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Canadian Journal of Osteopathy

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A Full Body Osteopathic Approach Part 3: Multiple Input Points of Pain and Stress

Written by Lee Jarvis. Proofreading and editing by Beccy Anderson.

In our previous two articles, we discussed the full-body treatment from an Osteopathic historical perspective and the body’s capacity for connectedness and compensation. In this article, we’ll discuss the concept of a full-body treatment as it relates to the body’s capacity for pain and its awareness of it.

In the past few decades, dedicated researchers have made it clear that pain can be experienced due to real or potential tissue damage. The concept that pain can be experienced from the potential for damage is very important and forces us to understand that pain is not always an indicator of true or progressive tissue damage. Pain can serve as a warning system and will not always be accurate to the severity of an injury or the actual state of the body. We can look at the work of Sensitization (Peripheral and Central) and Nociplastic pain that indicates pain can be generated in the long term (chronic) from repeated tissue injury [1, 6, 18], repeated (chronic) inflammation [1, 6, 25] and damage/irritation to nerves [22, 25]. Genetic factors, as well as mental (non-physical) stress, also play a role in chronic pain but are not the subject of this article. From a different area of research, we can also say that immobility and/or a sedentary lifestyle are associated with pain [8, 14, 21, 28, 41, 42]. There is some evidence that forced immobilization (casting) shows a direct relationship to persistent pain [13, 30, 31], but this is still limited and not shown in humans (likely due to the legalities around running such a study on humans).

The specific type of pain from chronically painful or immobile tissue is typically the C fibre type, often felt as a slow, burning pain [29]. True central sensitization involves what are believed to be permanent changes in the spinal cord that cause pain even after a tissue injury or inflammatory state has resolved. This pain can continue indefinitely but has been known to fluctuate in region or intensity and can even go into remission [2]. One of the issues with proving or even fully understanding central sensitization (or any chronic pain condition, really) is that we do not currently have the accuracy to track neuron changes believed to be occurring with our current scanning methods (CT and MRI, for instance). Furthermore, we have no tool to measure the pain experienced by each person, taking into account their amount of or unique experience of pain. Despite the mechanism, we understand that those with chronic pain have nearly constant pain.

For safety purposes, it’s crucial to understand that pain can (and in dangerous times, most definitely should) trigger the stress response in the body. This stress response, primarily enacted via the Sympathetic Nervous System (SNS), commonly known as the ‘Fight or Flight Response,’ is a vital aspect of pain management. In the case of acute pain (sent along the A-delta fibre), this can be a very rapid activation of the stress response. We commonly know this as the near-instantaneous heart rate increase that comes along with being startled by even non-threatening occurrences (noise in the night, for instance). The chronic pain associated with the slow C fibre pain takes more time to generate a stress response but, indeed, can still cause a stress response [4, 35, 38, 44]. Again, chronic pain is not immediate in sympathetic nervous system activation, but looking at the effects of chronic pain [7, 12] over time, it is still happening more frequently than in the unaffected person. Sympathetic stimulation tends to put the body’s energy towards physical efforts and take energy away from rest, repair, and digestion efforts (functions of the Parasympathetic Nervous System).

Chronic pain without the presence of real tissue damage, which so many of our patients experience, activating an inappropriate stress response, is an unnecessary use of the body’s energy. A prolonged and unnecessary stress response generally slows the body’s capacity for repair and recovery. It should not be of any surprise to us that the sufferer of chronic pain is exhausted, likely at all times, and feels as though they can never quite “catch up.” Additionally, sufferers of chronic pain are likely to have difficulty getting to sleep and staying asleep [20, 23].

So far, we’ve mainly discussed connective tissue and nervous system changes; however, tissue degeneration due to pathology is still a significant possible cause of chronic pain. Certain diseases, particularly those of the Rheumatologic category (Rheumatoid Arthritis and Ankylosing Spondylitis, for instance), will create inflammation and progressive tissue degeneration with more than enough severity to cause pain [6, 15, 26]. These conditions can go through periods of high and low expression of symptoms or even periods of remission but generally tend towards regular areas of painful inflammation. Over the years and decades, the sufferer of the condition can accumulate many painful, sensitized areas all over their body. Depending on the severity of the disease, the chronic pain associated with sensitization may not be the primary concern for the patient (there may be more life-threatening symptoms that take precedence). However, the pain is still a component of the afflicted person’s suffering, and the sufferer will still be improved by any partial removal of the pain for any length of time.

An interesting quality of the C fibre type of pain is that, at times, it can occur without acknowledgement from the sufferer [36, 37, 40]. Said another way for clarity; sometimes you can have this C-type pain generated in a tissue, but you, the conscious person, are not paying attention to it. The sufferer becomes tolerant of the (still constant) pain over time, perhaps describing it as “background noise,” or in many cases, the sufferer will have other areas that hurt much worse and so does not notice potentially numerous other lesser pains. In a clinical setting (the office of the Osteopathic Manual Therapist, for instance), the sufferer may only report the largest amount of pain they are currently experiencing, and should that pain start to reduce, only then will they notice other lesser pains. Whether or not the sufferer is fully aware of all of the pain occurring throughout their body, there is still a cost on overall energy consumption and recovery capacity.

In Osteopathic application, this can be used in reverse; as much as every tissue can send off pain signals, every tissue can reduce its pain with movement [27, 43]. It is a bit strange to the author that for their entire career, and many decades before, the Gate Control Theory, also known commonly as “Pain Gate Theory,” is still considered a theory [19]. “Theory” implies that something is a hypothesis without significant enough proof to say with certainty that something is true. Since the Gate Control Theory of Pain was initially coined in 1965, one would think that it would be proven or that some similarity of the gate would be proven by now. We still lack sufficient proof for Gate Control Theory, but regardless, the practical evidence is still the same; if something moves better, its capacity to inhibit the sensation of pain also improves. It is a fallacy to state that “movement stops all pain,” but movement does increase the ability of the body to reduce the sensation of pain, though it can’t block out all pain. That being said, even if movement doesn’t block all pain, someone suffering from pain at any intensity for any length of time appreciates any opportunity to reduce their overall pain.

To summarize, pain can result from reduced mobility and degenerating tissue, pain can occur with or without the sufferer’s full awareness, and pain can stimulate a potentially unnecessary stress response. So, if the Osteopathic Manual Therapist can reduce the pain their patients experience [17, 34], even if the pain is not entirely related to what hurts the most (the chief complaint), the practitioner can still reduce the overall pain the patient experiences. If the pain is reduced for the patient it should also make it much easier for the patient to be in a state of reduced stress and increase their capacity for recovery [3, 33]. Thus, the Osteopathic Manual Therapist should, when possible, attempt to create motion in any tissue that will respond to it to inhibit sources of pain and reduce unnecessary energy expenditure all over the body.

Though not the subject of this article, it is also worth mentioning that heightened pain and stress are associated with poorer lifestyle outcomes in mobility, diet, and exercise [5, 9, 10, 11, 16, 24, 32, 39]. So, if OMT can reduce the patient’s pain and stress in any capacity, it can help the patient make better lifestyle changes that will benefit the patient even further in the future (though these other things often require separate education and practitioners themselves).

To conclude and recap this set of three articles;

1. Historically, the founder of Osteopathy considers the exploration and treatment of the entire body to be of value

2. The body works as a unit over both small and wide-ranging areas biomechanically

3. Pain is something that can be experienced throughout the entire body, whether the patient is aware of it or not, and can activate an unnecessary stress response

These things together should hopefully encourage the Osteopathic practitioner to seek out the complete structure of the body whenever possible, treating even the smallest parts to get the biggest possible capacity for recovery from their patients. The author firmly believes that there is far more to Osteopathic Manual Therapy and what it can do than what is written in this small series of articles. However, we hope that in these very simple applications of anatomy and physiology, the value of a full-body Osteopathic treatment approach is clear.

References

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