Massage Therapy and Persistent Pain

There’s not many of us who don’t appreciate a good massage. Rubbing and kneading our muscles is our “go-to” when we’re experiencing pain. It feels good, if for only a small amount of time. It can decrease our pain and give our brains something else to focus on when we hurt. In this blog post, I will try to answer two questions:

1.      What can massage therapy do for those living with persistent pain?

2.     Is there anything else patients can do to achieve lasting results?

The answer to the first question is simple: massage can help make pain more manageable. This is possible because of the remarkable capacity of our nervous-system to turn-down the intensity of pain we experience. Something profound happens when we are touched. There are many complex effects in both brain and body that contribute to that magical feeling of relaxation and rejuvenation that occur after you have had a massage. These effects are beyond the scope of this blog to describe. Let’s just say, that by adding sensory input to our nervous-system, it has a chance to change its output or, in other words, decrease pain intensity. A perfect example of this is when you bump your shin and it hurts like heck until you reflexively start rubbing it. This is kind of like the brain receiving competing messages simultaneously but can only hear the loudest one. Of course, receiving a massage is a lot more complex than that. For one thing, no one receives a massage devoid of context. A warm room, peaceful music, and comfortable bed, coupled with an attentive and caring therapist will help turn down the nervous-system’s fight-or-flight response. This, in turn, can help decrease pain. This is called hypoalgesia, a fancy word for "less pain". And this is what most people are hoping for when they seek massage.

 

We know massage can decrease pain, but what else can it do? Something less obvious, is the effect of massage on how we move. It makes sense that when our pain becomes more manageable, our movement becomes easier, leading to increased confidence and resilience. This means getting back to the activities we love to do, making us happy and decreasing stress. And less stress will have a positive effect on almost everything in our lives. So, we could say the benefits of massage have a cascading effect reaching many facets of our lives.

Something I often hear from patients is that they feel great after the massage, but within the next day or two, their pain returns. Why is this? Well, for starters, there are 168 hours in a week, and probably only one of those is spent having a massage. The other 167 hours are spent doing all the things that got us seeking massage in the first place. Our beliefs and established neurological patterns probably play quite a large role in the persistent pain experience. We all have habitual ways of moving, sitting and standing that may not always be optimal for us. These things do not change overnight. For someone who has been experiencing pain for a short while, one hour of massage may be enough for their nervous-system to make a change in how they feel. Kind of like a car veering off the road needing just a little nudge to get back to centre. But for those with persistent pain, their nervous-systems has established a baseline that includes pain, and it may take more than just an hour of massage to make any lasting change. This scenario is more like a car that has veered off into a ditch and will need more than just a nudge to get back up on the road.

But for those with persistent pain, their nervous-systems has established a baseline that includes pain, and it may take more than just an hour of massage to make any lasting change.

So, what can we do to extend these short-lived benefits? Well, we can start with education. Knowing a little more about what is really happening when we are in pain has been shown to have benefits (ref). A common belief is that when we’re in pain, there must be something damaged inside our body. Or worse, the pain is an indicator of some seriously ominous disease. So, it’s not surprising that, for most people, pain of an unknown origin can lead to fear and stress; fear of living in pain the rest of their lives, unable to do the things they love, unable to live life to the fullest. Research suggests that these feelings can actually make pain worse (ref). However, it is possible to decrease the fear surrounding the experience by learning the basics of pain science.

The key point here is we don’t need physical harm to experience pain. Just like your car doesn’t need to have its window broken to have the alarm go off.

This starts by acknowledging that pain is a survival mechanism and exists to protect us. Without it, we wouldn’t live very long. It is a response by our nervous system to any threat, real or perceived, and doesn’t necessarily mean we are damaged. The key point here is we don’t need physical harm to experience pain. Just like your car doesn’t need to have its window broken to have the alarm go off. If we can just wrap our head around this concept, it can shift the way we view pain and, subsequently, decrease threat. This is not always easy and requires diligence on the part of both therapist and patient.

The concept of pain education has inspired a slight modification of the very popular saying: “no pain, no gain”. This has never been one of my favorite maxims. However, if we just add a couple of letters, it looks like this: “know pain, know gain”. I like this one much better, it’s more truthful, and less painful. Unfortunately, pain education is by no means a magic bullet. But, by adding it to massage and good movement, we can increase the chances of a positive outcome.

But knowing is not enough, we have to put what we learn into practice. You can spend hours learning exactly how to shoot a jump-shot, but without putting time in at the gym, shooting ball after ball, proficiency will be elusive. It’s the same for those with persistent pain. Learning how to move with confidence takes time and practice. It’s one thing to know that nudging our movement towards ever more challenging feats will build confidence and resilience, but to actually keep with it through all the ups and downs requires dedication and maybe some active cheerleading from family, friends, and your therapist.

Here’s a quick summary:

  •  Massage feels good and can help make pain more manageable.
  • Our nervous-system has a remarkable capacity to lessen the intensity of pain we experience.
  • Less pain means easier movement.
  • Good movement takes practice, and nothing changes overnight.
  • Pain doesn’t mean we are damaged and learning this can help decrease the fear surrounding the experience.
  • Know pain, know gain.

Thanks for reading.

To Orthotic, or Not to Orthotic?

There are many options out there in the world of orthotics: off the shelf, custom made, custom-moulded.

There are also many questions: which option is better for my needs? Do I actually need them? And, um, what are they, really?

How do orthotics work?

Orthotics are a tool to manage how stress falls through the bones and tissues, primarily in the feet, and in so doing they impact how stress falls through the knees and, to some degree, the hips.

Similar to using a brace, it’s very common for people to notice immediate relief from foot and knee pain when they start to use orthotics.

However, and unfortunately, this doesn’t mean that the underlying problem is fixed.

Rather, it indicates that the irritable structures are being shielded. Sometimes this stress-shielding gives the tissues the rest they need to heal, in which case treatment with orthotics can be curative.

In other situations, one needs to wear the orthotics consistently on an ongoing basis to avoid symptoms.

While this solution works for some, many folks don’t like the idea of orthotic-dependency.

The way to side step wearing orthotics indefinitely is to perform some corrective exercises and movement training, which improve the function of the feet and lower extremities. Wearing orthotics while you go through this course of exercises and treatments will improve or fix the mechanics of your foot, so that you no longer need to wear them.

How do you make custom orthotics?

At Tall Tree, we are unerringly thorough when it comes to creating orthotics.

We start with a musculoskeletal assessment consisting of an analysis of movement during gate, standing, changing directions, etc. The assessment also includes orthopaedic testing of the joints, ligaments, muscles, and nervous system of the lower extremities and feet.

Following this assessment, we do a state of the art scan of your feet and generate a digital replica of how your foot contacts the ground while walking. This data gives us diagnostic info and the foundation design for the corrective orthotic: measuring your foot posture during the movement of walking provides more relevant information than measuring a foot at rest. 

Then, we are able to make adjustments, additions, and accommodations based on a physical exam of the foot. This covers all the bases in creating an optimal foot orthotic.

How do I know if I need them?

Just because we can make you an awesome pair of custom orthotics doesn’t mean you need them.

A good first step is to determine if your condition is one that would benefit from orthotics. An assessment with a physiotherapist, chiropractor, or family physician will give you direction.

Once you’ve determined that you would like to get orthotics, it’s often worth trying the off-the-shelf variety first. These are less expensive and you can find them most local pharmacies and running stores. Sometimes these are enough to adjust how load falls through the foot and decrease symptoms. If they don’t do the trick, custom orthotics may be your next step.

At Tall Tree you can meet all your orthotics needs under one roof - come and see one of our chiropractors or physiotherapists, then drop by the orthotics office for a consultation with our kinesiologist, Jeremy. We'll help you take the next step - with or without orthotics in your shoes.

 

Being Active with Pain – Being Smart About It.

In our busy society, we do not take time to care for ourselves as much as we should with things like relaxation, getting together with friends, and exercise. When we do get the opportunity to do something important for our well-being like exercise, we often expect our bodies to operate at full capacity and without complaints. This is quite unrealistic and can often lead to aches, pains, and possibly injury. Often when these things show up, we don’t take the time to properly care for them, rather we continue to exercise the way we normally do, and expect the aches and pains or injury to resolve on its own – and sometimes it does. But what if it doesn’t?

The goal of this post is to help you better understand how to stay active while dealing with pain. We will cover the different views of pain, highlight the contemporary view of pain, as well as discuss how to interpret your pain and work with it.

"However, training to improve performance it is always a matter of balancing enough stress to create physical improvement, but not so much that we cause injury."

"However, training to improve performance it is always a matter of balancing enough stress to create physical improvement, but not so much that we cause injury."

3 views of pain:

The Old View of Pain – In the old view, pain meant damage to a body part. It was thought that the body sent a pain signal to the brain informing it of damage. This can lead to a mentality of “always listening to the pain.” We now know that the body actually does not have any pain receptors, nor does have the ability to send pain signals to the brain. Instead we have receptors which tell us about potential harm (nociceptors), but these can’t tell the difference between potential and actual harm.

Sport & Performance View of Pain – This is the “No Pain, No Gain” attitude that is commonly found amongst athletes or die-hard exercisers, and is often accompanied by the belief that “pain should be ignored.” However, training to improve performance it is always a matter of balancing enough stress to create physical improvement, but not so much that we cause injury.

The Modern View of Pain – We now know that pain is an OUTPUT of the brain. It is a behavior modifier, meaning that your body and brain are trying to get your attention! As an OUTPUT of the brain, pain is influenced by all our senses, past experiences, and stress/emotional level, which all reside inherently in the brain. As an example, professional violin players will report pain in their pinky finger at a lower temperature and pressure than the rest of us, demonstrating greater sensitivity as their little finger is vitally important to playing the violin and to them as a whole person (Zamorano et al., 2015).

To put it simply – Pain is complicated! However, this modern view that has emerged from 'Pain Science' demonstrates that “pain should be respected, and can be worked with.”

To put it simply – Pain is complicated! However, this modern view from ‘Pain Science’ demonstrates that “pain should be respected, and can be worked with.”

Bottom Line on Pain – Pain is good in that it serves a purpose! It is the messenger that gets your attention, BUT it is just the messenger and not the problem! Pain is your brain and body’s assessment of your own health, and it can be influenced by many things. Your pain should be respected, but it can and should be worked with to help you improve. This is the idea of training and being active intelligently!

How to be active with pain:

Respecting Pain – The first question that you need to ask when you are learning to deal with pain is how is it behaving? Is it always there (constant)? Is it only there sometimes (intermittent)?

Constant Pain – Here I mean truly constant, as in the pain never goes away even for a second. There are a few reasons for constant pain, but the one that we are most familiar with is after an acute injury. If you have an acute injury, you will know it. There will have been something you did that led to pain immediately and you will see signs of inflammation such as redness, heat/warmth, swelling, pain, and loss of function.

Look for redness, heat/warmth, and swelling – if these are all there, this is likely an acute injury and it deserves to be cared for. This is when protection, rest, ice, compression, and elevation, or PRICE, is the thing to do.

Intermittent Pain – This is great news! It means that there are some things that are perpetuating the pain and some things that are relieving the pain. This pain can be worked with!

  1. Determine which things cause your pain, and then minimize these for a short period.
  2. Keep pain after activity down(i.e. irritability). Here are some helpful guidelines to assess your pain with activity, think of it like a traffic light:
    • Green Light – the activity helps my pain; I should do more of this.
    • Yellow Light – I feel my pain while I perform the activity, but when I stop it goes                   back to normal in less than 5 minutes
    • Red Light – My pain is aggravated by this activity and stays aggravated for more than 30 minutes or I have notable pain the next morning.

The big take-away here is that pain does not always mean damage and, while it should be respected, you can work with it if you know how. Hopefully now you know a little more of the “how.” Think of pain as the messenger that the brain and body uses to get your attention. This messenger is meant to change your behavior, so don’t ignore it…work with it! Finally, if you continue to have difficulty or pain, reach out to your physiotherapist (book an appointment here). We can help with some hands on treatment, exercise and education to help you get moving better and pain-free again.

www.taitphysio.com

Reference:

Zamorano, A. M., Riquelme, I., Kleber, B., Altenmuller, E., Hatem, S. M., & Montoya, P. (2015). Pain sensitivity and tactile spatial acuity are altered in healthy musicians as in chronic pain patients. Frontiers in Human Neuroscience, 8. doi:10.3389/fnhum.2014.01016

Vitamin D and Menstrual Cramps

Dysmenorrhea, the medical term for menstrual cramps, is a common problem affecting over 50% of menstruating women of all ages. 

The term “dysmenorrhea” is derived from Greek, meaning “difficult monthly flow,” thus referring to the pain experienced by women during their monthly cycle. Pain is often experienced just before or during the first two days of the menstrual period and will usually ease as the period continues. The pain can be in the pelvic region, lower back or may even radiate down the thighs.  For some women, nausea, vomiting, fatigue, headache, increased urination and diarrhea may accompany the pain.  It can be so debilitating for some that they are forced to take time off work or school, disrupting social and family life. 

It is estimated that 10% of women who experience menstrual cramps are rendered incapacitated for one to three days each month.

Menstrual cramps can be classified as primary (physiological problem) or secondary (caused by underlying pelvic abnormality such as uterine fibroids or endometriosis).

It is estimated that 10% of women who experience menstrual cramps are rendered incapacitated for one to three days each month.

Primary dysmenorrhea starts after the release of inflammatory compounds called prostaglandins from the endometrial cells inside the uterus. And therefore, target treatment is often focused on the suppression of these prostaglandins.   Treatments may include non-steroidal anti-inflammatory drugs (NSAIDS), herbs, nutritional supplements and/or hormonal contraceptives.

Vitamin D has received much attention in the past few years regarding its role in calcium balance, bone health, and immune function. Vitamin D can also reduce the expression of the inflammatory compound cyclooxygenase-2 and can therefore regulate prostaglandin production, exerting anti-inflammatory effects in the body and endometrium.

Vitamin D has received much attention in the past few years regarding its role in calcium balance, bone health, and immune function.

Vitamin D has received much attention in the past few years regarding its role in calcium balance, bone health, and immune function.

A randomized double-blind placebo controlled clinical trial was conducted on 60 women with primary dysmenorrhea and vitamin D deficiency.  Women had to have at least four recent consecutive menstrual cycles with painful cramps during the previous 6 months.  Women also had to have a serum vitamin D level of <50ng/ml.

Women in the treatment group received 50,000 oral vitamin D once per week for 8 weeks, while 30 women received placebo once a week for 8 weeks.

In the vitamin D treatment group prior to treatment, pain was mild in 3 (13%), moderate in 16 (69.6%) and severe in 4 (17.4%) of the women.  After treatment (2 months), 22 (95.7%) had mild pain, 1 (4.3%) had moderate pain and none had severe pain.

Pain intensity significantly decreased in the treatment group after 8 weeks of treatment, with a significant difference in pain intensity between the two groups.

Vitamin D may be a useful and inexpensive strategy to reduce primary dysmenorrhea along with lifestyle and dietary recommendations.

 

Reference

Moini A, Ebrahimi T, et al.  The effect of vitamin D on primary dysmenorrhea with vitamin D deficiency: a randomized double blind controlled clinical trial.  Gynecological Endocrinology 2016, Early Online: 1-4.