It is very clear that chronic pain is a global health problem, and the evidence suggests that the current health care system is under-prepared to handle the complexity of the problem.1
Pain, which lasts more than three months, affects more than 20% of the American population, with an estimated health care cost of between $ 500 and $ 653 billion per year.2,3,4
What confuses many people with chronic pain is the fact that with all the technological and therapeutic advancements of the past 20 years, why aren’t we doing better? The answer, in my professional opinion, lies in how we identified the problem. Most clinicians, including myself, have been formally trained to handle the machine.
What I mean is that we have been inundated with a biomedical and mechanistic view of healing that focuses its attention on the body. If someone presents with low back pain, the traditional medical process is to treat the local painful area regardless of the individual attached to the body part.
What is pain?
Pain is defined by the International Association for the Study of Pain as an unpleasant sensory and emotional experience associated with potential tissue damage or described in terms of such damage.5
Dissecting this definition with our clients is a valuable opportunity to identify the non-biomechanical influences of the pain experience. Have an open discussion that pain, as noted, might be associated with potential tissue damage is telling for many. This allows us to question the linearity that tissue trauma equals pain and to recognize that the brain plays an important role in the experience. We have hunted down the root cause or what has been described as the pathoanatomical holy grail of pain with little success.6
May I suggest that sometimes gremlin’s search for causal pain can lead to increased fear and anxiety which amplifies symptoms? It is now clear that pain is an output generated by the brain and that it is strongly influenced by many factors, including biological, psychological and sociological inputs.seven
What is not clear, as stated by George Engle, MD, who coined the term biopsychosocial approach, is how pain is diffused by cultural, social and psychological considerations.8 This is where art meets manual therapy.
The key here is how the therapist interacts with the client to find out which component of the biopsychosocial is fueling and addressing their pain, simultaneously, as we intervene with tactile therapeutic modalities. With psychosocial factors in mind, let’s discuss how we can augment our traditional manual therapy practices with some guidelines to follow.
Observe, learn and listen
First, taking a biopsychosocial approach requires the therapist to observe, investigate, and listen more than we have in the past. The goal is to collect information from the person about the significant movement that motivated them to seek care. In short, what makes them move? It could be a tennis serve, a paddle stroke, a swim stroke, a bending motion to pick up a child. Either way, this will be the anchor to focus on rather than the pain.
Meaningful movement is what drives them, not necessarily the pain. So focus on that. The goal here is to distract from the experience of chronic, debilitating pain and address the meaningful movement they seek to return to.
The approach might seem subtle, but the landscape has now changed from one of them as a passively processed body part to an actively participating athlete with a goal of movement. Now, the tool used to help manage movement is integrated with a therapeutic experience to show the client that it is possible to regain the meaningful movement pattern painlessly.
It is essential to go beyond the emphasis on pain and give a feeling of HOPE (Hold On, Pain Ends) that one can return to a sport or to a psychologically and socially significant activity.
ten General Guidelines
Before you embark on applying this approach to manual therapy, here are some general guidelines to consider9:
1. Communication is essential when working with someone with chronic pain.
2. Inform the client about the movement-based approach to your care: “Let’s try an experiment or an exercise”.
3. Validation cannot be overstated. The pain they feel is real to them and it is important that we establish an empathetic alliance, so that they recognize that we are together.
4. The tool (if used) should be presented and explained to enhance scientific effectiveness in practice. This opens the way to a therapeutic confidence in the intervention which psychologically arms the nervous system so that it accepts the process as palliative.
5. Make sure you get buy-in from the customer.
6. Safety first: they must understand that they are in control of the experience.
7. Remind them that the brain and body are flexible to build confidence in the process.
8. Pay attention to psychosocial cues (pupil dilation, breath holding, jaw tightness, tool aversion) – respect limits and adjust if necessary.
9. Track Success — As you incorporate therapy into meaningful movement, be sure to document positive changes.
10. Get feedback and celebrate wins.
Significant Movement experiment: practical example
Client: 62 year old male
Complaint: Chronic shoulder pain
Diagnosis: “Too many birthdays” (idiopathic – no known cause)
In the initial phase of information gathering, it was identified that throwing a baseball with his grandson was the target of significant movement. With that in mind, we started with a careful exploration of the body part with a technique we call body mapping. The therapist will articulate the tool to the fabric with a light feather motion as the client draws attention, non-judgmentally, to the shoulder.
This is because they are responsible for drawing a picture of the body part in their mind. The tool acts as a kind of tuning fork, allowing both therapist and client to better appreciate and connect with the body part in a non-threatening way. As the person gains confidence, the significant movement identified can be explored while using the tool. Combining instrument-assisted technique with curious attention has been shown to alleviate the fear associated with moving the body part. This can and usually does lead to improvement in symptoms as well as confidence in returning to lost movement.
The goal of this approach to manual therapy is to bring the tissue attached person as an active participant in the therapeutic experience. Ask them to join in the process of reconnecting with the body and meaningful movement. That’s the point, isn’t it? All it takes is a caring guide: you!
1. International Association for the Study of Pain. Montreal Declaration. Declaration that access to pain management is a fundamental human right. Available online: iasp-pain.org/ Montreal Declaration (accessed March 8, 2019).
2. Yong RJ, Mullins P, Bhattacharyya N. The prevalence of chronic pain in adults in the United States. Pain, 2021; Publish before printing.
3. Macfarlane GJ. The epidemiology of chronic pain. Pain 2016, 157, 2158-2159.
4. GBD 2016 DALY and collaborators HALE (2017). Global, regional and national disability-adjusted life years (DALYs) for 333 diseases and injuries and healthy life expectancy (HALE) for 195 countries and territories, 1990-2016: a systematic review for the study of global burden of disease 2016. Lancet, 390 (10100), 1260-1344.
5. International Association for the Study of Pain. IASP terminology: Pain. Available online: iasp-pain.org/terminology?navItemNumber=576# Pain (accessed March 8, 2019).
6. Grant D. Body-mind dualism and the biopsychosocial model of pain: what did Descartes really say? J Med Philos. 2000; 25 (4): 485-513
7. Moseley G, Butler D. Explain supercharged pain. Noigroup publications; 2017.
8. George, E. The need for a new medical model: a challenge for biomedicine. Psychodyne. Psychiatry, 2012; 40 (3) 377-396. Reprinted with permission. © 1977 American Association for the Advancement of Science.
9. Mischke-Reeds M. Somatic Psychotherapy: Toolkit. PESI Publishing and Media, 2018.
About the Author
Steven Capobianco, DC, DACRB, CSCS, has been a practicing chiropractor since 2003. His professional aspiration is to help people move in more meaningful ways. He completed his traditional chiropractic training with a Rehabilitation Diploma from the ACA Rehabilitation Board and is certified as an NSCA Strength and Conditioning Specialist and NASM Performance Specialist. As co-founder of ROCKTAPE, Capobianco lectures around the world on topics related to kinesiological taping, IASTM modalities, myofascial suction cup, compression thread therapy, and movement / performance strategies.