Chronic conditions, which patients report as lasting more than three months, often manifest over an extended period and cause problems for several years.
For example, habits create posture, which over time becomes structure that ultimately affects function, movement, and performance.1
You’ve seen this scenario before: A patient, who has been working at a desk job for decades, comes to you with low-back pain. They think the pain is the result of their bending over the wrong way once. But in reality they have been setting themselves up for a lumbar disc herniation due to poor posture. Bending at their lumbar spine ended up being their body’s path of least resistance—and its weakest point—so it finally reached a breaking point.
Unfortunately, for providers, the patient usually won’t seek professional help until the condition creates a severe level of pain. At that point, the brain and the body’s ability to function have diminished to a decompensated condition, and normal motor control can no longer be restored by conventional interventions.
The power of pain
Nociception (also nocioception or nociperception, from Latin nocere, “to harm or hurt”) is the sensory nervous system’s response to harmful or potentially harmful stimuli.
When disease or trauma strikes, and recovery is delayed, chronic nociceptive stimuli, such as pain, stiffness, numbness and tingling, weakness, and other signs or symptoms can result in impaired cortical relay of motor output and reduced activity of painful muscles. Movement and function become limited because the sensory- motor interaction is inhibited.
Nociception-induced motor inhibition might also prevent effective motor training during recovery and rehabilitation. In addition, the hypo- thalamus in the sympathetic nervous system responds to chronic nociception with enhanced sympathetic activation, which manifests as a flight, fight, or freeze response. The diseased or injured area of the body is inhibited neurologically from feeling or functioning normally. The autonomic nervous system has been triggered into a state of emergency, followed by a cascade of other neurosensory events because it is under threat.
So, not only motor and sympathetic output pathways are affected by nociceptive input but afferent pathways (proprioception, interoception, exteroception, and somato-sensory processing) are also influenced by tonic muscle nociception as well.2
Effective interventions
The clinical consequence of remedying such conditions is to stop trying to restore motor control in cases of patients with chronic conditions and chronic nociception. Instead, consider interventions aimed at activating central nociceptive inhibitory mechanisms by decreasing nociceptive input.
Rather than providing audible commands or demonstrating better movement to an inflicted patient, provide a novel somatosensory input to elicit the desired motor output. Research shows that kinesthetic guidance can be translated into behavior 30 times faster than visual guidance and several thousand times faster than audio guidance.2
There are tools to help provide such kinesthetic guidance and address nociception-motor interaction. Applied appropriately, these can provide a novel somatosensory input to positively affect motor output. One can communicate with the somatosensory system through the skin and fascia, which is the richest sensory organ because it contains smooth muscle-like cells embedded within the fascia’s collagen fibers.
Fascia also contains a rich supply of sympathetic nerve tissue and sensory nerve endings. This is likely why these fascia cells enable the sympathetic nervous system to regulate a fascial pre-tension independent of the muscular tonus.3 Always consider what is actually occurring in the fascial network as you apply therapeutic interventions.
Instrument-assisted soft tissue mobilization (IASTM) is the use of any hand-held tool of various shapes, sizes, textures, and edges to apply types of strokes that stimulate mechanoreceptors and thus feed the neurosensory system to improve motor output.
Another possible mechanism of action is that movement becomes faulty because the brain’s perception of the body has become smudged. IASTM can improve body mapping—a person’s self-representation. The conscious correcting and refining of the body’s map produces efficient, graceful, and coordinated movement.
If the brain’s representation is faulty, then movement suffers. When the map is corrected, then movement improves.4 IASTM should be aimed at helping hypo-mobile areas of the body regain motion.
Additional tools and techniques
Foam rollers, stretch bands, and balls are ubiquitous mobility tools that can manipulate the myofascial system to normalize soft-tissue tone and remedy chronic conditions. These tools can address restrictions in motion that are seen at the joint and soft-tissue levels. Rolling, banding, and myofascial manipulation with balls can also help the body regain motion.
Kinesiology tape, which provides support while allowing full range of motion, is another tool that can be applied to the skin to provide kinesthetic guidance and normalize tone in the presence of movement dysfunction. Taping can decrease pain, unload tissue through decompression, and provide a novel stimulus to improve body awareness.5 Kinesiology tape can help key motor control centers of the body regain stability.
Topical analgesics can also temporarily relieve and manage chronic pain. Some topicals create a heating effect and contain capsaicin, which stimulates TRPV1 receptors. Others create a cooling effect and contain menthol, which stimulates TRPM8 receptors. Desensitization of both of these receptors with high dosage concentrations of capsaicin and menthol can have a positive neurological effect on pain management.6
The future of pain management
Patients with chronic conditions face unique dysfunctions that require the restoration of tissue tone, mobility, and motor control to regain efficient function and performance. When a patient with a chronic condition is treated using one of the aforementioned tools and they feel better, it is the nervous system that has responded.
The stimulation of intra-fascial mechanoreceptors causes alterations in the afferent input to the central nervous system, reducing the activation of certain groups of motor units. Treating the brain has been shown to better influence changes in mechanoreceptors than targeting the mechanical structures. This is becoming more widely accepted than the older mechanical models and is the future of rehabilitation.
John K. Koniuto, PT, MSPT, DPT, is the founder of Oakdale Physical Therapy & Fitness, and Koniuto Movement Therapy, both based in Court Jester Athletic Club in Johnson City, New York. His clinical specialty focuses on holistic functional assessment. As a RockTape instructor, he teaches the series of Functional Movement Techniques (FMT) certification series.
References
1 Myers T. (2014) [ITAL]Anatomy Trains: Myofascial Meridians for Manual and Movement Therapists[/ITAL] (3rd ed.).Churchill Livingstone, 2014.2 Birdwhistell RL. (1971). Chapter 3: Body Motion. NA McQuown, ed.[ITAL] The Natural History of an Interview[/ITAL] (pp.1-93). Microfilm. Chicago: University of Chicago.
3 Staubesand J, Li Y. On the fine structure of the crural fascia, with particular reference to the epi- and intrafascial nerves. [ITAL]Manuelle Medizin.[/ITAL] 1996;34(5):196-200.
4 “The Complete Guide to Alexander Technique.” The Alexander Technique. alexandertechnique.com. Accessed July 12, 2017.
5 Capobianco S, van den Dries G, Brink J. (2013). [ITAL] Rocktape Power Taping Manual[/ITAL] (3rd ed.). Rocktape.com.
6 Laing R, Dhaka A. ThermoTRPs and Pain. [ITAL]The Neuroscientist.[/ITAL] 2016;22(2):171-87.
