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.

Tip of the iceberg- international fascia research congress 2012 overview

Tip of the iceberg

I have just returned from the 3rd International Fascia Congress where  800 delegates and at least 100 presenters and exhibitors, met and shared their research, experience, observations and aspirations over 5 days of  conference , pre-conference and post conference workshops.

The theme of the conference was:-

What do we know? What do we notice? continuing the Scientist-Clinician Dialogue .

So why was I there? I am neither a Scientist nor a Clinician in the accepted definition of the word. I am a Pilates teacher who has spent the last 8 years soaking up every aspect of fascia research she can find. I started with the myofascial chains or lines, released by Rolfers or Structural Integrators, moved on to workshops  with Fascial research leaders such as Tom Myers and Robert Schleip, undertook applied myofascial anatomy qualifications, listened to webinars and read many scientific papers. I then integrated it all into my Pilates teaching. 

In my Studio and in my classes I notice a lot and I think that movement teachers/therapists have quite a lot to add to this conversation.

I was not totally alone as a movement teacher at the conference, I travelled with a Structural Integrator who is also a Yoga teacher, the partner of one of the main contributors is a movement teacher and several physiotherapists/clinicians attending had a Pilates/yoga/movement qualifications. We were, however, very much in the minority.

It is hard not to feel intimidated by science. Many of the scientists were there to protect their reputations, showcase their expertise or to challenge common held beliefs.  The atmosphere in the conference hall was often drenched in the emotions of awe, amazement, confusion, respect, admiration and fear. It was a privilege, and a challenge, to be part of it.

It will take a while to assimilate everything I heard, The Congress book measures over 1 inch thick, my hand written notes run to over 50 pages of highlights to be looked up later. Luckily the congress was video taped and re-hearing many of the keynote addresses is something I am looking forward to, as I know that  of the hundreds of pieces of information flung out to the delegates, only a very small percentage was successfully caught and scribbled down.

Along side the main congress hall and keynote addresses, there were Posters to look at. Each of these posters represented research projects undertaken all over the world. The exhibitors included  Clinicians, Scientists and Students and each one had the opportunity to present their work to the delegates during the congress. Amongst these posters there several research projects which included movement therapies. The posters however demonstrated the problems in trying to prove that an intervention, be it clinical, manual therapy or movement/exercise based,is very difficult to do in an objective manner, which can be presented to and scrutinised by the scientific world.

The congress timetable was very busy. We started at 8 am and listened until 5pm with coffee and lunch breaks. We had one evening session where we watched the multimedia presentations until 9 pm. In the breaks we mingled with the other delegates, normally starting with where we originated from ( our passes gave our names and home countries only), it then progressed onto what we did. From my point of view often the conversation stopped there, as many of the congress delegates were there to make useful contacts ( Pilates teachers aren’t considered useful!!), however I did meet some wonderful people and once we started to chat about the research we had much in common and I think I may have persuaded some that movement teaching does belong in the conversation.

I had the huge advantage of traveling with someone who had been to the first 2 congresses and who had worked along side many of the clinicians who were presenting at the congress. At our breakfast table we discussed new ways of ‘scientifically’ measuring changes in fascia following interventions, over supper we talked about how exercise and manual therapies could be measured to benefit clients.  

I attended a post- conference workshop delivered by Massage therapists on Chronic pain. The lady sitting next to me was a little put out that she would be working with a non-clinician, but I had the last laugh when the presentation moved onto proprioception and movement. I was on home turf. When we were taught ‘pelvic clock’ I couldn’t help chuckling to myself. I was, by that point, totally convinced that movement teaching does have an important contribution to the world of Fascia research. 

For me the most wonderful thing about the congress was that there was no question that Fascia is an important part of the human anatomy, not just the throw away wrapping around the muscles and bones. The body wide web was universally accepted and expanded upon. We could concentrate on the beauty of the bodies movement from within. Although there were still arguments about what each layer of Fascia should be called, there was no argument about the part it plays in proprioception, or pain. loose connective tissue was described as the ‘forgotten organ’ .We discussed ‘the secret life of water’ and fascia as a highway for the immune system. I know that we were all ‘fascia-holics in the room, only there because we believed, but as one speaker said: just because we believe in it’s existence does not make it a religion, this was Science and we could prove it.

Where does movement fit in? - Well I believe that the Fascial network is the bodies movement system. If we waited until our brain told our muscles when to move life would be very slow and jurky- like a robot’s movements. Fascia glides and reshapes, holds structure, encloses and connects,it moves internally so we can move externally with ease and grace. When the system is challenged or breaks down through injury, disease or under or poor use we lose this grace, we experience pain. The medical profession can fix our bodies, the massage therapists and manual body workers can move our tissue but ultimately it is up to each individual to move themselves, to make sure we keep our bodies and our movement system , our Fascia, healthy and that is where the movement teachers have their part to play and that is why I went to the congress and that is why I want to bring the research on Fascia into the movement world.

This is the tip of the iceberg, there is so much more for us to discover.

Tracey Mellor

April 2012 (c)