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 component of chronic pain, the entire therapy will move forward more 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 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, it is a psychiatrist’s and psychologist’s job to use various behavioral treatment techniques to additionally help patients. In these cases, the physician tries to actively change to 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 more efficiently adjust his or her therapy to the patient’s needs.
Since every health practitioner from physician to nurse assistant while interacting with the patient who suffers from acute or chronic pain deals with the patient’s brain, they need to have a basic understanding of 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 and hypochondriac type behavior. In Part II we are going to discuss the other three frequently observed self-defense reactions: denial, projection and rationalization.
Denial is refusing to recognize the importance of clinical symptoms and the necessity to address them with appropriate therapy. Technically speaking, the presence of denial behavior is an indicator of real fear the patient has with what is going on in his or her body. At the same time active denial of obvious facts eases the intensity of discomfort and decreases stress, anxiety and fear associated with it as long as discomfort 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 of being in the clinic.
To the first question of what bothered him, he replied that he was fine, and he 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 with obvious severe right-side compensatory scoliosis and right-side pelvis elevation.
His daughter stepped into the conversation and mentioned that her father was in this crooked position already for two months and he refused to treat it. He agreed to come to the clinic only after her husband, who is 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 very difficult self-defense reaction to work with since the patient insists that there is nothing that really bad happened despite of obvious clinical symptoms being present. To get through, it is better to detect the weakness in the patient’s self-defense mechanism. It can be a favorite hobby which can be jeopardized, upcoming vacation, love to spouse etc. During a further conversation with our patient it was obvious that his business was his soft spot. This is why he even agreed to come to the clinic since 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, while it allows him to function, may get out of hand any second. If that happens there is no way, he would be able to work at all for a while or he could even completely lose the ability to lift any weight which is required by the nature of his job.
Just saying all of that won’t be enough. We opened our laptop and showed him pictures of our patients with different degree 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 to the patient the medical articles where acute spasm in the QL muscle is listed as a very frequent cause of various visceral symptoms and even mimicking the kidney colic. Of course, the patient was not able to understand abstracts of medical articles, but the fact that we illustrated our words with similar pictures and medical data gave us necessary credentials in his eyes.
Our clear intentions were to create a sense of the emergency situation, which was completely justified by the intensity of protective reaction his brain developed, in hope that fear of the losing business would overcome his denial/fear of lower back pain and deformation he developed.
Treatment wise, it was an uphill battle since the patient had such severe spasm 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.
At the end, his posture was completely normalized, and a function of the lower back restored. Now he comes to our clinic monthly to prevent accumulation of tension and he makes panic calls if he feels even a slight increase in lower back tension.
Projection is a very interesting self-defense mechanism since the patient’s brain finds someone else responsible for his or her chronic pain and suffering as well as for the failure of the treatment. Usually this person or object is still present in the patient’s immediate environment and it constantly reinforces self-defensing reaction.
A 43-year-old patient comes to our clinic with chronic right arm and forearm pain accompanied by sensory (tingling and numbness along 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 originally happened. She was very vocal and acted anxiously. All 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 patient directly. According to the patient his arm pain started after his wife decided to re-paint their bedroom. After painting for entire day, he woke up with severe radiating pain down to 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 reduction of pain intensity, but it continued to bother the patient especially at night and he was unable to sleep. Two bulging disks on the levels C5-C6 and C6-C7 were detected by MRI and surgery was offered to the patient as the only solution.
The entire conversation was very strange. 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.
The reaction of his wife to all this barrage of words was interesting to observe as well. She shriveled and shied away. It was obvious that this was a very frequent exchange between them and the patient blames his wife for all his health problems. Our patient exhibited 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 up anxiety and stress.
The patient’s evaluation showed that the tension in the anterior scalene muscle, rather his bulged cervical disks, was a cause of all his symptoms. For this patient Medical Massage was supposed to deliver stable clinical results and avoidance of the surgery.
Addressing The Psychological Component Of Somatic Pain Syndrome:
Wife 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 waiting room while the therapy continued. She agreed. We also suggested she not ask her husband about therapy or symptoms until he himself started to share this information with her.
The patient started to feel better after the second treatment and after 5 sessions all symptoms dissipated. At the same time there were clear signs of restoration of loving relations between the patient and his wife. We observed him hugging his wife outside of the office and their interactions returned to normal.
Rationalization is the brain’s self-defense reaction which frequently shows itself later in the treatment and it greatly affects the outcome of Medical Massage Therapy. Successful somatic rehabilitation relies heavily on active participation of the patient 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 Temporo-Mandibular 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 was obvious that her posterior cervical muscles irritated the minor occipital nerve and this irritation caused shortening of fascia which covers temporalis muscle and that was the real cause of her TMJ dysfunction and temporal headache. Thus, her jaw pain and headache were a secondarily, reflex reaction and this is why previous therapies which targeted temporo-mandibular joint dysfunction as original cause failed.
Such a complete U-turn needed for successful treatment was very difficult to explain to the patient. After long conversation she agreed to try combined application of Medical Massage protocols arranged as a following course: 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 right. At the beginning of the second session the patient informed us that she didn’t feel any improvement and she 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 how she did it and it was obvious that she didn’t do any of necessary stretches since she had no clue of what and how to do it.
We asked her why she didn’t do the homework we agreed on. Her answer pointed to the presence of 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 which 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 I should do homework?
To convince the patient the logical counter-argument must be presented. This was our argument: “Let’s consider that you developed pneumonia and your pulmonologist prescribed you antibiotic three times per day. Would you agree with me that taking it once a day or skip the day won’t give you recovery from pneumonia?” She answered yes. “What we are both doing here is 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.
After the minor occipital nerve was freed from the pressure and 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 as chance and pneumonia’s analogy convinced her to follow through and she is extremely pleased with results.
Of course, the brain may use other self-defense mechanisms, but these 6 are most common. We collected for you clinical cases which fit into classical development of each self-defense behavioral change to illustrate each of them separately. In the clinical setting you may observe their elements or even combinations of these self-protective mechanisms. Thus, the goal of these two articles is to give therapists extra tools to optimized 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
Tags: 2018 Issue #4