A 1999 national survey found that approximately 50 million Americans live with chronic pain caused by accidents or disease, while an additional 25 million suffer acute pain resulting from surgery or an accident. Two-thirds of the people surveyed had been living with pain for more than five years.1 Researchers in 2000 found that 36 million Americans had missed work in 1999 due to pain, and 83 million reported that pain affected their participation in activities of daily living.2

Regardless of how and where you practice massage, you will encounter clients living with pain. The judgments you make about the client’s story, your knowledge of pain and its causes, your personal experience with pain, and your personal beliefs about how people should respond to pain, are likely to influence how you interact with these clients and the quality of the care you provide. This column defines pain, discusses the impact of chronic pain on activity levels and quality of life, and identifies reliable massage techniques that reduce pain.

Pain Defined
Pain is an unpleasant physical and emotional sensation associated with tissue damage or the immediate potential for tissue damage. This definition describes pain that arises in response to physical trauma, not as a result of mental or emotional suffering.

The intensity and quality of pain experienced due to physical trauma vary among individuals because of genetics, ethnicity, gender, past experience, present expectation, cultural background, situation and context, and a variety of other psychological and physiological factors. Personality characteristics, emotional reaction patterns, and mental state can play roles. For example, in a study conducted on depressed patients of the same age and sex, patients with more severe depression reported greater occurrence and sensations of physical pain than patients with less severe depression.3 It is important to point out that the pain perceived by a client may not always seem proportional to the degree and severity of tissue damage. Pain is a highly subjective and personal experience; this fact has prompted the nursing profession to widely adopt the following definition of pain: “Pain is whatever the experiencing person says it is, existing whenever the experiencing person says it does.”4 Pain is classified and further defined by time, its location, tissue type, and how it is generated, as shown in the table on page 37.  

Chronic Pain
Chronic pain is pain that persists for a period of time past the point of typical injury recovery. Most people respond well to treatment following an injury and return to full strength and function within a predictable time frame. In some cases, however, the tissue does not progress normally through the stages of healing and enters a recurrent inflammatory process that leads to the prolonged experience of pain. Chronic pain can also be a persistent symptom of a medical condition such as cancer, fibromyalgia, lupus, or rheumatoid arthritis.

Quality of Life
Chronic pain impacts people physically, psychologically, socially, and economically. Each person’s experience with chronic pain is different. Some clients have mild pain that does not significantly limit their daily activities, but still impacts their quality of life. The important thing is to honor each person’s experience with pain and not compare it to another’s. Following are some of the impacts chronic pain can have on a person’s quality of life.

Loss of Mobility. People suffering from chronic pain often lose the ability to comfortably move around and perform tasks that are usually taken for granted. For example, daily tasks like hair brushing, showering, getting dressed, driving, grocery shopping, laundry, and housework may be difficult or impossible. Other family members may be forced to assume responsibilities for the person living with chronic pain, and this can lead to feelings of lost self-worth.

Pain Avoidance. People living with chronic pain may begin to focus on pain to the extent that they avoid any activity that might increase pain. This leads to pronounced inactivity and higher levels of disability as the body’s condition gradually deteriorates. Over time, the intense focus on pain causes sensations that would normally not be unpleasant to be perceived as painful.

Medication Issues. Medications may decrease the amount of pain a person feels but can also produce side effects like gastrointestinal problems, drowsiness, fogginess, or aggressive behavior. Over time, the drug may lose its effectiveness and breakthrough pain might occur, or a person could develop a physical or psychological addiction to the drug. Drugs may cause other physical problems such as liver toxicity when they are used for extended periods of time.

Sleep Disturbances. Persistent pain makes normal sleep difficult, and people living with chronic pain usually experience pronounced sleep disturbances that leave them feeling inattentive, foggy, lethargic, and moody.  

Loss of Relationships. Chronic pain places a huge strain on relationships. Activities that once promoted bonding and connection with friends and family may be impossible for a person in pain: it may be impossible to enjoy normal sexual relations; lift and care for babies and young children; sit through a movie, sports event, or lunch date; go for a walk with a loved one; or many other social activities. As time passes, friends and family stop asking people living with chronic pain to participate in activities, and so they become more and more isolated.

Loss of Income. A person living with chronic pain may be forced to quit a job or cut back significantly on working hours. If the injury happened on the job, failure to heal from the injury may lead to a conflict with an employer or with a disability manager. The loss of income or a conflict over an injury settlement can lead to increased stress, which may exacerbate the pain.
 
Loss of Credibility. Friends and family members sometimes doubt the validity of the pain levels reported by the person in pain. At first, friends and family are supportive, but when the person in pain fails to improve, frustration and feelings of helplessness set in. These feelings may eventually transform into doubt that their loved one is really in pain. The person in pain loses his or her sense of credibility and retreats further into isolation.

Anxiety, Depression, and Stress. It is easy to understand why people living with chronic pain experience high levels of anxiety and stress. They may feel they are no longer the person they once were, or want to be, and are no longer able to participate in activities that give life meaning. They may feel that they are a burden on their family and friends. As they become more and more isolated from people they love and from activities that hold value, they may slip into depression. In fact, research suggests that people living with chronic pain are four times more likely to attempt suicide than people without pain.5

Research demonstrates that when people are encouraged to talk about their pain and set goals for pain reduction with health-care providers, the quality of pain management improves and they find greater relief.6 As a massage therapist, you can discuss pain with clients and ask them questions that will help you choose effective techniques and methods, while providing a baseline from which to judge the effectiveness of sessions over time. Develop a resource list that includes books, pain clinics, local support groups, mental health professionals, and referrals to other health-care providers like acupuncturists, chiropractors, naturopathic physicians, orthopedic surgeons, and physical therapists who may provide useful services.

Pain Management and Massage
Research has shown that massage effectively reduces pain. Although the mechanism by which pain is reduced is not always clear, certain techniques have proven reliable.

Promote Relaxation. Any type of pain information received by the brain signals a threat to survival, and so triggers the fight-or-flight response of the sympathetic nervous system. The increase in blood pressure, heart rate, breathing rate, and blood flow to voluntary muscles, the heart, and lungs is often accompanied by mental and emotional anxiety, anger, and fear. Norepinephrine, one of the neurotransmitters that mediate the fight-or-flight response, enhances transmission of nerve impulses, increasing the intensity of pain. Stress increases the sensation of pain, and pain increases stress. Massage can help reduce the stress through the parasympathetic nervous system response.
Break the Pain-Spasm-Pain Cycle. In this persistent cycle, pain triggers muscle spasms, muscle spasms cause decreased blood flow and a buildup of metabolic wastes in the tissue, leading to pain, which then triggers more muscle spasms and a recurrence of the cycle. Massage breaks the cycle by reducing muscle spasms, triggering the parasympathetic nervous system response to reduce sympathetic firing, and increasing circulation to the local area, which removes metabolic wastes, thereby reducing pain.

Use the Spinal Cord’s Gating Mechanism to Reduce Pain. Because the spinal cord has a limited ability to attend to multiple sources of sensory stimuli at one time, pain stimuli traveling on the slower C-fiber axons can be locked out when lots of sensory stimuli (such as that caused by massage) are traveling to the brain. Dull, aching, or throbbing pain, the type often associated with chronic conditions, can be blocked by somatic stimuli like massage.

Use Thermal Applications. Cold applications like ice packs or ice massage are most appropriate for acute pain, as they cause vasoconstriction of blood vessels and slow the metabolic process of cells, allowing them to survive a period of hypoxia, which reduces the zone of secondary injury. Cold applications have a numbing effect on the tissue and reduce the velocity of pain stimuli transmissions. Heat is most often used for chronic conditions because it increases circulation to the local tissue, improving the condition of the tissue through enhanced oxygen, nutrient, and waste exchange to decrease muscle spasm. Heat lowers pain perception because it slows the conduction of pain stimuli to the brain and sedates the central nervous system to aid relaxation.

Reduce Trigger Points. Trigger points are hypersensitive spots that usually occur within a taut band of muscle or fascia and cause the affected muscle to be shortened. Trigger points have a predictable pain referral pattern. They are related to tissue ischemia (vasoconstriction and decreased circulation) and increased metabolic processes in the local tissue brought on by many factors including stress, injury, a sedentary lifestyle, poor posture, and repetitive stress. Reducing trigger points is an important treatment goal in the rehabilitation of clients with many different conditions.

The “You” Factor
The compassion and understanding you demonstrate toward clients living with chronic pain enhances the therapeutic relationship, builds trust, and provides psychological comfort. The therapeutic value of this increased awareness and level of empathy cannot be quantified but will help you provide the best possible care to clients.  

Notes
1.    Ortho-McNeil Pharmaceutical, “National Pain Survey,” accessed September 2014, www.chiro.org/LINKS/FULL/1999_National_Pain_Survey.shtml.
2.    Gallup Organization, “Pain in America: A Research Report,” survey conducted for Merck, 2000.  
3.    L. Von Knorring, “The Experience of Pain in Depressed Patients,” Neuropsychobiology 1 (1975): 155–65.
4.    Chris Pasero and Margo McCaffery, Pain: Clinical Manual (St. Louis, MO: Mosby, 1999).  
5.    LifeNews.com, Steven Ertelt, “Study Shows People with More Chronic Pain More Likely to Commit Suicide,” University of Michigan Research Department, accessed September 2014, www.lifenews.com/bio2627.html.
6.    Lynda Juall Carpenito-Moyet, Handbook of Nursing Diagnosis, 12th ed. (Baltimore, MD: Lippincott Williams & Wilkins, 2008).

Anne Williams is the director of education for Associated Bodywork & Massage Professionals and author of Massage Mastery: from Student to Professional (Lippincott Williams & Wilkins, 2012), from which this article was adapted, and Spa Bodywork: A Guide for Massage Therapists (Lippincott Williams & Wilkins, 2006). She can be reached at anne@abmp.com.