“I am so embarrassed,” Mr. J. said. “I can’t believe I did something so stupid.” I waited for more details, but he wasn’t more forthcoming. He only looked at the floor, avoiding eye contact with me.
Mr. J. called me a few days after being in a car accident, but gave very few details about the incident. In the conversation, he described having neck discomfort as well as pain in his chest. During that conversation, I advised him to wait for a day or two as the neck pain would likely diminish. I doubted the pain in his chest would follow the same trajectory. His visit to my office was about five days after our phone conversation.        
“Can you tell me more about the accident?” I asked.
“Yes, but I’m curious,” he replied. “How did you know the neck pain was likely to decrease after we talked on the phone the other day? It happened just as you said. Within two days, the neck pain essentially disappeared.”
It wasn’t lost on me that Mr. J. avoided my question about further accident details. This was a subject he was obviously very uncomfortable with.
“I am assuming you were the bullet vehicle in this accident, meaning you hit someone, rather than they hit you, correct?”
Mr. J. nodded in reply, looking even more pained.
“If I remember correctly, your neck discomfort did not surface until two or three days after the accident. The data about this is pretty clear—if the pain is not immediate, the outcomes are far better. Moreover, the outcomes are far better if you are the bullet vehicle, not the target vehicle. I am guessing you saw the car in front of you right before the moment of impact.”
Again, Mr. J. nodded in reply while avoiding eye contact.
“What about the pain in my chest?” he asked. “It doesn’t hurt if I breathe normally, but if I take a deep breath or arch backward, I really feel it. It feels sharp, like a stabbing pain.”
“I’m guessing the pain is on the left side, correct?” I asked.
“Jeez,” replied Mr. J. with surprise. “How did you know that?”
“Your shoulder strap goes across your chest, but stabilizes the right ribs far more than the left,” I explained. “At the point of impact, your left rib cage went hurling forward, while the right ribs were secured by the shoulder strap.”
At this point, I asked Mr. J. to lie supine on the massage table, and I palpated the left ribs to find the exact spot of pain. This is important for two reasons. While it is important for the therapist to be clear about the precise location, it is also validating for the client to have the therapist place a finger on the exact locus of the pain.
“I don’t know if I can take much pressure on that spot,” Mr. J. admitted. “It’s really tender.”
“I understand,” I assured him. “Let’s just explore how this rib moves when you breathe.”
Watching the movement of his chest, there was a clear difference in the rib excursion of the left side compared to the right. The left side was anteriorly elevated and did not fully recede during exhalation.
Placing my hand underneath his posterior ribs on the left, I was able to palpate the rib at the same level next to the costotransverse junction. It was similarly tender, but not to the same extent as the front. Connecting the two spots, I gently guided the rib during his respiratory cycle, emphasizing a downward (posterior) movement during the exhalation phase. After a few breath cycles, the rib was moving normally. In response, the surrounding tissue was now far less sensitive to touch. I was then able to directly treat his external oblique and intercostal muscles, as they were much more amenable to touch.  
Mr. J. was smiling and shaking his head.
“You OK?” I asked.
“Every time I come here, I’m always astounded at how you know what you know. I can’t understand how you knew where the pain would be, correctly predicted how long it would last, and managed to diffuse the chest pain without having the treatment be painful. It seems like some sort of magic.”
“Not magic, just a deep understanding of anatomy and many hours of studying the literature to learn as much as possible,” I answered.
That is the lesson in this column: there is perhaps no greater predictor of success than the depth of our understanding. We acquire that understanding through years of reflective practice and/or learning from the experiences of others, in both formal (case studies and research) or informal (conversations with colleagues) ways. It is a rich and never-ending journey, one that serves both therapist and client alike.

Douglas Nelson is the founder and principal instructor for Precision Neuromuscular Therapy Seminars, president of the 16-therapist clinic BodyWork Associates in Champaign, Illinois, and president-elect of the Massage Therapy Foundation. His clinic, seminars, and research endeavors explore the science behind this work. Visit www.nmtmidwest.com, or email him at doug@nmtmidwest.com.