Takeaway: Instead of simply admitting “I don’t know why you hurt,” providers too often invalidate the experience of the patient.

It’s generally not ideal when you notice your client’s eyes welling up with tears. “How could I have so grossly underestimated the pressure I was using?” I thought. Just as I was about to inquire about her experience, her expression hardened. 

“I knew it,” she stated with authority. 

“Wait, what?” I thought. She was clearly having a very powerful personal experience, and I didn’t have the foggiest clue what it was about. 

This client, I’ll call her Mrs. M., was referred to me by her physician, where she was also a new patient. During her intake, she described her long odyssey with aching pain in her left lower ribs.

“This started three years ago, and there isn’t an accident or injury     that explains it,” she said. “It started as a mild discomfort that happened occasionally, but then the intensity and frequency slowly started increasing. Over time, it had an increasingly negative effect on my daily life. The pain is generally dull but can spike at random occasions. It’s never completely debilitating, but it never goes away either. I shouldn’t complain too much, but the constancy of this pain just wears me down.”

“Pain can be incredibly draining,” I said. “Is there anything that makes it better or worse?”

“It can be so random,” she replied. “The dull ache is pretty much constant, but activities like vacuuming the carpet are a no-no. Sleeping on my left side isn’t great either. Actually, any activity that gets my heart rate up can trigger an episode of pain.”

I think she saw my eyebrows raise for a second, and then responded. 

“I know what you are thinking, and my doctors were all over the idea that this was a heart issue,” she said. “I’ve had just about every cardiac test you can imagine, and they all came back negative. Next, they thought it was my gall bladder, then possibly the pancreas, and then a long list of other possibilities. The good news is that I have had the full organ recital and my internal organs are doing just fine. The bad news is that I still have the same pain, and no one has been able to figure this out. It’s incredibly frustrating.” 

Now, back to our story. 

“I knew it,” she repeated. “When you press on my ribs at that spot, that’s the pain I’ve been feeling all along.” 

“With the work I am doing, being able to replicate symptoms is helpful to determine that I’m in the right area,” I said. “It’s …”

She interrupted me mid-sentence.

“I don’t think you fully understand,” she said. “After all these tests came up negative, I could tell that the providers I had been seeing were increasingly thinking the problem was in my head, not my ribs. In fact, the last doctor (not the one who sent her to me) gave me a book on psychosomatic pain. Mostly, I was insulted by the insinuation that this pain is in my head. Yet, a small part of me wondered if indeed it might be true, that I am making this up. But when you pressed on that spot just now, that’s my pain. That’s what I’ve been feeling. This pain is real, and I was right all along.”

Yikes. It’s a story I’ve heard too many times. Instead of simply admitting “I don’t know why you hurt,” providers too often invalidate the experience of the patient. “If I can’t see it, you can’t have it” is too often the response to unexplained pain. First and foremost, we practitioners need to affirm that what people experience is real, even if we don’t understand the origins. I tell new clients their seemingly random symptoms are clues to the puzzle and my job is to put these clues into a cohesive model of understanding and then build a treatment strategy in response. If that ultimately is unsuccessful, it’s likely that my model or the response was off the mark, not the puzzle pieces.

As I began to examine muscles that might affect Mrs. M.’s rib mobility, I noticed that three of her left ribs hardly moved during the respiratory cycle. I had Mrs. M. put her hand over these ribs so she could feel the restriction. She felt the lack of movement and found it as fascinating as I did. I had her explore different ways to breathe into these ribs, encouraging movement. As the ribs began to move more fully, the sensitivity of the soft tissue decreased markedly. She was a happy camper when she left the office. 

I have checked in with Mrs. M. multiple times over the ensuing weeks and she continues to have little to no discomfort. When she does, she breathes into her ribs and the pain dissipates. She feels empowered to have something she can do to affect the pain. As important as empowerment is, validation is likely the first step in the process of healing. 

Douglas Nelson is the founder and principal instructor for Precision Neuromuscular Therapy Seminars, president of the 20-therapist clinic BodyWork Associates in Champaign, Illinois, and past president of the Massage Therapy Foundation. His clinic, seminars, and research endeavors explore the science behind this work. Visit pnmt.org or email him at doug@pnmt.org.