If you are reading this, there is a very good chance that you are a professional, dedicated Massage Therapist, or Myotherapist. You spend days, weeks, months and years up to your elbows in oil or balm, rubbing, kneading, pressing and prodding body after body, in an ongoing search for trigger points, tight tissue and that elusive “sore spot.” You most likely have aches and pains of your own, sore back, shoulders and hands are pretty common in our profession. Pain is something you deal with everyday. If it is not your own body, it is your client’s. So would it make sense to know as much about pain as you can?
It is All About Helping People, Not Just Science
Hopefully it doesn’t surprise you that Massage Therapists and Myotherapists are not the only professionals that deal with pain; physiotherapists, psychologists, GPs, rheumatologists, paramedics and scientists, are just some of the other professionals that are working with people in pain on a daily basis. Thankfully, we are currently seeing more and more co-operation between different fields and this is leading to a new wave of understanding regarding pain.
But this new wave of science can actually be a pain to understand. This wave of information is literally “flipping on its head” many of the concepts and ideas that we have taken as gospel for so long in the field of manual therapy. At the forefront of this wave is recognising that humans are complex biological systems with a huge capacity for change and growth dependent on a multitude of factors.
In fact, it is basically impossible to know every single factor that may affect an individual’s pain experience. The best we can do, is identify the most significant factors we find and hope that this has the desired effect and best outcome for our clients.
To assist us in identifying the most significant factors in helping people with pain, this is where science can be immensely useful. And the wonderful news is, a lot of this is (almost) common sense.
What are the Big Factors?
Most people that develop pain will heal just fine and this is really important to recognise. It is completely normal for people to recover from a painful experience. As an example, a 2008 study(1) of Australians that presented to primary healthcare practitioners for lower back pain, demonstrated that 72% (of nearly 1000 people) will return to pre-injury levels of pain and function within 12 months. This is really important, because if someone comes to you with back pain, you want to inform them that is is completely normal to have pain and recover back to normal function, but it may just take some time.
But that does leave 28% of those who did not recover to baseline, the reasons cited were old age, compensation claims, higher pain intensity than average, previous injury, depression and perceived risk of persistence. Of these factors it is possible that a Massage Therapist or Myotherapist may be able to assist with pain intensity, some of the general effects surrounding depression and perhaps most importantly, the perceived risk of persistence.
When someone comes to receive a massage from you, they listen to you and respect you as a highly trained health professional. In other words, what you say matters. We know that touch can help reduce pain intensity, even it is only a mild effect over a brief period, any pain reduction is a good thing. But as therapists, we can also have a huge impact on our client’s beliefs around their pain and this is really significant.
Beliefs About Pain Really Matter
Self-efficacy is a personal belief in someone’s effectiveness. In sport this would be a belief in how well someone will perform in competition. For someone in pain, this is a belief in how well they can manage their pain and potentially get better. Why is this important?
A 2004 study(2) looked at self efficacy, fear avoidance and pain intensity as predictors of disability. The study of nearly 400 patients showed that high levels of self efficacy was the best indicator of reduced levels of disability. Pain intensity was only a useful indicator of ongoing disability in a small group of the total patients in the study and fear avoidance behaviour (behaviour that demonstrates fear of movement) was also a better indicator of disability than pain intensity. In other words, the findings of this study was, the beliefs of people with subacute and chronic musculoskeletal pain have more of an effect on disability than the amount of pain they are experiencing.
How Does This Apply to Massage Therapy and Myotherapy practice?
What is being suggested here is not to counsel people on their pain, instead recognise that most people will recover fully from pain and injury given enough time. As a practitioner, we can make them feel more comfortable while nature does its thing.
For clients, having a strong sense of positive belief around their body and their pain is a really important part of recovery. On top of this, being fearful about their pain and their body increases the likelihood of ongoing disability and pain. And remember, the amount of pain someone experiences at any given time is often not a good indicator of long term outcomes.
So it becomes really important that we consider carefully what we are doing and saying to our clients. Are we a supportive health care professional, developing a sense of self efficacy, self belief, confidence and empowerment? Or are we creating a sense of fear and fragility around our clients that we know can actually make their pain worse?
Empowering Through Touch, Movement and Language
As a Massage Therapist or Myotherapist, we may think our job is to break up adhesions, release knots and stretch fascia. Almost like some sort of human jack hammer, we are here to resolve our clients issues through the application of external force and generally the more the better. But what is becoming very clear is that the effects of massage are much less to do with the application of force to change body tissues and more to do with the response of the client’s nervous system.
Pain is a product of the nervous system and our best tools to reduce pain and improve function (to use chronic lower back pain as an example) is a combination of touch, movement and language (3). It is now clear that combinations of exercise and movement, manual therapy, psychology and medical management are more effective than any one of these interventions on their own. And as therapists we should keep this in mind.
Positively framing a client’s situation, allaying any fears they have and giving them a plan to manage their pain should be a key component to any manual therapy session. Treatment should be aimed at normalising sensation and function, avoid any techniques that work from the basis of “breaking up tissue” and instead focus on triggering the nervous system to reduce muscle tone and sympathetic stimulation.
Encourage movement, either during your session or between sessions. Walking, swimming, running or anything else that will encourage, relaxed, comfortable movement should be recommended for both pain reduction and improved function.
Nocebo and Neuroplasticity
Above all, don’t give clients reasons to worry. It is becoming more and more clear that a huge number of apparent postural dysfunctions and misalignments are either “imaginations” (completely normal human variations) or not linked to pain in any discernable way. But drawing a client’s attention to some “dysfunction” that they don’t understand is only going to heighten their sense of frailty and fear towards their own body. This can actually increase the likelihood of pain and loss of function, as discussed earlier.
While we may mean well, talking up problems is not helpful. If there is something that you are legitimately concerned about then refer your client. But don’t speculate of the cause of the injury, unless you have an MRI machine and are qualified in how to use it. Leave the diagnosis to those qualified to do it. Instead support your clients, remind them that recovery is normal, and being active even with pain, is nearly always the best strategy.
By encouraging confidence and reducing fear, you will be encouraging a fundamental restructuring of the client’s nervous system that will down-regulate pain responses. This is generally understood to happen with the placebo effect. But if we make a client believe their situation is dire, we can actually have the opposite effect, known as the nocebo effect. Which is associated with structural changes to the nervous system that can increase a client’s pain intensity.
Yes, pain science can be a pain in the gluteus maximus! It reminds us that the knowledge around our understanding of massage is constantly changing. And this means that we need to spend time getting up to date. Unfortunately, there are some who are using “pain science” to attack massage therapy, and this is a shame, as massage itself is a very safe method of pain management especially if balanced with a healthy lifestyle. But, we do need to learn more about pain so that we don’t fall into the trap of unintentionally making our client’s situations worse by scaring them with overly technical assessments and language. Instead we can build their confidence and encourage them to be active and therefore be comfortable in the knowledge that we are doing the best we can for our clients.
We hope you have found this blog informative. The Author of this article, Aran Bright, is passionate about supporting Manual Therapists and Myotherapists – empowering them with the skills they need for a long, healthy career. To read more articles, or to find out more about our online professional development courses please go to our website www.brighthealthtraining.com.au
1. Henschke, N. et al. 2008 Prognosis in patients with recent onset low back pain in Australian primary care: inception cohort study. British Journal of Medicine. Vol 337 a171 pp154-157
2. Denison, E. et al 2004 Self efficacy, fear avoidance, and pain intensity as predictors of disability in sub acute and chronic musculoskeletal pain patients in primary health care. Pain Vol 111 Issue 3 pp245-252
3. Kamper, S. et al. 2015 Multidisciplinary biopsychosocial rehabilitation for chronic low back pain: Cochrane systematic review and meta-analysis BMJ 2015;350:h444