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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.
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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

  1. McIndoe R 1994 “A behavioural approach to the management of chronic pain:
    A self-management perspective”. Australian Family Physician 23:2284-2292
  2. Melzack R, Wall P D 1965 “Pain mechanisms: a new theory”. Science 150:971-979.
  3. McIndoe R, Littlejohn G 1995 “Management of fibromyalgia and regional pain syndromes”. Modern Medicine 38:56-69.

 

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