resourcesABOUT MT AUTHOR GUIDELINES CLASSIFIEDS EDITORIAL CALENDAR MEDIA GUIDE MASSAGE MART SCHOOLS & EDUCATION FEEDBACK
New Medical Technologies You Need to Know
We're all familiar with how fast computers become obsolete, as well as the rapid pace of development in the field of cell phone technology. The latest smart phones are far more powerful than desktop computers were only a few years ago.
Finders Keepers: The Secret to Relationship-Based Marketing
Becoming a successful practitioner has less to do with what you learned in school, and more to do with your ability to find new patients and keep them!
A Vibrating Capsule for Constipation? Relevance to Your Chiropractic Practice
The relationship between gastrointestinal (GI) complaints and back pain is not typically written about or discussed.
Building From the Bottom Up
I caught up with my dear friend Honora Wolfe, in her Colorado painting studio where, if she is not praying in Bhutan or doing charitable work in a Nepali free clinic, she spends most of her time now.
Peer Points: Always Seeking To Grow
Ellen "Kiki" Geary has spent the last decade honing her craft. As a specialist in integrative holistic care, she went straight from completing her master's degree in acupuncture and chinese herbal medicine from Bastyr University to building a successful and thriving practice in the small community of Anacortes, Washington.
Waking Up the Gluteus Maximus
In previous articles in this series, we expounded on the importance of the gluteus maximus (GM) in athletic performance and protecting the knee from injury. We also know there is a link between iliotibial band syndrome and GM weakness.
MPA Media Wins 7 Publishing Awards
MPA Media, publisher of Dynamic Chiropractic and DC Practice Insights, among other titles, has been recognized for editorial and design excellence with an unprecedented seven publishing awards by the American Society of Business Publication Editors (ASBPE), the nation's largest organization for business-to-business publications.
News in Brief
National Chiropractic Health Month: Be Proactive; Collegiate Roundup: Academic Appointments at Parker, Logan.
Medical Qigong for the Heart: Part III
Part 1 and Part II of this series focused on the physical aspect of the Heart and mental emotional aspects of the Heart respectively. Now, I would like to focus on the spiritual aspect of the Heart.
Pain Underfoot: Metatarsalgia
Foot pain can interfere significantly with normal activities and severely limit participation in sports. Metatarsalgia is foot pain involving the metatarsal bones in the forefoot – the complaint of pain on the bottom of the ball of the foot.
Chiropractic Research in Review
Chiropractic Treatment of Lateral Epicondylitis; Cost / Benefit Analysis: Different Doses of SMT for Low Back Pain; Imaging for Occult Rib and Costal Cartilage Fractures; Treating Neck Pain: Thoracic Thrust Manipulation vs. Non-Thrust Mobilization.
A History Worth Telling
The popularity and the use of acupuncture for the treatment of animals in the United States is at its peak.
CCE Finally Takes a "Baby Step" Toward Reform
During a 16-month period from October 2010 to February 2012, I devoted four separate columns to the heavy-handed attempt by the Council on Chiropractic Education to radically change the chiropractic profession through the accreditation process.
A Guide for Talking to Doctors about Acupuncture and Brain Chemistry
Before I begin any discussion of how to talk about the effects of acupuncture on brain chemistry, nervous and endocrine function, it is essential to understand just what physicians most need help with.
9 Common Causes of Thyroid Imbalance and How You Can Help
How you sleep, how easily you wake up, and how much energy and stamina you have during the day are directly related to levels of the thyroid hormones.
A Chinese Medicine Story: An Interview with Mazin Al-Khafaji
Mazin Al-Khafaji's work has interested me for years. In February 2014, we invited him for the second time to speak at the Southwest Symposium in Austin, Texas.
Why Young People Need Chiropractic Now More Than Ever
According to a recent study published in BMC Musculoskeletal Disorders, "It is now widely acknowledged that neck pain (NP), mid back pain (MBP), and low back pain (LBP) (spinal pain) start early in life and that the lifetime prevalence increases rapidly during adolescence to reach adult levels at the age of 18."
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.
Join the conversation
Comments are encouraged, but you must follow our User Agreementcomments powered by Disqus
Keep it civil and stay on topic. No profanity, vulgar, racist or hateful comments or personal attacks. Anyone who chooses to exercise poor judgement will be blocked. By posting your comment, you agree to allow MPA Media the right to republish your name and comment in additional MPA Media publications without any notification or payment.