Sometimes it takes a lot of patience when working with chronic pain clients.  It is difficult to impossible to do CTB manual therapy when the client is so guarded that they cannot let you move their joints without engaging the muscles.  They cannot consciously control the guarding against the movement. Their nervous system does not trust you, it doesn’t trust that you won’t cause them pain with a sudden or forceful movement, intentionally or unintentionally.  It makes sense, their nervous system is protecting them.

“Fear of movement, pain catastrophizing, anxiety and nervous system sensitization appear to be the main contributors to pain and disability.” - Lorimer Moseley

Based on previous experiences with pain, their nervous system has decided that protection against movement is necessary to prevent pain and injury.  At that point, the therapist’s goal becomes gaining the trust of the client’s nervous system so joints can be moved passively. Without that trust, you cannot move them.  If you cannot move them, you cannot retrain movement and get them out of pain.

I had a new client recently with chronic bilateral low back/sacral pain.  She had her left hip replaced 7 years ago and her right hip replaced 2 years ago.  She described her right hip replacement as “bad” and that the neck of the femur was too long and femur head was too big.  The surgeon thought revision surgery might be necessary. She had many pain issues, but the low back pain was the most prominent so we decided to focus on that.

She was very apprehensive and guarded after her experiences with hip replacement rehab.  She described her previous experiences as traumatic. She wanted to address the low back pain, but did not want me to do anything with her hips.  Well, that would be very problematic, a “Catch 22”, because the most common cause of low back pain is gluteus medius referral. I told her that in my experience sacral/low back pain was primarily referral from the glutes.  To deal with the low back pain, we had to go there. But I assured her that she was in charge, that we would go slowly and decide together what to do as we went along.

It is important in cases like this to let the client know, repeatedly, that they are in charge and you are not going to do anything that causes pain.  Some discomfort, perhaps, but nothing that exceeds their basic pain tolerance and nothing sudden. That would be counter-productive. With CTB, we are working to down- regulate a pain sufferer’s nervous system by giving them experiences of pain-free movement and gently increasing the pain-free range of motion.  That’s why we use a number scale, one through ten, to keep all movements and palpation below the perceived pain threshold of the client. The client tells us what they are experiencing and where so we can keep everything below threshold. This feedback system works very well and most of the time the client’s sensitization will start dropping immediately.  However, how you talk to the client is one thing, how you move them is another.

Talk is cheap.  Action speaks louder than words.

Talk is cheap and very much at the surface layer of your relationship with the client.  Meanwhile, beneath the verbal dialogue, the client’s nervous system is carefully sizing you up to determine if you are a threat.  Your nervous system has to prove to their hypervigilant nervous system that you are a friendly, helpful entity that is not going to hurt them.  You accomplish this through your own relaxed, confident and controlled movement.

Baby steps.

Be patient, start small and slowly build on the successes.  Every experience of pain-free movement adds to the evidence that it is possible and down regulates the client’s nervous system.  This seems to happen in an exponential expression. So it is very slow going at first but gets better and better, like a snowball gaining momentum and mass as it rolls downhill.

Use the breath.

Our parasympathetic nervous system facilitates relaxation during exhale.  Coach the client to inhale and exhale and time your breath with theirs. On the exhale, you both will relax more.

Contract/Relax with breath.

Combining contract/relax movement with breath is a key part of the CTB treatment cycle and greatly facilitates trigger point release and pain desensitization.  Instruct the client to gently contract the agonist muscle, have them take an inhale and hold their breath for at least 5 seconds, then have them exhale and relax everything.  When you feel them relax fully, take the agonist muscle into passive length. If the client is very guarded and pain sensitized, do this early and often.  

Physical feedback and CNS distraction

Another key principle in CTB is feedback compression on agonist muscles, antagonists and sometimes as many muscles in a functional group that you can touch at once.  Our preferred CTB treatment positions are ones in which this is possible. Often I have a client limb totally wrapped up with my body. It not only makes the limb feel totally secure so the client can relax the muscles, the contact gives the client’s nervous system additional inputs to calculate and facilitates a change in pain perception.

Years of constant low back pain, gone in one 90 minute session

In the treatment of this hip replacement client with low back pain, I employed all these techniques and strategies.  She got up from the mat, with no back pain for the first time in years and easier movement in her hips. After 2 weeks, no return of the pain.  I really only spent 10 minutes on each hip in the optimal treatment position at the end of the session, but it took me 70 minutes of patience and baby steps to get there!