Guest Post from Paul Ingraham: The Bamboo Cage

Time for another guest post from Paul Ingraham, his second. He contributed a post last November about stretching myths. Paul is a former massage therapist and current health science journalist and copyeditor for ScienceBasedMedicine.org, and creator of the excellent website SaveYourself.ca. His website has an extensive collection of well researched ebooks and articles on a wide variety of topics related to common therapies for chronic pain and athletic performance, especially overuse injuries like injuries like IT band syndrome and plantar fasciitis. Paul recently contacted me to say he wants to do a post that “criticizes the idea of trigger points,” which is interesting, because he’s written a whole book about trigger points. I told him do whatever you want, just make sure the title of the post sounds like a Chuck Norris movie. Read the result below …

The Bamboo Cage – Immobilization and Muscle Pain

Muscle often feels uncomfortable — stiff, sore, aching — but it is still unclear why that is, or even if it’s the muscle that is actually hurting. The problem may be in our minds, not our meat. This may be more literally true than it seems: not “all in your head,” but just a deeply neurological phenomenon. It may be that so-called “muscle pain” is a function of the central nervous system and the behavior of nerves, and not unhappy muscle tissue.

For instance, consider how intensely uncomfortable it is to be immobilized. Being stuck actually hurts — tissue responds to stagnation with discomfort and then pain, and it can become extremely unpleasant long before there is anything physiologically wrong with your tissue. Stay immobilized for too long, and stuckness can become torture — literally!

Actual torture by immobilization, as in a cramped bamboo cage, is the most macabre and extreme example of how much we hate to be stuck. (There is a memorable depiction of immobilization torture in The Bridge on the River Kwai, and unfortunately such methods are not just a Hollywood invention.1) As with relentless drops of water, immobilization can cause great pain and suffering without doing any apparent physical harm. Why? Such extremes of human experience are often instructive.

The same effect can be reproduced in a few minutes at home. Try this simple experiment:

Position yourself comfortably, but place one muscle group in a moderate stretch, something you can sustain without effort (for instance, your hand bent backwards, your fingers comfortably hooked onto something, stretching your forearm flexors). Don’t move. Wait. The stretch will become somewhat unpleasant for most people within a few minutes, and bloody awful within a half hour. Again, why? The muscle cannot possibly be damaged — not that quickly.

Now … imagine several hours like that.

Never bet against the importance of nerves and brains

More than a decade ago, Vancouver pain researcher Chan Gunn suggested an interesting mechanism for pain that might help us to understand why stagnancy is uncomfortable, and immobilization torturous. Here’s a translation of his idea from neuro-speak into English:2

Tissue health depends on a normal flow of nerve impulses. If nerves are impaired, tissue can become paradoxically super-sensitive. Once the sensitivity sets in, tissue may become over-sensitive to all kinds of stimulation, and not just injury. Ordinary stretch and pressure, for instance, could become painful.

Sound familiar? That is just how many people feel when they have “muscle pain”. Whether Gunn is right or wrong about the particulars is not important — it’s this kind of thinking that may be useful in understanding so-called “muscle pain”. If this is anything like how muscle pain actually works, you can see quite clearly that it’s not quite right to think of it as a “muscle problem”.

Gunn used his idea as a way to explain “trigger points,” the sensitive patches of muscle that people popularly call “muscle knots.” His explanation is outside the mainstream of trigger point science (if there is any such thing) and was summarily dismissed by Dr. David Simons, one of the pioneers of this field, who wrote: “Neuropathy can be, but is not always, a major activating factor.”3. Simons’ dismissal was basically, “it’s not the whole story, it’s too simple,” which is always easy to agree with. But I think his dismissal was entirely too quick, and ever since then pain science has relentlessly affirmed the importance of neurological dysfunction and central dis-regulation.4

Basically, when it comes to pain, never bet against the importance of nerves and brains.

What is immobilization pain trying to tell us?

Gunn’s idea depended on the phenomenon of “denervation supersensitivity,” in which muscles that have been cut off from their nerve supply become extremely sensitive to acetylcholine, the neurotransmitter that triggers muscle contraction. They become sensitive to it because there’s hardly any of the stuff coming from the nerve! Muscle cells literally build more receptors, coating their surfaces with them — a vivid example of how nerves can actually change the tissues they are attached to.5 With all those receptors, the muscles are “listening” very carefully for acetylcholine — they seem to be saying, “Hey! Where’s the acetylcholine?” And then they react strongly to any that they do get. (The same thing takes place in many different contexts: we get more sensitive to all kinds of signalling molecules when there’s a shortage, or insensitive when there’s a surplus.)

This phenomenon occurs in response to obvious nerve injury. It’s possible — unproven but plausible — that something analogous to denervation supersensitivity could also occur when there’s simply a lack of sensory variety and stimulation, which amounts to sensory boredom. Muscles might become very sensitive to nerve impulses as we stagnate, like an eager dog who lunges at the slightest movement that might herald a ball throw. That eagerness to contract, that “itch to move,” could become intense and start to burn like pain.

This makes good biological sense. Stillness is dangerous — a few days in a bamboo cage might well cripple or possibly kill, and there are many more commonplace examples of dangerous stagnation (ask any nurse). Undoubtedly it’s a good survival strategy to have nervous systems fine-tuned to avoid it. The sensory boredom of stillness is a meaningful warning, and doubtless it’s more meaningful still if there’s a constant drone of signals about stretch or pressure or anything whatsoever that is more likely to do damage if sustained, even if it is perfectly harmless in the short term.

As these signals pour in, we undoubtedly get squirmier and twitchier, literally over-eager to move, stretch, anything. The stagnancy alarm might lead to physical changes in the muscle and its subsequent behaviour — i.e. hypersensitivity to stimulation — or it might just be a matter of extreme psychological distress associated with the sensations of being stuck — pain! — or all of the above.

The urgency of that feeling — the loudness of the warning — will be dialled up or down by our brain, modified by our knowledge of the situation, how long we expect it to last, whether panic and thrashing about is a not such a bad idea … or if it would just ruin the meditation. Sometimes people actually practice being still, and are consciously, constructively resisting the urge to squirm — at least for a while. And sometimes they are actually being tortured. Or maybe they just have to work in a chair all day — which is a bit of both.

Context matters.

Breaking the cage

It’s not hard to understand how a good massage could scratch that itch to move, a stimulation-seeking impulse satisfied by hands and thumbs, introducing sensations that signal the end of stagnancy and soften the alarm.

It is often easier said than done to “use it or lose it.” Accidents of anatomy and modern lifestyle make it nearly impossible, even for a healthy person, to keep certain places in the body adequately stimulated — the low back, for instance. For chair-bound office workers, it is almost as though the low back is being tortured, locked in a tiny bamboo cage. Even when we get up to move, not every muscle entirely stretchable, and regardless it’s hard to compensate for so many hours in a chair (although it certainly makes sense to try).

Injury, disease and even emotional constipation can pile on and block our efforts to scratch our itches ourselves.6 The problem becomes much more obvious in the elderly, where these factors have accumulated. When I worked as a student massage therapist in extended care facilities, I had the strong impression that I was lending a helping hand, stimulating tissues on behalf of my elderly clients, helping them do what they desperately craved but literally could not do themselves — one fellow I remember well simply could not reach his swollen feet — or only with such difficulty and discomfort as to defeat the purpose. Our help was, of course, an intense relief for them, like breaking the bars of the bamboo cage that had been built around their bodies by age, arthritis, habit, tension, and every imaginable medical problem.

This is a surprisingly non-meaty vision of how muscles hurt and massage matters. It suggests that muscle pain might be a kind of illusion, that trigger points may be not be what they seem to be, and that pressing on muscle doesn’t “fix” muscle, per se. Instead, perhaps it “just” satisfies the organism’s intense craving for stimulation … a craving which may be far more urgent and important than we usually imagine it to be.

Notes

  1. My father is a Vietnam veteran, so I don’t use the example of bamboo cage torture lightly. Is it a real thing? When I first thought of it, I wasn’t sure where I’d even heard of the idea. My father is not only a veteran but a war historian, so I asked if he could check into this for me. It seems that “tiger cages” were used in WWII, and then again in Vietnam by the North Vietnamese. There are other similar methods. One torture that was used on captured pilots combined severe joint strain with immobilization — their hands were tied behind them, and they were lifted off the floor by a rope and left to hang there, which is a more extreme version of the more common stress positions method, which is much more widely used (at that last link, there’s a picture of a A Viet Cong prisoner being tortured this way by Americans). Of course, regardless of whether bamboo cages were used in this way, it’s obvious that severe confinment and immobilization would indeed be torture. Return to text.
  2. Gunn. Neuropathic Myofascial Pain Syndromes. Return to text.
  3. Mense et al. Muscle Pain. 2000. amazon.com, p. 61. Return to text.
  4. See Pain changes how pain works, which is a translation/summary of Woolf et al. Or see a guest post Todd did for SaveYourself.ca early this year, A tour of ideas from recent pain science. Return to text.
  5. Merlie et al. J Cell Biol. 1984. “In adult skeletal muscles, acetylcholine receptors are highly concentrated in the postsynaptic membrane, but virtually absent from the rest of the muscle’s plasma membrane. After denervation, however, [they] appear over the entire muscle fiber surface.This phenomenon, called denervation supersensitivity, has been studied extensively, with the aim of learning how nerves cause long-term changes in their targets.Return to text.
  6. Todd has been writing about the psychological dimension of this recently in his series on Barrett Dorko’s ideomotion therapy. “Dorko hypothesizes that the corrective movements produced by pain are often inhibited by other mental activity, the most likely culprit being mental activity devoted to social concerns. For example, the social need to use appropriate body language could inhibit corrective movements that would send the wrong signals.” It’s a strong theme in my writing as well; I do go on about the relevance of personal growth and emotional maturity to pain and recovery, what I call “healing by growing up.” Return to text.
Enhanced by Zemanta

25 Responses to “Guest Post from Paul Ingraham: The Bamboo Cage”

  1. Great post. Aside from the chemical change involving acetylcholine, isn’t simple anoxia secondary to any tensional situation in the nerve sufficient to explain the brain’s response to threat with pain? Isn’t this what Breig proposed in the ’70s?

    • I suspect multiple mechanisms must involved in immobilization pain. Ischemia and anoxia would presumably be much greater factors in pain from sustained pressure, and the warning there is “bed sores a-comin’.” This would certainly be involved in many cases of immobilization. And yet immobilization can also be painful without any significant tissue compression, and so presumably there are other indicators of immobilization distress. Although I don’t really spell it out in the post here, I’m floating the idea that pain/threat is only partially inferred by the CNS from obvious danger-indicating biological markers like anoxia, but interpreted at the highest level based on context and a rather broad collection of data points, including individually relatively harmless signals like, “It’s been a few minutes since I’ve moved this body part …” that become meaningful in the context of “… because it’s trapped under a rock.”

  2. Great post. We haven’t come on that much since the 70’s. We lost 20 years with core stability.

    • Yep. Gr. And it’s not like core stability is even dead. I hear about it every day from patients and professionals around the world. Hip strength as an alleged factor in running injuries is actually faddish and hot right now. It’s nothing but a new manifestation of core stability and the continuing fascination with marketable treatment of biomechanical subtleties.

      • I agree about hip strengthening. Poor old posterior glut medius. I feel sorry for the muscle, it gets such stick and it’s only a small wee thing. I want to start a campaign “free Posterior Glut med”.

  3. Excellent. Involuntary pandiculation is interesting, in this context.

    As I have been tiresomely saying ever since I first studied them, I’m not happy with any trigger point theory I know — nothing seems really to explain 1) why they form in response both to immobility and to overuse, 2) what exactly the “latent” state of a trigger point is, 3) why they can accelerate so quickly & agonizingly from 0 to 60, 4) why the worst ones so often appear, not right after the apparent insult to the tissue, but “after a good night’s sleep.”), 5) why some people are so susceptible to them that you can’t keep up even with multiple massages per day, while other people never get them at all, or 6) why the radically different treatment protocols (“spray & stretch,” injection of anesthetic, dry needling, unmoving finger pressure, deep friction) seem to be roughly equivalent in effectiveness. A satisfactory theory ought to account for all of this.

    This is the sort of thinking we need much more of!

    • Ooh, “pandiculation,” good word. Had to look that one up. How could I have missed it?

      Re: #6: Roughly equivalent, unpredictable, and large underwhelming treatment benefits regardless of modality are a plague on most manual therapies. I believe that the explanation for this is, very broadly, due to the fact that most treatments are only partially or erratically relevant to causes of pain that we still don’t understand well. So in the case of “trigger points”, for example, the therapeutic intention to physically “loosen” fascia around them is probably irrelevant to the actual mechanism of the phenomenon, because it’s almost certainly not actually a “stuck” spot in the muscle. And yet that treatment may still result in some specific benefit, more or less accidentally, due to a (hopefully) pleasing smorg of tactile inputs that that the CNS interprets as a reason to chill out and downgrade the pain alarm — because the phenomenon probably actually is largely neurological in character, and “pain is an output” in response to input.

      And of course there’s also the fact that most manual therapy tends to have a scads of minor and not-so-minor nonspecific effects (benefits due to the relationship and interaction, regardless of what is actually done to the patient). This tends to “sameify” treatment in a big way, making it pretty much impossible to determine what is really working from the vantage point of the clinician — despite the nearly universal pretension that we therapists “know what works for our patients.”

  4. Paul, I think you’re underestimating the effect of tension. Breig, Breig, Breig.

    • Tension? I’m afraid I don’t understand, Barrett. I’m not so much underestimating “tension” in this equation as I am entirely unaware of it. 🙂 Can you elaborate, and perhaps cite Breig more specifically? What kind of tension are we talking about here, and how does it make immobilization hurt?

  5. I mean MECHANICAL tension. Do you know what Breig proposed and what has been demonstrated in many studies? The speed with which pain can be altered with movement impresses me the most, and a change in chemistry alone wouldn’t account for this.

    Movement toward tension in some portion of the system happens with every position, and reducing it instinctively is part of life. A reduction in this motion must have a deleterious effect.

  6. No, I don’t know anything about Breig. What did he propose and demonstrate? (Something tells me I’d probably be able to pass this quiz if I’d been at your Vancouver workshop instead of in Amsterdam!)

  7. You can drive the body to perform at a high performance level and it likes it, but things have to be right.What you put into it,how you move and think, your relationships, and whether you have been hit by a bus recently are the big picture criteria.When you get a few drunks in the conga line things quickly go to shit.Sometimes muscles dont like something individually but they can also act as part of the crowd.Muscles have a limited function and it is within this range of function that they express dysfuction.In other words, they perform poorly.Focusing on muscles brings temporary relief and this in itself is ok as long as we remember they’ll be back.Any time I’ve recovered from a major trigger point issue it has always been a global solution..

  8. Check this out: http://www.amazon.com/Adverse-Mechanical-Tension-Central-Nervous/dp/0471041378/ref=sr_1_1?ie=UTF8&s=books&qid=1309819864&sr=1-1

    Dated but still relevant. A simple search on Soma Simple will answer all your questions, or you could just ask there. it’s a simple concept and accounts for so much of what we see. See this as well: http://physicaltherapyweb.com/articles/dorko/abduction_and_courage.php

    I can always come back your way.

  9. Paul,

    My three part series on nerve mechanics is very related to Breig:

    https://toddhargrove.wordpress.com/category/nerve-mechanics/

    My sources were Sensitive Nervous System by Butler and Neurodynamics by Shacklock.

  10. Todd’s right. These are far more contemporary and cover Breig;s discoveries quite well. Think about how easily and quickly we can make another output pain without injuring them and quickly that can be reversed by simply allowing them to move instinctively.

    Is it possible that the culture can suppress instinctive expression? Of course it can.

  11. Do you have some information on the myth of core stability that I can read and present to people?

  12. Well, not currently but I’m always interested in invitations. Please contact me privately for more.

    In the meantime, I continue to be impressed with mechanical tension in the nervous tissue as a primary “concrete” peripheral contribution to pain and an instinctive reduction in that (ideomotion) as a simple way of dealing with it. We are born doing this.

  13. Thanks for the comments and reading suggestions, gents. Barrett, note that I did refer to ideomotion in my post, even quoted you, although it was oblique (last footnote). I’m aware of the idea thanks to Todd’s more recent posts; and I will do some more reading soon and find out more about Breig, Breig, Breig!

    In general, I’m painfully aware that I don’t really have the neurology education to speculate much about a more neurological etiology for what people like to call muscle pain. However, I am interested in it, and interested in encouraging patients and therapists to at least start thinking like that, and I hope that post helps with that.

    For a little harder a push along that road, readers here may be interested in Diane Jacobs more direct criticism of trigger point concepts, posted yesterday on her blog, HumanAntiGravitySuit.

  14. Diane’s blog post should be sent to everyone and they should be asked to respond and defend their own ideas. Instead, she’ll be dismissed, probably.

    She’s right though. At least, according to me.

  15. Great post, and yes, the title does sound like a Chuck Norris movie!

Trackbacks/Pingbacks

  1. Wod 07/14/2011 | Class One Ninjas - July 14, 2011

    […] https://toddhargrove.wordpress.com/2011/07/03/guest-post-from-paul-ingraham-%E2%80%9Cthe-bamboo-cage%…   If you enjoyed this article, please consider sharing it! var addedComment = function(response) { //console.log('fbComments: Caught added comment'); //console.log('fbComments: Making AJAX call to update Facebook comment count'); $.post('http://www.classoneninjas.com/wp-content/plugins/facebook-comments-for-wordpress/facebook-comments-ajax.php', { fn: 'addComment', xid: 'QuKeAn74EkNKwJ8_post95' }, function(resp) { if (resp === 'true') { //console.log('fbComments: Updated and cached Facebook comment count for post with xid=QuKeAn74EkNKwJ8_post95'); } else { //console.log('fbComments: FAILED to update Facebook comment count for post with xid=QuKeAn74EkNKwJ8_post95'); } }); //console.log('fbComments: Making AJAX call to send email notification'); $.post('http://www.classoneninjas.com/wp-content/plugins/facebook-comments-for-wordpress/facebook-comments-ajax.php', { fn: 'sendNotification', xid: 'QuKeAn74EkNKwJ8_post95', postTitle: 'Wod 07/14/2011', postUrl: 'http://www.classoneninjas.com/?p=95' }, function(resp) { if (resp === 'true') { //console.log('fbComments: Sent email notification'); } else { //console.log('fbComments: FAILED to send email notification'); } }); }; FB.Event.subscribe('comments.add', addedComment); […]

  2. Guest Post on the Obsession with Symmetry at SaveYourself | Better Movement - September 19, 2011

    […] I just did a guest post called “Is Symmetry Important?”over at Paul Ingraham’s excellent site Saveyourself.ca. You may remember Paul from one of his several well-written posts at this blog, including “Quite a Stretch” and the provocatively titled “Bamboo Cage.” […]

Leave a Reply

Fill in your details below or click an icon to log in:

WordPress.com Logo

You are commenting using your WordPress.com account. Log Out /  Change )

Google photo

You are commenting using your Google account. Log Out /  Change )

Twitter picture

You are commenting using your Twitter account. Log Out /  Change )

Facebook photo

You are commenting using your Facebook account. Log Out /  Change )

Connecting to %s