It is very clear that chronic pain is a global health concern, and the evidence is suggesting that the current health care system is underprepared to manage the complexity of the problem.1
Pain, lasting greater than three months, affects more than 20% of the US population, with health care cost estimated to be between $500 to $653 billion annually.2,3,4
What confuses many people afflicted with chronic pain is the fact that with all the technological and therapeutic advances over the past 20 years, why aren’t we doing better? The answer, in my professional opinion, lies in how we have identified the problem. Most clinicians, including myself, have been formally trained to treat the machine.
What I mean is we have been inundated with a biomedical, mechanistic view to care that focuses its attention on the body. If someone presents with low-back pain, the traditional medical process is to address the local area of pain with little regard for the individual attached to the body part.
What is Pain?
Pain is defined by the International Association for the Study of Pain as an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage.5
Dissecting this definition with our clients is a valuable opportunity to identify the non-biomechanical influences of the pain experience. Having an open discussion about the fact that pain, as stated, could be associated with actual or potential tissue damage is eye-opening to many. It allows us to question the linearity that tissue trauma equals pain and to acknowledge that one’s brain plays an important role in the experience. We have been chasing the root cause or what has been described as the pathoanatomical Holy Grail of pain with little success.6
May I suggest that sometimes the search for the causative pain gremlin can lead to an increase in fear and anxiety that magnify the symptoms? It is clear now that pain is an output generated by the brain and that it is highly influenced by many factors including biological, psychological and sociological inputs.7
What is not clear, as stated by George Engle, MD, who coined the term biopsychosocial approach, is how pain is diffused by cultural, social and psychological considerations.8 This is where the art joins manual therapy.
The key, here, is how the therapist interacts with the client to discover what component of biopsychosocial is fueling their pain and address it, concurrently, as we intervene with therapeutic touch modalities. With consideration of the psychosocial drivers, let’s discuss how we can augment our traditional manual therapy practices with some guidelines to follow.
Observe, Inquire & Listen
First, embracing a biopsychosocial approach requires the therapist to observe, inquire and listen more than we’ve done in the past. The goal is to gather information from the individual as to what is the meaningful movement that motivated them to seek care. In short, what moves them? It could be a tennis serve, a paddle stroke, a swim stroke, a bending motion to pick up a child. Whatever it is will be the anchor to focus on rather than the pain.
The meaningful movement is what is motivating them, not necessarily the pain. So focus on that. The goal here is to redirect attention from the chronic, debilitating pain experience and address the meaningful movement they are seeking to return to.
The approach may seem subtle, but the landscape now has changed from one of them as a body part to be passively treated to an athlete actively participating with a movement goal. Now the tool used to help manage the movement becomes embedded into a therapeutic experience to show the client that there is possibility of regaining the meaningful movement pattern without pain.
Moving beyond the focus around pain and providing a sense of HOPE (Hold On, Pain Ends) that one can return to a sport or activity that is psychologically and socially meaningful is paramount.
10 General Guidelines
Before you embark on applying this approach to manual therapy, here are some general guidelines to consider9:
1. Communication is critical when intervening with someone experiencing chronic pain.
2. Inform the client of the movement-based approach to your care: “Let’s try an experiment or exercise.”
3. Validation can’t be overstated. The pain they feel is real to them and it’s important we establish an empathetic alliance, so they recognize we are in it together.
4. The tool (if used) should be introduced and explained to reinforce the scientific efficacy in practice. This sets the stage for therapeutic confidence in the intervention that psychologically arms the nervous system to accept the process as palliative.
5. Make sure to get the client’s buy-in.
6. Safety first—they must understand that they have control of the experience.
7. Remind them that the brain and body are moldable to build confidence in the process.
8. Pay attention to psychosocial cues (dilation of the pupils, holding of the breath, clenching of the jaw, aversion away from the tool)—honor the boundaries and adjust when necessary.
9. Track success—as you incorporate the therapy with a meaningful movement, ensure you document the positive changes.
10. Get feedback and celebrate the wins.
Meaningful Movement Experiment: Practical Example
Client: 62-year-old male
Complaint: Chronic shoulder pain
Diagnosis: ‘Too many birthdays’ (idiopathic—no known cause)
In the initial information-gathering phase, it was identified that throwing a baseball with his grandson was the meaningful movement target. With that in mind we commenced with a careful exploration of the body part with a technique we call body mapping. The therapist will articulate the tool over the tissue in a light, feathering, stroke while the client brings attention, in a non-judgmental manner, to the shoulder.
In effect, they are instructed to draw a picture of the body part in their mind. The tool acts as a tuning fork of sorts, allowing both the therapist and the client to better appreciate and connect to the body part in a non-threatening way. As the person builds confidence, the identified meaningful movement can be explored while using the tool. The combination of the instrument-assisted technique with curious attention has been shown to mitigate the fear associated with moving the body part. This can and generally does lead to an improvement in symptoms as well as confidence in returning to the movement lost.
The goal of this approach to manual therapy is to bring along the person attached to the tissues as an active participant in the therapeutic experience. Have them join in the process to reconnect to the body and the meaningful movement. That is the goal, isn’t it? All that is required is a thoughtful guide—you!
1. International Association for the Study of Pain. Declaration of Montreal. Declaration That Access to Pain Management Is a Fundamental Human Right. Available online: iasp-pain.org/ Declaration of Montreal (accessed on March 8 2019).
2. Yong RJ, Mullins P, Bhattacharyya N. The prevalence of chronic pain among adults in the United States. Pain, 2021; Publish Ahead of Print.
3. Macfarlane GJ. The epidemiology of chronic pain. Pain 2016, 157, 2158–2159.
4. GBD 2016 DALYs and HALE Collaborators (2017). Global, regional, and national disability-adjusted life- years (DALYs) for 333 diseases and injuries and healthy life expectancy (HALE) for 195 countries and territories, 1990–2016: A systematic analysis for the global burden of disease study 2016. The Lancet, 390(10100), 1260–1344.
5. International Association for the Study of Pain. IASP Terminology: Pain. Available online: iasp-pain.org/terminology?navItemNumber=576#Pain (accessed on March 8 2019).
6. Grant D. Mind-Body Dualism and the Biopsychosocial Model of Pain: What did Descartes Really Say? J Med Philos. 2000;25(4):485-513
7. Moseley G, Butler D. Explain Pain Supercharged. Noigroup Publications; 2017.
8. George, E. The Need for a New Medical Model: A Challenge for Biomedicine. Psychodyn. Psychiatry, 2012; 40(3) 377–396. Reprinted with permission. © 1977 American Association for the Advancement of Science.
9. Mischke-Reeds M. Somatic Psychotherapy: ToolBox. PESI Publishing and Media, 2018.
About the Author
Steven Capobianco, DC, DACRB, CSCS, has been a practicing chiropractor since 2003. His professional aspiration is to help people move in a more meaningful way. He supplemented his traditional chiropractic education with a diplomate in rehabilitation from the ACA Rehab Council and is certified as a Strength and Conditioning Specialist from the NSCA and Performance Specialist from the NASM. As co-founder of ROCKTAPE, Capobianco lectures globally on topics related to kinesiology taping, IASTM modalities, myofascial cupping, compressional floss therapies and movement/performance strategies.