Guiding Principle VI: Cooperate with the body

The notion that ‘we don’t actually fix anything’ is foundational for successful treatment of chronic pain.

We don’t actually fix anything.

Let me qualify that.

What I’m saying is this: Unless a therapist concedes that they are totally dependent on the body’s positive, active, intentional, ridiculously complex mechanical, chemical, neurological, fascial RESPONSE to their technique, then they will be frustrated as a therapist.

The therapist can only introduce an external intervention to the patient’s body. A force, a manipulation, a stretch, a mobilisation. But an intervention is just an intervention. There is a myriad of effective interventions out there. We call them techniques.

How the body responds to any intervention applied to it is the body’s prerogative.  A healing process may be stimulated by our external intervention, but healing itself is the body’s prerogative.

For example.

A chiropractor creates an external intervention by manipulating a vertebral joint. It goes ‘pop’. This is one form of intervention. Now the chiropractor states that he has ‘put the joint back where it should be’. He is wrong (1, 2). He has done no such thing. If there is a postural change, it is because the intervention has stimulated something in the body, and the body has in turn responded to the intervention. In other words, it is the body that does the healing and it will choose how it responds to the intervention.

In the same way, a Myotherapist creates an external intervention by massaging a specific muscle. This again is a form of intervention. Then he says that he has ‘released a muscle’. He is wrong (3). He has done no such thing. If there is a postural change, it is because the intervention has stimulated something, and the body has in turn responded to the intervention.

Unless we can successfully stimulate the body to respond, we will create no lasting change.

Contrary to primitive, simplistic thinking, skeletal manipulation does not ‘put things back where they go’ and massage does not ‘pound muscles into submission’.

As therapists we do not actually force mechanical changes upon the body. The body will always decide for itself. What we do do, is stimulate the tissues in one way or another in anticipation that the body will actively respond to that stimulation and choose to heal. Once again, we do not manipulate the body, forcing it to change, we have to figure out how to gain the body’s cooperation. All of our techniques must have this goal in mind. We must concede that, whatever technique we apply, our role is to stimulate a healing response. We must cooperate with the body.

Modern research.

This concept is not a new idea.

The idea that the therapist’s role is to stimulate a healing response in the body rather than do the fixing has been a foundation in osteopathic, naturopathic and homeopathic philosophy for centuries.

In physiotherapy circles today they are using the terminology, symptom modification. This terminology is a way of getting away from the idea that the therapist is fixing stuff. What a therapist does to a patient, from a joint manipulation or mobilisation, to soft tissue work, assisted movements or dry needling are all simply interventions.

To quote The Sports Physio, Adam Meakins: ‘. . . just because we can’t conclusively show how these techniques work, doesn’t mean we can’t use them. This is not how evidence based practice works. Instead we work with levels of probability and if there is plausible rationale, with no risk of harm, and demonstrable and repeatable effects, then crack on.’ (4)

Studies are showing that that connective tissues don’t change easily (5, 6, 7), and definitely not with a few minutes of manual therapy. We do know that interventions can modify a patient’s sensations and perceptions of pain, stiffness and weakness via interaction with a patient (8, 9) and as such interventions do get results. But it is now popular to distance oneself from explaining exactly what is happening physiologically.

A great little article that helps explain this to the lay person can be found here (10).

There is more than one way to skin a cat.

It is good to realise that there is more than one way to do something. There is a diversity of techniques that can be applied to the body that will stimulate a positive healing response. Ever been humbled when you have concluded that you are the guru on a certain pain pattern because you have figured out just the right form of soft tissue manipulation to fix it? Only to hear that someone with exactly the same symptom got a great result from a skeletal manipulation. No. Can’t be!

Truth be told, there are many forms of intervention that will stimulate a healing response from the body.

Some general implications.

Factors that empower the body to be able to heal become important. 

If we are so dependent on the body to heal itself then addressing factors that may inhibit a healing response becomes more important.

In my clinical experience, approximately 60 per cent of patients respond quickly and easily to treatment. In the other 40 per cent of cases we need to address lifestyle issues that are preventing the body’s ability to heal. The Big 3 Factors are movement, nutrition and sleep.

• Sleep: If the body is not getting restorative sleep, then its ability to recover, regenerate and heal is impaired. As such its ability to respond favourably to your intervention will be impaired as well.
• Nutrition: If the body’s nutritional intake is inadequate, then although your intervention might stimulate a healing response, the resources that the body would draw on to facilitate that healing process are simply not there.
• Movement: If movement is severely impaired, or the patient’s cardiovascular fitness is very poor then some of the body’s primary healing agents have been disabled. Namely, movement and associated circulation, healthy biomechanical patterns and so on. Truth be told, our treatment intervention usually reduces pain temporarily, enough for the patient to move differently, creating a window by which the healing effect of movement itself actually resolves the condition.

Implications specific to Myotherapy.

Reflect on the intelligence of the human organism.

In my articles in modules 6 and 7 I hypothesise that trigger point activity is much more than localised muscular damage from overuse or injury. Myofascial restrictions that trigger points create occur in predictable regional patterns so consistently, that it is easy to conclude that trigger point activity is an intentional and intelligent restriction. Like a low grade protective mechanism more akin to muscle guarding.

If this is true then it has big implications on our treatment of myofascial pain and dysfunction. The secret to successful resolution of chronic pain will have more to do with figuring out why the restrictions have activated, rather than simply focusing on what pain is present.

Can I say that again.

The secret to successful resolution of chronic pain will have more to do with figuring out why the restrictions have activated, rather than simply focusing on what pain is present.

Secondly the most effective treatment will involve cooperating with the body to address the injury that the myofascial pattern of restriction established itself to protect in the first place. Putting it simply, this thinking empowers us to address the cause, not just the symptoms.

Less is more. 

Myotherapy has evolved out of remedial massage, and as such this means that many Myotherapists have some of this thinking in their DNA. We need to begin to entertain the notion that in many cases, less is more. We need to be prepared to do just enough manipulation or massage to stimulate the healing response that we are looking for and then get out of the way.

In short, the old school notions of forcing the body to bend to our will are gone. This is a popular idea in the massage profession and will die hard.

Recent study of fascia is showing conclusively that we are not stretching the stuff. Even if our patient has a greater range of movement after treatment, it is not because we stretched the fascial substrate, it is because something else has changed. Perhaps the stimulation has encourage temporary muscular relaxation? This is a more likely explanation.

Retest regularly. 

If we are serious about resolving chronic pain complaints then treatment needs to become less about lying down for half an hour and going to sleep. Treatment should anticipate a response from the body. In my experience this can occur much, much more quickly than we realise.

When we are seeking to cooperate with the body rather than forcing it to do what we want, the process of treatment needs to be much more like a conversation. Manipulate, test for a response. Manipulate again, test for a response.

An example:

• A routine treatment for neck pain, patient seated.
• Pain in the right angle of the neck on rotation to the right.
• Manipulate lower fibres of splenius captus for 30 seconds.
• Retest rotation to the right. No symptom.
• Rotate to the left. New pain now appears in the left upper cervical area.
• Manipulate the left trapezius’ clavicular fibres for 30 seconds.
• Retest rotation to the left. No symptom.
• Retest rotation to the right. Mild restriction in the left sternocleidomastoid (SCM) locally.
• Manipulate SCM.
• Retest rotation right and left. No pain or stiffness anywhere.

What is going on here?

Firstly we are treating anticipating a response from the body, to our intervention. Secondly, as we stimulate a response leading to a change in function, connected secondary and tertiary restrictions emerge. It is literally like a conversation: Intervention. Test. Intervention. Test. This ‘conversation’ between your interventions and the body’s responses occur within a treatment session and also over a course of weeks.

I have lost count of the number of times that a course of treatment for a ten-year-old pain pattern has literally worked backwards through the same sequence of connected pain patterns that the patient experienced over the ten-year timeframe. Literally resolving one compensation after another, back to the original and primary injury. Patients in this scenario would commonly state: ‘I remember that pain! I had that four weeks after the injury that occurred ten years ago.’

Patients in this scenario would commonly state ‘I remember that pain! I had that four weeks after the injury that occurred ten years ago.’

Treatment is not all about pain!

A successful treatment should not be measured by whether the patient scored pain intensity at a 10/10 for the majority of the treatment. This notion of course is a hangover from the ‘force the body to submit to my will’ idea.

Granted myofascial trigger points are by nature exquisitely tender so some discomfort in the course of treatment cannot be avoided. But, once again if we are seeking to cooperate with the body, too much pain is clearly counterproductive. Trigger point manipulation, done well, can be very brief and very effective. In fact some therapists like Tom Bowen became so skilled that often the patient would feel that he ‘had not done enough’ only to find that the complaint was resolved! I regret to say the I have not yet attained such magic, but I can say that my treatments involve painful manipulation for a much shorter period than most Myotherapists and I get brilliant results.

My application.

After a thorough history I will manually survey a lot of areas. Where I find restrictions, often in locations seemingly unrelated to the pain in the patient’s mind, but related biomechanically in my mind, I will manipulate briefly and move on. I move on deliberately, enabling the area manipulated time to respond. I will work on other areas, sometimes because I want to check them, and other times just as a way of killing time while I give the problem area time to respond.

Often on returning to the area of restriction, the work is done without further manipulation. Tenderness is resolved and range of movement is restored. Now range of movement is not restored because I forcefully stretched that muscle, nor is it restored because I forcefully massaged the muscle loose.

No.

It is restored because I stimulated the muscle in a certain way, it had time to think about it and respond. It chose to release.

Save your arms, and extend the duration of your working life. Cooperate with the body, don’t manipulate it to do what you think it should. Less labour. Better results.

References

1. Tullberg T, Blomberg S, Branth B, Johnsson R. Manipulation does not alter the position of the sacroiliac joint. A roentgen stereophotogrammetric analysis. Spine (Phila pa 1976) [Internet]. 1998 May 15;23(10):1124-8; discussion 1129. Available from: http://www.ncbi.nlm.nih.gov/pubmed/9615363
2. Threlkeld AJ. The effects of manual therapy on connective tissue. Phys Ther [Internet]. 1992 Dec;72(12):893-902. Available from: http://www.ncbi.nlm.nih.gov/pubmed/?term=Threkald+manual+therapy
3. Chaudhry H, Schleip R, Ji Z, Bukiet B, Maney M, Findley T. Three-dimensional mathematical model for deformation of human fasciae in manual therapy. J Am Osteopath Assoc [Internet]. 2008 Aug;108(8):379-90. Available from: http://www.ncbi.nlm.nih.gov/pubmed/18723456
4. Meakins A. The Sports Physio: simple, practical, honest advice [Internet]. Available from: https://thesportsphysio.wordpress.com
5. Konrad A, Tilp M. Increased range of motion after static stretching is not due to changes in muscle and tendon structures. Clin Biomech (Bristol, Avon) [Internet].2014 Jun;29(6):636-42. Available from: http://www.ncbi.nlm.nih.gov/pubmed/24856792
6. Magnusson SP. Passive properties of human skeletal muscle during stretch maneuvers. A review. Scand J Med Sci Sports [Internet]. 1998 Apr;8(2):65-77. Available from: http://www.ncbi.nlm.nih.gov/pubmed/9564710
7. Weppler CH, Magnusson SP. Increasing muscle extensibility: a matter of increasing length or modifying sensation? Phys Ther [Internet]. 2010 Mar;90(3):438-49. Available from: http://www.ncbi.nlm.nih.gov/pubmed/20075147
8. Bialosky JE, Bishop MD, Price DD, Robinson ME, George SZ. The mechanisms of manual therapy in the treatment of musculoskeletal pain: a comprehensive model. Man Ther [Internet]. 2009 Oct;14(5):531-8. Available from: http://www.ncbi.nlm.nih.gov/pubmed/19027342
9. Pickar JG. Neurophysiological effects of spinal manipulation. Spine J [Internet]. 2002 Sep-Oct;2(5):357-71. Available from: http://www.ncbi.nlm.nih.gov/pubmed/14589467
10. https://simplifaster.com/articles/why-most-people-are-wrong-about-injuries-and-pain/