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F@#k that hurts! Why your patient has to feel it!

Updated: Jan 28, 2023

To truly help people-you have to hurt them. There I said it! Much like the vaccine debate the idea of “no pain-no gain” polarizes therapists just the same.

I recently published a raving patient testimonial that included the patient's subjective phrases like wanting to “kick” and “punch” and “cry”, and jokingly “calling an ambulance”. I was ridiculed and chastised by my “peers-”(loose term), for being unethical and abusive. Even though the same testimonial stated a reduction of a fentanyl patch from 62mg to 37mg in only a month and all in only 3 treatments. As well, she raved of being completely pain free from the first treatment with now full ROM.

I could have shared a “candy coated” earlier testimonial that I received from the same patient that was written after the first treatment with her, but rather I appreciated the real-ness of her experience mixed with the massive cumulative successes that were gained.

Pain and gain? How? At RAPID we work very hard to stimulate the free nerve endings in the body. We understand that these nerves are our conduit into the central nervous system. Scientific study has shown that free nerve endings, properly known as C-Fibers, when stimulated, release substance-P. Substance-P is well known to play an important role in many autonomic, sensory and cognitive functions in the body. Unfortunately, the only way to release substance-P is through nociception which leads to the perceived notion of pain in the person “feeling it”. A commonly researched pain mechanism in science is Diffuse Noxious Inhibitory Controls (DNIC) or the conditioned pain modulation (CPM) paradigm. Which basically state that “pain inhibits pain” through two main mechanisms; the activation of descending nociceptive inhibitory mechanisms and the release of endogenous opioids. Interestingly enough, substance P has been studied to play an essential role in nociceptive inhibitory mechanisms as well as stimulating the release of endogenous opiods and the stimulation of the endocannabinoid system in the body. All of which massively reduce pain and threat in the body. Pain inhibits pain indeed-so why are so many so reluctant to use it as a therapeutic tool? Substance-P has also been shown to speed healing and significantly accelerate the reparative phase of the healing process and inversely, it’s absence has been shown to impair wound progression. Even the inflammatory by-product of substance-P has been shown to enable progression to the proliferative phase and modulate macrophage activation in wound healing. “The body changes at the speed of the nervous system.” –Dr. Bob Rakowski As manual therapists every time we touch the body, we excite mechanoreception which potentially gains us access to powerful modulators of pain-how well we elicit and stimulate certain mechanoreceptors will determine our success in accessing the CNS and modulating and thus reducing pain. Which is precisely why some treatments take more time than others and why some treatments are lightning fast. If we can appreciate the fact that our touch can be less or more efficient, our psycho-physical interaction with our patient can also greatly affect them the same way, and equally effect the therapeutic outcome as well. Psychologically, “pain inhibits pain” can be much better described as “pain that meets expectation inhibits pain”. The number one reason people seek out therapy is because of pain, not only for pain reduction but for the experience of pain itself. Consider for a moment how many patients want “deeper than deep” treatments. How many believe that pain is the only means to an effective treatment. And how many people you have seen that have expressed disappointment at their experiences of other therapeutic interactions, and have subsequently judged those interactions as less than, simply due to the lack of “feeling” or pain that was elicited during treatment. Descending analgesia plays an important role here because the spine echoes what the brain expects. If your patient expects and believes that you are the only one who has listened to them, because you are the one who is going deep enough, meeting their expectations of how much they expect to ‘feel” and the only one who has listened to them, then this in itself becomes a powerful modulator of pain. Emotions and pain play a part here as well. Each and every time the “pain center” of the brain lights up the emotional center lights up as well. This in turn attaches an emotion to each and every painful event we experience. Precisely why when you stub your toe your mad as hell, or when you wake up with a stomach ache you’re sad, and worst case scenario why we fear when we have injury or even believed injury. When we elicit nociception in a professional therapeutic environment, we are able to enlist a new emotion to the same pain. So rather than have anger or sadness or fear about their pain, your patients can now attach hope or confidence in resolution to the discomfort. Even in the world of rehabilitation and therapeutic exercise, ensuring your client gets the “feels” has proven to be beneficial for pain reduction and reduced fear in movement. According to Smith et al, “painful exercises have the potential to help reconceptualise pain-related fear, that is, patients may be challenged to think differently about pain and tissue damage, and allowing painful exercises offers an opportunity for patients to reintroduce movement that were previously perceived as a threat.” Will just any pain do? No. The key to proper stimulation of C-fibers is to ensure the stimulation only elicits nociception for perceived threat and not actual threat and damage. Sure, many therapists can dish it out and hurt their patient but if they do it haphazardly and actually damage the tissues the benefits of substance-P will be used to repair and heal the damage, rather than reset the nociceptive inhibitory mechanism. How do you know if you’ve gone to far? The most obvious sign is any visible bruising. At this point your probably thinking but wait this really goes against everything I’ve come to believe or was taught. The current conservative “model” though well developed and influential has unfortunately been proven to offer a poor means of therapeutic intervention. At RAPID we have a saying…”if you want something you’ve never had, your going to have to do something you’ve never done." That something is RAPID NeuroFascial Reset. References

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