Chronic pain affects approximately 100 million Americans, almost one-third of the US population.1 With mounting evidence showing that massage helps with pain reduction, it’s likely that more chronic-pain sufferers will turn to massage for pain management.2 On the whole, the massage therapy profession has focused on the physical application of massage to treat chronic pain, yet we remain distanced from the psychological factors that affect our clients’ perception of pain and their treatment outcomes.3
Pain models can help explain how psychological factors may influence chronic pain over time. Though massage therapists are not psychologists, viewing chronic-pain clients through the prism of pain models allows MTs to refine treatment plans (including knowing when additional help is needed), which can result in an improved quality of life for chronic-pain clients.

What is Chronic Pain?  
First, let's define our terms. For our purposes, chronic pain is pain that has to be managed but cannot be cured by medical treatment, including massage. (Before the advent of hip replacement surgery, degenerative hip disease would have been considered a chronic-pain condition.) Medically speaking, chronic pain can be defined as any pain lasting more than three months. By contrast, acute pain is not persistent for long stretches of time.4 Chronic pain may arise from an injury, illness, or in the absence of both.5 Acute pain usually occurs suddenly, alerts us to possible injury (e.g., broken bone), and often resolves on its own or with proper medical care.6
Chronic pain can wreak havoc on sleep, be physically and mentally exhausting, and can lead to body guarding: restricting movements to lessen the pain. Years of restricted movements can result in tight and/or de-conditioned muscles, and, over time, chronic-pain sufferers may not be able to do the activities they once liked to do. For some chronic-pain sufferers, it takes a Herculean effort just to meet the day's basic demands. It is no wonder depression and despair are often associated with chronic pain.

Acute or Chronic?
How do we know if a client is in acute or chronic pain? Sometimes clients will know and tell you. Others have diagnoses that are associated with chronic pain, like arthritis, degenerative disc disease, fibromyalgia, or radiculopathy. If you are unsure, ask yourself these questions about your client:
1. Did the pain occur suddenly?
2. Has the pain lasted longer than three months?
3. Has the pain been addressed by qualified diagnosticians?
Knowing only the onset and duration of a client’s pain is not enough information to understand the totality of your client’s pain, especially if you are the first person your client has seen for it.
For example, Jamur came to me with a shoulder issue. He was into CrossFit, a high-intensity resistance workout. He had injured his shoulder when younger and would tweak it every now and then over the course of four decades. When he first saw me, he said he had been feeling a slow increase in pain in his bad shoulder for about two months. When I palpated his shoulder, I found hyper-tender areas on the tendon of the long head of his biceps. I suggested he go to an orthopedist for a diagnosis.
Jamur continued to work out, but modified the exercises. About two months later, I saw him again. I could gently cross-fiber the long head biceps tendon, but there was still significant pain in that area. He also had a new area of pain—in the body of the supraspinatus. At this point, if I had to guess acute or chronic pain based on only two questions—(1) was it sudden pain and (2) has it lasted for more than three months?—I would have guessed chronic.
However, Jamur hadn’t seen a qualified diagnostician. Eventually, he did take my advice and saw an orthopedist. She ordered an MRI, which showed a labrum tear. Jamur did have a chronic shoulder condition, but he also had an acute shoulder injury caused by multiple soft-tissue tears. When in doubt, encourage the client to seek clarification through qualified diagnosticians.

Massage & the Five Pain Models
Having a knowledge of pain models can help us better understand our clients' chronic pain issues. Through these models, we can more clearly see the factors impacting our clients and their pain, and give us guidance on how best to help them.

1. Fear-Avoidance Model
In the fear-avoidance model, a pain sufferer views pain as a threat: something that is going to, or has the potential to, get worse. Fear causes the person to focus on the pain (hypervigilance), which then results in avoidance behaviors (i.e., staying away from anything that could potentially increase the pain). Avoidance behaviors can lead to disability, disuse, and depression. According to the fear-avoidance model theory, if you take away the fear, the pain sufferer can start to utilize coping mechanisms that will improve quality of life.7
Recognizing if your client might be engaged in fear-avoidance behavior takes time. First, during the initial intake, you will need to gauge the client’s activity level, both past and present. Has his activity level shrunk over time? Understand that the process of aging also affects activity level. It has been my experience that someone whose activity level is shrinking out of fear and avoidance will often not be willing to try new activities to replace old activities. Someone who is simply accepting the aging process is often looking for substitute activities.  
If you suspect your client is headed down the disability path due to fear-avoidance behavior, recommend a counselor, pain-management specialist, or psychologist. For those not open to additional help, you can encourage them to remain active in ways that do not trigger pain.
For example, my long-term client Barry suffers from chronic neck and back pain. He manages his pain through light exercise, pharmaceuticals, and eliminating things that bother his back. His activity world has gotten smaller over the years. He used to enjoy going to the beach and swimming in the ocean. But the turbulence of the ocean bothered his back, and he gave that up. Then, he only swam in his backyard pool, using a snorkel so he wouldn’t have to turn his neck. Recently, he announced he is closing down his pool for good because swimming now bothers his shoulder.  
Barry is not open to the idea of counseling. Time to write him off? Nope. Barry’s feet still work. He likes walking. So, I’m encouraging him to walk.

2. Acceptance and Commitment Model
If your client is fixated on finding the cure for his chronic pain, pay attention. A chronic-pain sufferer who is psychologically inflexible and can’t change behaviors to support a long-term goal has a lower quality of life than a person who can accept his chronic-pain condition.8
Acceptance doesn’t mean the person has given up. Acceptance means that until there is a definitive cure (like hip replacement for chronic hip pain) the chronic-pain sufferer has decided not to spend his life chasing an answer that doesn’t exist. Instead, he is choosing to participate in activities and work toward goals that give him a sense of well-being.
When you’re working with a chronic-pain sufferer who is fixated on finding a cure, making him understand that you’re not the cure can sometimes be a challenge. Early on in my massage career, I thought if I did my job right, my client would be out of pain, period. If the levator scapulae wasn’t the problem, it must be the upper trapezius; if the upper trap wasn’t the problem, it must be the posterior scalenes, and so on.
This fruitless search for ending chronic pain ended only when the client tried something different. Until he left, I would hear: “I think it’s getting a little bit better, Mark.” But, after some time, I realized the cure wasn’t getting any closer.
If you feel yourself being pulled into your client’s unhealthy quest for a cure, tell him that, given his condition, you can only help with pain relief, not a cure. It is unethical to continue treatment with an incorrect, unattainable goal in mind.

3. Misdirected Problem-Solving Model
I think my wife would agree that sometimes I don’t worry enough, while sometimes she worries too much. According to the misdirected problem-solving model, in terms of human evolution, worrying is connected to problem solving—if one thinks about all the negative outcomes, one can figure out how to avoid them. In other words, if my wife and I were transported back 3 million years, I would have been lunch for a leopard, while she would have survived to pass on her genes.9
Though worrying may have had an evolutionary advantage for survival through being prepared for potential negative outcomes, it has a deleterious effect when connected to pain. Worrying can lead to hyperfocusing on the pain, and if pain is viewed and treated only as a physical phenomenon, the worry intensifies as each attempt to eliminate the pain fails.
If your client is a worrier, try redirecting her problem-solving attention from pain relief to practical goals.10 For example, years ago Hong came to me with knee pain. She had a Baker’s cyst in the back of her knee, resulting in constant inflammation, and had multiple knee surgeries for ligament and tendon damage. She had avoided knee replacement because she was susceptible to infection.  
Hong’s brain had two settings: worry and more worry. She was a problem-solver on steroids. In retrospect, I was ineffective as a massage therapist when my focus was only to eliminate her pain. My massage was more effective when it was meant to support her meaningful goals, like completing a charity bicycling event, where the focus then was on managing the pain, not eliminating it.

4. Self-Efficacy Model
Self-efficacy can be defined as the belief in one’s capacity to figure out and execute actions that will produce desired results (i.e., active coping).11 Active coping gives a chronic-pain sufferer confidence that she can deal with the pain, resulting in an improved quality of life.  
A chronic-pain sufferer who has embraced the self-efficacy approach to pain management understands her condition, uses self-care strategies to deal with a flare-up, works around limitations, and has a support system.  
You can help a client engaged in active coping by showing her self-massage options, suggesting different ways to lift objects and move during a chronic pain flare-up, and providing recommendations to health-care professionals you’ve vetted.
Also, be aware there may be times when how you present your findings and opinion to a client could affect her coping response. For example, Lucy came to me for neck pain and was actively coping. She was referred to me by a chiropractor who had told her that the chronicity of her neck condition was due to Lyme disease. When I palpated her neck, I found extreme tightness in the C2–C3 paraspinal muscles. My palpation findings, coupled with her intake history, led me to conclude that her neck pain hadn’t changed since she had contracted Lyme disease. It was always there and at the same intensity.  
Who was right? In terms of the self-efficacy model, it didn’t matter. Lucy’s neck pain was not a broken arm where causality was easy to determine (she fell down), and there was a sure-fix to apply (cast the arm). The cause of her chronic pain was unknown at that point. The most important thing was that she was actively coping in the midst of unknown causality. I simply stated my palpation findings and my massage approach without expounding on the differences between her chiropractor’s opinion and mine. It was up to Lucy to decide how she incorporated the different information to actively cope.

5. Stress-Diathesis Model
There is evidence to suggest a person who is highly stressed, anxious, and/or depressed may be more limited and emotionally distressed by pain than a person who is not stressed, anxious, and/or depressed. These highly stressed people are more likely to move from acute pain to chronic pain to disability. It is also true that depression can be brought about by persistent pain.12 It is beyond our scope of practice to determine which came first—the depression or the chronic pain. Our job is to guide the person to proper counseling if we suspect a person is anxious, depressed, or highly stressed.
I learned this the hard way. At one time, I was working for a massage spa. Bonnie, a chronic-pain sufferer, was sent to a few therapists, including myself, who specialized in chronic-pain treatment. Bonnie was very bright, but there were obvious signs she was troubled. For instance, she pulled a suitcase behind her everywhere she went, even though she wasn’t homeless, and during her intake she spent a significant amount of time ranting about her mother.
When I worked on her the first time, I didn’t find any significant areas of pain. In fact, she fell asleep. To my surprise, soon after, Bonnie scheduled to see me and the other therapists twice a week for a month, claiming her pain was severely reduced. Bonnie now had a rather unhealthy dependence on massage and believed it was the only thing that could help her. It took many weeks before Bonnie’s situation was resolved and she was back on track to getting proper psychological help, all because I had failed to communicate my concerns to her after the first session.

Pain Models & Your Practice
Pain models explain how chronic-pain sufferers respond to chronic pain. When a massage therapist can recognize pain-model responses, she can then adjust her treatment plans and help clients improve their quality of life. For instance, a problem-solver on steroids (misdirected problem solving) worries about all the negative outcomes that can be connected with her pain. You can potentially reduce that worry by redirecting her focus to a practical goal you can support with massage. For those clients who are doing the right thing by actively coping (self-efficacy), you can bolster their efforts with recommendations that empower them to cope with their pain, such as self-massage options and safe lifting techniques for heavy or awkward items.
Not recognizing a pain-model response and your connection to it can potentially make a client’s quality of life worse. For example, fueling a client who is fixated on a cure (acceptance and commitment) by posing as the cure, or encouraging him in a misguided search for a cure, can lead to more stress and anxiety for your client. Lastly, if your client is anxious and/or depressed (stress-diathesis), or if his activity world is shrinking (fear-avoidance), these are signs that your client needs help outside your scope of practice. Be honest with your client about your concerns and encourage him to seek appropriate assistance. Someone trained to help your client with his issues can shorten his path to self-efficacy, thus shortening his overall suffering.  
The body of research on chronic pain is growing. As it does, so will our understanding of chronic-pain responses and how we can further assist clients with chronic pain to improve their quality of life.

Notes
1. Institute of Medicine, “Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research,” June 29, 2011, accessed October 2015, http://iom.nationalacademies.org/reports/2011/relieving-pain-in-america-a-blueprint-for-transforming-prevention-care-education-research.aspx.
2. Daniel C. Cherkin et al., “A Comparison of the Effects of 2 Types of Massage and Usual Care on Chronic Low Back Pain: A Randomized, Controlled Trial,” Annals of Internal Medicine 155, no. 1 (2011): 1–9.
3. M.S. Shutty, D. E. DeGood, and D. H. Tuttle, “Chronic Pain Patients’ Beliefs About Their Pain and Treatment Outcomes,” Archives of Physical Medicine and Rehabilitation 71, no. 2 (1990): 128–32.
4. NIH MedlinePlus, “Chronic Pain: Symptoms, Diagnosis, & Treatment,” Spring 2011, accessed October 2015, www.nlm.nih.gov/medlineplus/magazine/issues/spring11/articles/spring11pg5-6.html.
5. Cleveland Clinic, “Acute vs. Chronic Pain,” accessed October 2015, http://my.clevelandclinic.org/services/anesthesiology/pain-management/diseases-conditions/hic-acute-vs-chronic-pain.
6. Neil Pearson, “Acute versus Chronic Pain: Understanding the Difference and Choosing Appropriate Treatment,” Orion Health, 2012, accessed October 2015, www.orionhealth.net/2012/01/acute-and-chronic-pain/.
7. Steven J. Linton and William S. Shaw, “Impact of Psychological Factors in the Experience of Pain,” Physical Therapy 91, no. 5 (May 2011): 700–711.
8. Ibid.
9. Rob Dunn, “The Top Ten Deadliest Animals of Our Evolutionary Past,” Smithsonian.com, June 20, 2011, accessed October 2015, www.smithsonianmag.com/science-nature/the-top-ten-deadliest-animals-of-our-evolutionary-past-18257965/?no-ist.
10. Steven J. Linton and William S. Shaw, “Impact of Psychological Factors in the Experience of Pain.”
11. Albert Bandura, Self Efficacy: The Exercise of Control (New York: W. H. Freeman, 1997).
12. Steven J. Linton and William S. Shaw, “Impact of Psychological Factors in the Experience of Pain.”

Mark Liskey relies on his 23 years of massage experience to write on topics ranging from client care to best business practices. Check out his latest article at www.markliskeymassage.com.