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Pain and Function - Not Always What we Think

Like many health care providers, I have always assumed that if pain is less, function will increase. It's a lovely idea. The reality however, is that this is not necessarily true. (Nothing screws up a great theory like facts.)

In the less pain, more movement model, many physicians had prescribed opioids at the onset of symptoms of back pain, hoping to get ahead of the curve. A number of cohort studies show that the result was in the opposite direction. Workers did not go back to work sooner. In fact, those who were prescribed opiates were LESS likely to return to work. One national study showed that opiate use increased the duration of time off from work. Why?

There are perhaps many different reasons, but inactivity is certainly one possibility. Patients given an opioid aren't generally told to go home and be as active as tolerated. They think of it as a medication for illness, in the same model as other medications. Go home, rest and recuperate. Much about the current understanding of pain is way in the other direction. (I remember when bed rest was prescribed for back pain. No knowledgeable doctor would do that anymore.)

Thinking about the passive vs active model makes me think back to a time I had with Dr. David Simons, of the Simons and Travell fame. I asked Dr. Simons if he would rather treat a trigger point with his hands or with a needle. Since he was a medical doctor, and obviously a very skilled one in his field, I assumed the answer was with a needle. His answer, surprisingly, was to treat manually. Looking somewhat stunned, I asked him why. His explanation was revealing. It was his belief that the moment you bring out a needle, the patient goes into a passive mode. They assume, as with other injections, that the medicine will do all the work. as he said, "When I use my hands, patients are more likely to do the home care necessary to regain health." I remember that he also added with a wry smile, "Perhaps they feel a bit sorry for me. They probably think all I have to offer is my hands and if this is going to work, they better help in any way they can!"

There is something very important in that concept, a lesson for all of us. This is something that Patrick Wall, one of the leading pain researchers of all time said before his death. Pain is both a sensory and a motor experience. When pain is experienced, the premotor parts of the brain light up. In the face of pain, action is called for. If we are uncomfortable, we are wired to move. The more we help people increase their capability to move, the better they will be.

This only makes sense from a neurological perspective. The brain essentially asked three questions of every new stimulus:

  1. What is it?

  2. What does it mean?

  3. What do I do?

Great emphasis is currently put on the second question- What does it mean? This is the sensory viewpoint and it has shed much light in the world of pain science. Equally important however is the third question- What do I do? What is the action step? Lack of action is dis-empowering. This is one of the reasons that soft-tissue work can be so incredibly empowering for clients. If you think your back pain is from arthritis, there isn't much for you to do. If soft-tissue therapy reduces the pain substantially, it is obvious that arthritis isn't the main issue. Soft tissue is the problem and that is something you can ACT upon.

It would seem to be best to approach pain from a sensorimotor perspective, incorporating the best of both worlds. The meaning of pain may be explored and reframed. At the same time, we need to encourage people to move, to counteract a Fear-Avoidance effect that can make pain worse. We, as massage therapists, can help people by exploring pain-free range of motion and gently nudging the boundaries of limitations. This may indeed have long-term positive effects as people reconnect with activities that give their life meaning and purpose.

Webster, B. S., Verma, S. K., & Gatchel, R. J. (2007). Relationship between early opioid prescribing for acute occupational low back pain and disability duration, medical costs, subsequent surgery and late opioid use. Spine, 32(19), 2127-2132.

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