To Predict Chronic Pain, Look to the Brain

Low back pain is extremely common. In fact, if you don’t have at least some back pain every year or so, you’re kind of abnormal. (Not that you’re really missing out on anything.)

Fortunately, if you do get back pain, your chances of getting rid of it in fairly short order are excellent. More than 90% of acute back pain resolves on its own in just a few weeks or months without any specific intervention. But for some people, pain becomes chronic, lasting for years. Why does the course of back pain differ so much between different people?

The answer probably cannot be found by looking solely at the back itself. Experts have tried for years to explain back pain outcomes in reference to the results of physical examinations. But collecting evidence about posture, core strength, or the condition of vertebrae and discs does very little to help you make good predictions. Posture and MRI results correlate poorly with pain, and a single structural/physical cause for back pain is rarely found.

More recently, there has been more emphasis on subjective factors – pain intensity, negative mood, catastrophizing, depression, or job satisfaction. Accounting for these factors will help you predict back pain outcomes quite a bit better than just looking at the physical condition of the back. But a good deal of mystery would remain.

Some recent research from the lab of Vania Apkarian has led some very smart people to wonder whether he has discovered the “Holy Grail” of explaining pain –  the precise factors that cause some people to develop chronic pain and others to recover.

If Apkarian is right, the grail is in the brain. (An important reminder and caveat: even when the brain is a major player in pain, this does not imply that pain is “in your head”, that pain is your fault, that you can just think pain away, or that the body doesn’t matter.)

Following is a collection of quotes from several papers from Apkarian’s lab. (See the bottom of the post for cites. Full text for each is available free online.) These help summarize the results and interpretations of his very interesting research, which mostly involves scanning the brains of people with and without back pain, and at various stages of recovery or chronicity.

The Relationship Between Nociception, Acute Pain, Movement, and Emotion

Pain is a conscious subjective experience that is most commonly driven by nociceptive activity. Baliki 2015.

Conscious acute pain perception is highly malleable … pain perception can reflect moment-to-moment shifts in value judgments. Baliki 2015.

The emotional limbic brain plays a critical role in bridging nociception and pain perception. Baliki 2015.

[N]ociceptors can be active in the absence of pain perception . . .The primary reason I fidget in my chair while writing this article is because nociceptors innervating my skin, muscle, and bone command that my posture needs adjustment. Baliki 2015.

The nociceptive control of behavior routinely occurs in the absence of consciously perceived pain, rendering it “subconscious.” Baliki 2015.

Daily motor movements could easily produce injury and tissue damage if one exceeds their natural range of motion . . . which supports the conclusion that motor behaviors are collectively inhibited by nociceptors. Baliki 2015.

We argue that nociception continuously occurs in the absence of pain perception and it is a fundamental physiological process . . . we presume that behaviors modulated by nociception, in the absence of pain, are contingent on already established habitual repertoires. In contrast, when pain is evoked it gives rise to new peripheral and spinal cord nociceptive learning/ sensitization, as well as emotional learning that is potentiated by the salience and perceived value of the aversive event. Baliki 2015.

The Transition From Acute To Chronic Pain

[O]nly a fraction of subjects who experience an acute painful injury develop chronic pain. Hashmi 2013.

The majority (>90%) of individuals with acute low back pain recover full function in days or weeks with little or no lingering pain. Apkarian 2009.

The 2 critical questions that the field has yet to address regarding chronic pain are 1) Who is vulnerable to developing it? and 2) What underlies this vulnerability?  Hashmi 2013.

Earlier clinical studies have identified a long list of risks for chronic pain, such as demographics, affective states, lifestyle, comorbidities, and others, yet collectively such parameters account for a relatively small amount of variance for chronic pain (10% to 20%). In contrast, the brain’s anatomic and functional properties predict development of chronic pain at 80% to 100% accuracy. Hashmi 2013.

Ample evidence now shows that the anatomy and physiology of the brain in chronic pain is distinct from that of healthy subjects experiencing acute pain. Vachon-Presseau 2016.

An accumulating body of animal and human literature has identified the cortico-limbic system, which is central to reward and motivated behavior, as a modulator for acute pain and as a mediator for chronic pain. Vachon-Presseau 2016.

In a longitudinal brain-imaging study, individuals who developed an intense back pain episode were followed over a 1-year period, during which pain and brain parameters were collected repeatedly. At the time of entry into the study, strength of synchrony between the medial prefrontal cortex and nucleus accumbens (i.e. functional connectivity) was predictive (>80% accuracy) of individuals who subsequently transition to chronicity 1 year later. Apkarian 2016.

Persistently enhanced functional connectivity between the mPFC and NAc may be interpreted as an increased emotional salience signal. Vachon-Presseau 2016.

There is now good evidence that all components of the corticolimbic system are either affected by or control or amplify persistent pain states. Vachon-Presseau 2016.

Redefining Chronic Pain

The definition of chronic pain remains tautological, as it simply asserts that it is a long-lasting pain, or a pain persisting past the normal healing period. Baliki 2015.

We propose a novel definition of chronic pain. Rather than defining pain by its sensations, we propose a definition that emphasizes the neurobiological mechanisms that control behavioral adaptations, and we hypothesize that persistence of pain is likely mediated through the reorganization of the cortex by corticolimbic learning mechanisms. (Baliki 2015)

Long-term shifts in the threshold mechanisms that gate the conversion from nociception to pain also underlie the transition to chronic pain. We further propose that the threshold shift is dependent on limbic circuitry invoking synaptic learning-based reorganization. Taken together, these ideas can be simplified as a lowered mesolimbic threshold for the conscious perception of pain, which functionally renders the brain addicted to pain. (Baliki 2015)

The Connection Between Chronic Pain and Negative Mood

Just as nociception and pain protect against bodily injury by limiting behavior, negative moods minimize exposure to danger and promote survival by inhibiting behavior as well. (Baliki 2015)

Just as chronic pain conditions are associated with decreased hippocampal volume, a rich parallel literature indicates that depression is associated with hippocampal volume decrease. (Baliki 2015)

It is therefore not surprising that these conditions are often comorbid, and indeed, there is now a small but emerging literature regarding the interaction between negative moods and acute and chronic pain. (Baliki 2015).

Implications and New Questions

How does this research add to what we already know? We have known for a while that chronic pain involves central sensitization and brain changes. But it was still possible that those changes were driven by persistent peripheral input. Apkarian’s research seems to suggest that peripheral nociception is not the central driver of chronic pain.

It should be noted that some of Apkarian’s research needs to be replicated and that others may interpret his findings differently.

Apkarian was a featured speaker at the 2018 San Diego Pain Summit, I spoke there a few years ago and wrote about my experience attending here.

I was sure to ask Apkarian some questions which are basically unanswered in his various papers: if chronic pain is mostly about the brain’s emotional systems, what can we do, as a practical matter, to help treat or prevent it? And for people who do recover from chronic pain (like me and many others), how did their brains change? Did they revert or evolve?

I suspected there are no simple answers that apply to everyone, and that success for any particular person involves somehow changing the way their brain subconsciously connects movement, threat perception, and a sense of value or meaning.

Resources/Citations

Apkarian, A Vania, Marwan N Baliki, and Melissa A Farmer. 2016. “Predicting Transition to Chronic Pain” 26 (4): 360–67. doi:10.1097/WCO.0b013e32836336ad

Hashmi, Javeria A., Marwan N. Baliki, Lejian Huang, Alex T. Baria, Souraya Torbey, Kristina M. Hermann, Thomas J. Schnitzer, and A. Vania Apkarian. 2013. “Shape Shifting Pain: Chronification of Back Pain Shifts Brain Representation from Nociceptive to Emotional Circuits.” Brain 136 (9): 2751–68. doi:10.1093/brain/awt211.

Vachon-Presseau, E, M V Centeno, W Ren, S E Berger, P Tétreault, M Ghantous, A Baria, et al. 2016. “The Emotional Brain as a Predictor and Amplifier of Chronic Pain.” Journal of Dental Research 95 (6). International Association for Dental Research: 605–12. doi:10.1177/0022034516638027.

Baliki, Marwan N, and A Vania Apkarian. 2016. “Nociception, Pain, Negative Moods and Behavior Selection” 87 (3): 474–91. doi:10.1016/j.neuron.2015.06.005.Nociception.

Apkarian, A.V., Balik, M.N., Geha, P.Y. 2009. “Towards a Theory of Chronic Pain.” Progress in Neurobiology 87 (2): 81–97. doi:10.1016/j.pneurobio.2008.09.018.Towards.

Anxiety, Crisis, And Recovery As A Massage Therapist

 

**The author of this post asked to remain anonymous, however, it is such an important topic we thought it VERY important to share and I can’t thank them enough for being brave enough to write this for all of our benefit. 

 

I made the mistake of going to a cadaver anatomy class, not really thinking if it was something I was fit to be doing, and signed up like you would any other continuing education.

I was at the height of a generalized anxiety disorder crisis that had been building for months, and my cognitive functioning was not letting me make the best choices.  I also failed to mention it to my psychologist who I had been seeing for three months and have a great relationship with. 

It wasn’t until I walked into the cadaver lab and the smell hit me, and I saw the people in bags on the tables that I realized I might have made a bad decision.

The bodies all looked like my Father, who I watched die and be put into the same bag two years before.  I was surrounded by them, laid out on stainless steel tables among buckets of tools from the hardware store and fans.

For some reason, because the money was non-refundable and I needed CEUs, I  justified staying when I should have left. I stuffed my nose with vaporub, put on a mask, and took breaks every 15 minutes.

We were able to touch, move, and dissect.

I kept my distance and observed, and forced my way through. There are many things I saw, which I feel today I should not have exposed myself to, although there are a few things I learned that were positive and do inform my massage therapy practice.

After throwing out my clothes and changing in the bathroom, I was tired and worn out. I drove home, showered, and went to bed.

Anxiety And Spiraling Negative Thoughts

The next day I was in shock without really understanding I was, I took a walk down to the lake. As I was walking I had some anxiety-provoking conversations on the phone with family and was in a complete daze.

As the day wore on, I got more and more anxious, and by 10 pm I was holding on just waiting for my partner to get home from work. Something snapped in me, feeling like I was full of anxiety on the inside like a container and it was everywhere all around me, there was no escape. 

I left the house and started walking really fast, blindly retracing my earlier walk. I was going to throw myself into the lake to escape the anxiety, thinking that hypothermia was the only way out.

I got to the lake but I could not see how to get in because it was dark and I was on an edge with a rock wall and vegetation, I didn’t want to mess it up. If I was going to do this I had to get it right. Delayed in confusion, I sat for a while on the ground.

Just then my partner called me.

I had left them a voicemail saying I was sorry and I had done everything I could, but it was too late. 

They kept alternating in a calm voice asking me where I was and telling me they loved me until I was able to respond and say where I was.

They came to get me and brought me to the hospital where I was put on a 17-hour hold. This was on a Tuesday when I was supposed to be in my university classes. On Wednesday I was let out and had an appointment with my psychologist, and was unable to really think or move or speak and was just wiped out mentally, emotionally and physically.

Massage Therapy Providing Comfort

The only thing I knew to do then was to keep moving through the things I normally do and had set up for the week, despite fully letting go of everything and giving up in my head.

I let myself physically go through the motions of doing things. On Friday I had a hair appointment, and the following Monday receiving a massage.

The feeling of being physically handled when you have given up is a thing I can’t describe. It’s like you have decided to fall into a giant hand and let it protect you. During each, I knew I could no longer comprehend caring for myself and was relying completely on the outside world, and the people touching me and making contact. 

It was complete helplessness with someone holding on to you.

I sunk deep into those hands and the relief I experienced with being able to shut down for a while and let others take over is the deepest relief I have ever felt in receiving massage and compassionate touch. I also kept all of my massage client appointments during this time, no matter how I felt or how long it took to get me to work. Once I was at work, I threw myself into my work and found extreme relief caring for others.

I spent most of the year working with my psychologist unraveling my anxiety that was now paired with suicidal ideation. 

I am proud to say that my anxiety is very much managed with my preventative care as well as my suicidal thoughts. This involves being vigilant about checking in with myself about my stress and anxiety levels, and determining what I need in terms of self-care for the day, and following through. I also make time regularly to reach out to the supportive people in my life and connect.

Showing up no matter what to my massage appointments and doing the work saves me, connects me to clients through touch and our therapeutic relationship. No matter how I am feeling, generally within 20 minutes of working on someone I feel better, and a day at work always makes me feel great, as well as the clients. I am so grateful there can be comfort on both sides, and I can make a massage session all about the other person while receiving human connection. I am also thankful to have worked with an amazing psychologist during that time and having school to occupy my mind, and a fantastic partner.

Massage continues to save me. Those days that I wake up and feel not quite like myself, when I get to work and focus on clients it brings me back, and generally, at the end of the day, I feel amazing and lucky. I also continue to feel a tremendous amount of relief from anxiety as the massage client.  I am unsure if it is the connection to people, or the actual massage process, or both that brings relief to me. I am grateful to massage therapy for helping my clients and helping me. 

If you are struggling with anxiety or suicidal ideation, it is important to reach out to someone. It can be difficult to break through the guilt and shame or even be able to talk about it. But, taking the first step is necessary because it is difficult to think clearly in that temporary irrational state, and you need the help of someone else to get through it. I have learned you don’t need to explain, just be clear and direct, and say, “I am having thoughts about ending my life.”  Start with calling or talking to someone you know, or if you can’t, go to or call your nearest community mental health center, or hospital emergency room. There is also calling 911 or the National Suicide Prevention Hotline, 1-800-273-8255 (U.S).

If you know someone that struggles with suicidal thoughts, call and check in with them occasionally, or spend some time with them. What keeps people well is human connection. 

 

Resilience – What It Is And Why Is It A Big Deal For Recovery?

 

Resilience is a term used more and more by therapists, some might suggest it is a buzz word, so I wanted to put down my thoughts about this complex subject. I have wanted to write this blog for a while and the struggle I have had here is to keep it bloggy, not too academic and above all not too long! I have tried to strike a balance between research and also some personal experiences of resilience I have collected.

Before we get into it, there are 3 main points I would like to make in this blog.

Firstly, resilience is NOT about manning (or womaning) up, it is NOT SIMPLY about just keeping going. It’s a flexible, adaptable state that recognizes the importance of specific actions, mental or physical, that have a positive impact on life.

Secondly, resilience is not a binary state between resilience and not resilient. It is a continuum that we move along dependent on a balance of internal and external factors.

Thirdly that resilience looks and feels different between people. What you may regard as resilience MAY NOT be the same as the person you are working with.

What Is Resilience?

Resilience is defined by Sturgeon *HERE* as,

“Maintenance of positive physical and emotional functioning in spite of significant difficulty or challenge”

So resilience is both a physical and a psychological thing. It is important that we don’t separate the two, however (much like pain!). Although physical things often signify resilience, they require a strong psychological component to achieve and also give a lot of psychological benefits.

This is also a good read *HERE*

Karoly *HERE* defines resilience as (2006) as

“Effective functioning despite the exposure to stressful circumstances and internal distress”

Both definitions use the word FUNCTIONING and ‘in spite’ or ‘despite’ of pain.

This makes resilience a REALLY individual thing that looks quite different between different folk. We should not make the mistake of assuming what signifies resilience to us is the same as someone else’s.

Pain is definitely a stressful circumstance for many, and it really becomes a problem when it interrupts our functioning. Focusing on the stressor, pain, however, could be part of this problem. Essentially resilience should be seen as a problem of function rather than pain. This is an important distinction, as identification and engagement of functions must form the key focus (IMO) rather than the focus that many can have (patient & therapist), pain itself.

Sturgeon writes;

”Attempts to control a chronic stressor like chronic pain are often counterproductive and can magnify the negative effects of the stressor”

Sustainability

Goubert & Trompetter *HERE* introduce the concept of sustainability; this is defined as:

“ability of a person to move towards long-term positive outcomes in life in the presence of adversity”

Here is a nice graphic outlining sustainability vs recovery from their paper.

Screen Shot 2018 10 26 At 07.32.40

Sustainability targets the PERSON in pain rather than the pain itself. Perhaps sometimes the focus can be on the pain going away before function is resumed, but we could view this the other way around with functioning through resilience being the first step.

The concept of sustainability is important, as it looks more at positive traits rather than risk factors. This is a bit like Antonovsky’s Salutogenic approach *HERE* that focuses on health rather than disease.

So to sum up resilience, it is about PEOPLE and FUNCTION more than pain and withstanding pain (IMO). Working through ANY pain or injury will require some element of resilience. Acute back pain, one of the most prevalent painful issues, probably exemplifies the need for resilience, with the first-line treatment for back pain being the advice to remain active and engage in your normal activities *HERE*.

Perhaps initial resilience may mediate the transition to more persistent pain states?

Adaptability & Flexibility

Resilience should not be seen as a brick wall. A resilient person is not simply a cold piece of rock impervious to any stressor. It is not about toughness, it is instead a flexible and adaptive state.

It could be quite the opposite, in that resilient people might be willing to seek out help instead of the strong silent type who may not be as resilient as they appear externally, unable to appear weak or vulnerable by asking for help. Resilience may be the ability to open the pressure valve and allow the excess to release and lower the stress by identifying things that allow them to do this or provide a balance with stressful situations.

Pain Relief Vs Resilience

Therapy has long been driven by pain relief, and whilst there is no doubt this is a reason why people seek care, they also seek care because pain is disrupting their lives and functioning, perhaps even more so for this reason.

This paper by Ferrara found that disability was a greater reason for care-seeking than pain intensity *HERE*

So perhaps to understand resilience we have to understand to understand our patients functioning and what THEY view as key markers to signify resilience. Traditionally VAS scales and physical measures such as strength have been used to measure clinical success. But do these measures capture valued activities and what resilience might mean for the person? Perhaps not. This paper looks at this subject of what is measured clinically vs peoples ACTUAL goals *HERE*.

So in order to help people BE resilient a good place to start is to find out more about how THEY view resilience, what defines their effective functioning and how we might bridge the gap between their current and desired states.

Resilience Is Personal

Valued activities may provide balance during stressful situations. Especially people that suffer from persistent pain can lose sight of things they used to do and the things that might define resilience. These are the people that may need a guide or a coach to find some meaning or goal again.

The sustained engagement in cherished activities, or stuff that MEANS stuff, seems to be a huge marker of resilience. To get a better idea of some of the meaningful activities, I asked some of the folk on social media (not in-depth research I know) to let me know some of the things they found important during painful times.

Exercise seems to be a really important sign of resilience for people and it was amazing to hear so many success stories against some pretty adverse situations. On a side note, communicating patient success stories to other patients, delivered at the right time and in the right way, can be a very powerful tool in my experience.

  • Weightlifting
  • Capoeira
  • Yoga
  • Pilates
  • Boxing
  • Bike riding
  • Crossfit
  • Running
  • Walking
  • Bouldering
  • Various sports
  • Gymnastics
  • Dancing
  • Making things
  • Hiking

Work also featured heavily. Just day to day functioning seemed important. Much like exercise, our working lives are pretty varied from being a therapist to nursing to simply driving. The concept of family also featured heavily with helping and providing for them forming an important part of resilience for many.

Resilience seems to be a rich tapestry of different things. The clinical implication of this is being able to effectively listen and ask a few questions that allow us to find out more about what activities may signify resilience and then be able to guide someone towards them and also provide planning and support for engagement.

Here are some example questions I use:

“What would your perfect day without pain look like?”

“What have you stopped doing because of the pain?”

“Are there things you feel are important that you avoid because of the pain?”

I also picked out some quotes. I have not used any names : )

“For many years, my default position was to isolate myself, try to power through, and go out of my way not to seek out resources or strategies. I thought that was the way I was supposed to do it; “man up” and push through. For me, I think I discovered (still am) resilience when I learned about acceptance. Getting to acceptance, and I think I still struggle with that a bit to this day, was a difficult time as I had to admit that I could not do this on my own. I hated that feeling”

“Resilience is in all of us, but sometimes we need a guide to help us find our path forward, but there is always a path forward”

“I would say the thing that made me the most resilient was asking for help. From my mentors, friends, counselors and family. Vulnerability helped me be more resilient”

“I love riding my bike but on a steep hill climb, my pain would escalate 10 fold. I persisted and after 30 mins or so of cycling it would go back down to normal levels. The bike ride was more important for my mental well being than the back pain maybe that is why I persisted”

“Resilience for me is knowing that there are things you can and can’t control and you put energy and focus into those things you can control/accept”

“Resilience is I get up every day and work with injuries on others. Sometimes leaving bed is the hardest part”

 It could be balancing the stressful parts of life with things that bring us happiness and joy is most important and when we lose this balance is when we start to become more vulnerable and our job may be to help with this process.

What Components Make Up Resilience?

Both Sturgeon and Goubert outline some positive elements AND some risk factors involved in resilience.

Lets first start with the positive elements.

Optimism & Positive Emotions

Optimism appears to be a key characteristic, with optimism being related to lower levels of pain and this may support why predicted expectations are related to outcomes. Optimism should be viewed both from a clinician and patient viewpoint and withou,t doubt both viewpoint will interact within the ‘third space’.

Here are some good papers *HERE* & *HERE*

Questions we can ask ourselves:

  • Are you a generally optimistic clinician/person?
  • How optimistic are you about a positive outcome?
  • Do you discuss what a positive outcome might look like, especially in regards to improved function?
  • Can we highlight positive aspects from the person’s story/history, previous positive experiences to be optimistic about?

Although it is important to not seem disingenuous, the need for positivity and a positive emotional perspective on life and activity should be highlighted, although this should probably come after a validation of normal negative responses to a tough situation such as persisting pain.

I feel it is also important to highlight the negative aspects of negative thinking and behaviour.

Pain Acceptance & Sustained Engagement In Valued Activities

Pain acceptance is defined as acknowledging that one has pain, stopping attempts to control pain, and learning to live a richer life in spite of pain. This in turn can lead to more engagement in valued activities.

Sturgeon writes

“individuals with greater levels of activity engagement are better able to bolster their positive emotions through sustained pursuit of valued activities despite their pain”

This appears to be a key factor, both highlighted in the research and also in the in depth qualitative research I performed above on social media ; )

Social Support

People who actively seek out social support seem to have lower levels of pain. We know from work such as Riikka Holopainen’s *HERE* that people with persisting pain reported that their circle of life had shrunk and they had given up doing things they used to enjoy.

Pain can interrupt positive social interactions that are important for resilience, however, pain can also narrow our ability to identify these positive social interactions and positive resilience resources in general.

Risk Factors

Pain Catastrophisation & Avoidance

Higher levels of pain catastrophizing and fear are linked to higher levels of pain and pain catastrophizing can also lead to ineffective coping strategies such as an avoidance approach to coping. This behaviour is consistent with the affective-motivational side of pain that can often motivate people to avoid things such as social interactions and physical activities. Essentially this can limit the enjoyment and positive aspects gained from valued activities, often for fear of pain, and can reduce resilience behaviours. This prolonged avoidance can also lead to depression and disability.

I feel it is important to highlight avoidant approaches and also help someone to rationalise if they are actually helpful for them or not.

But it is also important NOT to simply label people avoiders. Avoidance like all things is complex. Some activities may display avoidance behaviours whilst other things are engaged in. It is a touch harsh to take an area of someone’s life they are struggling with and use it to define them.

Resilience Or Vulnerability

We must be mindful that resilience does not appear to be a stable state. People are not simply resilient or vulnera,ble. Instead they appear to have components of both aspects co-existing in a sort of balancing act. Sometimes we maybe more susceptible to vulnerability, even the most resilient is resilient until they are not. We may also be vulnerable in some areas of our lives but not in others. We could be physically resilient but emotionally vulnerable or the other way around. It could switch from day to day. The one thing we know about the experience of pain, and all the dimensions that go into it, is that it pain is predictably unpredictable.

Resilience should really be seen as a continuum. Different injuries may require different levels of resilience and the person will have a current resiliency state dependent on many factors in their life. Some people may be super resilient or the injury type or state may not require much resilience. As with all painful problems, this relies on clinical reasoning to apply the right care at the right time.

Screen Shot 2018 10 26 At 07.40.13

Take Homes

  • Resilience IS NOT TOUGHNESS
  • Resilience is about adaptability and physical and psychological flexibility
  • Resilience lies on a continuum
  • Resilience looks and feels different to different people
  • Optimism is key
  • Sustained engagement in valued activities is key
  • Pain catastrophization and avoidance behaviour are risk factors

All Hands On Deck

 

Bell Let’s Talk has come, with all it’s social media fanfare and buzz, then gone taking with it the conversation that hardly ever happens. In a few days, the social media world falls quiet again.

The awareness raising campaigns do their thing and for a brief window, it is hip and popular to pay lip service to mental health problems… meanwhile, people living with mental health disorders continue to live with these disorders, quietly, privately, knowing full well the reality of living with mental disorders does not go away after a day or two of token buzz.

At first, I wanted to try and get on board with the bandwagon, jump in when the chatter was hot but something didn’t feel quite right about it so I did not push it.

Maybe it is my own mental disorders I live with getting in the way, maybe it is an as-yet unarticulated sense of “this isn’t the way I want to do it” thing. Whatever it is, I did not write a blog, a series of blogs or long-winded post on social media about mental health and mental disorders.

Probably because it is so damn important to me; if I am going to write about it at all, I MUST do it justice.

You see, I’ve been wrestling with this thing for years, this feeling, this itch, in my career.

When I first chose this path, I couldn’t quite articulate it, but now, I can. I became a Massage Therapist because I want to comfort people when the shit hits the fan. I wanted to provide a space where a person could arrive with armfuls of pain, gritted teeth and hunched shoulders and just put that down for a minute or 90, have a moment where they could just… breathe.

No hard questions, no pushing for deep thinking, no demands for change or healing, only kindness, compassion, acceptance and attention. I wanted to help people find a sense of peace and safety in their bodies. I wanted to help people learn that their bodies could be nice places to be, that it was possible to feel good being in a body. To me it seemed obvious; that’s what Massage Therapists do.

Our scope of practice is clear; we treat the soft tissues of the body to relieve and prevent pain.

We now know that pain and mental health problems can and do travel together [1,3], that childhood traumas (ACEs) are a strong predictor of negative adult health outcomes [2]. And while I may be extrapolating a little bit here, I think it is fair to say that trauma can be an outcome of severe pain experiences, especially those that persist.  

Taking all of this into account, I can’t help but feel certain in my firm adoption of the idea that all healthcare providers, and especially those who choose to work within an evidence-based, biopsychosocial framework, need to learn how to navigate the therapeutic alliance with awareness for managing the intersections of psychological and somatic health problems.

Canadian Mental Health Stats

When I look at the numbers, I wish I could say my heart breaks but the fact is, I see myself in the stats. I see my friends and my family members.  

In any given year, ⅕ Canadians are living with a mental health problem [5], it could be anxiety or depression, it could be an addiction, bipolar disorder or schizophrenia, it could be PTSD.

Regardless of the diagnosis, it’s COMMON; 3.5 million Canadians seek services from hospitals and physicians for mood and anxiety disorders annually [4]. Mood and anxiety disorders are the most common mental illnesses in Canada and worldwide. The highest prevalence is among men and women aged 30-54, with the 55+ group bringing up a close second. Youth and adolescents are the most rapidly growing group of people affected by these disorders. Possibly most painful of all is the fact that an average of almost 11 people dies from suicide PER DAY.

After accidents, it is the 2nd leading cause of death among young people aged 15-24 [5].

Our Role In Human Health Care

So what is a Massage Therapist doing talking about these things, seemingly drifting from out of her lane?

I firmly believe that, currently, the mental illness crises our communities have been living with for decades (upon decades) demand an all hands on deck approach. We can no longer afford the luxury of letting it be someone else’s problem.

It’s a problem that affects us all.

1/5 Canadians will experience a mental disorder, including addiction, in their lifetimes. That means every single one of us knows someone who is presently – RIGHT NOW – dealing with something that can make everything else that much more difficult. And they are often trying to do it privately because either they don’t want to burden you OR they are afraid you will drop them.

Stigma prevents 40% of Canadians living with a mood disorder from seeking medical help [6] risking unnecessary consequences to their mental health. As an RMT, I am a front line health care provider. As a member of those professionals governed by the RHPA, I have a responsibility to care about all of the health of my patients.

As an RMT I may even have a better opportunity to note changes in the health presentations of my patients, including changes in mental health. This reality behooves us, all RMTs and other health care providers, to learn about mental disorders, pursue mental health first aid training, and to destigmatize our practices.

Often when discussing these ideas with my colleagues I encounter pushback; the worry about crossing a scope of practice line emerges, obstructing progress towards a health care system that is fully capable of addressing human health concerns. Our scope of practice is focused on the somatic experience. Given the relationship between mental health and physical health that is emerging, it is clear that, for some people, their ability to access care, follow through with home care plans and overcome the mental hurdles of dealing with a pain problem can be impeded by mental health problems.

Practitioners who work with the soma exclusively may need to consider these additional hurdles, ensuring that they are:

  1. not contributing to the fear of stigma or retraumatizing in their conduct and language and
  2. recognizing when a mental health problem may be a barrier or yellow flag to the patient’s ability to move forward with their pain management strategy, and when it might actually move them backward.

This is no easy task; stepping into a new level of discomfort, digging deep into your humanity to find compassion, understanding, and the ability to walk with your patient through the discomfort, fear, and shame that health problems, mental or physical, can bring requires a great deal of mental and emotional labour. It asks for empathy and boundaries held in close proximity and it asks us to be much better connected to the health care community we are oft surrounded by, but isolated from. And it asks us to address our own biases about mental health and pain and uncover the ugly heads of the stigma that exist within us and our practices.

The time for us to start giving a shit about these problems and SHOW UP to the table has come and gone, over and over again since the days of Freud. It’s time for All Hands On Deck, because we all, ALL of us, need each other if we’re gonna make it through this at all.

Resources

If you’re still with me here then thank you for reading. Below are resources I have been using to inform my own practice and dismantle the barriers of stigma and incompetence when working with mentally ill and traumatized populations. These resources are all free as of this writing.

Trauma + Trauma-Informed Practice:

Trauma Informed Practice Guide

Handbook on Sensitive Practice for Health Care Practitioners

Trauma and Recovery by Dr. Judith Herman M.D. (1992)

ACEs

Sexual Assault:

Addressing Past Sexual Assault in Clinical Settings

Recognizing and Responding to Commonly Misunderstood Reactions to Sexual Assault

Stigma:

Addressing Stigma – CAMH (scroll to the bottom)

References

  1. Currie, S. R., & Wang, J. (2004). Chronic back pain and major depression in the general Canadian population. Pain, 107(1), 54-60. doi:10.1016/j.pain.2003.09.015
  2. Felitti, V. J., Anda, R. F., Nordenberg, D., Williamson, D. F., Spitz, A. M., Edwards, V., . . . Marks, J. S. (1998). Relationship of Childhood Abuse and Household Dysfunction to Many of the Leading Causes of Death in Adults. American Journal of Preventive Medicine, 14(4), 245-258. doi:10.1016/s0749-3797(98)00017-8
  3. Mcwilliams, L. A., Goodwin, R. D., & Cox, B. J. (2004). Depression and anxiety associated with three pain conditions: Results from a nationally representative sample. Pain, 111(1), 77-83. doi:10.1016/j.pain.2004.06.002
  4. Report from the Canadian Chronic Disease Surveillance System: Mood and Anxiety Disorders in Canada, 2016
  5. Mental Illness and Addiction: Facts and Statistics; Centre for Addiction and Mental Health. (https://www.camh.ca/en/driving-change/the-crisis-is-real/mental-health-statistics) accessed February 2, 2019
  6. Addressing Stigma; Centre for Addiction and Mental Health. (https://www.camh.ca/en/driving-change/addressing-stigma) accessed February 2, 2019

 

Four Meaningful Ways To Work As A Massage Therapist During Tough Times

 

You’ve just gotten some terrible news, news that brings you to your knees, news that makes you unsure about the future, news that breaks you open.

Perhaps a loved one has died or been diagnosed with a disease. Maybe your partner has lost their job. Maybe you have had a miscarriage. Maybe your child was in an accident.

Life throws us challenges that bring us down and may cause many emotions: anger, fear, sadness, grief.

As Massage Therapists, we are told to always check our emotions at the door. To enter our treatment rooms with a kind heart and open ears. To provide space for our patients. 

But what if we don’t have space for ourselves? What if our devastating news has left us unable to have empathy or to listen to complaints that now seem trivial? How do we care for other people?

In September 2018, I was diagnosed with breast cancer. I was 36 years old, had a one-year-old daughter, and had just gotten married. I had a busy massage practice, had applied for grad school and had big plans. I was so angry.

I love being a Massage Therapist. I love to listen to people’s problems. I loved to hold space and allow them to speak. I love to help people to feel better or get them moving again. Suddenly, I didn’t want to go to work. I was struggling to fight back tears when someone was complaining about the weather. I didn’t feel empathy.

In the coming months, I had a mastectomy, appointments at the cancer clinic and another mastectomy. I had a toddler and an amazing husband to care for. I had massage patients to care for and lastly, myself to care for.

Four Strategies To Get Through A Workday

While I know that we as health care providers are supposed to be present in our treatments, I also know that during times of challenge it is near impossible. So I came up with four strategies to help me get through a workday.

1. Allow Yourself To Grieve

While this post is not about grief I think it’s important to acknowledge that you might feel shock, anger, fear or denial. There have been many days that I have cried the entire drive to work. Once I got to work I was able to move on with my day. 

Cry, yell, give yourself space to be mad and sad.

2. Do Something For Yourself Every Day

After my first mastectomy, I worked hard to regain strength and some form of normalcy in my life. I am a gym rat, I love to lift weights. I could just sit in a gym and feel good. 

So,  just a few days after surgery I was in the gym working on my range of motion exercises. It felt SO good, it felt normal. 

I added in body weight leg exercises and eventually more intense rehab movements. I was back to work after a month and lifting heavy weights within three months. Getting back to doing things you love is so important, it can give you a sense of normalcy during a time that is far from normal. Find one thing you can focus on for yourself and make a point to do it.

3. Find Support. Talk About It

At first, I didn’t want to tell anyone I had cancer because I didn’t want my problem to be bigger than anyone else’s. I quickly learned that people care. People want to help. As hard as it is, let them.

You don’t have to tell everyone what is going on in your life. But it is important to find support from people who can give you coping strategies.

I joined several online young women with breast cancer groups. It has been so nice to have others who completely understand what I was going through. Reading other’s stories and comments and asking questions has been extremely helpful.

There are online support groups for various conditions and stages of life, I highly recommend seeking them out.

4. Trust Your Hands

I recently attended a workshop where the instructor said, “your hands are your brains”. It was much more eloquent than that, but I related to that statement.

Some days after my cancer diagnosis I didn’t have a lot of focus, I was too concerned with how long I was going to have to be off work, and if I could even afford that. I was too sad that I was losing my breasts. Did I mention I was angry?! On those days, while I tried hard to be present, I also just let my hands work. They know what to do, so I let them. Give your mind a rest and let your hands do what they are meant to.

 

Real life is hard. Everyone has something going on. Many massage patients come to us not just for us to rub their skin, but to share the good and bad moments in their lives with us. It takes a lot of energy.

Try to allow yourself time to grieve, focus on an activity you enjoy, give yourself permission to talk to someone and believe in your knowledge and skill to get you through your workday.

 

Articles Of The Week April 14, 2019

 

People will do all sorts of popular treatments for different parts of their body. There is a new trend where women are getting laser therapy on their vagina for a variety of reasons, but is the treatment actually valid? Well…there is still research to be done.

“Do Vaginas Need Rejuvenating?” – Sandy Hilton

Patient education and communication is a crucial part of treatment, but how much of what we say do they remember? This is where effective communication may be using short simple messages to help with education retention.

“Pain Science Education” – Lynita White

When it comes to our mental health, it turns out exercise does more for it than money. Although I’m sure most of us would have guessed that, there’s actually research out of Yale and Oxford that prove it.

“Exercise Makes You Happier Than Money” – Ruqayyah Moynihan

Continuing with mental health, how about its relationship with food? If we were to include education on nutrition as part of mainstream healthcare is there a potential for real change? This article argues it would.

“Why Isn’t Nutritional Therapy A Primary Therapy For Mental Illness?” – Eirik Garnas

Research is showing us that one of the best things we can do for arthritis, is loading the affected joints. When loaded properly we can actually combat the effects arthritis has on the joints.

“Arthritis And Movement: Your Weightlifting Prescription” – Mike DeMille, DPT, and Erin Murray