Guiding Principle I: Chronic pain is an intelligent messenger

Chronic pain is intentional and intelligent.

Conventional wisdom considers pain to almost always be caused by some kind of breakdown in the body’s machinery. As such, pain is typically considered to be a direct result of a ‘fault’ in the mechanics and subsequent inflammation, mechanical impingement or nerve compression. So when a patient experiences chronic pain the medical profession is immediately searching for whatever is ‘broken’. And so, all the scanning technology.

I am going to suggest that a huge percentage of chronic pain is not caused by the immediate structures (such as inflammation, nerve compression or mechanical impingement) but is secondary, mediated through the fascia and skeletal muscle … somehow. In other words the body intelligently ‘refers’ pain to the site of mechanical dysfunction or potential injury. So the pain is just the messenger. A very intelligent and intentional messenger.

Sound weird? Just give me a chance to explain.

Chronic musculoskeletal pain is still an enigma!

Now anyone who has worked in the musculoskeletal therapy industry for any time will concede that in many cases a musculoskeletal ‘pain’ cannot be seen on any scan. On the other hand often a scan will find a ’cause’ for the pain (a tear, inflammatory markers or degenerative change) yet when the tear, wear or inflammation is resolved and repaired the pain persists.

In other scenarios structural asymmetries are used as an ‘explanation’ for the pain a person is suffering, yet 124,890 people with exactly the same structural asymmetry live a full life never experiencing the same pain symptom?

Our understanding of physiologically ‘what pain is’ is evolving. We know for example that conventional wisdom used to say in regards to many structural injuries to ‘rest, rest, rest’ but now says ‘move, move, move’. Wait a minute. Isn’t pain caused by inflammation, and inflammation is aggravated by movement. Why does movement give pain relief? In short, we are still learning a lot about the enigma we call ‘pain’.

All of us: GPs, sports physicians and therapists of all sorts are used to answering the patient who asks:

‘Can we scan it to find out?’

With the response:

‘We can, and we will almost certainly find some things wrong, but they may have nothing to do with your pain!’

A caveat before continuing…

Now I am speaking broadly about chronic unresolved pain. I am not suggesting that inflammation around a tendon or bursa does not cause sensitisation and subsequently pain, nor am I suggesting that the pain associated with complete loss of cartilage capping in a knee (bone on bone) is not a painful inflammatory condition. What I am suggesting is that after treating nearly 6000 patients that a huge percentage of chronic pain is not directly caused by the visible tear, wear or inflammation but is a secondary mechanism designed to prevent permanent injury or communicate a degree of dysfunction. And being secondary it can be ‘switched off’.

Pain that can be ‘switched off’?

‘Switched off?’

What the…

This phenomenon is something I observe all the time. It was at first most noticeable to me when working on the neck with a patient seated. I was treating a patient who presented with months of pain in the mastoid, lateral neck and temple headache along with restricted movement (if you are a Myotherapist you are rightly thinking about a trapezius referred pain pattern).

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.