The Thrill and Threat of Innovation in Movement and Manual Therapy
By Jennifer Sokolov
Years ago, I watched a documentary on the history of breast cancer. It was an object lesson in the ways in which medical evolution is often achieved at the expense of the patient. Early surgeries were primitive; and, thus, lives saved were also lives compromised. As I started to work with clients as a movement and manual therapist, I began to grapple with my own relationship to medical innovation, especially with respect to pain science.
How do we emotionally and intellectually adapt as new learning challenges the paradigm of our work? When I think back on the early iterations of my teaching, I feel regret about the limitations of my knowledge. Like those early surgeons, my techniques were crude and I was far too emphatic about theories that were quickly and thoroughly debunked. Hopefully now I am more able to be present in the “not knowing” without losing optimism, but there is tremendous emotional tension between the thrill and the threat of innovation. Rarely do new theories melt easily into practice, and our work suffers because of it.
Sara*, a recent client, was a case in point. Her chronic pain story is a poignant reminder of how hard it is to challenge existing assumptions and disrupt old thinking.
In December of 2021, Sara entered my practice. She was one of those clients who had literally tried every kind of allopathic and holistic practitioner to attempt to resolve her pain. Her original injury was a groin strain years ago that landed her in physical therapy. Her PT said that she needed to “balance out” her posture and prescribed assisted stretching twice a week. Sara was diligent but her pain got worse. Eventually, she ventured to just about every corner of the physical medicine world trying to find a solution. She tried an orthopedist, an osteopath, a chiropractor, an acupuncturist and a physiatrist. Her diagnoses ranged from SI joint dysfunction to strains in the QL, ITB, Psoas, and Adductors.
When she got onto the table, I was surprised to find that none of those muscles were particularly short or hypertonic. If anything, she was hypermobile and weak from inactivity. When I asked her where she felt discomfort, she couldn’t easily show me. Her pain patterns were inconsistent and intermittent. As I sat at her feet and listened holistically, I felt a complex series of issues originating from her pelvic floor. Carefully, I started to ask her questions and an entire history bubbled forward that suggested not just physical trauma but psycho emotional trauma as well. This was not territory she was willing or interested in exploring.
I felt the burden of years of her life wasted. Sara was forced to take early retirement because she couldn’t manage her pain. In my opinion, that never should have happened. Current pain science speaks loudly against downshifting into an isolated and sedentary life. I wasn’t privy to her initial consultation, but my hunch is that the rush to diagnosis interfered with a thorough intake which would have led to a deeper understanding of her history, a comprehensive physical assessment, and time for education about her condition.
As we now know, pain is not synonymous with tissue damage. It’s a complex aggregate of sensory data that the brain evaluates for danger. If the neural input is sufficiently threatening the brain outputs rapidly through high threshold nociceptors and the body experiences pain. The quality of pain is no different whether the threat is real or perceived. A good analogy is a smoke detector. The intensity of the alarm is no different whether toast is burning, the house is on fire, or the battery is low. The same is true in the body. The degree of a client’s sensations may have nothing to do with the severity of tissue damage.
Additionally, postural imbalance is no longer seen to be clinically relevant. Postural asymmetries, weak core units, and fragile structures do not predict pain. Plenty of people are not strong, have terrible posture, and are also not debilitated; and many of us who are skilled movers experience pain in our training and our lives. Most importantly, studies also show that whether we are athletic, weekend warriors or laypeople, restricting everyday movement is counterproductive in chronic stages of pain. No one should be avoiding planes of motion, adopting bed rest, or fearing that daily living will damage them.
These are significant perceptual shifts that contradict many concepts from my early Pilates training. It has taken tremendous courage for me to let go of old ideas and broaden how I think about the body. How many clients over the years had I boxed into an alignment based assessment? How many people had I painstakingly taught core exercises because I thought it would bring them relief? How many clients have I progressed through exercise sequences only to see that, just like in my own body, there really is no such thing as balance? Yes, our work works, but not in the way we thought it did. It’s not surprising that clinicians and practitioners will need time to adapt their work to accommodate such radical shifts in the medical model. For me it led to years of study outside of Pilates.
Sara's life has been on hold for 3 years because of old science. Her multiple diagnoses reflect the anxiety of clinicians trying to find a musculoskeletal reason for a multi-factorial problem. Her medical team was not able to broach the harder issues like pelvic floor dysfunction, stress management, inflammation and fear of movement. Though I am arguably the least credentialed of her practitioners, I was left in the unenviable position of trying to remediate her treatment plan.
I explained that even though she was in a lot of pain, there was no reason that her condition couldn’t improve: however, I had a gnawing feeling that her time and patience had worn too thin. Though I tried my best to support her, her trust levels were understandably low. At the end of the session, she said three critical things: 1) that she knew I cared about her, 2) that I was the only one who tried to give her exercises that seemed to help and 3) that she probably did have issues with her pelvic floor. As she left the studio, I felt sadness and regret. I know that I have the skill to work with her, but I just couldn’t offer an off-the-cuff musculoskeletal analysis and ignore all the other factors underlying her pain. In the future, I will hopefully navigate these situations with more nuance, but probably not in time for Sara.
Written by: Jennifer Sokolov, Biodynamic Craniosacral Therapist, Integrative Manual Therapist, Pilates and Yoga Instructor"
Innovation comes with a price, but there are some guideposts that can help. As practitioners, we need the support and wisdom of mentors and colleagues to stay on top of current research and compassionately let go of ossified ideas. We need to be courageous in our willingness to discuss the bigger picture with our clients so that they can learn how to manage their pain now and in the future. And we need to take time to understand the clients specific pain triggers so that they can reduce fear and increase function. Our job as practitioners isn’t saving lives, it’s saving quality of lives and we owe ourselves the time and emotional space to be able to integrate the very best of what we do into our spirits and our sessions.
Jennifer Sokolov is a Craniosacral Therapist, IMT Therapist, Pilates and Yoga instructor practicing in NYC and Athens, NY. To read more from Jennifer, sign up for her eclectic weekly letter here or visit her website tenthhousehealth.com.
*details changed to protect the client’s identity
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