As professionals who help people achieve non-invasive pain relief, massage therapists are continually working with clients in chronic pain. When massage treatments don’t seem to break a chronic pain cycle, it is easy for therapists to think they are not delivering top-notch care. However, the most seasoned experts know that is not necessarily the case. When unresponsive to skilled bodywork, chronic pain often persists because of the perpetuating factors involved. If not getting the results they had hoped for, therapists who help their clients identify the responsible perpetuating factors can facilitate the realization of long-term pain relief.
Detecting a perpetuating factor behind chronic pain can be compared to the struggle with fixing a computer that is not operating properly. A person’s first instinct might be to turn the computer off and reboot it, or to clear up space on their hard drive. If that doesn’t work, getting help from others can help determine the cause of the problem. Calling a technical support associate typically involves a progressive series of assessments to try and reveal any number of possible aggravating factors. Often times, a setting deep within the computer’s operating system is found to be responsible for a computer’s suboptimal performance. Similarly, massage to relieve muscle tension may be insufficient if a daily pattern or internal imbalance is locking the body into a cycle of chronic pain.
All too often, one factor will initiate the development of a myofascial trigger point, and another factor will perpetuate it. For example, a trigger point could be activated from the force of a car accident and poor workplace ergonomics can perpetuate that trigger point. The more perpetuating factors a massage therapist can identify and guide clients to correct, the greater chance he or she will have at helping people overcome chronic pain.
Travell and Simons’ hallmark text, Myofascial Pain and Dysfunction: The Trigger Point Manuals, describes perpetuating factors as things that perpetuate myofascial pain due to muscle trigger points. Claiming them to be the most neglected part of managing myofascial pain syndromes, Travell and Simons categorized these factors as being either a mechanical, nutritional or metabolic/endocrine inadequacy:
- Mechanical Perpetuating Factors – These are forces that act on the external body. Mechanical perpetuating factors could include working conditions, such as standing all day on a concrete floor, typing on a keyboard for hours on end or bagging groceries for eight hours straight. Sitting for long periods of time, having poor posture or anatomical anomalies (like having genetically short upper arms) can also be at the root of a chronic pain cycle. Other factors in this category include using a cane that is the wrong height, wearing restrictive clothing and asymmetry caused by carrying a wallet in the back pocket.
- Nutritional Perpetuating Factors – Vitamin and mineral inadequacy, insulin resistance and other nutritional imbalances are common perpetuating factors of chronic pain. Often seen when specific bodywork only produces transient relief of symptoms, a nutritional insufficiency will perpetuate active trigger points. Common deficiencies perpetuating chronic pain include Vitamin D, Vitamin B1, Vitamin B6, Vitamin B12, folic acid, Vitamin C and serum ferritin (the iron available to muscle tissue).
- Metabolic/Endocrine Perpetuating Factors – This type of inadequacy can impair the internal metabolic rate of muscle, forcing the muscle into an energy crisis. The most common metabolic perpetuating factors are suboptimal thyroid function, hyperuricemia and hypoglycemia.
For most bodyworkers, detecting a mechanical cause is likely much easier than recognizing a nutritional or metabolic one. Symptoms accompanying pain are usually the biggest clue that an internal imbalance is present. If not due to a lack of sleep from the pain, persistent fatigue is the number one clue that something more is going on. Fatigue can be caused by many different nutritional or metabolic inadequacies, ranging from a lack of Vitamin B or iron deficiency to hypothyroidism. Additional symptoms indicating a nutritional or metabolic factor is perpetuating chronic pain may include:
- weight gain
- cold extremities
- depression or anxiety
- eye and face puffiness
- ridged or split fingernails
- pale complexion
Referring out to a nutritionist, endocrinologist or other health professional is advised when nutritional or metabolic perpetuating factors are suspected.
Although not a comprehensive list, some other perpetuating factors that don’t fit neatly into the three categories described by Travell and Simons are:
- irritable bowel syndrome
- painful menstruation
- polycystic ovaries
- vision problems
- shallow breathing
Massage therapists are certainly not expected to be master medical diagnosticians. Nonetheless, being aware of the broad range of perpetuating factors can help teach clients to approach their pain like a detective or computer technician. While massage therapy is certainly capable of relieving myofascial trigger points, perpetuating factors will keep bringing the pain back. Upon recognizing culpable perpetuating factors, bodyworkers and recipients can take ultimate corrective action – the only surefire way to be pain free.