Barrett L. Dorko, P.T.
The neurologist Barry Wyke says, “Pain is a disordered affective state brought into being by chemical or mechanical changes in various tissues…” There’s more to the quote but I’d like to stop right there and point out that he only mentions two things- “chemical or mechanical changes.” I think this is important, and the rest of this essay will explain why.
Origin: The source from which anything arises; the first stage of existence.
Cause: A thing that exists in such a way that some specific thing happens as a result.
I’ll often ask patients who’ve been to other therapists before landing on my treatment table what their previous caregivers thought what was wrong. I get two sorts of answers; “I don’t know,” or “They thought I couldn’t relax, They thought I was too fat, They thought I as weak, I had a short leg, I had bad discs, bad joints, bad fascia, bad habits…” I guess you can see where I’m going here.
There are two ways of considering another-their state of function and their state of being. The former is visible and certainly easier to measure and push in the desired direction than the latter. Function is often visible, palpable or obvious to the trained practitioner. Being is often hidden or well disguised. It’s internal and variable, difficult to define and lacks a normative value. Our profession’s fixation on function is understandable given what it offers us-a cause for the patient’s complaint of pain and you may note that the things I suggested the patient might say comprise a list of causes. We reasonably assume that when the cause is dealt with the pain will be also, and sometimes we’re right.
But there is a problem-many of the causes listed commonly exist in the absence of pain. I’m not suggesting that they’re healthy, just not necessarily painful.
If we return now to the concept of origin rather than cause, Wyke’s words become far more relevant and, I think, helpful to practice. Mechanical deformation beyond any tissue’s tolerance-and this can vary from tissue to tissue and moment to moment-is certainly painful and that pain will rapidly change right along with the amount of deformation present. (I’m rather conveniently ignoring centrally mediated influences here) Thus the patient with this sort of problem will describe distinct alterations in their discomfort dependent upon position and use. In other words the origin of the problem becomes clear on history-it’s mechanical deformation. Similarly, if movement doesn’t alter the pain the origin is chemical irritation. It’s history then that reveals the origin of the problem. Simple as that.
Finding the cause of the patient’s problem isn’t quite as easy, and, I would suggest, not always important. Careful functional assessment may reveal some cause for the eventual complaint of pain and I can certainly appreciate why that should be pursued, but causes exist some distance both in time and place from the origin of the pain and, in my experience, have a faddish and variable quality, often influenced by the latest craze in technique. Focusing on the origin is more reliably accomplished and actually offers the therapist an idea of where to begin.
When the origin is mechanical the solution to the problem lies in movement. The nature of that motion certainly varies from case to case, but it will always remain our primary tool.