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Need to know:
 Acute pain
 Chronic pain
 Intractable pain
 Pain evaluation
 Pain characteristics – location, types, intensity, severity, pattern
 Pathophysiology and neurophysiology of pain
 Common clinical presentations of clients with pain
 Massage techniques specific to pain
 Home care specific to pain
Pain is associated with nociception and tissue damage. The body reacts to pain
to prevent excessive tissue damage. Spinal cord reflexes remove body parts
from painful stimuli. CNS excitability stimulates the SNS response.
Pain is processed in the spinal cord and travels to the thalamus and cortex where
it is modulated. Signals from there areas as well as the cerebellum inhibit the
pain signal transmission at the spinal cord where the pain signals entered, thus
decreasing the person’s level of pain sensitivity.
Endorphins and other chemicals are also produced in the brain in response to
incoming stimuli, which modulate the perception of pain
Massage therapy can:
 help to block the pain signals (gate control theory)
 increase local circulation to remove noxious irritants
 induce a feeling of well-being further reducing pain perception
Specific massage techniques:
 ischemic compressions and muscle stripping can reduce trigger points
and hypertonicity
 effleurage, petrissage, joint play …. block the slow-transmitting pain fibers
 stretching and ROM restore joint movement
 frictions reduce painful adhesions
Types of Pain
Radicular pain – nerve root compression, sharp shooting pain associated with
other neurological signs such as paresthesia or muscle weakness
Cutaneous pain – superficial tissue damage, sharp, bright, burning, localized
Deep somatic pain – muscles, tendons, joints and periosteum, diffuse, can refer
to other areas of the body based on embryological development
Visceral pain – visceral distension or ischemia or GI contractions, diffuse pain
Referred pain – from cutaneous, deep somatic and visceral tissue, well localized
pain but is referred to a remote site from the original lesion
Functional or psychogenic pain – emotional source but experienced as if it
comes from an organic disorder
Bone pain – deep, boring, localized
Vascular pain – diffuse, aching, poorly localized
Muscle pain – dull, aching, often hard to localize, pain with stretch or contraction
Inert tissue pain (ligament, joint capsule, bursa) – similar to muscle pain, but
pain appears when the structure is stretched or pinched
Pain is influenced by emotional state, culture, past experiences, learned
behaviors and motivation
Pain, especially chronic, can be accompanied by depression and anxiety
Everyone’s pain perception is different so do not judge a person’s pain or
perceived pain
Use pain questionnaire, thermometer or visual analog scale
Systemic pain vs Musculoskelatal Pain
Systemic pain
 Disturbs sleep
 Deep aching or throbbing
 Reduced by pressure
 Constant or waves of pain and spasm
 Not aggravated by mechanical stress
Musculoskeletal pain
 Generally lessens at night
 Sharp or superficial ache
 Usually decreases with cessation of activity
 Usually continuous or intermittent
 Aggravated by mechanical stress
Pain Behavior
Guarding – stiff, rigid movement
Bracing – fully extended limb supports an abnormal distribution of weight
Rubbing the painful area
Grimacing, sighing
Red flags – need medical consultation
Severe unremitting pain
Pain unaffected by medication or position
Severe night pain
Severe pain with no history of injury
Severe spasm
Psychologic overlay
Acute Pain – 7-10 days
Subacute Pain– 10 days to 7 weeks
Chronic Pain– longer than 7 weeks
Constant – chemical irritation, tumors, visceral lesions
Periodic or occasional – mechanical, related to movement and stress
Episodic – related to specific activity
Health History Questions
Age – growth issues vs degenerative causes
Occupation – affects muscle strength, susceptibility to injury, overuse
Trauma – mechanism of injury, MVA – how?
Onset – sudden or slow, changes as the day progresses
Initial location
Movements that cause pain
Pain at rest
Aggravating factors
Relieving factors
Previous experience with same pain
Pain increasing or decreasing
Constant, periodic, episodic or occasional
Sleeping position
Sleeping pattern
Mattress – soft, hard
Pillows – foam, feather, buckwheat, how many
Joint locking, clicking, twinges
Changes in skin colour
Life or economic stress
Chronic or serious systemic illness
Family history of tumors, arthritis, heart disease
Pain that stops with rest – mechanical problem such as adhesions
Morning pain and stiffness that improves with activity – chronic inflammation and
Pain that increases during the day – congestion in a joint
Pain at rest and worst at the beginning of activity than at the end – inflammation
Pain not affected by rest or activity – bone pain, systemic disorders, cancer
Intractable pain at night – serious pathology, tumor
Peripheral nerve entrapment – worse at night
Pain and cramping with prolongued walking – lumbar spinal stenosis or vascular
Intervertebral disc pain – aggravated by sitting and bending forward
Facet joint pain – relieved by sitting and bending forward
Massage Therapy
Acute pain
Light techniques proximal – vibrations, effleurage, stroking
Drainiage techniques if edema is present
Shaking and rocking
Goal is to increase circulation proximally and treat compensating
Cold hydrotherapy
Subacute pain
More pressure but still use caution especially near/on site of pain
Cold hydrotherapy or cool/warm contrast hydrotherapy
Goal is to increase circulation, address hypertonicity of surrounding
muscles, treat compensating structures
Chronic pain
Pressure can vary from light to deep
Light pressure may be beneficial for an individual with chronic pain as a
way to relax and help them cope with the stress of their pain
Deep pressure can treat muscle hypertonicity, trigger points, scar tissue
Any hydrotherapy is appropriate, heat is most common
Breathing exercises
ROM exercises
Full body exercise – walking program
Stretching program
Attention to diet
Yoga, tai chi
Support groups