My guiding principle: Pain is intelligent and intentional – Part 2.
How you think about pain will determine how you treat it. Embody this principle and it will improve your efficiency and your treatment outcomes.
Manipulation that switches off pain immediately?
From part 1…
Treating the patient seated, ROM to the ipsilateral side was restricted by 30 per cent and reproducing the neck pain on movement. Cross-fibre manipulation to the fibres of trapezius near the clavicular insertion for no more than 20 seconds ‘switched off’ the pain immediately. Immediately, no referral to the neck or head. Immediately, full range of movement restored. So immediate in fact, that I considered the muscle did not have time to ‘relax’. There was no stretching involved. No rest period. No heat therapy. In fact in most cases, not only is the pain pattern ‘switched off’ but the tenderness associated disappears, range of movement is restored and strength and proprioception restored. Immediately.
A second example I see frequently:
Patient presents with impressive bunion on the left first metatarso-phalangeal joint. The shape of the joint, X-ray and 18 months of persistent pain indicate the presence of DOA (Degenerative OsteoArthrosis). Cross-fibre manipulation to the extensor hallucis longus muscle for less than one minute; instruct the patient to walk on it; no pain. Pain relief is immediate and lasts months. There is no way an inflammatory process resolved that quickly. There was no strengthening, heat therapy or stretching. Conclusion? Obviously the body, namely extensor hallucis longus or associated fascia was ‘creating’ the pain symptom as a messenger. A messenger trying to communicate that there is something wrong with that first MTP joint. Solution to the pain? Shoot the messenger! Well not quite. But you get the point.
A third example: Supraspinatus impingement pain with a positive painful arc test. Assumption: the tendon is inflamed and getting trapped within the subacromial space between 80-120 degrees of abduction. This impingement is a definite possibility but in many cases cross-fibre manipulation to the belly of supraspinatus eliminates all pain on abduction. Immediately. So did the inflammation in the tendon settle in seconds? Or is something else going on?
I see the same phenomenon often in relation to ‘trochanteric bursitis’, ‘carpal tunnel’ symptoms and more complex biomechanical dysfunctions of the neck or pelvic girdle. In fact I could cite similar examples in every region of the body. In many cases with scans in hand demonstrating the mechanical degeneration present!
What do I think is going on?
I think that chronic pain is caused by the visible measurable inflammation, tear or mechanical dysfunction far less often than we think. Although visible measurable inflammation, tear or mechanical dysfunction may be present, the pain is frequently present secondary to these observations not primarily arising from them. In other words the pain is an intelligent messenger.
In application.
So in a clinical situation when a patient presents with a chronic pain and I begin assessment I resist the temptation to ‘explain away’ the pain. I resist the temptation to say ‘oh you clearly have DOA in that joint, the X-ray confirms it’ or ‘you must have trochanteric bursitis because there is pain and tenderness overlying the head of the greater trochanter’. No. Instead I consider every myofascial pain pattern that can refer to that site, despite what the X-rays suggest, despite what the patient thinks they have diagnosed their pain as, despite what the specialist attributed the pain to. I start treating and assessing, treating and assessing. If I cannot resolve the symptom then nothing is lost.
So a foundational guiding principle for me, when trying to solve a chronic pain, is the assumption that the body is intelligent and intentional. There are reasons for pain as it is always a messenger in some capacity.
I would encourage every Myotherapist to have this mindset because myofascial pain is not a ‘separate’ list of pain patterns. It is nearly always ‘a component of’ most chronic pain patterns. Even in an example of advanced DOA in the knee where there IS bone on bone and inflammatory pain you will find that 20 per cent or even 80 per cent of the pain is myofascial and will respond to the right soft tissue manipulation.
Refusing the temptation to ‘explain away’ symptoms but attempting to fix them is a guiding principle to becoming a great problem solver and therapist.
Wishing you the best of success.
Timothy J. King
