Episode 131: Aubrey Gowing – What Exactly Is Chronic Pain and Where Does Manual Therapy Fit?
Chronic pain is one of the most demanding areas of manual therapy practice.
The client may arrive with recurring back pain, persistent tendon symptoms, an old injury that never quite settled, or a problem that seems to disappear and return without an obvious cause. They may have seen several practitioners, tried a series of treatments and developed their own explanations for what is happening.
The therapist is then left with several questions.
Where should treatment begin? Is the painful area also the source of the problem? How much pressure is useful? Should the goal be pain relief, structural change, improved movement, nervous system regulation, or some combination of these?
In Episode 131 of the Folding Towels Podcast, Jackie Kerin and David Clayton speak with Irish manual therapist and educator Aubrey Gowing about chronic pain, corrective manual therapy and the clinical principles that guide his approach.
Aubrey is the author of four books, including the Myoskeletal and Sports Therapy series and Kinesiology Taping Strategies. Together with his sister Alison, he runs HCD Massage School in Dublin.
His central argument is that therapists need more than a collection of techniques. They need a practical framework for deciding what to assess, where to begin and how to respond when the painful area does not appear to be the whole story.
A lifelong path into bodywork
Aubrey’s introduction to massage began unusually early.
His parents attended their first yoga class while his mother was pregnant with him. His father later trained as a yoga teacher and, on Sundays, lined up Aubrey and his six siblings to practise postures, breathing exercises and meditation.
The family grew up with what Aubrey describes as a holistic approach to health. His father later opened a holistic healing centre in Dublin in 1986, and each of the children completed at least some massage training.
Most moved in other directions. Aubrey and his sister Alison stayed.
Aubrey initially trained in holistic and relaxation massage. He describes himself as a naturally lighter therapist and remains interested in the skill required to produce a useful response without relying on heavy pressure.
His professional interests broadened as Alison explored new methods and brought them back to practise with him. He later studied sports massage and became particularly interested in the treatment of recurring and chronic musculoskeletal pain.
Further study with educators including James Waslaski and Erik Dalton shifted his approach again. Aubrey began combining soft tissue work with non-thrust joint mobilisation and a more structured process of assessment.
He describes the change through his clinical results. Back pain cases that once took several sessions to improve began responding in fewer appointments.
For Aubrey, becoming more effective did not undermine the business model. He found that people who experienced good results referred others. Faster outcomes generated trust and reputation rather than removing the need for a clinic.
That distinction is useful for therapists who feel pressure to secure repeated bookings. A treatment plan should serve the client’s presentation, not the clinic’s desire for recurring revenue.
Acute injury and chronic pain are not the same problem
One of the first distinctions Aubrey makes is between acute injury, acute pain and chronic pain.
An acute injury usually has an identifiable mechanism. Someone rolls an ankle, tears tissue and develops swelling, heat, redness and pain around the injured area. The body must then move through its own repair process.
In that situation, the therapist cannot simply remove the injury. Treatment and advice must respect the stage of healing.
Chronic pain often presents differently. Symptoms may build gradually, appear without a distinct traumatic event, settle for a time and then return.
Aubrey uses shin pain as an example. A client may feel burning or discomfort through the front of the lower leg, but his approach is not to assume that the painful area is the only relevant tissue. He looks for broader patterns, including the function of posterior tibialis and its relationship with the anterior compartment.
This reflects one of the main principles running through the episode:
“Where it hurts is not where the problem is.”
That statement should not be applied as an absolute rule to every presentation. It is better understood as a prompt to assess rather than assume.
With a recent ankle sprain, the painful area may correspond closely with the damaged tissue. With a long-standing pattern of upper back pain, the therapist may need to examine the chest, shoulder girdle, cervical region, movement habits and nervous system response rather than repeatedly working between the shoulder blades.
The clinical task changes from treating a location to interpreting a pattern.
Tight, weak and taut are not interchangeable
Aubrey’s discussion of upper back pain offers a practical example.
Clients frequently describe the area between their shoulder blades as tight. The usual response is to massage or stretch the rhomboids.
Aubrey argues that the sensation of tightness does not necessarily mean the tissue is shortened.
In a person with rounded shoulders, the rhomboids may already be lengthened and under sustained tension. Aubrey uses the word taut to distinguish this state from a genuinely shortened muscle.
He compares the rhomboids to a guitar string being wound tighter. The string becomes increasingly tense, but it does not become shorter. Stretching it further may add to the load.
In this pattern, Aubrey begins with the structures drawing the shoulder forwards, including the pectoral region, anterior shoulder and arm. His general principle is to address shortened or overactive tissues before attempting to restore function to lengthened or weak tissues.
This is not simply a technique choice. It changes the structure of the treatment.
A therapist who works only on the back may provide temporary relief while leaving the broader pattern largely untouched. A therapist who assesses opposing muscle groups has more information to work with.
The same reasoning appears in Aubrey’s approach to low back pain. He often looks at the hip flexors, including psoas and iliacus, rather than assuming the lumbar area must be treated first.
During the episode, he describes helping a woman at a yoga retreat who had persistent back pain despite receiving regular massage throughout the retreat. After gaining permission from the host, Aubrey worked through the abdominal and hip flexor regions before addressing pelvic mechanics.
He reports that the woman’s pain reduced substantially after the session.
This is a case example, not proof that all back pain originates from the hip flexors. Its usefulness lies in the reasoning process. The site of symptoms did not dictate the entire treatment.
Clinical reasoning has to be explained
Assessment is only useful if the client understands why the therapist is doing something unexpected.
A client with back pain may reasonably wonder why treatment has started at the front of the body. A client with pain between the shoulder blades may question why the therapist is working around the chest and shoulder.
The therapist needs to explain the rationale without overwhelming the person with terminology.
Aubrey describes this as the ability to move between professional language and ordinary language. Too much jargon can leave the client confused or intimidated. Avoiding terminology altogether can make the explanation vague.
The aim is not to impress the client with anatomy. It is to give them a clear account of what the therapist has noticed, what they propose to do and what outcome they are working towards.
For example:
“You’re feeling the pain between your shoulder blades, but those muscles are already working in a lengthened position. I’d like to begin with the tissues at the front of the shoulder that may be contributing to that load. We’ll reassess as we go.”
That explanation is brief, specific and open to revision.
It also supports informed consent. The client knows why the treatment is moving away from the area they identified.
The discussion expands beyond explanation into therapeutic rapport. Aubrey argues that the client’s sense of safety, confidence and expectation can influence how they respond.
He also cautions against overpromising.
When working with presentations such as vertigo or tinnitus, he explains that some components may respond to work around the neck and surrounding tissues, while others may not fall within the reach of manual therapy. He gives the client a realistic account of what treatment may and may not change.
This is a more defensible position than guaranteeing an outcome.
A roadmap for acute recovery
Although the episode focuses on chronic pain, Aubrey also outlines his approach to acute soft tissue injury.
He calls it the ladder of recovery:
- Pain-free movement
- Pain-free stretching
- Pain-free strengthening
The progression begins with movement that does not reproduce or increase pain. As comfortable movement returns, the person gradually introduces stretching. Strengthening follows once movement and stretch can be performed without pain.
In this framework, pain is not automatically treated as an enemy. It acts as a boundary marker. If the person pushes beyond what the tissue can tolerate, they may aggravate the injury and slow recovery.
Aubrey contrasts this with complete rest and discusses his concerns about routine icing. He states that he no longer recommends ice as a default approach because he believes it may interfere with inflammatory and repair processes.
This part of the conversation reflects Aubrey’s clinical position. The episode does not provide a full review of the research on acute injury management, and therapists should continue to work within current professional guidance, scope of practice and referral pathways.
He also distinguishes acute injury from an acute flare of pain without recent tissue trauma.
For example, a person who develops back pain after gardening may have a sudden increase in symptoms without a new tear or rupture. Aubrey describes using heat followed by gentle stretching in that situation, provided there are no signs suggesting trauma or another contraindication.
The practical point is that “acute” does not describe one uniform clinical problem. The therapist still needs to determine what happened, when it happened and whether the presentation belongs in massage therapy at all.
Manual therapy works through more than pressure
Aubrey’s treatment philosophy does not equate effectiveness with force.
He describes four variables that influence treatment intensity:
- area
- angle
- pressure
- pace
Adjusting these variables allows the therapist to create a strong sensory input without simply pushing harder.
This becomes particularly relevant for therapists who are straining their thumbs, shoulders and wrists in pursuit of deeper work. Aubrey suggests that fatigue during a technique can be a sign that the therapist is trying to reach deeper tissues too quickly.
He quotes Leon Chaitow:
“Relaxed tissue is transparent to palpation.”
As superficial tissues soften, the therapist can perceive and access deeper layers with less force. If the client guards against painful pressure, the tissues become harder to interpret.
Aubrey extends this idea:
“You should be an invited guest into the deeper tissues, not somebody barging their way through a barred door.”
The language is memorable because it describes both technique and relationship.
Painful treatment may provoke guarding, reduce palpatory clarity and increase the physical cost to the therapist. A slower, responsive approach may provide better access while protecting the practitioner’s body.
Aubrey summarises this by saying that massage therapists may think they are treating muscles, but they are also communicating with the brain through the nervous system.
Within his framework, manual therapy influences tissue behaviour, sensory input, guarding and movement. It is not simply a matter of pressing hard enough to change a structure.
Common patterns can guide treatment, but they do not replace assessment
Aubrey teaches what he calls common patterns of dysfunction.
His Essential Eight series identifies muscles he believes are frequently involved in common presentations across different regions of the body.
For conditions below the knee, he places particular emphasis on posterior tibialis. For low back presentations, he commonly considers psoas and iliacus. For more localised spinal symptoms, particularly through the thoracic region, he discusses multifidus.
The attraction of this approach is obvious. Complex pain can leave therapists unsure where to begin. A list of commonly involved structures offers a starting point.
The risk is that a useful pattern becomes a fixed recipe.
Aubrey partly addresses this by continuing to emphasise assessment. The common pattern is a hypothesis to test, not a substitute for clinical reasoning.
The episode also moves into nerve mobility. Aubrey notes that nerves glide rather than stretch and suggests that restricted neural movement may contribute to some persistent symptoms that do not respond fully to soft tissue treatment.
Again, these techniques sit within training and scope. Aubrey explicitly advises therapists not to perform joint or nerve work without appropriate education.
A roadmap should reduce confusion, not encourage practitioners to work beyond their competence.
Where manual therapy fits
So where does manual therapy fit in chronic pain?
Aubrey gives it a central role, particularly where recurring symptoms are associated with patterns of muscle imbalance, altered tissue behaviour, joint restriction, nerve sensitivity or overuse.
His approach is strongly mechanical and clinically structured. He looks for relationships between muscles, joints, fascia and neural structures, then uses assessment to decide where treatment should begin.
The broader conversation also points to a second role.
Manual therapy can provide a safe, tolerable sensory experience. It can reduce guarding, improve confidence in movement, create short-term symptom relief and help the client understand their body differently.
Those effects do not require the therapist to claim that every symptom has a single hidden root cause.
Chronic pain is rarely simple, and one episode cannot account for every persistent pain presentation. Fibromyalgia, complex regional pain syndrome, trauma-related symptoms, inflammatory conditions and neurological disorders require more than one explanatory model.
The most useful part of Aubrey’s framework is not the promise of a universal answer. It is the insistence that therapists should assess, think, communicate and respond rather than repeatedly treating the same painful spot without asking why the symptoms keep returning.
A more deliberate way to work
Aubrey’s clinical roadmap can be condensed into several working principles:
Begin with assessment rather than assumption.
Distinguish recent tissue injury from persistent or recurring pain.
Consider the relationship between the painful area and opposing or contributing structures.
Treat shortened tissues before asking lengthened or weak tissues to do more.
Work from superficial to deep.
Use area, angle, pressure and pace to manage intensity.
Keep treatment within a tolerable range.
Explain the plan clearly enough that the client understands and consents.
Stay within scope, particularly when joint mobilisation or neural techniques are involved.
These principles do not remove complexity. They give therapists a more deliberate way to enter it.
Episode 131 offers an introduction to Aubrey Gowing’s approach to chronic pain and corrective manual therapy, with examples spanning back pain, shin symptoms, tendon pain, acute injury, palpation, nerve mobility and pain-free deep tissue work.
Listen to Episode 131: Aubrey Gowing – What Exactly Is Chronic Pain and Where Does Manual Therapy Fit? on your preferred podcast platform.
You can learn more about Aubrey and HCD Massage School at: https://hcd.ie