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Chronic Pain: Research and Clinical Applications
somatic research

By Diana Thompson

Originally published in Massage Bodywork magazine, July/August 2011. Copyright 2011. Associated Bodywork and Massage Professionals. All rights reserved.

Millions of people--more than 25 percent of the US population1--live with pain. Pain affects more Americans than heart disease, diabetes, and cancer combined. The financial burden of pain in the United States is reaching $100 billion annually--health-care costs, lost income, and lost productivity, not to mention the emotional toll on the afflicted and their families--yet only 1 percent of National Institutes of Health (NIH) granting dollars are focused on pain research.2

Back pain, headache, neck pain, and the complications of conventional medicine are some of the top reasons people seek complementary and alternative (CAM) therapies.3 A recent study claims that massage use is higher and drug use is lower in today's older adult population.4 The negative side effects of both nonsteroidal anti-inflammatory drugs (NSAIDs) and prescription pain relievers are driving people young and old to seek alternative remedies for their pain.

These trends require massage therapists who understand the mechanisms of pain, have the skills to address a variety of pain conditions effectively and safely, and are equipped with communication tools adequate to participate on an integrative medical team. With and without physician referrals, people in pain are finding their way to massage therapists: massage is the number two most used practitioner-based CAM therapy for pain, second only to chiropractic and osteopathic care combined.5 It is critical for us to work with our clients and their health-care team to provide drug-free pain relief as people "just say no" to opioids and NSAIDs.

Acute vs Chronic Pain
Acute pain is a normal therapeutic sensation triggered in the nervous system to alert you to possible injury and protect you from further harm. It is typically responsive to treatment and often follows a trauma or surgery. Chronic pain, on the other hand, is no longer productive, lingering long after the injury or tissue damage has resolved, and is unresponsive to typical treatment methods effective for conditions common with acute pain symptoms. Acute pain that persists over time often transforms into a dysfunction of the nervous system--a disease in and of itself, a complex pathology--and becomes a contributor to multiple pathologies.6

Common types of pain include nociceptive pain (dull, achy, poorly localized pain, where sensory receptors or neurons found extensively throughout soft tissue perceive pain and send pain signals to the brain along A fibers and C fibers) and neuropathic pain (burning, tingling, stabbing, pins and needles, which is a central nervous system disorder). A third type of pain has also been identified--suffering. Suffering includes both physical pain (non-neurogenic, such as nausea and vertigo) and emotional pain (such as anger, anxiety, depression, and fear).7

To further legitimize this third type of pain, a survey from the American Pain Foundation indicates that 68 percent of people who have experienced acute pain in recent years feel that the recession caused, increased, or affected their pain.8A Harvard Health Report states that chronic pain is an emotional condition, as well as a physical sensation.9 The relationship is intimate: pain is depressing and depression causes and intensifies pain. People with chronic pain have three times the average risk of developing mood or anxiety disorders and depressed patients have three times the average risk of developing chronic pain.10

Inclusion of this third type of pain--suffering--demands a more holistic approach to meeting client needs.

Chronic Pain Syndromes
Clinical trials support the theory that chronic pain is best treated as a complex condition deserving of a multidisciplinary approach, rather than as a symptom with a specific remedy.11 In order to be effective as a massage therapist, one must embrace the chronic pain experience from the individual client's perspective and address its many facets.

To make individual treatment plans for complex conditions manageable, break it down into a clinical decision-making process:

- Understand the mechanisms of the syndrome (central or peripheral nervous system, emotional or physical, enhanced by inactivity and loss of balance).

- Identify presenting symptoms; measure its intensity.

- Select treatment techniques that will reduce symptoms and are consistent with the mechanisms of the syndrome.

- Educate the client on self-care exercises that support the reduction of symptoms between sessions.

- Reassess symptom intensity to measure progress; adjust your treatment plan accordingly.

First, learn about the various conditions associated with chronic pain. Included are arthritis, back and neck pain, cancer, chronic fatigue syndrome, diabetes, irritable bowel syndrome, fibromyalgia, headache, herpes, spinal stenosis, Lyme disease, myofascial pain syndrome, phantom leg syndrome, restless leg syndrome, sciatica, etc. A few of these conditions have an identifiable origin of pain that remains constant (cancer, herpes), however, most spiral into chronic conditions that no longer resemble the original onset and cannot be successfully treated solely by addressing the soft tissue trauma. Even fibromyalgia/myofascial pain syndrome/chronic fatigue, commonly identified by the presence of trigger points, may not be best treated by trigger point therapy alone: "While much of this pain and many of the test sites are located in the muscle, the allodynia [pain due to a stimulus that does not normally provoke pain] is now believed to come primarily from central nervous system neurosensory amplification of nociception in general, and not specifically from muscle pathology."12

Chronic pain also contributes to other pathologies. As discussed above, long-term effects of pain harm nerves and trigger psychiatric disorders (anxiety, mood). People with chronic pain have been found to have lower-than-normal levels of endorphins in the spinal fluid.13 In addition, it has been found to affect blood vessels and organs, for example, chronic migraines directly increase the risk of stroke.14 Chronic pain suppresses the immune system, results in excessive inflammation, and delays healing.15 Damage to cortical areas of the brain result in cognitive impairment, such as diminished attention span and mental flexibility, memory loss, and verbal deficiency.16

Symptoms of Chronic Pain
Next, identify the symptoms associated with the chronic pain pathology(s) specific to the individual client. To gauge the success of the treatments you provide, rate the intensity of the symptoms as you identify them. Use the knowledge gained from the research to assist in gathering information from clients. For example, a common response to pain is to minimize movement, thereby decreasing flexibility and balance. Mobility and balance assessments will help us identify dysfunction, and charting functional limitations will help to design self-care strategies to improve quality of life.

Following is a general list of pain-related symptoms supported by research, along with guidelines to assess their expression. Ask clients to report on the following:

- Pain--describe and identify location, intensity, frequency, duration, and triggers.

- Mental health--frequency and intensity of moods: depression, anxiety, stress.*

- Cognitive impairment--episodes of forgetfulness, diminished attention span, verbal deficiency.

- Activities of daily living--identify activities they no longer do because of pain and activities they must modify (not as often, not as long), and at what point the activity triggers an increase in pain.

- Sleep disturbances--how many hours of sleep, how many times waking, and how they feel upon waking (fatigued/rested).

*Note: Mental health assessments and treatment with talk therapy are not within a massage therapist's scope of practice. However, research supports the use of massage as an effective tool for relieving anxiety, depression, and stress. Therefore, we should responsibly track changes in mood as reported by the client to add to our knowledge base and support our clients' healing.

Perform assessment tests to note the following symptoms, using techniques within our scope of practice:
- Compensational patterns, muscle hypertonicity, muscle weakness, spasms--muscle tests, palpation findings, and posture.

- Flexibility, loss of balance--balance tests, mobility tests, and range of motion.

- Inflammation--heat, pain with movement, redness, and swelling.

- Adhesions, fibrotic tissue, scar tissue--palpate restrictions, movement tests.

Research-Supported Treatments for Chronic Pain
Massage research can provide insight into potential effective treatment strategies when designing massage sessions for patients with chronic pain. Previously, when reporting on the Highlighting Massage Therapy in Complementary and Integrative Medicine Research conference in my September/October 2010 column ("Research Conferences," page 114), I mentioned a study that found both general relaxation massage and specific treatment massage to be effective for chronic back pain. Understanding the mechanisms of chronic pain as discussed previously, we learned that chronic pain is a nervous system disorder more so than a soft-tissue disorder, hence the success of treatments that induce a parasympathetic state. While the specific treatment sessions were intended to address the original trauma, perhaps they were successful in balancing the compensational patterns that developed as a healing strategy, since it is likely that the original trauma has long since healed.

The next step in the clinical decision-making process is to identify treatment techniques that ameliorate the symptoms and are consistent with the mechanisms of the conditions identified. The following are guidelines and treatment options to consider:

- Pain, sleep--Never add to the patient's pain experience. Use techniques that are soothing to the nervous system and provide relaxation in an attempt to enhance restorative sleep. When applying techniques such as trigger point therapy, use pressure only to the point of slight discomfort, never pain, and intersperse specific techniques with general soothing strokes.

- Mood, immune function--The mechanisms of massage for enhancing mood and improving immune function are not totally understood, nor have specific massage techniques been found more effective than others. General massage has been found to positively influence mood and immune function.17

- Mobility, balance--Pain limits function. Limited function results in decreased flexibility, mobility, and balance. Stretching, strengthening, joint mobilization, and massage have been found to increase function in those with chronic pain.18

- Inflammation--Massage and movement are important components for reducing swelling. Common techniques include lymphatic drainage, joint mobilization, and effleurage. Modalities such as ice and topical analgesics are also beneficial.19

- Scars, adhesions--Manual massage, fascia massage, and stretching have been found to reduce scarring with burns, chronic pelvic pain, and fibromyalgia.20

Integrative Health-Care Team
Massage therapy is an alternative to pain medication; however, coaching people off their medications is not within our scope of practice. People suffering from chronic pain are typically under the care of a physician. Some are patients in sophisticated pain clinics under the supervision of many providers who are accustomed to a conventional hierarchy of communication. While many of these providers may not routinely refer to massage therapists, they are becoming exposed to us through their patients. Enhance your client's health care and promote referring relationships with primary care providers working with chronic pain by communicating your findings.

Those who refer to health-care specialists like massage therapists expect the following information to assuage their legal responsibilities (those who refer are legally responsible for the actions of those they refer to):

- Monthly reports--initial findings after the first visit and regular progress reports.

- Descriptions of our findings--symptoms, palpation, movement, and visual data.

- Proof of progress--measurable changes in symptoms and objective findings.
- Treatment plans--what we want to accomplish and the treatment techniques that will help us accomplish our goals.

- Self-care education--what we teach our clients to do between sessions.

Most physicians are eager to learn what we know and do, especially since our clients lavishly praise us, but typically do not have the words to describe our techniques, only the results they feel. Additionally, we spend more time with clients than physicians do, and thereby learn more details of our client's condition and how it affects the client's quality of life. This information can contribute to the overall success of care and should be shared. Learn to communicate using conventional methods: gather measurable information, chart your sessions, and report the results in writing.

Be an integral member of your client's medical team. We earned--and continue to earn--our seat at the table, both through supporting research and our contributions to the health and wellness of our clients.

A licensed massage practitioner since 1984, Diana Thompson has created a varied and interesting career out of massage: from specializing in pre- and postsurgical lymph drainage to teaching, writing, consulting, and volunteering. Her consulting includes assisting insurance carriers on integrating massage into insurance plans and educating researchers on massage therapy theory and practice to ensure research projects and protocols are designed to match how we practice. Contact her at soapsage@comcast.net.

Notes
1. National Centers for Health Statistics, "Special Feature: Pain," Chartbook on Trends in the Health of Americans 2006, accessed May 2011, www.cdc.gov/nchs/data/hus/hus06.pdf.

2. American Academy of Pain Medicine, accessed May 2011, www.painmed.org/PatientCenter/Facts_on_Pain.aspx.

3. P.M. Barnes, B. Bloom, and R. Nahin, "Complementary and Alternative Medicine Use Among Adults and Children: United States, 2007,"
CDC National Health Statistics Report #12, December 2008.

4. S.R. Knauer, J.K. Freburger, and T.S. Carey, "Chronic Low Back Pain Among Older Adults: A Population-Based Perspective,"
Journal of Aging and Health 22, no. 8 (December 2010): 1213-34.

5. P.M. Barnes, B. Bloom, and R. Nahin,"Complementary and Alternative Medicine Use Among Adults and Children: United States, 2007."

6. National Institute of Neurological Disorders and Stroke, accessed May 2011, www.ninds.nih.gov/disorders/chronic_pain/detail_chronic_pain.htm.

7. Richard Body and Bernard A. Foex, "Optimising Well-Being: Is It the Pain or the Hurt That Matters?,"
Emergency Medicine Journal, February 18, 2011.

8. "Spotlight on Acute Pain: Survey Reveals Economic Recession Contributes to Acute Pain,"
American Pain Foundation, accessed May 2011, www.painfoundation.org/learn/pain-conditions/acute-pain/.

9. "Depression and Pain," Harvard Health Publications, accessed May 2011, www.health.harvard.edu/newsweek/Depression_and_pain.htm.

10. Ibid.

11. M. van Middelkoop, et al., "A Systematic Review on the Effectiveness of Physical and Rehabilitation Interventions for Chronic Non-Specific Low Back Pain,"
European Spine Journal 20, no. 1 (January 2011): 19-39; M.M. Tse, V.T. Wan, and S.S. Ho, "Physical Exercise: Does It Help in Relieving Pain and Increasing Mobility Among Older Adults with Chronic Pain?" Journal of Clinical Nursing 20, no. 5-6 (March 2011): 635-44.

12. Siegfried Mense, David G. Simons, and I. Jon Russell,
Muscle Pain: Understanding Its Nature, Diagnosis, and Treatment (Baltimore: Lippincott Williams Wilkins, 2000).

13. National Institute of Neurological Disorders and Stroke, accessed May 2011, www.ninds.nih.gov/disorders/chronic_pain/detail_chronic_pain.htm.

14. National Institute of Neurological Disorders and Stroke, accessed May 2011, www.ninds.nih.gov/disorders/headache/detail_headache.htm.

15. "Spotlight on Acute Pain," American Pain Foundation, www.painfoundation.org/learn/pain-conditions/acute-pain/.

16. M.N. Baliki et al., "Beyond Feeling: Chronic Pain Hurts the Brain, Disrupting the Default-Mode Network Dynamics,"
The Journal of Neuroscience 28, no. 6 (February 6, 2008): 1398-403.

17. M. Krohn et al., "Depression, Mood, Stress, and Th1/Th2 Immune Balance in Primary Breast Cancer Patients Undergoing Classical Massage Therapy,"
Support Care Cancer, (July 20, 2010); M. Listing et al., "The Efficacy of Classical Massage on Stress Perception and Cortisol Following Primary Treatment of Breast Cancer," Archives of Women's Mental Health 13, no. 2 (April 2010): 165-73; Y. Noto, M. Kudo, and K. Hirota, "Back Massage Therapy Promotes Psychological Relaxation and an Increase in Salivary Chromogranin A Release," Journal of Anesthesiology 24, no. 6 (December 2010): 955-8.

18. M.M. Tse, V.T. Wan, and S.S. Ho, "Physical Exercise: Does It Help in Relieving Pain and Increasing Mobility Among Older Adults with Chronic Pain?"; G.A. Malanga and E.J. Cruz Colon, "Myofascial Low Back Pain: A Review,"
Physical Medicine Rehabilitation Clinics of North America 24, no. 4 (November 2010): 711-24.

19. J. Lee and P. Nandi, "Early Aggressive Treatment Improves Prognosis in Complex Regional Pain Syndrome,"
Practitioner 255, no. 1736 (January 2011): 23-6, 3; B. Herbert, "Chronic Pelvic Pain," Alternative Therapies in Health and Medicine 16, no. 1 (January-February 2010): 28-33.

20. R.K. Holavanahalli et al., "Select Practices in Management and Rehabilitation of Burns: A Survey Report,"
Journal of Burn Care Research 32, no. 2 (March-April 2011): 210-23; G.L. Liptan, "Fascia: A Missing Link in Our Understanding of the Pathology of Fibromyalgia," Journal of Bodywork and Movement Therapies 14, no. 1 (January 2010): 3-12; P. Vercellini et al., "Medical, Surgical, and Alternative Treatments for Chronic Pelvic Pain in Women: A Descriptive Review," Gynecological Endocrinology 25, no. 4 (April 2009): 208-21.




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