Massage Therapy Treatments for Low Back Pain

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Massage Therapy Treatments for Low Back Pain

Introduction to back pain

Low back pain is surprisingly common among all Americans and is one of the foremost reasons we miss work. Based on that it is not surprising that we are always looking for ways to solve, treat, or rid ourselves of nagging back pain. The truth is though, our medical system is not the best at treating it.

I am a massage therapist and I love massage therapy but I will be the first to tell you, the number one recommended treatment for back pain is not massage therapy; it is movement. Let’s first clarify what I mean by “recommended.” When I say that what I mean is supported by research and recommended by experts in back pain. Unfortunately that does not mean that recommendation is actually reaching the people in pain. Our medical system is so saturated with other noise that it’s hard for people navigating within the system to find what is best for them.

When you’re ready to a seek medical Massage Therapy Treatment

I gave a short list of questions to go through in a previous post so here’s a condensed version. If you are coming into Body Mechanics for back pain the first thing you need to know is; it is best to come in 3-5 days after an initial injury. You need to be able to lie comfortably on the table during treatment. Please come in unmedicated as well. It is very important that you can accurately feel what is happening to your body while receiving your massage. If you are coming in for more chronic kinds of back pain, the kind that rears its ugly head every once in a while but that you  are very familiar with, you can come anytime – but you may want to time your visit based on the cycle of this chronic pain.

Low back pain can be nonspecific but even without a diagnosis, we can divide it up into a few subcategories:

  • Back pain that is more related to the hip
  • Back pain that is more sacral
  • Back pain that is more located around the spine
  • Pain that is more muscle spasm related to the area between the hip and the last ribs.

We can get into the individual diagnosis, but it may not matter so much in terms of massage therapy because we are treating symptoms. For example, you may hear that massage therapy is treating any of the following: sacroiliac joint pain, labral tears, bursitis, tendinopathy, disc degeneration, disc herniation, nerve impingement or stenosis.

Saying we are treating a spesific pathogy is slightly off  base. We are more managing your body’s response to its pathology.

Massage Therapy for Back Pain that is hip-dominant or is stemming from labral tear, cam impingement or other hip dysfunction

It is important to note that even though the issue may be in the hip, the pain might be felt in other areas, this is called referred pain

We treat back pain that stems from the hip will in a slightly different way than a back injury. Functionally, this type of pain often appears to create spasm in the glutes, the rotators of the hip and the piriformis. It is essential that a massage address these areas fully. Ideally, and with sufficient time, the hamstrings and the back would also need to be treated.

The area should be thoroughly warmed with massage and/or a heating pad first. Restoring internal and external rotation to the hip through range of motion, active release and mobilizations often significantly helps relieve symptoms. Additionally, as the muscles have a lot of bulk, the glutes need to be treated. I frequently work by creating a lot of slack by putting clients into what I call the “froggy position.” I find it helps to relive the trigger points without causing the patient a lot of undue pain. Depending on the type of injury, relief might be temporary or longer-lasting.

Hands massaging the low back
Body Mechanic Licensed Massage Therapist treating hip-dominant pain

Using Massage Therapy Treatment to treat Back Pain that is from Acute injury

If you are coming in for an acute injury treatment is far different. Ideally you would be coming in after you have a diagnosis, and you are out of the initial stages of healing (again, we recommend 3-5 days after injury.) There must be no open wounds, active infection or swelling. That being said, if you are too uncomfortable for massage in the area that is directly affected, there is a fair bit of research that indicates that working with one area of the body can affect another. Check out this research on stretching the hamstrings affecting neck’s range of motion.

Essentially, a massage therapist who is skilled is going to be able to get you more comfortable while you heal. They’ll do this by working on another body part and by just generally relaxing the nervous system. 

Massage for acute areas of pain must be gentle, and focus on relieving discomfort rather than gaining function. Heat or ice may be applied to the back depending on what feels better. Soft strokes such as effleurage, scooping, and techniques that lift the surface of the skin like cupping, might all be utilized. As the massage expands towards the periphery, the strokes can become deeper. If movement is in the therapist’s scope of practice, breathing and tense and relax exercises can all help to signal to the body that it is time for the area that is affected to relax and un-brace. 

Addressing chronic back pain with Massage Therapy Treatment

Massage for back pain that is from a chronic injury is where massage therapy really excels. It is generally safe to use a wide variety of depth, massage strokes and movement. The hips, low back, glutes, and mid-back can all be treated safely and effectively. Ideally, due to their size and potential to create tension in the back, the glutes and rotators are treated first with both movement and massage. Then the therapist would move on to treat the erector muscles along the spine and quadratus lumborum (the deepest abdominal muscle) with stripping and trigger point therapy.

Since therapists have the option to choose from many massage therapy modalities, the best techniques to use are the ones that 1) The patient enjoys, and 2) Are most effective for the situation. Some people naturally respond better to movement, tense and relax, stroking, trigger point or fascia work. Here good listening skills both with the hands and the ears are very useful in deciding how to proceed.

Sacroiliac joint issues and Massage Therapy Treatments

Massage therapy for SI joint issues has a very different plan than other massage therapy plans. The SI joints are small joints to the left and right sides of the sacrum. They have very little movement, and in fact over time, the movement reduces, but they cause a great deal of pain for many people. Since the pain is radiating from a bony area that often feels inflamed and pinched, many people feel relief through ice application to the joint.

Additionally, since it is a joint, we can relieve the tension on it by making sure the muscles around it are relaxed. Treating the quadratus lumborum and the glutes (specifically the cute medius) seem to provide the most relief. Massage and stretching can be applied to these areas to provide the sensation of even pressure across the joint, which helps to relieve the pain.

Summing up

Beret Loncar Massage Therapist, Personal Trainer and Yoga Therapist

There are many different kinds of low back pain and they can present in different ways. While movement is the best way to address it, I think I’ve pointed out some specific and effective ways Massage Therapy can be used to help people in pain. Provided the therapist pays close attention to what kind of massage techniques are safe. Based on where the issues are stemming from and listening closely to the patient’s body and preferences, massage therapy can be a helpful treatment. If you would like to talk to us about what treatment options are right for you, you can reach out to us, send an email at info@BodymechanicsNYC.com!

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Body Mechanics Orthopedic Massage

1 W 34th St
#204,
New York, NY 10001
Phone: 212-600-4808
Email: info@bodymechanicsnyc.com

Can Massage Therapy Help My Lower Back Pain?

Can Massage Therapy Help My Lower Back Pain?

Can massage therapy help my pain? The answer to this question is more complicated than you would think. Massage Therapy research is all over the map. For starters, there are some inherent conflicts with the studies because people LIKE massages. And people are more likely to choose massage over another treatment that they do not like, even if something else could be more effective.

Back Pain is Common

To examine how others have answered the question, let’s start by taking a look at lower back pain in general. Did you know it is normal to have some pain sometimes? Lower back pain is the 2nd most common cause of disability in the USA and a surprisingly common cause of missed work. 80% of Americans will have an episode of low back pain in their lifetime. So you are not alone if your back is feeling achy and sad. 

Back Pain is Often Non-Spesific

Medical professionals are historically bad at treating lower back pain. You might have experience with a doctor suggesting a list of seemingly unrelated treatments for your pain, like throwing a dart at a target with their eyes closed, hoping for a bullseye. That may be because the WHO lists that 60-70% of back pain is “Non-specific,” meaning the cause is unknown. cause.  If we do not know what the cause is, planning the treatment becomes extremely difficult. The National Institute for Neurological Disorders and Stroke lists about 30 different possible causes and contributing factors to back pain alone. 

Research is Complicated and Low Quality

To complicate matters, though massage has excellent research supporting the treatments of both depression and anxiety, the research is rather underwhelming in the area of back pain. Instead, movement is often the recommended treatment. However, massage can incorporate things that are not massage; On table exercise, stretching, mobilizations, and resistance might also be included in your message. So the research that measures the effectiveness of just massages on back pain, isn’t really accurate when a therapist is including these other treatments to help you recover.

Body Mechanics Sports Massage Therapist Matt performing a lower back massage NYC
Sports Massage Therapist Matt massaging a client’s back. Photo credit Adam Ninyo

Pain is Complicated

Muddying the matter further, pain in your back may not solely be caused by an injury. Going back to that WHO the number of 60-70% of back pain being nonspecific, many of us have back pain that chronically exists and isn’t a reaction to a movement or standing or bending. Pain is generated for a number of reasons, the number one being to protect you. Your nervous system takes into a number of variables such as your medical history, your environment, your mental state, your sensitivity, your general physical health and more, before it generates pain as a warning. 

So how do you know if massage is for you and your  back pain?

It is a hard question. I suggest you ask yourself the following:

Massage therapist treating low back pain

  1. Is it safe? I recommend having a diagnosis from a doctor and being out of the range of acute pain before coming in. Even when the diagnosis is “non-specific back pain,” it’s important to rule out other injury as the culprit. Being able to lay still and be touched for the duration of the massage is important, so if your back is too sensitive to touch, wait a day or two.
  2. Am I seeking an alternative route of pain management? When natural and over-the-counter options aren’t up to the task, massage can be a powerful ally in pain mitigation.
  3. Do I like it? If you enjoy being touched and it makes you feel safe, that can be advantageous. Our mental well-being affects the physical, so the boost from treating yourself and the physical connection of massage could help with your pain.
  4. Am I using it in addition with another rehab? If you are in physical therapy, massage can loosen up tight muscles and make a big difference in increasing ease of movement.
  5. Am I additionally stressed or depressed? If you’re burning the candle at both ends or in a stressful time, massage might really help. The trauma of being injured itself can be very stressful and so managing that can be a huge boost to recovery.
  6. Has massage worked for me before? If you have a history of massage working for you it is a good bet that it will work again!

If you answered yes to a few of those questions, then massage therapy might be a great choice for you and your back pain. Check out our booking options for medical massage to see if is right for you:) 

Stay tuned for our next blog on what goes into a good massage for back pain.

Body Mechanics Orthopedic Massage

1 W 34th St
#204,
New York, NY 10001
Phone: 212-600-4808
Email: info@bodymechanicsnyc.com

Back Pain & Knee Pain: Body Mechanics’ Orthopedic Study Corner

Our second look at recent studies and findings in the world of body and movement science!

massage therapist matt

Welcome back to Body Mechanics Study Corner where we do all the research so you don’t have to! Actually, Matt does all the research. Normally he does this to satiate his own thirst for knowledge and drive to learn any findings that could make him a better massage therapist, but once again we are offering up the fruits of his labor up to you all. We hope you find it enlightening and interesting.

Reads

What are the Major Contributing Factors to Osteoarthritis Knee Pain?

Many people suffer with knee pain and many people are given a list of different things that could be causing that pain. Todd Hargrove, of Physio Network, sought out to get to the bottom at the issue and find the real root of the issue.  He analyzed a study comparing general health workshops, high load strength training, and low load strength training for people with knee osteoarthritis, to see which method produced the most relief. Interestingly, he found that all three methodologies produced about the same amount of results, meaning the most important factor was the work being something the person would actually do consistently. These findings debunk the notions of “wear and tear” being the vague, inevitable, problem causing these osteoarthritis knee issues. 

Videos

Pinpointing Pain Along the Scapula

In the video above, physical therapist Marc Surdyka DPT discusses why most pain felt along the medial border of the scapula is actually referred from the structures of the neck. Without addressing habitually poor conditions such as sleep quantity and quality, and a lack of breaks when sitting for a long time, chronic shoulder pain will return no matter how much you roll your back out and stretch.

Interview with Dr. Mark Laslett on SI Joint Pain

This is a long one, but if you’re interested in Sacroiliac Joint pain then this is the video for you! Sports therapist Matt Phillips interviews Mark Laslett PT PhD about all things SI joint pain. Dr. Laslett is a true giant in the world of musculoskeletal physiotherapy, with over 50 years of experience as both a treating clinician and research scientist. Dr Laslett discusses the extra joint pain women feel when pregnant and theorizes that the cause of SI joint pain may, in fact, be chemical and not physical!

Research

What’s Really Helping Our Back Pain After Exercise

Working out and getting a massage to address your lower back issues are a surefire path to pain relief, right? Maybe not! This systematic review examined 16 studies to see if the reason exercise therapy really improves pain and disability levels in people. Surprisingly, the takeaway here is that brain functions and psychological health may have a bigger impact on chronic back pain, than regular exercise.

Bdy Mechanics Sports Massage Therapist showing cow pose for home care back pain presentation

Will Clients Do Their Homework?

Home-care is an important part of healing and strengthening. But what can we, as massage therapists, do to get clients to actually do the work at home? A study found at the National Library of Medicine tracked the progress of over a hundred military service people in physical therapy. It found that the recovering clients who had 4 or more exercises were far less likely to complete their at home work than the ones who were given only 2. From this, healthcare providers can see that it’s more important to be practical with a client’s home care notes, instead of giving them a long regimen of all the most effective exercises.  

Thanks for reading! Use the comments below to let us know what findings you found most interesting or if you have a contradictory idea about anything here. Also, let us know if you want to see a certain theory researched or explained in our next post.

Body Mechanics Orthopedic Massage

1 W 34th St
#204,
New York, NY 10001
Phone: 212-600-4808
Email: info@bodymechanicsnyc.com

Pain and the Zombie Apocalypse

Whether it’s another exhausting election cycle or the impending zombie apocalypse, many of us are a bit more stressed and anxious lately than usual.  Intense times, it’s totally normal to start experiencing some physical symptoms that might feel abnormal if you don’t realize their source.  Some of your old injuries might start hurting again, your back or neck may become stiffer or achier, and if you’re already dealing with some kind of pain, that may become worse.

Stress and/or anxiety can increase or decrease normal pain thresholds directly or indirectly.  Prolonged stress will tend to decrease a person’s pain threshold so that the exact same physical stimuli might become more painful than usual, or something that didn’t used to hurt might begin hurting.  People with persistent pain are often aware of how a stressful day at work can cause a flare-up, but far fewer people realize that stress and depression are two of the biggest predictors of painful flare-ups in people with acute low back pain.

Stress can also decrease pain thresholds by influencing behavior.  Most of us know that a stressful day, week, or decade can make it harder to get to sleep or stay asleep.  Lack of sleep and non-restful sleep are significant risk factors in developing physical pain and prolonging it.  Being tired can also make it far more difficult to push yourself to get some of the physical activity our bodies need to stay happy and healthy.

In these stressful times, it’s perfectly normal to begin experiencing all sorts of symptoms that might seem as if they came out of nowhere.  That’s all the more reason to take care of yourself in all the ways you can.  Spend time engaging in meaningful activities, talk to the people you care about, make time to be mindful or to relax, practice good sleep hygiene, ask for and accept more help from others, and get in some movement where you can.  You’re not broken and you’re not falling apart—we promise.

By Matthew Danziger

References:

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4795524/?report=classic

https://journals.lww.com/spinejournal/Abstract/2018/03150/Do_Physical_Activities_Trigger_Flare_ups_During_an.14.aspx

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4046588/

The Benefits of Manual Therapy- An Interview from the Knowledge Exchange

Benefits of massage therapyOur Massage Therapist, Matt Danziger sits down with the Knowledge Exchange to talk Manual Therapy or rather what manual therapy is NOT in this blog/podcast

One of the things we pride ourselves over here at Body Mechanics Orthopedic Massage is our devotion to science and giving people a real outlook on what massage can and cannot do. We are for the most part, for what its worth science based-ish with the understanding that minds do not change over night and therapists need room and time to grow. When Matt told us that this podcast blog post was coming out we immediately asked him if we could re-post it for the Knowledge Exchange.

If you have never heard of the Knowledge Exchange, they are a professional education group that runs courses and mentor ships on the BPS model of pain (that’s Biopsychosocial if your not up on your acronym’s).  They have some wonderful online resources and blogs you can check out and they specifically define what they do as:

“We don’t see our selves as educators but rather facilitators of ideas, discussion and critical appraisal. We do this because we aren’t satisfied with the status quo of health care and believe we can all do far better for our patients.”

I do not want to give too much away in what this podcast covers but it gives some great insight into how Matt sees the role of massage in terms of fitting into the BPS framework. Frequently, a massage therapist who uses this model is viewed as anti-manual therapy and that is not the case.

You are also going to get a great look into Matt’s personal journey as a massage therapist as well as his journey with pain.

Want to check it out? Go ahead and read their post by following this link to listen to the podcast.

You can check out this blog with Adam Meakins  by the Knowledge Exchange if you want to go further into the manual therapy rabbit hole.

If you want to book with Matt and his talented mind, you can read more about Matt’s Massage therapy her or book here.

To connect to Matt’s blog follow this. 

 

Body Mechanics Orthopedic Massage

1 W 34th St
#204,
New York, NY 10001
Phone: 212-600-4808
Email: info@bodymechanicsnyc.com

Don’t Tell Me to Relax

Relax….

You book the massage appointment. You take the risk. It is a financial stretch but you have to do something because you have not been able to manage on your own. You lay down on the table. The massage therapist says “Take a deep breath…Relax…”

In the last few years I have become very conscious of what I say to people. As I have gotten older I have given less ‘%#@’s’ about some things and more about others. One of the things I have given more about is how I might accidentally harm someone whom I am caring for. That fills two categories; people I treat, and the people I teach to treat.

I primarily work with massage patients in  pain. Frequently those people have the kind of pain that has been untreated, underestimated, and has fallen through the medical cracks. They are sometimes angry, vulnerable, difficult to deal with, as well as they are often generous beyond belief, humble, and full of hope. They come in all forms and shapes and sizes…but what they have in common frequently is they cannot relax. This may pertain to their whole body, or a single part…but if they could simply relax and gain control of whatever they are seeing me for, they would have done it long ago.

And so, it really bothers me when people say ‘relax‘. It has become somewhat of a trigger word because, what I hear is the response: “Don’t you think I would if I could? I booked an appointment specifically because I need HELP relaxing, and here you are telling me to relax, when I have admitted, I can’t”. In fact, in my case being told to relax, specifically makes me more anxious. I am pretty sure every dentist I have ever known has said “take a deep breath and relax” right before he has done something awful.

I think in terms of massage therapy, the word relax is old, is loaded and full of harm. It is like a brand that has ceased to have meaning to us, and yet has become the only word we use. For people looking for a spa day, it may have no connotation, but for many it could be one of the worst things I say to them all day.

While it is hard to watch your words all the time, I have tried to omit relax completely from my massage practice. I had to think for a bit on what exactly should take its place. Frequently I am communicating a lot with people on how an area feels to them, and I will ask whether or not they felt a tone drop in an area or if that is my perception- ie ‘should I move on? Do you feel more comfortable now? And then, of course, the old stand by word “release” pops up. I am not a big lover of the “release” description either. What has been released? Certainly I am releasing nothing…something might be relaxing…but then there is that word again!

Neither word is the correct thing I want to say to anyone, but those two words are flung about, both of them holding too much meaning, and way too little at the same time. What I want is to give someone an actionable word or words, that they have control of, something that removes my hands from the picture, other than to bring awareness. The words I want to use need to suggest that they have self efficacy in a process that I am creating a space for. And so for the moment, I have settled on “Let go” or “Be heavy”.  As in, “I am going to be gently moving you around for a moment, and so there is no resistance, I would like you to try to let go of that area/practice being heavy, but if you cannot, that is okay…we can just move together for a little while and it will be just as good.”

 

Finding Naturalism in Massage

naturalism and massage

Many of us in the massage industry spend a lot of time talking to other therapists about massage therapy. What is holding it back? Is it the non-science based nature that is the issue? Is it the lack of research? Is it the people it attracts? Is it the professionalism? What about the spiritual aspects that some seem to want to connect to?

As most of you know, I am firmly in the science-based camp. My background is  pain management with rehabilitative exercise. This is what I was taught in school and I was exposed to nothing else. Prior to my RMT training, I had taken pre-med courses in college, and before that all the AP science classes offered in high school so the Canadian program fit right in with my science-based ideals. It made sense to me.

The US massage industry frustrates me to no-end. I desperately want it to change because, after working in Canada as part of a heath care continuum, I know how good a massage program can be.

I know there are a lot of us pushing for a shift to a science-based program. However, given the condition of the US system and its irregularity, changing to science-based might be asking too much transitionally.

The US massage industry faces a number of problems. With such a large number of workers currently in the industry, the change would surely need to be gradual. One of the things I constantly think about is, with the current requirement of 500-1000 hours and no competency requirement, are we barking up the wrong tree demanding science? Is science even doable? Of course I learned some science in my education, but I didn’t necessarily learn the act of science in massage school. Often times what we receive is the outline of science, the puppetry of science, the mimicry of science…not actual science, even from the best and brightest who teach and share knowledge.  I am not saying don’t teach the science aspects, I am saying expecting meta data analysis from someone still trying to figure out where the elbow is, is probably unrealistic.  The results may be as poor and dangerous as pseudoscience.  Maybe what we should be asking for is naturalism…and leave the science to the experts.

Naturalism is defined as: A philosophical viewpoint according to which everything arises from natural properties and causes, and supernatural or spiritual explanations are excluded or discounted. 

Massage therapy lends itself  very well to naturalism. At its base even the most complex thing that I have done with a patient through a rehabilitation is simply mimicking how the body would normally behave in a controlled, suggestive state in the hopes that the body realizes it can keep moving and that it does not need whatever protection or feeling it has produced.  I try to remind the body of its normal function by setting the stage with relaxing/safe elements, and then lead it through passive, active and resisted activities.   And follow up by assigning exercises that will re-enforce that. There are only so many things the body can do. We take the body through these activities in order to start a dialogue. A dialogue with words like – rest, slack, stretch,  move, stimulate, sense, resist and strengthen.  I try to build windows of time where there is an altered signal or decreased signal, so the body can get back to doing what it loves to do…homeostasis. I monitor all of it through range of motion and pain scales. It is not rocket science;) Of course it can get more complex when you start building in limitations and conditions, but at its base its fairly simple.

Science can be a complicated system of testable questions and answers. There are entire systems in place to understand how to correctly ask the questions, let alone address  the answers. Rarely is it simple. It takes years to study, explore and even begin to understand even small parts of it. Naturalism however is beautiful in it’s simplicity. With 500-1000 hours of training and little time to test the application let alone question it, perhaps some of the answers lie there.

Starting with a few simple observations, perhaps we could make a safer, simpler, more ethical massage world. Here are some of the simple statements I keep in mind when practice daily.

  • Relaxation has value and potential.
  • The body is fine the way it is. Homeostasis works. For the most part the body will correct itself naturally, unless disease is present.
  • In the end, all change comes from internal function, not external force *other than trauma
  • Setting the stage for rest and digest may help remind the body that things are ok, which may let the person move more or differently, so they can get back to their normal.
  • Form is not necessarily representative of function.

What are the statement you practice under? More and more I see statements like “the science of massage”. Yet that statement is pretty misleading, when I think about what I do, as I am not really doing anything. I am simply setting the stage for what the body does for itself…naturally. Absolutely there is room for more advanced practitioners in advanced practice settings,  but at the core we need to get comfortable with who we are.

*I want to make a small disclosure here, as to the above statements of rehab. Rehab or rehabilitative exercise falls within the scope of an RMT (Canada). In no way do I advertise the practice of that here in NY, the example is based on my past experiences where it would be very normal for me to work with stroke patients, whiplash patients, etc combining manual therapy, movement and rehab exercise on my own. Your scope will depend on where you practice, and you should follow the local law to that effect.

 

Massage Therapy and Pain (Continued)

FullSizeRender (1)Massage 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