Neurocentrism: A Unified Field Theory?

 If all you have is a hammer, everything looks like a nail.

There are many modalities in the field of manual therapy. All of them sometimes work yet many of their explanations contradict each other. 

A massage therapist is trained to treat trigger points. When a client comes to them seeking relief for a pain problem, the therapist will look for trigger points, will inevitably find them, and attempt to resolve them. The client often feels some relief after the treatment. Both client and therapist conclude that the pain was a result of trigger points and that the trigger points have been resolved, at least temporarily.

Another therapist is trained in myofascial release. A client comes seeking relief from pain. The therapist will look for and inevitably find fascial restrictions. The client may feel better at the end of the session, may even find long-lasting relief. Both assume that the pain was the result of fascial restrictions that have now been properly treated and resolved.

A person with pain walks into a chiropractor's office. The chiropractor takes X-rays and finds subluxations and adjusts the patient. After a few treatments, the person feels less pain. Both the person and the chiropractor assume that the pain was the result of subluxations that have now been corrected.

Another person with pain visits an acupuncturist. The acupuncturist determines that their chi is blocked and inserts needles in certain places in order to restore its proper function. After a few treatments, the person feels less pain. The acupuncturist and the person assume that the cause of the pain must have been blocked chi which has now been restored to proper function.

What is wrong with this picture?

Is it a coincidence that every person who walks into our office just happens to have the very pathology that we have been trained to treat? What happens to the person with trigger points who visits the therapist who treats fascial restrictions? Will they get better? How would that happen if the therapist is not treating the trigger points? 

What happens to the person who has subluxations who visits the acupuncturist? Does acupuncture correct subluxations? How does that happen? If a person with subluxations never sees a chiropractor, does that mean they will never get out of pain? 

What of all the people whose pain comes and goes? Did their trigger points/fascial restrictions/subluxations/blocked chi resolve itself and then come back? What of people who have pain for awhile and then, without treatment, it goes away and never returns? Did their body magically correct the supposed pathology? And if it's capable of that, did they need therapy in the first place?

Is there a common denominator?

It seems unlikely that only those who have the pathology that we are trained to treat come to see us. All modalities seem to have some effect with some people and no modality works for everyone. Many modalities completely contradict other modalities which are often just as effective with some populations. Some people get better without any treatment at all. How can we explain this?

Modern pain science is changing the way we think about pain. Melzack and Wall, authors of the Gate Theory of pain, later developed the Neuromatrix Theory of pain to fill the gaps that Gate Theory left unexplained. Current pain science looks at pain as an output of the brain, rather than input from tissues. Pain is seen as an experience created by the brain in response to perceived threat rather than a direct result of tissue damage. Melzack and Wall propose that pain is not purely a result of tissue damage but has physical, psychological, and social factors involved. 

Taking what we know about current pain science, how can we find a common denominator among the disparate modalities used to treat pain? I would like to suggest that the nervous system is the common denominator.

Neurocentrism as a unified field theory.

When the various modalities in manual therapy are seen as separate entities with different and competing explanations, it is hard to explain why they may all work to varying degrees, how it is that any person who visits a manual therapist happens to have the very pathology that person is trained to treat, and how it is that people often respond to whatever treatment they are given. However, when manual therapy is examined in the light of current pain science, it makes perfect sense.

The various modalities of manual therapy share certain common characteristics. First of all, the fact that they are a manual therapy means that the therapist will be handling the client's body. This direct contact with the body has an influence on the nervous system and  if it is done in a manner that makes the brain feel safe, rather than threatened, that alone may allow the body to relax and begin to turn down the volume on pain. If the therapist is confident and interacts with the clientin a manner that puts them at ease, that can have a positive effect. If the therapist has an explanation that appears to make sense and holds out a possibility for correction, that sets up hope for the client and enhances the possibility for a positive outcome.

If the modality involves gentle handling of the body, this novel input into the nervous system can get the brain's attention and focus it on something outside of the persistent pain. If the brain likes the handling, it may then relax and restore a state of normalcy. Some types of handling may relieve mechanical pressure on nerves, interrupting the impulses that have been signaling the brain that something potentially dangerous is happening. 

All manual therapies create some sort of novel input to the nervous system. Whether one believes they are treating trigger points, fascia, chi, or subluxations, one is touching the body in a different way, stimulating the nervous system, and the nervous system is responding both locally and centrally. All manual therapy relies on a response from the nervous system in order to work. 

Does this mean we need to abandon our modalities? I think not. I think it means we need to think a little differently about them. If our particular approach to handling the body works well for us and our clients, there is no reason to stop handling them in that manner. However, if we start thinking about the role of the nervous system in how we handle the body, it might begin to modify what we do with our hands. If we have been employing approaches that cause pain, we would certainly want to modify our approach as to not cause pain. As we understand better how the brain is in control of the experience of pain or tension or ease, it may expand our thinking and open us to new possibilities. However, most existing manual therapies can continue to be used with an understanding that it is the brain making the changes, not our hands effecting a structural change on joints or tissues. 

Recognizing the role of the brain and the nervous system in manual therapy enhances and deepens our understanding as a therapist and can increase our effectiveness with clients, no matter what modality we use, no matter what the goal of the treatment session. It takes us to a new level, takes us the to the next step.

The brain is the master controller of the body. It appears to be able to respond to many different types of input. If we understand that, it may not matter a lot which modality we choose but, rather, the way in which we use it. 





The best PT manual therapists learn from many masters. Their theories often conflict but hands on is about skill. Each of us must create gestalt with each PT session.

thank you for writing this! I work in an integrative health clinic with acupuncturists, chiropractors, and massage therapists. Some of my coworkers and I often talk about about our frustrations that our treatments seem to contradict each other, but our patients still seem to get better. I have over the past 2 years changed my outlook and my view on my role as a massage therapist to be oriented towards nervous system/psychological response, or pure structural/mechanical work. The longer I work in this environment, the more I realize that what we say we are doing is actually quite false. i know.... what I am saying is absolute blasphemy! but I truely believe that something about what we are doing is real.... and our explanations is totally false.

 Alex, I think you've stumbled upon an important but often overlooked point: that seemingly contradictory approaches appear to "work." If that is the case, how can we explain it? I think it suggests that there is an underlying common factor. 

You can be blasphemous here! I'm with you on that one. 

It's hard to have our cherished beliefs challenged, but I belief that for our personal and professional integrity, we need to be more committed to the truth than to our hypotheses. Our hypotheses are an *attempt* to explain what we observe, but it is not the thing itself. 

There is a saying that in science we can never be completely right, but over time we can hope to be less wrong. I think that neurocentrism is a step in the "less wrong" direction. Time will tell. Meet me back here in 10 years and let's see what we've learned by then! ;-)

A colleague of mine shared your article on "stretching" fascia. I was happy to see the inclusion of a neurobiological theory. Then I found this article and was even happier.

I was surprised how closely this jives with my own theory on why or how manual therapy works. As a traditionally trained massage therapist I was taught many theories that lacked scientific support. There was a big emphasis on anatomy, but physiology was often lacking.

It was when I began studying to become certified as a personal trainer that scientific study became much more important. There's a higher demand for scientific literacy in the fitness field. And there's a greater emphasis on physiology.

I felt that the main goal of almost all manual therapy was to reduce tone (tightness) in muscular tissue. I looked into it and sure enough muscle tone is controlled neurologically. It was a short jump to realize that the only way to reduce muscle tone was by somehow stimulating the nervous system to reduce tone.

The big questions for me now are 1. What is more important, stimulating nerve reflexes locally or more general stimulation of the (mostly parasympathetic) nervous system? 2. What are the most effective ways to cause this stimulation?

Ryan, I'm not sure you can separate local and central responses. My Russian Massage teacher Zhenya was the first person to introduce me to the idea that the CNS is controlling everything, and she would say that when we touch people, there are three responses: an emotional response, a local response, and a general response. The general response may be so subtle that we don't notice it, but at every moment our brain is receiving impulses from a million different sources, processing that, and creating a response to them. In turn, that creates more input, more processing, and more output. This is the core of the Neuromatrix Theory of pain as I understand it. 

Ryan, if you have not checked out the SomaSimple forums, I'd like to suggest it. It is mostly physical therapists but there are other manual therapists, yoga instructors, personal trainers, coaches. The common factor is an interest in understanding pain science and applying it to practice. It is very focused on understanding the nervous system. 

I felt lost, overwhelmed, and intimidated when I first wandered into Soma but I appreciated the high level of discussion and the sincere efforts at trying to understand how the body actually works, rather than our fantasies about how it works. 

In an effort to make it a little easier for my fellow massage therapists, I wrote a Massage Therapist's Guide to SomaSimple. 

As for what are the most effective ways to soothe the nervous system? I think there are many approaches and that as long as they are gentle and respect the client, it may be less about the specific technique and more about the therapist understanding how the body works and making use of that understanding. These days, I tend to blend the skin stretching I learned from DNM (Dermoneuromodulation) with Russian Massage. I draw a bit from what I learned in a Feldenkrais class many years ago. But our techniques are tools. A skilled therapist will choose an appropriate tool and use it well. A less skilled therapist might use the same tools but may not apply them as well. The nervous system is interactive. Humans are not machines where we can turn a dial and get a predictable outcome. There are many complex factors - biological, psychological, and social - and they all need to be taken into consideration. It's a bit daunting when you think about it very much and yet a good therapist is already doing that. 

It's a fascinating, whole new world to explore!

Thanks for your thoughtful comments. I'm glad you found us!


Submitted byGuest (not verified)on Mon, 07/28/2014 - 11:32pm

Hi Alice -

A little late on the conversation here but very glad I stumbled onto this piece about how we perceive pain and from where that perceived pain is produced.

It's mind blowing stuff and I feel a little like a pinball machine in "tilt" mode. But I will right myself as I read and reread and chew on what's been said here and also in Lorimer Moseley's lectures.

Thank you again.
Stacey Brown, CMT