By Dr. Ross Turchaninov

With this article, we finish the series of publications on the importance of central mechanisms in somatic rehabilitation we started in issue #1 #2018 (https://www.scienceofmassage.com/2018/05/the-placebo-effect-and-its-role-in-massage-therapy-part-i/) and continued in issues #2 (https://www.scienceofmassage.com/2018/08/the-placebo-effect-and-its-role-in-massage-therapy-part-ii/) and #3 (https://www.scienceofmassage.com/2018/10/chronic-pain-and-brain-self-defense-mechanisms-part-i/)

We believe that understanding and correctly engaging the brain of patients with chronic pain is a vital component of successful therapy. Thus, if the therapist considers the importance of a central element of chronic pain, the entire treatment will move forward quicker, and results will be more stable. In other words, the relationship between therapist and patient must be untangled and settled from the very beginning:

After the publication of Part I, some readers expressed concerns that its subject is out of their scope of practice. It is an unfortunate and incorrect reading of the article. Yes, a psychiatrist’s and psychologist’s job is to use various behavioral treatment techniques to help patients. In these cases, the physician actively tries to change the PATIENT’s behavioral patterns. In our articles, we are not discussing that since we are talking about changes in the THERAPIST’s behavior to adjust his or her therapy more efficiently to the patient’s needs.

Since every health practitioner, from physician to nurse assistant, deals with the patient’s brain while interacting with the patient who suffers from acute or chronic pain, they need to understand how the brain protects itself in these difficult situations. In many clinical cases, disregarding the patient’s brain self-defense mechanisms can negatively affect treatment outcomes. 

In Part I, on the examples of patients from our clinic, we discussed behavioral patterns of patients with anger, regression, hypochondriac behavior and fear. Part II will discuss the other three frequently observed self-defense reactions: denial, projection, rationalization, and emotional instability.

 

5. DENIAL

Denial is refusing to recognize the importance of clinical symptoms and the necessity of addressing them with appropriate therapy. Technically speaking, the presence of denial behavior is an indicator of the patient’s subconscious fear of what is going on in his or her body. At the same time, active denial of obvious facts eases the intensity of discomfort. It decreases stress and anxiety associated with it as long as the pain is tolerable to some degree.

 

The daughter of a 53-year-old male who runs his own air-conditioning repair business made an appointment for her father and came with him for the initial evaluation. The patient was fit, but severely tilted to the right. He walked with a visual limp and turned with his entire body. He exhibited visual signs of irritation at being in the clinic.

To the first question about what bothered him, he replied that he was fine and had some minor lower back issues. It was due to his work, and he was sure that with time, everything would be normalized. His words didn’t match the intensity of his lower back twist, which had obvious severe right-side compensatory scoliosis and right-side pelvis elevation. 

His daughter stepped into the conversation and mentioned that her father had been in this crooked position for two months and refused to treat it. He agreed to come to the clinic only after her husband, her father’s business partner, refused to work with him until he found help.

Clinical evaluation indicated the presence of severe spasm in the right quadratus lumborum (QL) muscle with severe compensatory protection.

Addressing The Psychological Component Of Somatic Pain Syndrome:

Denial is a complicated self-defense reaction to work with since the patient insists that nothing really bad has happened despite obvious clinical symptoms being present. It is better to detect the weakness in the patient’s self-defense mechanism to get through. It can be a favorite hobby that can be jeopardized, an upcoming vacation, love for a spouse, etc. During a further conversation with our patient, it is evident that his business was his soft spot. He even agreed to come to the clinic because his business partner refused to work with him.      The best therapist’s behavior to work with him was a logically formulated proof that the compensatory reaction, which his body developed to deal with QL spasm, may exhaust itself at any second. If that happens, there is no way he could work for a while or even completely lose the ability to lift any weight required by his job.

Just saying all of that won’t be enough. We opened our laptop and showed him pictures of our patients with different degrees of tilt. Since some pictures were almost identical, he now connected his pain with a real medical problem, since he is not the only one who suffers from a similar thing.

Next, we opened PubMed and showed the patient the medical articles in which acute spasm in the QL muscle is listed as a very frequent cause of various visceral symptoms and even mimics kidney colic. Of course, the patient was not able to understand the abstracts of medical articles, but the fact that we illustrated our words with similar pictures and medical data gave us the necessary credentials in his eyes.

Our clear intentions were to create a sense of the emergency, which was completely justified by the intensity of protective reaction his brain developed, in the hope that fear of losing business would overcome his denial/fear of the lower back pain and deformation he developed.

Results:

Treatment-wise, it was an uphill battle since the patient had had such severe spasms for two months. At the beginning of the therapy, family support was the key since his daughter or son-in-law drove him to the clinic. However, everything started to sail smoothly as soon as the patient noticed a decrease in side tilt. At this point, he started to feel better and became actively involved in the treatment process.

In the end, his posture was completely normalized, and the lower back function was restored. Now, he comes to our clinic monthly to prevent tension accumulation, and he makes panic calls if he feels even a slight increase in lower back tension.

 

6. PROJECTION

Projection is a very interesting self-defense mechanism since the patient’s brain tries to find someone else responsible for his or her chronic pain and suffering and for the failure of the treatment. Usually, this person or object is still present in the patient’s immediate environment, constantly reinforcing the self-defending reaction.

 

A 43-year-old patient comes to our clinic with chronic right arm and forearm pain accompanied by sensory (tingling and numbness along the ulnar nerve distribution) and motor (forearm and hand weakness) deficit. His wife called and made the appointment on his behalf. 

They both came to the clinic, and as soon as they walked into the therapy room, his wife started to tell the patient’s complaints and what had originally happened. She was very vocal and acted anxiously. All the time while she was talking, the patient was silent and looked upset and irritated. There was definite tension between them.

We interrupted her monologue and started to communicate with the patient directly. According to the patient, his arm pain began after his wife decided to re-paint their bedroom. After painting for the entire day, he woke up with severe radiating pain down his right arm. According to the patient, the initial pain was so severe that he went to the emergency room. Weeks of different therapies brought a reduction of pain intensity, but it continued to bother the patient, especially at night, and he was unable to sleep. MRI detected two bulging disks on the levels C5-C6 and C6-C7, and surgery was offered to the patient as the only solution.

The entire conversation was bizarre. The patient started to tell his symptoms and history of his illness normally, but while he continued, he became more and more upset, angry, and irritated. He constantly mentioned this ‘stupid’ painting of the bedroom as the trigger of all his symptoms, and became more and more irritated while mentioning it over and over again.

His wife’s reaction to all this barrage of words was also interesting to observe. She shrank and shied away. It is evident that this was a very frequent exchange between them, and the patient blamed his wife for all his health problems. Our patient exhibited a classical projection self-defense reaction since he blames his wife for health problems, and it helps his brain to cope with the intensity of chronic pain and ease anxiety and stress.

The patient’s evaluation showed that tension in the anterior scalene muscle, rather than his bulged cervical disks, caused all his symptoms. Medical Massage was supposed to deliver stable clinical results and avoid surgery.

Addressing The Psychological Component Of Somatic Pain Syndrome:

Wife’s removal from the therapy room became the first critical step in the treatment process since her presence was going to be a continuous source of the patient’s irritation. At the same time, her desire to be present and support her husband was completely understandable. Before the first session, we called her and suggested that she remain in the waiting room while the therapy continued. She agreed. We also suggested that she not ask her husband about treatment. She should act as if nothing had happened and wait for him to share his symptoms and treatment details. As soon as he does that, she must show her full support. Technically speaking, we used the wife as a tool to turn the projection back to the patient. Finally, we explained to the patient that cervical disk degeneration was the real cause of his suffering. The bedroom painting was just a trigger, and his symptoms may have begun with any other triggers.

Results:

After the second treatment, the patient started to feel better, and after five sessions, all symptoms dissipated. At the same time, there were clear signs of restoring loving relations between the patient and his wife. We observed him hugging his wife outside the office, and their interactions returned to normal.

 

7. RATIONALIZATION

Rationalization is the brain’s self-defense reaction, which frequently shows itself later in the treatment. It greatly affects the outcome of Medical Massage Therapy. Successful somatic rehabilitation relies heavily on the patient’s active participation in the treatment process, and rationalization undermines that.

 

A 54-year-old woman with chronic temporal headache and lower jaw pain on the left came to our clinic after months of suffering. From the very beginning, she proclaimed that she had severe Temporomandibular Joint Dysfunction and that she tried all available therapies and everything failed to eliminate her jaw pain and temporal headache.

Clinical evaluation revealed a completely different scenario. It is evident that her posterior cervical muscles irritated the minor occipital nerve, and this irritation caused shortening of the fascia that covers the temporalis muscle, and that was the real cause of her TMJ dysfunction and temporal headache. Thus, her jaw pain and headache were a secondary, reflex reaction, and this is why previous therapies that targeted temporo-mandibular joint dysfunction as the original cause failed.

It was challenging to explain to the patient that such a complete U-turn was needed for successful treatment. After a long conversation, she agreed to try a combined application of MEDICAL MASSAGE PROTOCOLS arranged as follows: protocol for Minor Occipital Nerve Neuralgia + Scalpotherapy + TMJ Protocol.

Each of our patients is given homework, and its correct execution is obligatory. After each session, we check if the homework was done correctly. At the beginning of the second session, the patient informed us that she didn’t feel any improvement and thought that our therapy would not work for her either.

At the same time, she didn’t offer a reasonable explanation of “why?” We asked her if she did her homework, and she said, ‘Yes.’ We asked her to show us how she did it, and it was obvious that she didn’t do any of the necessary stretches since she had no clue what to do or how to do it.

We asked her why she didn’t do the homework we agreed on. Her answer pointed to the presence of a rationalization self-defense mechanism: “It doesn’t make sense to do homework if the treatment is not helping me!”

The patient tried to find an excuse not to participate in the therapy, since active involvement requires her brain to be additionally aware of her pain and discomfort. Thus, to decrease the anxiety, the brain shields itself by avoiding anything that is associated with her symptoms, including therapy and homework. In a sense, she consciously would like to get better, while her brain subconsciously pushes any treatment option out.

Addressing The Psychological Component Of Somatic Pain Syndrome:

The patient’s acknowledgement that she didn’t do her homework gave us leverage in communications. The best way to deal with rationalization is counter-rationalization. The patient lies to herself, but at the same time, she does that by establishing a cause-and-effect argument. If therapy (any therapy in her mind) won’t work, why should I do homework?

To convince the patient, the logical counterargument must be presented. This was our argument: “Let’s consider that you developed pneumonia and your pulmonologist prescribed you an antibiotic three times per day. Would you agree that taking it once a day or skipping a day won’t help you recover from pneumonia?” She answered ‘Yes’. “What we are both doing here is a treatment procedure with the same clinical rules of application as your antibiotic therapy for pneumonia. The only difference is that instead of a pill, you do treatment sessions and support them with homework used daily between the sessions.”

This simple analogy got our patient’s attention, and as soon as she started to feel even slightly better, she fully committed to therapy.

Results:

After the minor occipital nerve was freed from the pressure, and the normal bite was reset and restored, her temporal headache and jaw pain vanished. After the therapy was over, the patient confessed that she didn’t believe in ‘conspiracy theory’ about irritation of the minor occipital nerve being the real cause of her problems, but her friend’s insistence to give her a chance and pneumonia’s analogy convinced her to follow through, and she is highly pleased with the results. 

 

8. EMOTIONAL INSTABILITY

Emotional instability is another defense mechanism the brain uses to cope with chronic pain. The patient with severe symptoms of peripheral neuropathy in the right lower extremity came to our clinic for initial evaluation. She has suffered from severe numbness and periodic burning within the common peroneal nerve distribution for four months. She exhibited motor deficit in the form of weakness of foot dorsiflexion by 50%.

The patient had already used several treatment modalities without any success, and only spinal surgery was offered as a possible solution. She shared with us how much time and money she spent on various therapies and how she was afraid of surgery since her father had it, and he is still miserable years later. She can’t live with such intense pain. While she was telling all these, she was constantly on the edge of breaking down.

 

Addressing The Psychological Component Of Somatic Pain Syndrome:

The therapist must emotionally stabilize the patient by doing two important things:

  1. At the end of the clinical evaluation, every detail that was collected should be explained to the patient, and the patient must see that this clinic gives her light at the end of the tunnel
  2. While telling the patient about the treatment plan, the therapist must get personal. A handshake, gentle hug, etc., will give the patient assurance and emotional stability.

While talking with the patient at the end of the evaluation session, we sit next to her and touch her hand. Suddenly, unstoppable tears started to pour over her face, and she began to cry hysterically. We gently hugged her, and she cried on our shoulders for a couple of minutes. This sudden release of suppressed subconscious anxiety triggered by chronic pain gave her some emotional stability, and she was able to cooperate for the first treatment session.

Results:

Seven sessions of Medical Massage protocol for Lumbalgia decompressed the sciatic nerve and completely restored her health.

Of course, the brain may use other self-defense mechanisms, but these eight are most common. We collected for you clinical cases that fit into the classical development of each self-defense behavioral change to illustrate each of them separately. In the clinical setting, you may observe their elements or combinations of these self-protective mechanisms. Thus, these two articles aim to give therapists extra tools to optimize performance when treatment of somatic abnormalities is combined with adjustments to the therapist’s behavior.

 

To read Dr. Turchaninov bio please click here


Category: Medical Massage

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