Why Does Most Bodywork Fail to Address Pain?
I tried bodywork for low back pain and it failed me by Chuck Duff
As a consumer of alternative medical approaches, massage and bodywork for many years prior to entering the field myself, I found a lot of it to be very disappointing. I tried many modalities, because I was in pain. I had recurrent low back pain dating from my teen years, and sometimes it would flare up and literally put me on my knees. So I tried many types of massage, structural therapy, acupuncture, chiropractic and many more approaches. Some would help temporarily, some not at all, some made it worse.
Yoga was more effective than bodywork
I began doing yoga classes on a more regular basis, and while that was also hit or miss, I found that overall, yoga did help my pain overall, but the pain would still come back. At the time, I didn’t have a focused approach to yoga (I changed that quite a few years ago, and it had a dramatic impact on my pain – more on that later). But just showing up to a yoga class and doing whatever sequence the teacher decided to do that day was not a perfect solution. And in fact, some of the teachers had ideas about “proper alignment” in yoga that in retrospect were actually perpetuating my pain. It did occur to me though – why does yoga have more impact on my pain than all these sessions with very experienced bodywork practitioners?
Mysterious shoulder pain
I had another experience that had a dramatic impact on my thinking about pain. Before I became a bodyworker, I was a software entrepreneur and founded five software companies. Needless to say, I spent a lot of time on computers – sitting in bad chairs and homemade desks that were ergonomic nightmares. At one point, my shoulder got so painful that I could hardly lift my arm. There was no event that I could associate it with, it just happened one day and then it was all of a sudden disturbingly bad.
The Osteopathic approach: restoring normal joint motion
I had the good fortune to know some people at an alternative medical practice in my town of Evanston, IL and made an appointment with an osteopath who specialized in sports medicine. At the time, I knew little about anatomy, and she took the time to show me the anatomy of the shoulder, vulnerable areas in the joint. She asked me how I sat when I worked on the computer. I showed her how my mouse was very far forward and I had to reach to use it. She pointed out specifically now certain muscles in my shoulder were being placed in a distorted state, and I needed to change the alignment and do some exercises to reeducate the movement of my arm.
At no point did she mention MRIs, anti-inflammatories or surgery, nor did she recommend that I strengthen my shoulder using weights or bands (all typical medical recommendations for this type of complaint). I did the range of motion exercises, changed my mouse and in a couple of weeks, my pain was gone. Bravo.
The other practitioners I went to all seemed to have a specific worldview around what causes pain: your vertebrae are out of alignment and constantly need to be knocked back into place, your fascia is distorted, you have “scar tissue” in your muscles that needs to be stripped out. My doctor’s approach — very much from osteopathic tradition — was on normalizing the movement of the joint, and then the pain would take care of itself. Muscles attach to and move bones, so ultimately the muscles have to change to accomplish that, but the focus was on reeducating movement and restoring normal function.
My early Thai Massage training
Later, I decided to become a bodyworker, and pursued training in traditional Thai massage — because it seemed to have a close relationship with the movement patterns of yoga and martial arts, disciplines that I was already familiar with. I learned hundreds of poses. While it was called “Thai massage”, it was very different than any massage I had ever had, because the body was constantly being moved and compressed in various positions.
I had low expectations that I would be able to help people in pain, because my own experience had been so unsatisfactory. The massage therapists that I went to just basically rubbed and stripped my muscles where it hurt, but that had little or no lasting benefit for my pain. They weren’t trained to move my joints or help me reeducate movement as my D.O. had. I knew that the Thai positions could be useful in that regard, but I needed to have a theoretical framework behind it for why and when you would use the techniques, and that simply did not exist.
I wasn’t taught any anatomy — that isn’t part of traditional Thai medicine or bodywork. I learned techniques and sequences, with no real understanding of what to do when. Nobody really taught me any of the potential effects, positive or negative, of the techniques. And these weren’t bad teachers – I studied with some of the best teachers in the US and Thailand. It just isn’t part of the traditional approach.
There was a lot of focus on energy and intuition. I don’t minimize the importance of these aspects, and I use them to this day – it’s part of being a good bodyworker. But more knowledge is a good thing. Intuition is very difficult to teach, is not reproducible and doesn’t allow effective communication with clients and other medical professionals.
Realizing how much I didn’t know
When I became a practitioner, right away I began attracting clients who had pain and were looking to get help with it – athletes, dancers, music students, yoga practitioners — and I found that sometimes I could help them, but I didn’t really know why. And sometimes it didn’t help, which I found to be very frustrating. I began reading anything I could get my hands on about the origins of pain in the body.
Trigger Point Therapy
I discovered trigger point therapy in 2002, when Claire Davies’ Trigger Point Therapy Workbook first came out. Claire also had been trained late in life as a massage therapist, and his focus was entirely on cross-fiber compression of the tender points. He didn’t care for stretching and “twisting yourself up like a pretzel”. His attitude was that the body would work out the rest on its own.
His book was very successful, and I found the map of trigger point pain referral to be a miraculous missing piece in my work. Claire actually took me aside in a workshop, and told me that he admired how I worked, using all of the movements from my Thai training, but it was very foreign to him. Later, Dr. Simons of Travell & Simons made him aware that active range of motion was a critical aspect of resolving trigger points, and he incorporated that more into his shoulder pain book.
The need to communicate
I found the popular attitudes about massage to be confounding. It seems that to many people, massage is supposed to be this pleasant, nearly unconscious spa experiencethat magically also relieves your pain as you lay there in a trance. The doctor, on the other hand, wasn’t concerned with my having a relaxing visit to her office – she talked with me and gave me solid advice that when I practiced it, did make my pain go away. And I found that to be very relaxing — because I could lift my arm without pain.
I’m a great fan of relaxation – but without communication, the therapist is in their own world, limited by their assumptions about the experience of the client, and in a situation where you’re trying to help them with their pain, not interacting just delays the process of discovery.
As far as communication goes, the norm in my Thai training was for the receiver to be relaxed and even drift off, a passive participant in the session. Trigger point therapy is based on finding taut fibers and tenderness, and then using various techniques to restore the fibers to normal tonicity and length. We can feel taut fibers but we cannot feel tenderness — that has to be reported by the client. I can try and guess, but I’ve had some very frustrating sessions with Thai therapists who assumed they knew where I would feel tenderness because of their ability to “feel” — but 80 percent of the time they were working areas that weren’t tender at all.
Another issue is that “How is the pressure?” is not generally a useful interaction. For example, the pressure where I’m pushing might be just fine, but the client is feeling cramping in another part of the body where the muscles are shortening. So they would answer “fine” to that question, but then I miss some key information that could have been used to guide my session. In trigger point therapy, when we’re looking for tenderness we use a 1-10 scale — which takes it out of the judgement zone and makes the information more objective. We also give the client permission to tell us about any sensation they’re feeling anywhere in their body.
Clinical Thai Bodywork and Functional Anatomy
I was gaining a lot of bits and pieces, but it took me several years to integrate these ideas into what I practice and teach today, which at that time I called Clinical Thai Bodywork – now Coaching The Body. Along the way, I had to learn functional anatomy, because you can’t practice trigger point therapy without knowing how muscles lengthen, shorten, function and dysfunction. I had to learn not just basic anatomy and what muscles were called, but how muscles behave dynamically, in motion and the activities of living.
Learning anatomy wasn’t tedious for me. I found it to be a pleasure, because I was using it – and my knowledge very quickly translated into my ability to help my clients, sometimes dramatically. I never took an anatomy class, but because I was immersed in it, I became very fluent.
Having seen how I would have personally benefited from more knowledge of functional anatomy early on, I’ve since created a functional anatomy course as part of my program that focuses on experiential anatomy and the information that you really use, rather than memorization.
Understanding the effects of the techniques
The other piece I had to put together for myself was understanding in each Thai positionwhat was happening to the muscles. Thai massage includes a lot of dramatic stretches, and that is what attracts thousands to Thailand to get training at the large schools, but in my view that is a misrepresentation of the art. Those big stretches are inappropriate for many many people — particularly if you don’t understand the effects of the poses on muscles. And the effects are not being taught, really not anywhere. The highly experienced teachers and practitioners that I know use those poses very sparingly, or not at all. But it’s flashy, and I guess effective marketing.
Initially my focus was on what was being stretched, but I eventually came to understand that the shortening muscles on the other side of the joint often were a bigger impediment to normal motion than the stretching ones. I’ve spent years analyzing the muscular effects of the poses via lots of clinical work and experimentation. I would have killed for that information when I started out, but it’s now available to my students in our CTB course materials.
Intentional techniques backed by solid theory
I have learned the hard way that it doesn’t help to know a million techniques if you don’t know what to do with them. And it helps to know something about trigger points and referral, but conversely, you need to have an arsenal of appropriate techniques for each muscle that allow you to efficiently treat both sides of the joint and move it through range, without having to move around a lot yourself.
CTB combines the most useful traditional techniques with the theoretical framework of trigger point therapy, and includes the results of my research into the best positions and techniques for each muscle. It’s taken a lot of work over many years. I taught the first CTB course in 2005 – a single weekend covering the entire body. That seems laughable to me today, but you have to start somewhere. Today, our program includes 7 CTB weekend body areas, online courses, apprentice-style mentoring sessions and a teaching clinic.
Protocols: how to get results in a single session
One of my major challenges in the development of CTB has been sequencing and designing treatmentsso that you have some chance of making an impact in a reasonable amount of time. It’s very easy to get lost in a muscle or area that isn’t actually central or important to the client’s issues, and then you don’t have time for the truly important ones.
I’ve come up with an elegant solution that I call protocols, and again they have emerged from the last 15 years of experimentation and clinical practice. A protocol is like an interactive map through the body, but it isn’t a hard sequence. It’s like a “choose your own adventure” story. At each step, you have to decide if the muscle is important, if it needs treatment, and if you need to jump to a different step in the sequence as a result of your findings. The protocol gives you a typical order of events as well as what decisions and assessments should happen at each step.
This is the only practical way to get concrete results in a single session — always my goal. I’m not satisfied unless a client says that their pain is greatly diminished or gone in 90 minutes, and I’m able to do that consistently at this point. If you were to exhaustively treat every single muscle that could be relevant to a pain area, it would take hours.
Protocols are the key to each body area
Protocols organize the treatment in terms of positions that we use with the client, and each position is associated with specific joint motions that we assess and possibly treat. I learned from my shoulder pain experience, and the osteopathic focus on normalizing joint behavior (both quality and range) is central to what I do. The focus on joints makes it possible to take in fast impressions that convey a wealth of information about what is happening with the muscles.
The protocol as a dynamic map is an extraordinarily helpful part of our curriculum. Following a protocol efficiently does take knowledge and practice. This year, we’ve begun the process of creating online treatment and protocol courses for each of the 7 body areas that we teach in person. This is a huge undertaking, and at the time of this writing, we’ve completed the online courses for one body area – shoulder, upper back and arm pain. Forearm and Hand will be out shortly.
Making it work and teaching others
After refining this modality for the last 15 years and going through the learning curve that I have, I have a very high success rate. My goal with everyone I’ve worked with is to resolve pain complaints quickly, with significant progress in the first session – and also to educate the client and make them independent of me as quickly as possible.
In the early years of my practice, I saw many more clients who were interested in the general benefits of regular Thai massage. Today, I’m too busy teaching to see clients for weekly maintenance, so I focus on clinical teaching sessions with people who have serious pain complaints. One or more of my CTB apprentices accompany me in the session and may do some of the work depending on where they’re at with their studies.
I believe that the CTB approach can be tuned to meet the needs of anyone along the spectrum of general to specific. It’s possible to do general, very relaxing sessions in which these principles are applied, perhaps adding some specific work for a few minutes in an area that is bothersome to the client. Serious pain requires serious focus if you hope to get results in the first session, which I always strive for (and generally succeed).
The role of intuitive work
I’ve learned that it’s much easier to do something well than it is to convey that to others. In my own education, I was often counseled to use my intuition, but intuition is difficult to teach, quantify and make repeatable. I’ve had to structure a lot of what is instinctual and intuitive in my own work into something that can be given more definition, written down and expressed so that others can take the same steps and repeat it. Hard to do, but well worth the effort. The people I’ve trained are getting great results.
I’ve experimented a lot over the years with the best way to teach what I know to others. It’s definitely one of the hardest things I’ve tried to do. Some of my ideas have worked, and others sent me back to the drawing board. At this point, it’s working extremely well. My students are emerging with a level of competency and knowledge that is super inspiring.
I’ve been thinking about how to describe the differences that makes our program work.
How our program is different than others
I’m horrified at what the mainstream healthcare system does to people. In my teaching, my underlying agenda is changing the medical system, helping the world become independent of conventional “experts” who are failing badly in the treatment of pain.
It’s a disservice in my opinion to teach general Thai massage sequences, hundreds of poses, and give students little or no knowledge of how or why to use them. That’s why I’ve spent 15 years building two levels of certification and over 500 hours of training.
Some key points about our program:
- Practical, memorable, hands-on training in functional anatomy early in the student’s education – in positions we use on the mat, not just anatomical position.
- We teach students how and when to interact with the client – ask what they are feeling and where– and make treatment decisions based on that.
- We build a repertoire of basic techniques, but even early in the program we provide information on muscular effects of each technique.
- We don’t teach robotic, empty sequences — our Therapeutic Thai Bodywork for the Lower and Upper Body provide basic protocols for lower and upper body work, setting the stage for the student to refine those protocols in the CTB body area classes. Those courses may be taken immediately after Level 1.
- Traditional stretches are taught in a way that gives solid anatomical background on the pose, what its therapeutic use would be, order of events, and why you would choose to not use it.
- We teach traditional elements such as Thai Herbal Compress in a way that makes them powerful therapeutic tools as opposed to the typical feel-good spa treatments that are the norm in massage education. There is no reason why treatments can be pleasant and also therapeutically effective.
- Students who enroll in certification may repeat classes for free – this reinforces apprentice-style learning and is good for everyone.
- Even students in the basic TBP certification emerge with some ability to address a range of specific pain issues.
- Students in the basic TBP certification are encourage to take Clinical Thai Bodywork body area classes as they come along. We have found that this greatly enhances the student’s knowledge and clinical effectiveness early in their studies.
- I and other instructors interact personally with students and provide feedback, using an apprentice-style learning environment rather than just class attendance.
- We’re developing an extensive library of online courses to supplement in-person learning, allowing students to get the most out of their classroom time.