Thoughts on Manufacturing Depression by Gary Greenberg

“If we claim to see massage as a component of a holistic therapy, and feeling depressed is so common, there is much in this book for massage therapists.” Geoffrey Hugh Miller shares his thoughts on Gary Greenberg’s Manufacturing Depression: The Secret History of a Modern Disease.

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A Massage Therapist’s Journey Through A Career Crisis

What happens when all your long-held beliefs about massage and your place within the massage industry get blown out of the water? Do you quit? Do you continue spreading outdated info? Or do you dust yourself off, open your mind to new theories and science? Sharon Livingstone explains her journey through a career crisis.

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Cultural Safety for Massage Therapists

Do massage therapists consider the cultural safety of their Aboriginal and Torres Strait Islander clients? Karen Wyld provides practical tips and resources, as well as suggestions on how massage therapists can better engage with First Peoples.

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Conference announcement – save the date!

The rooftop at Rydges. We’re holding a breakout here. Truly. We are.

We are chuffed to announce that the AMT Annual Conference will be held on October 12, 13 and 14 at the Rydges Sydney Central. The venue is located within five minutes easy walking from Central Railway Station in Sydney. That’s ten minutes by rail from the airport. We’ve negotiated a special room rate for conference delegates but there’s loads of accommodation options within easy reach of the venue to suit all budgets.

We are working in earnest to finalise the program. This year, you’ll be able to choose whether you’d like to attend for any single day, two days or all three days of the shindig. There will be a cosy welcome event on the evening of Friday 12th and a cocktail function on Saturday evening (13th October). We’re closing the entire event on Sunday afternoon with a mystery session that we reckon you’re going to love.

So far we have two confirmed breakout presenters. We’re really excited to be hosting guest international presenter, Robert Libbey, who will also be taking his workshops on a road tour around the country during October 2018. We are just beginning to work on the details of Robert’s visit, so now would be the right time to check out his website and put in your bid for particular presentations in the comments section!

We are also pleased to be hosting Josephine Key who will present breakout sessions on movement and manual therapy.

We have some exciting prospects on our plenary presenter hit list and look forward to sharing details as sessions are confirmed.

Breakout workshop participants at the Annual Conference in Canberra, 2017.

The AMT annual conference is the keynote educational event of the Association and it’s actually fun! It’s your chance to learn new stuff, earn CEUs, catch up with old mates, connect with peers and, god forbid, let your hair down a bit. It’s also tax deductible …

We really hope we’ll see you in mid-October!

 

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Being A Health Fund Provider: Your Responsibilities And Obligations

What are your responsibilities and obligations as a massage therapy provider? What records do you need to maintain and keep? And how do you avoid committing health fund fraud? Some simple guidelines and reminders to follow as a provider to private health funds.

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Is Pain Science Just a Pain in the Gluteus Maximus?

By Aran Bright

(This article originally appeared in the June 2017 AMT Journal ‘In Good Hands’.)

It is all about helping people, not just science

If you are reading this, there is a very good chance that you are one of Australia’s professional, dedicated massage therapists. You’ve spent days, weeks, months and years up to your elbows in oil or balm, rubbing, kneading and pressing bodies in an ongoing search for trigger points, tight tissue and that elusive “sore spot”. You likely have aches and pains of your own: sore back, shoulders and hands are pretty commonplace in our profession. Pain is something you deal with every day – if it is not your own, then it is your clients’ pain you’re faced with.

So, you’d think it would make sense to know as much about pain as possible?

Hopefully it won’t surprise you that massage therapists are not the only professionals who deal with pain: physiotherapists, psychologists, GPs, rheumatologists, neurologists, paramedics and researchers/scientists are just some of the other professionals who work with people in pain on a daily basis. Thankfully, we are currently seeing more cooperation between different fields and this is leading to a new wave of understanding about pain.

But this new wave of understanding can actually be a bit of a “pain” in itself because it is upturning many of the concepts and convictions we have so long held as gospel in the field of massage therapy. At the forefront of this wave is the recognition that humans are complex and irreducible, with a huge capacity for change and growth depending on a multitude of factors. In fact, it is basically impossible to know every single factor that may affect an individual’s pain experience. The best we can hope to do is identify the most significant factors and support positive change by tailoring our treatments and interactions towards addressing these individual factors in partnership with our client.

Science can be immensely helpful in supporting clinicians to identify the most significant factors in people with pain. And the wonderful news is a lot of the current science is (almost) common sense!

So what are the big factors?

Most people who develop pain will heal just fine – this is really important to recognise and acknowledge. It is completely normal for people to recover from a painful experience. As an example, a 2008 study of Australians that presented to primary healthcare practitioners for lower back pain showed that 72% (of nearly 1000 people) returned to pre-injury levels of pain and function within 12 months. This is really important because if someone comes to you with back pain, you want to inform and reassure them that it is completely normal to have pain and recover to normal function but it may just take some time.

But that does leave the 28% who did not recover to baseline. The reasons cited in this study were old age, compensation claims, higher pain intensity than average, previous injury, depression and perceived risk of persistence. Of these factors, a massage therapist may be able to assist with pain intensity, some of the general effects surrounding depression and, perhaps most importantly, the perceived risk of persistence.

When someone comes to receive a treatment from you, they listen to you and respect you as a highly trained health professional.

In other words, what you say matters.

We know that touch can help reduce pain intensity, even if it is only a mild effect over a brief period. But any pain reduction is a good thing.

However, we can also have a huge impact on our clients’ beliefs around their pain.

Beliefs around pain really matter

Self-efficacy is a personal belief in someone’s effectiveness. In sport, this would be a belief in how well someone will perform in competition. For someone in pain, this is a belief in how well they can manage their pain and potentially get better. Why is this important?

A 2004 study of 400 patients examining self-efficacy, fear avoidance and pain intensity as predictors of disability, showed that high levels of self-efficacy were the best indicator of reduced levels of disability. Pain intensity was only a useful indicator of ongoing disability in a small group of the total patients in the study. Fear avoidance behaviour (behaviour that demonstrates fear of movement) was also a better indicator of disability than pain intensity. In other words, the findings of this study were that the beliefs of people with sub-acute and chronic musculoskeletal pain have more of an effect on disability than the amount of pain they are experiencing.

What is the relevance to massage therapy?

I am definitely not suggesting that we start counselling clients about their pain but rather that we must recognise that most people will recover fully from pain and injury given enough time. As massage therapists, we can make our clients feel more comfortable while nature does its thing.

For the client, having a strong sense of positive belief around their body and their pain is a really important part of recovery. Conversely, a client being fearful about their pain and their body increases the likelihood of ongoing disability and pain. It’s important to remember that the amount of pain someone experiences at any given time is not a particularly good indicator of long-term outcomes.

We have an ethical obligation to carefully consider what we are doing as massage therapists. Are we supportive health care professionals working with our clients to develop a sense of self-efficacy, self-belief, confidence and empowerment? Or are we cultivating a sense of fear and fragility around our clients that we know can actually make their pain worse?

Empowering through touch, movement and language

We may have come to believe that our job is to break up adhesions, release knots and stretch fascia: almost like some sort of human jackhammer, we are here to resolve our clients’ issues through the application of external force (and, generally, the more, the better). However, the science is beginning to make it clear that the effects of massage are much less to do with the application of force to change body tissues and more to do with the response of the client’s nervous system.

Pain is a product of the nervous system and our best tools to reduce pain and improve function (to use chronic lower back pain as an example) are actually a combination of touch, movement and language (see systematic review by Kamper et al, 2015). The evidence clearly shows that combinations of exercise, manual therapy, psychology and medical management are more effective than any one of these interventions in isolation.

The take home message for massage therapists is that touch on its own is less effective.

Positively framing a client’s situation, allaying any fears they have and giving them a plan to manage their pain should be key components of any massage therapy session. Massage therapy should be aimed at normalising sensation and function, so avoid any techniques that work from the basis of “breaking up tissue” and instead focus on triggering the nervous system to reduce muscle tone and sympathetic stimulation. Encourage movement, either during your session or between sessions. Walking, swimming, running or anything else that will encourage relaxed, comfortable movement should be recommended for both pain reduction and improved function.

Nocebo and neuroplasticity

Above all, don’t give clients reasons to worry. We now know that a huge number of apparent postural “dysfunctions” and “misalignments” are imaginary/unhelpful constructs, completely normal human variations, or not linked to pain in any discernible way. Drawing a client’s attention to some dysfunction that they don’t understand is only going to heighten their sense of frailty and fear, which can actually increase the likelihood of pain and loss of function as discussed earlier.

“When someone comes to receive a treatment from you, they listen to you and respect you as a highly trained health professional. In other words, what you say matters”

Talking up problems and issues that you identify through your client assessments is not helpful. If there is something that you are legitimately concerned about then refer your client for further investigation. But don’t speculate on the cause of an injury. Instead support your clients, remind them that recovery is normal and that being active – even with pain – is nearly always the best strategy.

By fostering confidence and reducing fear, you will be encouraging a fundamental restructuring of the client’s nervous system that will down-regulate pain responses. This is generally what is understood to happen with the placebo effect. But, if we make a client believe their situation is dire, we can actually have the opposite effect, known as the nocebo effect, which is associated with structural changes to the nervous system that can increase a client’s pain intensity.

Conclusion

 

Yes, pain science can be a pain in the gluteus maximus; it reminds us that our understanding of massage and its effects is constantly changing. It is also a reminder that we need to spend time staying up to date. Pain science also rewards us with great insights that have broad clinical application within our wonderful discipline.

To some extent, it frees us of the constraints imposed on our work by biomedicine but that’s a subject for a whole other article.

However, we do need to learn more about pain so that we don’t fall into the trap of unwittingly making our clients’ situation worse by scaring them with overly technical assessments and language. Instead, we can build our clients’ confidence and encourage them to be active, using pain science as a pillar of positive change in our clinical practice.

References

Denison, E. et al (2004) Self efficacy, fear avoidance, and pain intensity as predictors of disability in sub acute and chronic musculoskeletal pain patients in primary health care. Pain Vol 111 Issue 3 pp245-252.

Henschke, N. et al. (2008) Prognosis in patients with recent onset low back pain in Australian primary care: inception cohort study. British Journal of Medicine Vol 337 a171 pp154-157.

Kamper, S. et al. (2015) Multidisciplinary biopsychosocial rehabilitation for chronic low back pain: Cochrane systematic review and meta-analysis.

Further Viewing

Aran Bright presented a plenary session on Pain Science at the AMT Conference in October 2017. You can watch the full presentation on the AMT YouTube channel.

Further Reading

Explain Pain Supercharged by Dr David Butler and Professor Lorrimer Moseley is aimed at health professionals who treat people with pain, providing explanations and metaphors to use with patients/clients.

About the author

Aran started his career as a massage therapist in 2002 after graduating from the Australian College Aran Bright started his career as a massage therapist in 2002 after graduating from the Australian College of Natural Medicine in Queensland. In 2006, he completed his Diploma of Remedial Massage and, in 2007, his Bachelor of Health Science in Musculoskeletal Therapy. Aran has also graduated from University of Queensland with a Graduate Certificate of Sports Coaching, completed a Certificate IV in Fitness and an Advanced Diploma of Myotherapy. He currently runs his own businesses, Bright Health Training and Brisbane Workplace Massage, with his wife, Sheree.

All images (except author pic) are courtesy of Pixabay.

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