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The 4 Ds of Pressure Therapy

14 min read. Posted in Exercise Prescription
Written by Dr Chris Leib info

What industry do you picture when thinking about girthy, ribbed cylinders, firm balls, and mechanical vibrators?

Why, the fitness industry of course!

With such a wide variety of self massage tools on the market, it’s becoming harder and harder to differentiate a gym from a room in “Fifty Shades of Grey.”


Ok, getting past the slightly inappropriate attempt at humor, seriously, what are we doing with all these tools? Do they really help?

And what about all the controversy over what they are supposed to be doing?

Stretching the fascia, breaking up adhesions, releasing the muscles, what does any of that really mean?


I don’t mean to come off as another foam rolling hater, but some of these theories are just bonkers, but such is the fitness industry.

Anyway, with all the confusion about self-massage, self-myofascial release, smashing, body tempering, or whatever its being called these days, I thought I’d throw my hat in the ring and offer my take (combined with some research) on how to get the most out our mobility toys.



Right off the bat, we need a better term than foam rolling when discussing the benefits that can be offered from these implements.

The foam roller is like the old timer that got it all started but is slowly being pushed out by a younger, more tech savvy crew.


And you know what? He needs to go. This clumsy log is hardly a capable spokesperson for the very specific claims that have been made regarding its use. Moreover, this single tool lacks the versatility to be the face of a category of movement that is actually quite valuable.

So what should we call the collective use of these implements of pressure?

My vote is for pressure therapy. Allow me to explain.


What is Pressure?

The Oxford dictionary defines pressure as a continuous physical force exerted on or against an object by something in contact with it. A little academic maybe, but otherwise pretty clear. The common thread to the use of all these tools is that they create different variations of contact with an individual. Otherwise stated, they manipulate pressure.

Understanding the techniques involving these tools from the starting point of pressure manipulation allows us a broader view of the value they can offer. Instead of debating very specific structural theories of fascia or muscle we can look at their value in relationship to how they change our TOLERANCE to loads being applied to our anatomy.

In this way, we can develop a framework for working with these implements in much the same way as we approach other aspects of strength and conditioning or rehabilitation. Mainly through the concepts of progressive adaptation and motor learning.


What is Therapy?

What do you think about when you hear the word therapy? Do you ever give the meaning of the word a second thought?

The word is frequently accompanied by physical, psychological, occupational, etc. and the specificity of those qualifiers often bring our minds straight to the duties of those specific professions without considering the commonalities of all therapeutic endeavors.

This consideration is valuable in that it helps to differentiate interventions meant to be therapeutic from those meant to be curative.

So what are these commonalities and what are these differences?

To my mind, for anything to be considered a therapy, it needs to be a process that gradually changes an individual through progressive increases in challenge.

This category of treatment differs from those interventions, such as pharmacy and surgery, that allow for physical change without any gradual process. These approaches simply require that an individual stay compliant with what is prescribed, or put trust in a surgeon to fix what is broken. They are meant to mitigate or minimize symptoms so we can get back to business as usual with no change of mindset or lifestyle required.


Therapeutic processes on the other hand require an individual to learn something new, and develop some attribute or capacity that was previously absent or lost due to some change in circumstance (i.e. injury, onset of pain). These processes require that an individual be an active participant in their own change and are by nature not rapid and have no definitive endgame.

As a physical therapist, one of my first responsibilities is to make sure clients understand this difference. Due to the diagnostic fallacies promoted in orthopedics, patients often come in with a mindset that because I hurt, something must be broken and if what’s broken is not fixed I won’t be able to change for the better. Conversely, there is rarely any thought that a process needs to be undertaken to improve tolerance to certain actions or inactions to which we have grown sensitive.

To my mind, this difference between something needing to be structurally fixed versus something needing to be progressively desensitized is the major contrast between therapy and curative interventions such as pharmacy and surgery. Therapy is not meant to change structure in any direct way. Therefore, if something is broken, therapy won’t fix it. However, it can teach us how to allow the body to fix itself when possible, as well as teach us to gain access to attributes that would have been useful to prevent our problem in the first place.


Pressure Therapy: the Process of Improving Tolerance to and Learning from Various Pressures

Putting the definitions of pressure and therapy together we are left with a process of gradual change that allows us to gain both greater tolerance and knowledge of various pressures. This tolerance and knowledge will be explained in greater detail throughout the rest of this article via the easily remembered 4 D’s of Pressure Therapy. These D’s are as follows:

  1. Desensitization
  2. Deepening
  3. Duration
  4. Dissociation

Each of these four categories is necessary in order to get the most out of any pressure therapy technique, and will be deconstructed separately below. With this being stated, no one factor is of much value by itself, and requires the other three to create positive change.



In psychology, desensitization is a process that diminishes emotional responsiveness to a stimulus after repeated exposure to it. Simply stated, it is the process of allowing the body or mind to get more comfortable with something through experience.

We must be careful here not to confuse this process with a “grit and bear it” mentality, where we attempt to survive the pain of pressure via toughness and might. This approach does not teach the nervous system that the stimulus is not a threat, but instead, challenges the nervous system to come back harder with a more aggressive deterrent.

In order to truly desensitize, we must be willing to gradually accept the pressure. To accomplish this, we must make sure the stimulus is not so great that we are overwhelmed. Otherwise stated, we need to find the appropriate stimulus that provokes the onset of discomfort but is perceived as a manageable threat that we can spend some time relaxing into.

So how do we know we have found this appropriate starting point? The answer to this begins to link the concept of desensitization to other aforementioned Ds in the pressure therapy process.



For us to be sure the initial pressure we apply is appropriate, the pressure needs to be able to “deepen” into our anatomy. What this refers to is the ability for our body to accept the pressure in a manner that allows it to move through our superficial guarding strategies.

When we initially apply pressure to our skin, there will likely be a protective response to move that pressure “out” away from our tissues. This response is a mild version of the withdrawal reflex we experience when we accidentally touch something hot. When applying pressure to the body, the more threatening the force, the more intense and longer lasting this guarding response will be. This response is often associated with our muscles contracting in a manner that creates a motion away from the pressure.

A common example would be arching the back when attempting to apply pressure to the paraspinal muscles in a supine position. In this case, allowing ourselves to deepen into the pressure would be allowing the initial arching response to subside so the weight of the body can rest into the pressure as opposed to away from it.

Regardless of the area, for this deepening response to occur, two things need to happen:

  1. We need to be in control of our breath
  2. We need to spend ample time on the pressure (duration of pressure; 3rd D)


Duration of Pressure

Having an understanding of how to manipulate our breath to direct our nervous system, it should be clear that for us to desensitize to pressure we must spend ample time in contact with the pressure to allow our bodies to relax. Without this duration, we have very little hope of teaching our bodies that the pressure being applied is not the threat we initially thought.

The very nature of spending more time doing any action is evidence that the action is less threatening. The SNS is built to either confront or avoid a threat, not explore it. Therefore, taking time to allow pressure to sink in promotes a curiosity that moves us away from the physiology involved in dealing with danger, allowing PNS activity to dominate.

Understanding this, a general rule of thumb is to be able to spend at least two minutes on any pressure applied. In this time, we should be able to allow our breath to be directed and slowed, as well as allow the nervous system to recognize that the pressure is not sinister.



The Oxford Dictionary defines dissociation as the disconnection or separation of something from something else. In the movement world, this refers to separating out actions from one joint from that of another. Examples of this concept include being able to extend your hip without extending your back or, as mentioned above, being able to inhale without the use of your accessory muscles.

Regardless of the example, whenever we are able to create this action among joints, we are able to gain greater amounts of range of motion in all joints involved. This is because in order for us to create motion to a joint we need one area to stay fixed while the other moves. If we don’t have this condition, the direction we are attempting to gain is cancelled out by the other joint moving in the opposite direction. This concept is easily understood by imaging an effort of pushing a heavy table forward while standing on a slippery surface. Each time we attempt to push the object forward our feet move backward, cancelling out the intended direction of action.

In the human body, the inability to dissociate joint actions is harder to recognize due to our awesome ability to compensate. Compensation refers to the body’s ability to find an alternative way to accomplish a task even if we lack the movement capabilities that would be most efficient.

This happens frequently in the case of joint mobility due to the references we hold for what joint actions look like. For example, when contemplating hip extension, it is common to perceive that the more the knee moves behind the hip the more hip extension we are getting. In this case, the reference is the changing position of the knee. However, without the reference of a relatively fixed position of the pelvis and trunk, the movement of the knee becomes useless.

image image

In order for hip extension to truly be improved, we would need the knee to move straight back while the pelvis and trunk stay put. But this is much easier said than done. Because our bodies like to move in a manner of least resistance, we will need to put considerable effort into holding our position.

Here we have an optimal utilization of pressure therapy. Instead of forcing our consciousness to squeeze the muscles involved in stabilizing our position, we can use the pressure that we have allowed time to desensitize and deepen to block the undesired compensatory movement.

Again using the example of gaining hip extension, we can apply a ball to our abdomen and allow it to sink in deep enough so that as we attempt to lift the leg into extension the ball will disallow the lumbar region to compress into extension (extension in the back side of the body will move the belly forward into the ball).

image image

This example and others are expanded upon in the Pressure Therapy Routine below.


Summary of Pressure Therapy Benefits

Before we look more specifically at examples of how to apply the 4 Ds, let’s quickly summarize the main benefits of pressure therapy:

1. Improved Proprioception/Body Awareness

By allowing our bodies to desensitize and deepen to pressure in areas that rarely get touch or movement, we get an education on our anatomy and movement limitations. This is especially true when we bring pressure to areas that we cannot visually observe such as the muscles attached to our spine and shoulder blades. Control of these areas is often important when rehabilitating injuries of the low back and shoulders. However, without proper awareness of their anatomy and kinesiology, we are unlikely to be able to do what is necessary to be effective in our endeavors.

2. Promotes Relaxation

By taking ample time to desensitize and deepen to pressure, we are teaching our nervous system that the pressure stimulus we are applying is not threatening. In order for this to happen, we need to actively relax our breathing and muscle guarding. By consistently spending time on a mildly uncomfortable pressure and prompting slow, well-directed breathing, we will quickly feel the contrast of our initial sympathetic guarding response and the parasympathetic feeling of the “letting go”.

3. Increased Muscle Activation

As our bodies get more tolerant to more specific pressures, we will be able to place an object (ball or roller) on or near muscles that we may have a difficult time contracting. Once we have desensitized into the pressure, we can cue our muscles to contract the pressure “out of the muscle”. This cueing provides direct feedback for whether we are actually engaging the correct area, for if we are not, the pressure will stay deep in the muscle.

4. Improved Joint Mobility

As mentioned in the section regarding joint dissociation, when we allow ample time for pressure desensitization and deepening, we can create a “joint block” that allows one joint to better move on another. In my experience, the most common reason that mobility routines fail is that the individuals performing them cannot control their joint compensations. Using pressure to create a passive barrier to these compensations is one of the easiest ways to eliminate this common problem.


Final Note

The above are just a few of the multitude of interventions that can be explored with various pressure implements. Regardless of the exercise you choose, the 4 Ds will be foundational to get the optimal benefit. These principles take into account the integration of the systems involved whenever pressure is applied to our bodies. They are also, by design, not specific.

Too often arguments persist in the fitness industry over techniques and methods that involve the same activities with different theories. Both sides of the argument agree that the activities of interest are valuable, but contention persists due to the how and why. The debated theories usually revolve around which specific structure or system of the body is the most affected. Although it is certainly important to attempt to understand the structural mechanisms at play, the more we reduce the less we see the grander picture.

As an industry we need to gain more respect for broad principles as they will be much better able to be transferred to a variety of individuals and environments. They also create a scenario where we can respect each other for where we agree instead of dwelling on our differences.

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Leave a comment (2)

If you have a question, suggestion or a link to some related research, share below!

  • Russell Turbill

    Hi Chris. Interesting article. I would appreciate it if you, or any other reader, could please define the term ‘Increased Muscle Activation’. This term is frequently used, and I am yet to understand/be convinced exactly what it entails/means? Thanks in advance 🙂

    Russell Turbill | 17 November 2020 | Likes
    • Christopher Leib

      @russellturbill So the way I’m looking at in this article and the way I find it useful in the clinic is for the client or patient to have a better ability to contract a muscle as a reference for position or direction of motion. For example, the contraction of the proximal hamstring can be a reference for initiating a posterior orientation of the pelvis, or a contraction of the glut. max can be a reference for moving toward hip external rotation. Therefore, increased muscle activation can be viewed as improved proprioception of the muscle (s) needed to direct patients away from habitual patterns, toward motions that may be more optimal for their movement limitations.

      Happy to discuss further if I’m not being clear.

      Christopher Leib | 23 November 2020 | Likes

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