If this is always true, why can we feel pain when we have not injured ourselves? 

For example, we feel neck or back pain after sitting for a prolonged periods or a trivial action like reaching for a towel causes severe back pain?
How is this possible if pain = damage? This is confusing.

What The Research Shows

The research tells a different story:

One study ( Brinjiki et al) showed a high rate of ‘pathology’ in lower back MRIs in over 3000 subjects without any pain or dysfunction – and this was in people ranging from 20 to 80 years old.

In the shoulder, many studies have painted a very similar picture. One study (Grisih et al) found that a remarkable 96% of subjects who reported no pain or issues had at least one identifiable ‘pathology’ on their ultrasound scan. 

So you can see that tissue damage does not lead to pain in many cases, and pain can arise without  evidence of tissue damage. This is precisely why we constantly remind our patients that ultrasound scans don’t tell the full story.

The general understanding of pain and injury needs to be updated so that people can overcome pain more easily and get back to living their (best) lives.

A New Understanding of Pain

The new understanding of pain is that it is an output signal created by the brain, as a warning sign. It can be out of proportion to the injury. This serves to change behaviour to prevent further damage, which is often required to fix the problem.

The issue is that most people don’t understand this, and remain stuck with a painful condition because they are fearful to move in case it causes more tissue damage. The problem with this is that people are thinking about local structures, not the whole body. There are compensations and protective mechanisms that can develop in other areas of the body that can contribute to your pain…. Where your pain is located is not necessarily where it comes from.

For example, someone can get knee pain because they had a recent back pain episode that affected the way they walked. The back pain improved, but the knee persisted because of secondary protective mechanisms that have not resolved.

A Whole Body Approach

This is why we look at the whole body and how it works together. We want be as thorough as we can and find all the contributors, both local and remote for your pain. This will enable you to get back to the things you love doing without the pain you have been suffering.

We use a 7 step process (the ridgway method) that will find the main drivers of your pain and fix them quickly. It is scientific, objective and based on the latest neuroscience research. 

If you’re not open to a new understanding of pain, you will remain stuck and restricted by your pain and fear of movement. Are you really willing to let your pain dictate your quality of life? 

Or are you looking for a new approach to regain your lifestyle, independence and get on top of your pain long term?

If you’re ready to take control of your life, book an initial consultation with us. We’d love to help you!

References

Brinjikji W et al; Systematic literature review of imaging features of spinal degeneration in asymptomatic populations. AJNR Am J Neuroradiol. 2015 Apr;36(4):811-6. doi: 10.3174/ajnr.A4173. Epub 2014 Nov 27.

Girish G et al; Ultrasound of the shoulder: asymptomatic findings in men. AJR Am J Roentgenol. 2011 Oct;197(4):W713-9. doi: 10.2214/AJR.11.6971

I want to talk about the challenges I faced and how I have managed to maintain a level of activity and exercise despite the injury, as well as some lessons I learnt along the way.

I had been lucky to avoid injury in my youth playing cricket, squash, and footy competitively plus loads of social sport with friends. I’d seen the cost of injuries in my nine years as an AFL physiotherapist. We had a brilliant rover at the Bulldogs called Brian Royal. He represented Victoria many times, but during his 199th game against Essendon at the MCG in 1992, he tore his Achilles tendon. At his age, it was career over.

The first thing I realised about my own injury was that, although it was limiting and painful, there were no signs of serious injury or red flags. However, there were times when I was severely incapacitated by the pain. At one stage I lost power in my triceps and I couldn’t even lift a 2 kg dumbbell overhead. Later I got excited about chin-ups. After a session of preparation work (not even doing a full chin up), the resultant pain stopped me from sleeping for 2 nights. I tossed and turned and would maybe get some slight relief before a deep shoulder ache came back with a vengeance.

Working with a team of physios was a great opportunity for me to have treatment and work through a prescribed rehabilitation program. I was a living case study. However, I wasn’t consistent with my treatment, only seeking help when the shoulder became particularly painful. Most of the time, I could get on with my life and put up with the discomfort. There weren’t signs of serious pathology, so we decided not to go down the path of further investigation and scans.

I had a chronic annoying shoulder injury that only episodically became severe. I think this is a story that many people can relate to. As Ridgway Method practitioners, we recognise the importance of finding the main drivers of your pain and restriction. These can be addressed by changing movement patterns and habitual postures, and improving tolerance to load with strength and mobility exercises.

Using the Ridgway problem solving approach, Nicole identified my left biceps and anterior deltoid muscle as the main contributors to my shoulder pain. I also have a nerve component to my pain with increased nerve tension in the upper and lower limbs. Now I have treatment on a regular basis with Nicole and have seen consistent improvement in my pain levels, range of movement, and strength.

When she treats these structures, this always improves my shoulder movement by reducing pain and guarding. More importantly, I have an exercise program to build on the improvements made during the treatment sessions. At the beginning, I couldn’t do a push up with proper technique with my left shoulder – but now I can do 3 sets of 15 push ups with good form.

With consistent treatment, specific exercise, and Nicole’s guidance, the movement control of my shoulder has steadily improved and with that, the level of chronic pain and tightness in the shoulder has also reduced to the point where I’m not even aware of my shoulder most of the time. Now I continue with the strength and motor control exercises on a daily basis.

My take-aways:

1. Recovery from injury is never a smooth linear process. There will always be setbacks and obstacles to overcome.

2. Persistence trumps all. To move forward you can’t give up. Always try to find the best pathway forward. Ask questions and get the best understanding you can.

3. You may not get 100% recovery and that may be an unrealistic expectation. You want to be as independent as possible but also know your limitations so you don’t overdo it. I look at my pain as a reminder. It keeps me on track.

4. Always look for guidance and assistance. This can come from your therapist, supportive friend, or family member who can check on your exercises and keep you accountable.

5. There is a difference between pain and suffering. One does not automatically lead to the other. We can get caught up in the emotions, and the negativity of pain does not help our recovery. We always have a choice.

She had suffered some trauma to her head and neck region when she was 15 years old, and she had traced the start of her problems to after this event.Mrs D suffered with 2 migraines a month generally, but lately she had been experiencing headaches on a daily basis around this. Her symptoms were usually aggravated by stress.

Her headaches and migraines were in similar areas, usually around the left eye and into the back of the skull on the left, and she had associated pain into her left shoulder and the top of her arm.

Mrs D had been under the care of a neurologist, and had seen other Physios and Chiropractors with good but short to medium term relief only.Her good result was:

What we found

1. Reduce or eliminate the constant headaches.
2. Reduce migraine frequency, duration and intensity.
3. Feel less stiff in the neck and shoulders.
4. Improve energy levels.

We took Mrs D through a whole body assessment, because we know through experience and research that where your pain is may not be where the cause of your problem is.

What we did

Summary of assessment findings:

1. Muscle tension/knots in many of the neck and shoulder muscles on both sides.
2. Adverse nerve tension in the upper limbs.
3. Stiffness in many joints around the neck, thoracic spine and lumbar spine.
4. Restricted passive neck flexion/rotation test, worse to left.
5. Weakness in the deep neck flexors and scapular stabilizers.
6. Poor pattern of shoulder movements, left worse than right.

We trialed treatment on the the unhappy muscles and joints that we had found on the initial assessment, and used a single test movement(passive flexion/rotation of the neck) to measure the response of each intervention. we also monitored other key movement tests related to Mrs D’ condition, especially shoulder and neck range/quality of movements.
From this we made a list of structures that had made good changes to Mrs D movements tests.

We then worked on that list to narrow down further the main dysfunctions that were contributing to Mrs D’s condition. This involved a process of elimination and clinical reasoning.

We finally narrowed down to the left infraspinatous muscle in her shoulder, that was continuing to make differences to all of Mrs D’s relevant movement signs. Working to release this muscle also improved the stiffness in many of the neck joints.

Results

The graph below shows the improvement in Mrs D’s key movement tests over the course of treatment, which involved 7 x 1 hr treatment sessions.

The objective improvement matched improvements in Mrs D’s symptoms:

1. General headaches were largely eliminated between migraines, except for times of high work related stress. In these cases headaches were much less severe, and of shorter duration.
2. Migraines were also less frequent, less severe and shorter duration, on average 1 very 4-6 weeks.
3. Mrs D was very satisfied with her results, feeling more energetic and more in control of her condition. she had simple tests she could use to self monitor her body, to know when muscle and joint tension was increasing, and a range of strategies that she could use to manage her condition long term.

Why was the left shoulder contributing to Mrs D’s condition?
The left shoulder had a large trigger point/knot in the infraspinatous muscle. This was adding to the level of noxious input to her central nervous system, sensitising the main receptor nuclei(trigemeni cervical nucleus) in the brainstem that trigger headaches. Reducing tension in this muscle reduces the level of this noxious input, thus making it harder for a headache/migraine to be triggered.

This shoulder dysfunction related to weakness to of the shoulder stabilisers, poor posture in sitting at her desk, and poor movement control, problems we addressed as part of a long term solution for Mrs D.

This case study highlights the importance of looking beyond the neck in the management of headaches.

It is unlikely that such a result would have been achieved by treatment of the neck alone, as the shoulder release work improved the neck stiffness when re- assessed immediately afterwards.

In our experience, most people who present with pain or injury have postural imbalances that contribute significantly to their problem. Improving posture, strength and mobility can help you move more freely with less pain and stiffness.

What we find in our assessments

1. Tightness and trigger points in the muscles at the front of the chest and shoulder: usually the pec major and minor, upper trapezius and levator scapulae (which run from the shoulder blade to the neck) and biceps.
2. The shoulder joint is often sitting forward with posterior tightness in the joint capsule and weakness in the muscles that stabilise the shoulder blades and bringing them back towards the midline.
3. Restricted movement in the neck and thoracic spine, particularly rotation and extension and reduced  movement in the ribs.

Why is this important to know?

This posture results in an increase strain of the neck muscles because the head is pitched forward and it takes increased muscle activation to keep your eyes level.
Decreased mobility in the thoracic spine and ribs reduces capacity for breathing and full movement of the diaphragm.
These immobile and weak dysfunctional regions can also contribute to pain in other, more remote areas of the body.

Why does this happen?

Poor posture has become more common because many of our modern work tasks  involve prolonged  sitting and computer based work. We don’t move enough and our head and shoulders are held fixed and slumped forward.
A generation ago more people had manual jobs which required being on their feet, changing positions and moving between work areas. This constant movement allowed for better mobility in the neck and shoulders and strain did not build up to the same degree because of static loading.
Prolonged static postures cause a accumulation of strain in our bodies. When the amount of strain exceeds a safe threshold, our brains are alerted to send out protective guarding responses which can lead to feelings of pain and stiffness.
This protective guarding cycle leads to poor movement patterns due to pain and relative immobility.
All these are warning signs for us to change our behaviour or seek help.

What this looks like

What you can do about it

The first step is to change your posture so there is better alignment between you neck, shoulders and pelvis in standing and sitting. Good cues are to sit tall, draw in your chin and square your shoulders. In standing, try drawing in your tummy and standing tall.

If this does not help to reduce pain, careful assessment and then treatment to improve joint stiffness, nerve gliding, muscle tightness will reduce the protective guarding response initiated by the brain,improve mobility and reduce pain.

Along with careful systematic assessment and treatment, we also suggest three simple exercises to improve posture and joint mobility. The video below will take you through how to do these.

1. Step in front of an open door with your elbows and shoulders level and the forearm supported by the doorway frame. Gently lean forward and let your shoulders open up and feel a  stretch in the front of your shoulder and chest. Make sure you keep your neck neutral and relaxed as you perform this exercise. Hold for 10 seconds by five repetitions.
2. To improve the thoracic rotation sit in a comfortable chair with your feet flat on the ground to keep your pelvis stabilized. Gently turn your shoulders, turning your spine using your arms on your thighs to assist. Make sure you breathe normally and don’t strain. Hold the  stretch for 10 seconds and alternate from left to right
3. Sit on the floor with your knees bent and feet flat on the ground. Reach behind you placing your palms on the ground with your arms straight. From this position gently lift and open your chest while squeezing your shoulders back and your shoulder blades together. Feel a stretch in your chest and in the front of your shoulders. Feel the shoulder blades squeeze together. Do five stretches holding for 10 seconds.

These are three simple exercises that when done regularly help to gently and progressively stretch away from joint stiffness caused by prolonged sitting and working a desk or computer.
These exercises work both on mobilising joints and muscles and places a steady stretch on the connective tissue around joints which gradually adapt over time. These exercises work very well over time and should be incorporated into a daily stretching or warmup program.
Remember that mobility is the key to good health and as a consequence you have more freedom of movement, can exercise more effectively and just feel a whole lot better.

How you can self test

Do a quick scan of your mobility by first looking at your posture in the mirror. Is your head forward with your shoulders slumped and rounded?
Try turning your head to either side and then your trunk and reaching overhead. How far can you go? How comfortable is the movement?
If indeed you do feel your movements are restricted or painful, it may be worthwhile to start these exercises.
If you continue to have problems with pain or stiffness and  would you like more information about managing these issues.

Feel free to call us at Northwest Physiotherapy Group, either through our website or message us through our Facebook page.

We are here to help!

‘Unknown’ and forgotten even amongst health practitioners (trust me I know!!). The subscapularis is a large triangular shaped muscle that lies between your ribcage and shoulder blade. Why an entire blog post about just one muscle? I hear you ask.. From our experience the subscapularis muscle is a common source of pain for many of our clients, both local (shoulder region) and remote pain. Subscapularis also happens to be the muscle that relieved remote pain in my own body and hence is another reason I have chosen to write my first blog post on this incredibly annoying but fundamental muscle.

Subscapularis – What? Where? Why?

The image above to the left shows the subscapularis muscle insertion, the lesser tubercle of the humerus or upper arm bone. The second image on the right shows the muscles origin on the flat surface of the shoulder blade (subscapula fossa).

Ever heard of the rotator cuff? Subscapularis is one of four muscles that makes up the rotator cuff, which creates stability of the shoulder joint. The rotator cuff works similarly to that of the four guy ropes on a tent, should one become too tight or loose the other three are impacted creating an imbalance. As we know any malalignment within our bodies has the potential to produce pain.

The muscle is innervated by nerves travelling out of the neck. 

In our experiences, when subscapularis muscle becomes dysfunctional often it has the potential to lead to a number of other conditions, and very rarely produces local pain at the site of the muscle. Common referral patterns of a tight and unhappy subscapularis muscle include neck, back and shoulder pain, arm and wrist pain and you may also find reduced strength in these areas (Perry, 2018). 

How does Subscap become problematic?

Prone to becoming tight and shortened, this muscle is most commonly accessed by clinicians via the armpit. There are many different reasons why this muscle can become dysfunctional and aggravated. The most common we find is posture… There’s a reason why you were constantly reminded as a child to sit and stand tall!!

In certain positions and postures the subscapularis muscle can be shortened such as at the desk with use of a mouse, especially with the arm held away from the body. Other repetitive action also have the ability to produce dysfunction such as activities that involve a reaching action behind the back, common in swimming and racket sports.

A fall onto an outstretched hand in most cases will lead to prolonged periods of immobilisation such as a cast on the wrist or a sling for a shoulder injury, but did you know it can also  cause dysfunction to the subscapularis muscle. Once the immobilisation and rehabilitation period are complete, you may still find yourself feeling that things are ‘just not the same since that fall/break/accident’. This could potentially be due to unresolved dysfunction of the subscap. 

Even sleep position, one where you are side lying onto the shoulder, arm outstretched can lead to an accumulation of strain within the subscapularis muscle and resultant issues…. JUST FROM SLEEPING!

… I hear the cogs ticking over now….

How do you know if your Subscapularis needs attending to? 

STEP 1.

• Assess your posture using a mirror.
• Where are your shoulders sitting in relation to the rest of your body?
• Do you have a gorilla’s posture? (arms and shoulder position rolling inwards) 

STEP 2.

• Assess your Range of Motion
• Can you comfortably reach over head or do your shoulders feel restricted and tight?
• Can you complete a Subscap Stretch against wall as pictured below?

STEP 3.

• Identify Weakness using the Lift-off Test
• Leaning on an angle, shoulders resting against and feet slightly forward.
• Place hand behind back palm contacting the wall.
• Press the palm into wall as your body subsequently travels forward. 

If you noticed your posture is looking gorilla-like and/or had difficulty completing steps 2 and 3 it is likely your subscapularis muscle has been suffering in silence… or you have been soldiering on in pain!!

Addressing the subscapularis is relatively easy (unfortunately I cannot promise it will be completely pain free) but following on from treatment you will be sure to notice a difference! The catch, we can not do all of the work for you, if order to achieve long-term and effective results you will need to commit to simple postural correction, strengthening exercise and gain an understanding of how to assess and manage this area in future. If you are interested to learn more or found yourself to have some positive tests, please call our clinic to book your appointment. We are ready to help you!

References:

1. Kenhub (2018). Available at: https://www.youtube.com/watch?v=_NvVjLUL3F4 [Accessed 13 Jun. 2018].
2. Perry, D. (2018). Subscapularis Trigger Points: The Icicles of Shoulder Pain | TriggerPointTherapist.com. [online] Triggerpointtherapist.com. Available at: http://www.triggerpointtherapist.com/blog/subscapularis-trigger-points/subscapularis-trigger-points-shoulder-pain-icicles/ [Accessed 30 May 2018].
3. Vizniak, N. (2012). Muscle manual. Professional Health Systems.

The pain was localised to the left buttock with some spread into the back of the left thigh. It would also be aggravated by driving immediately after a run. Mrs H’s general health was otherwise good, and there were no other red/yellow flags(cautious signs).

A thorough whole body examination revealed the following main problem areas:

1. Adverse neural tension in the right lower limb and the upper cervical quadrant.
2. Muscle tension/guarding in the right shoulder and neck region( especially infaspinatous).
3. Stiffness(hypomobility) in the neck and thoracic spine left>right.
4. Restricted lumbar movement and early guarding of upper traps with shoulder abduction.
5. Restricted hamstrings range on the left, but no other local signs of tension around the buttock.
6. Good strength and activation of the gluteal muscles, but left hip flexor muscle weaker than right.
7. Running assessment revealed some over-striding, and the shoulders held elevated and abducted(elbows away from body).

Through a systematic process of elimination and clinical reasoning, we found the main area that produced the most change to all of Mrs H’s signs(above) was release of the right infraspinatous(shoulder). This muscle had a large trigger point in it. This cleared the hamstring tension(on the left) and resolved Mrs H’s symptoms so she could run painfree again.

Why was Mrs. H’s  right shoulder so tight? Further discussion revealed that Mrs H often performed Ultrasound testing with her patients, which often required holding her right shoulder away from her body and in awkward extended positions. This had lead to strain building up over time in the shoulder. She also ran with her shoulders in a tense state, which contributed to more accumulation of strain.

So why had this lead to buttock pain? There are a few possible explanations:

a. The tension in the right shoulder affected upper body rotation while running, which was compensated for by increased load on the left hip/gluteal area.
b. Tightness in the right shoulder lead to compensatory tightness developing in the left buttock following a diagonal pattern, a common movement pattern in normal bodily functions(right arm moves with left leg in walking/running).
c. The left buttock pain was an output signal from Mrs H’s brain warning of some imbalance in the body. The area of pain was not necessarily the area of greatest tension in the body, but this was the most effective area of symptoms to cause a behavioural change in Mrs H as it was affecting her running, something that was very important to her general health and well-being.

Whatever the mechanism there was measurable and objective improvement in Mrs H’s condition. Further correction involved teaching postural strategies Mrs H could employ at work to minimise strain from accumulating in her upper body, and some simple corrections to her running mechanics.

What is interesting about this case is that although Mrs H had buttock symptoms, no treatment was performed locally to that area, as there was no measurable signs of tension in the muscles or joints in the area.

Mrs H went on to run a PB (personal best) in the half marathon and is now well on the way to completing her 1st marathon.

Today, we will show you a simple test to monitor the build up of muscle tension in the upper trapezius, a muscle at the base of the neck.

It’s important to be aware of increased muscle tension which can lead to strain and later, pain. Cath will show you how to feel for tension in the upper trapezius by raising her shoulder or stretching her neck.

When testing, the muscle should be soft and relaxed, if tensed, it it often due to the shoulders rolling forward and the upper trunk being bent. Correct this by gently straightening the upper trunk and pulling the shoulder blades back and down. Ideally, check for muscle tension and correct every 30 to 60 minutes. If you still can’t reduce tension in the upper trapezius by correcting your posture, visit our website for a simple routine of exercises.

If tightness or tension persist, there may be other issues that we can address, call Northwest Physiotherapy Group on 9370 5654.

Mr B’s main goals: (self rated as 10/10 being pain free and full function)

1. To sit and drive for greater than an hour without pain (6/10)
2. To bend painfree (currently 5/10)
3. To run greater than 8km without hip pain.  Ultimately to complete a half marathon (21km)

We performed a systematic assessment of Mr B’s musculoskeletal system and found the following imbalances:

1. Neural tension in the left lower limb
2. Significant restriction in flexibility of hamstrings bilaterally: Left – 60 degrees; right – 45 degrees.
3. Widespread muscle tension and guarding, particularly of left gluteals, quadratus lumborum and calf, and left and right subscapularis, infrapsinatus and pectorals.
4. Stiffness in the anterior portion of disc at L2 segment, right worse than left.
5. Stiff lumbar and thoracic segments at T6-8 and L1-3.
6. Significant muscle guarding with lumbar flexion and extension movements.

Through a clinical reasoning approach, we worked out together that Mr B’s left hamstring flexibility was a good test to measure changes in his condition. Through a process of treatment trials and reassessment, we found the biggest and quickest change in this test occurred with a release of his left subscapularis muscle (underneath shoulder blade). It increased his left hamstring flexibility by more than 40% and even improved his right hamstring flexibility by 30%. When re-testing the main dysfunctions in his body, most of them had improved (decreased muscle tension around his back, lower limbs and shoulder and increased movements in his hip and back (lumbar and thoracic).

Following the reassessment, we were confident that we had found the main driver of his left hip and low back condition.  With only a further 2 sessions of treatment directed to the left subscapularis muscle, hamstring, hip, lumbar and thoracic movements all returned to approximately 80%. A secondary contributing factor was identified in the right L2 anterior disc and with 2 treatment sessions directed to this segment, we restored all of his movements to 100%.

In line with these objective improvements, Mr B had achieved his goals of sitting and driving for greater than an hour without pain and bending without pain.  He was also now running greater than 10km without pain and limitation and feeling much more confident in his ability to achieve his ultimate goal of running the half marathon.

Mr B was taught postural and motor control strategies to look after his primary and secondary contributing factors in order to prevent aggravation in the future.  He managed well with this and
integrated these into both his daily tasks and exercise regime.  Following the initial 5 sessions of treatment which achieved these goals, Mr B was able to maintain these gains with a tune-up approximately every 6-8 weeks.

This is another case which demonstrates how other areas in the body can affect the overall condition and without a thorough assessment, we can’t be sure we are treating the main driver of the condition.

If you would like to learn  more about the neuroscience behind the approach we used with Mr B, please click here.

Mrs M. main goals: (self rated as 10/10 being pain free and full function)
To reach overhead e.g. hanging clothes, reaching in high cupboard (3/10)
To carry bags without pain (6/10)
To do weight bearing activity e.g. Pilates exercises (5/10)

We performed a systematic assessment of Mrs M’s musculoskeletal system and found the following imbalances:

1. Neurodynamic tension in both upper limbs
2. Severely restricted shoulder movement bilaterally (Flexion, Abduction, External Rotation)
3. Tight posterior shoulder capsule bilaterally
4. Muscles guarding around both shoulders and right side of the neck (scalenes, upper trapezius)
5. Stiff neck (C6-7) and thoracic (T1-2, T9-10) segments
6. Over-activation of upper trapezius with active shoulder movements

Through a clinical reasoning approach, we worked out together that Mrs M’s right shoulder external rotation was a good test to measure changes in her condition. Through a process of treatment trials and reassessment, we found the biggest and quickest change in this test occurred with a release of her neck (C6-7). It increased her right shoulder movement by more than 50% and even improved her left shoulder by 30%. When re-testing the main dysfunctions in her body, most of them had improved (decreased muscle tension around shoulder, increased hamstring flexibility, increased thoracic and neck movements).
Following the reassessment, we were confident that we had found the main driver of her shoulder problems. With more treatment of her neck, the shoulder mobility got to 90% and it only needed a few minutes of local work on each shoulder to get back to full range.

Mrs M. achieved all her goals and even more. In the week that followed the treatments, she found out her neck was a lot freer allowing her to reverse the car easily, her hamstrings were less tight so it was easy to do some Pilates exercises that she was struggling with.

To make sure she doesn’t overload her neck area again, I gave her postural exercises and attended a Pilates reformer session with her to make sure she was doing the exercises appropriately. I also discussed Mrs M’s condition with her Pilates instructor and strategies to prevent recurrence of her problem

This case demonstrates that even if there is a diagnosis of local problems where the pain is, other areas in the body can affect the overall condition and without a thorough assessment, we can’t be sure we are treating the main driver of the condition to get the best result.

If you would like to learn more about the neuroscience behind the approach we used with Mrs M, please click here.