It’s fair to say that all of us have experienced some level of pain during our lifetimes, it’s simply unavoidable. It’s our brain’s way of telling us if something is potentially dangerous or if there is a threat to our wellbeing. It is also subjective, learnt through our own experiences.
The International Association for the Study of Pain defines it as “An unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage” . This last part, concerning pain as being ‘described’ in terms of tissue damage, is worth pausing on for a moment because it is important to note that pain is 100% illusion. Pain is a response to a stimulus that is processed by nerve endings which then carry a message to the brain where it decides, based on previous experience, whether the stimulus is potentially harmful. If the brain decides the stimulus is potentially harmful it will create a pain sensation in the corresponding region of the body.
Chronic pain, on the other hand, is widely defined as pain lasting more than three months and has a, “complex sensory and emotional experience that varies widely between people depending on the context and meaning of the pain and the psychological state of the person”. 
With chronic pain the issue of ‘central sensitisation’ comes into play. Central sensitisation is when the nervous system gets into a cycle of persistent high reactivity and subsequently maintains pain even after the initial tissue damage may have healed. This is where treatment of chronic pain becomes much more complex as emotional states begin to play an important role in the perception of the pain sensation. For example, it is possible that two people with the same injury and same treatment plan have very different outcomes due to other non-physical factors, such as the psychological, historical and social contexts of the person. Someone who is regularly active, happy at work, has a stable living situation and a good relationship with their therapist will most likely recover more effectively than a person who leads a sedentary lifestyle, is fatigued due to their shift work and feels isolated from friends because of unsociable working hours.
It is vital to note that central sensitisation occurring in chronic pain conditions does not make the pain any less real—it is after all still pain—but it does complicate matters in regards to treatment as the therapist, and indeed patient, is no longer dealing with solely physical tissue problems.
A MODEL FOR TREATMENT
The late George Engel, American internist and psychiatrist, believed that in order to understand and respond adequately to patients’ suffering—and to give them a sense of being understood—clinicians must attend simultaneously to the biological, psychological, and social dimensions of illness.  “He offered a holistic alternative to the prevailing biomedical model that had dominated industrialised societies since the mid-20th century.”  Engel did not deny the important advances of biomedical treatment but demanded a new perspective, saying, “We are now faced with the necessity and the challenge to broaden the approach to disease to include the psychosocial without sacrificing the enormous advantages of the biomedical approach”. 
This model came to be known as the biopsychosocial model (BPS), a call from Engel to include biology, psychology and social behaviour when treating disease. His belief was that illnesses are multifactorial and in biomedicine they were defined in an excessively narrow manner. Reducing medicine in this way, by separating mind and body, was for Engel detrimental to understanding illness and meant the subjective experience of the patient was ignored.
His influence can be seen in the definition of chronic pain above, where it is noted that pain can vary between people depending on the psychological state of the person.
The biological aspect of the BPS model focuses on the physiological causes of a disease. Illnesses have biological factors, for example genetic issues, hormone imbalances or physical trauma. According to Engel’s model the physiological causes alone are not enough for the manifestation of a chronic illness in the body and they will coexist with the following two aspects he includes in his model.
The psychological component of the model suggests there is likely to be an underlying mental health condition that is contributing to the occurrence of an illness. Aspects such as depression and anxiety, negative thinking or loneliness may play a part directly or indirectly. For example, a person with depression may be inclined to self-medicate with alcohol which, in excess, can lead to a multitude of physiological diseases, such as chronic pancreatitis.
The social aspect of the model attributes significance to the environment of the patient, which could include religious belief systems, economic background, close relationships or peer groups, for example. To extend on the illustration above, a contributing reason for a person being depressed might be triggered by a toxic relationship with a close family member.
This model will seem reasonable to a lot of people. In a broad way it can be helpful in assessing an individual’s big picture so that we can understand potential causation factors and, with knowledge of the wider picture, construct a plan of care that takes advantage of the best treatment options, which may not be physiological but psychological, or vice versa.
There is however a danger of the model being too simplistic and it is a concept that has not gone uncriticised within the medical arena. Nassir Ghaemi, psychiatrist and researcher of depression and bipolar, has been one of those critics. Ghaemi states Engel’s model is based on a too simplistic idea of biology and disease, and that in fact biology does in incorporate interactions of genetics and environment into its very definition. He also takes issue with the lack of clear boundaries between biological, psychological and social. Engel offers no clarity on where one discipline ends and the other begins, which can be problematic when developing treatment plans for patients. It also assumes that all three components must be present and go hand in hand.
Despite these valid concerns, the biopsychosocial model does highlight an obligation for care-givers to discern the overall picture of a person’s health in order to provide more comprehensive support.
Certainly, within the realm of massage therapy, it is a helpful tool when trying to determine the contributing factors to a client’s particular complaint. Interpreting a person’s muscular pain symptoms involves not only assessing how they move physically, but also considering how a person uses their body on a day-to-day basis, why they use their body in this way and what pressures are they under physically, emotionally and socially. It is also important to understand how the chronic pain is limiting their life and the cost of this limitation to them, for example not being able to exercise and having the knock-on effect of low mood and energy, or not being able to get a good night’s sleep and missing work deadlines because of tiredness, causing increased stress levels.
Understanding these wider factors enables the therapist and client together to develop a plan of treatment and care that will have the most effective and positive outcomes, both inside and outside the treatment room.
TAKING CARE OF OUR OWN CHRONIC PAIN
The BPS model can be a useful way of thinking about our own chronic aches and pains. Suffering with muscular pain for more than a few months indicates it may be appropriate to step back and observe current habits, responsibilities and relationships, to reflect on how they could be negatively impacting on overall health. The trigger for psychological struggle may be blatantly obvious for some, but often it isn’t glaringly clear, and it may even be something that is hard to articulate. Once a cause, or causes, have been identified, it becomes possible to begin the process of managing it.
If mental health issues are a feature in your life, whether prominent or in the background, then talk therapies are a helpful way of gaining support (Mind offers great information on how and where to find help). And if you don’t feel therapies are appropriate for you then many people manage their mind with exercise, meditation or keeping connected with friends and family. For some it may be running 3k a few times a week, for others playing and making music with friends, a regular yoga class or scheduling a massage once a month. After a few months of utilising your preferred strategies it is worth checking in with your chronic aches and pains again; are they still causing pain, has the pain decreased, have they disappeared completely?
Reflecting on the here and now can be daunting, it requires us to address the things that aren’t making us happy in our lives, but it can also be a good time to look for those things that we can be grateful for too, providing enlightenment and a sense of helpful perspective.
In my treatment room I treat chronic pain on a regular basis. In particular my area of interest is TMD, or temporomandibular disorder, which brings about symptoms related to jaw pain such as pain in the joint of the jaw itself, headaches, neck and shoulder pain, tinnitus and bruxism, to name a few. TMD is considered to be among the inventory of central sensitisation syndromes with links to other CSS conditions, such as IBS and chronic fatigue syndrome.
Fortunately, there are a vast array of techniques available within massage therapy, that have been proven effective in reducing chronic musculoskeletal pain, such as fascial work, trigger point therapy and stretching. But now we have the knowledge that chronic pain—especially those categorised as CSS—is a perception of the brain, rather than an accurate portrayal of what is happening at the tissue level, it is just as important to continue nurturing and reflecting upon our emotional states alongside making the most of physical therapy techniques like massage. A combination of the two is the ideal tool kit needed in order to positively progress with treatment and achieve a better state of wellbeing.
Amy Moffat, July 2018
1. Merskey H, Bogduk N. Classification of Chronic Pain: Descriptions of Chronic Pain Syndromes and Definitions of Pain Terms, 2nd Edition. Seattle, Washington: International Association for the Study of Pain (IASP) Press; 1994.
2. Leslie J. Crofford, MD. Chronic Pain: Where the Body Meets the Brain: The American Clinical and Climatological Association, 2015.
3. Engel G. The need for a new medical model: a challenge for biomedicine. Science. Pub Med, 1977.
4. Francesc Borrell-Carrió, MD, Anthony L. Suchman, MD, Ronald M. Epstein, MD. The Biopsychosocial Model 25 Years Later: Principles, Practice, and Scientific Inquiry. Annals of Family Medicine, 2004.
5. Nassir Ghaemi, MD MPH. The Biopsychosocial Model in Psychiatry: A Critique, Existenz, 2011.