Does That Feel Tight?

By Sam McCracken

The question I face most often in the clinic – and I imagine most therapists are asked this question multiple times a day – is “Does that feel tight to you?” Given that this is such a common question, we would do well to analyse why we are being asked and what the most appropriate response is.

One reason we are being asked is that the client is seeking validation for what they are feeling. But am I able to confirm that feeling? Am I able to feel the same thing?

At the 2016 AMT annual conference we were fortunate to have Dr Tasha Stanton as keynote speaker.

Dr Stanton shared with us her research1 investigating if the feeling of back stiffness actually reflects having a stiff back? Her research concluded that “feelings of back stiffness are a protective perceptual construct, rather than reflecting biomechanical properties of the back. This has far-reaching implications for treatment of pain/stiffness but also for our understanding of bodily feelings. Over three experiments, we challenge the prevailing view by showing that feeling stiff does not relate to objective spinal measures of stiffness and objective back stiffness does not differ between those who report feeling stiff and those who do not. Rather, those who report feeling stiff exhibit self-protective responses: they significantly overestimate force applied to their spine yet are better at detecting changes in this force than those who do not report feeling stiff.”

If we were to try to measure tightness, we would invariably run into confounding factors with our assessment. Varied kinematics and ratios of collagen fibre types would only lead us to the conclusion that variation is normal and, as for inter-rater reliability, we find that even the experts fail miserably when trying to gauge tight muscles or taut bands of muscle fibres.2

Before we go any further examining what we as therapists are feeling, we need to ask if it is the same thing the patient/client is feeling. The answer is ‘probably not’. In fact, they might as well be asking “does my nose feel itchy to you?” My exteroception is not the same as the client’s interoception. This is not to say that the physical exam is not important. Indeed, it is essential, but we must exercise awareness that it may be illusory.

We have all heard people proclaiming “it’s this muscle here” while pointing to an area of the body. When I ask why a client thinks it’s the muscle that’s problematic, I usually get a confused look and the reply of “well I don’t think it’s the bone, so it must be the muscle”. The general public are pretty well versed in major muscle groups: lats, traps, glutes, quads and hammies can all be easily identified. However, any mention of our physical nervous system usually draws a blank, even though we have an estimated 72 kilometres of nerves running through our bodies and that all pain is neurogenic. The public’s ignorance of the role of the nervous system can be excused but what about massage therapists? By not acknowledging the role of the nervous system, have we set ourselves up to blame and even punish innocent muscles? If we were to disable the nervous system by administering a general anaesthetic, we can temporarily eliminate pain, but we can also often observe complete restoration of restricted range of motion. as the video below clearly demonstrates.

Reported tightness is an emotional and sensory experience related to unpleasant bodily sensations and as such can be classed as a pain descriptor. The renowned pain scientist Ronald Melzack began collecting the words that patients used most frequently to describe pain, organising this vocabulary into categories to capture pain’s temporal, sensory and affective dimensions, as well as its intensity. The result was the McGill Pain Questionnaire, a scale comprising some eighty descriptors, including tight, stabbing, burning, and heavy. The descriptors fall into four major groups: sensory; affective; evaluative and miscellaneous.

A muscle that is reported as feeling tight is not necessarily biomechanically tight. Just as a report of a leg feeling heavy does not weigh more, or a burning sensation is not associated with heat.

I don’t think we should discourage people from using these terms because they are wonderfully informative descriptions.

When someone tells me they feel “tight”, I may or may not be able to feel that tightness but I have a good idea what they are talking about. In fact, that is the same word I would use to describe that sensation. I may not literally have knots in my muscles but I can feel all knotted up. My back my not be “out” but it doesn’t feel right, it doesn’t feel like everything is in order, it feels “out”. A discussion about these reported sensations combined with some open-ended questions and a thorough physical examination can streamline the formation of a treatment plan.

In her conference presentation, Dr Stanton also spoke about the importance of explaining pain and how it can be empowering to have a greater understanding of pain, and how massage therapists are exceptionally well placed to provide this information. Massage therapists are generally more affordable, more accessible and many have advanced pain content knowledge and, critically, they know how the musculoskeletal system works.

Is this an E flag?

The question “Does that feel tight to you?” is sometimes asked mid treatment with the patient lying face down. Since this may not be an opportune time for complex explanations, I would like to share a method used by Dr David Butler. While he is taking a history or doing an assessment, he places what he refers to as an E flag in his notes, this serves as a reminder to come back to this later to offer more “explanation”. Similarly, we can make a mental note, an E flag, to explain things further at a more opportune time.

It is possible to offer validation of peoples lived sensory experiences, in this case the feeling of “tightness”, by demonstrating an understanding of the science and using metaphors and storytelling that gives meaning to the subjective nature of pain and discomfort, and moving to a form of discourse that might be called the intersubjective that emphasises negotiation towards shared meaning.

References:
  1. Feeling stiffness in the back: a protective perceptual inference in chronic back pain Stanton, T et al, Nature.com, Scientific Reports volume 7, Article number: 9681 (2017)
  2. Travell, Simons and Cargo Cult Science, Posted by Fred Wolfe on 14 February 2013, Fibromyalgia Perplex
About the Author

Sam McCracken is a remedial massage therapist on Brisbane’s north side. Sam qualified in traditional Thai massage in 2006 from the world’s oldest massage school (Wat Po Traditional Medicine School) and with the benefit of over 30 years of daily Tai Chi practice, he believes he is on track to achieving his goal of becoming the world’s oldest massage therapist. Sam has a keen interest in modern understandings of traditional massage methods. He has studied many lineages of massage, mostly from Asian traditions.

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