Chronic Back and Neck Pains:
Those That Heal; Those That Do Not
Paul Gordon, M.A.
Recently a client of mine, whom I shall call Rosalie, turned and asked, “Will I ever get better?” It was a sad moment in what had been a difficult week for her. Rosalie is working her way along the long, slow path of healing a chronic back pain. She had badly injured the left side of her neck and upper back in a car accident two years ago and has progressed, step by step, from those first hours after the crash when she was wounded and completely dysfunctional. (See charts 1 and 2.) She went through the black days when she hurt all the time. She’s seen the pain decrease: it was only a few months that she hurt irregularly. These days she feels ok but she is still vulnerable (although she certainly did not this week). Rosalie is better; she's just not healed.
Chart 1 (Healthy Versus Damaged)
||Rosalie’s R Back
||Normal (every-day living)
||Rosalie’s R Back
||Abnormal (tension or accident)
||Rosalie’s L Back
||Normal (every-day living)
||Rosalie’s L Back
||Abnormal (tension or accident)
It is my experience that many, if not most people who have suffered with chronic back and neck pain never reach the end of the road and will never be balanced and strong. Somewhere along the line, for some reason, they get bogged down. They may be fine for a while, but they remain at risk. Eventually, almost inevitably, they fall again. The intention of this article is to begin an examination of the process so that, if pain is bogging a person down, they may know where to look to help get them going again; to help bring it to its potential conclusion.
Before discussing something as complex and controversial as why some patients heal while others never will, it is necessary to define healing. Healing is a process by which damage is repaired so that a (person) structure may respond appropriately to both normal and abnormal demands. To heal something is to reconstruct it; to put it back together. It is the opposite of wounding and degeneration.
How does one “respond appropriately?” In the first few days after the accident, Rosalie stayed in bed and was in considerable pain. She was put on Percocet and Motrin. Within a week, she had progressed to the point where she hurt constantly, but was at least able to move around. Her doctor prescribed physical therapy, kept her on muscle relaxants, anti-inflammatories, and when needed, pain relievers. Today, the pain is much less, but she remains unable to reach her upper kitchen cabinets and it still hurts to wave goodbye. Rosalie’s response to normal demands is “inappropriate.”
Chart II (Healing Versus Wounding)
|Completely Dysfunctional (Cannot be used)
||Rosalie’s L back at time of accident
|Hurts All the Time
||Rosalie’s R back after painting
|Questionable (Hurts irregularly)
||Rosalie’s L back two months after accident
|Feels O.K. (Does not hurt but does not feel normal; still vulnerable.)
||Rosalie’s L back now
|Resolution (Does not hurt but does not move)
|Feels “not bad” (Not strong but not vulnerable)
|Feels good (Do not need to think about it)
||Rosalie’s R back usually
|Feels Great (Balanced and strong)
||Rosalie’s R back occasionally
Rosalie’s right side has never been injured; it is, she reports, “just fine.” When she overuses it, it does hurt, but never out of proportion to what she’s done. Last month, for instance, she painted part of her living room ceiling and her right upper back and neck were sore. Within a couple of days, the area felt fine again. Rosalie is a high-powered executive secretary and I once asked her how her back responds to the pressure. “The shoulders get really tight,” she said. “But if the right side hurts, the left side kills.” The same degree of emotional stress affects one side much more than the other.
If Rosalie were involved in another accident, what might happen? In an accident her right shoulder she would hurt of course, but only to the degree that it was injured. Her left upper back had already been injured and its response to the accident might be very different.
An abnormal demand—such as another accident—may cause a reaction totally out of proportion to the actual event. Already weakened, another stress might compound the injury and make her left upper back and neck completely unusable.
Rosalie’s right upper back has no problems; it is healthy. Under normal demands (everyday living) it feels fine. When she exercises regularly and takes care of herself, it feels even better; it feels good. Under abnormal conditions (painting ceilings or an accident) it responds as it should: it hurts. A little stress hurts a little; a big stress hurts a lot.
Rosalie’s left side is damaged; although not as bad as it was two years ago, it’s still not healed. It’s been healing, but remains on the damaged end of the ledger. Abnormal demands can set off a seriously inappropriate response. When Rosalie was referred to me by her orthopedist, we did an initial interview.
I asked her about her life, her pain, her medical history, her expectations about our work together. In discussing her experience with physical therapy, her reactions were generally negative. I asked her why she did not get anything from therapy and she said that she had gone twice weekly for about two months but not much had happened. Further discussion, however, revealed a different story. What had happened was that she had improved—about 25 percent, it turned out—but when she left she was still hurting. On the chart she had moved three spaces: from “cannot be used,” when she began therapy, to somewhere between “hurts most of the time” and “hurts irregularly."
This reaction to therapy is commonplace. Rosalie, like most of us, saw pain as an “all or nothing” condition. If it still hurts, even at a reduced level, our tendency is to discredit the therapy. She did not view healing as the charts show it: a continuum. The progression from wounded to healed is just that—a progression. Healing is a process, by definition it involves time. “Healed” is the positive end result of that process. Almost always the success we achieve today is built upon the work we did yesterday.
A back is not healed if the injury continues to significantly detract from the sufferer’s physical emotional or spiritual well-being. The important word here is “significantly.” Healing is not always synonymous with “good as new.” It is a relative term—it may not be perfect. It is a subjective term, what feels good to one person may be only okay to another. But if the result of the injury is that there is a significant, limiting physical, emotional or spiritual adaptation, the condition has not been healed. A fully healed back is pain free—positive, even quite supportive and strong: it is not just “not bad,” it is good.
Do healed backs ever hurt? Of course they do. Healed or not, structures subjected to abnormal demands will complain. The point is that a totally healed structure will not complain disproportionately to the demand. All things being equal, it is not a “weakened link” that will break under normal stress or will break inappropriately under abnormal stress.
In a recent Physical Therapy Forum, Patricia Lyall, RPT and Arun Hejmadi, Ph.D., wrote a provocative article entitled “A new Paradigm for Working with Chronic Myofascial Pain.” As I understand their model, our brain has developed into a tri-level structure and that treatment which bridges the gap between subcortical needs and cortical expectations will be most effective with chronic pain patients. This conception, if it holds up, will help explain why techniques like P.N.F., Feldenkrais, Rolfing, Alexander Work, “unwinding,” relaxation techniques, even psychotherapy, are something very helpful. All of these methods, to a greater or lesser degree, reach a subcortical level.
And yet, after ten years as a Rolfer, with close to ten thousand client hours of soft tissue and joint mobilization; with experience in movement work, meridian (acupuncture) energy, psychotherapy, trigger point compression, unwinding, cranio-sacral techniques, guided visualization and other subcortical methods; I know that while many chronic pain patients get better, there are still some who do not. Those who reach all the way to being fully healed are, sad to say, a relatively small minority.
A realistic prognosis for a chronic back condition is that often the discomfort which accompanies a specific episode can be temporarily relieved; that over the years the condition will be slowly and painfully adapted to and, through a process of compensatory rigidification, more or less resolved; that only rarely will a back be healed to the point where it is no longer a significant issue in the sufferer’s life.
All back pain—in its original cause, its location, duration, intensity, quality, and reasons for recurrence—is not the same. The taxi driver whose low back begins to ache after twenty minutes in his cab may or may not have the same problem as the surgeon whose right leg throbs after an hour in the operating room. The school teacher who experiences excruciating stiffness every morning cannot be treated the same as the physical therapist whose pain occurs at one end of the day. The damage done and the repair needed to take Rosalie to the place that she no longer needs to think about it is, and must be, different from anyone else. There are no simple remedies for complex problems, no exercises that everyone should do, no “root cause” that explains all discomfort, no one method or cure that fixes everything. The specific rehabilitative process a suffered undertakes is for him; it must be designed for his life, his pain, his structure. It is not transferable.
What is transferable, what is universal, are the fundamentals—as opposed to the specifics—of healing such conditions. The components involved will differ with the individual. The healing process can be stopped, slowed down, or reversed at any one of these steps. If the process is stopping, slowing down or reversing, I suggest these are the areas which should be examined. Something in one of the following six categories has gone astray. Although, I call these categories “steps,” and I write about them in order, they are not necessarily sequential, linear progressions which we move through one at a time. Often, many of the components must be dealt with simultaneously.
The fundamentals involved in healing chronic back and neck pain are: 1) commitment to the process of healing; 2) appropriate evaluation of the issues; 3) correction of the structural problems; 4) lengthening what has shortened and strengthening what has weakened; 5) learning balanced movement; and 6) avoidance of re injury. Healing is natural; it is at the heart of life. If the tissue is viable and the work is done, healing will take place.
Healing is the condition we enter when the initial wounding is over. There are almost always “ups and downs,” plateaus during which nothings seems to be happening. But as long as the overall movement is toward repair, we are healing. If healing stops or is incomplete, we may revert to any combination of stalemate, more wounding, degeneration or dysfunctional compensation. A healed back moves freely; it is not painful. It is something we do not need to think about. Unafraid, we can take it anywhere.
In future issues of PT Forum, I hope to discuss what Rosalie has and has not been doing; to look at the nature of the process that begins with wounding and can end as healed. It is my intention to contribute articles discussing each of these categories.
Chart IlI (The Components Involved In Healing Chronic Back And Back Pain)
- Commitment to the process of healing
- Appropriate evaluation of the issues
- Correction of the structural problems
- Lengthening what has shortened, strengthening was has weakened
- Learning of balanced movement
- Avoidance of re-injury