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practices a massage therapist can perform. Understanding how the musculoskeletal system functions, the physiology of injuries and pain, and the corresponding physiology of our treatment approaches is paramount to quality massage. When we understand the physiology and science behind what we are doing, we can apply our work more appropriately and generate better outcomes for our clients. Clinical reasoning and comprehensive assessment are still the basic groundwork for responsible and effective treatment of musculoskeletal conditions and pain. Let's take a look how these research findings might affect our approach to specific issues our clients may experience. Musculoskeletal Conditions Traditional treatment revolves around treating pain at the site of sensation. This still holds true for many types of conditions. For example, let's say we discover through our orthopedic assessment a palpable defect in the muscle that is disproportionately painful to the surrounding tissue. There are also significant factors in the history that indicate a potential acute muscle strain. The primary treatment goals will still be facilitating healthy rebuilding of scar tissue, encouraging tissue remodeling, and returning to optimum function. In this instance, we treat the condition, and generally the pain subsides as the soft-tissue dysfunction is addressed. Chronic Pain A key lesson from current pain science is that in our evaluations we might consider that our client's chronic-pain condition may not involve significant tissue injury, postural malalignment, biomechanical alterations, or other tissue-based causes. These various factors may have initially played an important role in the pain condition. However, as time has progressed and the tissues have healed, pain may persist due to sensitization in the nervous system. This is certainly not the case in every chronic-pain condition, but it can be a factor in a number of them. Another concern occurs when pain persists for a long period of time. In these situations, various psychosocial factors may be playing a key role for some clients. Massage therapists should be cautious with a focus on these factors because identification and deeper investigation of psychosocial factors driving the chronic-pain experience is generally outside our scope of practice. In these cases, it would be helpful to have a referral network for others that deal with this dimension of the client's treatment. But just because a person has a chronic-pain experience, it doesn't necessarily mean there is a prominent psychosocial dimension to this case. Clinicians shouldn't stop looking at any potential contributing factors, as tissue- based biological challenges can be missed. Pain Volume There are cases, such as severe whiplash, in which pain is so severe that it is difficult to identify which structures are generating the primary nociceptive input. This is what occurs with the concept of ascending facilitation. In these cases, gentle forms of massage are most effective at decreasing the excitability of the nervous system and returning the overall system to homeostasis. A specific technique or modality may not be as important as the quality of touch, interaction between client and therapist, and overall sense of comfort and safety provided for the individual. The primary goal in these situations is to use massage to help turn down the sensitivity of the alarm system. When various pleasurable sensations like massage are experienced, the upper portions of the brain can send signals to lower portions of the brain and spinal cord and block some nociceptive input, thereby decreasing the eventual pain. 72 m a s s a g e & b o d y w o r k m a y / j u n e 2 0 1 8 The San Diego Pain Summit just completed its fourth year, and though it is primarily aimed at physical therapists, it has become an interdisciplinary gathering of practitioners from a variety of fields. This event reflects the growing interest in the research of pain physiology occurring across a spectrum of health- care practitioners. To read more about this event, check out "Reframing Pain: A Conversation with San Diego Pain Summit Founder Rajam Roose," on page 80 of this issue of Massage & Bodywork.