4 Lessons on Chronic Pain

Notes from a Mountain Guide

By Mark Liskey

At the age of 30, Jayson Simon-Jones suffered a debilitating back injury that was hard to explain to fellow mountain guides because it was virtually invisible—he had no cast or crutches or other visible signs of injury. To address the injury, he tried everything from Rolfing to epidural injections. When those didn’t work, he elected to have back surgery, which eliminated his leg dragging but didn’t eliminate the pain completely; in fact, a six-Vicodin-a-day flare-up was not out of the question. Simon-Jones, like 100 million other Americans, then faced the challenge of living with chronic pain.1
I had the good fortune to interview Simon-Jones in 2006 and then again in 2015. Though he still sometimes suffers from severe pain, he continues to work at his dream job as a mountain guide. More than inspirational, his story provides valuable lessons that massage therapists can apply to improve the quality of treatment for clients with chronic pain.    

Biomedical Model Versus Biocultural Model
Experts agree that in the United States we operate under a biomedical approach to medicine. A biomedical approach focuses on treating the patient’s disease, and a biomedical approach to pain primarily views and treats pain as a function of tissue damage.
A biocultural approach to medicine goes a step further, taking into account the patient’s psychological and social factors when treating disease. A biocultural approach to pain includes treating the person in context to his community, not just the biological aspect of his pain.
There is evidence to suggest that a biocultural approach to treating pain is better for the chronic-pain sufferer. A 1997 cross-cultural study comparing chronic pain attitudes between New Englanders and Puerto Ricans found that New Englanders were more likely to feel stressed and alienated under medical care.2 The New England doctors treated their patients using a biomedical model, whereas the Puerto Rican doctors operated under a biocultural model.
Initially, Simon-Jones experienced treatment-related stress in the same way that many New England participants had in the 1997 study. “The first surgeon I met with was like a mechanic,” he says, describing the meeting that left him feeling agitated, confused, and dejected. But Simon-Jones persevered, searching until he found a surgeon who could answer all of his questions. “He treated the person,” Simon-Jones explained, “not just the symptoms.” Simon-Jones had found a surgeon who practiced medicine in a biocultural way.
What lessons can we take away from Simon-Jones’s reactions to the surgeons he interviewed?

Lesson 1
Don’t Induce or Exacerbate Treatment-Related Stress
For the massage therapist, preventing treatment-related stress starts with the intake process. During your intake, do you ask only questions specific to pain, or do you give the client an opportunity to discuss his entire experience around the pain? Here is an example of a question that leads the conversation toward a biomedical slant:
Therapist: “Where is the pain?”
Client: “In my neck. Right here. Sometimes it goes down my arm.”
Though this is an important question to ask, it is specific only to the physical pain (biomedical approach). If not followed by questions that move the intake process toward the client’s psychological and social experience of pain (biocultural approach), it may induce treatment-related stress.
Open-ended questions provide an opportunity for the chronic-pain sufferer to fill in the story, allowing you to move toward framing pain in a biocultural way. Here’s an example:
Therapist: “Tell me more. When did it start? How long have you had it? What have you tried?”
Client: “Well, I was driving, and when I came to this intersection, I was T-boned. I didn’t feel the neck pain right away, but it started to get bad about two weeks later. The doctor sent me to physical therapy and that just made it worse. I was thinking about going to a chiropractor, but my sister-in-law, who is an orthopedist, said not to. But my friend goes to a chiropractor, and it seems to help him. What do you think about chiropractors?”
So far, the client has talked about the driver who hit him, the doctor who treated him, the physical therapist who didn’t help him, the sister-in-law who doesn’t want him to go to a chiropractor, and the friend who does. The therapist can begin to understand that the client’s pain experience includes significant confusion and frustration, and can then acknowledge and validate the client’s emotional experience, thereby reducing a client’s treatment-related stress.
The intake process is not the only potential hazard for overemphasizing the biological side of chronic pain. Once you have the client on the table, especially if you practice massage from an orthopedic or sports philosophy, be careful that your desire to “fix” chronic pain doesn’t turn you into a mechanic.
For example, when I became certified as a neuromuscular therapist, I was ready to fix the pain of all chronic-pain sufferers. At the time, I was working for a chiropractor who sent me a client with chronic neck pain. I did a structural analysis, mapped out a plan of attack, and worked the muscles the way I thought they needed to be worked. It was 100 percent biomedical.
Later that night, the chiropractor relayed some feedback to me regarding the chronic neck-pain sufferer. He had asked her, “How was the massage?” She snapped back: “That was a massage?!” Needless to say, I stressed her out, and she didn’t come back to see me.
No one, and no one discipline, has a cure for chronic pain. It’s complex and requires the massage therapist to put her belief in her specialty training and/or massage abilities second to the reality that she is only one component of a pain-management system.  

Lesson 2
Steer the Client Away from Catastrophizing
Catastrophizing—“I will only get worse; all is lost”—is serious business. Catastrophizing is associated more with a lower quality-of-life rating than the actual intensity of pain.3
According to scholar and writer David Morris, in a biomedical setting, “Pain that fails to respond to treatment, or pain that medical authorities can’t understand” can lead to catastrophizing. Morris goes on to say that a healthy and more positive narrative can diminish catastrophizing.4
When I spoke with Simon-Jones, I felt like I was talking to someone in charge. After all, if you are leading a backcountry trip in Crested Butte, Colorado, you’d better be in charge! When his chronic pain first started, however, quite the opposite was true. He had more questions than answers, and the interactions he had with the medical community left him feeling that he was headed toward a catastrophe.
Massage therapists are not trained or licensed to treat catastrophizing. However, if a client is demonstrating this behavior, don’t play along. For example, if Simon-Jones were on my table saying he would never get back on the mountain, I wouldn’t say anything to reinforce that fear. Instead, I’d encourage him to seek out a support system to help him develop a more positive narrative. Examples might be chronic-pain support groups, trained therapists, or other climbers who made it back to the mountain.  
In the massage room, catastrophizing may occur as a result of a therapist making promises she can’t keep. If you promise a cure, and it doesn’t materialize, the client’s massage experience can become another “failure,” contributing to a downward emotional spiral. However, if a therapist makes realistic treatment goals, explains her treatment plan, and checks in regularly with the client to see if the treatment approach/goal is working, she can make adjustments without making the client feel like all is lost.
For example, let’s say your goal is to reduce (not fix) the client’s pain. You explain to the client that you are focusing on the levator scapulae and posterior scalenes. You do your work, but the client is still in the same amount of pain the next day.
All is not lost. Because you’ve explained your approach and haven’t promised more than you can deliver, you’ve therapeutically managed client expectations, and, subsequently, lowered the chance for catastrophizing. In addition, you’re now in a position to adjust your treatment for a second attempt. For example, you could tell the client that you would like to shift your focus to the cervical spinal erectors. And the second attempt might be the one that helps.

Lesson 3
Empower the Client
In his chronic-pain journey, Simon-Jones empowered himself when he fired his doctors and got new ones. He also paid out-of-pocket when insurance would not cover his initial consultation with his choice of doctor. He handpicked his postsurgery rehab team, which included a physical therapist and yoga and Pilates instructors. All were experts in their respective fields—and all listened to his concerns. As in the biocultural model, Simon-Jones surrounded himself with a support system.
You can’t fire your client’s doctors (though sometimes you may want to). So how do you empower your client?  
One way is to put yourself in a position to be fired if the client’s goals are not met. If you establish a therapeutic relationship that is outcome-based and honestly evaluate to see if objectives are being met or need to be redefined, you are saying to the client, “If it’s not working, it’s OK to move on.” In fact, as massage therapists, it’s our ethical obligation to do so.
“Moving on” is an opportunity to continue with your goal to help the client. Do you think he needs to go back to his primary or pain-management doctor for a recheck? Is a referral to a practitioner of a different massage modality or different health modality, such as physical therapy or Pilates, warranted?
During the treatment session, you can also empower the client by establishing the appropriate pain-relief pressure through a dialogue where the client has the last word on the pressure. One way to do this is to ask: “Using this as a starting point, would you like more or less pressure?”
If the client never had a pain-relief massage before and has no reference point for pressure, then a scale from 1 to 10 can be used, where 1 indicates no pain and 10 means a great deal of pain. Working conservatively between 4 and 6, the client can be instructed to let you know if the pain ever gets above 6, thus providing the client with control over the amount of pressure you are applying in the massage session.
Using these techniques, you’ve empowered your client and, hopefully, you’ve shown him how he can and should expect to be treated in other therapeutic relationships.

Lesson 4
It almost seems counterintuitive to think that accepting the condition of chronic pain can be healthy—until we understand what experts mean by “acceptance.”
“Acceptance of chronic pain entails that an individual reduce unsuccessful attempts to avoid or control pain and focus instead on participation in valued activities and the pursuit of personally relevant goals,” writes researcher Lance M. McCracken.5
There is evidence to support the theory of acceptance. In one study that compared coping (behavior in response to pain and/or behavior that reduces pain) versus accepting chronic pain, the authors concluded “… acceptance of chronic pain was associated with less pain, disability, depression and pain-related anxiety, higher daily uptime, and better work status.”6 Or, more simply stated: quit chasing a cure and get back to living.
Simon-Jones’s story seems like a textbook case of pain acceptance theory. He stopped unsuccessful attempts to control pain, but didn’t avoid situations that may cause more pain. And he focused on what gave him pleasure—climbing.  
How does a chronic back-pain sufferer get back into climbing? First, he accepted that he couldn’t climb the way he used to climb. For example, overhangs now tweaked his back, so he avoided them. He also learned that an easy climb served as a good warm-up for a more challenging one. Through trial and error and some modifications, Simon-Jones figured out how to do what he loved doing.  
Determining if a client is nonaccepting can be difficult and out of your scope of practice. If you suspect a client is having trouble with acceptance, refer him to a counselor.
Lastly, the therapist herself may also struggle with accepting that a client’s pain condition isn’t curable. Why? Because to the therapist, it may feel like she has failed. But the reality is no one has cured chronic pain. We need to do what is best for our clients, not our egos. That is not to say massage can’t be a valuable tool in helping a client manage chronic pain once the client has accepted his pain is chronic.

Applying These Lessons to Your Practice
First, reduce treatment-related stress during intake by providing open-ended questions so the client can tell his story. Next, work to “help” a client feel better, rather than promising to “fix” a chronic-pain issue. Remember, a good support system and a well-explained treatment plan with realistic expectations can reduce castrophizing. Also, empower the client in the session by providing a means for him to control tactile pressure and provide a therapeutic exit strategy if the treatment isn’t helping.  
Finally, accepting chronic pain does not necessarily mean the client is giving up. It can actually mean the client is moving on and is creating the best life possible. We cannot cure chronic pain, but by applying Simon-Jones’s lessons we can help our clients work toward better pain-management outcomes.

1. Institute of Medicine, “Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research,” accessed March 2015, www.iom.edu/Reports/2011/Relieving-Pain-in-America-A-Blueprint-for-Transforming-Prevention-Care-Education-Research/Report-Brief.aspx.
2. M. S. Shutty, Jr., D. E. DeGood, and D. H. Tuttle, “Chronic Pain Patients’ Beliefs about Their Pain and Treatment Outcomes,” Archives of Physical Medicine and Rehabilitation 71, no. 2 (1990): 128–32.
3. I. E. Lamé et al., “Quality of Life in Chronic Pain is More Associated with Beliefs about Pain, than with Pain Intensity,” European Journal of Pain 9, no. 1 (February 2005): 15–24.
4. Author interview with David Morris, January 12, 2006.
5. L. M. McCracken, K. E. Vowles, and C. Eccleston, “Acceptance of Chronic Pain: Component Analysis and a Revised Assessment Method,” Pain 107, no. 1–2 (January 2004): 159–66.
6. L. M. McCracken and C. Eccleston, “Coping or Acceptance: What to Do About Chronic Pain?” Pain 105, no. 1–2 (September 2003): 197–204.

Mark Liskey is a massage therapist specializing in neuromuscular massage. He is a CE provider and co-owner of PressurePerfect (www.pressureperfectmassage.com), a massage company that practices the tenets of conscious capitalism. He can be reached at mark@markliskey.com.