Victims and Criminals: Decoding Chronic Pain

Tue, Oct 24, 2017

"Find the pain and look elsewhere for the cause." - John F. Barnes

I’ll set the scene: a client comes to see me, complaining of chronic pain. For the sake of specifics, let’s say it’s neck pain, though the broad strokes of what I’m describing would apply to chronic pain anywhere in the body.

This pain, my client says, has built up gradually over the past several years. Her neck muscles have been tight for as long as she can remember, but lately the tension has worsened to the point that she gets frequent headaches and can barely turn her head. She’s desperate for relief. “Please, fix my neck,” she begs.

Once she’s on the table, I will, of course, address her neck. But even before I touch her, I’m 99% sure that what really needs fixing – that is, the source of her pain – is somewhere else in her body. Why?

Well, to start with, chronic pain is very different from acute pain. With acute pain, you injure a body part and that part hurts – badly, and immediately. Acute pain is obvious; chronic pain is much sneakier. More about that in a moment.

It’s also important to remember that pain is only a symptom. Which is not to say it’s unimportant, but symptoms generally aren’t the problem. Rather, they are information about the problem. Of course nobody wants to suffer, and it’s understandable that my client views her pain as a problem to solve. But if I work only on her neck, though that might make her feel great while I’m doing it, soon after she gets up off the table her pain will return. My challenge is to find and address its cause.

This leads me to: our bodies are three-dimensional. (That would seem to go without saying, but it’s surprisingly easy to lose sight of that fact when studying two-dimensional images of anatomy.) In our 3D bodies, every single cell is connected by fascia to all of the surrounding cells. Every single structure is anchored – by tendons, ligaments, and still more fascia – to all of the surrounding structures. This means that no individual part of the body functions in isolation, but exerts a pull upon those surrounding structures. When a muscle shortens, it pulls on everything around it; other muscles must lengthen to allow the movement, while still others must tighten to brace against that movement in order for us to maintain our balance.

So let’s come back to that client with chronic pain. Her neck, remember, has been tight for years. “That’s just where I carry my tension,” she explains. Sure, but chronic tension implies that the body is out of alignment, which means something is pulling it out of alignment. Occasionally this will turn out to be a structural (i.e. bone-related) issue, and therefore beyond my ability to fix, but most often it’s soft tissue.

And if it is soft tissue, I don’t think it’s soft tissue in her neck. This is what makes chronic pain so sneaky; what hurts is hardly ever what’s doing the pulling. Rather, it’s what is being pulled upon. As physiotherapist Diane Lee memorably phrased it, “It’s usually the victims that cry out, not the criminals.” The criminal part shortens and stays shortened – which is what happens when, for example, we hold the same posture too often – and those parts that have to brace for stability are the victims. They feel tight, yes, but they’re tight in a lengthened position, known as eccentric muscle contraction. As the criminal keeps pulling, the victims must keep bracing, maintaining that eccentric contraction while being stretched to the point where they can barely do their job. They start to weaken, and hurt. Nearby muscles will clamp down to try to help those victims stabilize the area, but ultimately this tightens the region still more, restricting the fascia and diminishing blood flow such that those victim muscles don’t get all the nutrients they need, which makes them hurt even more, which leads to yet more tension. This is the vicious cycle of chronic pain.

For me to break that cycle, I can’t just work on the parts that hurt; I have to identify the criminals and treat them. Fortunately, I have an array of tools to help me solve the mystery. Knowledge of anatomy, combined with a few years of practical experience, lets me start by mentally assembling a rogues’ gallery of likely suspects. With neck pain, for example, I always want to look at the low back and the front of the shoulders to start with, and pelvic alignment is usually a factor as well. I’ll get additional clues from my client’s posture, and once I begin to touch her, my hands will give me information about lines of pull. Sometimes I have to work by process of elimination, and in complicated cases it can take multiple sessions of bodywork before I zero in on the culprits, but that’s what makes my job so interesting.

A good massage therapist, then, is also a detective. Got any mysteries I can solve for you?