The underlined words below are used in the traditional medical language and should be used or at least known when we inquire about pain. They are very descriptive even if they are often based on Latin and not used in daily speech. They nonetheless are very clear and every well trained person in any other related field will understand you. I’m sure that words like bad, horrible, incredible, bothersome, nagging do tell us about what pain can do but not much about the pain.
A local, well determined pain that can be pointed to and that is superficial indicates a minor acute or chronic problem that we can approach with no problem.
A diffuse pain, when the location is difficult to determine exactly, indicates a deeper, more severe problem that has been present for a longer time. It may have fibrotic components and may also be exactly what we can handle well.
With radiating pain or spreading pain we have to be more careful.
Is it a well delineated radiation, meaning does the pain clearly spread somewhere? Is the client able to tell you where it is and where it isn’t? If yes, the question to ask is: “How far does it radiate?”
If it radiates to the immediately adjacent muscles or joints, it can be the result of an impact or motion injury (swelling or fibrosis) or a different kind of local nerve compression and mostly can be addressed by careful Rolfing. In this case we should be able to see what is happening. Examples: Pain in the SI joint going to the buttocks or thethigh, check the pyriformis, the rotators (sciatic nerve). Pain going from the neck or shoulders to the elbow, check the the trapezius, the scalenes, the pectoralis minor, the subclavius, the axilla (brachial plexus). Pain going from the neck up to the skull and maybe even to the eye socket, check the atlanto-occipital junction, the neck muscles, the position of the Atlas, Axis and Occiput (greater occipital nerve). If the client does not get even a little better from the session, it is wise to refer.
If the pain radiates down the entire extremity, arm or leg, the problem is more complicated, it may still only involve the type of structure just mentioned but it may also indicate a nerve compression due to problems more severe than just mild peripheral compression from swelling or fibrosis. If you are experienced with this, try your best, you may do well and you may not. “Caution is the mother of the china box” say the Germans, you may be out of your league! The structural problem may be obvious, but there may be other important and more relevant issues.
If the pain radiates bilaterallv or if there are bilateral “shock” sensations, refer fast, there is central nervous system damage in the brain or somewhere along the spinal cord.
If there is diffusely radiating pain the possibilities are manifold. The client in this case can only vaguely tell you what he or she is feeling. It is in any case impossible to exactly figure out what is going on. It can be a deep bone or joint pathology. It can be referred pain from an organ (heart pain can refer to the neck, shoulder, arm, -gallbladder pain can refer to the scapula, -kidney pain can wander down to the groin). No hesitation here! Refer, then ask questions, should the client comes back with a clean bill of health.
Quality refers to the kind of pain. If we have a clear, sharp pain, it can be an acute injury and it may be accompanied by signs of inflammation. Minor, acute inflammation should be left alone; it should be treated by someone competent if it is severe. It can be the result of a minor impact and be aggravated by an antalgic posture, (anti-algia, a posture that attempts to relieve the area in pain) held in place by muscle spasms. We then can try our skills, provided the underlying damage is minor. This again is not our daily bread and butter Rolfing situation and it requires knowledge and caution.
If it is a lancinating or shooting pain, it is a sharp radiating pain, and mostly is due to a nerve root lesion, and best referred as soon as possible.
If it is a tingling pain (some people call it “electric” pain), that is monolateral, we most probably have a peripheral nerve lesion which is also a radiating pain and described above under Location.
If the tingling pain is bilateral, it cannot be a peripheral nerve irritation, because the nerves in question are still together in one location, and the nerve irritation can only be either in or around both inter vertebral foramina or inside the spinal canal. This could also be a neuropathy due to severe alcoholism. Whatever it is, it needs to be referred to a Neurologist… of course there are rare exceptions: a problem that usually only occurs mono laterally can occur bilaterally. I guess people are entitled to have any amount of problems. Sometimes, as, when the doctors do not find a reason for this they call it a hysterical symptom. I would only recommend such a client to a Rolfer who is a saint.
If the pain is described as dull and aching, it will be deep muscular or bony pain, this is to be handled with caution. It can be our kind of problem, but should be watched carefully. There are other structures in the musculo skeletal system that we do not normally think of, for example a deep, dull, aching pain in the back of the calf could be an old fibrosed Achilles tendon sprain that gets irritated by weekend warrior exercise, but if it worsens it could be a phlebitis.
A throbbing pain should be a red flag, whether it is due to an injury or not, it indicates arterial damage of some kind and cannot be treated lightly. Depending on how strong that throbbing is, you may even consider the ambulance. Severe throbbing headache can be a migraine. Unless we are highly skilled in Osteopathy we shouldn’t touch it.
A crushing pain in the chest is a similar situation, this could be a heart attack and is an emergency! Get help! You may look ridiculous if you overreact, it’s better than risking somebody’s life.
Onset refers to how the pain started. A sudden onset is usually a bad sign. It can be accompanied by fever, malaise, sweating, joint pain indicating an infection. Refer ASAP
It can be due to injury, of course. If the pain worsens within 30 minutes of impact there can be injury of ligaments, accompanied by inflammation and restricted passive range of motion (meaning you move the part, not the client). You need to refer, somebody needs to determine if ligaments are destroyed. There probably needs to be a period of rest and/ or medication. If the pain worsens the day after the injury there may be muscular tears, which also are not our field, at least not in the stage of initial healing. If the client does not want to move the injured part at all, there may be a fracture.
In any of these cases send the client to the hospital but do tell them that you are excellent in rehabilitation of scarred tissue, check on them in a few days, find out what it is. Tell them to come back when the pain is small and start Rolfing then.
Insidious onset means slow onset in this context. Insidious also means: “devised so as to entrap, sly, treacherous”, it may not look like anything much but watch out! I want to remind you that we as Rolfers are dealing with musculo-skeletal pain. The people who invented this terminology were M.D.s who most of the time deal with really bad pathologies when there is an insidious onset. Often people finally go to the doctor with these problems when it is too late.
Insidiously on setting musculo-skeletal pain can be anything from our daily postural restrictions that get bad and hurt overtime to degenerative diseases to cancers. Your best approach is a good medical history and family history of degenerative musculo-skeletal disease*.
Go back to what you read above. Where is the pain. Does it radiate etc … Keep your attention on the client. How is their general vitality? Do they get better from Rolfing? If not, refer.
When in time does the pain occur?
Occasional pain happens now and then, when they walk down hill, when they reach for the top shelf, when they get up in the morning, at the end of their day etc. These all refer to specific problems, ask the questions you have learned to ask, where, how etc.
Intermittent pain is definitely more regular and probably a worse problem.
Unrelenting (meaning constant) pain is most probably a severe pathology, ask all the questions and be ready to refer.
Aggravation and Palliation
It is also customary to ask about aggravation and palliation of pain. What makes it worse? What makes it better? Here I think we are well versed. As Rolfers we can probably see what we need to do if certain positions or activities make a pain worse or better.
If people rely on medication we need to be more careful. We could have the guts to ask them not to medicate themselves the day they come, so we can understand their problem better. We could ask them to cut down the medication to see if they need less as the work progresses, provided they take only light, over-the-counter aspirin type things. The more I think about this the more complex the situation becomes. What if they take Cortisone? Find out what they take, the name of the medicine, the lab, why prescribed, how long they have been on it. Refer if you are not comfortable. If you have experience with this, rolf carefully*. The client may feel good enough in a while to ask for a reexamination by the physician (which you could also suggest). If the physician declares them cured, he will take the credit, of course. Let him have it! You as a Rolfer, in the eyes of the very conventional doctors, practice something they call: Coincidental Spontaneous Remission! I hereby exclude all the doctors who do not do that, of course.
When asking about the intensity of a pain you could ask things like: “On a scale of one to ten, ten being the worst pain you could imagine, how would you rate your pain?” It does not matter how you ask about the intensity of pain, as long as you ask the same question to monitor the lessening or worsening of pain. The intensity of pain and sufferring is highly subjective and, as far as I know, cannot be reliably measured.
A few words to end this long diatribe: I am sure that you have experienced some impatience with my writing style, all these maybes, perhapses, sometimes, of tens and ifs. Even though the art of inquiring about pain, the art of distinguishing between how upset people are about their pain from how their pain manifests is important, pain is a symptom. This means, according to Webster: anything that has befallen one, a perceptible change. It is not a sign, something that can be measured, such that anyone measuring it the same way would find the same result.
… As Rolfers, even though we need to understand pain, we do not treat pain. Understanding pain will make you a safe Rolfer, which is a big part of keeping your heart open and C.Y.A.
* Read: Rolf Lines Vol. XXII No.1 PP 5-12 “An Interview with Rosemary Feitis D.O. and R.Louis Schultz Ph.D.”