Fred is Dead

By Douglas Nelson
[Table Lessons]

Mr. K came to my office with complaints of back pain that had started about two weeks earlier. He had been doing some pretty heavy weight lifting, ramping up his routine prior to the injury. He had also been doing a significant amount of cleaning in his basement. He first noticed the back pain while lifting a box and moving it onto a cart. This motion was essentially side bending to the left.

Mr. K’s pain was on the right side of his low back. My first task was to gather information as to the exact source of his pain. There were several options and the task is to, as reasonably as possible, eliminate them one by one. As always: one symptom, many possible causes. I asked Mr. K to first side bend to the right and the left for me first. Side bending to the right was not painful, but side bending to the left was. As he side bent left, he felt pain on the right side of his low back. Since side bending away from the pain was problematic, it pointed to muscular issues on the right side of his low back.

At this point, I decided to palpate his musculature to assess it both statically and dynamically. To static pressure, there was a slightly different feel to the two sides, the right being a bit less compliant than the left. This difference was slight enough that I am not sure I could have known this without some prior knowledge on my part.

The real issue was revealed when I asked him to sit in front of me and slowly side bend to the left while I palpated his quadratus lumborum muscle on the right. As soon as the quadratus muscle felt the lengthening, it reacted almost violently. The muscle was clearly hyperreactive about any change in length. (This sensitivity also did not go unnoticed by him.) More clearly, this seemed to be centered at exactly one spot, the insertion at the L4 transverse process.

Plan of Attack

Perhaps in years past, I might have pressed on the perceived epicenter of Mr. K’s pain. Since I was confident that L4 was the source based on dynamic evaluation and the assessment also revealed extreme hypersensitivity, I decided not to address the epicenter itself, but diffuse it by treating surrounding areas.

Generally, if I make this decision not to address the epicenter, I always explain to clients what I am doing and why. Without this explanation, clients usually feel I’m lost and/or fishing around. This is especially frustrating to them as at one point during the assessment, I indeed press on the epicenter. In their estimation, I must not have recognized the importance of this epicenter, because I do not directly address it. In these cases, I explain how direct interventions carry some risk of rebound/backlash. Usually, this is a rather tough sell. They prefer I just go right after it. I often relay a piece of data I once read, that in a study of 300 military battles, six frontal assaults resulted in victory. For whatever reason—I cannot say why—I did not do this with Mr. K. I said nothing, just kept working, diligently assessing and treating his muscles.


All about networks

As I was addressing surrounding tissue—every avenue that might affect the L4 attachment—Mr. K turned his head and asked, “Counterinsurgency?” I was stunned. Speechless. I just stared at him while a faint (albeit restrained) smile emerged on his face. Never has anyone, ever, actually understood what I was doing and why. The look on his face told me he comprehended the whole strategy from the moment I found the epicenter and did not pursue it. I remember thinking it a bit odd that he acknowledged how L4 recreated his symptoms, but he did not protest when I promptly moved on.

At that moment, I remembered that I noticed a small insignia on his lapel when he arrived at my office, marking him as a law enforcement agent of some sort. It began to make sense. This man had a clear understanding of my strategy from a different perspective, one as a training officer of some sort.

While I was still in my speechless/inarticulate/looking-for-something- intelligent-to-say phase, he continued. “It’s all about networks, right? You know that Fred is the epicenter, and you want to eliminate Fred. The problem is, Fred is volatile. Too volatile to address directly. But Fred knows a guy named Frank. They have a relationship. Connect with Frank and you will affect Fred. Another guy, Jack, knows both Frank and Fred. Marty does not know Fred, but he knows Frank and Jack really well. Affect any one of them, and you affect Fred. It may be circuitous, but it is effective and safer than dealing with Fred directly. In the end, it is all about Fred. Counterinsurgency strategy, right?”

I could do nothing but smile and nod my head in approval. In a few minutes, I readdressed the L4 attachment of the quadratus lumborum, finding it significantly less tender and less hyperresponsive to passive motion. Mr. K then stood up and tried some gentle side bending to the left, finding it to be quite comfortable.

“Fred is dead,” he quipped.

 Douglas Nelson is the founder and principle 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 or e-mail him at