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“Why do I have this pain?”

December 9, 2013

It is commonplace in manual medical practice to be faced with the question “why do I have this pain.” The way in which this question is answered can represent a pivotal moment in the lives of the patient as the answer provided can shape their concept of musculoskeletal health for the duration of their lives.

Commonly, when faced with this scenario, manual therapists resort to the standard answer, which often involves producing a sequence of events that would, or so they believe, predispose one to the presenting injury. Common answers include muscle imbalances, anatomical variants (ex. short leg), cumulative trauma/repetitive strain, etc. The common theme amongst all of the suggested answers is that there is “something wrong” with the patient that requires “fixing.” Further to this, it is common for the therapist to continue care even in the absence of the original symptomology under the guise of “preventative maintenance.”

This description is riddled with problems. What if the patient does not perform repetitive tasks that can explain the problem? What if the patient is a well-tuned athlete that doesn’t have “imbalances” (what ever that means)? What if they do not have any overt anatomical variants, etc. This “problem” is often overcome by the practitioner by claiming/inventing an overly complex reasoning that is unfounded by science. Your ‘x’ muscle is ‘inhibited’ which is leading to the ‘facilitation’ of ‘y,’ causing pain in ‘z.’ Whilst this ‘x+y=z’ explanation may indeed be causative (of course there is no real way to know in absence of evidence…especially as many of the utilized ‘buzz’ words have very, very poorly understood explanations at best), there is an easier, more accurate answer that can be used. Namely….because you are human.

Possibly unknown to some, the process of evolution is not believed to be directional towards an optimal state. It is not the best traits that survive; it is only those that conferred advantage against environmental pressures that are present. The bi-pedal posture for example is believed to have come about from an energy conservation standpoint. Humans were able to get more travel out of less energy demand. Never in this equation was factored what standing upright would do to ones musculoskeletal well being. Further to this, most recent innovations such as chairs, shoes, cars, laptops, desks, etc., were never factored into the physical evolutionary process. Thus while the species is still getting used to this new development (‘new’ from an evolutionary sense) of bipedal locomotion, the rapid implementation of these types of innovations means that the body really has no idea how to deal with them.

What does this mean in terms of our original question of “why do I have this pain?” It means that it is most accurately answered by re-phrasing the question and directing it back at the origin…. “what have you done to prevent this pain from occurring?” How have you physically prepared your injured tissues to withstand the stress of sitting in a chair, working on your computer for hours on end, driving a car, etc.

I do not mean to pass blame onto to the patient seeking advice. If anything, I am questioning how we as manual practitioners, who are supposed to experts in musculoskeletal health, are not more active in informing our patients, and the population as a whole, as to the various predispositions that we have to painful conditions (low back pain, neck pain, headache, plantar fasciitis, patelofemoral pain syndrome, etc.). Further, why are we not in the habit of prescribing exercises to mitigate these problems (notice I didn’t say ‘prevent’ as this is often not possible) even in absence of symptomatology?

IMO – conferring this understanding that “it is not our right to live pain free” would also do well to encourage life long physical activity as truthfully, our physical bodies still think they are in the forest hunting and gathering food. In this context, patients begin to understand that the body desires constant motion and physical activity, and although not possible, perhaps they will realize that they need to actively, and consistently work to decrease pain and maintain function.

— Dre


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