaps the subject of a different post.

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29 Responses to The Monday Effect, or Why Your Massage Lasted Only Two Days

  1. darius sohei says:

    these posts are great, keep it up, thx

  2. Wonderful writing. I’m going to start saving these and pointing future students this way as well.

    • Todd Hargrove says:

      Thanks Barrett,

      I appreciate the compliment. It means a lot coming from an excellent writer. Also, as you probably know, you deserve credit for introducing me to many of the ideas that form the basis for the blog.

  3. Sheffield physio says:

    I’ve only just found your web site. It’s excellent, I’ve very much enjoyed reading it. I have very similar views myself and the more people that start saying this stuff the better. You never know, one day we might even stop chopping painful bits of the body off!

    • Todd Hargrove says:

      Thanks David!

      Maybe I can make chopping the painful bits the topic of my next post.

      • Sheffield physio says:

        I love the thought process of orthopaedic surgeons….. If cutting the disc out doesn’t work, let’s burn it instead!…. Which i’ve been told is the latest craze.

  4. Todd Hargrove says:

    Burning? Hadn’t heard that one. It works for crop management.

  5. [...] The Monday Effect › LikeBe the first to like this post. [...]

  6. jim says:

    Great posts and great site. It’s really opened my eyes up to the role of the CNS.
    Please keep posting (at a comfortable rate).
    Separately, I think the title of this post should read “only” two days.

  7. V. says:

    Hey Todd.
    Im a competitive powerlifter and was sent to your site a week ago and it is very interesting. Your writing is very clear and what you say “makes sense”. I thought I had it right with special sessions to work on flexibility and such to maintain the tension-length relationships in muscles and prevent them from getting stiff but the more you think you know…

    There is no z-health nor Feldenkrais method on my country (Portugal) but I’ve been told to follow stretch to win and do the stretches in a relaxing way and not a “TOUCH YOUR HEAD TO YOUR KNEES NOW OR I’LL SHOOT YOUR DOG” way.

    Is there any chance in the future you’ll write about how to approach general and specific strength training from your perspective?

    Cheers!

    • Todd Hargrove says:

      Rabdallahsuperstar,

      Thanks for the comments. Glad you like the blog. I would guess there are some feldenkrais practitioners in Portugal, buy maybe not.

      As to strength, I think all my posts bear on this issue to some extent, because practical strength always depends to some extent on optimal coordination and freedom from pain. But I don’t anticipate doing posts on reps, sets, exercises, that type of thing, at least not right now. There are many excellent sources for that, e.g. Lyle McDonald.

  8. V. says:

    Thanks for the quick reply Todd.
    I’ve been searching and sadly if there are there is no advertising at all on the internet.

    I actually was talking about stuff that is not so much common knowledge. For example I was flabbergasted when I read this: http://toddhargrove.wordpress.com/2010/05/19/should-you-stretch-a-sore-muscle/
    It is pretty general practice to stretch to feel better and stretch in not a zen relaxing way but in a “I need to get further” way if you know what I mean. So more about what would not be common knowledge.

    I have devoured Lyle’s knowledge over the years, also Matt Perryman’s, Borge Fagerli’s, Mike Tuschscherer’s and a few other. But even Mike seem to reccomend stretching for flexibility AFAIK so your post was very much news to me.

    Cheers Tood

  9. Anoop says:

    In the strength & conditioning g field, everything is about muscle, bones, fascia… and hurt always means harm there. I am not surprised since most do not read or work in the rehab area. All the people who mentioned are not real experts in the rehab field. The so-called experts int he field are still clinging dearly to the bio-mechanical model.

    • Todd Hargrove says:

      Anoop,

      I wonder how long the paradigm shift will take? Perhaps there is something inherently counterintuitive about an ectodermal perspective.

  10. Anoop says:

    The more we people believe the greater the bandwagon effect and greater the confirmation bias among experts. Even people who have counter evidence will keep their mouth shut to confirm with the crowd.

    I wrote an article abt posture almost 6 years back and introduced the weak structural -pain relationship and I thought in couple of years this will be common knowledge. But still nothing has changed.

  11. V. says:

    Is this the kind of thing we are talking about: http://www.youtube.com/user/mwich40#p/u/1/JhwkdBuU0TA ?

    It seems quite exploratory (I retained that word for whatever reason). Doesn’t look slow though, but it seems fun and almost like he is a child playing with his body.

    • V,

      Yeah, I like it. Looks exploratory, curious, playful, relatively gentle. Interesting novel movements. Looks like he is paying very close attention to what he is doing and making sure the movements have quality.

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  13. [...] or movement is used repeatedly in a coordinated and mindful fashion, there are actual physical and observable changes in the part of the brain that controls that body part or movement. This is part of the reason why [...]

  14. Joe Kistner says:

    Hi Todd,

    Thanks for all the great info. You have a great gift for interpreting complex concepts into easily understandable terms.

    I, too have been plagued by this “Monday Effect”. In the last several years, through clinical trial and error, I may have found a key to unlock some of what could be happening for most patients/clients.

    It all boils down to the feet and footwear.

    You perform your therapy, whatever you do, and get great results. As soon as they walk out the door though, if the joints in their feet are not moving or are not able to move properly because of their footwear, a whole cascade of events occurs that may negate all your hard work.

    If they lack joint movement, joint mechanoreceptors will not be sending info to the brain, and they will have a big void in the brain map for that area. The CNS is under threat and in survival mode. If you remember in Z ( 2-3X body weight 3-5 thousand times a day) our body is having to balance and dissipate tons of force daily, and it all starts with the foot hitting the ground. What I’ve discovered is that the CNS/brain, in an effort to protect the foot joints that have limited or no movement, inhibits proprioception in the muscles up the chain. It follows the muscle sling systems contained in the back force transmission system. Usually lower left to upper right. This may cause compensations to occur all through the body, even up to the neck. Other joints up the chain have to go into the extreme ranges of motion in an effort to make up for a lack of movement occurring in the feet. Plus, the body has to deal with large amounts of abnormal forces going up thru the joints that have not been balanced out at foot level. I find it crucial to restore proper joint function in the feet and to wear shoes that do not inhibit proper joint motion. This keeps the body out of this dysfunctional pattern, and helps preserve your work. I also found footwear that you have to hold on with your toes (flipflops, clogs, etc.) is not functional and will cause compensations. This may be due to the 1st ray not being able to fully dorsiflex, interfering with the windlass effect, causing an unlocked foot in supination.

    In the final analysis, when your clients walks out, are they moving and balancing the forces up the body, or are they reinforcing and perpetuating imbalances and compensations? Might be something to consider.

  15. Joe,

    Thanks for the comment and glad you like the blog.

    That is an interesting hypothesis about the footwear, it could easily be a contributing factor in regression. The feet are certainly an important part of the body and shoes for many people are a big problem. However, I would hesitate to conclude that the feet are the key to the puzzle – every body part has its role to play, plus the the whole is greater than the sum of its parts. As Dr. Cobb might say – all the body all the time!

  16. [...]  “The Monday Effect” from Better Movement. [...]

  17. [...] still need to do them. Some of the possible reasons for this are looked at on Todd Hardgrove’s Better Movement blog. As he suggests the problems aren’t just physical from the point of view of restrictions [...]

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  19. [...] The monday effect Har du någonsin undrat varför dina patienter verkar kunna hoppa från bänken efter en behandling men kommer tillbaka två dagar senare med exakt samma problem? Todd Hargrove har en idé  om hur det fenomenet uppstår. [...]

  20. Karen says:

    As a NO HANDS Massage therapist I ask my clients to walk barefoot around my therapy room after their treatment.
    I am also a birth worker and teach Hypnobirthing whilst I am also studying to become a certified EFT practitioner. The mind and body are linked very closely in many ways. Just as what plays out in the mind plays out in the body so a physical trauma can have an emotional impact.
    I’m fascinated that my various ‘hats’ are coming closer and closer together as I learn about us humans. ;-)

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