resourcesABOUT MT AUTHOR GUIDELINES CLASSIFIEDS EDITORIAL CALENDAR MEDIA GUIDE MASSAGE MART SCHOOLS & EDUCATION FEEDBACK
Chiropractic Prevents ADHD? Research Shows...
Now that I have your attention, let me tell you what the latest study actually states. As you may have noticed, research over the past few years has begun to reveal that acetaminophen (the primary ingredient in Tylenol) is not as safe as once thought.
The Healing Properties of Light: An Interview With Researcher Anna Cocliovo
This interview is with Anna Cocliovo, a light researcher and Acupuncturist in Arizona. During my own research in light, I came across the article she published for the American Journal of Acupuncture and sought her out as a result.
Steven Rosenblatt: Birthing A Cross-Cultural Acupuncture Profession
The existence of a cross-cultural acupuncture profession in the United States, one that is legalized, licensed, supported by formalized, academic training and inclusive of non-Asian practitioners, is an important part of the medical landscape in this country and is responsible for improving the lives of hundreds of thousands of Americans.
AAAOM – Making Promises They Can't Keep
When the AAAOM first formed in 2007, their mission was clear: to support the profession through education, resources and legislative advocacy. The first years of the organization were filled with promise and hope.
Monoculture of the Mind: Part II
Cases are built within boundaries. Such bounds may be a program, event, activity or individuals. In this instance, a medical case has boundaries that include clinical interactions that are comprised of history, signs, symptoms, diagnoses, treatment plans and treatments.
Green Tea Catechins Lower PSA, Other Biomarkers in Men With Localized Prostate Cancer
A 2006 study (Cancer Research) was the first human investigation to show that green tea catechins (GTC) are highly effective in reversing premalignant prostate lesions (high-grade prostate intra-epithelial neoplasia), an established precursor to prostate cancer.
Get That Shoulder to Move: Restoring Internal Rotation
How many times have you mobilized, performed ART, Graston, FAKTR and PIR, and stripped a patient's posterior capsule, yet on re-exam, discovered it was still blocked?
Epigenetics: The Western Science Supporting Essence
Since the days of Darwin, western medicine has touted that our genes were set in stone, that our genetics were our destiny. We were told that the diseases that ran in our family were likely coming to us as well.
News in Brief
Hamm Elected New President of the ACA; WFC / ACC 2014 Education Conference: Call for Papers; F4CP Recognizes Standard Process as $1 Million Supporter; Texas Chiro. College Begins Search for New President; League of Chiropractic Women Hosts Women's Success Summit.
Why DCs Need to Understand the Principles of "Inclusive Design"
In the past few columns, I've written about the negative effects of prolonged sitting at work. I've attempted to make the point that prolonged sitting (or prolonged standing) takes a toll on workers. Now let's discuss a related issue: the concept of "inclusive design."
Risk Factors for Heel Problems
Heel pain and gait disability are common occurrences in adults, often the result of thinning heel pads and a lifetime of exposure to heel-strike shock. One condition experienced by many people is plantar fasciitis.
What is a Discipline in Medicine?
In my now prolonged dialogue with physicians, one question emerges with enough regularity to deserve mention and naming: what is a discipline?
Are You Guilty of Paternalism in Your Approach to Patient Care?
Einstein is purported to have said, "When a man sits with a pretty girl for an hour, it seems like a minute. But let him sit on a hot stove for a minute and it's longer than any hour. That's relativity." In some way, everything is relative to one's point of view.
One and Done: Keeping Patients From Vanishing After Just One Appointment
What happened to my 3:30 p.m. ROF? They may have rescheduled, but there are two common answers no one wants to hear: 1) "She called to cancel. I tried to get her to reschedule, but she refused." 2) "She no-showed.
Resilience is the New Longevity
Sometimes we must enter a room through one door and not another, even though they both lead into the same space. I am talking now of the recent cachet with the concept of "resilience" regarding health, chronic pain and longevity.
Leaving a Lasting Legacy: Donna Liewer
For the past 31 years, Donna Liewer has been on a personal mission "to comfort the afflicted and afflict the comfortable." In her role as executive director of the Federation of Chiropractic Licensing Boards, Liewer has accomplished that and much, much more.
Stress in the Modern Age: Impact on Homeostasis and What You Can Do (Part 1)
In 1926, Hans Selye first used the word stress in a biological context, referring to the nonspecific response of the body to any demand placed upon it.
AAAOM – The Beginning of the End (Part II)
In 2012, the AAAOM board members met in Chicago for their annual meeting. The goal was to come to a consensus on a long list of issues the AAAOM needed to work on including a functional board and budget.
Successful Strategies in Integrating Acupuncture and Shiatsu in a Hospital Oncology Program
Colleagues from the Network of Researchers in Public Health in CAM recently published an article of interest to our Traditional Asian Medicine community.
Collaboration for a Cause
The Patient Protection and Affordable Care Act strongly encourages the formation of multidisciplinary practitioner teams called Patient Centered Medical Homes (PCMHs) and Accountable Care Organizations (ACOs).
Flexion-Intolerant Lower Back Pain (Pt. 3): Mobilization & Soft-Tissue Treatment
What is the biggest challenge to the chiropractor in treating discogenic pain? You have to completely reframe the purpose of your manipulation. It is rarely about unlocking a stuck segment at the disc involvement level; it is not about putting a joint back in alignment.
February, 2013, Vol. 13, Issue 02
Fear Avoidance and the Issue of Chronic Pain
By Nicole Nelson
According to the American Pain Foundation, an estimated 50 million Americans suffer from chronic pain each year. Let's take a closer look at those suffering with chronic non-specific pain (CNSP) and explore how fear may be partly responsible.Specifically, this discussion will attempt to shed some light on how fear might perpetuate the pain experience without the presence of any musculoskeletal problem. Although the pain these clients feel is very real, it is distinct from those suffering from biophysical causes of pain, such as infections, tumors, osteoporosis, spondyloarthropathies and stepping on a nail.
Current understanding of pain neuroscience suggests that pain is a multi-dimensional experience that involves sensory, emotional and cognitive components.3,13,18,21,26-28,32 Likewise, the way the brain interprets and processes these components can vary pain intensity. It seems pain may involve more than structural problems, making our job as massage therapists a bit more intricate than addressing leg length discrepancies or elevated shoulders. A review of more than 900 studies involving back and neck pain concluded that psychological factors play a significant role, not only in chronic pain, but also in the etiology of acute pain — particularly in the process of transition to chronicity.13
The Fear Avoidance (FA) model, originally presented in the early 80's, is a psychological model that accounts for why certain clients may make the leap from acute to chronic pain. FA suggests that it is overly fearful individuals that wind up suffering with chronic pain, to the degree that they avoid seemingly benign movement patterns so as to protect themselves from further pain.23 The model theorizes that there are essentially two pathways an individual can take after suffering from an incident of acute pain. The first and more functional pathway suggests the individual perceives the pain as a non-threatening experience, daily activities are likely continued with a reasonable level of protection and a functional recovery ensues. The other path involves catastrophizing, where the individual perceives the injury as very threatening and develops a "worst case" outlook.4,7,21
According to the model, the nociceptive system becomes persistently active which leads to an extension of pain beyond the time frame of normal tissue healing. The worry associated with doing more harm leads to an avoidance of activity which can eventually cause further de-conditioning, and in severe cases, depression and isolation.30,32 In essence, these clients have lost confidence in their body's ability to withstand a physical challenge to the area they associate with their pain. Multiple studies have set out to examine the relationship between pain-related fear and it's potential to increase pain perception and delay recovery.2,3,12,32
The researchers have found some traits among those that exhibit fear avoidance:
So, how do we apply this knowledge to an actual client? By recognizing those with fear beliefs and behaviors, we can tailor our suggestions and therapy accordingly. Above all else you must help fearful clients understand that they are not helpless victims of pain, rather they are active managers of pain and do have a great amount of control.26,31 Generally speaking, this includes exposure to current biopsychosocial pain theory, getting them to move better, more often, as well as including positive lifestyle changes such as improving nutrition, reducing stress and optimizing posture. The list below includes a few specific ideas collected from the literature that will help shape your treatments to those exhibiting FA and experiencing CNSP. This list is hardly exhaustive, but should serve as a jump off point for you to study and explore treatment ideas which will complement traditional massage methods.
First, seek out the right practitioner. After bouncing around from practitioner to practitioner looking for answers, your FA/CNSP client is probably feeling extremely anxious about the source of their suffering and is starved for an explanation. If this is the case, help them seek out pain specialists that utilize a comprehensive treatment approach which incorporates cognitive behavioral therapy (CBT). This network of professionals will help your client realize that their pain is not necessarily a tissue problem, but one that is perpetuated by an interaction of physiological and psychosocial factors.
Cognitive behavioral therapy (CBT) attempts to alter FA behaviors, emotions and beliefs.22,31 This is commonly done through teaching the impact that thoughts and emotions have in maintaining pain as well as teaching stress management techniques, problem solving, goal setting and activity pacing. CBT can be performed in a group setting to reduce costs and allow the therapist to share successful cases of alternative thought and behavioral patterns from other group members.
Second, try to encourage meditation and mindfulness. It is believed that catastrophizing accounts for 7% to 31% of the variance in pain severity.26 Improving the client's mindfulness has been shown to be an effective approach to pain management, likely by interrupting the thoughts of a doomed outcome.6,16,17,27 Mindfulness has been defined as, "awareness that emerges by way of paying attention on purpose, in the present moment, and non-judgmentally to the unfolding of experience moment by moment." Proponents of practicing mindfulness exercises, such as mediation, theorize that a mindful state is mutually exclusive of one that is busy catastrophizing, which involves interpretation, conceptual processing and judgment.27,28 Simply put, when one is mindful, one cannot have a doom and gloom outlook.
The third concept to keep in mind is that hurt does not mean harm so encourage them to move. One must consider that well intended medical professionals that are unfamiliar with psycho-social and behavioral perpetrators of pain, may have actually exacerbated your client's fears about movement and exercise (i.e. "let your husband carry your purse, it's too heavy for you" or "be extremely careful when getting up.") Naturally, flare ups as a result of too much activity is a legitimate concern for many with chronic pain; however, exercise has repeatedly been shown to be an effective pain management strategy.1,5,10,14,25,29,33 It is worth mentioning that these clients will feel discomfort when increasing their levels of activity, particularly when they have been leading sedentary lives. That said, a graded exercise plan is indicated and should be encouraged as the client will eventually adapt to increased levels of activity. I generally advocate clients begin this process by consulting with an individual with clinical exercise experience. If they are apprehensive about this idea, suggest they perform something they enjoy doing, perhaps walking (de-conditioned clients might do best by walking in a pool.) Recommend they walk 3 to 4 days per week for a length of time and speed that is challenging but not exhausting. Propose they add five additional minutes to their walk each week.
It is widely accepted that chronic pain sufferers exhibit deficits in proprioception.19 It has been observed that chronic back pain patients no longer consider their back as being a part of them and do not feel that the back can be controlled automatically.18 Lorimar Moseley's research has shown that sufferers of chronic low back pain have been found to have difficulty delineating the outline of their back when asked to complete a drawing of "how it feels."12 It is also possible that the varied alterations in trunk muscle recruitment patterns evident in CNSP patients may be a manifestation of a disturbance in body perception.8 Moseley and the NOI group have also shown that people in pain often lose the ability to identify left or right images of their painful body part(s).
This research suggests that the brain has an altered image of itself. One way to help your client gain a more accurate picture of their own body is by performing right/left rolling patterns, similar to how a baby begins the movement experience. Rolling, is not only a movement strategy that is believed to improve proprioception, mobility and core function, but it is a great assessment tool to see where you should direct your soft tissue work.9 As your clients perform these movements, keep an eye out for any lack of symmetry between rolling from right to left and left to right.
There are four basic rolling patterns.
It is well documented that those suffering with chronic pain also have poor breathing patterns.11,19,24 It stands to reason that better breathing habits will yield a more functional core by improving diaphragmatic motor control and will also help in relaxing the client, thereby making it a very useful strategy in FA/CNSP cases. Learning to evaluate and correct poor breathing habits is an extremely important skill. I highly suggest Leon Chaitow's book, Multidisciplinary Approaches to Breathing Patterns Disorders, for further information.
Progressive muscle relaxation
PMR is an excellent way to reveal to the client that they are holding unnecessary tension within their muscles. Have your client either seated or lying on the massage table. After beginning with several deep breaths, instruct your client to alternately tense, hold, and then relax groups of muscles in his or her body. Direct your client's attention to the sensations of tightness felt while contracting and tensing the muscles. Your client's awareness should be dialed into the sensations of warmth, heaviness and relaxation in their body, as they review each muscle group individually, spending some additional time on problem areas. Instruct your client to perform this technique at home two to three times per day or at moments when they are feeling stressed or are about to perform an activity that they associate with pain.
The pain experience can be more complicated than just a physical problem. FA can perpetuate pain, limit activity, lead to further de-conditioning and ultimately lead to depression and isolation. Although great bodywork will be hugely beneficial to your FA/CNSP clients, a comprehensive treatment approach involving CBT might be necessary. Likewise, this specific set of clients must realize that they are not passive in this process. Meditation, better breathing habits and exercise are all terrific ways your clients can regain a sense of control over their pain.
Nicole Nelson a licensed massage therapist in Jacksonville, Fla. She has a masters degree in Health Science from the University of North Florida and is a certified Advanced Health and Fitness Specialist through ACE.
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