Shifting away from nociception and mesodermalism and towards "yesciception," neurocentrism, and pain science.

Posted on: Mon, 04/28/2014 - 8:12pm By: Alice

Most of us were brought up, professionally, with an idea of "deep tissue" and the need to "break up adhesions," "stretch fascia," and generally "fix" the meat and bones. Along the way, some of us discovered pain science, neuromatrix theory, and the realization that it is the nervous system that creates tension, creates the sensation of pain, and it is through the nervous system that one corrects it. We came to understand that manual therapy works not by mechanically altering muscle, facia, posture, etc., but by influencing the nervous system.

Modern pain science has found that the more the nervous system is subjected to nociception, the more sensitive it becomes. Therefore, we avoid creating pain.

When one has been taught to press hard into already irritated tissue and think in terms of fixing flesh and bones, giving that up creates a vacuum. How does a massage therapist make the shift to a kinder, gentler, approach that is still effective? Where does one start learning pain science and how to apply it in practice? This question has been asked by massage therapists who have discovered this new world of pain science exists, are eager to learn more and put it into practice, but aren't sure exactly where to start or how to proceed. 

Here are my personal suggestions of where to start. There is lots to learn and it could keep you busy for the rest of your life, which keeps it fun and interesting. However, the basic concepts are not difficult to grasp and one can begin to incorporate them pretty quickly. It may take time for some concepts to sink in because they are different from what we were taught as massage therapists as well as from what most of the world has believed about pain for the last 350 years or so since Descartes. Eventually it does sink in and when one's point of view begins to shift, the whole world of pain and manual therapy starts looking different. And it gets a lot more interesting.

So, without further ado, this is what I suggest:

First of all, you can probably keep using whatever modalities you already use that work well for you. It's your thinking about what you are doing that will start to change. Eventually that shift in thinking may alter how you use your modalities, but if those tools serve you and your clients well, there is no need to abandon them. The one thing you must give up is causing pain. Back off a bit. Have faith. You are going to learn how to be in conversation with the nervous system rather than trying to impose yourself on the body. You don't make the changes, the body does it. You can't force it to change, you can only learn to speak its language and try to sweet talk it. Make friends with it.

Get familiar with the term "nociception." Understand how it is different from pain. Don't worry if it takes awhile for it to sink in.

I think the easiest place to start is with Lorimer Moseley's 15 minute TED Talk on Why Things Hurt. Fun, engaging, and brilliant, it will introduce you to pain science.

After that, I recommend this more detailed lecture by Moseley. Towards the end, he explains how central sensitization works. Pay particular attention to that. Understanding central sensitization will make it clear to you why you must give up causing nociception.

This recent lecture by Moseley has a great story that illustrates very clearly how pain is an output of the brain. If you don't have time for the entire 40 minutes, at least watch the first 10 minutes and listen to his hilarious (and educational) hitchhiking story.

Watch anything on YouTube with Lorimer Moseley or David Butler. If you do nothing else, these videos will give you a basic but solid understanding of how pain works, an essential step in learning how to help alleviate it. 

Read the book Explain Pain by Butler and Moseley. It's a very solid, very readable book on pain science. You will learn all the basics. It's pricey. It's worth it to me because I use it so much. It's my model for teaching pain science to clients. If you don't want to pay that much, at least not before you've looked at it first,  you can ask your library to get this (and just about any other book) through the interlibrary loan system if they don't have it in their own system. You may have to ask them specifically to do this for you, they may not volunteer the information that they can do that. There is also a kindle version but tech savvy people tell me to make sure it is not "DMR restricted." (I hope I got that right.)

Read Diane Jacobs' essays on the difference between an "operator" and an "interactor" approach. (links at the end of this paragraph.) You will be shifting your thinking away from the idea that you do something to the body to fix it (break adhesions, stretch fascia, etc.) and towards the idea that you are engaging with the nervous system, recognizing that it is the brain that makes the changes, and you have to learn to communicate with it, make friends with it, learn its language. Don't worry that you will have to understand a lot of difficult, technical details about the brain. You can if you want but you don't have to do that to understand basic concepts and begin to integrate them into your treatment. The brain is very cool and learning about it will inspire you and deepen your understanding, but the most important thing to understand is that you want to handle the body in a kind and gentle way that makes the brain feel safe so it can relax and stop thinking it has to create pain and tension in order to protect the organism.

If you're looking for an interesting way to use your hands that doesn't create nociception and doesn't require you to believe in any imaginary constructs, you can read more about DNM at the Dermoneuromodulation website. I use a lot of what I call "nonspecific DNM" or "nonspecific skin stretching." It feels great and my clients say it's very relaxing. I have found it very effective for reducing tension and turning down the volume on pain.

Here's some links to some other resources on DNM.

Don't worry that you have to learn a new technique. I highly recommend the DNM seminars but you can also incorporate what you already know. Concentrate more on understanding how the body works, how pain works, how the brain and the nervous system work. Avoid causing pain to your clients and focus on helping them to understand their condition and to feel safe and relaxed in your hands. Learn principles. If you understand how the body works and understand principles, technique will rise out of that. Everyone does not have to work in exactly the same way. You are engaging in a conversation with the nervous system, not reading a script. As your understanding takes shape, you can adapt what you already know how to do with your hands.

Read "Pain and the Neuromatrix in the Brain" by Melzack. It is only a few pages long and not at all scary for an academic paper. Don't worry if you don't understand everything at first. This will help you understand pain as a bio/psycho/social phenomenon.

Seriously consider going to the Clinical Applications of Pain Science conference in San Diego in February, 2015. It will be an amazing gathering of some of the top people in this field. Seats are limited to if you want to go, register now. 

Somewhere along the line, check out the SomaSimple forums. It is an online community of manual therapists interested in applying pain science to practice. I wrote a guide for massage therapists to try to help make it easier for them. It can be daunting and intimidating at first, but I've learned a lot there.

There is more, but this will keep you busy for awhile. Feel free to ask questions. Remember, the reason we do this is so we can help the client in pain. If you keep that in mind, you will never run out of inspiration or motivation.