Using Massage to Combat Fear-Avoidance and the Pain Tension Cycle

in International Journal of Athletic Therapy and Training
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Massage is a common therapeutic modality utilized by clinicians in a variety of settings to help treat injuries, reduce pain, and return function to patients. Massage benefits the patients both psychologically and physiologically, as patients report less pain and anxiety along with better mood and even decreased blood pressure following massage. Additionally, on the cellular level, massage has the ability to modulate the damaging inflammatory process and, in some cases, influence protein synthesis. Although massage has not been linked to a rehabilitation theory to date, this paper will propose how massage may influence fear-avoidance beliefs, or the patient’s inability to cope with pain that then leads to a pain tension cycle. Pain will often result in use avoidance, which creates muscle tension that further exacerbates the pain. Massage can affect the Fear-Avoidance Model because the beneficial effects of massage can break the cycle by either relieving the patient’s pain or eliminating the muscle tension. A modified Fear-Avoidance Model is presented that conceptualizes how pain and fear-avoidance lead to tension and muscle dysfunction. Massage has been incorporated into the model to demonstrate its potential for breaking the pain tension cycle. This model has the potential to be applied in clinical settings and provides an alternate treatment to patients with chronic pain who present with increased levels of fear-avoidance beliefs.

Hunt, Baez, Olson, Butterfield, and Dupont-Versteegden are with the University of Kentucky, Lexington, KY. Baez is also with Michigan State University, East Lansing, MI.

Hunt (emily.hunt@uky.edu) is corresponding author.
  • 1.

    Melzack R. Pain and the neuromatrix in the brain. J Dent Educ. 2001;65(12):1378–1382. PubMed ID: 11780656.

  • 2.

    Engel GL. The clinical application of the biopsychosocial model. Am J Psychiatry. 1980;137(5):535–544. PubMed ID: 7369396 doi:10.1176/ajp.137.5.535

  • 3.

    Cafarelli E, Flint F. The role of massage in preparation for and recovery from exercise. An overview. Sports Med. 1992;14(1):1–9. PubMed ID: 1641539 doi:10.2165/00007256-199214010-00001

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 4.

    Vlaeyen JW, Linton SJ. Fear-avoidance and its consequences in chronic musculoskeletal pain: a state of the art. Pain. 2000;85(3):317–332. PubMed ID: 10781906 doi:10.1016/S0304-3959(99)00242-0

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 5.

    George SZ, Stryker SE. Fear-avoidance beliefs and clinical outcomes for patients seeking outpatient physical therapy for musculoskeletal pain conditions. J Orthop Sports Phys Ther. 2011;41(4):249–259. PubMed ID: 21335927 doi:10.2519/jospt.2011.3488

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 6.

    George SZ, Valencia C, Beneciuk JM. A psychometric investigation of fear-avoidance model measures in patients with chronic low back pain. J Orthop Sports Phys Ther. 2010;40(4):197–205. PubMed ID: 20357418 doi:10.2519/jospt.2010.3298

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 7.

    Glaviano NR, Baellow A, Saliba S. Physical activity levels in individuals with and without patellofemoral pain. Phys Ther Sport. 2017;27:12–16. PubMed ID: 28780340 doi:10.1016/j.ptsp.2017.07.002

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 8.

    Ross MD. The relationship between functional levels and fear-avoidance beliefs following anterior cruciate ligament reconstruction. J Orthop Traumatol. 2010;11(4):237–243. PubMed ID: 21116674 doi:10.1007/s10195-010-0118-7

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 9.

    Piva SR, Fitzgerald GK, Irrgang JJ, et al. Associates of physical function and pain in patients with patellofemoral pain syndrome. Arch Phys Med Rehabil. 2009;90(2):285–295. PubMed ID: 19236982 doi:10.1016/j.apmr.2008.08.214

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 10.

    Houston MN, Van Lunen BL, Hoch MC. Health-related quality of life in individuals with chronic ankle instability. J Athl Train. 2014;49(6):758–763. PubMed ID: 25299444 doi:10.4085/1062-6050-49.3.54

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 11.

    Baez SE, Hoch JM, Cramer RJ. Social cognitive theory and the fear-avoidance model: an explanation of poor health outcomes after ACL reconstruction. Athl Train Sports Health Care. 2019;11(4):168–173. doi:10.3928/19425864-20181002-02

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 12.

    Rainville J, Smeets RJ, Bendix T, et al. Fear-avoidance beliefs and pain avoidance in low back pain--translating research into clinical practice. Spine J. 2011;11(9):895–903. PubMed ID: 21907633 doi:10.1016/j.spinee.2011.08.006

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 13.

    Leeuw M, Goossens ME, Linton SJ, et al. The fear-avoidance model of musculoskeletal pain: current state of scientific evidence. J Behav Med. 2007;30(1):77–94. PubMed ID: 17180640 doi:10.1007/s10865-006-9085-0

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 14.

    Sparkes V, Chidwick N, Coales P. Effect of The Back Book on fear-avoidance beliefs, disability, and pain levels in subjects with low back pain. Int J Ther Rehabil. 2012;19(2):79–86. doi:10.12968/ijtr.2012.19.2.79

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 15.

    Severeijns R, Vlaeyen JW, van den Hout MA, Weber WE. Pain catastrophizing predicts pain intensity, disability, and psychological distress independent of the level of physical impairment. Clin J Pain. 2001;17(2):165–172. PubMed ID: 11444718 doi:10.1097/00002508-200106000-00009

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 16.

    Baez S, Hoch MC, Hoch JM. Evaluation of cognitive behavioral interventions and psychoeducation implemented by rehabilitation specialists to treat fear-avoidance beliefs in patients with low Back pain: a systematic review. Arch Phys Med Rehabil. 2018;99(11):2287–2298. PubMed ID: 29247627 doi:10.1016/j.apmr.2017.11.003

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 17.

    Waddell G, Newton M, Henderson I, et al. A Fear-Avoidance Beliefs Questionnaire (FABQ) and the role of fear-avoidance beliefs in chronic low back pain and disability. Pain. 1993;52(2):157–168. PubMed ID: 8455963 doi:10.1016/0304-3959(93)90127-B

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 18.

    Main CJ, George SZ. Psychologically informed practice for management of low back pain: future directions in practice and research. Phys Ther. 2011;91(5):820–824. PubMed ID: 21451091 doi:10.2522/ptj.20110060

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 19.

    Nicholas MK, Wilson PH, Goyen J. Comparison of cognitive-behavioral group treatment and an alternative non-psychological treatment for chronic low back pain. Pain. 1992;48(3):339–347. PubMed ID: 1534400 doi:10.1016/0304-3959(92)90082-M

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 20.

    Morone NE, Greco CM, Weiner DK. Mindfulness meditation for the treatment of chronic low back pain in older adults: a randomized controlled pilot study. Pain. 2008;134(3):310–319. PubMed ID: 17544212 doi:10.1016/j.pain.2007.04.038

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 21.

    Best TM, Hart L. A growing concern: the older athlete. Clin J Sport Med. 2008;18(6):477–478. PubMed ID: 19001880 doi:10.1097/JSM.0b013e3181862a4d

  • 22.

    Crane JD, Ogborn DI, Cupido C, et al. Massage therapy attenuates inflammatory signaling after exercise-induced muscle damage. Sci Transl Med. 2012;4(119):119ra113–119ra13. doi:10.1126/scitranslmed.3002882

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 23.

    Haas C, Butterfield TA, Abshire S, et al. Massage timing affects postexercise muscle recovery and inflammation in a rabbit model. Med Sci Sports Exerc. 2013;45(6):1105–1112. PubMed ID: 23274593 doi:10.1249/MSS.0b013e31827fdf18

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 24.

    Field T, Diego M, Cullen C, et al. Fibromyalgia pain and substance P decrease and sleep improves after massage therapy. J Clin Rheumatol. 2002;8(2):72–76. PubMed ID: 17041326 doi:10.1097/00124743-200204000-00002

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 25.

    Hernandez-Reif M, Ironson G, Field T, et al. Breast cancer patients have improved immune and neuroendocrine functions following massage therapy. J Psychosom Res. 2004;57(1):45–52. PubMed ID: 15256294 doi:10.1016/S0022-3999(03)00500-2

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 26.

    Field TM. Massage therapy effects. Am Psychol. 1998;53(12):1270–1281. PubMed ID: 9872050 doi:10.1037/0003-066X.53.12.1270

  • 27.

    Shin MS, Sung YH. Effects of massage on muscular strength and proprioception after exercise-induced muscle damage. J Strength Cond Res. 2015;29(8):2255–2260. doi:10.1519/JSC.0000000000000688

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 28.

    Moyer CA, Rounds J, Hannum JW. A meta-analysis of massage therapy research. Psychol Bull. 2004;130(1):3–18. PubMed ID: 14717648 doi:10.1037/0033-2909.130.1.3

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 29.

    Hemmings B, Smith M, Graydon J, Dyson R. Effects of massage on physiological restoration, perceived recovery, and repeated sports performance. Br J Sports Med. 2000;34(2):109–114; discussion 115. PubMed ID: 10786866 doi:10.1136/bjsm.34.2.109

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 30.

    Haas C, Butterfield TA, Zhao Y, et al. Dose-dependency of massage-like compressive loading on recovery of active muscle properties following eccentric exercise: rabbit study with clinical relevance. Br J Sports Med. 2013;47(2):83–88. PubMed ID: 22736207 doi:10.1136/bjsports-2012-091211

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 31.

    Waters-Banker C, Butterfield TA, Dupont-Versteegden EE. Immunomodulatory effects of massage on nonperturbed skeletal muscle in rats. J Appl Physiol (1985). 2014;116(2):164–175. doi:10.1152/japplphysiol.00573.2013

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 32.

    Miller BF, Hamilton KL, Majeed ZR, et al. Enhanced skeletal muscle regrowth and remodelling in massaged and contralateral non-massaged hindlimb. J Physiol. 2018;596(1):83–103. PubMed ID: 29090454 doi:10.1113/JP275089

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 33.

    Waters-Banker C, Dupont-Versteegden EE, Kitzman PH, Butterfield TA. Investigating the mechanisms of massage efficacy: the role of mechanical immunomodulation. J Athl Train. 2014;49(2):266–273. PubMed ID: 24641083 doi:10.4085/1062-6050-49.2.25

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 34.

    Butterfield TA, Zhao Y, Agarwal S, et al. Cyclic compressive loading facilitates recovery after eccentric exercise. Med Sci Sports Exerc. 2008;40(7):1289–1296. PubMed ID: 18580410 doi:10.1249/MSS.0b013e31816c4e12

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 35.

    Bialosky JE, Bishop MD, Price DD, et al. The mechanisms of manual therapy in the treatment of musculoskeletal pain: a comprehensive model. Man Ther. 2009;14(5):531–538. PubMed ID: 19027342 doi:10.1016/j.math.2008.09.001

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
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