Stress, chronic pain, and advanced massage approaches
A quick Google search for the word ‘stress’ reveals 594,000,000 results – that’s an enormous amount of web space devoted to a term that didn’t even exist in its contemporary connotation before the 1920s! Even Beyonce only turns up 40,600,000 search results! Wherever we look, people are stressed and it is affecting our mental, physical health, productivity and enjoyment of life.
Research estimates that 12.8 million working days were lost to stress, depression and anxiety in 2004/5. Each new case of stress leads to an average of 29 days off work. (http://www.acas.org.uk). Stress has been linked with a host of common illnesses and chronic pain conditions including headaches, back pain, RSI, digestive problems, lowered immune response, fibromyalgia, ME, chronic fatigue syndrome, rheumatoid arthritis, allergies, asthma, cancer and heart complications. Not to mention the psychological counterparts such as depression, anxiety or more serious mental health problems.
Maybe all these conditions sound familiar? That’s probably because they make up the caseload of the majority of working massage therapists in this country! Developing an understanding of the links between physical pain and stress can help us to develop appropriate and effective treatment plans for our clients.
What is stress?
Richard Lazarus, a prominent stress researcher at the University of California, considers stress to be a transaction between a person and his or her environment. He defines stress as “a particular relationship between the person and the environment that is appraised by the person as taxing or exceeding his or her resources and endangering wellbeing.” What this essentially means is that an event can be more stressful for one person than another, depending on their coping resources. The important thing about stress and ill-health is how we react to it. We react to stressors in different ways depending on whether our mind–body perceives them as threats. We all go through a physiological reaction when feeling under threat – the well-known ‘fight or flight’ reaction. The fight or flight reaction leads to physical and psychological hyper arousal that is characterised by muscle tension, strong emotions, rapid nervous system firing and release of adrenaline and other stress hormones. This is useful in a life or death situation i.e.: running from a lion. In contrast, in modern society most stressors are not actually life-threating situations – however, our body and mind react automatically in the belief that they are. We are unable to fight or run because these are socially unacceptable.
As a result, all the effects of the arousal are just carried around inside ourselves leading to hyper arousal becoming a permanent way of life that we come to think of as normal. This leads to long term physiological disregulation causing both psychological distress and physical symptoms such as insomnia, high blood pressure, digestive problems, chronic headaches, backaches and sleep disorders. This creates more internal stress in the body leading to yet more triggering of the stress cycles. Ongoing chronic stress can lead to more persistent and difficult to treat conditions such as fibromyalgia, rheumatoid arthritis and chronic fatigue.
Long before Western psychology and the fields of psycho neuro-immunology caught on, most ancient systems of healing were clear about the role of stress and imbalance as a fundamental factor in pain and disease. Traditional Chinese medicine views imbalance as a primary causal factor in disease, identifying a particular emotion with each organ – joy for the heart, anger for the liver, worry for the spleen, sadness for the lung, and fear for the kidney. Excess or insufficiency in emotions can cause imbalance and therefore ill health and pain. The Hawaiian concept of health is based on the word ‘ola’ which means ‘life’ and the ‘attainment of peace’ with strong root associations with abundant energy. Sickness is called ‘ma’i’ with the root meaning of a ‘state of tension’ – a very clear indication of ill-health being related to stress. The shamanic approach sees all sickness to be self-generated as an effect of stress; the location is simply where the stress is focused. The source of stress is seen as resistance – our desire for things to be different than they are.
What can we do about stress?
Ancient and modern psychological wisdom are both united in agreement that we can deal with the adverse responses of stress by firstly becoming aware of our automatic reactions. Observation (mindfulness) is always the first step to change. Meditation, yoga and qi gong are ancient arts that enable us to become more aware of our bodies and therefore when we are going into a stress reaction. Biofeedback is a modern approach that does the same. By noticing our habitual stress responses we can choose to react differently – using deep breathing, taking a break, exercising – all these actions lead to dissipation of the stress reaction rather than an increasing build up. In this way we can intervene in the vicious cycle that leads to chronic illness and pain.
Advanced massage approaches
In my experience, most chronic pain has an element related to stress and it is just as important to acknowledge and work on this, as it is to work on the soft tissues. Working with stress in treatment involves three broad areas
1. Identifying the potential role of stress in your consultation:
It is important in your consultation to assess the role that stress may be playing in your client’s condition. To do this you will need good interpersonal and listening skills – you need to be able to ask questions sensitively to gauge your client’s stress levels without moving into the role of counsellor. A simple question on your intake form such as ‘on a scale of 1-10 where would you place your stress levels overall at the moment’ can be enough to give you an idea. You can then follow up with reflective questions such as “I see you have placed your current stress levels at an 8. Can you tell me a bit more about that?” Your clients’ responses will enable you to gauge how much of their pain condition may be related to stress – I often find in my clinic that clients with long-term chronic pain conditions such as neck or back pain have led stressful lives over a long period of time, often since childhood. I know that just treating the soft tissue with trigger point or fascial work will not be enough for the long-term resolution of their pain – they will also need appropriate techniques for stress reduction. Of course you should be addressing the soft tissue as well – however, in most chronic pain conditions there is such a habitual response to stress, your good work will constantly be being undone unless you help the client address the underlying cause of the pain.
2. Appropriate bodywork techniques
The first and most important role that bodywork can play is in helping the client to become literally ‘in touch’ with their bodies again. Most people stuck in a vicious stress cycle will be living in their heads, totally unaware of how their bodies are reacting to perceived stressors. I like to start my sessions with some still work – one hand on the sacrum one between the shoulder blades, then talking the client through a brief body scan which enables them to notice how their body is feeling. Start with asking your client to tune into their breath then asking them to become aware of different parts of their body. There are plenty of ‘scripts’ for this in books on meditation or relaxation techniques.
Secondly don’t make your massage too ‘busy’. The client needs a chance to slow down, to notice their body, their breath, to tune into the feeling as your bodywork moves them from living in a state of hyper arousal (dominated by the sympathetic nervous system) to relaxation (parasympathetic nervous system). Include slow, deep strokes, the gentle yet powerful techniques of myofascial release and craniosacral therapy, hot stone work and lots of times where you just sit and hold body parts such as the feet or the head. Finish with talking the client through a body scan where they can notice how their body feels now that is different from before.
3. Appropriate aftercare suggestions
This is the most important part of the process, as you need to empower your client to take control of their own response to stress and help them understand that they have choices around their bodily reactions. The simplest and most helpful exercise you can teach your client is a basic breathing exercise. Just encourage them to spend five minutes every day noticing the breath – the in breath and the out breath, how it feels in the body, whether it is short or long, deep or shallow, the sound of the breath and how they imagine the breath looks in the body. Encourage them to use as many of the senses as possible while noticing the breath. If they find themselves in a stressful situation they should aim to just tune into the breath for a minute or so. Sounds simple yet observation of the breath is the basis of most relaxation, meditation and spiritual practices.
Encourage your client into self-help practices such as Yoga, qi gong, tai chi or meditation classes. I also highly recommend the eight-week mindfulness-based stress reduction classes (MBSR) based on the work of Jon Kabat Zinn that provide a simple and effective programme for dealing with stress.
I leave you with the wise words of Thich Nhat Hanh –the one step instruction to a stress free life! “Breathing in, I calm body and mind. Breathing out, I smile. Dwelling in the present moment I know this is the only moment.”
― Thich Nhat Hanh, Being Peace ! CHW
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