Guiding Principle V: Follow the pain

I am a problem solver . . .

As a kid I would get myself into trouble because I spent hours pulling a something important apart because I was curious. Then I couldn’t put it back together. There was more than one occasion that my ‘mechanically minded’ uncle would be called in to help me reconstruct mum’s vacuum so she could use it!

As a Myotherapist, problem solving – or figuring out what is going on biomechanically or physiologically that is perpetuating my patient’s pain – is something I really enjoy.

As a problem solver, and a dedicated one at that, I have over the years developed a number of guiding principles, so to speak.  These are principles that have become foundational in my practice for solving chronic musculoskeletal pain patterns. I have formed these principles from reading, experimentation, clinical experience and patient feedback. Several of them can be clearly validated by current science and some of them are shamelessly anecdotal.

I am pleased to say that these principles, which in some cases conflict with conventional wisdom, have enabled me on many occasions to solve pain complaints in patients that have ‘tried everything’ the medical profession has to offer. The articles you will read in each of these modules summarise the foundational guiding principles that I use to get great results every day. I am confident they will do the same for you.

So lets get into it…

Follow the pain.

It may sound simple, but the location of the pain is typically your first observation, and the most valuable information, when beginning to assess and treat. As you treat and assess with follow up treatments, the pain patterns will often change. Where the pain moves to provides you with critical information. Discerning why the pain has moved is often critical in leading you to identify the primary dysfunction. And trust me, it is not always where the patient thought it was.

It starts with charts.

I was lucky enough to – straight out of high school – stumble into a course that taught myofascial pain patterns in great detail. I did not know where this training would lead. All I knew was that I was fascinated by human anatomy, physiology and biomechanics. I think the fact that my next university choice would have been mechanical engineering says something about my brain.

I must confess that at the time I commenced study, I had no idea what myofascial pain was and presumed that this type of pain must constistute a small percentage of musculoskeletal pain out there. As such, I assumed that my career would consist of treating a niche market; people that suffered with myofascial pain. It only took me a few months to realise that this particular type of pain was not only common, but present in nearly every chronic pain sufferer I met. How am I so sure? I recognised the pattern and I was able to fix it!

Because pain referred from muscle was, and still is, so poorly recognised by the medical profession, I regularly encountered patients who had tried every therapy, scan and specialist before trying Myotherapy as a last resort.

In some cases a patient would literally cry when I stated that I recognised their pain pattern! No-one had every said that.

After three years of practice and, at the time, treating one hundred patients a week, I became convinced that a thorough knowledge of myofascial pain patterns was, in fact, my greatest asset in being able to assess and solve chronic pain syndromes.

I am not suggesting that all chronic pain patterns are myofascial. But because so many chronic pain patterns are either entirely myofascial or include myofascial components, a thorough knowledge of these pain patterns enables one to easily identify pain that is not myofasical and empowers your differential diagnosis.

Know Travell and Simons’ referred pain patterns!

The gurus on myofascial pain patterns are the late David Simons and Janet Travell. These highly regarded physicians invested some 50 years into the clinical observation of pain referred from skeletal muscle. Their research is immortalised in Myofascial Pain and Dysfunction: The Trigger Point Manuals.

Although some recent studies have thrown doubt on the trigger point mechanism proposed by Travell and Simons, the referred pain patterns clinically observable in most chronic pain scenarios are incredibly accurate. Although there may be doubt as to the mechanism by which the skeletal muscle and associated fascia actually refers the pain, there is no doubt, in my experience, as to the presence and reproducibility of the pain patterns themselves.

We can, for now, leave the trigger point hypothesis and related physiological hypotheses that attempt to explain the mechanism of the pain up to further scientific study. This does not affect our ability to assess, treat and resolve chronic pain, by carefully learning the observed pain patterns that Travell and Simons have charted.

In short, these charts are so comprehensive and accurate in their description of pain patterns and their origins that even the slightest detail in a particular pattern has at times made the difference between successful assessment and treatment and unsuccessful. This means that, for me, Travell and Simons’ charts are effectively The Bible for assessment and evaluation of chronic pain.

6 Simple tips for solution-driven assessment.

1. Where is the pain?

As I said at the start, the location of the pain is your first observation and the most valuable information when beginning to assess and treat. Use a body chart in your notes to annotate where the pain is. I use a firm scribble colour where the strongest pain is and a lighter scribble for lesser pain. I use a criss cross pattern to annotate pins and needles and like symptoms. Be accurate. Ask lots of questions. Chart ALL the pains that the patient describes, including those that do not seem related to their primary complaint.

Patients with chronic pain present to you with pain in many places. I liken this to turning up to the scene of a road accident involving multiple cars. You can see the mess, you can see the consequences but you have no idea how it happened or what came first. In the same way, a patient with chronic pain presents to you with a variety of symptoms and it is hard to know what is primary, what is secondary, what is tertiary and so on. It is often only as you treat and assess with follow up treatments that it becomes possible to identify the primary dysfunction.

2. Differentiate between different types of pain. 

At risk of being simplistic, myofascial pain is generally deep and aching. With your knowledge of myofascial pain patterns, determine which of the pains may be myofascial and use tactile skills to assess and treat the muscles that may refer these patterns. My tactile assessment technique is be explained in ‘Cross Fibre Manipulation’ (Module 2) and ‘Micro and Macro’ (Module 3).

The patient may have joint inflammation or neurological patterns, like pins and needles. Do not address these symptoms with direct treatment to begin with. Address the myofascial pain and associated restrictions first. It is this type of pain that usually is the most responsive to treatment. Treating the myofascial pain is a good way to get early results, reducing pain and improving movement. This helps the patient gain confidence in the treatment.

3. Educate your patient. 

If your patient has joint or neurological symptoms, explain that such structures take longer to heal and we will get to that. 

Secondly, encourage your patient to be observant. This is critical but counterintuitive. Patients with chronic pain have usually made a career out of learning tactics to forget the pain. Ignoring the pain, shutting it out, getting on with the job are coping mechanisms that have helped them survive up until this point. You are asking them to change all that.

4. Where is the pain AGAIN?

Your first follow-up treatment is as important as your initial consultation. 

With your initial body chart in hand, ask your patient where is the pain? You have to inquire just as you did in the first consultation. Short answers will not do. Be accurate. Ask lots of questions. Has the pain moved? What pain has disappeared? What pain is new? Is it more intense or less intense?

In a different colour chart ALL the pains that the patient describes, including those that do not seem related to their primary complaint. Again use a firm scribble where the strongest pain is and a lighter scribble for lesser pain. Be accurate. Ask lots of questions.

Once again, with your knowledge of myofascial pain patterns, determine which of the pains described may be myofascial and use tactile skills to assess and treat the muscles that may refer these patterns. Some of these will be the same muscles you treated last week and some will be new muscles that did not present any symptoms last week.

5. Encourage your patient when the pain moves! 

I have had patients return for a follow-up visit somewhat downcast as they state ‘I am no better’. After sympathising with them briefly I will request that they show me exactly where the pain is. Often they will point to a different location. When I ask ‘Wasn’t the pain on the right before?’, they pause and then realise, yes it has changed.

They have been so used to having pain in the back, that as far as they were concerned they still simply have pain in the back. Yet with a little questioning, clearly it is a different pain in a different place and often from from a different muscle or structure.

6. Deduce biomechanical change.

The pain patterns may have been your initial tool for assessment. But how the pain patterns move in response to manipulation gives insight into the biomechanical compensations that your patient has been living with.

A simple example.

Session 1: Your patient presents with long standing upper right suboccipital pain in the neck. You determine that this pain is arising from a trigger point in the upper trapezius on the right. Manipulation resolves this pain and restores their movement.

Session two: The patient returns with no pain in the right suboccipital region but pain in the left angle of the neck and pain in the right shoulder blade. Great! You have doubled their symptoms!

Don’t fear, this is a great result. Encourage your patient.

Tactile assessment and treatment confirms that these new pain patterns are from the lower fibres of splenius cervicis and the thoracic portion of iliocostalis thoracis.

Session three: The patient returns with no pain, and a full range of movement in their neck and upper back. Success. In this scenario always perform tactile assessment and full range of movement testing on all the previously symptomatic areas to confirm there is no painless restrictions (latent trigger points) present.

Over time you will begin to observe familiar shifts in pain patterns and even be able to predict them. When you explain to your patient that their neck pain will improve this week but don’t be surprised if your shoulder blade hurts, you will gain credibility and trust.

Deduction: In this example the trapezius pain was the myofascial restriction that was creating a symptom, however trapezius was not the only myofascial restriction present. The splenius cervicis and iliocostalis restrictions were present in the initial consultation but asymptomatic to both you and the patient. It was not until you restored full cervical range of motion by releasing trapezius that the other dormant restrictions manifested. Once these were revealed as a component of the dysfunction they could be treated effectively.

I have found in many examples similar to this that the primary dysfunction is often asymptomatic articular dysfunction around the cervicothoracic junction. But that’s another article.

Be a lifelong learner.

Great therapists are observant.

Carefully charting the original locations of the pain then doing the same in subsequent sessions is a great way to solve long standing complaints. Keeping an open mind to consider why the restrictions occurred where they did, in the order they did, can give great insight into the body’s compensatory patterns.

As you learn some of these patterns you can begin to predict where asymptomatic restrictions may be hiding and assess those areas in the first session, not the second. This will make you a more efficient therapist. Discerning why the pain has moved where it has is often critical in leading you to identify the primary dysfunction. And trust me, it is not always where the patient thought it was.