Pain is also incredibly subjective. I recall Doug Nelson pointing out, "Anyone who studies pain, knows the patients are in as much pain as they say they are in, they aren't lying" and "there is no diagnostic exam or image that will show pain. It won't show up on a computer screen".
I've come to understand, in a very broad sense, pain is a symptom signaling something's not right. People who have congenital insensitivity to pain, a rare condition where they can't experience pain, often have miserable, short lived lives.
A few years ago, a coworker of mine (at the time) made the comment, “it seems to me that Massage Therapists should pick only one modality, study it until they master it to the point where that’s the bulk of what they do. It becomes all they’re known for and the only thing they practice.”
This comment bugged me at the time, but I really couldn’t articulate why, so instead of saying “That’s not how I feel about it”, (at the time I really wanted to have a stronger, more justifiable, informed opinion that could explain why I felt a certain way; which feels awkward as I write it, you can't always verbalize a feeling. I digress...) and instead of creating any hostility, I chose silence. But this comment rebounded in my mind until now.
To jump back a bit, by 2009 at least 80% of my sessions were pain related and this motivated me to study pain more. I came to learn all of the following information through study and hands-on workshops.
Here is the definition from the International Association for the Study of Pain (IASP) "Pain is an unpleasant sensory or emotional experience associated with actual or potential tissue damage, or described in terms of such damage."
In The Mystery of Pain, Doug Nelson explores both physical and emotional aspects of pain (with and without tissue damage), phantom limb pain, current treatment strategies (interventions), and a bunch of other really interesting topics. It’s fascinating and written in an accessible style, without a lot of jargon. I’d highly recommend it for both practitioners and those dealing with pain.
You probably heard that pain is complex, and yes it certainly is, but what does that mean? There are 11 major recognized organ systems in the body (12 if you include the fascial system. It would be the largest system, it’s certainly the most medically disregarded; however, we will see what the future brings and also that is another blog post. I digress again…). According to Smithsonian Magazine, there are 37.2 trillion cells in the body (the most current estimate, less if the estimate is by volume and almost 70 trillion if guessing by weight, it’s tricky..)
If by some chance, any 1 of the (12) body's organ systems falter or if how those systems interact with each other isn’t up to par, your brain may receive pain signals (nociceptors). With 12 organ systems and 37.2 trilIon cells, a lot can go haywire.
If anything in the external environment brushes against your skin and causes any tissue damage, you might receive more pain signals. To include but not limited to falls, scrapes, cuts, or any type of accident or blunt trauma.
These examples only include a physical change and don't consider emotional responses, or how thoughts can create pain. Yes, both thoughts and emotions can be responsible for suffering. What's worse, suffering brought on by mental or emotional stress is often largely dismissed as there's usually no tissue damage and often this is a double whammy of pain and skepticism (especially from others).
These examples only include a physical change and don't consider emotional responses, or how thoughts can create pain. Yes, both thoughts and emotions can be responsible for suffering. What's worse, suffering brought on by mental or emotional stress is often largely dismissed as there's usually no tissue damage and often this is a double whammy of pain and skepticism (especially from others).
In The Biology of Belief, Bruce Lipton, PH. D. shows how your thoughts influence and shape cellular behavior. The information in The Intention Experiment, by Lynne McTaggart, was a game changer for me and it was chalk full of different experiments people have done that emphasize the power of focused thoughts.
This March I attended a workshop on treating upper extremity neuropathies. All the other attendees were PTs, mostly from chronic pain treatment facilities. The lecturer spent the final 2.5 hours discussing and showing laterality training, guided imagery, and mirror therapy; it was fascinating. These approaches are all about neuro-reeducation. Witnessing the local PTs embracing this information was super encouraging, it reminded me of Doug Nelson's book and this clip by Lorimer Moseley.
So what do I do?
When focusing on pain treatment, I treat to resolve symptoms from a bodywork perspective. Assessment becomes an essential element because there are so many things that can manifest with similar and often overlapping symptoms. The client's history is vital. Once the pain symptoms that drove the client to seek therapy in the first place have been addressed and calmed, then I can begin to seek their sources. Some likely sources which I often consider and assess for:
When focusing on pain treatment, I treat to resolve symptoms from a bodywork perspective. Assessment becomes an essential element because there are so many things that can manifest with similar and often overlapping symptoms. The client's history is vital. Once the pain symptoms that drove the client to seek therapy in the first place have been addressed and calmed, then I can begin to seek their sources. Some likely sources which I often consider and assess for:
- Trigger points- can often create and refer pain, weakness, and numbness to remote areas, cause a loss in range of motion, swelling, headaches or nausea. They can neurologically inhibit a muscle to prevent it from doing its work and generally refer a sensation to another area, especially seen with an active trigger point.
- Tender points- They can manifest similar symptoms as trigger point, however, they only cause local sensation. Trigger points refer, tender points do not.
- Fascial restrictions- can do all the things that trigger points can especially diminish range of motion. Fascia is heavily influenced by emotion and its restriction feels different than a trigger points chord like quality.
- Neuropathies- Like trigger points, they often refer sensation, cause weakness and can limit range of motion. However, nerve impingements and entrapments tend to refer sensation along their pathway. They don’t like to be stretched, compressed or friction of any kind.
- Lymphatic Impairment- This can cause pain signals, limited range of motion, mimic nerve compression symptoms, and especially make the extremities heavy. However, a typical characteristic of lymphatic impairment is swelling/inflammation. Extra fluid in the area can press on pain-sensitive structures like nerves, muscles or periosteum. When inflammation is present it makes it difficult to tell what’s going on. Its removal becomes a helpful initial step in identifying underlying causes.
- Emotional restrictions- (Considered but not palpated for) Not only is fascia highly influenced, but also restricted emotions may be sending a barrage of constant pain signals to the brain. Without having damaged tissue in need of healing, emotional restrictions can take a longer time to mend. Bodywork can be very helpful at helping to release restricted emotion and beneficial at calming an overstimulated nervous system and restoring emotional well-being
- Somatic pain- often referred to an area of the body by a corresponding organ. Organs are suspended and surrounded by fascia and often supplied by a specific nerve branch. If they get stuck, if the supplying nerve gets pinched or entrapped, or if they become compressed either by an external force (fall or trauma) or by fascial structures (capable of generating 2000lbs of pressure per square inch) painful signals (nociceptors) will be marshalled.
- Dietary allergies or nutrient deficiency- (Again considered but not palpated for) Often we are lacking in nutrients like vitamin D or magnesium or have an unknown allergy to something in our diet. While treating this is outside what I do, it is yet another source of pain for many and a thing that a healthcare professional cannot discount when considering treatment.
- The Unknown- There is so much to consider when treating pain and no one knows it all. An integrated approach may be the best option. The unknown variable must always be an option. As technology advances new and exciting discoveries and observations abound, but we should always consider there may be something we don't know about.
This brings me back to my ex-coworkers comment from the beginning of this post. Specializing and sticking only to that paradigm feels like an inadequate model when treating something as multifaceted as pain. This can often lead to short-sighted treatments. Having a deeper understanding and more treatment options are boons to both the therapist and client. Our bodies are not simply machines, there are a ton of interrelated parts that work synergistically.
Bodywork is very sacred. experiencing other people's vulnerability and grace, feeling their trust is truly humbling. Often after the session, I realize very few other people in that person's life touches them in this meaningful way. This thought makes me pause and be grateful that I get to do bodywork. I’m constantly awed by what can be treated manually; it's amazing!
When someone who I’ve never met before, comes into my treatment room and decides to trust me to try to help resolve their painful issues, I become more empowered to do all I can to be of service. I’m so glad I sought out more tools to pull from and to broaden my understanding. If I hadn’t, I wouldn’t have been able to work with and help so many people with such a variety of issues If any readers want to serve others through massage therapy or bodywork, I highly recommend you expand yourself as much as you can.
When someone who I’ve never met before, comes into my treatment room and decides to trust me to try to help resolve their painful issues, I become more empowered to do all I can to be of service. I’m so glad I sought out more tools to pull from and to broaden my understanding. If I hadn’t, I wouldn’t have been able to work with and help so many people with such a variety of issues If any readers want to serve others through massage therapy or bodywork, I highly recommend you expand yourself as much as you can.
Joe
CLT, PNMT, John F Barnes MFR practitioner, OMT, BCTMB
