Bodywork Treatment for Chronic Pain – how to get the best from your treatment…

I decided to write this blog as I realized I should develop an advice sheet for clients with chronic pain including things they would find helpful to learn (or accept), and lifestyle advice which will help them optimize their recovery from chronic pain/illness. There are things the client can do before, during & after treatment, and in their day to day lives, which will increase any therapy benefit, so aiding their recovery. The following advice is also indicated for suffers of chronic illnesses, autoimmune disorders, stress related health problems, headache/migraine and chronic fatigue syndrome.

What Causes Chronic Soft Tissue Pathology (i.e. chronic pain)?

As you can probably imagine, this is not a straightforward question, with one simple, straightforward answer. There are, of course, many varied causes of chronic pain in humans. Some may be obvious to us (including the causes of our own pain condition/s) such as traumatic injury. Others may be less obvious, or we may not yet have comprehended that our pain has different diverse causes (including emotional/psychological factors). The mind-body link is very relevant when it comes to chronic pain (& health) conditions; negative feelings, stress, and trauma often, over time, manifest as soft-tissue (myofascial) pain.

A good way to identify factors which can cause soft-tissue pain/pathology is to consider it can be ‘anything which is bad for you’. Its important to note that this does not does not just apply to things which are bad for the body (e.g. junk food, poor posture) but also things which are bad for the mind & spirit (e.g. trauma, stress, negative emotions). Everything which is bad for the body, mind and spirit can cause soft tissue pathology in the form of painful trigger points, myofascial adhesion’s and muscular spasm. Scar tissue can also dehydrate, tighten and adhere over time; an old injury or operation might be far more problematic years after its occurrence for this reason! Doing what we can to reduce the contributing factors of our pain is a gift we can give ourselves; it will also benefit our general well-being, and can make our therapists job easier!

How to Limit the Development/Deterioration of Soft Tissue Pathology (ie. trigger points, myofascial adhesion’s, muscle spasm)

So, to establish what might contribute to our pain, we would be wise to consider factors which are bad for our body, mind and spirit, and how we can omit these, or reduce their impact. Its important to highlight at this point that we must ‘go easy on ourselves’! Many of the causes of our pain might be unavoidable and/or not be our fault; avoiding them entirely might also not be practical, possible or desirable. For example, if we are depressed then socialising might be too much. This is ok, just do what you are able at this time. It may also not be easy, or possible, for you to simply ‘drop’ harmful negative emotions, or forgive those who wronged/abused you. This is again ok, I am not telling you how you should feel or who/when you should forgive, just making you aware of factors which can manifest as chronic pain. Trauma can play a big part in chronic pain so having a psychotherapist or trauma healer (i.e Somatic Experiencing) help us process this (and any related guilt/resentment) can be cathartic, if required. We also can’t help suffering with mental illness, though we may of course be able to do more to help ourselves (and related pain/symptoms). Fears and insecurities are also part of being human; the fast paced nature/pressures of the modern world are also somewhat outside of our control – we need to cut ourselves some slack . Progress, not perfection, is the aim!

Factors which may contribute to chronic pain/illness:

Dehydration – drink more water/fluids & less caffeine/alcohol.

Stress – learn a relaxation technique, meditate, take time out for yourself, get into nature (i.e. a walk), work less.

Alcohol, drugs, smoking – Quit drinking (or drink less). Quit drugs & smoking. Pursue alternative pastimes. Work a 12 step program and/or indicated cognitive behavioral therapy (CBT).

Isolation/loneliness – Arrange to see friends. Get a (sociable) hobby. Accept help from individuals, groups and agencies. Accept invitations to social events.

Poor posture – Do rehab to correct posture. Stretch tight areas. Learn Alexander Technique. Correct your posture when working/sitting/walking.

The pain/stress of active addiction – Face your denial & confront your addiction. Use a 12 step program and/or CBT to address your addiction. Accept help, attend support groups.

Overwork – Stick up for yourself (i.e to Manager/HR): refuse to work over whats reasonable . Change jobs. Delegate, even when you don’t want to.

Trauma – Get psychotherapy. Read indicated books. Use help groups (inc. online). Do trauma healing.

Injuries – Do your rehab (see rehab PT, Physio, Sports Therapist), stretch injured areas, rest injury if required. Google rehab exercises on YouTube.

Rushing through life – Remind yourself to ‘slow it down’. Take your time, settle down and ‘reground’ yourself as required. Take some deep breaths, or a time out.

Disease/illness – Follow your doctors/therapists advise. Change your diet if indicated. Rest when required. Take medication if helpful/essential.

Hypermobility/being too flexible – Do Pilates/core strengthening. Strengthen muscles supporting painful joints (i.e rehab). Don’t overstretch, or do too much Yoga.

Stiffness/lack of flexibility – Stretch daily, especially tight areas. Do a regular Yoga class. Warm up before & stretch after physical activity/exercise. Google YouTube exercises to help tight areas.

Hate/resentment (i.e. People, family, circumstances, past events, institutions, employers) – Consider if forgiveness and/or reconcile are possible. Can you ‘let this go’? Be mindful of this feeling. Get therapy.

Repetitive Strain (on muscles/tendons) – Have ‘recovery days’ between ‘sport days’ (i.e. don’t do the same sport/run day after day). Do the aggrivating activities less often, or for shorter times. Talk with your employer about reducing/mitigating aggrivating activity.

Sedentary lifestyle/lack of movement – Go for a walk each day. Do a sport you enjoy 3 x week. Get up and move about regularly. Learn & practice Tai Chi.

Poor diet – Avoid junk food. Eat more fruit, veg and pulses . Take a quality multi. Avoid unhealthy snacks. Cut down on processed food and sugar.

Fixated/stiff joints – Do a regular Yoga class and/or Shiatsu/Thai Massage treatment. See a good Osteopath or Chiropractor, to have this addressed.

Psychological incongruence – Be our ‘true self’ (i.e. don’t try to be someone we are not). Behave the way we feel we should. Follow our own morals and principles.

Scar tissue – Stretch and move the area. Apply indicated oils & balms. Get myofascial treatment. Strengthen affected/antagonistic muscles, if indicated. Stay hydrated. Consider scar tissue problems when doing cost-benefit analysis of potential operations.

Being overweight – Look to change your lifestyle, rather than unsustainable/fad diets. Eat less unhealthy snacks. Reduce portion sizes and alcohol intake. Explore your reasons for overeating with a psychologist.

Guilt/shame/regret – Learn to forgive yourself. Accept we cannot change the past (but can improve the future). Make amends with those you have wronged. Get therapy.

Family ‘stress’ – Make sure you have ‘me time’, away from your family. Do not take on their problems as your own (i.e. if they are adults). Practice mindfullness. Learn to say no. Try not to ‘enable’ their poor/selfish behaviour.

Lack of exercise/unfitness – Commit to exercise 3 x week. Go for walks and avoid using the car/lifts/escalators, if possible. Find active pastimes you enjoy.

Mental health problems – Study and implement indicated CBT. Learn mindfulness. Explore different types of psychotherapy. Accept medical help/medication if indicated.

Lack of strength – Do a regular Pilates class. Get a strength and conditioning PT, or join a gym and get a bespoke strength program from the PT’s. Google YouTube workouts.

Taking on too much – Learn to say no. Try not to ‘live for others’. Try to make sure family/colleagues/friends do their fair share (and if they don’t, don’t do it for them).

Fears & insecurities – Try to identify, understand and accept our fears and insecurities. Use CBT and psychotherapy to explore these, and reduce them (if possible).

Go through the above list and consider which apply to you, and how you might reduce them, or mitigate their impact on your health/pain. This is, of course, easier said than done. We must show ourselves kindness and accept that we are human and being ‘perfect’ is unrealistic; perhaps pick 2-3 key issues to work on? After all, having overly high expectations of ourselves we cannot live up to will also cause us spiritual pain, which may manifest as physical pain.

‘Feeling’ your Pain & Experiencing your Uncomfortable Feelings/Emotions

As humans we are hardwired to avoid unpleasant things. Often this is to our advantage; taking our hand off a hot plate to avoid burning ourselves, for example. However, it is becoming increasing clear in the fields of psychology & bodywork that this natural self-protection strategy can backfire, causing us emotional discomfort and even physical pain. What has been accepted in Buddhism & Asian culture for centuries is now gaining understanding and acceptance in the West through the study and promotion of mindfulness and mindfulness based stress reduction (MBSR). Anyone suffering chronic pain (or chronic ill health) would be wise to read about mindfulness, take a course and practice regular mindfulness-meditations!

Those of us in chronic pain need to learn to really ‘feel’ & accept our physical pain, to pay attention to its quality & sensations. Trying to ‘shut the door on it’ mentally doesn’t work, we must be open to it, and any painful related connotations. To do this we ideally need a mindfulness teacher, though much can be learnt from a good book. We also need to learn to let in our emotional/spiritual pain, and unpleasant feelings, not (mentally) run from it. Trying to hide from our pain can make us spiritually unwell, and can cause it to manifest in our soft-tissues (i.e. muscles, tendons, ligaments, FASCIA) as physical pain/tension! We need to learn to ‘lay out the welcome mat’ for emotions and feelings we find uncomfortable, and to sit with them, experiencing them viscerally. This can help our soft-tissues to heal, letting go of pain, tension and trauma locked within them (i.e. due to us trying to hide from our emotions, feelings & ‘spiritual pain’).

Exercise and Stretching for Chronic Pain

Your massage/bodywork therapist can only do ‘half the job’ when it comes to the treatment of soft tissue pain & injury, the rest is up to you. We cannot stabilize your core, ensure your muscles/fascia are stretched and moved daily, improve your lifestyle, strengthen your weak muscles, or exercise on your behalf. Although there is much a good bodyworker can do, which the individual (or medical staff) cannot, the important aforementioned points can only be done by you! Its important you find the motivation to do these things, put in the effort and find the time. Again, we are looking for progress not perfection, but help us help you, and take some personal responsibility for your recovery from pain or injury (its not only your therapist’s job to treat your pain, you need to help yourself!).

Part of taking responsibility for your recovery from pain might be finding and attending a regular exercise class, or joining (and attending) a gym. If you are hypermobile (i.e. very flexible), or get back pain, I recommend you attend a Pilates class. People that are stiff and/or have joint issues would be wise to find a suitable Yoga class; Hatha/relaxing Yoga may also be a good fit for stressed/overworked individuals. If you suffer with fibromyalgia/CFS/long-COVID then a Tai Chi class might be just what you need, or a specialist (i.e. low intensity) Yoga class. I don’t recommend Yoga if you are flexible/hypermobile, at least ensure you don’t do it too often, or engage in strong/prolonged stretching on muscles which are not tight. If you are weak/frail then you need a strength & conditioning personal trainer, physio, or sports therapist (or ask your gym PT’s to develop an exercise plan). Take the time to learn how to stretch your tight muscles, or painful areas, ensuring you do this after physical activity & work (if it tightens them). Another important habit to develop, to reduce myofascial pain, is to ‘move’ your body regularly! Take your limbs, joints, head & neck through their range of movements regularly – this will help keep the fascia supple and stop it sticking – so less pain!

Frequency of Treatment & Committing to the Initial Course

Frequency of treatment is a very important factor concerning how much benefit you get from treatment. I know your commitments, modern life and your therapists diary being booked up can all make getting your regular treatment challenging. Also, for many people, cost can also be an issue (especially at the initial stage when regular treatment 1-2 times per week is required). However, this is important and needs to be a priority for your time and your money! Your health, being relatively pain free and having a body which functions well are all very important (not just for you but also for your work, family and friends). If this means rearranging/adapting social commitments, childcare, work (a good boss/manager should see that having you functioning, and in less pain, will also benefit them) or skipping a hobby/sport/exercise session, then so be it. I appreciate this can’t always be done, but if it can, prioritize your treatment!

When you start your treatment, you are going to need to commit to (at least) weekly sessions. For acute conditions, recent injuries and more severe ailments (i.e. which deteriorate quickly) you may need treatment twice a week to begin with (with at least 2 days between treatments, for your body to process-recover). Progress will be allot slower (so treatment cost allot more), if you have sporadic treatments, here & there, to ‘fit in with your busy life’. The reason progress will be slower (or you may not even improve, in this instance) is that you will be allowing time to deteriorate again, between treatments. For progress to be steady/continuous you need to be having your next treatment BEFORE you start to substantially deteriorate again, otherwise your progress will go up and down. This means, at least weekly treatment, until you have significant improvement, is essential! If you need to, book a few in to get your desired time (you can always cancel them nearer the time, if you don’t need them/can’t attend). Further down the line you can of course space these treatments out more (i.e. fortnightly > 3 weekly > monthly) and maintenance treatments are recommended every 1-2 months, for most chronic pain issues; follow your therapists advice though!

Before Treatment – advice

The treatment should still be beneficial regardless of what your up to beforehand. However there are a few do’s & don’t’s which can put you in a better place for bodywork treatment, and/or improve the outcome:

Recommended:

Try to relax – Take it easy and chill before a treatment (if possible). Perhaps meditate if you have time?

Leave extra time to get to your appointment – you wont be centered or relaxed if you are rushing, or late for your appointment.

Have a wee – its better if you are relaxed during treatment, not needing a wee aids this (plus might avoid the disruption of you needing to use the loo during treatment).

Turn off your phone – Your phone can disrupt you and your therapists relaxation & concentration. Even if you don’t answer it, you might fret of who and why someone called.

Avoid taking painkillers & antiinflamatories for 4 hours prior to treatment – Its best not to have your pain sense dulled for treatment. Also the drugs may affect your healing reactions to treatment.

Have a hot bath* – To relax muscles and warm/hydrate fascia. *Avoid if you have a recent injury, acute pain or inflamed body part/s.

Not-recommended:

Drink alcohol or coffee – being under the influence of alcohol or drugs contraindicates treatment. Too much caffeine will also overstimulate you – not good for treatment.

Have a big/heavy meal – Its better your not overly full; best to leave an hour post eating before treatment.

Do really heavy exercise – Light exercise shouldn’t be a problem, but its usually better you haven’t done ‘hardcore exercise’ before treatment (unless having post-event sports massage).

Do very stressful work – Not always possible, but its better if you arrive relaxed and not under too much pressure/stress.

During Treatment – advice

Firstly, its important to say that this is YOUR treatment, so how you chose to enjoy it and IF you choose to follow any of the following tips is your call! Don’t feel you should or shouldn’t be a certain way, feel a certain way, or react a certain way; there are no expectations on you. However, you may find the following advice helpful:

Try to let the therapist take the weight of your limbs/head – relaxing the head and limbs (unless instructed otherwise) can help the therapist release your tissues better.

Tell your therapist if something is too uncomfortable/painful – We want to avoid anything over a 6/10 (i.e. pain scale), so you don’t tense against challenging work.

If you don’t want a specific area worked, do say – Even if not painful/rational; emotional stuff can get held in the tissues, you may not be ready to have it released yet – that’s fine.

Try to ‘relax into’ any discomfort – If you find any massage work uncomfortable (e.g. trigger points, deep frictioning, direct myofascial work) try taking in slow deep breaths, then letting go of tension as you breathe out.

Try to relax your body and mind – Let your muscles soften and your mind calm – try not to ruminate on life’s worries for this short, precious time.

If you need to make a noise, cough, laugh, fart, cry or move; do so – Its important you are comfortable during treatment, your body may also need to do certain things to help ‘release’ emotions or body tissue. Trust your instinct & body.

Try to stay present, in the body (For myofascial work [slow, focused work, without oil] or trigger point therapy [treating the painful points which cause pain]) – Try not to ‘dissociate’ with whats going on. It can be helpful to try and stay with the experience, in the moment, feeling what the therapist is doing to your body tissues. This is not essential, if it doesn’t suit you.

Don’t feel you have to chat to your therapist – You are of course welcome to chat, but if you need some quiet time then that’s fine, its your time.

Ask if you need extra towels, bolsters, or a change of position – Your comfort is paramount so ask if you need something – we are also trained to treat clients in a variety of positions, so we can probably amend your position if required.

After Treatment – advice

The following advise is for immediately after treatment, and for the following 48 hours:

Drink plenty of water after a treatment – To help rid the body of toxins released and also to re-hydrate the muscles & fascia (connective tissue).

If possible rest & relax after treatment – To allow your body time to process & recover. Avoid work, exertion and stressful situations (as much as possible) for 2-3 hours; take a nap if your body wants this.

Avoid strenuous exercise for 24 hours after treatment – Also avoid heavy exercise involving any specific problem areas/injuries worked for 48 hours after treatment.

Do not apply heat to the area worked (or have a hot bath/sauna) for 24 hours after treatment, longer if treated areas are sore/tender. Apply an ice pack or cold peas (wrapped in a tea towel) for 15-20 minutes to sore/tender areas.

If possible, do not drive straight after treatment (esp. if lightheaded) – Wait for a quarter of an hour or so until you are fully alert, keep a car window open and drive slow/with care.

Avoid alcohol, recreational drugs, excessive caffeine for the rest of the day – Unless you are dependent and avoiding them will cause you withdrawal symptoms.

Do not eat straight after treatment – Make your next meal light and nourishing.

Contra-actions:

Although most reactions to receiving massage/bodywork are positive, some people may suffer temporary odd, or negative effect/s in the 48 hours following a treatment. These may include headaches, soreness, symptoms of illness, lightheadedness, feeling ‘wiped out’ or unusual moods/emotions. You may notice other effects, such as increased urination/perspiration, feeling hot, vivid dreams, fatigue or altered sleep. These reactions are usually a sign that the treatment was much needed, and are due to the detoxification process, your body processing the treatment and beginning to heal & re-balance.

Firmer massage & myofascial work can also cause localized tissue inflammation (causing local heat & discomfort, often the following day) and even sometimes mild bruising. If you have tissue soreness, apply an ice-pack to the affected areas regularly (you can also use anti-inflammatory’s such as ibuprofen gel [consult a pharmacist], or supplements such as devils claw or turmeric) to calm tissue inflammation. Rest and protect any reactive areas and contact your therapist if the reaction is overly sore, or lasts over 48 hours.

There is much we can do to help ourselves, and improve the outcome of our therapists bodywork. Anything we can do to bring the body and mind back into balance may help our pain and/or illness. Making peace with ourselves, our pain and our uncomfortable emotions may really help make the difference in our healing journey.

Recommended further reading:

Tai Chi for Beginners & the 24 forms: Dr Paul Lam (+ DVD Tai Chi for Arthritis & Fall Prevention)

Yoga for Chronic Pain – 7 steps to aid recovery from fibromyalgia with Yoga: Kayla Kurin

The Trigger Point Therapy Workbook – your self treatment guide for pain relief: Clair Davies

The Anatomy of Stretching – your illustrated guide to flexibility and injury rehabilitation: Brad Walker

Adrenal Fatigue – the 21st century stress syndrome: James L. Wilson

Myofascial Release – healing ancient wounds: John Barnes

Fascial Fitness – practical exercises to stay flexible, active & pain free: Robert Schleip

The Body Remembers – the psychophysiology of trauma and trauma treatment: Babette Rothschild

Waking the Tiger – healing trauma: Peter Levine

Overcoming Chronic Pain – a self help guide to using cognitive behavioral therapy: Dr Francis Cole

The Mindbody Prescription – healing the body, healing the pain: John E. Sarno

Mindfulness for Health – a practical guide to relieving pain, reducing stress & improving well being: Vidyamala Burch (+ audio meditation CD)

Seven Minutes to a Pain Free Back – Yoga and Pilates to ease back pain, strengthen your core & improve your posture: Melinda Wright

Why Conventional Medicine will always fall short in the treatment of chronic pain

Firstly, its important to note that most chronic pain (long term, dull, achy) is soft-tissue (muscle, tendon, ligament & fascia pathology) in origin. It is estimated 75-95% of regional (chronic) pain is myofascial (muscle and/or fascia pathology). Furthermore, most soft-tissue pathology does not show up on medical scanning techniques (x-ray, MRI, ultrasound etc) or blood tests, meaning medical investigation may not reveal the ’cause’ of your pain.

Chronic Pain is a health problem, so your doctor or the NHS is the place to go to get your pain (musculoskeletal issue) treated, right? If your really lucky you will be referred to a pain consultant, neurologist, or rheumatologist who can diagnose and fix your problem, sorted! After all, no one could be better qualified to treat chronic pain than a highly intelligent, top medic who has spent 10 years studying evidence based medicine (and 5 further years specializing), can they? Besides, even if you don’t get a consultant referral, an NHS physio should be able to sort you out with some decent treatment, no?

If you have ever suffered with chronic pain and gone the conventional medicine/NHS route you are likely to have found yourself somewhat frustrated and disappointed with your treatment options. What use is a diagnosis if your still stuck with the pain, or just ‘dosed up’ on painkillers? But why is this? With all the science, money, specialist consultants, physios and specialist equipment, why does conventional medicine still struggle so much in the effective treatment of chronic pain? In this blog I aim to discuss some of the main reasons I feel conventional medicine falls short, and will continue to do so, unless it integrates specialist ‘hands on’ practitioners into the NHS.

Perhaps the most important point is that most chronic pain is ‘soft tissue pain’. Interestingly, no medical specialty covers ‘soft-tissues/muscles’. We have neurologists, rheumatologists, orthopaedic surgeons etc, but no ‘musclologists’! Soft tissue pain, of course, requires soft-tissue treatment… MASSAGE! Massage (& Bodywork) Therapy are not part of conventional medicines remit. Therefore, if you are going to a ‘Pain Consultant’ with chronic, soft tissue pain, they are unlikely to be highly trained in the specialist massage and myofascial treatment required to effectively address your pain! Even, by some miracle, if the consultant is a highly skilled soft-tissue therapist (ie. Level 5+ qualified, including extensive trigger point therapy & myofascial release training) they would not be able to book you in for a 1 hour treatment on the 4-8 consecutive weeks required to address soft-tissue pain (neither can your GP, in a 10-12 minute appointment slot). You get your half hour, a prescription, possibly booked in for a ‘pain treatment procedure’, or referral to a physio. So, why can’t the physio just do the required specialist hands-on treatment to address your pain?

Contrary to popular belief, most physios are not experts on ‘hands on’ treatment (esp NHS/junior physios) . Generally physios are experts on rehabilitation (teaching you exercises/stretches to help your body heal & repair). Their degrees are packed full of information on anatomy, pathology, theory, electrotherapy, exercise, diagnostics, and neurological/respiratory/injury/surgery rehab; there is very little time left for ‘hands on’ interventions (I have been told many modern physio degrees don’t even include massage training). More and more, physiotherapy is moving away from ‘hands on’ treatment, and focusing on motivating the patient to help themselves with rehab. This is a noble aim, and important, but most soft tissue pain also requires decent soft tissue (massage/myofascial) treatment, at least until the stage your pain is reduced enough to effectively do your rehab. Few physios have high level massage & bodywork skills, most of their massage training is also taught by physios who may also lack massage/bodywork expertise. To give physios a sound knowledge of massage/bodywork treatment university’s would have to add (at least) a year to their degree courses, or cut a massive amount of their current syllabus to make way for this training; neither is going to happen! To get specialist soft-tissue treatment you need to go elsewhere, or find a physio who has extensively trained in specialist massage & bodywork before, or after, their physio degree.

So what about the specialist procedures, injections and operations the doctors employ, to treat chronic pain conditions? Unfortunately, most of these options do not actually treat the soft-tissues of the body. The aim is usually to reduce the symptom (pain sensation, or inflammation), as with painkillers, not actually address the cause of the pain (eg. soft-tissue pathology, musculoskeletal problems). They can help relieve the pain (often they don’t) but they may not treat the causative problem; often the relief is also short-lived or not acceptably substantial. Another point to consider is that chronic pain conditions are complex and multi-faceted. Medical pain treatment procedures usually target 1 part of the chronic pain picture, looking for the single ‘silver bullet’ to fix the issue. Unfortunately, a course of treatment is usually what the body really needs; holistic (complementary medicine) treatment does this while attempting to address all aspects of the chronic pain picture. I will give an example to highlight my point:

Facet joint injections for lower back pain

A common, conventional treatment for lower back pain is facet joint injections. These aim to reduce pain and inflammation in the compressed/irritated lumbar facet joints to reduce back pain. But what aspects does the conventional medicine treatment fail to address:

  • Muscle imbalances which have caused the facets to become compressed by hyperlordosis. A massage therapist would lengthen hypertonic muscles/fascia to reduce facet compression.
  • Painful trigger points causing dull-achy pain. Trigger point therapy (massage) would address these to reduce chronic myofacial pain.
  • Restricted fascia around the back/pelvis. Myofascial treatment could release this easing pain/stiffness, and correcting aggravating structural misalignment.
  • Fixated (stuck) facet joints. Mobilization and/or manipulation could free up painful stuck facets, restoring lumbar biomechanics.
  • Muscle spasm and fascial tension. Massage and myofascial treatment can be used to address spasm and tension which may be contributing to chronic pain.
  • Visceral restrictions around the abdominal organs which refer to the lower back, or cause related muscular spasm.

As you can see from my example, chronic pain is not simply the ‘one thing’ which medical procedures often aim to address. Many of the aspects which need treating, also need ‘hands-on’ interventions outside of the remit of doctors (and many physios). If you need/want medication, injections, rehabilitation or surgical intervention conventional medicine can cater for you well, however for specialist hands-on intervention for pain/injury it falls well short.

So the solution is simple then, conventional medicine/NHS just needs to employ Massage/Bodyworkers to address chronic soft-tissue pain, and Osteopaths/Chiropractors to address neurological & joint pain. If only, but where is all the extra money going to come from to pay for 1000’s of extra NHS staff, when the NHS is already understaffed, underfunded and overstretched; higher taxes? Surely all the hospitals, community hospitals and larger GP surgeries could employ Massage Therapists & Osteopaths instead of Physiotherapists, to get better results in treating chronic pain? Not really, they (rightly) cannot ‘fire’ current physios to make way for complementary therapists, without good cause. Also, if NHS institutions started to hire non-medically trained (ie. unqualified) Massage Therapists & Osteopaths, instead of physios, the physios (& CSP) would be up in arms… “their taking our jobs, and there aren’t enough jobs to go around as it is!” Therefore, even if NHS institutions had the foresight to employ a percentage of complementary ‘hands-on’ therapists, instead of physios (for chronic pain treatment), it would not be easy to implement (and NHS budgets may not allow non-physio employment).

In 2009 NICE decided the evidence for massage, osteopathy, chiropractic and acupuncture was good enough with back and neck pain, to allow NHS funding for these treatments through the Any Qualified Provider (AQP) route. Many complementary therapists (and patients) were excited, hoping that ‘at last’ patients could easily get decent hands-on treatment for chronic pain, on the NHS (as an alternative to Physiotherapy). Unfortunately bureaucracy & regulation put many obstacles in the way of this happening. NHS Clinical commissioning groups (CCG’s) were only looking for large-scale musculoskeletal practices in their area, which tended to be the bigger private physio clinics (all but 3 AQP contracts in Hampshire were physio clinics). Most of the Massage & Bodywork Therapists (soft-tissue specialists) best qualified to address chronic (soft-tissue) pain were one man bands, who had no chance of securing a contract. Further to this, clinics who tendered for the AQP contracts had to to undertake unnecessary, costly and time consuming training, deal with endles ‘red-tape’ and prove their treatment effectiveness through statistical data (which most therapists don’t have). This took months of work and many great therapists were either too small to apply for AQP, could not meet the required criteria, or decided it wasn’t worth the hassle! It’s turns out the ‘Any’ in Any Qualified Provider was far from literal, and most complementary therapy providers could not get NHS funding! NHS funding of soft-tissue specialists therefore remain a rarity.

This last point I wish to address in this blog, which deserves a blog all of its own, is if Massage & Bodywork is so ‘amazing’ at treating chronic soft-tissue pain, surely the scientific evidence would reflect this? Well no, sadly not! Why is this? Its quite simple really; there is no money to be made in proving massage is highly effective in treating chronic pain. This is because there is no ‘product’ to sell at the end of the study (eg. drug, biomedical technology, retail product). If your going to invest £10million in a good quality, large scale randomized controlled trial (RCT) you have to be pretty sure your going to make at least £20million back! Most massage schools, therapy teachers and (massage/bodywork) professional bodies are not valued at the cost of one, good quality study. Good quality scientific evidence remains the privilege of pharmaceutical giants, biomedical companies, multinationals and governments, ‘you get what you pay for’. Conventional medicine is ‘evidence based’ so makes it treatment decisions based on the best evidence, pay-rolled by big business. Doctors are not about to prioritise hands on treatment (with sketchy evidence) they cannot do, over proven drugs, biomedical procedures and operations within their remit!

In summary, the majority of chronic pain is soft-tissue in origin. The best people to treat chronic soft-tissue pain are not, in fact, the doctors and physios who treat it in a conventional medicine/NHS setting. Soft tissue pain requires specialist ‘hands-on’ soft tissue treatment by Massage & Bodywork Therapists, this is rarely available with NHS funding, and most NHS physios have little quality training in this area. Drugs, injections & biomedical procedures tend to focus on treating the symptoms, not cause of chronic pain; they also only tend to deal with ‘one part’ of a multi-faceted problem. It is unlikely the NHS will ever be able to employ/fund the required numbers of Massage Therapists (or Osteopaths/Chiropractors for neurological pain) to effectively treat a large proportion of the UK population in pain. Radical improvement in chronic pain results are possible in the NHS, but only if it employs large numbers of (non-medically trained) ‘hands-on’ specialists who do what the drugs, medical devices, doctors and physios cannot, and this, for now, seems an unlikely scenario.

Should I get an MRI scan for my back or neck pain?

This is a question I get asked quite often in my clinic and not one with a simple, quick answer, so I used it as inspiration to get my blog started. The answer depends on a number of factors, of course, and while there is no doubt that there is much you can see with an MRI scan that you cannot with the naked eye (or x-ray), there is also much you can ‘feel’ (through palpation), which you cannot see with an MRI! It’s important to note here that your GP or consultant is unlikely to have the refined soft-tissue palpation skills required to feel smaller myofascial/scar tissue adhesion’s, trigger points and subtle soft tissue pathology. To be an expert at assessing these you need to be a soft-tissue (massage/bodywork) specialist, with advanced training in trigger point therapy and myofascial release.

Other, common, ‘pain-causing’ musculoskeletal issues, which don’t generally show up on an MRI scan, are better assessed by case history, orthopedic testing and movement observation (eg. fixated joints, muscle imbalances, facet joint irritation); an Osteopath, chiropractor or Physiotherapist can better assess these than an MRI. So, MRI’s are great for identifying disc & vertebral pathology, bone spurs, narrow spinal foramen etc, but what CAN’T they see?

Pain causing musculoskeletal issues, which are unlikely to show up on an MRI scan:

  • Myofascial trigger points
  • Myofascial tension or adhesions
  • Smaller scar tissue adhesions
  • Muscle imbalences
  • Muscular hypertonicity or acute spasm
  • Fixated facets, costovertebral and sacroileac joints.
  • Facet joint irritation

…the majority of chronic (long-standing) back pain, would in fact be due to a combination of the above musculoskeletal issues, all of which would probably not show up on an MRI! So if they don’t show up the majority of pain causing back/neck issues, why have one?

Factors to consider:

Type, severity and length of pain

Dull-achey pain tends to be muscular or myofascial (soft-tissue) in origin. Not only will the likely causes of this not show up on an MRI scan, but also conventional medicine has little to offer in regards of effective treatment of soft-tissue pain (painkilling drugs to mask symptoms, ineffective injections, poor NHS access to specialist massage/bodywork treatment, & surgery not indicated). If the pain is mild to moderate, and dull-achey, I would therefore advise that there is little point in having an MRI scan. If the dull-achey pain is severe, especially if long lasting (over 1 year) it may then be worth having an MRI to see if it can shed any light on your pain, which assessment and palpation cannot. Extreme lower back stiffness and difficulty bending forwards or standing up can also indicate disc issues, so this further indicates an MRI, even with dull-achey pain.

The type of pain MRI scans are far more useful (indicated) for is neuralogical, ‘nerve root’ (or severe pain). This type of pain tends to be more acute, sharper and ‘stabbing’. Numbness, burning, electric/pins and needles indicate nerve pain and an MRI can identify causes such as disk pathology, bone or cartilage impinging nerves, larger scar tissue issues and spinal pathologies. If you have moderate to severe nerve-type neck/back pain then I would say an MRI scan would be wise. If the pain is very severe and disabling you then it might be prudent to get an MRI regardless of ‘pain type’. However, if your back/neck pain is due to an injury, an MRI is not indicated unless the severe pain persists past 2-3 months as the severe pain is likely to be due to the tissue not yet having healed fully (& resultant inflammation/muscle spasm pain).

Cost of an MRI scan

MRI scans are expensive (£200 > £700, average £350), so ‘is it worth it?’ is an important consideration, less so if the NHS or your health insurance is footing the bill. Can you afford this expense? Even if you can, you could get 7-10 treatments for this price, which might do your back/neck allot of good, perhaps fix it! If you are hoping to get an NHS referral for an MRI scan, you should also be aware your GP can no longer refer you directly for this (to save the expense of unnecessary MRI’s). GP’s have to first refer you to a consultant, it it their decision whether an MRI is an appropriate scanning technique for your back/neck. You may also be required to try a course (possibly 6 appointments?) with an NHS Physio, to try and ease/resolve your back/neck pain before they refer you to a consultant. Most of my patients report this does not help their symptoms much, but either way you will have a delay while you wait for a consultant appointment and/or have your course of physio (perhaps 2-4 months?). Going private skips much of the delay, but it will cost you! Other points to consider regarding funding a private MRI:

  • Will you be gutted if they find nothing? If the MRI scan does not find the ’cause’ of your pain, will you be upset, feel like a fraud? Maybe not, now you know many issues which cause back pain wont show up on MRI.
  • Will you be in the same situation as before? So finally you have your coveted diagnosis, so the doctor can fix it, right? It may well be your treatment options are similar to before, are undesirable to you, or non-NHS ‘hands on’ treatment is more effective at bringing relief.

Is the MRI discovered pathology ‘really’ the cause of my pain?

Is what they find the ‘real’ cause of your pain? MRI scans will probably find something, and one of the problems with medical scans is it can be assumed the ‘found’ issue is the cause of your back pain! But what about all the other causes of back pain the MRI cant see which we discussed earlier?

Studies on asymptomatic individuals (people without back pain) have shown high levels of disc bulges and spinal degeneration, as discussed in the following studies:

Magnetic resonance imaging of the lumbar spine in people without back pain

Systematic Literature Review of Imaging Features of Spinal Degeneration in Asymptomatic Populations

This means the pathology/s the MRI finds may not be the cause of your pain, but will likely be assumed as the cause, and pursued medically. An important point to note here, however, is that if your pain is obviously neorological (eg. true sciatica), and the MRI finds something pushing on the nerve corresponding with your pain pattern, it is pretty damn likely to be the main cause of your pain! Dull-achey pain is more likely to be due to musculoskeletal issues which wont show up on an MRI scan. Also, the vast majority of back pain (even neurological/disc) is due to a combination of musculoskeletal issues (9/10 times), not just the ‘1 pathology’ (eg. disc bulge, bone spur, facet joint) conventional medicine aims to identify & treat.

Likely outcome regarding treatment

Before you see your GP about back/neck pain, see a pain/orthopedic consultant or have an MRI scan, consider what treatment conventional medicine has to ‘fix’ your pain. Conventional medicine for musculoskeletal issues/pain is generally based on medication, operations, therapeutic injections and rehabilitation exercise (Physio). If these treatment options don’t seem appealing, or have proven ineffective in the past, then you really should go elsewhere for treatment as this is whats on offer! Just because the MRI has shown up something, and/or you have a diagnosis, does not mean they can fix you in other, non-medical ways…

You could be offered painkillers, anti-inflammatorys or other pain relieving medication (you don’t want long term pain medication). You might be offered a course of Physio (you tried this and it didn’t help much). You might be offered an operation (you don’t want risky, invasive, spinal surgery). You might be offered spinal injections (these didn’t work, or wore off after 3 months). You might be offered a sensory nerve block (you want they cause treated, not the nerve fried).

However, although you might not be exited with the medical treatments on offer, after your MRI results/diagnosis, this information can still be very useful for a non-medical ‘hands on’ therapists (few NHS Physios are proficient at ‘hands on’ treatment, in my opinion), to inform their treatment! I have found MRI results very useful for my treatment plans when they have identified disc issues, spondylolisthesis and severe spondylosis, for instance. I have been able to tailor more effective treatment protocols and avoid possibly aggravating techniques in my clinic.

I hope you find this blog informative and helpful in your decision as to whether have/fund an MRI, and you have a better understanding of the possible outcomes and treatment options.

Kipp Clark JACSMT

Alton Advanced Bodywork web-page