Massage Articles

A New Paradigm for the Pain Spasm Cycle

By: Jeffrey J. Budzek, R.N. , L. M.T.

The classic pain spasm cycle has been a model used by massage therapists for decades. There are different variants of it, but the essence remains the same. Pain in an area generates messages to the brain, the response is tightening of the affected area in an attempt to prevent further injury. In many musculoskeletal conditions, this splinting process creates additional pain, which generates additional messages to the brain, causing more pain, and the cycle continues. By interrupting this cycle, the muscles should release.

If only it were that simple. This is only one aspect of the cycle. Massage therapist’s confronted with relieving muscular pain find that the areas of congestion created by the muscle malady is a far more complex chain of events. This complexity is the reason that so many different styles of bodywork therapy tout their litany of success stories. Each therapy addresses entirely different physiological systems, affecting one or two elements of this complex cycle achieving various measures of success. For instance; the fascial therapies affect the fascia, Swedish Massage affects the circulation, Trigger Point Therapies affect the neural system, and so on. This is why a new model is needed that is specifically applicable to the needs of the massage therapist.

The more elements of this complex pain cycle that are simultaneously addressed in therapy, the greater the success rate. This is what led me to develop a new muscular pain model which demonstrates all the elements of this Musculoskeletal Pain Cycle. This new paradigm creates a foundation for the massage therapist. From this foundation the massage therapist can formulate his or her own sequence of therapies in the Medical Massage session so as to best suit the needs of the client.

This new Musculoskeletal Pain Cycle;[ A very simplified illustration of it is shown below ]; displays the complex chain of events that usually manifest after an injury, illness, chronic condition or stressor. It must be noted at the outset that each element reinforces the other creating a snowballing effect. Also important is that any single element in this Musculoskeletal Pain Cycle, especially stress, can initiate this complex chain of events. The nine elements of the Musculoskeletal Pain Cycle, are:

PAIN: Excites the nerves, tightens muscles, activates trigger points, impairs circulation, and can profoundly effects body mechanics. Trigger point therapies, Swedish Massage, and Deep Muscle Therapies exhibit the best results for this element.

STRESSORS: Can be mental, emotional, or physical in nature. Stress can lead to all of the other elements, but especially to muscle tension, circulation, trigger points and pain. Client re-education of posture, sleeping position, and work ergonomics are some areas to review for this element.

INCREASED NEURAL ACTIVITY: Activates stress hormones and the sympathetic nervous system which directly affects muscle tonus, pain, stress, and Intra Articular Pressure. Trigger Point Therapies and specific applications of vibration and percussion yields good results here.

INCREASED MUSCLE TENSION: Directly affects the neural, fascial, circulatory and skeletal systems. Additionally, certain muscle tensions and postures are related to specific emotional states. The Deep Muscle Therapies, Swedish Massage, Trigger Point therapies, stretching techniques and Yoga work well on this element.

REDUCED LOCAL CIRCULATION: Affects muscle tonus, reinforces trigger points, and exacerbates the formation of fascial adhesions. Swedish Massage is the superior therapy for this element along with some of the Deep Muscle Therapies.

TRIGGER POINTS: Affect the muscle tension, circulation, the fascia and the neural pathways. There is debate as to what body mechanism is taking place in the de-activation of these areas. That being said, I have found the Trigger Point Therapies, Stretching and some specific Deep Muscle Techniques to be extremely valuable here.

FASCIAL ADHESIONS: They top off the formation of this capsule of congestion that occurs with the pain cycle. Adhesions directly affect all other elements and respond best to various Fascial Therapies, Stretching and the Deep Muscle Therapies.

INTRA ARTICULAR PRESSURE: This joint compression is a result of localized congestion and directly reinforces all the other elements. Stretching, Yoga and Articular Therapy are best suited for this element.

IMPAIRED BIO-MECHANICS: Is an applied compensation, either consciously or sub-consciously, in response to the whole muscle malady, which, not only reinforces it, but also creates imbalances in other areas of the body, consequently leading to the beginning of a brand new cycle and secondary area of pain.

As you can see, if a singular therapy was applied, [IE. Swedish Massage or Trigger Point Therapy], one or more of the elements of the Musculoskeletal Pain Cycle would be addressed, which would in turn affect several others, generating various results. But if the massage therapist uses a Multi Modality Medical Massage, addressing ALL of the elements simultaneously, the result is a reverse snowball effect.

One last item must be noted, the longer a muscular condition exists, the more compounded it becomes, affecting additional muscle groups, creating secondary pain areas, and increasing the duration of time it takes to reduce the original malady. In these cases both the original and secondary pain areas may need to be addressed simultaneously.

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Jeffrey J. Budzek, R.N.,L.M.T. is owner and director of the Stress Relief Center in Lehigh Township [Northampton], PA. He is a Registered Nurse, Licensed in the state of New Jersey and the Commonwealth of Pennsylvania. A 1983 graduate of the Central Ohio School of Massage, Jeff is licensed by the Ohio State Medical Board and Certified by the ABMP. Jeff Budzek is also a member of the National Association of Nurse Massage Therapists and a Registered Yoga Teacher, Certified in the Kripalu Tradition. He is also listed in the National Directory of WHO’S WHO in Executives and Professionals.

This article appeared in the NANMT, (National Association of Nurse Massage Therapists), offical news publication in 2005.

Articular Therapy, The Missing Link

By: Jeffrey Budzek, R.N., L.M.T

The capsule of congestion created be a muscle malady is the result of a complex chain of events, which I refer to as the Musculoskeletal Pain Cycle. This cycle was stated in the article “A New Paradigm for the Pain Spasm Cycle”, from the NANMT NEWS volume 4, issue 4, Fall 2004. As explained in that article, the more elements of this cycle which are addressed in the massage session the more successful the result. The 9 elements of this cycle are: Pain, Stressors, Increased Neural Activity, Increased Muscle Tension, Reduced Local Circulation, Trigger Points, Fascial Adhesions, Intra Articular Pressure, and Impaired Bio Mechanics.

There are several massage modalities designed to address the trigger points, the fascia, the increased neural activity, the increased muscle tension and the local circulation. There are also bodywork modalities that focus on the bio mechanics and movement patterns; such as the Alexander Technique and Feldenkrais. In addition to several of the massage modalities, hypnosis and Dr. prescribed muscle relaxants, can also work directly on the pain element, (Yes, I do feel traditional prescription medication can work hand in hand with massage). However, I found no massage modality to effectively address the joint compression and it’s related problems created by the intra-articular pressure. This is an extremely important component that must be recognized in order to maximize healing and possibly promote a reverse snowball effect. Stretching and traction aid in the relief of the intra joint pressure that builds up in response to the increased muscular tension and the binding of the fascia, but they do not address the decreased range of motion, especially from chronic conditions, and the tendon displacement from the taut and constricted muscles that are associated with this aspect of the cycle.

It is questionable that any other therapy competently addresses this aspect of the Musculoskeletal Pain Cycle. A therapy is needed, within our scope of practice, to focus on this crucial element. In my quest to find a massage technique to effectively broach this missing link, “Articular Therapy” was created. It has since become a complex set of techniques. To simplify it down to its basic roots, it is a systematically applied approach of stretching, passive range of motion and joint mobilization procedures. When stretching is applied to an affected area at the latter part of a medical massage session, and is immediately followed by movement (passive range of motion and joint mobilization), the modalities augment each other creating a synergistic effect. This, not only decompresses the joint capsule, but also increases overall range of motion, increases local circulation, stimulates biological activity by moving synovial fluid, helps maintain the extensibility and tensile strength of the articular and periarticular tissues, ameliorates the tendon and ligament displacement and is an important source of proprioceptive feedback.

A quick follow up of the basic procedures of Articular Therapy are as follows: (1)The stretching techniques I use are: a basic static stretch (simple but effective), and also PNF (proprioceptive neuromuscular facilitation), a very powerful stretching technique used in MET (Muscle Energy Technique). (2)The passive range of motion of the Articular Therapy, or arc stretching procedures, is when the bony lever is used to stretch and move the joint (this is the basic range of motion you learned in massage school). Precautions should be used here if there is any joint injury or trauma present. (3)The Joint Mobilization used in the Articular Therapy is different from range of motion. In Joint Mobilization there is no movement of the bony lever which is usually described as flexion, extension, abduction, adduction, and rotation of the range of motion exercises. Instead, the articulating bone surfaces are moved, within the joint, in a variable combination of sliding, rolling, or spinning within the joint capsule, with minimal movement of the bony lever. The movement occurs within the joint capsules dispensability or give. These movements are actually necessary for normal joint functioning through it’s range of motion and are easily performed, passively, by the massage therapist, but these movements cannot be performed actively by the client.

In Medical Massage sessions at my center, the last 10 to 15 minutes is spent on these stretching, passive range of motion and joint mobilization techniques of Articular Therapy. The affected joint as well as joints in the referral areas must be treated in order to obtain maximum results. For example: If neck tension is the primary complaint being treated, then stretching and range of motion of the neck must, of course, be performed. In addition, the shoulder joint needs to be stretched and have passive range of motion applied along with the joint mobilization techniques of shoulder rolling and translateral sliding, since the shoulder intimately shares several muscles with the neck and will always be affected in neck problems. The shoulder, therefore, must be released in order for the neck to let go. The wrist, hands and fingers, and sometimes the elbow, must be worked in a similar manner because they are also in the referral areas from the neck and shoulder.

These Articular Therapy techniques, when performed with the Medical Massage session, have been of paramount importance with such issues as: Thoracic Outlet Syndrome, Carpal Tunnel, Frozen Shoulder, Neck Problems, Headaches, Sciatica, Sacral Iliac Problems (Lumbago) as well as most knee and ankle issues I’ve treated.

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This article appeared in the NANMT, (National Association of Nurse Massage Therapists), offical news publication in 2005.