Chronic Pain

Chronic Pain

We all have experience of clients coming into class or the studio who have chronic pain. Many attempt to carry on with their lives, continuing classes because they believe that movement is helping. It's up to the teacher to respect this brave decision and not make matters worse. We adapt exercises, listening and observing carefully. In some cases we have to gently persuade the client that today may not be a good day to exercise.
I thought it would be helpful to record some of the comments made by the presenters of the post-congress workshop on Chronic pain, Fascia and Feldenkrais. The workshop was taken by fabulous presenters, Diana Thompson and Barbara Frye, who are lecturers in Massage therapy and Feldenkrais practitioners.

Chronic pain statistics

• Globally, 1 in 5 people suffer from moderate to severe pain (IASP)
• 1 n 4 people aged over 65 live with pain (IOM)
• 116 million live with chronic pain in the U.S. up 40 million from 10 years ago! (IOM)
• unrelieved pain is more prevalent in low and middle income countries with an increasing burden of chronic disease - AIDS, Cancer (WHO)
• Global war on drugs is leaving countries without access to pain medication - Uganda, India, Ukraine. (the pain project)

The IOM report on relieving pain in America - we were encouraged to download, sets out suggested underlying principles:

• Effective pain management is a moral imperative, professional responsibility, and duty of people in the healing professions
• the importance of prevention
• clinician, patient and family working together
• Public health and community based approach

I liked the idea of the patient working along with the clinician or in our case instructor, as movement requires the client to move themselves. This is quite a big jump from being moved, and requires more effort and engagement on the part of the client. We should not forget that for someone with chronic pain just getting to the class sometimes requires huge effort. 

Conditions associated with Chronic pain:

• Aids, Cancer
• Arthritis, back pain,neck pain,headache
• Diabetes, herpes, Lyme
• Fibromyalgia,syndromes (chronic fatigue,irritable bowel, myofascial pain, phantom leg)
• Spinal stenosis,sciatica, restless leg syndrome
• inflammatory nerve conditions, neuralgia/neuritis (brachial plexus, thoracic outlet, carpel tunnel)

Types of pain:

• Nociceptive - dull, achy, poorly localised, sensory receptors or neurons perceive pain and sends pain signal to the brain
• Neuropathic - burning, tingling, stabbing, pins and needles. central nervous system disorder
• Allodynia - pain due to a stimulus which does not normally provoke pain, involves a change in the quality of a sensation.

Pain definitions/ therories:

• Acute pain serves a vital function as a warning sign of injury or infection, typically responsive to treatment
• Continued pain, once it's warning role is over, is maladaptive, unresponsive to typical treatments
• Chronic pain results in changes in the peripheral and central nervous system that aid in it's persistence.

Chronic Pain definition

• often a disease in and of itself
• A complex pathology - cognitive, behavioural impairment, anxiety, depression, sleep disturbances, function
• A dysfunction of the nervous system - neuroplastic changes, pain signals active even when resting
• original injury is no longer the source of the pain.

Complications of pain

• Psychological factors  - pain and fear of pain affects how people move, limited activity leads to de-conditioning and a drop in well-being
• Neuroplastic changes - toxic effect of prolonged excitation, cortical damage - sensory and motor changes
• Fibrotic connective tissue - compromised muscle function which leads to an increase in fibrosis and this in turn can lead to a decrease in lymph and nerve flow
• Predisposed to future exacerbations
• vulnerable to unusual activity, from new sports to prolonged sitting
• if nerve inflammation is present, cannot tolerate normal activity or full range of motion, according to pain research and practice, 2010 American pain foundation, nerve inflammation can cause damage to nervous system, damage to circulatory system, damage to soft tissues and organs, suppression of immune system,  excessive inflammation and delays healing

From the above information we can see that chronic pain will affect the way a client moves and approaches movement. The bodies fascia changes in response to chronic pain.

The workshop went on to list treatment guidelines for massage therapists. As movement teachers/instructors it is not up to us to diagnose, just to be aware of the issues surrounding chromic pain. The treatments however can be adapted to the movement world.

Treatment guidelines

• Do not cause pain
• Address the whole body
• Give the body time to rest during a session
• Use awareness as a tool for learning/neuroplasticity
• teach self-care for in between sessions

Research on massage/bodywork for chronic pain

• Maintaining mobility is an important component in decreasing pain in older adults; stretching, strengthening, balancing and self massage can help. ( Tse et al, journal of clinical nursing 3/11)
• Long term benefits of myofascial release/massage on sleep, short term improvements in pain, anxiety and quality of life. ( castro-Sanchez et al Evidence-based CAM, 12/11) - I wonder if they looked at restorative movement???
• multiple-disciplinary treatment more effective than single treatment approach; exercise, massage, lumber supports, education, hot/cold packs, traction, low-level light therapy etc ( Van Middlekoop et al, European Spine Journal, 1/11)
• 6 Alexander lessons nearly as effective as 24 when combined with exercise homework one year post treatment ( Little et al, British Journal of sports medicine, 12/08)
• Fascia innervation is nociceptive and likely to be responsible for nerve trunk pain ( Bove 2009)
• Movement at ankle and hip results in nerve motion at distant joints ( Hodges 2006)
• Nerve endings are concentrated where stresses are the highest (Solomonow 2004)

I think that the research is quite exciting for movement teaching. Pilates and Yoga addresses the whole body. One of the things I hope I teach my clients, is a greater awareness of their body, re-learning movement patterns etc. we use rollers and rolling to create localised myofascial massage for the tissues. We move and use our fascial net to move, keeping the fascial fabric healthy is, I believe, very important for my chronic pain clients.