Parameters of Pain
Relentless vs. "right now": sussing out the subtleties of chronic and acute pain.
In an ideal world, every client seeking pain relief would enter a massage therapy practice knowing exactly what caused their discomfort, when it started, where it lived on the body, and any associated medical information. More often, says Charleston, South Carolina-based massage therapist Wayne Hampleton, LMT, they come in saying, “My shoulder hurts.”
“Part of my job is to figure out the rest of the story,” he says.
Proper pain assessment is a vital yet challenging process that calls upon a therapist’s skills in listening, observation and massage technique. Among its most nuanced prospects: determining whether pain is acute or chronic in nature.
Defining Acute and Chronic Pain
Definitions of acute and chronic pain vary, but they are characterized generally according to source and duration. Acute pain usually stems from specific, identifiable causes (accidents or surgeries, for example) and lasts briefly—between seven and 30 days, according to The American Academy of Pain Medicine.
Chronic pain, on the other hand, lasts much longer (from months to years), and its causes are sometimes less clear-cut. Chronic pain can originate from disease, like lupus or muscular dystrophy; structural issues, such as posture; or environmental factors, like work-related overuse injuries. Some suffering from chronic pain know nothing at all about the cause of their discomfort.
Understanding the acute or chronic root of clients’ pain helps massage therapists plan sessions that will be most beneficial to the client. But even more to the point, this understanding keeps clients safe. “When a client comes in with an acute injury, the first thing I want to know is if they’ve been to see a doctor,” says Ben Brown, LMT, owner of New York-based business HND + TMPL Massage Therapy.
A doctor’s referral, in combination with any tests or X-rays, mitigates the risk of inflicting additional damage to unseen injuries. “If it’s an acute injury from a strenuous workout or an extra-heavy load of groceries, I wouldn’t necessarily need medical clearance,” Hampleton says. “But anytime there’s been an accident or neck injury or possible broken bone, they need to see a doctor.”
Questions, Clues and Queues
How does a massage therapist arrive at an accurate acute versus chronic assessment? Most start with a set of questions—a triage of inquiries ranging from the obvious (How long has the pain been going on? Where does it hurt? What does it feel like?) to the more subtle (What do you do for a living? How does the pain affect daily life? Does it come with any non-physical symptoms, such as depression or isolation?).
At his practice, Rhythm and Relaxation, Hampleton begins every session with three questions: Is the pain passive (does it hurt all the time, in other words, without a specific trigger)? Is there a specific movement that causes or exacerbates the pain? And, does it hurt to be touched? Passive pain often goes hand in hand with chronic pain, while pain that results from touch can indicate inflammation, a common partner of acute pain.
Brown likes to know what, if anything, a client does to cope with the pain. “Let’s say ice and rest provide relief, but the client finds they have to do it every day,” he says. “That tells me there either could be something more chronic and underlying going on, such as arthritis, or that the person is simply re-injuring themselves every time they return to work or the gym.”
With these responses in hand, a massage therapist can call upon other tools, including observation and massage itself, to develop a more accurate understanding of their client’s condition. “A person might come in saying they have sciatica [a chronic condition marked by a compressed nerve], but in initial sessions, they wince when I touch the piriformis muscle,” Brown says. “That indicates something different at play; something possibly more acute. An injury to the piriformis can mimic sciatica but is not the same thing.”
Here, again, it might make sense to refer a client to a physician before scheduling a massage appointment or beginning a massage session.
Hampleton performs similar verbal-to-physical benchmarking when clients complain of neck pain. “People often associate neck pain with a pulled muscle or awkward sleeping position,” he says. “But then I’ll do a gait assessment, and I’ll notice they have poor posture.”
Myofascial work is another great assessment tool. “My massage work always begins with myofascial because it gives me an opportunity to assess what’s going on through what I feel,” Hampleton says.
Massage techniques for pain. Once massage therapists are done with intake and assessments, they can use what they’ve learned to develop a massage treatment plan that’s tailored to their clients’ acute or chronic conditions. Following are a few techniques and strategies massage therapists said are at the top of their list when working with clients experiencing acute or chronic pain.
Massage + Acute Pain
Fewer sessions. Massage therapy for acute pain aims to facilitate short-term relief and—in that regard—is typically also short-term. “If something’s acute, it usually will resolve itself over one or two sessions,” Brown says.
Of course, there are exceptions. “When it comes to things like sports injuries, I’m going to take it slower with range-of-motion work and soft-tissue massage,” Hampleton says. “I want to avoid their going back out and re-injuring themselves the following day.”
Deep tissue massage. Deep-tissue massage can be the natural catalyst to acute pain’s short recovery periods. “Generally speaking, the more massage therapy a client can tolerate, the more it will expedite their healing process,” Hampleton says.
It’s a fine line, according to Brown. “I want to take it far enough to get quick relief—but not push it so far as to make it worse.”
Swedish massage. Hampleton finds petrissage and effleurage to be rock-solid and reliable in relieving acute pain. “Effleurage is one of the best means to get blood to different parts of the body,” he says. “It’s also one of the most comforting and soothing strokes in massage.”
Lymphatic facilitation. Lymphatic massage can be particularly effective in diminishing the excess fluid, dead cells and swelling that accompany post-surgical acute pain. “I’ve actually only used lymphatic facilitation on acute injuries,” Hampleton says.
Massage + Chronic Pain
Ongoing sessions. Chronic pain’s extended life span usually calls for an equally extended massage treatment plan. A chronic-pain client might see their massage therapist on a weekly basis for several months or several years, depending on their lifestyle and the issue at hand. The more willing a client is to invest in their health—whether it be with exercise, stretching, or nutrition—the sooner and more successful their outcome.
Mindful adjustments. This refers to musculoskeletal corrections a client must consciously make in order to avoid repeat injury. They are most relevant to environmental situations, like work. “If you work in construction, you’re not going to stop hammering; hammering is what you do,” Brown says. “What we can do instead is focus on strengthening exercises, and the way you hold the hammer.”
Hampleton has personal experience with mindful adjustment. “I used to have a really bad curve in my lower back when I was younger, until after years of consciously lifting out my chin and chest, I was able to correct it,” he says.
Trigger point therapy. Brown and Hampleton use trigger point therapy in both chronic and acute applications, but they find it especially useful with chronic conditions like joint pain. “It breaks up the little knots and adhesions that form over time in the muscle fibers,” Brown says. “It creates more ‘space’ around the joints so that everything feels better and moves better.”
Cross fiber therapy. Similar to trigger point therapy in its aim but different in its technique, cross fiber therapy uses transverse friction to relieve excessive tension and soreness that accumulate in muscles over time. “The muscles get locked up in this negative cycle where they grow increasingly tight and sensitive,” Hampleton says. “I use cross fiber therapy all the time for chronic tension in the lower back.”
Lifestyle changes. Clients’ lifestyles—and their willingness to adapt and maintain them—can be the single biggest influence on a massage treatment plan’s duration and effectiveness. Hampleton shares an example of two clients with identical chronic conditions (degenerative disc disease) but vastly different lifestyles (one physically active and one not).
Hampleton achieved a decreased level of pain with the non-active client and continues seeing her once a month. The active client was able to completely eliminate her pain in six months and has not returned to the massage studio since.
Chronic and acute pain can be difficult to assess and manage, but its challenges are also what make it interesting. “Massage is fluid and its applications are going to evolve in both cases,” Brown says. “In the end, it’s a matter of listening to what your clients are saying and having enough techniques in your skill set to be able to adapt to what’s happening.”