Article - Body Therapy and the Paradox of Chronic Pain

[Guest guest]

Body Therapy and the Paradox of Chronic Pain

by Dianne L. Woodruff, CMA, PhD

ISMETA conference presentation 8 June 1996, Toronto

Introduction:

I am a movement therapist and a craniosacral therapist specializing in

chronic pain. In various clinical settings for 7 years I've treated a wide

variety of clients but those in chronic pain were always the most

challenging. Some of my questions about these cases were answered when I

heard Dr. Greenwood, the team physician at the Pain Clinic

(VPC) speak on CBC. Then I read his book, Paradox and Healing and it all

struck a chord with me. I first went to VPC in September 1993 as an intern.

Then I went back this year for 3 months to get a closer look at the clinic,

its clientele and staff and to get a feel for the business. Today I will

speak about my experience at the VPC and use that approach as a context in

which to discuss a view of chronic pain and an approach to sequencing its

treatment.

Pain clinics in general offer an array of therapies and learning

experiences. Most use a cognititve-behavioural approach focusing on active

self-management techniques. They are dedicated to helping their clients live

with their pain and accept that there is nothing medical intervention can do

for them. Clients learn to manage their lives in such a way as to avoid

flare ups by judicious use of medication, exercise, and pacing of

activities. Day programs are similar to residential programs in content, but

the latter offer a more intensive experience, and more importantly, remove

the client from day to day life. Time frames vary. The three programs I

looked at range from 10 days to 6 weeks.

OVERHEAD: THREE CANADIAN CLINICS

The Chronic Pain Program at Chedoke-McMaster Hospital in Hamilton, Ontario

was established in 1972. It is a 4-week hospital based program with 14

clients per program. The third party funded stream is $7000 for the day

program and $12,000 for overnights during the week. Ontario Health Insurance

Plan funds a limited number of patients; there is a waiting list for 2-5

months for this stream. Treatment is limited to active modalities.

The Canmore Pain Clinic Canmore, Alberta started up in 1989. It is a 6-week

program in 2 modules of 3 weeks each and is also based in a hospital. There

are 11-18 clients in each program. They have a drug reduction and active

self-management program using mainly conventional therapies and exercise.

Massage and acupuncture are used for selected clients at certain stages. The

cost is $14,000 for six weeks. It is privately funded only. They also offer

a modified program for people needing less than a 6-week stay.

VPC in , BC is a 10-day residential program in a homebased setting

with 10-12 clients in each module. VPC began in 1980 and has had a

residential program since 1985. The cost is about $4000. About 20% of VPC

clients repeat the program. It is privately funded only. It uses an array of

alternative therapies combined with conventional learning experiences, but

it differs in other ways: it uses an intrinsic transformational approach and

it emphasizes body work. VPC does not prescribe drugs.

The day-to-day dynamic of the programs is notable. The hospital-based

programs run a 9-5 schedule after which the clients go to their

accommodations. The program content is amenable to starting and stopping

each day. 's 12-hour day has a different, more intensive dynamic.

The clients live in the same house where they have their therapy. The

transformation process takes place 24 hours a day and is not amenable to

starting and stopping. It requires the continuity of emotional and spiritual

support that comes from the setting, the staff, and the clients themselves.

My feeling was that the clients were on a therapeutic journey going from one

experience to another each one building on the last and continuing for 10

days.

Each clinic selects its clients with a certain philosophy and set of goals

in mind. For example, a candidate who cannot walk for 20 minutes is not

admissible to the Chedoke program. Clients with psychoses or severe

personality disorders would not be admitted to Canmore or to .

Clients who are still seeking a cure for their pain through medical

intervention may not be prepared to take responsibility for their own

healing process; they are not suitable clients because they are not at a

stage to accept that change comes from within. Thus the readiness factor is

both in the client and in relation to the clinic itself.

Validation is a term that has come to mean truth or confirmation that pain

exists. Unfortunately, chronic pain can be seldom be " validated " by the

structural and chemical testing commonly used in our medical system. There

is no pain meter to objectify the subjective experience of pain. Lack of

validation is a great frustration for clients who sometimes develop pain

behaviour if no one will listen to their words. They will show their pain by

actions - very slow or wincing movement, for example, with every motion. Not

wishing to appear uncooperative or malingering they are nevertheless caught

up in the validation problem. I personally feel that one should never have

to prove he/she is in pain. When clients feel validated they can get on with

their healing.

The social setting of the clinic is important. Chronic pain patients are

often isolated from their friends and even their families. Unable to

participate fully, they become increasingly solitary. Living in a group

situation is socializing. They do not have to explain or excuse themselves.

A community is formed of these people with common suffering; they sympathize

and empathize with one another; they bond. They take courage from the

progress they see in others; they encourage and support one another. They

take photographs, like a family, and they take home memories of a positive

social experience.

The environment is also important. Clients are away from day to day demands.

Such cloistering allows the client time for learning and reflection away

from job, commuting and family responsibilities. It is a place where you

don't have to function; where you can let down your guard and fall apart,

lose control, be upset. It is a place to face your pain rather than ignore

it. A place where you can be yourself and not be a bother to others.

This description emphasizes how important the environment is in the

effectiveness of a pain program. I will get a discussion of the treatment

shortly, but just now I'd like to present my " garbage can theory of chronic

pain " to help you see why it is such a problem for conventional treatment

approaches.

OVERHEAD OF GARBAGE CAN

As I see it, we're born with a large garbage can into which we dump

everything we don't want to deal with. Like abuse of all kinds and

unresolved conflicts with self and with others; inner child issues -

abandonment, not being valued or cared for. These are all wounds that don't

heal. The garbage can is a place to store or hide our problems - out of

sight out of mind. Even though its a big garbage can and it holds a lot, one

day it fills up and when it starts to overflow, that's the day we have a

major whiplash injury or fall down the stairs or whatever. And then we

develop pain that doesn't get better -- chronic pain. And what's even more

frustrating, the pain doesn't always seem to be related to the " accident " .

And the doctor can't seem to find a reason for it. Chronic pain is

irrational pain that defies objective testing.

The body harbours the pain for a reason. It's a way of getting and keeping

our attention. Our bodies are really all we have. The body is the place

where the self lives, after all, and when the self suffers so does the body.

Its seems to remember experiences -- good, bad, indifferent.

The energy cyst and tissue memory are two useful concepts related to this

body memory. An energy cyst is a place where disorganization in the tissue

prevails. It is a pattern that carries the imprint of the body's movement

during the fall or impact, for example. Tissue memory is another way the

body stores experience and expresses it through the quality of the tissue

and the surrounding electromagnetic field. These phenomena can only be

addressed through working with the body. This does not mean putting it

through a formulaic pace to raise its fitness level but attending to these

energy blocks and helping the client release them.

So it is the body that tells us that something is wrong. When we are

depressed, the body shows it and feels it. When we have injured a part of

the body, there is pain. If when we are hurt in any way, the body is able to

rally, we get better. But if the garbage can is overflowing, the body's

healing powers seem to shut down.

You might ask why did it have to come to this? We seem to have ignored the

earlier, less debilitating signals like frequent indigestion, headaches,

poor concentration, irritability and depression to name few. But we were

able to rationalize those -- write them off to having a bad day and such. In

order to really get your attention, we have to " hit the wall " with some kind

of major pain or dysfunction that won't go away and can't be ignored.

So the only thing left is to clean out the garbage can. One doctor I spoke

with remarked that garbage cans often stink. That's true, but there's no

need to be afraid of that. It's our stuff and we can deal with it given a

safe and supportive setting.

The VPC approach to the full garbage can is an eastern one and starts with

releasing the blocked energy that prevents the function of the body's

natural self-regulation and self-healing systems. The therapeutic catalyst

for this release is acupuncture but the same effect may come from the other

therapies offered. The body work includes stretching, relaxation, massage,

connective tissue work, stretch and spray, biofeedback and while I was there

craniosacral therapy and movement therapy.

You will notice that there is no exercise program. There's an exercise bike,

a swimming pool and hot tub and fresh-air walking is popular for the

ambulatory clients. But at VPC the goal is to re-connect oneself and that is

best done through associative rather than disassociative activities. The

competitive, accelerative, number crunching, endurance-pushing,

goal-oriented approach to exercise popular in fitness settings is

inappropriate at this stage of healing.

I have known this practically and intuitively for years and have always

pushed for a different sequencing of physical treatment in rehabilitation.

In my dissertation of Bartenieff Fundamentals I wrote a chapter explaining

the differences between movement and exercise contrasting the mechanical and

the wholistic approach to working with the body. When I witness the VPC

approach it validated my own beliefs that a more intrinsic approach to the

body must precede exercise as therapy. Majid Ali in his book on chronic

fatigue syndrome suggests an attitude change re: exercise. The way it is

done must be relaxed, non-goal oriented, paced not pushed, and so on. He

calls this " limbic " exercise, in contrast to " cortical " exercise. This idea

of sequencing brings me to a model for chronic pain treatment which I have

developed from my experience and observations:

OVERVIEW OF CHRONIC PAIN RECOVERY PRISM

Engage and activate through exercise, ADL, work, play

Cardio -- Strength -- Flexibility

Prepare for change through work with the CNS

Coordination

Soft tissue conditioning

Body Awareness

Autonomic nervous system balance

Connect with the spirit and the inner child.

Dialogue/Reflection

Energy Catalyst

CHRONIC PAIN RECOVERY PRISM

Each level from base to apex provides a foundation for the next. Experience

all the level and revisit them as the need arises.

Most recovery approaches start with exercise. This approach starts with an

intrinsic process and progresses to exercise because the " pain " of chronic

pain is deeper than the tissues themselves.

This model has three areas of focus starting from the base of the prism:

Connect with the spirit and the inner child: the wounds of life and of

living are always with us and we can use or suppress them. When the garbage

can is full and the pain doesn't go away we have to start looking at the

denial of our wholeness and the fears of the unknown that block the energy

and underly our dysfunction. At VPC this process is started through

acupuncture which serves as an energy catalyst. Client's who are ready enter

what we call a phase transition and transformation of thinking. As Drs.

Greenwood and Nunn say in their book, " The change in attitude is the key

element that activates our intrinsic healing system " (p, 40). Such changes

are supported by reflection and dialogue with counseling and body work staff

and with each other.

Prepare for change in the body through work with the central nervous system:

the CNS mediates all movement and there is no function or expression of

anything in us without movement of the body or tissue. We have to work with

the foundations and the support systems for our movement. And we have to do

that before we can condition the musculature or the cardiovascular system.

We need to restore autonomic flexibility -- a balance and give and take

between the sympathetic and parasympathetic systems. Some useful methods for

this are craniosacral therapy, reiki, rubenfeld synergy and polarity work

among many others. Body awareness can be promoted through various somatic

approaches ( Technique, Feldenkrais work, as well as biofeedback,

breathe support training, relaxation training and nutritional work).

Awareness is crucial to change and much of it must be learned with an

observant teacher.

The soft tissue must be normalized in preparation for the demands placed

upon it in activities. Myofascial techniques of many types are useful here

including massage, direction of energy, Hellerwork, rolfing, connective

tissue massage, shiatsu and so on. The tissue must be directly treated with

touch because, while a problem here will never show up on an X-ray, it can

be felt with the hands and treated.

Coordination, an often neglected component of movement, is essential. A

well-ordered readiness in the CNS insures that movement will be efficient,

organized and a part of a whole-body process. I use Body Basics (from

Fundamentals) and movement pattern restoration. Tai Chi Chuan is also good

for clients who can manage it. Movement exercises here must be slow,

non-ballistic, and low in resistance.

Engage and activate through exercise, ADL, work and play: here, at the top

of the prism is the exercise part of rehabilitation, familiar to us all. It

rests on a foundation of intrinsic energy and body work and personal

transformation that readies the mind and body for the fitness process.

Within this area there are still many choices to be made about sequencing

for optimal growth and change. A sensitive and broadly trained

kinesiologist, movement therapist or athletic therapist will teach and

support the client at this stage.

To go right to the top of the prism at the beginning of treatment just seems

to slow down the change. There seems to be something in the way. The tissue

doesn't respond or gets worse. It also assumes that everyone is ready for

exercise of some kind, which is not the case. Don't rush the client through

the process by pushing him/her into activity before the spirit, the nervous

system, and the neuromuscular structure is ready.

This model is still progress. I don't expect anyone would follow it like a

bible but to have all of these options and the sequence in mind as we assess

and treat our clients only strengthens our repertoire of treatment.

My experience at VPC enhanced my clinical and my teamwork skills. I was

scheduled to treat clients in 30 minute blocks instead of my usual 55-minute

block so I had to change gears quickly. I learned to read my client, devise

a strategy and plan what I could do in that time. I learned that my client

would go on to another sensitive therapist who would pick up where I left

off. I could leave my ego at the door; the client would make use of mine or

of others' treatments as appropriate and timely. Being there for a client

was at times more important than delivering a therapeutic technique. I

didn't always need to do something. To serve my clients well I had to listen

carefully, evaluate the appropriateness of my treatment plan, and relax into

the treatment process. In this way, I could avoid getting in the client's

way.

Therapist readily shared information, traded ideas and asked for help from

other team members. We traded ideas and asked for help from other team

members. We traded treatments among ourselves and thus got to know and

benefit by each others skills. This served to cement the team and help us

each take care of ourselves as one must do in a program like this.

I had many wonderful treatments. For example, Snyder, the biofeedback

therapist, also does SHEN and pranic healing. I was having some problems

with my voice when I got to and she offered to work with me. We set

up a regular trade of my craniosacral work for her energy techniques and

dialogue. Her work touched me deeply and I found I had to schedule time to

integrate what she started. As we worked she suggested I connect with other

therapies including acupuncture. As a result of these experiences I have

moved forward in my own healing process and in my work as a therapist.

My current project is to set up a clinic in Ontario modeled after the VPC

approach. I will base the clinic in Oakville and plan to offer 6 ten-day

programs in 1997. I am currently assembling my staff and doing the planning,

marketing and other groundwork for this venture. I have the support of VPC

in doing this and hope to bring Dr. Greenwood and his associate in

acupuncture, Dr. Joan Zakovy for one of the early programs. There will

also be training opportunities in the form of internships and traineeships

for future staff members. I would be happy to hear from anyone interested in

participating in this venture including potential therapeutic staff and

clients.

CHEDOKE-MCMASTER CHRONIC PAIN PROGRAM

Location: Hamilton, Ontario

Est: 1972

Length: 4 weeks

Cost: $7,000 - 12,000

Size: 14 clients

Approach: Cog-behav.; active self-management; no passive treatment

CANMORE PAIN CLINIC

Location: Canmore, Alberta

Est: 1989

Length: 6 weeks in 2-3 week modules

Cost: $14,000

Size: 11-18 clients

Approach: Cog-behav.; active self-management; some massage and

acupuncture

VICTORIA PAIN CLINIC

Location: , BC

Est: 1980

Length: 10 days

Size: 10-12 clients

Approach: Intrinsic transformational approach