Published in JHH 19.2- Embodiment and bodywork

Introduction

Long ago, in the far-off 1980s, I was a conventionally trained family doctor (GP). All the same I had a few additional skills and had been using medical acupuncture, homeopathy and nutritional medicine for a decade, and I knew several doctors with similar extended toolkits. I suppose jack-of-all-trades GPs like us were early explorers of an emerging version of holistic medicine. Freshly qualified in osteopathy I joined a new central London NHS primary care centre in 1987. GP-osteopaths were rare (and still are), and back then only a handful of non-medical complementary therapists (CT) had found ways into the UK’s NHS.

When he established Marylebone Health Centre (MHC) Dr (now Prof) Patrick Pietroni changed all this. Based in the repurposed crypt of Marylebone parish church and with funding from the Waites Foundation we set out to explore innovation in inner city primary care: two GPs who were joined for a day a week by an acupuncturist, a massage practitioner, and a homeopath. Twice a week I shape-shifted from GP to osteopath, and the whole care team (including two part-time psychotherapists and a social worker) met weekly to share food and discuss clinical problems and progress our embryonic research. Patrick founded the BHMA around then too, and at the time both of us were teaching medical students about general practice at St Mary’s Medical School. We worked together at MHC for over a decade, and after that at the University of Westminster, where our explorations of health and social care were shaping the Centre for Community Care and Primary Health (CCCPH) which eventually became the School of Integrated Healthcare.

For a brief spell in the 1990s and early 2000s MHC was the national prototype for a radical new take on multiprofessional primary care: an early form of what we now call integrative medicine (Peters et al, 2001). By the mid 1990s, with public interest booming, complementary medicine was on the rise in the NHS. Surveying England’s primary care services in 2002 we found nearly half were spending significant sums on complementary therapies. To our surprise there were 67 public sector-funded CT services around London (Wilkinson et al, 2004). Since then, sad to say, funding cutbacks have pushed complementary therapies out of the state sector, frustrating for a while the many doctors who had found them helpful, especially for patients caught in one of primary care’s ‘effectiveness gaps’ (Fisher et al, 2004) where GPs and patients feel conventional treatments are often unsatisfactory.

Topping the list of these common conditions is musculoskeletal pain – just the kind of problem where the CT’s low-tech and high-touch approaches are (according to clinical experience, public testimony and pragmatic outcome studies) said to be highly effective (Artus et al, 2007). But far too little research has been done to establish the objective efficacy of these practices for, unlike well-defined, objective and easily measurable drug-like interventions, their outcomes depend greatly on individual practitioners’ technical skills and human engagement. These subtle and holistic elements that nudge the body’s healing processes into action and are so fundamental to complementary therapies are difficult to quantify and tricky to control for. In fact the medical community’s gold standard for evidence – the randomised double blind controlled trial (RCT) – is designed quite properly and explicitly to bracket off the powerful non-specific effects of these human variables. One might reasonably argue therefore – and many have – that RCTs are a poor fit for evaluating complementary therapies. This is a wicked problem wherever skilful techniques and collaborative therapeutic relationships are involved and even more so with the IM’s individualised complex packages of mind, metabolism and movement. Let’s hope future research into IM’s value and risks will be conducted in ways that don’t bend it out of shape.

‘Hard’ evidence for our complex care is thin on the ground. We have instead a mass of ‘anecdotal evidence’: stories about patients with persistent problems whose prior conventional ‘treatment as usual’ had failed. Here I present three examples of apparent effectiveness from my own casebook; all women with atypical shoulder and arm pain, whose recovery was against the odds. All three were seen in Central London where, as an NHS doctor and osteopath, I saw many patients with similar long-term pain. There are common themes: disabling acute or chronic pain without gross neurological signs, high anxiety, a degree of over-breathing, myofascial trigger points, and treatment involving acupuncture, osteopathy and relaxation techniques. Two patients were found to have histories of significant traumatic events.

Three women with atypical shoulder and arm pain

Patient 1 Vicious circles

A 30-ish mother of two young children had felt stiff in her right shoulder for about a year. Lately, after suddenly over-reaching eight weeks before, it was worse. Now she described a severe and disabling poorly delineated pain in the back of her arm down to the wrist. Her GP had diagnosed frozen shoulder and though his cortisone injection (near the supraspinatus) had initially helped her mobilise, it left the pain unaffected. On the advice of a friend and with her GP’s begrudging consent, she sought me out.

At her first visit, she was near to tears, rating her morning pain level as 5 out of 6, by lunchtime 3/4, and in the evening 6 (= ‘as bad as she could possibly imagine’). She couldn’t sleep nor, with her arm clasped close to her side, could she wash properly, nor raise it much herself, but she could actively rotate in both directions. Frozen shoulder seemed a reasonable label, but there were some very sensitive trigger points in the trapezius and upper sternomastoid: when I pressed on them pain spread into her arm, neck and head. She was at that point much relieved to learn that her pain had a definitive cause. Clinically this was neither acute capsulitis nor a ‘frozen shoulder’, but myofascial pain and dysfunction (MFP&D) – something we don’t usually learn about at medical school. It isn’t due to inflammation in a joint or tendon but rather arises in tense, irritable and highly localised ‘trigger points’ in muscles. Curiously, the typical sites where the trigger sites form quite often correspond with major acupuncture points. Initially I had considered a better-placed cortisone injection, but after soft tissue stretching, soft tissue work plus local acupuncture to various tender trigger points (trapezius, supraspinatus, infraspinatus and traditional ‘channel points’ on her arm and hand) she could abduct half way.

My patient was obviously hyperventilating when she came in, in fact her whole shoulder girdle was tensing up with upper chest breathing. I taught her a simple relaxation technique and asked her to pay attention to her out-breath. As she relaxed, perhaps sensing that her arm was at last eligible to leave her side, she reported her pain much reduced. Two days later she returned, more comfortable still: pain level 3 at worst, 1 at best, and she had slept, which in itself reduced her anxiety and tension. She looked and said she felt much calmer. I treated her three more times at longer intervals until she was pain free, instructing her along the way in how to restore strength in her disused muscles, reminding her that tense muscles response to stress, and to beware the vicious circle of tension, pain and over-breathing.

I assume that needling stimulates local circulation and produces bursts of gamma fibre and mechanoreceptor nerve impulses, allowing more freedom of movement and breaking the pain spasm cycle It can release pain-relieving endorphins too. Whatever the mechanism, myofascial trigger point pain can often be relieved by some simple acupuncture.

Patient 2 The body remembers

A woman in her early 40s presented with several weeks of severe left arm pain that had spread into her hand. She was not from the UK and had lived here alone for some years, separated from her ex-husband and two children who still lived abroad. The pain, though not worse on exertion, made her understandably fearful of a heart attack. But because it worsened when she tried to lift her arm to brush her hair I reassured her the pain was musculoskeletal. She found it frightening nevertheless and had been increasingly anxious. After her sister visited recently, this tendency had dialled up into episodes of near panic, and she was descending into an all too familiar melancholy.

Her heart rate was 110; respirations 20 a minute; BP 160/90. The story did not suggest cardiac ischaemia; the movement-related elements, and the extremely tender point I found in her left trapezius was a clue to what was going on. I noted her ‘fear posture’ (shoulders up, head slightly extended, rapid upper chest breathing), how she braced her body as though anticipating a blow; that she was recruiting her scalene and sterno-mastoid (anterior neck) muscles and how little her belly moved in with each upper chest-breath. I explained to her what was happening in her anxious body (though I suspected she had little free attention available to take my words in): that the pain was from muscle spasm in her shoulder and that her panic, over-breathing and pain were locked together in a pain-spasm loop. I let her know that the pain was neither a heart attack nor some disembodied psychic illusion, but the result of trapezius trigger point pain which I fully expected to reduce. When my pressing on the point reproduced her pain and spread it down her arm she visibly relaxed; then burst into (potentially therapeutic) tears. I suggested we try acupuncture, which she had used years before and which she knew had helped her friend. Fortunately she was an ‘acupuncture strong responder’, so her body visibly quietened down once I had inserted some needles locally and into traditional calming points. Osteopathic soft tissue techniques on the muscles of her neck relieved some of the tension and stiffness. Manipulating her cervical spine enabled more normal neck movement, and with this her arm pain reduced.

Her anxiety had been so extreme that I asked her to take 2 mg of diazepam three times a day for three days as a muscle relaxant and to help her sleep. Three days later she seemed more in control but during this session she had a sudden memory of a time when she was fleeing a war zone with her children and husband. She recalled he had punched her and dragged her by her left arm to the departing plane. This abrupt and highly charged intrusion of a traumatic body-memory shocked us both. We sat, taking time to notice the impact and let our bodies relax again. Subsequently, needing to integrate the reverberations of this forgotten event, and old repressed feelings about her sister, she sought the help of a counsellor.

I often find trigger points in anxious people, though they often don’t realise they are the source of their diffuse referred pain. Sometimes I am the first to make the connection, and this can be highly reassuring in someone who was fearing that a crucial diagnosis was being missed. It’s important too for anyone working on the body to be prepared for buried emotions to surface and to know how to deal with their resonance and reverberations.

Patient 3 Medically unexplained symptoms

A woman of 70 with right-sided chest and arm pain and disabling headaches came with her daughter. The GP had referred her to me ‘to see if acupuncture could help’. Over the previous three years – dating back to a knee replacement, closely followed by a hernia repair which had broken down – her episodic chest pain had been extensively investigated. Though her blood pressure was up a bit the pain was not thought to be cardiac: the provisional diagnosis was gastro-esophagial reflux disorder (GORD). She had been prescribed three anti-hypertensives, a statin, plus a proton pump inhibitor for the reflux. She had weaned herself off long-term antidepressant medication some months before although she had no appetite and was waking early which suggested clinical depression was a possibility.

She felt short of breath, dizzy, unable to concentrate and frightened. Her squeaky and unsteady voice was another sign of over-breathing. When I inquired about any severe shocks she burst into tears and looked even more terrified. With some difficulty I was able to calm her down and pull her out of dissociation. Only then could I set about identifying the myofascial component of her pain, deal with her over-breathing, and show her the connection between the pain and her upper chest and neck tension. Once I had explained that the pain was from tense muscles and ‘not all in her mind’, she slowly relaxed and was able to breathe a little better and with abdominal diaphragm. As her breathing slowed and the pain eased a little, to everyone’s surprise, her voice became more normal. We agreed to try acupuncture to help control the pain and tension. Her homework involved diaphragmatic exercises and slow 7 in/11 out breathing. I urged her to start her anti-depressants again.

Perhaps as many as two-thirds of people eventually diagnosed with depression first present to the GP with bodily symptoms: pain, fatigue, sleep disturbance. This woman had the full set yet so far medication had made no difference. Progress was slow despite my seeing her weekly, though she was sure she felt better after every treatment. Positive transference will have been an important factor in her recovery, but let’s not dismiss this as a placebo effect: we know for sure that human effects can trigger physiological shifts. No doubt the gradual increase of anti-depressants helped and I suspect in this case that homeopathy did too. I recognised in her a pattern of characteristics corresponding to the symptom picture of white arsenic poisoning. She was anxious, obsessively tidy, sleepless and so restless that she was compelled to get up and walk around at night, plus her dyspepsia improved (weirdly) with hot drinks. I gave her the matching homeopathic remedy in high dilution. A placebo? She was definitely suggestible and very certain the little white pills made a difference each time she took them.

But here’s the thing: though we never discussed the detail, in addition to pain and depression there were intimations of an unspeakable, shameful long-ago traumatic event. My assumption is that her experience of perioperative trauma and helplessness three years before had restimulated old, deeply repressed but embodied feelings. The outer manifestations were her physical anxiety and depression, as well as gut and myofascial dysfunction. We might also speculate that post-traumatic flight-and-fight responses had over-activated her sympathetic nervous system and pushed her blood pressure up. It took six months to pull her out of the mind-body tailspin she had fallen into.

Would a talking therapy or anti-depressant meds alone have been as effective as integrative medicine? I think not: osteopathy and acupuncture entail touching and feeling the person in their suffering body. As manual approaches they oblige one to take the patient’s embodied experience at face value, to explore how the body is actually behaving, to ask why and make some narrative sense of it. This is talk-and-touch therapy but it also involves doing things to the body that invite relaxation. These brief spells of pain relief are opportunities for the person to break out of their bodily prison. Sometimes when tensions are released so too are bottled up emotions. Fortunately this woman’s own GP knew another local practitioner who was using the Human Givens (NLP-like) ‘trauma rewind technique’ in his NHS clinic. In ways beyond my ken, this method can take the traumatic sting out of a painful memory. I have seem eye movement desensitisation reprogramming do this too. Two sessions made the embodied memory much less overwhelming.

Afterthought

It has been said of doctors’ work that ‘life is short but the art is long’. Fortunately for us occasionally certain patients are sent to wake us up and propel us on deep learning journeys into ‘the art’. So it was for me. My encounters with these three women left me wondering about their constricted, tense post-traumatic bodies and the associated unrelentingly anxious or absent mind. I pondered on how aftershock might be shaping these patterns in order to wall off unbearable memories of overwhelm and why, although these emotions often fade over time (most people who experience a traumatic event don’t go on to develop long-term PTSD), they sometimes loop together in persistent cycles of pain-tension-anxiety and dissociation. So I became fascinated by these all too common syndromes of under- and over-arousal. Might they be the bedrock of chronic pain and somatic functional disorder? I offer my gratitude to these suffering women for the direction my clinical work took because of our meetings and in hope that I was able to help them.

References

Artus M, Croft P & Lewis M (2007) The use of CAM and conventional treatments among primary care consulters with chronic musculoskeletal pain. BMC Primary Care [online]. Available at: https://bmcprimcare.biomedcentral.com/articles/10.1186/1471-2296-8-26 (accessed 6 July 2022).

Fisher P, Van Haselen R, Hardy K, Berkovitz S & McCarney R (2004) Effectiveness gaps: a new concept for evaluating health service and research needs applied to complementary and alternative medicine. Journal of Alternative and Complementary Medicine 10(4) 627–632.

Peters D, Chaitow L, Morrison S & Harris G (2001) Integrating complementary therapies: a practical guide for primary care. Harcourt Brace.

Wilkinson J, Peters D & Donaldson J (2004) Clinical governance for complementary therapies in primary care. Final report to the Department of Health and the Kings Fund. University of Westminster.