We sat down with Dr. Pete Murray of the NCCIH, Keynote Speaker for the Massage Therapy Foundation’s 2022 International Massage Therapy Research Conference held this past May, to hear more about the latest research on pain, how health care providers are thinking about pain differently, and the role integrative medicine has in pain management.

Many massage therapists are drawn to the profession because of a personal experience themselves or with a loved one seeing how massage therapy can help with pain management. Why do you think it is so important to identify and incorporate nonpharmacological interventions for treating pain?

Pain is a public health problem in the United States, with nearly one-third of Americans burdened by chronic pain, 8 percent of those experiencing so-called high-impact chronic pain, defined as pain that lasts 3 months or longer and is accompanied by at least one major activity restriction, such as being able to go to school or do household chores.

Implied in the widespread prevalence of chronic pain is the inadequacy of current approaches to treat it. Surgical procedures and pharmaceuticals, most notably opioids, are largely ineffective in treating chronic pain and are associated with significant risk. And although opioid prescriptions have decreased steadily over the last 15 years, opioid misuse and abuse continues to be a major public health challenge—in 2020 there were a total of over 142 million opioid prescriptions in the U.S.

In response to the intersecting chronic pain and opioid addiction health crises in the U.S., multiple pain policies and research initiatives have identified the need for nonpharmacological options for pain management. The Institute of Medicine (IOM; now the National Academy of Medicine) issued its landmark report in 2011 calling for the transformation of pain prevention, care, education, and research, calling pain “deeply personal,” originating in the nervous system but manifesting through a complex interplay of biological, behavioral, environmental, and societal factors. This view of pain aligns with NCCIH’s Whole Person approach to health that understands the limitations of purely biological or pharmacological approaches to health and acknowledges that the deeply personal experience of pain involves interconnected, multi-order systems and requires multicomponent, evidence based therapies that impact health across these systems. Too often pain treatment involves a unidimensional approach that fails to address the biopsychosocial complexity of a person’s experience.

Why have pharmacological approaches become the go-to approach for pain management and how does that approach begin to shift back to non-pharmacological interventions when appropriate?

Unfortunately, it is true that, while we have learned a great deal about how to manage pain effectively, understanding that in addition to the biological, cognitive, and emotional aspects of pain also need to be addressed, pain management practices

remain geared toward medication and procedure-oriented treatment. Several reports, including the IOM’s 2011 report and a 2019 report by the Health and Human Services’ Pain Management Best Practices Inter- Agency Task Force cite structural barriers at institutional, educational, organizational, and reimbursement levels that make it challenging to implement a comprehensive approach to pain management.

Clinical services are typically organized according to disease condition such that neurology, cardiology, and surgical centers often approach pain management through their own siloed practices. Moreover, as alluded to in the IOM observation that because “pain belongs to everyone, it belongs to no one,” health care professionals are generally undereducated in best pain management practices, a training deficit that extends to medical school and even before. Academically based pain clinics do have the capacity for comprehensive, interdisciplinary approaches, but they are relatively scarce and they don’t always fit well in our current health care model.

Another factor limiting widespread use of multimodal, multidisciplinary approaches is that these approaches often require time and resources not readily available to clinicians, leaving them few options to treat their patients holistically by addressing those complex cognitive and emotional aspects of pain. Overcoming these barriers to treating the whole person with approaches that address the complex, multidomain nature of pain will take, as the IOM report concludes, “a cultural transformation in the way pain is viewed and treated.” It is going to take time.

I’ll mention one interesting development that we at NCCIH and across the NIH have observed in the clinical trials we fund following the onset of the COVID-19 pandemic that may bear on the future of pain management. The pandemic limited or shut down many clinics across the nation, prompting a shift to virtual delivery of care, as many of us now know who had never previously met with our doctors by video. As clinical care shifted to remote delivery, so did many of the interventions being tested in clinical trials. This shift to virtual delivery for complementary interventions may represent an opportunity for greater access to individuals who seek these interventions but face access, time, and travel limitations. NCCIH is supporting several ongoing clinical trials evaluating the feasibility, efficacy, and effectiveness of remotely delivered interventions, so we’ll have to wait and see if group-based mindfulness sessions, for example, are as effective when delivered remotely versus conducted in-person. It will be interesting to see if interventions such as yoga and chiropractic care, which involve several multimodal, psychological components that are amenable to remote delivery, are as effective when delivered remotely. And although I wouldn’t rule out opportunities for remote facilitation of self-massage, I would expect the full benefit of massage to involve in-person delivery.

What are some of the non-pharmacological interventions for pain management you have seen work best in lieu of or in conjunction with pharmacological approaches?

Owing to the fact that many medications provide only limited relief to chronic pain, many individuals turn to complementary health approaches as part of their pain management strategy, and national data shows that the number of people using complementary approaches for pain is increasing.

A growing body of evidence suggests that some complementary approaches, such as acupuncture, hypnosis, massage, mindfulness meditation, spinal manipulation, tai chi, and yoga, may help to manage some painful conditions. However, the need for more high-quality, rigorous research into nonpharmacologic interventions for pain management remains.

One challenge in studying complementary and integrative approaches for pain management is that the effect sizes tend to be modest. Moreover, clinical outcomes are often inconsistent, such that cognitive behavioral therapy (CBT) for migraine might work for some but not for others. Combined, these two factors—modest effect sizes and heterogeneous outcomes—often lead to noisy data that is often difficult to interpret.

These two factors, however, also present opportunities for future research directions. NCCIH’s latest strategic plan includes a focus on whole person health research, which emphasizes a multimodal, multisystem approach to health. Much of the current mind and body portfolio studies single systems (e.g., nervous system). Pain management approaches that involve integrated, multicomponent therapies that impact multiple biological and psychological domains (e.g., combining massage therapy with CBT) have the potential to enhance benefit to individuals compared to standalone interventions. It is also important to study multicomponent interventions that combine conventional and complementary medicine.

What is the HEAL Initiative, and how can massage therapists get involved?

The HEAL— Helping to End Addiction Long-term®—initiative is an aggressive effort involving almost every Institute and Center across the NIH to speed scientific solutions to stem the national opioid public health crisis. The initiative is funding hundreds of projects nationwide across two broad focus areas: (1) understanding, managing, and treating pain, and (2) improving treatment for opioid misuse and addiction.

Massage therapy obviously has the potential to impact pain, but what may be less clear to researchers are the opportunities to impact opioid misuse and addiction. One great example of exploring complementary and integrative approaches in this area is the HEAL-funded Behavioral Research to Improve Medication-Based Treatment (BRIM) program. Medication-based treatments, such as methadone and buprenorphine, are demonstrated to be effective in treating opioid use disorder. However, adherence to these medications often drops off after a short time. The BRIM program is assessing whether behavioral interventions can improve adherence and outcomes of medication-based treatment.

The interventions currently being assessed within BRIM include yoga and mindfulness, cognitive behavioral therapy, multidisciplinary rehabilitation, and mobile health technology, but one could imagine a role for massage therapy in this space. In fact, one BRIM study conducted by Dr. Cynthia Price at the University of Washington centers on interoception in individuals with opioid use disorder and chronic pain. Interoception involves the processing of sensory input from inside the body and, for this study, it is performed in the context of massage therapy to facilitate sensory awareness related to attention to the quality of soft tissue.

What should a massage therapist know before working with clients who are managing chronic pain?

I would give the massage therapist the same advice that I would give any caregiver dealing with a client who has chronic pain. Namely, that, there is a growing awareness that pain is not simply a physiological consequence of tissue damage, but that it is an individual, subjective experience that is impacted not just by the biological domain, but also by the psychological, social, and environmental domains.

A greater awareness of the broader context of pain enables a more holistic approach to pain management. At the same time, there is a growing realization that the goal of pain management is not to get the pain to “zero,” but to manage the pain in such a way that allows the individual to live a life of quality and fulfilment. This approach requires providers to take a patient-centered approach to pain care, to first ask the patient what are their goals in managing their pain?

Very few of the pain treatments we can offer today will “cure” a person’s pain completely. So, the question then is how can we empower people to live a fulfilling life that includes pain? Much of the research funded by NCCIH tries to answer the question as to what role can complementary and integrative approaches play in helping individuals with pain live their lives to the fullest. While some research has been performed exploring the role that massage therapy has to play in pain management for specific conditions, there are certainly scientific opportunities for additional research.

It’s imperative that the public, health care providers, researchers, and policymakers are informed and knowledgeable about the safety and effectiveness of complementary and integrative health approaches including massage therapy. We must continue to support rigorous studies to determine what approaches are effective in managing pain and other conditions, and then widely disseminate the results of those studies so that clinicians and individuals can make informed decisions about pain management.

See Also: A Conversation with Melissa Ryan: Massage as a Nonopioid Option for Pain Management