So you’ve probably experienced this before.
When you’re working with someone and you just can’t clear that long standing hip pain, back pain headaches and jaw pain.
When you have done the testing and assessing, and you still can’t find just what is causing the problem.
When the pain is moving around the body.
When the patient in front of you has tried physio, acupuncture, multi-body work techniques and they have heard you’re good so they’re giving you a try.
We want to help – and then question – can we? Should we choose as therapist’s to take these people on?
Here’s my confession. I love treating these patients. I love thinking how can I help, what did all these other practitioners miss. Did you ever watch the medical programme House? Think of yourself like Dr Gregory House, M.D., an elite diagnostician with a puzzle to unravel – without the drug habit, terrible bed side manner and limp, preferably.
Let’s start with my checklist – often people have missed asking these questions (some of which are clearly gender dependent).
- Do you have children? How was childbirth?
- What sport did you play as a child?
- Were you ever involved in a road traffic accident?
- Have you ever been physically assaulted as a child/adult?
- Have you ever been bullied? As a child or adult?
- Have you ever fallen out of tree, off a rock climbing or at pony club?
- Have you ever felt so stressed you have needed time off work, or an extended holiday?
- Have you ever been so frightened or fearful that you might not survive the moment you’re in?
- Do you have any scars? From childhood or surgeries?
These questions in my experience have not always been asked. And that’s because they’re quite intense. They take a lot to ask, for the practitioner and the patient. But often they’re the only way get to the root cause of someone’s pain.
It’s all down to whether you are willing as a therapist to hear the whole story, and be open to hearing the whole story of their body. Be open with no judgment, offering curious compassion.
All these incidents I’ve listed can cause, if unaddressed, tension and compression throughout the body, often accumulating in the mid body/abdominals.
People find ways to unconsciously compensate. It usually involves at lot of holding themselves with tension, at an unconscious level. Here’s how things develop over time.
- Foot pain > altered gait
- Altered gait > lumber pain
- Unexplained knee pain > disruption in the pelvis
- Kyphotic posture with a forward head > digestive issues, tight breathing, holding breath.
- Tightness or holding in the TMJ (jaw) > headaches and shoulder pain.
When patients have suffered trauma in the past, it creates a false baseline for the nervous system. Whilst the patient might have developed a mental resilience which can make them forget the extent of their trauma, this isn’t reflected in the body. The body instead is more sensitive to future pain and future trauma, as it’s on a constant high alert – the signals being received by this new trauma are interpreted at a more extreme level.
This is something I have seen time and time again in my practice, and has been explained further by research completed by the Noigroup. If you’re interested more in this, I recommend the book Explain Pain.
This is why it’s so important to understand the patient’s history and know where their baseline is at.
Here’s a good place to start.
- Ask them what would be a good outcome for them?
- Ask them what be a great outcome for them?
This means you can work toward a small improvement on their way to their idea of wellness. Sometimes in the beginning small changes, indicate that greater changes can come.
I explain to the patient what will happen once the whole story is told. Here’s what I think should be said next, based on my experience.
- We’re going to work through small steps so we don’t set up a fear response in the nervous system
- Would reducing the pain be a good outcome? Even though I may not be able to change the soft tissue injury
- I’m going to make the treatment as pain free as possible so it doesn’t pose a threat to your nervous system
- You’ll be in charge of overseeing your recovery
- Are you ready to take on small movements at home to support your recovery?
I always start with holding the feet, and slowly moving on from there I create a protocol that is just for them which could contain any or all of the below.
All from a supine position:
- Holding the feet first allows the nervous system to feel input that isn’t a threat
- Use HM soft tissue mobilisations for calfs, hamstring, and quads
- Abdominal massage, NIM style
- HM soft tissue for neck and jaw
I find this begins to calm the nervous system. Remember that them being open to the plan changing as change begins to take place is key. Work with the confidence that your knowledge and learning will back up what you intuitively find and help the patient feel safe in your hands.