In the last few years, my understanding of pain and its relationship to bodywork has been slowly and radically transforming. Today I was speaking to a woman who is doing her Ph.D. thesis on this topic, and it was one of those times where the act of talking about something made all the various pieces of knowledge come together for myself. I’m always really interested in those moments, where it seems like some other version of me has integrated everything and has control of the voice while the rest of me watches and wonders when and how this all got integrated without my knowing.
Anyway, I’d like to share with all of you what I’ve been learning because it’s truly a radical shift that has huge implications for how we work with individuals with chronic pain. This is one of the new offerings at PCAB that makes it stand apart from most massage schools, so I want to share it with all of you who did not get this material in your class.
Many bodywork clients present with chronic pain, and it’s fair to assume that if they have chronic pain, they’ve probably been to a ton of people and tried a ton of different things to change it before they get to you. Along the way, they have probably experienced a high level of dismissal from healthcare providers who are reasonably frustrated by this population because they are accurately assessing that ‘nothing works’.
This idea of ‘nothing works’ begs the question of what is pain in the first place, because if one doesn’t have a proper understanding of what pain IS, then attempts to address it are going to be misguided and not work. Most people think of chronic pain in the same way they think of acute pain, but just something that lasts longer. They’ve had numerous experiences of stubbing their toe or lacerating themselves over their lifetime, and they know that the pain they feel from that derives from the damage that some tissue incurred. This idea of pain = body injury gets lodged in the mind, so it makes sense that when a person finds themselves with chronic pain, they apply the same logic and go looking under every rock to find what the mystery cause is in the tissue. Blood tests, urine samples, x-rays, supplements, medical and alternative treatments, and so on and so on. Most of them find nothing. Some of them will get x-rays from a chiropractor who will point to some imperfection in the spine (that the vast majority of humans have with no pain at all), and this will become the assumed, hopeless cause, unfortunately. But for most people, this is a wild-goose chase because chronic pain has nothing to do with tissue damage. Instead, it’s about the nervous system.
Before explaining what this means, we have to back up to some basic science and some philosophy. First the philosophy. Western thought is dominated by dualism, which was popularized by Rene Descartes. Dualism is basically the idea that there is a physical world and a nonphysical world. Even people in spiritual circles who use terms like ‘non dual’ and disparage dualism are still usually dualists because this way of thinking is very embedded in our culture. For instance, if you think that you are not a body but rather that you HAVE a body and that there’s a real you that is separate from your body, congratulations….you’re a dualist. When one takes a dualist approach to reality and combines it with the belief that pain is tied to tissue damage (body), unresolvable problems emerge. Keep reading…
Most people think that we have pain receptors in our body and we have pain signals that travel to our brain. Neither are true. We have nociceptors in our periphery and they generate nociceptive signals, which might continue onward and ultimately result in the experience of pain, but not necessarily. You can, and do, have nociceptive signals that do not result in pain, and you can also have pain with no nociceptive signals. To understand this, you have to switch your idea of pain as being a sign of tissue damage to the brain’s way of saying “danger”. Between the input at your skin and the final determination of pain or no pain, there’s a lot of in-between steps that alter the final outcome. The most important step to understand is called Descending Modulation (DM), which is a signal that comes down from the brain and intercepts the nociceptive signals as they pass through the spinal cord (and brainstem). DM can turn the nociceptive volume up or down. Right now as you read this (if you don’t have chronic pain), you have tons of nociceptive signals reaching the spinal cord and then turned off because the brain is assessing that nothing dangerous is happening so we can ignore those inputs. Or if someone you trust a great deal tells you it’s going to be fine, the same inhibition occurs, and the signals don’t get any further. The opposite can also happen where a minor scratch creates extreme pain if one believes it’s a serious problem or if a therapist convinces them that they are broken and not fixable. So, this is DM, turning the nociception up or down before it reaches the brain. It’s highly related to placebo and nocibo.
Now when we get to the brain, the signal splits and goes to two places. One signal goes to the somatosensory context to give the person a feeling of ‘pain’ and the location of that pain. The other signal goes to cingulate, which gives the person an emotional response to the pain. If you cut off the signal to the cingulate, a person will report that they can feel pain in a specific location but the pain does not bother them. It’s just a factual report. If the signal is cut off from the somatosensory cortex, the person experiences unpleasant feelings but can’t say where they are coming from.
The cingulate is also going to be involved with agency and control, which is why pain is more miserable when we fear it’s long lasting and beyond our control. One simple way to convey why control is valuable is the example that a person who has control over how much pressure is being applied to a body part will experience less pain than if the same pressure was applied without control over it—agency (and novelty) inhibits nociception.
When a person experiences pain, a number of changes occur to the nervous system over time. One thing that happens is the number of nociceptors increases and the sensitivity of those nociceptors increases, both of which likely result in more pain. There is evidence that if the pain persists for over 6 months, the physiological responses to this in the spinal cord are such that some of the inhibitory neurons in the spinal cord that are normally blocking nociceptive signals die. Yes, die. What this means is that once a person has gone beyond 6 months, their descending modulation system doesn’t have the hardware to block any and every nociceptive signal, no matter how innocuous.
Furthermore, chronic pain is closely tied to early childhood trauma. Why is that? Because pain is a danger signal, so if a person grows up in an environment that isn’t safe and nurturing (i.e. nurturing blocks nociception), then that person’s nervous system is going to become sensitized and more likely to not block whatever is coming in.
Hopefully this was enough of a neuroscience lesson so far to convey the idea that pain is a subjective experience that is generated in the brain based on numerous factors and is not based on tissue damage.
So getting back to dualism…. From a dualistic perspective, tissue damage is real. Telling a person with chronic pain that there is no tissue damage will SOUND like one is saying the pain isn’t real. I’ve had this experience quite a bit, where I literally say “your pain is real. you don’t have tissue damage though” and the dualism is so embedded that this simply doesn’t have a place to land in the listener sometimes. And note that also from a dualistic perspective, when a doctor finds no evidence of tissue problems, the doctor is reasonably concluding “it’s just in your head” since “tissue vs head” are the only two options in dualism.
Once we throw out dualism and understand pain as a neuroscientist sees pain, then something very amazing happens. We realize that all of our attempts to solve some tissue issue was misguided. We realize that what we are doing is not working on soft tissue (despite the antiquated definition of massage) but rather the nervous system. We realize that BOTH massage therapists and psychotherapists are working on the nervous system, which instantly makes the bodywork and the consciousness tools blend seemlessly—to put it another way one could say that thinking of massage as working on soft tissue is like thinking of psychotherapy as working on the ear. We realize that one of the most important things we can do for such clients is to work with descending modulation, which means that we completely change our language in such a way that gives the client a sense of agency, control, and non-brokenness, in stark contrast to what they and others have been conveying. It also means that we provide novel input to the client and encourage movement.
At this point it should be noted that most clients won’t like this approach because as frustrating as it is to try a million solutions and always be in pain, most of us would rather solve a problem with a pill or at least point to a clear physical cause. Suggesting that the only way out is by slowly changing ones nervous system doesn’t sound simple, and to a dualistic ear can sound blaming even though this approach is actually empowering to the client. It’s also worth noting that a client’s willingness to pursue these empowerment options can also be met with resistance by the very defense mechanisms that formed during early trauma, and this topic is a very big rabbit hole that I won’t go into here.
Lastly it should also be understood that touch inhibits nocieption. This is why massage and chiropractic almost always feels good. But this touch-override mechanism is temporary. People will leave your office feeling better, but it’s not because any tissue changes occurred. From a dualistic perspective, one would conclude that you didn’t do anything and that bodywork is a pointless endeavor. But what one has to do is realize that this temporary block in nociception can be very useful while also not confusing it with “fixing” something.
One of the things I’m learning about and that I will be adding more and more to the program are specific language tools to use that utilize descending modulation appropriately. We throw out any language that suggests the body is broken and needs fixed and we replace it with pro-agency language. Even phrases like “try exercising” get thrown out due to the subtle negative suggestion of failure in the term “try”. This is a HUGE topic that will likely show up in greater detail in future posts.
There’s plenty more to delve into, but I’ll leave it at this for now. If you’d like to dive into these ideas further, I recommend the book “Painful Yarns”, which is a very short, nontechnical, and funny book written by the world’s top researcher on pain. I read it in one day cuz it was so fun to read.
I hope this was valuable for some of you.