Sometimes called arthralgia, joint pain can limit many daily activities that we often take for granted, and it does not necessarily mean the treatments always focus on the joint itself. Different kinds of joint pain can rear different types of symptoms, including inflammation, swelling of the tissues at the joint — and, of course, pain.

Clients and patients often see a massage therapist or another manual therapist for various types of joint pain, such as back, neck, shoulders, hips, and knees. Joint pain can be caused by external (e.g. contact injury, wounds) or internal factors (e.g. arthritis, sprains, bursitis), and one may increase the risks of sustaining the other type of pain, such as acute or chronic.

A typical approach that most manual therapists would do is to silo joints. That means most of the treatments, assessments, and focus are almost entirely about that specific joint.  Sometimes they may take little regard to other factors that contribute the pain experience.

This is not to say that anatomy and physiology does not play a significant role in pain behind your knee or another joint. There are so many different causes of joint pain that there is unlikely a single causal relationship. Since pain is a biopsychosocial experience, clinicians must consider factors beyond structures and tissues.

In 2019, a team of researchers, led by Dr. J.P. Caneiro from Curtin University in Perth, Western Australia, suggested “five actions” to change how physiotherapists—and perhaps among other manual therapists—manage and treat musculoskeletal pain. They highlighted that such pain “share common biopsychosocial risk profiles for pain and disabilities,” and there are already guidelines for best practice that clinicians should follow, “irrespective of body region.”

Go beyond the “bio” factors of joint pain causes

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Diane Jacobs outlines the principles behind DNM at the 2017 San Diego Pain Summit. Photo: Nick Ng

Whether it is biomechanics or biology, current trends in massage and other manual therapy treatments and assessments often focus on these factors. These would include examining posture, joint range of motion, and imaging. Therapists need to hone their communication skills to identify other potential factors of pain, such as how patients cope with pain, lifestyle, habits, what beliefs they have about pain, and other diseases or disorders that may be coexisting with the joint pain.

Caneiro et al. suggested that physiotherapists use the Örebro Musculoskeletal Pain Questionnaire, which is used to predict the outcomes of patients during a treatment and the barriers to recovery. It has 25 questions or statements where 21 of them are rated on a ten-point scale.  Higher scores mean higher disability.

“Musculoskeletal pain disorders need to be assessed and managed within the biopsychosocial framework,” said physiotherapist Jay-Shian Tan, who works at Flex Physio in Perth, Western Australia. He is also a Ph.D. candidate at Curtin University. “There are some practitioners who work largely on ‘bio’ only, some who work psychosocial only, and some who do all of it, depending on their approach and patient type.”

Tan said that the first thing a healthcare professional would do is to look for “red flags,” which are conditions that are potentially dangerous, like cancer, infection, or progressive neurological conditions.

“Those conditions have specific management,” Tan explained. “For instance, if someone has a history of cancer, they have a larger chance of having some cancer that metastasize in the proximal humerus. That can masquerade as an arthritic shoulder or adhesive capsulitis — or frozen shoulder. If the person does not have a history of cancer, then you diagnose it as osteoarthritis or frozen shoulder.”

Tell me about your joint pain story

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The interaction between the therapist and the patient can also affect how they feel after a treatment. Photo: Penny Goldberg

Patients and clients tend to expect the therapist to be an authoritative figurehead who can identify their root cause of pain and “fix” it, but this may  not be the ideal approach for either party. Therapists should use open-ended questions that allow patients and clients to tell their pain experience.

For example, ask “What do you think is the cause of your pain? And why?” or “What do you do when the pain flares up?” or “If you don’t have low back pain right now, what would you do today or tomorrow?”

This may seem like a breach of scope of practice where manual therapists might cosplay a psychologist, counselor, or another mental health professional. Thus, there is a fine line that they must consider that differentiate both professions.

“There are things like motivational interviewing, acceptance commitment therapy, and cognitive behavioral therapy, which—obviously on their own—are not things that we do,” said Erica DeNeve, who is a registered massage therapist in Edmonton, Alberta, and a board member of Pain Society of Alberta. “But there are components of them that absolutely fall within what we do, especially if we’re talking about the biopsychosocial model.”

DeNeve gave an example with acceptance commitment therapy (ACT), which involves patients exploring the relationships among their emotions, thoughts, and behaviors.

“We can use these basic ideas without getting into, ‘Okay, we’re gonna be using this to address your neurosis,’” she said. “Talk to them like, ‘When you have pain coming up, here’s how you can look at that. I talk to patients all the time about this. ‘Okay, here’s how you can reframe those thoughts to help turn down the alarm bells in your nervous system so your brain stops sending out pain signaling.’

“That basic ‘pain science’ talk is what I use with every single patient I see within the first two or three sessions. Here is how your brain works, here is why you have this pain experience, and this is what you can do to modify it.”

Sometimes people get a massage not just for the sole purpose of pain relief or the experience, but it is also a way for them to socialize.

“Every person has thoughts and feelings, right,” Tan said. “You might go to your hairdresser to get a haircut, while somebody else might go to a hairdresser and have a good, old chat, and they enjoy that chat because it’s part of the experience of getting a haircut.

“Massage therapy, from the way I understand it, is that there are two intents people have, which are ‘I’m going there to get treatment for this problem’ or ‘I’d like to go through the experience of getting a massage because it’s pleasant.’ And they overlap a bit. Within that, you have an interaction. You talk to your client and ask them what they’d like done, and some people are there to describe their problem and have it managed. Some people just like a good, old chat, and they get a lot of benefit from that.”

Tan also emphasized that the interaction itself between the therapist and the patient is also another vital part of the treatment without stepping over scope of practice. It is part of being human.

Personalized joint pain relief education

Rather than dispensing information in a one-way path (e.g. therapist speaks, patient listens), have patients be part of the learning, such as providing interactive online resources, have them write down their daily experiences about pain, and exercise therapy as a way to help dispel myths about pain and movement.

Of course, this is not a one-size-fits-all format. Each patient would have a different approach to pain education.

Build independence, not reliance on joint pain treatment

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Give patients the tools and knowledge to be more independent, such as reliable website for information and how to filter good information from the bad on social media. Photo: Nick Ng


Some patients might need a little boost to help reduce disability and pain to become more independent from treatment. Therapists should teach patients how to keep track of their progress and ways to self-manage their condition.

For some people, it would be a cinch; for some, it can be an excruciating journey to independence. Caneiro et al. emphasized that therapists should address “unhelpful cognitions,” such as the patients’ negative self-talk, “physical barriers to recovery,” such as building strength and endurance and reducing movement avoidance behaviors, and lifestyle factors, such as sleep, regular physical activity, and position social interactions.

Tag team with other health professionals

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Dr. Silje Endresen Reme speaks with physiotherapist Sigurd Mikkelsen during a break at the 2018 PainCloud Conference in Oslo, Norway. Photo: Nick Ng

Much like the diverse crew that creates a movie or completes a successful heart transplant, manual therapists should establish a network of other healthcare professionals to refer out. Sometimes patients with chronic pain have other diseases or disorders that are outside of the therapists’ scope of practice, such as diabetes, eating disorders, and trauma from domestic violence.

“It is the responsibility of the massage therapist or physio to suggest a referral,” Tan said. “In a healthcare setting, if someone is having threats of suicide, it’s the responsibility of the physios to contact the patient’s doctor, making sure that they are fully aware of that presence. [The physio] would write a letter and give a phone call to the doctor, making sure that they will follow up on the patient.”

The diagnosis of the type and source of pain would be different, but pain management would be similar. We may know all the anatomy and physiology about knee pain or SI joint pain, but if therapists miss out the patients’ narrative and have poor communication skills, probably no amount of stretching or skin pushing would give them the pain relief they need.

For more information about practical applications of the “five actions,” visit: Musculoskeletal Framework for an ebook. Purchase will go 100% back into research funding.

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A native of San Diego for nearly 40 years, Nick Ng is an editor of Massage & Fitness Magazine, an online publication for manual therapists and the public who want to explore the science behind touch, pain, and exercise, and how to apply that in their hands-on practice or daily lives.

An alumni from San Diego State University with a B.A. in Graphic Communications, Nick also completed his massage therapy training at International Professional School of Bodywork in San Diego in 2014.

When he is not writing or reading, you would likely find him weightlifting at the gym, salsa dancing, or exploring new areas to walk and eat around Southern California.