Does massage need to go towards the heart?

Many therapists were taught a simple rule early on. When you work on the limbs, move the tissue towards the heart. From the feet to the hips. From the hands to the shoulders. The usual explanation was circulation. The idea was that these strokes help return blood to the heart and improve blood flow around the body.

It sounds sensible, and for years it was repeated as if it were basic fact. But when you stop and look at the science, the story starts to wobble.

That does not mean massage is pointless, or that direction never matters. It means the explanation needs cleaned up.

Massage can influence how someone feels, locally and more generally. It may affect comfort, pressure sensitivity, muscle tone, body awareness, and the overall experience of being touched. It can also feel calming, reassuring, or relaxing. But that is very different from saying a therapist is manually pushing blood around the body in a meaningful cardiovascular sense with a few upward strokes.

One of the more useful findings here is that limb perfusion has been shown to increase with effleurage regardless of stroke direction. That should immediately make us more cautious about the old claim. If massage only ‘worked’ for circulation when it was done towards the heart, direction ought to matter much more clearly than it appears to.

There is also a difference between local and systemic effects. Some research suggests massage may alter local blood flow in the tissue being worked on, at least for a short time. That is plausible. Local pressure, friction, and mechanical stimulation may change what is happening in the area under the hands. But that is not the same as boosting circulation throughout the whole body. Those are two very different claims, and they are often blurred together in teaching.

That blur is where the trouble starts.

A person’s circulation is not waiting for a therapist to come along and sweep it home. Blood flow and venous return depend on pressure gradients, vessel structure, valves, breathing, and muscle activity. The body already has systems for this. Walking, moving, changing position, and using the calf muscles do far more for venous return than the old massage story tends to admit. Once you remember that, the idea that routine massage strokes are somehow driving blood centrally starts to sound more like tradition than physiology.

And yet the old line survives because it is tidy. It gives a neat reason for a familiar technique. Therapists like rules, especially when they sound clinical. Clients often like them too. They make practice feel precise. But tidy is not always true.

So where does that leave us?

It leaves us with the chance to be more honest. A long stroke from ankle to thigh may still feel good. It may feel soothing, connected, rhythmical, or grounding. It may help the client settle into the session. It may help the therapist create flow and structure in their treatment. Those are all fair reasons to use it. We do not need to prop it up with a circulation claim that is far bigger than the evidence can support.

There is also a more modern and more believable way to talk about some of these pleasant effects. Research into C tactile, or CT, afferents has helped shift attention towards affective touch, in other words touch that feels emotionally and socially pleasant. That does not explain every kind of massage, and it does not reduce treatment to one mechanism. But it does give us a better language for why some strokes feel calming, safe, and regulating without pretending we are manually pumping blood around the body.

That is a far more transparent place for therapists to stand.

Instead of saying, ‘I’m doing this to move blood back to your heart’, we might say, ‘I’m using longer strokes here because they often feel soothing and flowing through the limb.’ Or, ‘This style of touch can feel calming and connected.’ That language is simpler, more defensible, and probably closer to what the client is actually experiencing.

So, does massage need to go towards the heart?

Not as a blanket rule, and not because we have strong evidence that routine massage strokes can move blood around the body in the way many of us were taught. Therapists can still work proximally when it suits the treatment, the person, and the feel of the session. But we should stop dressing that choice up as a cardiovascular intervention unless we can genuinely defend it.

Sometimes the technique can stay, but the explanation needs to go.

References

Matsuda, Y., Nakabayashi, M., Suzuki, T., Zhang, S., Ichinose, M. and Ono, Y. (2022) ‘Evaluation of local skeletal muscle blood flow in manipulative therapy by diffuse correlation spectroscopy’, Frontiers in Bioengineering and Biotechnology, 9, article 800051. Available at: https://doi.org/10.3389/fbioe.2021.800051. 

Rodrigues, L.M., Rocha, C., Ferreira, H.T. and Silva, H.N. (2020) ‘Lower limb massage in humans increases local perfusion and impacts systemic hemodynamics’, Journal of Applied Physiology, 128(5), pp. 1217–1226. Available at: https://doi.org/10.1152/japplphysiol.00437.2019. 

Schirmer, A., Croy, I. and Ackerley, R. (2023) ‘What are C-tactile afferents and how do they relate to “affective touch”?’, Neuroscience & Biobehavioral Reviews, 151, article 105236. Available at: https://doi.org/10.1016/j.neubiorev.2023.105236. 

Tauraginskii, R.A., Lurie, F., Simakov, S., Agalarov, R., Khramtsov, P., Babushkin, M., Gurina, T. and Borsuk, D. (2025) ‘The human lower leg muscle pump functions as a flow diverter pump, maintaining low ambulatory venous pressures during locomotion’, Journal of Vascular Surgery: Venous and Lymphatic Disorders, 13(1), article 101996. Available at: https://doi.org/10.1016/j.jvsv.2024.101996. 

Vijayakumar, V., Boopalan, D., Ravi, P., Chidambaram, Y., Anandhan, A., Muthupandi, P., Shanmugam, P., Kuppusamy, M. and Karuppasamy, G. (2024) ‘Effect of massage on blood pressure in patients with hypertension: A meta-analysis’, Journal of Bodywork and Movement Therapies, 37, pp. 109–114. Available at: https://doi.org/10.1016/j.jbmt.2023.11.028.