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the stories behind our techniques
March 16, 2017
Pain is the one thing that all of us have experienced during our lives. This is normal, it’s part of being human. It’s also normal to want an explanation for our pain. If you are searching for an answer, you will find many. In this over-saturated market of therapists, the number of answers to your pain is only limited by the number of practitioners you seek out. Everyone you encounter will profess to having the answer. Trigger-point therapists will say you need your trigger-points released. Myofascial release therapists will find fascial restrictions that need attention. The chiropractor will say you have a subluxation in your spine. The physio will tell you your pelvis is rotated forward. And the TCM doctor will discover an area of blocked or stagnant chi. Don’t you find it a little coincidental that each of these practitioners will find the very thing they have been trained to treat?
We all know that seeing any of the above professionals can make a positive change in our pain levels. Yet each of these professionals will give a different explanation for the cause of the pain, and most often, with enough confidence that you’d never question their authority. Surly they can’t all be right. What’s going on here? Could there possibly be something else they’ve overlooked? Could there be a common mechanism shared by these (and all other) modalities that could produce a desired outcome? Yes, there is. Yet, this commonality is hardly ever mentioned. So here it is: each and every one of them has an effect on the nervous system. And it just so happens that it is the nervous system that dictates whether or not we feel pain. Hmmm, interesting.
Let me tell you what’s not happening. A chiropractic adjustment does not put our spine back into alignment (Ernst, Homola), myofascial release does not change the structure of our fascia (Chaudrey, Schleip, Threlkeld), and trigger-points (Quintner) are not being released (if they even exist). These are all fantastical stories unsupported by science (Bialosky).
Here’s a more correct explanation that works for all of these modalities: each of these treatments provide a novel sensory experience for the patient’s nervous system. Something profound happens when we touch people. When we add sensory input, we give the patient’s nervous system a chance to change its output. The brain is processing new information; it has been given the opportunity to feel something novel and exciting. And if this new stimulus is delivered in a safe and caring fashion, in the context of a therapeutic environment, the brain may turn down the intensity of pain. Any positive outcomes we achieve can be attributed to our successful engagement with the patient’s nervous system. It’s as simple as that. And any changes the patient feels are likely not changes in structure, but changes in perception. Doesn’t this explanation sound more plausible than the previous ones mentioned?
Unfortunately, fanciful stories and explanations on how our techniques work dominate the health and wellness industry. Most have been around for decades or even longer, long enough that they preceded a time when anyone would have thought to scientifically test them. We didn’t need to test them; we knew they worked. But with advances in science and the ability to test our hypotheses we’ve learned that these stories are just that: stories.
You may ask why this matters? Why should we care how we explain our techniques?
Think of it this way. You have a new car. Every time you let your teenage son uses the car, he wipes it out. You believe the reason behind these wipe-outs is the performance of the car.
So, you have the car fixed like new after every wipe-out, yet they still keep happening. You’re bewildered because the car runs perfectly. And until you realize there might be another explanation for the wipe-outs, i.e. your son is a really poor driver, you can’t take the proper steps to rectify the problem.
It’s much the same with our techniques and how we choose to explain them. If we believe we are changing the structure of fascia, putting joints back into place, or releasing trigger points, we are missing the bigger picture. Muscles, joints, and fascia do not exist in isolation, they don’t decide on their own if they will be tight or potentially lead to a painful experience. They have a driver, just like the car. Once we understand the nervous system is that driver, we can take a more refined approach with our treatments.
We can focus on things that are congruent with current pain science. Which tells us pain is a protective response by the nervous system to any real, or perceived, threat. Anything we do to convince our patients (their nervous systems) they are safe, will likely decrease the amount of pain they experience. For the record, telling patients they have a biomechanical fault or movement dysfunction does not usually make them feel safe and does nothing for their self-efficacy.
Our priority should be to create a safe and comfortable environment for the patient. We can do this by reassuring the patient that hurt doesn’t equal harm and avoiding the nocebo effect: explanations that make the patient feel weak, broken or damaged. We can use more feel-good techniques and less painful ones. And lastly, we can worry less about feeling for things that may not exist, like trigger points, subluxations or fascial adhesions.
At the risk of sounding like a religious zealot, I will say this: once we accept the nervous system as the all-powerful, supreme ruler of our bodies, we are on the path to enlightenment. Does that sound a little over-the-top? Maybe so, but it’s not far from the truth. Understanding the nervous system’s role in the pain experience gives us a better chance at positive outcomes. It allows us to focus on what might feel best for the patient. A patient with his or her own unique nervous system, his or her own likes and dislikes, and his or her own story.
Let’s stop pretending our treatments are magic and we have special healing powers. Let’s just call it what it is: a dynamic interaction between two human beings. Let’s consider therapy as something we do with patients, not to patients.
To be clear, I’m not saying to dump all our techniques in the trash. That would be foolish. The more ways we can touch people the better. This gives us more opportunities to find what resonates with our patients, what feels therapeutic to them. However, it’s time for the explanations behind these techniques to change. No more ‘putting joints back in place’ or ‘releasing fascial adhesions’ or ‘getting rid of trigger-points’. These explanations are based on folklore and it’s long past due we put them to rest. We don’t need these stories anyway, because we have a more plausible one. One that is supported by science.
Ernst, E. (2012). Chiropractic spinal manipulation: What does the best evidence show? Focus on Alternative and Complimentary Therapies, 17(4), 202-206.
Homola, S. (2010). Real orthopaedic subluxations versus imaginary chiropractic subluxations. Focus on Alternative and Complimentary Therapies, 15(4), 284-287.
Bialosky, J., Bishop, M.D., Price, D.D., Robinson, M.E., and George, S.Z. (2009). The Mechanisms of Manual Therapy in the Treatment of Musculoskeletal Pain: A Comprehensive Model. Manual Therapy,14(5), 531–538.
Quintner, JL, and Cohen,ML., (1994) Referred pain of peripheral nerve origin: an alternative to the "myofascial pain" construct. Clinical Journal of Pain. 243-251.
Chaudrey, H., Schkeip, R., Zhiming, Ji., Bukiet, B., Maney, M., and Findley, T. (2008) Three-Dimensional Model for Deformation of Human Fasciae in Manual Therapy. Journal of the American Osteopathic Association, 108(8), 379-390.
Threlkeld, J. (1992). The effects of manual therapy on connective tissue. Physical Therapy, 72, 893-902.
I'm busy working on my blog posts. Watch this space!