It takes a village to manage pain, especially back pain. Research shows that back pain is relatively resistant to monodisciplinary therapy regimens. To make it even more complicated, no one treatment is best for all patients.
Integrative care—Eastern modalities, massage therapy, mental health, movement therapies, relaxation techniques, structural modalities, etc.—in addition to conventional treatments, such as medication and injections, may be the answer.1 According to a recent clinical trial, the most common multidisciplinary treatment plan for low-back pain included exercise, massage therapy, and self-care education. This treatment was the most recommended combination by the study’s integrative care team, and the second most selected combination by the patients (acupuncture was selected slightly more often than massage by patients in this study).2
Comparative effectiveness studies like these are on the rise. Many complementary and alternative (CAM) therapies are seen as viable treatment options for complicated conditions such as back pain, but research has not explored the combination of conventional medicine and CAM until recently. Several such studies have been published in the past year, demonstrating that a multidisciplinary treatment approach ameliorates pain and improves function and quality of life with medium to high effect, even for patients with a long history of chronic back pain. Results were better than for monodisciplinary treatments, and treatment effects remained stable at a six-month follow-up.3
Recommendations have come out of these studies, including the optimal integrative model of care, which should involve a collaborative, interdisciplinary, and nonhierarchical team approach. All disciplines should be represented and contribute to the treatment plan discussions.
The recommendations also say that patients who participate in their care tend to be more satisfied with their care and experience better outcomes. Multiple efficacious treatments introduce greater opportunity for patient choice. Therefore, to enable true patient-centered care, patients should be included in the integrative medicine (IM) team’s decision-making process.
Finally, care plans should remain fluid. Any chronic condition is episodic, and frequency of care and response time to treatment varies from individual to individual. Being willing and able to make changes to a care plan is a key characteristic of maximizing clinical outcomes.
Massage’s role on IM Teams
Multidisciplinary approaches to care are not foreign to us. Most massage therapists work in tandem with other providers, getting referrals and recommendations from physicians, chiropractors, physical therapists, and nurses. Unfortunately, however, it is not common for massage therapists to be included in the treatment planning. It is critical, therefore, to insert our recommendations using standard communication pathways. Unless we are located in the same office, our best communication tools are our treatment notes and progress reports. Following conventional communication protocols can garner respect and increase referrals, as well as provide us with a mechanism for influencing the client’s care plan and claiming a spot on the IM team.
We have valuable information to share. Somatic therapists are at a distinct advantage when it comes to client choice and participation. Typical sessions are an hour long, giving us optimal time to get to know our clients and their preferences for treatment. Our training encourages frequent check-ins regarding comfort, music, scents, and treatment styles. We often know more about the needs and desires of a patient than many others on the health-care team. This is valuable information that can be shared via progress reports. Demonstrating our value may become the impetus for including us as active members of the IM team in the future.
Perhaps the most beneficial aspect of our routine care, according to the research, is in providing self-care education. We spend time educating our clients on proper sitting and lifting techniques, help increase awareness regarding forward-head posture and wrist stress at the computer, and often suggest pillow supports for the neck and low back, topical pain relievers, and simple contract-relax exercises to support change.
In a low-back study on which I was a consultant, massage therapists were prevented from providing stretching and awareness exercises because self-care education was part of the control group. No one realized how difficult this would actually be! It is such an integral and natural component of a client-therapist relationship, discussing ideas about how to continue the benefits of massage in between sessions and customizing self-care routines. Needless to say, self-care education became a part of the massage therapy protocol in subsequent studies.
The multidisciplinary protocols used in these studies include a variety of separate disciplines, such as structural modalities (chiropractic and osteopathic techniques), Eastern modalities (e.g., acupuncture and herbs), and mental-health therapies (e.g., behavioral counseling), but many of the recommended techniques are within the scope of practice and training of massage and bodywork therapists. In particular, some of the self-care education techniques are a good fit: relaxation therapies such as breath work and awareness exercises, postural reeducation, and stretching and strengthening techniques. These treatment options can be part of a bodywork session and encouraged between sessions.
Self-Care Treatment Options: Massage and Exercise
The success of multidisciplinary therapies is a balance of active and passive techniques. Researchers of a recent study published in the Journal of Pain Research said, “Patients suffering from chronic pain prefer passive treatment, which is helpful in symptom control. On the other hand, one of the main aims of treatment is to increase the activity levels of the patient, which can only be achieved with adequate active therapies.”4 This theory is supported in many studies involving a variety of chronic pain conditions in various populations. This is valuable information to consider not only for the IM teams, but also for MTs when designing our treatment plans and selecting our hands-on techniques and homework strategies.
Combination therapies are easily achieved through a multidisciplinary team approach to care. However, if there is no one on the team providing active therapies, along with stretching and strengthening self-care routines to support change, it may be necessary to incorporate exercise and self-care education in your sessions. Take care to stay within your scope of practice regarding stretching and strengthening, but when possible, make it a priority to include active and resistive treatment techniques and self-care education in your massage and bodywork sessions.
In a study published in the Journal of Bodywork and Movement Therapies, researchers updated an evidence-based clinical practice guideline on therapeutic massage for low-back pain based on a systematic review, demonstrating that massage interventions are effective to provide short-term improvement of sub-acute and chronic low-back pain symptoms and decreasing disability at immediate posttreatment and short-term relief when massage therapy is combined with therapeutic exercise and education (emphasis added).5
A comparative effectiveness study found that massage therapy, when combined with exercise, stress management, and relaxation therapy education, decreased pain intensity, pain duration, and depression, and increased functional status and quality of life in people with migraines.6
Some of the simple stretching and strengthening exercises studied include:
• Eccentric strengthening.
• Hamstring stretching and quadriceps strengthening.
• Manual fascial stretching of the back.
• Slump stretching.
• Spinal extensor strengthening.
Other Self-Care Options
There are several categories of self-care discussed in the literature. The most common is in regards to posture: body awareness and correct positioning, as well as the flexibility, mobility, strengthening, and stretching exercises involved in supporting postural changes. These were accompanied by lessons on how to avoid overload and pain during activities of daily living.7 Increasing awareness around what movements or activities cause or increase the pain can lead to better choices about how to move or what activities to modify or avoid.
Relaxation, meditation, and mindfulness exercises are considered effective in managing pain and improving sleep.8 Breathing exercises are easy to include on and off the table, and many variations exist. There are even apps available to support your breathing and provide meditation homework suggestions (eg., Breathing Zone, Long Deep Breathing, etc.). Aromatherapy and music are other ways to address relaxation. One study found trigger point therapy, when combined with music and an aroma selected by the client, reduced the symptoms of fibromyalgia.9
Tiffany Field, PhD, conducted a study comparing the benefits of self-massage and movement exercises to relaxation techniques. Self-massage tools included wooden dowels and tennis balls rolled across the surface of the limbs, stimulating the pressure receptors. The self-massage was combined with yoga-like stretches. The movement/massage therapy group was compared to a progressive relaxation therapy (instructions on tensing and relaxing large muscle groups moving from the head to the feet). Both groups showed reductions in pain and anxiety, but only the movement/massage therapy group experienced improved mood, decreased anxiety, and lower pain results.10 In a recent study, Field builds on her previous results, theorizes that yoga is a form of self-massage, and finds both massage and yoga to have similar effects on prenatal depression.11
What is the Client Willing to Do?
Self-care education is a common practice for bodywork therapists. We first ask our clients if they have time to help themselves, gauging what they are willing and able to do on their own. We then ask what they already do to take care of themselves, and tailor our suggestions to support what they already fit into their daily practices. Then, we offer customized tips on postural awareness, relaxation, and pain relief. We have topical ointments, pillows, and self-massage tools for sale to ensure their compliance. When possible, we recommend stretching and strengthening exercises to support newfound changes in their body.
We would be wise to practice these self-care routines ourselves, and stay productive, healthy, and pain free despite our physical jobs. As expressions of calmness and vitality, we can be shining examples of what is possible.
Notes
1. J. Artner et al., “Intensive Interdisciplinary Outpatient Pain Management Program for Chronic Back Pain: A Pilot Study,” Journal of Pain Research 5 (2012): 209–16.
2. M. Maiers et al., “Integrative Care for the Management of Low-Back Pain: Use of a Clinical Care Pathway,” BMC Health Services Research 10 (2010): 298.
3. B. Moradi et al., “Efficacy of Multidisciplinary Treatment for Patients with Chronic Low-Back Pain: A Prospective Clinical Study in 395 Patients,” Journal of Clinical Rheumatology 18, no. 2 (2012): 76–82.
4. J. Artner, “A Pilot Study.”
5. L. Brosseau et al., “Ottawa Panel Evidence-Based Clinical Practice Guidelines on Therapeutic Massage for Low-Back Pain,” Journal of Bodywork and Movement Therapies 16, no. 4 (2012): 424–55.
6. M. Lemstra et al., “Effectiveness of Multidisciplinary Intervention in the Treatment of Migraine: A Randomized Clinical Trial,” Headache 42, no. 9 (2002): 845–54.
7. J. Artner, “A Pilot Study.”
8. Y. Nakamura et al., “Investigating Efficacy of Two Brief Mind-Body Intervention Programs for Managing Sleep Disturbance in Cancer Survivors: A Pilot Randomized Controlled Trial,” Journal of Cancer Survivorship (January 22, 2013), accessed April 2013, www.ncbi.nlm.nih.gov/pubmed/23338490.
9. B. Demirbag et al., “The Effects of Sleep and Touch Therapy on Symptoms of Fibromyalgia and Depression,” Iranian Journal of Public Health 41, no. 11 (2012): 44–53.
10. T. Field et al., “Movement and Massage Therapy Reduce Fibromyalgia Pain,” Journal of Bodywork and Movement Therapies 7, no. 1 (2003): 49–52.
11. T. Field et al., “Yoga and Massage Therapy Reduce Prenatal Depression and Prematurity,” Journal of Bodywork and Movement Therapies 16, no. 2 (2012): 204–9.
A licensed massage practitioner since 1984, Diana L. Thompson has created a varied and interesting career out of massage: from specializing in pre- and postsurgical lymph drainage to teaching, writing, consulting, and volunteering. Her consulting includes assisting insurance carriers on integrating massage into insurance plans and educating researchers on massage therapy theory and practice to ensure research projects and protocols are designed to match how we practice. Contact her at soapsage@comcast.net.
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