Moving
Out Of Pain: Hands-On or Hands-Off
Rosemary
McIndoe
Paper
given at “Moving in on
Pain” Conference, Adelaide,
1995
Moving out of pain is the objective but practitioners
continue to debate about the best way this can be achieved.Practitioners
using ‘hands-on’ approaches presumably operate from the
assumption that ‘hands-on’ work is necessary. In contrast,
some programs advocate ‘hands-off’ approaches actively
discouraging ‘hands-on’ work. Who is correct? From the
patient’s point of view it is difficult to see how self-management
can compete with the allure of ‘hands-on’ therapy. Self-management
requires a shift in the focus for responsibility from practitioner
to patient. Who would opt for taking responsibility if a practitioner
is promising to fix the problem. It can take years for a person
with chronic pain to be referred to a self-management program because
all the other options are explored first. It is often seen as the
last resort, something to be tried when all has failed. Yet why
can’t self-management be combined with other ‘hands-on’ therapies
in the early stages of the problem? This would eliminate the need
to choose one or the other and the transition from ‘hands-on’ work
to full self-management can be gradual and supported by the therapist.
By looking at a selection of physical therapies and a self-management
approach, the question of ‘hands-on’ or ‘hands-off’ will
be explored and possible solutions proposed.
Why
Self-Management?
It is common for people in pain to attend practitioners for months or
even years and report little or no progress. Perhaps they get some symptomatic
relief but the pain persists and they return week after week. Some say
they hope the treatment will eventually solve the problem: others say
they can’t manage without it. Fear of symptoms increasing if treatment
is discontinued can also keep patients in a dependent relationship.
Self-management,
on the other hand, can incorporate skills for self-help
and self-healing including relaxation training, a
graduated exercise program, education about chronic
pain, cognitive behavioural therapy and support (see
McIndoe, 1994). The aim of such a program is to restore
a life shattered by chronic pain and in the process
to provide pain relief. Instead of waiting for the
pain to go before starting to live again, patients
are encouraged to start living first. Frequently
pain reduction is the outcome or at least the pain
becomes less bothersome.
Self-help is about
letting someone help themselves, not trying to fix
them or remove the problem. Many treatments provide
short term symptomatic relief but tend to create
dependency in the process and certainly don’t
solve the problem. Treatment could even provide a
disincentive for a person to start actively developing
their own resources. They may keep searching for
the treatment that will solve the problem.
In this age of reliance on increasingly sophisticated technology it can
be easy to forget that people have a remarkable capacity to heal themselves.
The key to self-healing is creating an environment to facilitate healing
and reawaken the healing potential in the person experiencing chronic
pain. It is a paradigm shift for both practitioner and patient: a medical
model to a self-healing model, or a change in focus from outer resources
(medication, manipulation and machines) to inner resources (relaxation,
exercise and attitudinal change). The person in pain needs to learn to
take responsibility and the practitioner can support them in making the
shift. Top of Page
Reasons
For The Failure Of Conventional Treatment
Conventional treatment is often based on the following assumption: “Physical
treatment for a physical problem”. If the nature of the physical
problem cannot be determined then the problem must be in the patient’s
mind. This approach symbolizes the dualism of medicine, the split between
body and mind. Yet there is another perspective where no clear distinction
between body and mind is made, they are viewed as being in constant communication.
What happens to the body affects the mind and likewise mental events
register as changes in the body. Figure 1 shows a model which helps to
explain how the mind and body interact in chronic pain. Both physical
and emotional stressors can contribute to the development of pain whether
there is an injury or not. When a negative cycle of thoughts and feelings
develop as a result of the persons expectations, advice they are given,
prior conditioning and current life circumstances, a pain amplification
or sensitization state can develop. The body responds to this pain amplification
state with an increase in muscle tension, guarding, restriction of movement
and postural changes. This in turn leads to more pain and the establishment
of a chronic pain cycle. Most importantly, once the pain cycle is established
pain can persist independent of the original injury. In addition to the
mind-body cycle, the inner reflex cycle of pain and spasm frequently
develops and becomes habitual. Table 1 summarizes the consequences of
this mind-body model.
The model makes it clear that physical treatment alone cannot break the
pain cycle. It can provide temporary relief but once the mind reacts
to further pain and difficulties, physical symptoms will return. Similarly,
working with the mind alone is unlikely to break the cycle. The greatest
impact will come when the pain itself, the mind and the body are addressed
with an integrated program or by a multidisciplinary team. Above all,
self-management is essential. It is extremely unlikely that someone else
can fix the problem once the cycle is established.
Conventional treatment for chronic pain fails because there is rarely,
if ever, just a physical problem with a physical solution. The Gate Control
Theory of Pain (Melzack and Wall, 1965) provides an explanation for the
diverse influences on the person’s perception of pain. Pain is not
only a function of the amount of tissue damage but is influenced by a
tension, anxiety, suggestion, prior conditioning and other psychological
variables. This must be taken into account at every phase of treatment:
in diagnosis, selection of treatment, actual treatment, and assessment
of progress. Although this has been widely accepted for a long time it
is frequently forgotten. Physical treatment is often pursued without
acknowledgment of other influences. Top of Page
Options
For Moving Out Of Pain
Treatment options for moving out of pain include everything from invasive
procedures such as surgery and nerve blocks to massage. The focus here
will be on physical therapies both ‘hands-on’ and ‘hands-off’.
The following selection can illustrate some of the difficulties arising
from adopting one approach over another or integrating one with another:
manipulation and mobilization, functional restoration, Feldenkrais Method,
self-management and massage.
Practitioners’ attitudes to pain vary enormously. The following
are illustrative:
“Stop when it hurts.”
“Ignore the pain”
“Push through the pain.”
“It shouldn’t hurt.”
“It will hurt at first.”
It is not surprising that patients end up confused.
What is the right attitude? Patients often report that mobilization
hurts at the time but they get some relief for a few hours afterwards.
Massage may feel good at the time but hurt the next day. How can
we make sense of all of this?
Many of these approaches are practiced to the exclusion of others. A
manipulative therapist may not take account of functional restoration.
A Feldenkrais practitioner may not be concerned about fitness, and functional
restoration programs may emphasize strength and stability at the expense
of moving with ease. Self-management as the total solution can ignore
the benefits of ‘hands-on’ therapy such as massage. Strength,
mobility, stability, fitness, and relaxation all contribute to full functioning.
Can practitioners afford to practice one method to the exclusion of others,
or even worse, actively discourage other approaches?
Reductionism
or Holism
These different techniques reflect different philosophies. In trying
to isolate one vertebral segment for treatment, the manipulative therapist
clearly supports a reductionistic and mechanistic approach. In contrast,
the Feldenkrais practitioner constantly looks at the way different segments
interact and combine to perform movements. The whole person is more often
the focus than isolated segments. Self-management can incorporate an
even more holistic approach where physical, psychological, social and
even spiritual perspectives are addressed. Undoubtedly arguments could
be mounted for taking a reductionistic view or adopting a holistic perspective
but what about the person in pain? Could it be that important solutions
are missed by adopting one approach over the other? There may well be
a place for incorporating both. If specific weakness or dysfunction is
not treated, a holistic approach may never offer a full solution. Similarly
treating a neck or back without considering the person’s psyche
can lead to frustration and disappointment for both practitioner and
patient. The solution may well be a new generation of practitioners who
are prepared to venture into unknown territory. Physical therapists would
need to be willing to embrace a more holistic approach and likewise the
more holistic practitioners may need to embrace a reductionist approach
at times, or at least support it. Top of Page
The Problem With
Exercise
Part of the answer to the allure of ‘hands-on’ therapies relates
to difficulties encountered with exercise. The following short case studies
illustrate some of the difficulties.
Case 1
Mary has RSD in three limbs and describes her condition as the “spoilt
brat” syndrome: it dictates what she can and cannot do. Her neurosurgeon
has told her that she must walk but do no other exercise. To satisfy
him she walks to the shops daily to get the bread and milk taking one
or two hours and cursing the neurosurgeon all the way home. She uses
hypnosis to get herself home and then cannot keep records of her progress
in walking because the hypnosis makes her forget. She hates exercise
saying that it is purposeless and therefore, getting the bread and milk
creates a purpose but at the same time makes the trip home very difficult.
Her tendency in life has been to get the task done, out of the way, and
consequently the homework for her self-management program is all done
at once even if it causes a flare-up. Mary doesn’t know how to use
a dimmer switch. The light switch is either fully on or off. Pacing herself
doesn’t fit with her drive to get it done and out of the way. With
this attitude, exercise will always aggravate her symptoms. The approach
with Mary was to suggest that she plan to walk only as far as she can
maintain a feeling of enjoyment and liberation. The concept of finding
out how little she could do while exercising, (turning the dimmer switch
right down) was explained. We also discussed ways she could incorporate
stretches into her daily activities to solve the problem of exercise
being purposeless.
Case 2
Barbara had given up. A back injury had left her unable to work and even
carry out basic household chores. She used one or two sticks to walk
and smiled as she related her story. Life had dealt her a very heavy
blow and she was helpless in the face of it. When asked to move her neck,
the range of movement was extremely limited but when she talked her necked
moved through a considerably greater range. It wasn’t that Mary
was putting on her symptoms. It did hurt when she tried to move her neck
because she expected it to hurt and she tried very hard. When she spoke
she was unaware of the movement and was therefore free of expectations
and effort. Mary believed that all movement hurt and would aggravate
her condition. In other words her belief system controlled her activity.
When she was taught to relax as she moved, the range of movement increased
and the pain decreased. Using imagery of herself getting out of the chair
with lightness and ease, prior to actually doing it, enabled her to stand
up with relative ease. Unfortunately Barbara was still involved in litigation
and the disincentive to improve her functioning was strong. These changes
could be seen during her therapy but did not transfer to her general
life and interaction with other practitioners.
Case 3
Ellen arrived for a self-management of pain program wearing a collar
and moving stiffly. One of the activities for the day was juggling. This
was taught in easy steps starting by throwing up one scarf, then two
and three. Finally, the transition to balls was made. Scarves and balls
had to be picked up off the floor so that reaching, bending, and chasing
stray balls were all carried out automatically as part of the fun and
absorption in the activity. It was wonderful to observe this transformation. Top
of Page
Chronic
Pain Myths
One of the traps for both patient and practitioner is using an acute
pain model rather than a chronic one. The acute pain model focuses on
pain as a warning signal which keeps the patient and practitioner vigilant
searching for the cause of the pain. Once the pain has become chronic
it is no longer an alarm indeed it can be a false alarm. Consequently
both the patient and practitioner may need to explore their beliefs about
chronic pain. An important part of the education process can be dispelling
myths about chronic pain.
Myth 1: You have
to learn to live with it
Myth 2: Rest cures
chronic pain
Myth 3: Let pain
be your guide
Myth 4: Hurt is
harm
Myth 5: Real pain
is organic
Myth 6: Search
long enough and you will find the cause and the cure
Myth 7: Abnormal
CT scans validate and explain the pain
A further explanation of these myths can be found in McIndoe and Littlejohn
(1995), but myths 2,3 and 4 are relevant to the question of exercise.
Rest does not cure chronic pain: rather it can be a recipe for disaster.
The need to balance rest and activity is fundamental to good management
and an inability to develop an appropriate balance can lead to failure
of exercise programs. There is no satisfactory rule for rest and activity
because people in pain may need to push themselves sometimes and be gentle
at other times. Following the principle of “letting pain be your
guide” will inevitably lead to an escalating loss of function. When
we acknowledge the multiple influences on a persons perception of pain
we cannot assume that “hurt is harm”. Frequently fear generates
more pain than the exercise itself. It is common for patients to anticipate
pain and even experience an increase in pain before they undertake an
activity. Equally common is the expectation that it will take many days
to recover once they experience a flare-up. Assisting people to challenge
their beliefs about pain and their condition can lead to remarkable changes
in their actual experience with exercise and other activities. Learning
to carry out activities in a relaxed way and with confidence that they
can handle the outcome, is a key to good self-management. They can be
surprised and delighted to find that exercise becomes a tool for pain
relief. Top of Page
Possible
Solutions
‘Movement’ might be a better word than exercise because the word exercise
frightens some people in pain. Fun, play and pleasure will facilitate movement
whilst effort and diligence can inhibit it. However, some people do enjoy the
discipline and routine of daily exercise and others can come to enjoy it. A good
place to start is with gentle movement like that used in the Feldenkrais Method
or hydrotherapy. More vigorous exercise can be introduced gradually. The principle
of ‘movement for enjoyment’ can be adopted in all aspects of an exercise
program: stretching, strengthening and fitness. Learning to move with awareness
is another essential component of successful exercise programs. This requires
concentration and ‘slowing down’. Stretching with awareness has far
less risk of causing a flare-up than rapid and forceful stretches. It can take
a lot of patience to teach a ‘hard driving’ person to slow down and
find an effortless way of moving. However, using approaches like the Feldenkrais
Method is not enough. Fitness and strength may be sacrificed when this is practiced
exclusively. Similarly functional restoration can fail when a person pushes themselves
too hard or fast. The art is in achieving a balance and assisting the person
in pain to become finally tuned to their body so that they know when to stop
and when to push their limits little further. Assistance with creating a daily
routine is also essential. The value of charts, rewards or at least regular checks
cannot be overestimated. Most people find it difficult to maintain exercise programs
even when they are pain free. It is only by daily practice that function can
be restored and movement can become enjoyable and effortless. We can learn a
great deal from the ancient tradition of yoga where daily practice is accepted
as essential. Top of Page
The Promise And
Problems Of Hands-On Therapy
Some programs are promoted as ‘hands-off’ with the assumption
that ‘hands-on’ work creates dependency and may discourage
active participation by the patient. However manipulative therapy, massage
and functional integration (Feldenkrais Method) require ‘hands-on’ work.
How can these therapies be practiced without creating dependency and
at the same time allowing patients to develop their own resources? The
answer to this question is probably complex because each of these approaches
differ in their philosophy and practice. Perhaps some are more suitable
than others for treating people with chronic pain. However some guiding
principles could be developed to allow for the practice of ‘hands-on’ therapy
without creating dependency or even worse, aggravating the condition.
Reactivity
When pain sensitization/amplification develops a person can become very
reactive to touch: even hugs become painful. Therefore it is not surprising
that massage and manipulation can aggravate the problem. Yet some patients
return repeatedly for manipulation or mobilization tensing themselves
in anticipation of the pain. Massage is tried once and not repeated because,
although it felt good at the time, the muscles were sore the next day.
Sometimes the sensitivity can be reduced by further massage and developing
a close rapport between patient and therapist. Indeed this is probably
the guiding principle. Both patient and practitioner need to observe
the level of muscle tension closely and also their attitudes to pain.
If the treatment is increasing muscle tension it should be discontinued.
Interestingly pain can increase after a Functional Integration session.
Not because of the pressure used, but because of the release of muscle
tension. The process of releasing holding patterns can generate pain
initially. However, discontinuing treatment after one session can be
psychologically damaging because it represents another treatment failure.
Again, close observation of attitudes and reactions can help the transition
to work which will provide pain relief.
Dependency
When a patient says they cannot manage without a particular treatment
the warning bell should sound. The best way to avoid dependency is to
introduce self-management practices from the start of therapy. It can
also be helpful to set time limits and review progress regularly. Home
based exercise programs can complement manipulative therapy and the Feldenkrais
Method. Progress with exercises should be checked on every visit so that
the patient is introduced to the idea that they are participating in
the process. Their role is as important, or more important, than the
treating practitioner.
The Healing Power of
Touch
Any manual therapy offers the potential for healing simply through the
power of touch. Touch can provide comfort and a basis for communication
beyond words. However when technique dominates the power of touch can
be forgotten and yet it can so easily be incorporated with whatever technique
is being practiced. It is possible that when the power of touch is forgotten
it could have a detrimental effect. In a busy practice with short appointments
a sense of urgency can be conveyed by touch. This would be counterproductive
in a person who is already tense.
It can also be very comforting for someone whose tests are negative to
have a therapist confirm that there is something wrong. Simply acknowledging
the changes in soft tissue such as local spasm, muscle tension or muscle
imbalance, means a great deal to someone frightened or angry that the
doctors can find nothing.
Touch can be used as a form of biofeedback. Immediate feedback can be
given while teaching relaxation or relaxed movement. It is also possible
to use touch whilst discussing psychological and emotional issues. This
can enhance the communication between therapist and patient and provide
considerable insight for the therapist. It is remarkable how rapidly
issues are revealed when the therapist incorporates touch with talk. Top
of Page
The Future - Integrated
Programs And Practitioners
Pain clinics were established to provide a multidisciplinary approach
because it became obvious that single modality treatment was rarely successful
for chronic pain. Perhaps the same principle could be applied to the
question of ‘hands-on’ versus ‘hands-off’ therapy.
There could be a place for both provided that some guiding principles
are followed. These guiding principles could reduce the pitfalls of particular
approaches and provide a basis for integrated programs and even better,
integrated practitioners. This would involve working with a mind-body
or body-mind rather than one or the other. There would be a place for
reductionism and holism. Both practitioners and patients may need to
participate in a paradigm shift from a medical model to a self healing
model where ‘hands-on’ work becomes a stepping stone to self-management
and more of a tool for education than fixing the problem. Practitioners
working in this way would need to be aware of their attitudes to pain,
movement and touch and the consequences of these attitudes. Likewise
people experiencing pain would need to develop an awareness of their
attitudes. Some possible guidelines are listed below.
Top of Page
Possible Guidelines
‘Hands-on Therapy’
1. Time limits and regular reviews of progress.
2. Passive mobilization always combined with active mobilization.
3. Touch for education rather than a quick fix.
4. Careful monitoring of reactivity.
5. Touch as a form of communication.
Exercise and Movement
1. Movement with awareness.
2. Movement for enjoyment.
3. Learning to move with ease and effortlessness.
4. Exercise for mobility, strength and fitness.
5. Matching the person with the program.
6. Exercise as a habit.
Attitudes to Pain
1. Movement may hurt at first.
2. Pain is not necessarily bad.
3. Hurt is not harm.
4. Cease resisting the pain - learn to be with it.
5. Cease reacting to the pain.
6. Listen carefully to the pain - push limits sometimes and set limits
at other times.
7. Be in the moment - the past and future alter the experience of pain.
The more all treating practitioners are aware of the whole person and
the context of the pain, the less the risk of inappropriate treatment.
Any issues a practitioner is unable to address should be referred on
to an appropriate person and liaison between treating practitioners is
essential for good outcomes. Finally, technique is not enough: attitudes
to pain, touch and movement are integral to all approaches and provide
the link between them. Integrated practitioners would need to be aware
of developing strength, mobility, stability, fitness and relaxation to
restore full functioning.
References
- McIndoe R 1994 “A behavioural approach to the management of chronic
pain:
A self-management perspective”. Australian Family Physician
23:2284-2292
- Melzack R, Wall P D 1965 “Pain mechanisms: a new theory”.
Science 150:971-979.
- McIndoe R, Littlejohn G 1995 “Management of fibromyalgia and
regional pain syndromes”. Modern Medicine 38:56-69.
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