Pain, especially when it's chronic, can be difficult to treat. For too long, however, the first—and sometimes only—option considered for pain management was a prescription, most commonly for opioids.
The cost of the ongoing opioid epidemic, however, is too large for us not to examine other ways to manage pain. According to the NIH’s National Institute on Drug Abuse, the opioid epidemic costs the United States roughly $78.5 billion a year in health care, lost productivity, addiction treatment and criminal justice. This figure doesn’t even account for the human cost: the approximately 130 people who die every day because of an opioid overdose.
The fact remains that people need help managing pain. For many, integrative therapies like massage may be part of the answer.
Is Pain Really a Problem?
Part of understanding the scope of the opioid epidemic is honestly assessing how big a problem pain is in the United States. According to Halena Gazelka, M.D., who chairs the Mayo Clinic’s Opioid Stewardship Program and was appointed to the federal Health and Human Services Pain Management Best Practices Inter-Agency Task Force in 2018, the answer can be found in the millions of Americans affected by pain. “Pain affects more Americans than diabetes, heart disease and cancer combined,” she explains. “An estimated 50 million Americans suffer from chronic pain, and for some 20 million, pain significantly impacts their life.”
Pain is also reported as the most common reason Americans access the health care system. “It is a leading cause of disability and a major contributor to health care costs,” Gazelka adds. “Chronic pain is the most common cause of long-term disability.”
Cindy Steinberg, National Director of Policy and Advocacy for the U.S. Pain Foundation, explains that our understanding of chronic pain is evolving, however. “Improved neuroscience has shown us that chronic pain is a disease itself of the nervous system and brain,” she says. “So, regardless of the original etiology of the pain, chronic pain becomes the disease or becomes a co-morbid disease.” For example, with a patient with diabetes who develops neuropathy as a result of diabetes, the neuropathy becomes a co-morbid disease of chronic pain. “This is important because lacking that understanding may cause some physicians to ignore the pain and continue to search for a disease rather than accepting that chronic pain must and can be managed so that most people can still be functional and have some quality of life,” Steinberg adds.
These patients are also some of the most stigmatized, which can complicate treatment. “Stigma associated with having chronic pain, especially when opioid therapy is used as a treatment modality, is a major concern and has far-reaching effects on patients and all those involved in their care," explains Bruce Schoneboom, Ph.D., who currently serves on the U.S. Department of Health and Human Services National Advisory Council for Nursing Education and Practice and the HHS Inter-Agency Pain Management Best Practices Task Force. "Studies suggest that patients who are receiving or who have previously received long-term opioid therapy for nonmalignant pain face both subtle and overt stigma from their family, friends, coworkers, the health care system and society at large for their opioid treatment modality."
Of course, the flip side, Gazelka acknowledges, is that pain also isn’t a symptom or condition that has—or always needs—immediate remedy. “I think that at times we’ve created an expectation that all pain should be ‘fixable,’” she notes. “While we do want to manage pain to allow for function and activity, some pain is to be expected at times in life, and not all pain requires a pill to fix it.”
Patient Demand: Pain Relief Without Prescriptions
What’s missing in some of the national coverage of the opioid epidemic is the role patient demand is playing in the drive for more comprehensive approaches to pain management. “Patients desire alternatives to opioids,” Gazelka explains. “Even when patients do need opioids, massage as a complementary therapy can be very beneficial.”
The numbers back this up. According to a 2019 Health Checkup survey done by the Mayo Clinic, 94 percent of patients surveyed prefer an alternative to opioids, and many of them specifically mentioned massage and integrative therapies, Gazelka notes. “Universally, the patients tell us that they find significant benefit—and many of them come to see our massage therapists as very important members of their treatment team, developing relationships with them as they do with their physicians and nurses.”
Brent Bauer, M.D., research director with the Mayo Clinic’s Integrative Medicine and Health, believes the rapidly growing recognition of more comprehensive approaches to complex problems like chronic pain is directly related to the current opioid epidemic. “Because pharmacological alternatives are limited, more and more doctors, hospitals, health systems and insurance companies are starting to understand the value of integrative medicine,” he explains. “Suddenly, massage therapy, acupuncture and mind-body medicine are becoming mainstream in doctors’ offices and hospitals across the country.”
Gazelka sees the same trend. “I think we are going to see an increase in demand for services outside of ‘typical medical care’ to help manage pain,” she explains. “The opioid epidemic has heightened awareness of patients and providers alike that we must provide alternative options for pain management. Patients want it. Providers will demand it.”
Steinberg suggests best practice is for health care providers to try non-pharmacological therapies and non-opioid pharmacological therapies for chronic pain before prescribing opioids, given the risks. “Integrative therapies, especially noninvasive therapies like massage therapy, have a potentially big role to play in helping manage chronic pain,” she says.
Related: An Evidence Based Guide to Treatement of Fibromyalgia for Massage Therapists | 2.0 CE hours
Making Choices: Massage + Pain Management Research
One of the trickier parts of the opioid epidemic is that opioids do have a place in pain management, especially when treating trauma, like for soldiers injured during combat or the person who comes into the ER after being in a car accident.
Other types of pain, however, are likely better served by integrative care approaches that, though they may include opioids, also incorporate therapies like massage—which research shows has some real promise. From chronic back pain1–9 to neck and shoulder pain10–12 to osteoarthritis13–17 to fibromyalgia,18,19 research suggests massage therapy may be a viable alternative to opioids.
One study examining massage and chronic pain management compared the effects of two types of massage to usual care on 401 participants suffering from nonspecific low-back pain and found that participants who received massage had superior functional outcomes and symptom improvement than those in the usual care group, with benefits that lasted at least six months.3
Another study of women with chronic low back pain indicated that participants who received massage therapy had a greater decrease in pain intensity and disability than participants who received physical therapy.7
Two meta-analyses found that massage therapy yielded greater pain reduction when compared to inactive therapies for neck and shoulder pain.20,21 Additionally, a randomized controlled trial where participants had 10 massage therapy sessions over 10 weeks or a self-care book on managing neck problems found significant improvement in the Neck Disability Index score for those who received massage therapy.22 Interestingly, a dose response was discovered between the number and duration of massage sessions and the improvement in neck pain intensity and the Neck Disability Index score.23
Several randomized controlled trials and prospective studies indicate that massage therapy has positive results with respect to osteoarthritis and rheumatoid arthritis, including less pain and stiffness, and enhanced function.24,25 One randomized controlled study found that participants who received an eight-week massage therapy intervention for symptoms associated with osteoarthritis of the knee had significant improvements compared to those who received usual care.15 Another similar study found that a one-hour course of massage therapy given for eight weeks provided better pain relief than usual medical care.16
Even when compared to just exercise, patients with knee arthritis pain who received massage therapy along with exercise showed significant improvement on the pain scale, get up and go test and the WOMAC index.17
Perhaps most helpful is the research that indicates massage therapy can provide relief for patients who have conditions where pain is not localized to a specific part of the body, as is the case with fibromyalgia. A meta-analysis pooled from 145 study participants indicated that myofascial release has positive effects on fibromyalgia symptoms such as pain, anxiety and depression when compared to a placebo.18 Experts have recommended that massage therapists be regular partners in a team-based treatment of fibromyalgia, along with physicians, psychologists, and physical and exercise therapists.26
Related: Learn how massage therapy can treat pain and reduce opioid addiction rates in the U.S. by reading AMTA's book "Massage Therapy in Integrative Care & Pain Management."
A Path Forward
Patients want integrative care approaches for pain management and providers recognize the need for alternatives to opioids, so what are some of the obstacles to getting care that includes therapies like massage? “How to pay for it,” Gazelka says. “Massage therapy is not currently covered by most insurance, so patients must have the means to pay for the massage therapy themselves.”
Bauer and Steinberg agree. “The biggest obstacle is the lack of insurer coverage and reimbursement for massage therapy, which makes the treatment inaccessible for many people living with pain,” Steinberg explains. Remember, Steinberg encourages, many pain sufferers are not able to work or they may only work part-time, so the money they have available for treatments not covered by insurance is limited.
Bauer recognizes the inconsistency here. “We have payment models that readily cover expensive procedures but still haven’t figured out a way to appropriately compensate the valuable work that a massage therapist brings to a patient’s bedside,” he says.
Change on that front may be coming. Earlier this year, the Centers for Medicare and Medicaid Services, which wrote to all Medicare Advantage programs encouraging them to cover massage therapy as part of their non-opioid pain management supplemental benefits recommendations for 2020, went a step further than their 2019 statement indicating massage therapy would be accepted.
Gazelka, who works on the Health and Human Services Pain Management Best Practices Inter- Agency Task Force, is hopeful. “I hope that we will see better coverage for massage therapy and other integrative services from Medicare and other insurers,” she says. “My work on the task force specifically called for increased availability and coverage for massage and other therapies, and we’ll be releasing our recommendations to Congress soon.”
Timing can also be an issue, according to Gazelka, as often massage therapy isn’t offered in conjunction with other medical care. “So, patients have to seek massage therapy out on their own,” she notes. For someone in chronic pain or with a condition that may be debilitating, like fibromyalgia, that can prove to be burdensome.
Medical providers also need to do a better job of telling patients about the benefits of massage therapy, Gazelka says. “Medical providers aren’t always educated on the potential benefits of massage therapy,” she adds, “and do not have the relationships with massage therapists necessary to make referrals.”
Related: Learn more about how massage therapy fits into integrative health care in "Integrative Health Care + Massage Therapy" from the Spring 2019 issue.
What can massage therapists do to help overcome some of these challenges? Both Bauer and Gazelka say that massage therapists are an important part of the patient’s care team. “They are vitally important to the patient’s pain control and well-being,” Gazelka says. Both also agree, however, that massage therapists need to regularly communicate with their client’s health care team. “Let them know what you are doing, what you are seeing and ask for feedback about anything that you can do to help the patient meet the care team’s goals,” encourages Bauer.
“An integrative approach for chronic pain across various disciplines, utilizing one or more treatment modalities, is encouraged when clinically indicated to improve outcomes,” Schoneboom says. “Communication of goals and response to treatment like massage therapy to the pain specialist is essential for an integrative approach to work.”
Success also depends on listening to the client. “There is no one-size-fits-all when it comes to treatment for managing chronic pain,” Steinberg explains. “It is therefore important for the therapist to listen closely to their client’s description of their pain and response to the techniques tried.”
Massage therapists should also manage client expectations about how much pain relief they might expect and how quickly they can expect those results. “What I typically tell people living with pain is if you can get a 10 percent to 20 percent reduction in your pain with a single treatment or activity limitation, and you find several treatments that give you this amount of relief, you can combine them and get a 40 percent to 50 percent reduction in your pain," Steinberg says. "A 50 percent reduction in pain may mean the difference between staying at home or being able to go out and enjoy an evening with friends."
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