Questions of Pain

Keeping a beginner’s mind in relationship to familiar circumstances is exceedingly difficult. For example, when I give someone a tour of the city in which I have lived for many years, they always seem to point out things I never noticed. Familiarity can lead to comfortable assumptions, and observations from someone else can help us see familiar surroundings with new eyes. Such was the case recently with a new client in my practice. 

As this was only her second experience with massage therapy, she had few preconceptions. Her first session had been months ago, when she came home to visit family and sought treatment for back pain she’d been experiencing. This young client is an engineer—clearly someone who seeks to explore how things work and why. Her in-depth questions forced me to reflect on them and cut right to the heart of the work we do every day. 

I also want to be clear that her questions came from an attitude of curiosity, not intentionally challenging. There isn’t space to share my full responses, but I invite you, the reader, to think deeply about how you might respond, which would then unveil the processes of your session design. Savoring these questions can help us be more intentional and create treatments by design, not default. 

At the beginning of this session, my client relayed that her pain had substantially improved after our first session several months ago. She had since experienced occasional pain, but not the same frequency or intensity. In that first session, I had found and corrected a rather significant pelvic asymmetry, and I was delighted to find that the pelvic landmarks were still symmetrical, about where they were at the end of that last session. 

Her first question: “Since the pain is lessened after changing my pelvic position, I assume that my pelvic position is related to the pain. Did the asymmetry originally come from a posture or movement I was doing or was it caused by some event, such as a fall?” Next, she asked, “Since the pelvis is still level, does that mean that the genesis of the asymmetry was an event? Or, after the pelvic position changed, did the altered position change my movement patterns as well, and is that why the change lasted so long?”

Familiarity can lead to comfortable assumptions, and observations from someone else can help us see familiar surroundings with new eyes.

These are brilliant observations. What does it mean that the change lasted so long after just one treatment? Moreover, the idea that form (pelvic position) changed function (her movement patterns) is a fascinating concept.  

After a brief exploration of these ideas, I decided to examine the position and movement of her sacrum and its possible relationship with her back pain. I sensed a restriction on the right side, which was made more visible with respiration. After treatment of the muscles and ligaments affecting the right sacroiliac joint, I then had her lay supine to examine potential cervical influences. As I was exploring the movement of the occiput, she asked her next question: “Is my neck discomfort somehow related to my back pain?”

After I demonstrated the biomechanics of occipital and sacral movement and their relationship with each other, she followed with more excellent, thoughtful questions. 

“If they are related, then which problem came first? Which one is causing the other? And, how do you know?”

For therapists, understanding that two issues are related is important, but discerning the hierarchy between them is crucial to effective treatment. After I responded in some length, her next question was deeply insightful. 

“If you just treat the primary restriction, will the secondary one disappear, or do you have to address 
it directly?”

We then explored bidirectionality—how each influence affects the other and both must be addressed—but the order and percentages matter. That discussion then evolved into a conversation about the multiplicity of influences in any pain condition. As I explained, each primary component has a list of influences, creating systems inside of systems. All this creates a very complex network of potential influences. 

“Wow, this is much more complex than simply treating an area that hurts,” she said. “How do you know where to go next? And, how do you know when it’s time to move on to the next area?”

I must admit that at this point I was lost in thought, savoring these fundamental and insightful questions. Writing down my client’s questions after the session to create the framework for this column, I kept thinking about how reflecting on these ideas can help us all be better therapists. Sharing these questions with a small group of my clinic staff, I loved seeing the smiles on their faces when they realized the potential value of exploring how they might respond. I sense we will be having many conversations exploring their own answers to these questions. I hope you will do the same.