resourcesABOUT MT AUTHOR GUIDELINES CLASSIFIEDS EDITORIAL CALENDAR MEDIA GUIDE MASSAGE MART SCHOOLS & EDUCATION FEEDBACK
A House Divided?
The American Chiropractic Association's House of Delegates voted on 30 resolutions at its annual business meeting in Washington D.C., but two in particular took immediate center stage due to their controversial nature.
Turning a Blind Eye to History – and Reality
The American Medical Association is taking the Supreme Court's Feb. 25, 2015 decision exactly as it always does – by turning a blind eye to history, legal precedent and reality.
The Way We Are Designed: A Conversation with Gil Hedley, PhD
I was first introduced to the work of Gil Hedley by Tom DiFerdinando. He gifted me Gil's DVD series.
Talking to Patients About Lumbar Facet Denervation (Medial Branch Neurotomy)
Lumbar facet denervation, more appropriately termed medial branch neurotomy (MBN), is a procedure that may be considered when patients suffer from recalcitrant non-radicular axial back and/or leg pain.
TCM Congress in Rothenburg is Largest in Western World
In the medieval town of Rothenburg, deep set within the Bavarian countryside in Southern Germany, the TCM Kongress Rothenburg each year draws around 1.200 participants from more than 40 different countries to attend the biggest TCM conference in the Western world.
An Excerpt from TCM Case Studies: Pediatrics
This excerpt is reprinted with permission from Jamie Wu. TCM Case Studies: Pediatrics was released in 2014 by People's Medical Publishing House.
Term Limits: What's in a Word?
It was the French historian and philosopher Voltaire who once declared the Holy Roman Empire was neither holy nor Roman nor an empire.
Functional Hip Impingement (Part 1)
Every time I sit down to write an article, I realize how much more there is to know about musculoskeletal pain. I also learn something new every time. (I want to give special thanks to Lucy Whyte Ferguson for assisting with this article.)
Synergy Doesn't Happen in Silos: Acupuncture in Hospitals and Other Healthcare Settings
As acupuncture and traditional East Asian medicine continue to intersect and integrate with biomedical approaches, the conversation about integration expands and becomes richer.
Will You Be an Amplifer or a Mute?
These times are changing, and changing quickly. There have been many challenges to this profession throughout the past few years. The challenge is to talk, then talk and talk some more about this medicine.
Converting More Patients to Your Practice
In 2013 and 2014, the theme was "the money is in the list." This meant that if you had a big email list, you were really making some "cha-ching." Unfortunately, having thousands of emails doesn't equate to thousands of dollars in profit.
Low Back Pain in Professional Golf: A Common Muscular Relationship
Every sport creates its own unique demands on the body. Some sports require such a myriad of body positions that assessing pathology is often difficult and unpredictable.
A View From the ER
The University of Western States has inked an innovative agreement with local nonprofit health system Legacy Health whereby UWS sports-medicine fellows can experience observational clinical rotations in emergency-room settings within the Legacy system.
Sleep, Less Sleep or No Sleep?
I had a dream I wasn't getting enough sleep. It was a very realistic dream, even though I was probably slightly awake and not really deep dreaming. Most likely I had been dozing, caught in that twilight of sleep and wakefulness.
There Really is No Room for Sexism
Recently, Matteo* (a transgender male) approached me during a break in an advanced shiatsu class in Berlin where he was one of two men in a group of 20 women. "Pamela. Don't forget to remind the translator to include male endings."
Applying the Thin Skull Principle
The "thin skull" principle, also known as the "you take your victim as you find them" principle, is a legal principle that can be summed up by the following statement.
The Need for a New Medical Model: A Challenge for Biopsychosocial and Ecopsychologica Medicine
Chinese medicine speaks of alignment between humans, heaven and earth. It is a complex view with a focus upon relationship. These are comprehensive ideas with no specific terms in contemporary medical practice.
Optimism = Compassion = Trust
A randomized clinical trial recently published online in JAMA Oncology examined how patients viewed their doctor based upon how the practitioner presented bad news to the patient.
The Dietary Supplement Research Dilemma
I do not care what the truth is, one way or another; I just want to know it. And when it comes to dietary supplements, the truth can be hard to find for a number of reasons.
Recreational Cannabis Use and TCM
Many people are drawn to cannabis for its effects physically, mentally and emotionally. Medically, cannabis has some legitimate uses, however the scope of this article is limited to the recreational use of cannabis.
Treating Beyond Pain
More often than not, when a patient presents to the office, it is for a pain complaint. Headache, neck pain, low back pain, sciatica, carpal tunnel... The pain is often the focus of the patient's mindset, and they don't often have any thought of what comes after the pain.
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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