A “Software” Problem

Troubleshooting Sources of Pain

By Douglas Nelson
[table lessons]

“Thanks for checking in with me,” I said, taking a call from a client I had seen three weeks earlier. “I hope you are a bit better, especially since you drove so far for the appointment.”

“Not just a bit better, a lot better,” she said. “The pain is almost completely gone. I am thrilled!”

Given that Mrs. G. had been suffering from nearly constant pain in her left buttock, this was great news.

With any presenting problem, the old adage applies: one symptom, many possible causes. Mrs. G.’s pain could have been due to a multitude of factors—hip joint pathology, piriformis issues, trigger point referral, a spinal facet issue, or sacroiliac joint (SIJ) dysfunction, to name just a few. Let’s reason through this partial list together. When Mrs. G. first came to me, my first question was whether the pain was worse sitting, standing, or walking.

“Sitting is fine, but I cannot stand or walk for very long,” she responded.

Pain during walking that is relieved while sitting could implicate arthritic changes in the hip. However, standing does not typically bother an arthritic hip. I asked Mrs. G. to lie supine on the table while I checked her left internal femoral rotation, which was even greater on the involved left hip than the right. External rotation of her left femur against resistance also elicited no pain. With full range (external rotation and flexion were also normal) and nonpainful contraction, neither hip pathology nor piriformis issues seemed likely.

Careful palpation of the iliocostalis and the costal attachments of the quadratus lumborum revealed sensitive areas, though none that referred to the buttock. I crossed trigger point referral off the list.

To explore facet compression, I rotated her lumbar spine to the right (which did not recreate her pain), but rotating the lumbar spine to the left caused an immediate reaction.

“Oh my gosh,” she said. “That feels great. I feel a wave of relief from my spine to my hips.” Score one for facet compression. Lying on the right side with the left hip forward and the spine rotated left decompresses the left lumbar facets, so I continued to hold Mrs. G. in that spinal position as long as it provided her relief.

To address the SIJ, I did several tests, none of which were positive. Reflecting on the relief she had from decompressing the spine, I tried the same strategy with her SIJ. Positioning her supine with her knees bent, I put my hand under her sacrum, pressing it anteriorly in relation to both innominates. She immediately experienced a wave of relaxation throughout the involved area.

Decompression of both the facet and the SIJ clearly provided immediate relief. But why didn’t compression elicit symptoms? Perplexed, I asked her to stand and point to the epicenter of her pain. Guided by her hand, I felt obvious soft-tissue restriction. Just as I was about to say something, the muscle under my finger relaxed.

“Are you in pain now?” I asked.

“No, it just stopped,” she responded. Suddenly, the muscle under my finger contracted again, and she immediately reported that the pain had returned.

“Feel this with me,” I requested as I guided her hand to the spot in question. As she did, the muscle alternately relaxed (relieving the pain) and contracted (causing the pain to return).

“Let’s try using your hand as a feedback system to monitor muscular activity,” I said. “Try to make the muscle contract and then relax it. Figure out how to do that.” After several tries, she was able to selectively contract and relax the muscle.

“That is crazy,” she said in amazement. “I never realized I could control it.”

“This could be more of a software problem than a hardware problem,” I said. “This muscle is firing randomly and inappropriately. Learning to selectively contract and relax the muscle can help rewrite the program.”

At the end of the session, I reviewed with her the three possible sources of her pain (facet compression, SIJ, and inappropriate muscle firing.) Each had a self-care component: spinal twists for facet decompression, a rolled towel in place of my hand to decompress the SIJ, and daily practice of muscle reprogramming.

Returning to our current phone conversation, I wanted to know which of the three strategies was most helpful, hoping the ultimate source of her pain would be revealed.

“If I felt the pain, I practiced contracting and relaxing,” she said. “If that did not work, I did the spinal twist or the towel under the sacrum.

“Perhaps the most important factor was that I felt empowered to know there were things I could do to help myself. The truth is, I don’t know what ultimately did the trick, and I don’t really care. I am just happy the pain is gone.” In the slightly messier world in which we practice—where symptoms often result from the convergence of multiple factors—who can blame her?

Douglas Nelson is the founder and principal instructor for Precision Neuromuscular Therapy Seminars and president of the 16-therapist clinic BodyWork Associates in Champaign, Illinois. His clinic, seminars, and research endeavors explore the science behind this work. Visit www.nmtmidwest.com or email him at doug@nmtmidwest.com.