Does Poor Function Always Cause Pain?
By Aran Bright
There is a fundamental error that has emerged in the massage field that I’d like to see stop. It is the assumption that changes in function are the cause of pain. Too often we assume that because someone has “poor” posture or “less than acceptable” range of motion, this must be the cause of their pain. What is much more likely is that changes in function are the result of pain.
Changes in range of motion and posture are a normal protective mechanism, and that’s ok.
The perfect example of this error in clinical reasoning is a postural assessment for someone with a sore neck. Let’s assume a client has lost rotation and sits with a forward head posture. When I learnt assessment, it was normal to blame the muscles involved in posture and the loss of rotation as the cause of the problem. Oh no, it must be the dreaded Upper Cross Syndrome.
Normally, muscles like levator scapulae, trapezius and SCM will be blamed for being “too tight”, and rhomboids and the deep neck flexors blamed for being “weak”. This is a real issue, because we are talking about function and mistaking it for pain. If the focus of our treatment is about restoring normal function, then sure, this is a perfectly logical approach to treatment. But, if we are talking about the source of pain, we are making a fundamental error.
In an old school remedial massage treatment, having identified the perpetrator of the crime, we can begin an all out assault on the SCM, Trapezius or any other poor, innocent muscle. Assuming it is the fault of this delinquent muscle, we also assume there is something wrong with this muscle and it must be punished. It is at this point where anything short of beating it with stick seems to be justified to fix the client’s pain.
Naughty Muscles (musclus naughtius)
It is absolutely possible that massage or manual therapy to the SCM or another specific muscle can reduce the client’s pain, but it is more likely that a general massage sequence over the neck and shoulder area will reduce their discomfort just as effectively. In fact, when we look at the evidence of general massage and targeted approaches (such as Myofascial Release), it appears that general massage appears to be the more effective option for pain management. (Source, source)
The most likely reason for this is that reduction in pain is the result of changes at the level of the spinal cord and brain, rather than local changes to the target tissue that a therapist may treat.
BUT! Targeted approaches have been shown to be very effective for function. Manual trigger point approaches are typically associated with improvements in function, and that is very useful. If the goal of your treatment is to improve posture or range of motion, then methods such as trigger point therapy can be quite useful, but please note, it is not “fixing” anything. (Source)
So What Is Going On?
Changes in muscle tone and function are all regulated by the Central Nervous System, and this is most likely the only thing that is changed in a massage or manual therapy treatment. Unless, of cause, we are successful in our all out assault on our target muscle and the whole thing just explodes (bruises) – that would probably qualify as change?
Instead of targeted annihilation of musclus naughtius, keep in mind that reduction in pain occurs in areas of the body you can’t rub, but you can talk to it by touching someone. What exactly are you saying in your tactile communication? Is it “your muscles are evil and must be punished” or maybe a little more “it’s OK, I got this, you can relax now”?
That’s Great, But What About That Sore Neck?
The good news is that you don’t need to do anything you aren’t already doing. Massaging a sore area of the body is something you probably do really well already. Applying soothing massage at a level of pressure the client finds therapeutic is all that is really needed. There is no need to exorcise demons from your poor client’s neck.
If, in combination with your awesome massage, you decide to perform some functional treatment, that’s amazing. Please know, however, that most musculoskeletal pain is not easy to identify, and certainly not as easy as a quick postural and range of motion assessment. What you are assessing is posture and function, and that’s great, but let’s be open-minded about what is causing a client’s pain.
The Sting In The Tale
The biggest problem here isn’t misdiagnosing a client’s signs and symptoms, it is creating a belief in the client that they are full of dysfunctional, evil muscles, and their posture is permanently wrong. We have successfully created a nocebo belief and potentially the sort of hypervigilance that we know can significantly increase the likelihood of chronic pain. (Source, article.) In fact it is very likely, the therapist themselves can end up being a greater cause of pain than the poor SCM.
Let’s Stop Being A Pain In The Neck
Let’s stop blaming muscles, posture, alignment or range of motion for pain.
Next time, instead of jumping to a conclusion, why not ask the client what they think it is, and go from there? It’s their body and it’s much more likely they know what’s going on inside better than you do. We just need to provide the right sort of experience for them to self-regulate their pain and function.
About the Author
Aran Bright started his career as a massage therapist in 2002 after graduating from the Australian College of Natural Medicine in Queensland. In 2006, Aran completed his Diploma of Remedial Massage and, in 2007, his Bachelor of Health Science in Musculoskeletal Therapy. Aran graduated from University of Queensland with a Graduate Certificate of Sports Coaching, completed a Certificate IV in Fitness and an Advanced Diploma of Myotherapy. He currently runs his own businesses, Bright Health Training and Brisbane Workplace Massage, with his wife, Sheree.