We need to talk about pain. In this month’s blog, I want to draw attention to aspects of my work as a Rolfer that are sometimes harder to explain as part of the one-minute ‘dinner party’ pitch (when it comes to networking, I favour dinner parties* over elevators) that I often find myself having to make in response to the dreaded question, ‘And what do you do?’
It’s easier to talk about posture, fascia, gravity (and easier in turn to talk about posture than either fascia or gravity) than it is to talk about, say, tonic function, Golgi tendon organs, or neuroplasticity. Yet the reality of my practice points clearly to a need for therapists who work directly with the body to take account of new research that both questions a narrowly physical model of manipulation therapy and suggests that we take the neurological, psychological and cultural components of both health and ill-health more seriously.
Last week I attended a course led by the craniosacral therapist and chiropractor, Steve Haines, called ‘Understanding Pain’. I’m currently training with Steve and his colleagues to become an accredited TRE Practitioner. That’s an interesting story in itself, so I’ll save that for another post.
Steve has recently published his new book, illustrated by artist Sophie Standing, called ‘Pain Is Really Strange’. The strangeness extends to its format: a deceptively short booklet in graphic novel style that belies the depth and detail of its message. After initial befuddlement I’m completely won over to it, and I suspect that I’ll be recommending Pain Is Really Strange to many of my clients for years to come.
Steve’s central contention is that pain – especially chronic pain – does not work the way we think it does. While the short-term pain we associate with acute injury can be a fair indicator of risk (and both research and anecdote suggests that even this is far from clear), the research on chronic pain, defined as episodes of pain that go on for more than six months, has produced a range of counterintuitive findings with significant implications for the treatment and management of chronic pain.
Pain, it turns out, is really strange: it’s an unreliable indicator of tissue damage. Conversely, tissue damage observed in MRI scans or X-rays is not a reliable indicator of pain. Where a discrete injury has occurred at a particular place in the body, histological analysis shows that tissues typically repair within 3-6 months, and yet pain at that site can be perceived for years at the initial site of injury. The most dramatic illustration of this is the curious phenomenon of the ‘phantom limb’, where apparently physical pain is felt acutely by amputees in their non-existent limb; on the flip side we know of cases where people really ‘ought to’ feel pain (and I use the scare quotes there advisedly), but don’t: take the example of a man severely mauled by a shark who ‘laughed about it to his mates’ on the way back to the shore (and then received medical attention).
Haines follows research definitions of pain that re-describe pain as a complex output that registers your ‘brain’s assessment of safety’ (quoting Paul Ingraham, 2011). When you perceive a feeling, or a movement, or a potential, as unsafe, your body and your brain experience this assessment as a painful sensation ‘allocated an anatomical reference in your virtual body’. Two points are particularly worth unpacking here: the idea of pain as a complex output, and the idea of a ‘virtual body’.
The complexity of our individual pain responses derives from the many factors that go into creating what Haines calls a ‘neurotag’ or ‘neurosignature’; that is, the specific ‘recipe’ that we cook up (for the most part, unconsciously) when we encounter a situation felt to be unsafe. A soupçon of tissue damage, a side-serving of stored immune system responses to earlier inflammatory responses, and a hefty dollop of our own signature blends of culture, personality, understanding and memory. None of this is to say that the pain we feel at a particular time is ‘not real’. The pain is real. It’s just that the damage which we imagine the pain to be witnessing may not be real. And where this is the case, the pain is not only really strange, but really unhelpful.
The idea of a ‘virtual body’ references the fact that our knowledge of the body is always mediated both by our body image (our conscious ideas about our body) and our body schema, the slightly more technical term to describe the way in which our body is mapped within the brain. A supple gymnast ‘knows’ (both consciously and unconsciously) that his or her body can twist and bend in certain ways; as a physical therapist I am often asked by people unused to my line of work whether I can actually ‘feel’ tight shoulders under my hands: these are ranges of mobility and sensitivity acquired from experience. Someone who ‘knows’ that their back is unable to make certain movements equally constructs a world in which their body is perceived as fragile, brittle or damaged in some way.
And while we can detect the most egregious discrepancies between the ‘real’ and ‘virtual’ bodies, we should remember that the ‘virtual’ body is not mere overlay to the ‘real’: the perceptions we have about our bodies actively construct our physical reality. One example: the remarkable study featuring two groups of hotel room cleaners, in which the experimental group were simply told that their work was equivalent to a daily gym session, consisting as it did of miles walked, calories burned and cardiovascular exercise. After just one month, the experimental group showed significant improvement in various measures of health, such as blood pressure, weight, and waist-to-hip ratio.
So why do we feel pain if there is no damage to the tissue? Haines quotes Louw (2013): ‘We know most tissues in the human body heal between 3-6 months. It is now well-established that ongoing pain is more due to a sensitive nervous system. In other words, the body’s alarm system stays in alarm mode after tissues have healed.’ The keyword here is ‘sensitive’: the body’s central nervous system not only remains sensitive (receptive to sensation) at a site of previous injury, but actively turns up the volume. In extreme cases, increasing sensitisation at a site of previous injury can result in allodynia, in which even the lightest touch is exquisitely painful. Remember: in these instances, the pain is real, but the injury to which it would seem to point is not. That’s either very depressing, or very hopeful, since we can retrain our body in respect of sensitisation: through movement, awareness, experience, and reframing. It also suggests a valuable role for painkillers which is sometimes downplayed in the holistic/alternative health communities.
All of the above has significant implications for my work as a Rolfer. For one thing, the relationship between posture and pain is more complex than the ‘little boy logo’ (currently licensed for use only by certified Rolfers, and dating from the 1970s) implies. You only have to watch a group of runners go by in a marathon to see that apparently poor form does not necessarily equal pain (and vice versa), which is not to say that form can’t be improved, or that postural patterns don’t have long-term effects.
For another thing, understanding pain as a complex output of the body’s various intelligence systems (by which I mean not only the brain) requires us to take account of the whole person: body, mind, nervous system, and personality. Rolfers have already supplemented the static image of the little boy logo with a dynamic, functional account of the body in movement, and superadded to that a sensitive awareness of sympathetic and parasympathetic response. Combined, all these elements describe our individual ‘pattern’, and patterns, of which our pain response – that ‘complex output’ – is another.
* I’ve intentionally created the impression that I go to a great many modish dinner parties. The reality is that I spend a lot of my time commuting between London and Luton.