Pain is the most common complaint we see in our massage practices today.1 Pain compounds other client issues—elevating stress, altering posture, and reducing one’s ability to participate in daily activities. Fear of movement and the resulting isolation eventually make it difficult for the person in pain to reach out for help. According to the World Health Organization, “Chronic pain is one of the most underestimated health-care problems in the world today, causing major consequences for the quality of life of the sufferer and a major burden on the health-care system in the Western world.”2 Estimates are that 1 in 5 adults suffer from pain and that another 1 in 10 adults are diagnosed with chronic pain each year.3
Frequently, clients in pain come to bodyworkers as a last resort. Those individuals with chronic pain are often disappointed with conventional medicine.4 Physicians may grow frustrated trying to identify a cause that could inform a treatment plan and end up prescribing anti-depressants and pain medications. But pain is rarely fabricated, and pain medications aren’t a long-term solution. There is a growing body of evidence that shows prolonged use of pain medications can worsen pain symptoms and pose substantial risk.5 But a lack of information about massage regarding scope of practice, access (insurance reimbursement), and efficacy leaves pain sufferers seeking alternatives to pharmacology without support or counsel from their primary care providers.6
The president of the United States; the American Medical Association; Health and Medicine Division of the National Academics of Sciences, Engineering, and Medicine; the US military; and the US Centers for Disease Control have all called for a reduction in drug use, but what we really need to demand is always trying nonpharmacologic approaches first.7 To ensure the inclusion of massage, movement, and mindfulness-based approaches, we must use current language about “whole-person approaches” and “patient-centered care,” and be fluent in the literature about safety, efficacy, and patient satisfaction to entice physicians to support their patients’ choice to receive massage therapy. Clients are finding their way to us, with or without the direction of their primary care providers, so let’s make sure we are prepared to meet their needs.
But before I go on, I want to address the most common claim I hear us make: “I can fix their pain, not just help them manage it.” While this is true in many instances, and I myself have brought permanent relief to many individuals living with pain when conventional treatments failed, there are myriad degenerative or complicated conditions that may test your skills and your ability to avoid frustration or fall into the trap of blaming the client. For example, we may often slow or stall degenerative arthritis and keep the surgeon at bay, but at some point the knee or hip replacement or the spinal fusion may be necessary. Poorly healed trauma early in life may create havoc as one ages and leave the person confused about what happened to cause the current state of pain. Other conditions require treatment that permanently alter the soft tissue, such as radiation for cancer. Complicated conditions such as ALS, Parkinson’s, cerebral palsy, or spinal cord injuries typically necessitate management considerations. Meet the clients where they are without judgment, keep your treatment approach flexible, adapt to their needs, and maintain your personal sense of self so as not to confuse your identity with progress that does not measure up to your ideal.  

Massage, Movement, and Mindfulness-Based Approaches
Disciplines that include educated, healing touch; safe movement; and conscious breathing are most often sought by clients who have given up on, not seen improvements from, or are otherwise unsatisfied with conventional approaches to pain treatment.8 These approaches, such as massage therapy, are noninvasive with few side effects,9 and have been linked to lower health-care utilization and costs, and better health outcomes.10 Experience tells us massage therapy is an effective and safe approach to managing pain. The research agrees, adding that clients like it for many additional reasons—it provides hope, creates positive emotional changes, and increases their ability to cope with pain and enjoy life.11
Current thinking on pain management is to create multidisciplinary teams to address the whole person from a patient-centered approach.12 Massage is a natural fit, and we must remember to be true to its holistic nature. Go beyond the physical and include a variety of self-care and treatment approaches in your sessions that address the emotional, spiritual, and social aspects of wellness. Movement and mindfulness approaches are common adjuncts to massage therapy and are easily incorporated into a pain management treatment plan. Many are within our scope of practice; for those that are not, we can make informed recommendations.

Massage Therapy
Massage is as varied as the therapist. There is good evidence of the highest order (two meta-analyses and three systematic reviews) behind the use of massage for pain,13 but often the research does not identify specific techniques or modalities. There are limited studies that identify lymphatic techniques, scar massage, fascial work, and osteopathic or orthopedic techniques, among others, and the specific aspect of pain they are intended to influence. One large, randomized controlled trial compared full-body relaxation massage to site-specific treatment massage and found equal success in treating chronic low-back pain.14 Never underestimate the effects of a general massage when short-term pain becomes a long-term problem because of pathologic changes in the central nervous system, altering our perception of pain and ability to manage stress.15  
Massage therapy may also satisfy social and mental health benefits while managing pain symptoms. Researchers showed that the neural correlates for pain and social rejection are expressed in the same brain region in the anterior cingulate cortex.16 Massage can improve sleep, contributing to a positive outlook on life, and touch has been shown to increase social bonds and cooperative behaviors.17
Encourage prolonging the benefits of massage by teaching self-massage techniques, such as dry brushing, a beneficial technique for improving lymph and circulatory flow for inflammatory conditions and postcancer surgery. Avoid sensitive areas, cuts, infections, and wounds. Scars also benefit from manual lymph drainage. Keep the scars hydrated and instruct clients to rub them daily to limit adhesions and improve function. Self-massage and partner massage help emotionally when trauma is associated with scars, especially when surgery alters the normal geography, as with a mastectomy.
Functional taping can be an effective self-care choice between sessions when the client is taught precise application techniques by the informed massage therapist. Many companies that sell kinesiology tape have precut strips for easy use. Make sure clients practice applications in your treatment room to ensure they understand proper joint position, tension of the tape, and how to reassess after self-application to monitor results.
There are many tools that encourage and enable self-massage practices, such as canes, foam rollers, foot rollers, and massage sticks. The self-massage techniques previously mentioned are inherently gentle, but some people may be too aggressive when using tools. It is important to provide clear instructions to avoid pain and the inflammatory flare-up that often follows deep pressure. Be sure to caution against overworking a painful area. There are a few common tendencies with people in pain: ignore it, push through it, or overdo it when they find something that provides relief. Self-care education is about awareness, finding ways to touch and move that do not increase pain, and teaching people to notice and avoid triggers that increase pain, rather than avoiding or ignoring the pain itself.

Movement Practices
Massage modalities often include movement, and some massage therapists are certified in movement disciplines outside the traditional massage field. Some use movement as the primary technique, such as Active Isolated Stretching (AIS), Feldenkrais, and Trager, and others integrate movement techniques into the massage sessions, such as muscle energy technique, strain-counterstrain, and Aston-Patterning.
Supported, comfortable movement in a session can increase clients’ confidence in their ability to move outside the session. People often are afraid to move because of the pain, and the lack of movement further compromises their balance and flexibility. This cycle of immobility increases their chances of additional injury and trauma, results in isolation, and has been linked with mortality. Supporting self-discovery of pain-free movement can reduce fear and improve clients’ resiliency and mental and physical health. Homework regarding balance, posture, and simple strengthening exercises becomes possible when demonstrated in the context of a session and practiced before and after the massage.
As people resume ordinary tasks with more ease, they begin to consider adding pleasurable activities and hobbies. Once people learn coping skills for regulating pain and feel empowered to move, encourage them to go for walks with family or friends, or join group movement classes. Social engagement is critical for mental and physical health and reduces the isolation. Peer interaction is rich with support, understanding, and a general sense of happiness that comes with a robust network of family, friends, and those who share similar life experiences.18
In addition to one-on-one treatment sessions, Feldenkrais offers group sessions called Awareness Through Movement (ATM). These lessons invite an individual exploration of movement, and practitioners are adept at making considerations for all levels in a single class, reminding participants to avoid pain and perform movements within comfortable ranges. ATM sessions offer slow, attentive explorations that encourage awareness of physical, mental, and emotional states. As students expand their repertoire of healthful movement, their self-efficacy evolves along with their understanding of efficient movement, and their self-image is clarified.19 ATM sessions offer a gentle transition into group movement experiences.
Yoga therapy and tai chi/qigong can also be safe options for group movement classes. Yoga therapy is an interactive process, allowing for individualized interventions that incorporate awareness, self-regulation, and acceptance, and restore functional movement.20 All yoga is therapeutic, but typical yoga classes and yoga therapy are not the same. A yoga therapy designation requires 1,000 hours of training—different than the 200-hour training required to teach yoga classes. Certification by the International Association of Yoga Therapists is a recent designation; it may not be easy to find a yoga therapist in your area. Tai chi/qigong does not yet have a designation that separates instructors from therapists, but the movements are generally subtle and slow, are intended to support health and address health conditions, and are not commonly used for strength and conditioning. When selecting a tai chi/qigong instructor, or when there is no access to a certified yoga therapist, consider not only years of experience, but experience in treating chronic pain disorders. Additionally, the client should inquire about ways the therapy might be modified to accommodate their condition.

Mindfulness and Awareness
Many massage therapists work with the breath, incorporate visualization techniques, and use rhythmic, soft-vocal instructions to create a calm environment for healing. We often place our hands on painful areas of the client’s body to facilitate the client’s ability to focus attention on their inner experience of the pain. We might ask them to describe what they feel and guide them to access internal experiences of discomfort with gentle curiosity, helping them to differentiate the boundaries of the pain—size, shape, textures—and discover where there is ease. Once out of the soothing environment of a massage session, it may be difficult for the client to recreate that same sense of peace and internal connection with their experience of pain and comfort when at home or at work. Support your client by teaching breathing, meditation, or visualization techniques to enhance self-care between sessions.
Cynthia Price, PhD, LMT, does extensive research on body-mind interventions, focusing on mindful awareness and presence during and between hands-on sessions. In June 2016, Price was appointed to the National Advisory Counsel for the National Institutes of Health, National Center for Complementary and Integrative Health. Massage therapy can play a unique role in teaching body awareness and can facilitate our clients’ engagement with dimensions of body awareness that are linked to regulation, self-care, and stages of acceptance and change in relationship to both the experience of pain and the experience of self.21 She recommends that we ask our clients to spend time every day engaged in a body awareness practice, something that is easily achieved, such as attending to an area of discomfort by placing their hand on the area and breathing into it while being present to what they notice internally. This can be done every few hours for just a minute or two, or before going to sleep at night.
Mindfulness meditation, with its emphasis on nonjudgmental, curious observation of emotions, sensations, and thoughts, offers another practical approach to the self-management and relief of chronic pain. Meditation can teach clients to observe maladaptive cognitive, emotional, and physical habits that escalate pain with acceptance, curiosity, and friendliness. This helps clients learn to make new choices that reduce pain and improve mood and physical function.22
An at-home practice of mindful awareness or meditation can be cultivated through sitting or walking in meditation, practicing a mindful body scan, and using breathing techniques to keep one’s attention focused on inner sensations rather than distractions of the mind. This also helps clients find pain-free areas and control muscle tension that is often a reaction to pain. In addition, body awareness and mindful meditation can enable clients to better pace activities, adjust posture and body position, and prevent pain and tension escalation.23
Carolyn McManus, a physical therapist who teaches mindfulness practices to pain patients at a hospital in Seattle, discusses the difference between the sensation of pain and reactions to the sensation using the equation: pain = sensation + your reaction. This can be an invitation for clients to try techniques to manage their reactions to pain. Here are three at-home strategies McManus teaches:
1. Repeat mantras aloud to identify emotions and create compassion:
• Breathing in, “I am aware I feel angry.” Breathing out, “I meet myself with compassion.”
• “Right now there are other people just like me, in pain and feeling fear. I send compassion to myself and everyone in pain who feels fear.”
2. Explore imagery, naming a painful sensation and thinking of it like a cloud in the sky.
3. Download guided relaxation, meditation, or mindfulness apps, and set aside 10 minutes once or twice a day for internal reflection.

Building a Therapeutic Presence
Self-care starts with us. We can be mentors for our clients, sharing our experiences as well as the experiences of other clients who have successfully found ways to lead full lives with pain. Develop and commit to your own self-care routines. Suzanne Scurlock-Durana, CMT, explains that being more grounded and present creates the safety and permission necessary for clients to be able to achieve deep relaxation and healing. In addition, “Learning to embody a steady, strong therapeutic presence significantly increases your ability to feel what’s going on with your clients.”24
Practitioner skills are needed to teach and facilitate client body awareness. With skillful assessment, the practitioner can learn to distinguish the client’s presence from a lack of presence. We can feel a change in muscle tone, or vitality of the tissues, and we can feel when the person’s overall demeanor moves inward. At the same time, we can feel the shift in focus and vitality when the client “leaves.”25 This requires us to remain present during the session, both to feel and respond to the client’s presence during the session and to support a practice of presence between sessions.
There are simple techniques for staying present during sessions. First and foremost, we resist the temptation to think about ourselves, our life challenges, and our to-do lists, or the need to chat and entertain during the session. Instead, we can briefly respond to the light chatter that accompanies the transition from the outside world to the relaxing, healing environment of the massage room, then invite an inner dialogue. Reflective questions such as “How does this feel?” and “What do you notice here?” and statements such as “Breathe into the space between my hands,” can invite presence. Match the client’s breathing, notice connections in other parts of the body, and feel for subtle shifts to maintain your own presence.
Develop your sense of awareness outside of work. Attend movement or meditation classes to learn about options to recommend, and discover practitioners you can trust with your clients. We can use the research to enhance our own skills, giving us techniques to use in sessions with complicated clients when we get frustrated or stuck. If you have a rigorous yoga practice, take a few beginner classes or gentle yoga classes to learn what modifications are possible and how to think about movement with a beginner’s mind. Download mindfulness breathing or meditation apps to both increase your own awareness and practice vocal instructions for body scans that you can implement in practice. Spend an hour on the foam roller and explore gentle ways to use it, rather than going right to the iliotibial band because you can.
My favorite technique to use with my chronic pain clients is to teach the ability to differentiate between what moves well and what doesn’t, to notice where there is grace and where stiffness prevents graceful movement. This awareness came to me through my personal experiences using Feldenkrais to manage chronic pain. It enhanced my sense of awareness greatly, and to this day, I use what I learned with my chronic pain clients. For example, while working with the hips and the ribs, I gently and increasingly move them in different directions. Then, I ask how it feels to move them independently, if they can notice the difference between before and now, and what else can move now that their ribs can move separately from their hips. The homework starts by simply noticing when the hips and the ribs move independently, then advances to choosing to move them independently, and noticing if the pain returns when they are not differentiating the movements.

Moving Forward
Chronic pain conditions present with complex interactions of cognitive, behavioral, and psychological components, for which self-regulation is crucial. As massage therapists, we are in a unique position to ease the physical, emotional, and spiritual pain in the moment, both through educated healing touch and by teaching self-massage, encouraging safe movement, and enhancing mindful awareness between sessions. Our work ultimately creates hope, provides coping skills, and empowers the person in pain to lead a full and satisfying life.  

Working with Interdisciplinary Teams
The current health-care climate is ripe with opportunities for conventional and complementary health-care providers to come together and take a central role in addressing the epidemic of pain. Clients are demanding access, physicians are listening, insurance companies are starting to cover services, and complementary approaches, such as massage, movement, and mindfulness disciplines, are becoming more evidence-based. In this transitional time, both conventional and complementary providers have a responsibility to improve communication and make the full complement of services available to clients.1
Communication begins with documentation. Take a health history and chart each client session. SOAP charting can be very overwhelming if you are not accustomed to keeping written records. Electronic health records can simplify charting, prompting you to fill in the necessary information, and automatically populating graphs to produce outcome measures that demonstrate progress and enhance client retention. Sharing outcome measures and writing reports is a standard communication method in conventional health care.
Learn to describe your techniques and scope of practice using biomedical language. Avoid jargon, and at the same time, educate referring providers on how your work specifically addresses pain, and how you educate clients to use self-care to regulate and manage their pain between sessions. Active coping strategies are associated with less reports of pain, less depression, less functional impairment, and higher general self-efficacy.2
Self-care education is an important aspect of massage therapy to share with conventional health-care providers, since it is something they do not always have time to address. For us, it is second nature and easy to incorporate due to the length of time and the level of intimacy involved in our work. We can easily uncover what works and alter our care plan to meet the needs of each individual client.

Notes
1. M. Brooks and D. L. Thompson, “Pathways to Integrative Clinical Care,” in Integrative Pain Management: Massage Movement and Mindfulness Based Approaches, eds. D. L. Thompson and M. Brooks (Edinburgh: Handspring Publishing, 2016).
2. G. K. Brown and P. M. Nicassio, “Development of a Questionnaire for the Assessment of Active and Passive Coping Strategies in Chronic Pain Patients,” Pain 31, no. 1 (1987): 53–64.

Notes
1. T. C. Clarke et al., “Trends in the Use of Complementary Health Approaches Among Adults: United States, 2002–2012,” National Health Statistics Reports 79 (Hyattsville, Maryland: National Center for Health Statistics, 2015).
2. World Health Organization, media release, 2004, accessed July 2016, www.who.int/mediacentre/news/releases/2004/pr70/en/.
3. D. S. Goldberg and S. J. McGee, “Pain as a Global Public Health Priority,” BioMed Central Public Health 11 (2011): 770, doi:10.1186/1471-2458-11-770.
4. B. M. Berman, “Integrative Approaches to Pain Management: How to Get the Best of Both Worlds,” British Medical Journal 326, no. 7402 (June 14, 2003): 1,320–1.
5. D. Fulton-Kehoe et al., “Opioid Poisoning in Washington State Medicaid,” Medical Care 53, no. 8 (2015): 679, doi:10.1097/MLR.000000000000384.
6. L. Launso and N. Haahr, “Bridge Building and Integrative Treatment of People with Multiple Sclerosis. Research-Based Evaluation of a Team-Building Process,” Journal of Complementary and Integrative Medicine 4, no. 1 (2007): Article 7.
7. John Weeks, preface to Integrative Pain Management: Massage Movement and Mindfulness Based Approaches, eds. D. L. Thompson and M. Brooks (Edinburgh: Handspring Publishing, 2016).
8. T. C. Clarke et al., “Trends in the Use of Complementary Health Approaches Among Adults: United States, 2002–2012,” National Health Statistics Reports no. 79 (Hyattsville, Maryland: National Center for Health Statistics, 2015).
9. Jerrilyn Cambron et al., “Side-Effects of Massage Therapy: A Cross-Sectional Study of 100 Clients,” Journal of Alternative and Complementary Medicine 13, no. 8 (October 2007): 793–6.
10. B. I. Martin et al., “The Association of Complementary and Alternative Medicine Use and Health Care Expenditures for Back and Neck Problems,” Med Care 50 (2012): 1029–36; C. Plastaras et al., “Manipulative Therapy (Feldenkrais, Massage, Chiropractic Manipulation) for Neck Pain,” Current Rheumatology Reports 15, no. 7 (July 2013): 339.
11. C. Hsu et al., “Unanticipated Benefits of CAM Therapies for Back Pain: An Exploration of Patient Experiences,” Journal of Alternative and Complementary Medicine 16, no. 2 (February 2010): 157–63.
12. L. Launso and N. Haahr, “Bridge Building and Integrative Treatment of People with Multiple Sclerosis. Research-Based Evaluation of a Team-Building Process.”
13. C. Crawford et al., “The Impact of Massage Therapy on Function in Pain Populations—A Systematic Review and Meta-Analysis of Randomized Controlled Trials: Part 1, Patients Experiencing Pain in the General Population,” Pain Medicine (2016): 1–23.
14. D. C. Cherkin et al., “Comparison of the Effect of 2 Types of Massage and Usual Care on Chronic Low Back Pain: A Randomized, Controlled Trial,” Annals of Internal Medicine 155, no. 1 (July 2011): 1–9.
15. R. Werner and G. Box, “Anatomy and Neurobiology of Pain,” Integrative Pain Management: Massage, Movement and Mindfulness Based Approaches, eds. D. L. Thompson and M. Brooks (Edinburgh: Handspring Publishing, 2016).
16. N. I. Eisenberger et al., “An Experimental Study of Shared Sensitivity to Physical Pain and Social Rejection,” Pain 126, no. 1–3 (2006): 132–8.
17. V. Morhenn et al., “Massage Increases Oxytocin and Reduces Adrenocorticotropin Hormone in Humans,” Alternative Therapies in Health and Medicine 18, no. 6 (2012): 11–8.
18. J. W. Shega et al., “The Relationship of Pain and Cognitive Impairment with Social Vulnerability—An Analysis of the Canadian Study of Health and Aging,” Pain Medicine 13, no. 2 (February 2012): 190–7.
19. N. Haller and P. Buchanan, “Interactive Movement: The Feldenkrais Method,” in Integrative Pain Management: Massage Movement and Mindfulness Based Approaches, eds. D. L. Thompson and M. Brooks (Edinburgh: Handspring Publishing, 2016).
20. N. Pearson, “Yoga Therapy,” in Integrative Pain Management: Massage Movement and Mindfulness Based Approaches, eds. D. L. Thompson and M. Brooks (Edinburgh: Handspring Publishing, 2016).
21. C. J. Price and W. Mehling, “Body Awareness and Pain,” in Integrative Pain Management: Massage Movement and Mindfulness Based Approaches, eds. D. L. Thompson and M. Brooks (Edinburgh: Handspring Publishing, 2016).
22. Ibid.
23. C. McManus, “Mindfulness-Based Interventions,” in Integrative Pain Management: Massage Movement and Mindfulness Based Approaches, eds. D. L. Thompson and M. Brooks (Edinburgh: Handspring Publishing, 2016).
24. S. Scurlock-Durana, “Healing from the Core: A Journey Home to Ourselves,” Massage Message 31, no. 2 (May/June 2016): 16–17.
25. C. J. Price and W. Mehling, “Body Awareness and Pain.”

Diana L. Thompson, a licensed massage therapist for over 30 years, has a private practice in Seattle, Washington, treating acute and chronic pain disorders. She lectures at massage, acupuncture, midwifery, chiropractic, physician, and physical therapy conferences internationally and is a consultant for massage therapy research with The Research Institute at Group Health Cooperative in Seattle. Her newest endeavor, Hands Heal Electronic Health Record, is a patient-centered, intuitive, cloud-based EHR that turns bland treatment notes into expressive graphs that chart meaningful results. She authored Hands Heal: Communication, Documentation and Insurance Billing for Manual Therapists (Lippincott Williams & Wilkins, 2011), now in its fourth edition, and is an editor of Integrative Pain Management: Massage, Movement, and Mindfulness Based Approaches (Handspring Publishing, 2016). She was the proud recipient of four national awards in 2013, including Massage Therapist of the Year (One Concept) and Humanitarian of the Year (Performance Health).