{"id":446,"date":"2017-12-27T09:00:26","date_gmt":"2017-12-26T22:00:26","guid":{"rendered":"http:\/\/blog.amt.org.au\/?p=446"},"modified":"2017-12-26T16:01:51","modified_gmt":"2017-12-26T05:01:51","slug":"is-pain-science-just-a-pain-in-the-gluteus-maximus","status":"publish","type":"post","link":"https:\/\/blog.amt.org.au\/index.php\/2017\/12\/27\/is-pain-science-just-a-pain-in-the-gluteus-maximus\/","title":{"rendered":"Is Pain Science Just a Pain in the Gluteus Maximus?"},"content":{"rendered":"

<\/h4>\n

By Aran Bright<\/h4>\n

(This article originally appeared in the June 2017 AMT Journal ‘In Good Hands’.)<\/p>\n

It is all about helping people, not just science<\/strong><\/h6>\n

If you are reading this, there is a very good chance that you are one of Australia\u2019s professional, dedicated massage therapists. You\u2019ve 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 \u201csore spot\u201d. 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 \u2013 if it is not your own, then it is your clients\u2019 pain you\u2019re faced with.<\/p>\n

So, you\u2019d think it would make sense to know as much about pain as possible?<\/p>\n

Hopefully it won\u2019t 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.<\/p>\n

But this new wave of understanding can actually be a bit of a \u201cpain\u201d 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\u2019s 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.<\/p>\n

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!<\/p>\n

So what are the big factors? <\/strong><\/h6>\n

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<\/a> 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.<\/p>\n

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.<\/p>\n

When someone comes to receive a treatment from you, they listen to you and respect you as a highly trained health professional.<\/p>\n

In other words, what you say matters. <\/em><\/p><\/blockquote>\n

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.<\/p>\n

However, we can also have a huge impact on our clients\u2019 beliefs around their pain.<\/p>\n

Beliefs around pain really matter <\/strong><\/h6>\n

Self-efficacy is a personal belief in someone\u2019s 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?<\/p>\n

\"\"A 2004 study of 400 patients examining self-efficacy, fear avoidance and pain intensity<\/a> 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\u00a0and chronic musculoskeletal pain have more of an effect on disability than the amount of pain they are experiencing.<\/u><\/p>\n

What is the relevance to massage therapy? <\/strong><\/h6>\n

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.<\/p>\n

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\u2019s important to remember that the amount of pain someone experiences at any given time is not a particularly good indicator of long-term outcomes.<\/p>\n

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?<\/p>\n

Empowering through touch, movement and language <\/strong><\/h6>\n

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\u2019 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\u2019s nervous system.<\/p>\n

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<\/a>). 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.<\/p>\n

The take home message for massage therapists is that touch on its own is less effective. <\/em><\/p><\/blockquote>\n

Positively framing a client\u2019s 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 \u201cbreaking up tissue\u201d 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.<\/p>\n

Nocebo and neuroplasticity <\/strong><\/h6>\n

Above all, don\u2019t give clients reasons to worry. We now know that a huge number of apparent postural \u201cdysfunctions\u201d and \u201cmisalignments\u201d are imaginary\/unhelpful constructs, completely normal human variations, or not linked to pain in any discernible way. Drawing a client\u2019s attention to some dysfunction that they don\u2019t 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.<\/p>\n

\u201cWhen 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\u201d <\/em><\/p><\/blockquote>\n

\"\"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\u2019t speculate on the cause of an injury. Instead support your clients, remind them that recovery is normal and that being active \u2013 even with pain \u2013 is nearly always the best strategy.<\/p>\n

By fostering confidence and reducing fear, you will be encouraging a fundamental restructuring of the client\u2019s 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<\/u> effect, which is associated with structural changes to the nervous system that can increase a client\u2019s pain intensity.<\/p>\n

Conclusion <\/strong><\/h6>\n

 <\/p>\n

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.<\/p>\n

To some extent, it frees us of the constraints imposed on our work by biomedicine but that\u2019s a subject for a whole other article.<\/p>\n

However, we do need to learn more about pain so that we don\u2019t fall into the trap of unwittingly making our clients\u2019 situation worse by scaring them with overly technical assessments and language. Instead, we can build our clients\u2019 confidence and encourage them to be active, using pain science as a pillar of positive change in our clinical practice.<\/p>\n

References <\/strong><\/h6>\n

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.<\/a><\/p>\n

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<\/a>.<\/p>\n

Kamper, S. et al. (2015) Multidisciplinary biopsychosocial rehabilitation for chronic low back pain: Cochrane systematic review and meta-analysis.<\/a><\/p>\n

Further Viewing<\/strong><\/h6>\n

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<\/a>.<\/p>\n

Further Reading<\/strong><\/h6>\n

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

About the author<\/strong><\/h6>\n

\"\"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<\/a> and Brisbane Workplace Massage<\/a>, with his wife, Sheree.<\/p>\n

All images (except author pic) are courtesy of Pixabay.<\/p>\n","protected":false},"excerpt":{"rendered":"

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\u2019s professional, dedicated massage therapists. You\u2019ve spent days, weeks, months and years up to […]<\/p>\n","protected":false},"author":1,"featured_media":447,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"jetpack_post_was_ever_published":false,"_jetpack_newsletter_access":"","_jetpack_dont_email_post_to_subs":false,"_jetpack_newsletter_tier_id":0,"_jetpack_memberships_contains_paywalled_content":false,"_jetpack_memberships_contains_paid_content":false,"footnotes":""},"categories":[32,110,30],"tags":[17,12,119,102,5,96],"class_list":["post-446","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-amt","category-clinical-practice","category-massage","tag-aran-bright","tag-back-pain","tag-explaining-pain","tag-nocebo","tag-pain-science","tag-placebo"],"jetpack_featured_media_url":"https:\/\/i0.wp.com\/blog.amt.org.au\/wp-content\/uploads\/2017\/12\/Pain-Sparkle.jpg?fit=1920%2C1080&ssl=1","jetpack_likes_enabled":true,"jetpack_sharing_enabled":true,"jetpack-related-posts":[{"id":1411,"url":"https:\/\/blog.amt.org.au\/index.php\/2019\/02\/20\/does-poor-function-always-cause-pain\/","url_meta":{"origin":446,"position":0},"title":"Does Poor Function Always Cause Pain?","author":"admin","date":"20\/02\/2019","format":false,"excerpt":"Is it time to stop the assumption that changes in function are the cause of pain? 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