The following is a case study of a women I worked with as patient demonstration at one of my hospital-based courses for physical therapists. While I see my private clients in a studio rather than hospital setting, I address many of the same movement issues and challenges as I discuss here.
Following an accident, the patient, let’s call her Ann, had a difficult knee injury that was now infected. She was in a lot of pain and tactilely defensive-- fearful of being touched or even approached.
Ann, who was around 25 years old, was wheeled in to me at a hospital. She had an I.V. in her arm and a drainage tube in her right knee. The infection was spreading to other parts of her body and she could no longer step on her right foot.
Ann had experienced so much pain in the hospital that she was in a state of alarm as to what I might do to her, especially in front of so many of the staff. As I approached her from across the room, she winced with pain. What could I do?
We started by my asking Ann to tell me how close I could come to her and still have it be comfortable, and by my promising that I would do nothing to hurt her. I said that under no circumstances would I touch her right knee of leg unless she begged me to. This reassured her enough to allow me to get closer. I maneuvered slowly around her body, looking for the areas where there were "windows of opportunity" to bring us closer. I then got close enough to ask her if we could shake hands. I asked her if that hurt. She said "No," and I asked if we could shake hands for a longer time.
And so, I began working with her through her right hand, then, up the right arm to the right shoulder. I then asked for the other hand. As she began to relax, I asked her if she wouldn't be more comfortable lying down. This involved carefully transferring her to the table to avoid any pressure under her right foot. She said she woke up in the morning on her back, so that's where we started.
I then began to play a game with Ann that she found intriguing. I asked her if I could touch her head. My question to her was, "On a scale on one to ten, ten being the most painful, how much does it hurt?" She said that she liked it. In fact, she was amazed that she liked it. So I asked her to develop another scale--a pleasure scale. Ten would be the most ecstatic pleasure she could imagine. I began to explore her shoulders and ribs and I worked deep in her belly and diaphragm. She began to appear larger. Color came to her skin and I said to her, "Now could you smile please?" which made her laugh. Her laugh immediately turned into crying because she hadn't laughed for so long. I then asked her if I could touch her left (non-painful) leg. She became nervous and said, "If you touch the bottom of my right foot, I couldn't bear the pain. Please don't touch it." So, I did lots of things with her left leg, her head and her pelvis, always asking her, "On a scale of one to ten, how much did it hurt or how much pleasure is there?"
I then asked Ann to help me make her feel good. She learned how to breathe and to reorganize her tensions in very subtle but precise ways so that she didn't trigger or overreact to pain. She then said, "I wish my right leg could feel like the rest of me." I replied, "Doesn't it feel better?" She confessed that it did, but attributed this to the fact that I had not been touching it. I said that maybe if I touched it, it would feel better and she agreed to let me touch it. I would not touch the foot until she asked me to, as we had agreed. She laughed, now without tears.
Eventually, I touched the right foot and was able to push on it. I touched the knee and taught her what to do with the rest of herself to make the knee feel better while I was touching it. For example, Ann learned how to lower her high-set startle tone throughout her body so she could lower her muscular stresses and not react so strongly to the fear of pain and the pain itself. She was very impressed that she had control over the pain in her knee by using the rest of her body in particular ways. In fact, she was delighted. Ann first described the knee pain as a ten, and we were able to get down to two.
Basically, we re-created a map of her body so that rather than having all of herself feel stress and pain, especially her knee, she now had a body that felt good almost everywhere. She had also differentiated the pain in her knee into several controllable stages that stayed compartmentalized at the area of the knee itself. Ann no longer hurt -- she simply had a sore knee.
I then ended the session by moving her body through functional patterns that would be useful for walking such as relearning how to flex her hips and move her pelvis. As I worked, I always made sure that whatever I did would reflect itself in movements of her right knee and feel very good. She began to build a pleasure scale for her body, rather than an absence of pain scale. Next, I had her contract the muscles of the right leg and learn what to do with her breathing so that she could actually have voluntary control of her extraordinarily thin muscles.
At the end, Ann was able to stand up and step in her right foot for the first time in many weeks. With amazement, she walked several feet to her wheelchair. But that was not the end.
Several days later, after returning home, I received a call from one of her attending physicians who told me that her knee had been undergoing an impressive healing. They had been considering the possibility of amputating her leg but now decided that they certainly would not have to remove her leg and were already able to remove the drainage tube from her knee. He also reported that she was starting to eat again and was beginning to go for short walks. He thanked me and at the end of our conversation said, "How do you pronounce the name of this stuff, again?"
This lesson re-inspired an idea I have had for something I am calling a Pleasure/Pain Chart. In pain clinics everywhere, there is often a stiff-looking body on paper, with painful words on the same page. The clinic asks the patient to circle the painful words and draw an arrow to where he feels that pain. (For example, if a client has a stabbing pain in a specific area of his back, he circles the word "stabbing" and draws a line to that part of the figure's back.)
In my Pleasure/Pain Chart, we had an artist draw a relaxed-looking person, standing in a natural pose. To the left of the person are thirty words for pleasure, many of which we use during body scans in movement lessons. To the right of the person are only eighteen words for pain. The instructions are that for every painful word, the patient circles and relates to some part of his body, he must also circle two words from the pleasure scale and relate them to parts of his body.
What this does for the pain patient is remarkable. Most people in extreme or long-standing pain feel their body as an undifferentiated mass of pain. As in the lesson with Ann, people filling out the Pleasure/Pain Chart form a differentiated image of their body which both reduces the area of pain for them, and the intensity, by shifting their attention away from "things only hurt more or less," to very specific descriptions that they are forced to come up with in relation to pleasure. I have seen people filling out this chart visibly alter their posture, muscle tone, respiration, and entire demeanor by the time they were finished, with an often desperate attempt to locate pleasure in their body. For some people, especially pain patients, it may by the first time they have ever had the experience of their pain reframed. For most people, it is a radical and startling experience to bring into language, and therefore into their field of attention, very specific pleasurable qualities throughout their body.
-Frank Wildman, PhD