Title: Manual Therapy Approach to Chronic Pain Relief By Gavin Crump OMT MMT LMT
I. Introduction
Understanding Chronic Pain: It is estimated that nearly 17 million people suffer from chronic pain conditions in the U.S. alone (Rikard, 2023). Understanding chronic pain and how it differs from other types of pain will help us empathize with those who suffer. “Unlike acute pain, which carries survival value, chronic pain might be best considered to be a disease” (Cohen et. al, 2021). Affecting daily activities, work life and overall health, chronic pain can take a huge toll on someone's life and can become debilitating.
Chronic pain is defined as pain which lasts weeks to years and may come in many forms. Common categories of pain are tissue damage and injury (Nociception), Nerve pain (NeuroPlastic) and sensitive nervous system (Nociplastic) (Rikard, 2023). Looking at pain from this point of view gives us perspective and draws better conclusions about an individual's experience. Chronic pain can be accurately described by the BiopsychoSocial model (BPSM) in identifying the multitude of aspects that can contribute to chronic pain. (Miaskowski et al., 2020). BPSM is defined in the 3 sections of a venn diagram: Biological factors being physical pathologies such as bruising, inflammation, muscle strains, tears and sprains. Psychological factors are thoughts, behaviors and feelings such as self talk, fear of movement of preconceived notions about the body and mental health. Lastly, sociological factors contribute to the economy, environment and work/life circumstances. One of the most important skills we possess is how we are listening to our clients/patients when they come into our office. Understanding their story and where they come from and having sympathy for their conditions is an important factor in how they are going to perceive their pain and progress through recovery. Communicating truthful and uplifting information to our client/patients is paramount to recovery. We are all familiar with the placebo effect. However, the nocebo effect already exists in many of our practices!
Nocebo is defined by the “cause of harmful side effects or worsening symptoms because the patient thinks or believes they may occur or expect them to occur” (Definition of Nocebo - NCI Dictionary of Cancer Terms - NCI).
In this article we will identify the key points in how to manage chronic pain from the perspective of massage, osteopathic and manual therapy practice and look at the key points in our communication skills and most evidence based techniques and how to approach our clients/patients with pain.
II. Role of Massage Therapy in Chronic Pain Management
Therapeutic touch has long since been our primary therapeutic tool as movement therapists. Just as chronic pain has many mechanisms of action, so too does therapeutic touch. The hormone Oxytocin is released in response to sensory nerve activation (“Self-Soothing Behaviors With Particular Reference to Oxytocin Release Induced by Non-Noxious Sensory Stimulation,” 2015). Oxytocin has anti-stress effects and therefore adding therapeutic effects to our toolbox. One randomized controlled trial has shown therapeutic touch to be an effective non-invasive treatment for low back pain (Mueller et al., 2019). An important aspect to remember about all massage and manual therapy is that we are introducing novel stimuli to the body. This has a strong effect on how their body is perceiving their pain while we have our client/patient in treatment. Similarly, this is how many other “fad” treatments work. Introducing a “feel good” sensation interrupts the nociceptors signaling briefly with a change in the mechanoreceptors perception. Using that novel stimuli to our advantage and developing clinical skills designed to give lasting effects is our best line of defense against chronic pain.
III. Approach to Chronic Pain
1. Assessment and communication: An in-depth intake process is the first step in assessing relevant parameters such as pain quality, range of motion (ROM), background and quality of life goals (QOL). Understanding the client/patient's pain with sympathy delivers psychological comfort to them and begins a sound therapeutic relationship. Avoiding statements that emphasize the state of their condition or blaming their pain on things they present to you in the intake process could contribute to Nocebo. Staying positive and listening to them with care is vital to keeping them in a positive mindset.
2. Treatment Plan: Next is to create goals on how they want to improve their QOL with massage and manual therapy. Typically, this looks like creating ROM goals, pain sensitivity goals and routine pain relieving experiences. This leads to release of the hormone dopamine. Dopamine is our primary pleasure hormone. Anticipation of “feel good” sensation increases the likelihood of dopamine release. Further adding to our therapeutic toolbox. Additionally, the effects of recommended at-home retraining activities that are uniquely designed to fit their expectations of getting better can be extremely beneficial to achieving new pain goals.
3. Collaboration and Communication: Clearly communicating that MT benefits typically yield short results in pain relief and ROM is important honesty the client/patient needs to understand when reaching new QOL goals. This prevents the mindset that they need to be “fixed”. Negative self perception contributes to psychological factors of pain. With the Biopsychosocial of pain in mind, all 3 aspects need to be considered when treating a human experiencing the multifactorial experience of pain. Helping our client/patients with mindset aspects such as self efficacy, fear, pain avoidance and coping skills allows us to extend further than the physical effects of massage and manual therapy treatments (Marshall et al., 2022, ).
IV. Techniques Employed for Chronic Pain Relief
A. Rhythmic movement - Techniques that involve a rhythmic movement such as; jostling passive range of motion, petrissage and tapotement are excellent elementary techniques to help decrease protective muscle guarding and instill relaxation in those suffering chronic pain. One scientific report shows the effect of a mechanism that rocking babies to sleep yields similar benefits into adulthood as well (Omlin et al., 2018). Our rhythmic manual therapy techniques may have a similar effect on the sleep spindles which gives us the therapeutic release response.
B. Stretching, Movement and Exposure - In order to access new goals we may introduce movement to our client/patient in a way that responds to their nervous system. While there are many variables in how an individual may present with a joint restriction or reduced range of motion. Using stretching, range of motion as a means to introduce new movement to the joint and nervous system begins the body process in reducing protective muscle guarding, aids in capsulitis and reduces perceived joint pain overtime.
C. Nerve gliding - Nerve gliding, Neurodynamics or nerve flossing are a synonym for a specific type of manual therapy techniques used to treat nerve entrapment syndromes. Nerve pain has long since been one of the most complicated and debilitating conditions for our clients/patients. Nerve Gliding techniques are an effective adjunct to nerve pain management. One study has shown a significant effect in those participating in Neurodynamic exercises in the treatment of Carpal Tunnel Syndrome (CTS) (Sheereen et al., 2022)
D. Importance of isometrics - Whether you are performing isometrics on the therapy table or providing at home retraining exercises for you clients/patients. Isometric work has a tremendous effect on treating pain. Oftentimes osteoarthritis, tendinopathy or other nonspecific joint pain yields great benefits from isometric exercises of the surrounding tissues. One Randomized controlled trial has shown the benefits of isometric exercise on patellar pain (Rio et al., 2015).
VI. Conclusion VII. Chronic pain is such a grandiose undertaking for our industry and understanding it from all angles is our best attempt at helping our clients/patients feel their best when they have appointments with us. Taking into consideration our effects with placebo and nocebo are huge hidden gems in our therapy that when we can take control over may yield wonderful benefits and extend our therapeutic tools in therapy. Ditching the soft tissue model of pain for a whole person centered approach to help better understand our clients chronic pain can help guide our therapy techniques. And a collection of effective manual therapy techniques to emplore to get our clients feeling the best they can leaving our offices.
Written by: Gavin C Crump OMT MMT LMT
Edited By: Kathleen Benanti MMT
References
Cohen, S. P., and Hooten W. M. 2021. “Chronic pain: an update on burden, best practices, and new advances.” The Lancet 397 (10289): 2082–2097. https://doi.org/10.1016/S0140-6736(21)00393-7.
“Definition of nocebo - NCI Dictionary of Cancer Terms - NCI.” n.d. National Cancer Institute. Accessed April 18, 2024. https://www.cancer.gov/publications/dictionaries/cancer-terms/def/nocebo#.
Marshall, A., C. Joyce, B. Tseng, H. Gerlovin, Y. G. Ye, J. K. Sherman, R. B. Saper, and E. J. Rooseen. 2022. “Changes in Pain Self-Efficacy, Coping Skills, and Fear-Avoidance Beliefs in a Randomized Controlled Trial of Yoga, Physical Therapy, and Education for Chronic Low Back Pain.” Pain medicine 23 (4): 834-843. https://pubmed.ncbi.nlm.nih.gov/34698869/.
Miaskowski, C., F. Blyth, M. Haan, F. Keefe, A. Smith, and C. Ritchie. 2020. “A Biopsychosocial Model of Chronic Pain for Older Adults.” Pain Med 1;21 (9): 1793-1805. https://academic.oup.com/painmedicine/article/21/9/1793/5679926.
Mueller, G., C. Palli, and P. Schumacher. 2019. “The effect of Therapeutic Touch on Back Pain in Adults on a Neurological Unit: An Experimental Pilot Study.” Pain management nursing : official journal of the American Society of Pain Management Nurses 20 (1): 75-81. https://pubmed.ncbi.nlm.nih.gov/30425012/.
Omlin, X., F. Crivelli, M. Näf, L. Heinicke, J. Malafeev, A. Fernadez, A. Riener, and P. Achermann. 2018. “The effect of a Slowly rocking Bed on Sleep.” Scientific Report 8 (1): 2156. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5794757/.
Rikard, S. M. 2023. “Chronic Pain Among Adults.” Chronic Pain Among Adults — United States, 2019–2021. https://www.cdc.gov/mmwr/volumes/72/wr/mm7215a1.htm#suggestedcitation.
Rio, E., D. Kidgell, C. Purdam, J. Gaida, G. Moseley, L. Pearce, A. J, and J. Cook. 2015. “Isometric exercise induces analgesia and reduces inhibition in patellar tendinopathy.” British journal of sports medicine 49 (19): 1277-1283. https://pubmed.ncbi.nlm.nih.gov/25979840/.
“Self-soothing behaviors with particular reference to oxytocin release induced by non-noxious sensory stimulation.” 2015. Frontiers in psychology 5, no. 1529 (Jan). https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4290532/#:~:text=Oxytocin%20is%20released%20in%20response,stroking%2C%20warm%20temperature%2C%20etc.
Sheereen, F., B. Sarkar, P. Sahay, M. Shaphe, A. H. Alghadir, A. Iqbal, T. Ali, and F. Ahmad. 2022. Pain research & management 1975803. https://pubmed.ncbi.nlm.nih.gov/35719196/.
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