A major concern for massage therapists is clients who come in with pain, but pain measurement can be effectively used to determine ongoing treatment plans.

A major concern to massage therapists are clients who come to our tables with pain, which can take any form, from back pain to “shooting pain down my leg,” to headache pain—or pain all over.

Pain. This one word alone demands that you create a treatment plan in order to attempt to alleviate suffering.

To help, you must know more about what’s going on with the client. In massage school, you learned to distinguish between musculoskeletal and neurogenic pain.

You remember that the musculoskeletal pain descriptions include “dull, aching, throbbing, localized” as opposed to “shooting, tingling, burning, sharp, traveling” commonly used to describe pain originating from nerve involvement.

Somewhere in this intricate process of trying to unravel the puzzle of pain—as you try to determine an intelligent and responsible treatment plan—you will most likely use the 0-to-10 pain scale.

You will use the words we have all been taught: “On a scale of 0 to 10, with 0 being no pain and 10 being the worst pain imaginable, how would you rate your pain right now?”

We attempt to use some measuring tool both at the beginning and at the end of the hour, or after several sessions, so we can responsibly say to ourselves and our clients, “Aha, our techniques must be working because we are decreasing your pain. You started at a 6 and now you state the pain is at a 2.”

Massage therapists are in good company in our use of this tool.

Healthcare professionals—physicians, nurses, physical therapists and chiropractors among them—use the 0-to-10 pain scale. (Pediatric nurses have ingeniously turned the scale into a series of smiling-to-frowning faces for our younger population.)

Yet, those who professionally study pain now realize that the 0-to-10 pain scale is rudimentary at best. Many pain experts want healthcare providers to look more closely at this simplistic scale and expand its use into specificity not previously employed. They want a deeper, more meaningful use of this scale to help determine all levels of a patient’s pain.

Evolution of the Pain Scale

The verbal instruction to “tell me how bad your pain is,” is really an evolution of the scientific linear Visual Analog Scale (VAS) used for decades by researchers. The VAS is a 10-centimeter line drawn on a page.

Patients/research subjects were asked to draw a mark on the line to determine their pain level. The VAS measurers used the exact wording we now ask verbally when they inquired, “Draw a mark on this line to explain your pain, with 0 meaning no pain and 10 means your pain as bad as possible.”

It became immediately apparent that this means of pain measurement had drawbacks:

  • It is an abstract concept (to translate physical pain into a measurable number is not readily understandable by everyone);
  • It does not take into account cultural differences;
  • It cannot reflect the social issues involved in reporting pain;
  • It is impossible to measure “secondary gain” (it may serve a person well for a multitude of reasons to be in pain and stay in pain and not improve);
  • It can be skewed depending upon the relationship and communication skills of the researcher to the subject;
  • As noted previously, a 0-to-10 measurement means nothing to some subjects.

So, with all these drawbacks, why use this scale? It continues to be very popular because it gives the research subjects (or our clients) some sense of control over explaining their pain, and it helps researchers (and healthcare professionals) determine the efficacy of specific modalities as used on subjects (or clients).

The pain scale we’ve been using for years can continue to be used effectively for individual clients and to determine their singular treatment plans—but it should not be used in a serious research study when trying to draw conclusions across populations or about modality efficacy.

Where Does Pain Come From?

Massage therapists are holistic practitioners. We pride ourselves on caring for more than the body, and we are insightful.

We know, even if it is only in our gut, that if a woman is going through a painful divorce, she will experience physical pain.

The physical pain is real, but it may not be organic, or physiologically measurable, pain. Her pain comes from her life’s agony—and measuring that agony is the hoped-for evolution of the 0-to-10 pain scale.

The following story was told by Samuel Dworkin, DDS, PhD, at an Annual Scientific Meeting of the American Pain Society (APS), in his presentation, “Psychogenic Pain: Totem or Taboo”:

“One of my medical residents took a short holiday to her parents’ farm a couple of years ago,” Dworkin said. “She and her husband and 3-month-old baby were enjoying a week away from medical school when her father decided to take the baby out one morning for a ride on the combine (a huge piece of farming equipment).

“During this ride, the 3-month-old infant fell out of the combine’s cab and into the blades of the machine and was killed. When this stellar student returned to school, she was suffering from terrible physical pain.

“We could find no known physical cause of any pathophysiologic mechanism accounting for her pain. She increasingly deteriorated and was never the same person. We never found a cause for her physical pain.”

Dworkin reminded the assembly that, “There is a persistent subset of people who continue to confound science” with their complaints of pain.

He believes that when a patient reports “muscular tension or muscular pain,” that a physician’s first question should be to try to investigate psychogenic pain, or pain that is emotional or psychological in origin. Why then, should that not be our first question as well?

Raymond Tait, PhD, also made the astounding point in his APS presentation, “Psychogenic Pain: Pain and the Pain Prone Person,” that “People would rather unconsciously experience physical pain than handle the psychological reality of the true source of their pain, [such as] guilt [or] anger.”

Tait hoped to make the point that when healthcare providers measure pain, we must take into account the context in which the pain occurs as a huge precursor of the person’s perception of that pain.

Translation: The body often hurts because something non-physical hurts. Your client’s perception of her pain and the social context in which she is experiencing that pain are inextricably intertwined.

What may be running through your mind right now is the massage therapist’s “watch your scope of practice” mantra. You’ve learned that massage therapists are not psychotherapists, we don’t give advice to clients with psychological problems, and all we’re supposed to do is listen.

That’s all absolutely correct.

However, in evaluating our client’s pain, when it becomes obvious the pain is beyond our scope, we most certainly can be prepared to refer to the appropriate professional.

How the Process Works

Here’s how this process might work: Let’s take the previous example of the woman who is experiencing a painful divorce and “her muscles hurt all over.” Let’s call her Helen.

It doesn’t take a degree in psychiatry to realize that her pain is emotionally based; it should also occur to you that massage therapy alone will not be sufficient in this woman’s total care. And that’s the key here—your being willing to give total care, not just attending to her muscle mass.

So you’ll use hot packs, soothing music, great Swedish strokes—but Helen will get off your table, go home, sob, face her demons and hurt all over again.

You can help her profoundly by using the 0-to-10 pain scale, yet not crossing your professional boundaries, by doing the following two things:

  1. R-tool your intake form to expand the use of your 0-to-10 scale, or at least add to your verbal inquiry; and
  2. Acquaint yourself with several healthcare professionals of various specialties to whom you can refer.

During Helen’s intake, when she responds to your pain inquiry with, “I hurt all over,” rather than look at her from a strictly physical point of view, ask her more questions.

Probe a little.

Ask, for example: “Why do you think that is?”; “Has something happened recently that has upset you or given you pain?”; “Have you lost a job or a loved one recently?”; or “Tell me more about what’s going on with your body.”

Don’t give up until you get an answer. It is a rare human who will not divulge her pain to a truly caring inquirer.

Once you determine the root of the condition, you’ve got something to work with. You can honestly tell Helen that although you are not equipped to help her deeper concerns of the loss of her husband, that you’d like to help her body relax, and then, when the session is over, perhaps you could refer her to the appropriate type of therapist.

Your opportunity to provide referrals, once you find out the real source of the pain, is endless. Has your client lost his job? Have cards for career counselors.

Did he lose his wife in an accident? Offer him the cards of area grief-support groups.

In each case, you’ve stayed within your scope of practice while still caring deeply about your clients—and attending to their pain on more than a physical level.

As importantly, you have become part of the solution, rather than one more practitioner who simply saw a body in pain.

About The Author

Charlotte Michael Versagi, LMT, is author of Step-by-Step Massage Therapy Protocols for Common Conditions.

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