Massage Therapy and Pain (Continued)

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Massage Therapy and Pain (Continued)

decorative imageMassage Therapy and Pain

Working with Clients in the Pain Zone

This is a continuation of the last pain blog which offered some history on pain science and also some really general guidelines on massage therapy and pain.

If your client has no red flags in assessment and you have decided it is safe to touch, working with clients experiencing chronic pain not associated with an injury has its own challenges. For many people, pain has the distinct effect of stopping us from moving, regardless of its cause, and so getting your client back to a place where they feel that they can move can be considered a success. To work safely as a massage therapist with an understanding of this, you are going to want to switch from the treatment model where massage is passively received by a client into one where the client has full control of the experience, both physically and mentally.

First lets look at the physical aspects of a client having control

This can be challenging, especially considering that most massage therapy programs teach massage as a passive activity that is ‘done’ to the client. In this role the massage therapist acts more as a facilitator to touch. Consider that touch is not a one way experience and that every time you gently “rub” a muscle, you also have the ability to instead have that muscle and skin move gently under/against you. If someone is in pain, you have the option of saying “I am going to gently put my hand here on your back, why don’t you try breathing up into that feeling”, or “I will never press harder, why don’t you try pressing gently into me?”, or “I am going to hold your arm gently, why don’t you just tense the muscle a little and then relax or wiggle your fingers?”. There should be a direct relationship to the amount of pain present and the amount of control the client has. The more pain present, the more the patient should be in control of what is happening.

This does 3 things in my opinion:

1. Lowers the anxiety associated with treatment, and the anticipation of pain, and possibly dropping their pain level.
2. Facilitates change in the body by signaling normal function and behavior as the patient moves.
3.Protects you the therapist from stepping over a boundary. If the client has control, they only go as far as they want, and no further. 

I want to be clear that if you are using this kind of treatment with someone who is in pain, you never want to cause pain. Their may be pain associated with the treatment, but it should not be from a new stimulus you are providing, such as pressure or forced movement. The pain associated with treatments of this nature should be caused by a patient moving through their own pain signal. What does that mean? It means that if someone has had long standing neck pain, and they are completely cleared for treatments, with no red flags, you should never aggressively treat with traditional deep massage. Instead I should gently guide the person to the edge of their painful experience and create a safe, controlled, comfortable setting in which they can explore going further-if they choose to do so. If the feeling of pain does not abate, you should, discontinue and refer out, but often reducing the anticipation of pain and giving the client control is the first step in the pain management in Massage Therapy.



How do you do it?

It all sounds pretty simple-give the client the control and they might get past their pain, but its actually a bit more complicated than that, because you don’t want to be randomly trying techniques. I divide my techniques up into graded categories to help me organize the treatments.

  • Low pain– resisted eccentric/concentric contractions and dynamic stabilization, and holding the tissues muscle while the muscle moves beneath
  • Medium pain– gentle active resisted techniques, holding the skin while the muscle moves underneath, simple isolated muscle movements
  • Higher intensity pain– tense and relax exercises for muscles or groups of muscles, breathing exercises that activate accessory breathing muscles

You will notice the different categories of pain could also be explained as acute, sub acute, chronic, or you could use a pain scale to divide them up. The important thing is that you know where you with the person you are treating. I use LP, MP and HP for short hand charting proposes. Lets look again at that client with the neck pain so we can get a better idea of the application of these techniques for the different pain categories.



Lets look at some examples to make things clearer

Client with HP  neck –  This client is afraid to move and has pain on movement of any aspect of cervical spine or upper thoracic, with a history of whiplash. Does not go about normal activities.

Treatment– Is a gentle skin deep gliding massage. The goal is just to get used to the client getting used to touch. Once the client is relaxed we are going to begin graded breathing exercises to see if we can get them to reduce the bracing in the accessory breathing muscles. I isolate a muscle by gently touching it and say “can you make this expand and contract by moving air?” We go though each and every muscle that would be effected by breathing. Then we switch to tense relax and do the same. Isolate the muscle, or muscle group by gently touching it, ask the client to control it by tensing up and then relaxing. I finish by going back to very gentle surface treatment of gliding massage.

Client with MP neck -Client has some movement but feels very limited by their pain. Range of motion is reduced to about half, and some of the ranges are less quality than others. Goes about normal activities but has stopped participating in any sports or anything unnecessary to their day.

Treatment– General massage with light to medium pressure. Once the client is comfortable I begin holding isolated areas skin in areas of pain and asking the client to gently pull away from me. If the client experiences pain we go back to the above treatment. We reverse the technique and this time I isolate muscles and have the client push into me (essentially bowing the muscle) If the clients pain level keeps dropping we then move to full simple isolated muscle movements. I hold the muscle and they run though a full rang of motion. (Video example of type of activity)I often do this by saying “ok now try to squish my fingers with your neck”. I correct any movement where they are recruiting another unnecessary muscle to complete the movement or avoid moving through the whole range. At the end of the treatment we return to gentle massage.

Client with LP neck-This client has pretty much full range of motion, but experiences pain at the end range. In their words “I just feel I can’t get past the final stage of the injury”. They are going about their daily lives, and participating in sports with occasional flairs. (this is the client you should most often be treating and seeing unless you are an advanced practitioner)

Treatment–  A general massage with light to medium pressure. You can use any of the above mentioned techniques to warm the tissues. As the treatment progresses, I move to holding the muscles firmly while they go through a range of motion. If no pain is present I ask the client to gently resist the movement for the selected muscle. (Video example of activity)If still no pain is present, I ask the client to resist with movement and move on to eccentric concentric moments. All of these activities are still gentle (the client need only meet you with enough force to activate the muscle)We end the treatment with the same general massage. If at any point the pain or the tone of the muscle rises, we go back to a previous treatment plan.

Wait!!!

But we have gotten ahead of ourselves…before you can do any of this cool stuff, you have to talk to your client about exactly what you will be doing with them and why you think it is the best choice!!!! And that’s exactly what we will go over next time.

Massage Therapy and Pain

Massage Therapy and Pain, What Does it All Mean?

Massage therapists live in a world of touch. So it is no surprise that the new science that relates to how touch, sensation and pain is processed and experienced would be relevant to massage therapists. This is particularly true since many clients seek out massage therapy for complaints specifically relating to pain.

Pain science in one form or another has been around for years. One of our first understandings of it was provided by Descartes [1], who theorized that pain and physical illness were limited to a nervous system experience, i.e. you hurt your hand and so you feel it. It essentially separated the mind and body experiences.

As our understanding of pain sensation grew, we realized that feeling things was a far more complex process, and that our bodies are filled with different kinds of receptors that relay information, not just one way to process. Melzack and Wall changed [2] our perception further by bringing in the “gait control” theory to our clinical understanding. In this view, when the system is stimulated, it is sent through a ‘gait’ in the dorsal horn of the spinal cord. That gait however can be modulated by some psychological components resulting in a difference in the perception of the stimulus.

Our most current and newest understanding of pain is that of the biosocial understanding of pain. [3] In this model, we have a stimulus of some kind that is relayed to be processed, but at that point many factors such as environmental, social or emotional, might come into play to determine if pain is generated and at what intensity. And from that we see pain as an output of the brain, rather than something that is the result of poor biomechanics or even, in some cases, injury. In other words, pain can stand on its own without us having to find causation in the body.

What does this mean for Massage Therapy?

For a lot of massage therapists, this has left them a little confused as to their role in treatment. If pain is not generated exclusively in the body, what are we treating? If I am not ‘fixing’ a structure or posture, what am I doing? If pain is an output, then why seek physical treatment at all? It could be easy to start feeling a little redundant in the mix of it all, but now more than ever, massage is a viable option to those experiencing pain.

From a massage therapy perspective, the biosocial model of pain is far more inclusive than exclusive. If pain is influenced by thoughts, feelings and emotions, then doing things that feel good have the potential to benefit the client, even from a general treatment perspective. Asking your client “how do you feel?” during treatments, and “was that good for you?” afterwards becomes a relevant way to guide success for generalized treatment. It’s a step towards the clinical world seeing ‘feeling good’ as a part of heath care, rather than a luxury associated with indulgence.  If the body is spending much of its time protecting us by sensing threats around us, we can also help send the message back to the body, that everything is “a ok” (within reason).

Don’t throw the baby out with the bathwater

It would be easy to read the new information coming out about pain and assume that from here going forward massage has only general feel good treatments to offer in the context. Should massage therapists stop treating for specific conditions? The answer is both yes and no. Moving forward with quality treatments is going to have to do with how humble and honest a massage therapist can be with him or her self. And that is no easy task in an industry trying to prove itself as medical professionals. Massage therapists have to accept two truths about their treatments and understanding of them. 1. that they have a limited understanding and education about what they know about the person on their table.  2. That they may never know the answer to why the body has decided to protect itself.

This model does not mean that structural problems don’t exist. The normal rules of physics involving force, friction, leverage and space are still in effect. Bones still break, posture still degrades to bone to bone contact, and fitness plans still ramp up too fast, but a therapist has to be willing to open the door to other possibilities when the evidence does not add up, question it, even when it does, and treat the structural issue as a symptom rather than a cause in some cases.

Pitfalls in Treating Pain with Massage

You may find yourself getting caught in a few traps if your a massage therapist treating people with pain. Operating safely in the biosocial model of pain does have its challenges. If pain is not always associated with injury, then assessing “pain” as a contraindication for treatment may not be the best guide. Without fail, a massage therapist must be able to  assess the signs and symptoms of pain associated with acute injury pain-vs-the signs and symptoms of pain itself. The signs may not always be so clear.  If you are inexperienced, it is always best to refer out so that you can remain safely in the boundaries of “Do No Harm”.  A biosocial pain assessment for a massage therapist looks like this:

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The sooner therapists get comfortable with treating pain, the sooner they can help get their clients comfortable. Next time we will go over the guidelines for talking to your clients about pain to provide some answers about when and how talking to people about their pain is appropriate in the contexts of Massage therapy as health care.

 

 

 

[1][2]R.Melzack, P.Wall. Science, New series, Vol. 150, NO. 3699.Nov, 19 1956 Pain Mechanisms: A new theory Retrieved from https://isle.hanover.edu/Ch14Touch/Ch14GateControlTheory.html

[3] R.J. Gatchel, Psychological Bulletin, Vol. 133, NO 4, 581-624 2007. The Biopsychocial approach to chronic pain: Scientific advances and future directions. Retrieved from http://enniscentre.com/Presentations/Gatchel-Biopsychosocial%20Approach%20to%20Chronic%20Pain.pdf

Body Mechanics Orthopedic Massage, 1 W 34th St, #204, , New York 10001, United States (US) - Phone: 212-600-4808

What does Massage Therapy Mean?

When I lived in Ontario, it always gave me a chuckle that, if I wanted to buy beer, I had to go to a place called the “Beer Store”.  At the store you walk in and order your beer, sight unseen, from the cash register, which means as a customer you have to know what you want before you get there. I mean, what kind of marketing is that?  I know they are selling beer, but what kind? What does beer really mean? Does it include cider? Does it include gluten free? What if you have never had beer before? Or had only had one kind? How do I, as a customer, know what I want?beer 1

Massage is exactly the same. What is massage therapy really? Even within the industry there is a fair bit of debate due to regional differences and scopes of practice. Oh, sure, we could wiki it, (here is the wiki link for massage -which is not where you should get your info by the way) For my practice I consider movement-oriented techniques  and mobilizations for pain a major part of massage therapy, but in another state they might consider only stroking, and kneading  to be massage. In Thailand massage means  you are to be fully clothed while the practitioner bends and flexes you, in Russia they might beat you with wet leaves and in India slowly drip you with oil.  The word massage seems to convey simply that you will come and  have some sort of interaction where someone else will do something to your body.  Even if we get specific, i.e. ,”Today we are doing medical massage.”, what does that mean? Is it massage that is done by a doctor? Or is it done in a medical clinic? Is it massage done for a medical reason? Even if we define medical…there is still that word massage there, which could mean anything. What are we doing when we preform massage.

From a client perspective this has got to be very confusing. Give your clients a little credit, because every time a new client books with you they are taking a chance. They really have no clue what they are getting before they get there. Chances are when they book with you for a sports massage they are either hoping it was just like their last sports massage or nothing like their last sports massage. But still, what is  sports massage? How do we as therapists convey what it is we do to our clients in a way where they know exactly what they are getting before they get it.

It is time to get really specific about what you are doing as a professional, and that specificity will set the tone for a better, safer experience for all involved (and earn you more money because you are seen as more professional). After your client intake I would consider dropping the word massage entirely form your vocabulary, because to clients it has no meaning, nor does trigger point, fascia work, neuro-muscular, stabilization and all the rest. It’s not enough to say “lets work on your lower back” because what does that mean? You have to say “I am going to gently touch your lower back by stroking it, and then move to deeper work with my finger tips. If, at that point, I think that we need to go further, I would like to pick up the skin and stretch it a bit. How does that sound?” At which point most clients would respond by saying, “Oh no…I hate the skin pulling part…my last therapist did that and I HATED IT” or they might agree fanatically.  It does not matter, but you have just had effective and clear conversation about what ‘massage’ is, and that is HUGE.

When someone says ‘yes’ to massage therapy on their back they may actually have no idea what you are about to do. So make it good practice to make it clear and  specific with your clients.  Their stress level will go down and their happiness with you will go up. You might even try dropping those buzz words all together and see what you are left with. Possibly it is a more professional, more science friendly package.