resourcesABOUT MT AUTHOR GUIDELINES CLASSIFIEDS EDITORIAL CALENDAR MEDIA GUIDE MASSAGE MART SCHOOLS & EDUCATION FEEDBACK
Leaving Footprints on Capitol Hill: Tribute to Dr. Kenneth Luedtke (1930-2014)
It was with great sadness that I heard of the passing of Dr. Ken Luedtke.
The Conscious Evolution of Healing, Part 2
The idea of transmission is very important in the Chinese medical classics. According to author Claude Larre, the ancient Chinese were highly interested in the connection between things. Nothing was looked at as an isolated entity.
Let's Speak With One Voice in 2015
For the longest time, the chiropractic profession has attempted to achieve some form of unity. On a political level, this was characterized by an ultimately unsuccessful two-year merger effort between ACA and ICA leadership from 1986-1988.
News in Brief
An Encouraging Sign at Palmer; NBCE Announces Retirement of Longtime Director of Testing.
The CDC came out with a report in March 2013 that suggests 1 in 50 children will be diagnosed somewhere on the autism spectrum – significantly higher than the 1 in 86 figure that came out in 2007. What does this mean moving forward, particularly for children?
Old TCM Sayings: Treat the Front to Treat the Back
Chinese medicine college was, and always will be, a memorable time. It was a time of massive personal and professional growth.
Acupuncture and Homeopathy: Bioenergetic Brothers
Acupuncture and homeopathy share an important healing principle: bioenergetics. "Bio" means "life," so bioenergetics is literally "life energy."
Reflections: The Art of Teaching Asian Medicine
Over the past three decades, my global workshops have been translated into German, Swiss German, French, Romansch, Spanish, Lithuanian and Xhosa. Time to offer you new teachers a few tips!
It's Time to Create a Strong Acupuncture Footprint
Footprints in the sand. Footprints in the snow. Where do these footprints go? Some are big, some are small, but footprints are made by all.
Help Your Parents Stay Engaged
As much as parents may wish it were so, children do not come with an instruction manual. There's no "how to" that can be followed and no two children are alike, so what works with one generally won't work with the next.
Are You Really a Healthy Eater?
I always giggle a little bit (to myself) when someone comes into my office and informs me that they are a healthy eater. What exactly does that mean? Does that mean they eat sugar in moderation? And what's that, exactly?
The Top Seven Website Mistakes Clinics Make
The majority of acupuncture clinics finally have a website for their business. Having a website is crucial for being found online through Google, Facebook and review sites like Yelp.
Finding Balance in the Clinic
This past December, I celebrated 11 years in practice. I seriously don't know where the time went. I feel beyond blessed and grateful to be practicing our profound and beautiful medicine and to be helping guide my patients restore a state of optimal health.
Cell Health (Part 2)
Dr. Barsten, your book is about restoring "cell vitality." Can you briefly define the term? Cell vitality is more than the mere absence of symptoms or pathology, but optimum structural, physiological and energetic health.
Connecting the Dots
In 2002, I published a book on patient examination procedures that included information on the procedural coding of the recommended examinations. The book should have been published in 2000, but I had trouble finding a publisher. Why?
Neuroscience: Where Western Medicine and Chinese Medicine Can Come Together
The recent advances in neuroscience are truly incredible. With this expansion of scientific knowledge, I would like to see even more research into the neuroscientific basic of acupuncture and Chinese Medicine.
Mind-Body in Motion
A central goal of low back pain treatment involves the correction of dysfunctional movement patterns believed to be responsible for spinal overload.
It might have been a miserable start to the day in the heart of downtown San Diego. A heavy rain had soaked the large homeless population congregating near the intersection of Third Avenue and Ash Street as they waited for a free breakfast to be served at the First Lutheran Church on the corner.
Put the Social Back Into Social Media
Social media is more than a passing fad, it is definitely here to stay. Social media apps and channels of distribution may evolve, but the concept of social media is now big business and a part of all our lives.
Unlevel Pelvis in the High-School Athlete: Exploring Causes and Effects
The unlevel pelvis is all too common in the high-school athlete and if not detected, will likely cause a lifetime of musculoskeletal issues. Any provider who doesn't look for this common finding is missing critical information.
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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