In order to understand how pain science research affects massage therapy practice, it is helpful to first understand what all the hoopla is about. To be clear, “pain science” is not a new modality or treatment technique. Rather, the phrase simply refers to science that seeks to understand and explain the process of pain perception. As such, pain science informs our work, rather than dictates protocols.
For those working within the model of massage as a health-care practice, we seek to inform our treatment approaches with scientific principles whenever possible. New findings in the pain science realm might influence our understanding of treatment strategies in the same way that research in biomechanics, physiology, or anatomy could. That influence may or may not change what we do in the clinic.
What is Pain Science?
Entire books have been written on the detailed neurophysiology of pain and what new research is revealing about pain perception. It is beyond the scope of this article to cover these points in detail, and the science is not entirely in agreement. However, let’s look at some key pain science concepts that are relevant for massage therapists.
Pain is essentially an alarm system that alerts us to physical emergencies or issues that need attention.
It is the body’s way of telling us to take action of some kind. Even chronic pain is the body warning us as to what it perceives as something we need to address. Current research tells us that pain is generated in the brain, not at the location of issue. So, pain science literature refers to pain as an output of the brain. The brain tells us whether there is pain, or not, and makes this determination through an interconnected and complex system that includes various parts of the central nervous system. The body then responds. Like any decent alarm system, the body’s sensitivity can get altered (think of this as an alarm system that is out of calibration) and thus alert us to issues that don’t require a high level of response.
The process of pain recognition starts with the nociceptors, which are sensory receptors that exist throughout the body.
Nociceptors are sensitive to, and send signals about, chemical, mechanical, and/or thermal stimuli to the brain. We call this process of information transfer nociception. The brain evaluates a wide number of factors in its determination of whether to register pain from nociception. In an instance in which an extremely strong (noxious) signal is registered, the signal may skip the brain first, going straight to the motor fibers leaving the spinal cord. This is why we pull our hands away so quickly from a hot stove, usually prior to feeling pain.
There is an abundance of evidence in which people have extreme tissue damage, and subsequent nociception, with little or no pain.
This is seen in sports with players continuing to play with an injury or on the battlefield when a person “soldiers on” through sometimes horrendous injuries without reporting pain. In contrast, someone can also register extraordinary pain with what seems to be little or no tissue damage, as in allodynia (pain felt from stimulus that should not be painful, like dragging a finger across the skin). Exaggerated pain, as in situations of allodynia, is likely due to an increase in the sensitivity of the central nervous system to the stimulus. This increased sensitivity is called central sensitization and may provide an explanation for numerous situations where pain seems to be much greater than it should be.
There are multiple factors that cause pain to be either suppressed or enhanced.
Two people exposed to the exact same stimuli may have very different pain experiences. This is not just about pain tolerance. It is a complex process that involves sensory processing, memory, biomechanical stresses, tissue chemistry, psychological and social factors, and other physiological issues that can influence the pain someone feels. Any client’s pain experience can be a blend of these various factors, with some factor(s) playing more of a role than others. For example, generally, with acute injuries, tissue damage will play the largest role. Yet with chronic pain, a wide diversity of factors that may not be related to tissue damage can produce pain.
In the late 1970s, psychiatrist George Engel proposed a holistic model based on the emerging views of systems theory.
He noted that in some instances, an illness or injury is not simply a biological problem alone but includes psychological and/or social factors that influence the person’s experience. This framework is known as the biopsychosocial or BPS model. A number of psychological or social factors, such as attitudes, beliefs, culture, and mood, can play a part in the level of pain a patient experiences. Stress and anxiety have also long been associated with increased levels of pain. We have also learned that fear of pain and movement avoidance (called kinesiophobia) can increase the disability period and lead to greater pain levels. These various psychosocial factors can be difficult to measure or identify, but they can play a role in certain pain complaints.
Pain can be perpetuated through what is called long-term potentiation (LTP).
LTP is a process by which a neurological pattern is strengthened through repeated reinforcement, which increases signal transmission between the associated neurons. LTP can be observed in different situations. For example, motor skill improvement (e.g., ice skating) occurs due to repeated practice of neuromuscular patterns. LTP indicates that the more frequently the motor patterns are practiced, the stronger they become. The same thing can occur with pain patterns. The more frequently a pain sensation is felt, the more that sensory pathway is reinforced. In addition, the more frequently that pathway is used, the fewer stimuli are needed to set off the pain sensation.
Various factors can cause pain signals to be amplified—this is called ascending facilitation.
Think of it as turning up the volume on the nociceptive signals that are arriving. When nociceptive signals reach the central nervous system, they travel through the spinal cord and then ascend through the lower, mid-, and upper portions of the brain until they are fully processed. As they travel through these different sections, the intensity of the signals can be increased. There is a corresponding process that turns down the volume on nociceptive signals. The brain does this by blocking signals as they travel up through these pathways. This process of turning down the volume or limiting nociceptive input is called descending modulation.
Applications
The above concepts are important core principles of current pain science research that can inform massage therapists’ thinking about musculoskeletal conditions. However, these principles don’t require a radical change in what we actually do in the clinic as massage therapists. Pain science principles should inform our understanding of the various factors in the experience of pain. However, that knowledge may or may not change our treatment. There are elements of pain science application that are outside the scope of practice for massage therapists to pursue, such as probing potential psychosocial factors. Let’s now look specifically at how we might use pain science concepts effectively in massage treatment.
Interestingly, much of the broader implications of the new pain science theory indicate that treatment should be more holistic and consider other factors at play. The idea of the body/person as a whole has been a founding concept in massage therapy for years. This is not news to us. In fact, our treatment approach—with safe, quiet, calm, relaxing settings and the emphasis on client/practitioner relationship—is a hallmark of what we do. Massage therapists have pioneered a whole host of highly therapeutic approaches to the treatment of pain. The effectiveness of massage and its unique applications is well-recognized by the people who matter most: our clients.
The most important takeaway regarding pain science is that massage therapists should become better at what they do, not necessarily change what have been historically effective treatment approaches to pain. Before any consideration of “other neurological factors” come into play, the relevant biological factors must be investigated thoroughly. One cannot leap into issues of complex neuroscience or psychosocial considerations without fully exploring a client’s complaint. To do so would be poor treatment.
For close to 30 years, I have been beating the drum on the importance of assessment. (For more on the importance of assessment, read Ben Benjamin’s “Pain Points,” page 60, in this issue of Massage & Bodywork.) It continues to be one of the most important practices a massage therapist can perform. Understanding how the musculoskeletal system functions, the physiology of injuries and pain, and the corresponding physiology of our treatment approaches is paramount to quality massage. When we understand the physiology and science behind what we are doing, we can apply our work more appropriately and generate better outcomes for our clients. Clinical reasoning and comprehensive assessment are still the basic groundwork for responsible and effective treatment of musculoskeletal conditions and pain. Let’s take a look how these research findings might affect our approach to specific issues our clients may experience.
Musculoskeletal Conditions
Traditional treatment revolves around treating pain at the site of sensation. This still holds true for many types of conditions. For example, let’s say we discover through our orthopedic assessment a palpable defect in the muscle that is disproportionately painful to the surrounding tissue. There are also significant factors in the history that indicate a potential acute muscle strain. The primary treatment goals will still be facilitating healthy rebuilding of scar tissue, encouraging tissue remodeling, and returning to optimum function. In this instance, we treat the condition, and generally the pain subsides as the soft-tissue dysfunction is addressed.
Chronic Pain
A key lesson from current pain science is that in our evaluations we might consider that our client’s chronic-pain condition may not involve significant tissue injury, postural malalignment, biomechanical alterations, or other tissue-based causes. These various factors may have initially played an important role in the pain condition. However, as time has progressed and the tissues have healed, pain may persist due to sensitization in the nervous system. This is certainly not the case in every chronic-pain condition, but it can be a factor in a number of them.
Another concern occurs when pain persists for a long period of time. In these situations, various psychosocial factors may be playing a key role for some clients. Massage therapists should be cautious with a focus on these factors because identification and deeper investigation of psychosocial factors driving the chronic-pain experience is generally outside our scope of practice. In these cases, it would be helpful to have a referral network for others that deal with this dimension of the client’s treatment. But just because a person has a chronic-pain experience, it doesn’t necessarily mean there is a prominent psychosocial dimension to this case. Clinicians shouldn’t stop looking at any potential contributing factors, as tissue-based biological challenges can be missed.
Pain Volume
There are cases, such as severe whiplash, in which pain is so severe that it is difficult to identify which structures are generating the primary nociceptive input. This is what occurs with the concept of ascending facilitation. In these cases, gentle forms of massage are most effective at decreasing the excitability of the nervous system and returning the overall system to homeostasis.
A specific technique or modality may not be as important as the quality of touch, interaction between client and therapist, and overall sense of comfort and safety provided for the individual. The primary goal in these situations is to use massage to help turn down the sensitivity of the alarm system. When various pleasurable sensations like massage are experienced, the upper portions of the brain can send signals to lower portions of the brain and spinal cord and block some nociceptive input, thereby decreasing the eventual pain. This process is descending modulation (or descending inhibition). Applying soothing and comforting touch during treatment enhances the process of descending modulation and is one of the most powerful effects of massage for pain management.
There is a tremendous amount of neurological input to the central nervous system from the skin. Gentle massage approaches, such as those described as myofascial release, or dermoneuromodulation, can be helpful in acute and severe pain situations where the nervous system activity is ramped up. Knowledge of relevant nerve anatomy and which neural structures might be irritated in a particular region are important in guiding these applications.
Structural and Pain
One area of massage treatment that might be adapted to meet new pain science ideas involves structural or postural components. The biopsychosocial model of pain strives to look more at the whole person as a system and not place so much emphasis on mechanics and structure. There are treatment approaches and modalities in massage therapy that still keep biomechanical and structural models as the foundation of their treatment approach. What’s most important to recognize is that the uniqueness of a person’s pain experience means that any one particular issue (swayback for example) is not always the cause of that person’s (in this case, low-back) pain. Simply because there are notable postural “alignment” issues, does not mean they are the cause of the client’s pain. Postural or structural factors have to be looked at in context.
Take the common forward-head posture (FHP) during texting, pathologized now as “text neck.” We know from biomechanical studies that large numbers of people have FHP and no pain. So, is FHP irrelevant for back or neck pain? No, it isn’t—be sure to note it in your assessment. However, a single static postural position is not sufficient to determine that pain will be felt. If that person moves around a good deal, there may be no problem at all. If, however, that position is held for long periods of time, the position is now compounded with time and load as factors that can overwhelm the tissues.
Similarly, just because back pain exists along with a leg length discrepancy does not mean the length difference has caused the pain. In fact, most people have some degree of discrepancy. However, if the client history shows the individual recently began a vigorous running regimen, that postural aberration is now compounded with repetitive loading, which makes it a far more likely component of the existing pain complaint. In both situations, skilled assessment and clinical reasoning are critical for determining when various factors are a key part of an existing pain complaint.
In Sum
Current pain science research offers fascinating new ways to understand how pain functions. However, if there is a takeaway about what not to do, it is this: do not try to turn your clients into neuroscientists by overloading them with complex neuroscience principles. The most misunderstood concept in pain science is the idea that pain is an output of the brain. This concept is sometimes interpreted as pain being “all in a person’s head” and therefore less real. And sadly, this is sometimes still told to people who have idiopathic pain by other health-care professionals.
Limit your consults about pain to factual tidbits that are consoling, not negating. Massage therapists remain a frontline health-care profession, where a person’s pain may be validated. We do not want to misinform our clients on complex pain science concepts or risk accidently making their pain sound like something unreal (“pain originates in the brain”). We can console clients by letting them know that pain is complex, and that different treatments might be warranted to relieve other aspects of their experience.
We should strive whenever possible to offer treatments that don’t cause more pain. The concept of “no pain, no gain” simply doesn’t work in this context. Perhaps more gentle and superficial work is provided for heightened neurological activity instead of deep and specific work, for example.
It has been shown that clients benefit from learning about pain. However, effective communication is key. Simple pain science concepts can be dripped into conversations in a limited way. For example, a client with anxiety over a diagnosis of degenerative disk disease can be consoled with the fact that people can have significant disk degeneration without any pain. Similarly, those in chronic pain might be informed that pain can be made worse by being overly protective in their movements.
However, this kind of advice can only come after thorough assessment and a solid clinical history with the client. Dropping factoids on clients without proper context or substantial investigation of the client’s issues and treatment history can lead to bungled messaging and may actually be detrimental to progress.
In the end, we are massage therapists. The care we provide cannot be attained elsewhere for our clients. Always look before you leap. And remember, science and research are evolutionary processes that guide us. Rarely do they provide absolute black-and-white answers for clinical reality that are the same for every person.
Whitney Lowe directs the NCBTMB Clinical Rehabilitative Massage Specialty Certificate, which prepares professionals with essential clinical skills and advanced knowledge for musculoskeletal pain/injury treatment. This innovative program integrates clinical science with hands-on protocols. Grow today! www.academyofclinicalmassage.com.