Response to a Question Regarding What Do We Know For Sure (For therapists)

Posted on: Sun, 09/04/2011 - 9:02pm By: Alice

A colleague on a private forum asked the following questions in response to some thoughts I posted yesterday. In particular, he wondered about the description of an experience I had with a client. His question:
 

Having effect on the nervous system by stretching skin will relieve pain?  . . . [Is] Dianna [sic] relieving trigger points in this fashion? Seriously? Sixteen years ago, I never knew what was causing my pain. Doctors didn't know either. And then I ran into a PT who did know and mentored me. Trigger Point work, as I have benefitted, is painful. Paul Ingraham and Amber Davies agree, they hurt like hell when compressed. That "painful work" is the only thing that has ever given me tempory relief. I'm just not seeing where skin work is going to effect a mechanical release of myofascial contraction knots.....


I understand why my colleague might think I am suggesting that stretching skin relieves trigger points but no, that was not what I intended to communicate. The question deserves a thoughtful answer because it raises many issues that we massage therapists deal with in our work.

 

My Limited Understanding of DNM

First of all, let me say that my understanding of what Diane Jacobs does in the practice of DermoNeuroModulation (DNM) is very, very limited. In no way do I want to misrepresent Jacobs' approach or the thinking behind her approach. I have read some of her writing; some of it I think I understand, some I certainly do not. However, she has caused me to think about what I do in a slightly different light and it's always good to step outside of our own assumptions and look at them from another's point of view. This is how we learn from each other.

I have never seen Jacobs practice DNM and have only a sketchy idea about it from her writing and from the description of others who practice DNM. In its simplest form, it seems that she engages the skin in a very slow, sustained stretch, most often in a lateral direction. Does this relieve pain? As a physiotherapist, I assume that she treats patients with pain and that they must find some relief or else there would be no reason for this treatment. So I assume the answer is yes, she relieves pain through her particular approach of sustained stretching of skin.

 

The Trigger Point Controversy


Does Jacobs use this treatment for trigger points? This question brings up another subject. Although I am not yet aware of all the evidence or arguments, I do know that there is controversy about trigger points. Some manual therapists question whether they exist at all. I am not going to address that issue at the moment. I think, if I am not mistaken, that Jacobs may be among those who question the existence of trigger points. Whether that assumption is correct or not, I do not believe, based on what I have read, that Jacobs sees herself as treating trigger points with her approach.

For the sake of simplicity and staying on subject, I am going to proceed accepting the model of trigger points as described by Travell & Simons.


Skin, Nerves, and the Central Nervous System
 

Back to the first question: will stretching the skin have an affect on pain? I don't know. I don't have an answer to that. What I can describe are a couple of experiences I've had recently and the thoughts that have been generated by those experiences.

First, Jacobs' approach intrigued me. I know from personal experience that stretching the skin can feel good. Now, just because something feels good does not mean it has therapeutic value, but it's one place to start. It does no harm.

In Russian massage, we are taught to respect the central nervous system. We are taught not to inflict pain. When we create pain, we cause a stress response. This makes perfect sense. However, it's also in direct conflict with some other things we are taught and even our own experience. This is a conflict with which I've struggled ever since I first began to study Russian massage.

 

No Pain, No Gain?


I assisted at NeuroMuscular Therapy seminars for 10 years, so I am very, very familiar with how it is taught. In NMT, we are taught to hold pressure on trigger points for a period of time. It is emphasized to participants that the level of pressure should elicit mild to moderate discomfort. However, we all know that, in fact, most therapists use a level of pressure that is far above what would be described as "mild to moderate." "Hurts like hell" is common. "Hurts like hell" is not "mild to moderate discomfort," yet that is the way TP work is usually practiced. Why? One reason is that we believe that this is the right thing to do. The other reason is that our clients want and demand it. Both clients and therapists alike seem to believe that "hurts like hell" is good, necessary, and effective. It seems to work well enough often enough.

What is going on here? Why do we want to hurt our clients? Why do our clients want us to hurt them? This is something I've thought about a lot and will surely come back to again. However, for now, I'll just set that aside.

Why does pressure on TPs work? After all, we do have the experience of pain fading and pain going away. So, at a certain level, it gets results. However, is this much discomfort necessary in order to relieve pain? What about the stress we are causing to the CNS when we inflict this much pain? And how does this work, anyway?

How does digital pressure on TPs create a reduction in pain? I don't think we have an answer to that. In the beginning, it was postulated that it happened by means of the gate theory, that our input interrupted the constant flow of pain signals to the brain and gave the brain something different to think about, kind of like distracting the brain from a headache by hitting the thumb with a hammer. That theory seems to have lost ground and, if you think of it, does it make sense that we could change neurological patterns that have existed for years by interrupting them for 10 seconds or so?

A more recent theory, put forth in the second edition of Vol. 1 of Travell & Simons, is that trigger points are the result of damaged end plates at the neuromuscular junction, resulting in an uninterrupted flow of acetocholine and causing a sustained contracture. The thought is that our concentrated pressure further destroys the already damaged endplate, causing the body to rebuild it. I have never been completely satisfied with this theory since sometimes it does not take great amounts of pressure to resolve TPs. My experience is that sometimes TPs can be resolved without strong amounts of pressure. That, to me, suggests that input to the nervous system is creating the change, but that's my personal theory of the moment.

If you accept either the gate theory or the endplate theory, it still comes down to the nervous system. It is the nervous system, for whatever reason, that causes contracture and it will be the nervous system that ends it, either by the brain changing its mind (the gate theory of interruption) or by losing the ability (destroyed end plate theory).


Back To My Client


My client had a classic trigger point in his anterior scalene that was referring into his rhomboid area. Discovering this was one path to reducing his pain. There were also areas of complaint in his upper back and posterior axillary region. I never found trigger points in these areas but there were many areas of taut, tender tissue. Normally, I'd warm the area with Russian massage and then apply direct pressure in certain areas. This tactic often works well for me. I don't work with as strong a pressure as many therapists, preferring to work firmly but not hard. However, clients often want a lot of pressure and it seems to work. It's a dilemma.

I'd recently listened to an interview with Karen Lines and she talked about not wanting to cause pain to nerve and tissue that was already irritated. Her words echoed in my mind. How could I do that? But the body, sometimes, seems to cry out for contact, even strong contact. What to do?

I thought of Jacobs' approach. At that moment, with that client, her approach didn't seem quite right. But the idea, the principle, did seem right. So what I did was a bit of a compromise. I pressed the heel of my hand, which provides a broad and firm, but not hard, contact, into the area that seemed to want attention, and pushed, not directly into the body but somewhat laterally. I'm not sure why, but my impression is that Jacobs seems to favor this direction and it seemed like the right direction to go. The thinking, if you could call it that, at that moment was that the body sometimes craves strong contact, strong sensation. We interpret that as pain or pressure directly into the tissue but maybe it doesn't have to be in that direction. I know from feeling it myself that one can push in a direction that puts a stretch on the tissue, that creates tension in it, and it can create a sensation that is strong, that has intensity, but is not the same as what most of us would call pain. At that moment, it seemed like the right thing to do. Afterward, the client told me it felt very good and very effective.

A few days later, with another client, I tried the same approach and she said the same thing. She has ongoing pain in her upper back. She has some spinal deformity, a section has been cut out of the lamina groove, and her days are spent hunched over a microscope. She gets a lot of tightness, a lot of pain, in the muscles of her upper back and she, too, likes pressure on those areas. And, when I took this different approach, she liked it even better than the intense pressure.

 

What is Happening?

What is happening? I don't know enough about how the mechanoreceptors work to speculate. What I will say is this: without pressing hard into already irritated tissue, my clients experienced a reduction in pain. These are clients who usually want a lot of pressure. The experience apparently provided them with a sensation that was strong enough to satisfy the tissue's craving for contact without being hard and eliciting pain in already irritated tissue. The fascia folks would probably assert that it was stretching fascia but if that's what happened, it was only superficial fascia. I think it more likely that the brain liked what I did to its cutaneous nerves and changed its mind about the pain.

Can one relieve trigger points by stretching the skin? I have no answer to that question. Can one relieve pain by stretching the skin? Well, the cutaneous nerves attach to the skin. The skin is full of mechanoreceptors. The physiological effects produced by massage come about because we stimulate mechanoreceptors in the skin. Could pain be relieved by stretching the skin? I don't know that but it seems plausible that it could happen. I'm willing to try it again, when it seems like the right thing to do, and see.

There's more, but that's enough for now. I use a lot of Russian heel of the hand friction. It's a wonderful stroke and I think a lot about exactly what is going on when I am doing it. I think about how deep do we actually affect the tissue and suspect that it's not nearly what we think. But the nervous system can reach deeper than we will ever reach with our hands. If we learn to speak to the nervous system, no telling where we could go.

My sincere apologies to Ms. Jacobs if I have misunderstood or misrepresented DNM or her ideas in any way. However flawed my understanding may be, her ideas have stimulated a lot of thinking.

 

Hi Alice,

Diane here.

I want to reassure you that you have not misrepresented me in any way.
About the "trigger point" issue, I offer you this article (old but very good) by Quintner and Cohen. They like to take apart pain constructs of all sorts, the biomedical one, even the biopsychosocial one.

Here is their paper arguing that the construct "trigger points", lacks validity, and their proposal that instead, tenderness felt on palpation likely has more to do with peripheral neural structure being stressed. They don't say specifically, but I would guess, either physiologically (hyperalgesia) or physically (tunnel syndromes). http://www.pain-education.com/referred-pain.html . I would concur with the authors that whatever "trigger points" are, if they exist at all, they aren't a "meat" problem but rather a physical nerve problem.

Cheers!

Thanks, Diane! I will check out that link.

I am not attached to any particular explanation for the phenomena we call "trigger points" and the idea that it is a nerve problem not only seems reasonable (and likely) to me, I don't even think it contradicts what Travell & Simons had to say but, rather, perhaps elaborates on it. That many people experience very tender points that refer pain and other sensations elsewhere is so common that I would not trust anyone who insisted that did not happen. However, even Travell & Simons admit there is much they don't know, much is speculation. I don't think they are the last word. They began an exploration that I'm sure they hoped would be continued.

I've only read one criticism of T&S and, while I thought it made good points, there were some points made that made me wonder if they'd read and understood T&S.

As for whether the problem is nerve or "meat" - I'm in agreement with you there and, actually, I think so are T&S. I think we massage therapists have put our attention on the meat without thinking much about how it actually functions. What makes muscle contract, relax, and how do we feel pain? It's all nervous system. The meat is in service to the nervous system. We've paid lip service to the CNS but haven't really given it its due. You and other "neuronuts" have been an important reminder of the role of the nervous system. Thanks for waking us up!

Hello Alice. First off, I get on the Midwest LMT facebook page and have always recieved very helpful feedback from you so I have been looking at your blog here every now and then. I really enjoyed this post.
I am fairly new to massage (practicing for two years) but many of the things you have mentioned in this particular post resonate with me. I work in an office where most people are looking for pain relief and many of them want the hard and painful work that some of the other therapists there do. I have never felt comfortable with it and have been very intrigued by modalites that work closely with the nervous system. I am intrigued by the mind-body connection and I feel that the nervous system is key. I don't have a lot of cont. ed at this point or advanced training so I can't say I can back that up by knowledge, but that is where I feel led. I am interesed in learning some of the russian massage techniques if you can recommend classes, books, ect. Thank you for posting and keep it up! I aspire to learn as much as you have.