Myotherapist and educator, Aran Bright shares why he believes that massage therapists should be embracing the power of placebo.Continue Reading →
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.
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.
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.
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.
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.
Rebecca Barnett attended the Placebo Symposium in Sydney in November, and now provides an insight into the presentations and what she learned, and how massage therapists can benefit from the lessons of placebo.Continue Reading →