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Symptom Cascades

An overview of symptom cascade theory

This article explores the concept of a symptom cascade; where an injury or issue may itself not cause clinically relevant signs or symptoms, but will set up ‘downstream’ issues that eventually lead to pain and dysfunction; often in regions quite distinct from where the original causation occurred.

Let us first start by limiting this discussion to something that a person would reasonably expect to go to a Myotherapist for (i.e. not cancer or a severed hand etc.).

In short, a symptom cascade is a bit like an avalanche in snow country.

Avalanches have very specific triggers which start a snow shelf sliding BUT the circumstances where an unstable accumulation of snow occurs typically have happened well in advance of that final trigger.  This is actually a very good example of how a symptom cascade acts.

A possibly very minor misalignment triggers a limitation in a particular tissue, requiring compensation (think of limping after stubbing a little toe).  In many cases, this restriction is so minor it goes without notice.  As the body compensates for the restriction, more ‘bits’ go ‘out’ in an ever increasing cause and effect cycle.  Eventually, the person bends over to pick up a piece of paper or sneezes at the wrong angle and BANG!.. they are now in pain.

There are two elemental reasons a muscle hurts:

This is probably the most challenging thing for a structural therapist to hear.  Two reasons?!?! Why do Myologists (muscle specialists) study for years then?  I hear this objection often, yet when thought about, it comes back down to these two EVERY time.

Reason 1.  Pathology – trauma.  A muscle is vulnerable to direct injury or a lesion creating dysfunction including systemic problems (MS for example).  Getting hit by a cricket ball, tearing a muscle during exceptional exertion, being injured by a gun shot; these are all traumas.  Illness directly effecting how a muscle functions, even though the muscle itself may remain mostly functional, falls under pathology, but includes muscular tumours etc too.

Reason 2. Compensation – protection.  If a vital tissue is challenged by malplacement or other restriction of whatever cause, the body only has one real goal; protect that tissue & prevent further damage.  Protection is facilitated by the body tightening the muscles in the area to suppress mechanical forces placed into the distressed tissues.  By far the most common, this protection – compensation is the leading cause of muscular pains and misalignments in the body based upon mine, and my colleagues clinical observations over the past twenty + years.

Here is a simple thought,.. if a muscle keeps hurting, time and again, there has to be a reason.  If there is no history of trauma or pathology effecting that muscle, it MUST be compensation triggered pain.  Poor posture requires muscular compensation just as much as the cascades illustrated below.

A clinical symptom cascade in illustration

I will assume a little poetic license not to list every bit of connective tissue in this example but rather, to focus on the logical steps of progression.

A person presents with 3 month history of increasingly restricted right shoulder movement, pain when lifting their arm past horizontal and a ‘dropped’ right shoulder following an impromptu tennis game.

In their history, we might find a skiing accident a couple of years previously where they were ‘winded’ for a couple of hours following a solid fall onto their right buttock and then onto their head and shoulder before sliding to a stop.  Whilst the buttock and head impacts were more significant at the time, their liver was also subjected to some extreme physical forces leading to a restriction in the way it moves during in-breath.

The body will not tolerate a restriction endangering such a vital organ so it tightens up the muscles between the ribs around the liver to reinforce the physical space the liver occupies and reduce the physical requirements placed upon it.  Limitation in the way the muscular diaphragm sucks air into the chest will also be commenced – as the liver is situated against the bottom of this muscular bell.

The cascade continues.  Now the bottom of the rib cage is restricted, movement is limited in the lower chest causing the latissimus dorsi muscle to over-do its movements of the shoulder.  The body responds to this by asking the pectoralis minor to activate a bit more than normal, pulling up on the top of the ribs which are limited to protect the liver already.

Eventually, this mobility restriction of the shoulder is challenged during an irregular tennis game (they watched a tournament on TV and got inspired).  When trying to serve, they felt the restriction in their shoulder for the first time.  After this match, the shoulder just never got better!  Now three months on, they are here for their shoulder which has already had cortisone injected for the pain and manipulations trying to get it moving again.

Getting to the cause

Without addressing the still problematic restriction to the liver’s mobility, the shoulder problem will remain perpetuated, despite localised attempts which will inevitably fall back into disability.

In this case

This is a real person and a real case referred by a doctor after the shoulder remained unresponsive past short term relief.  Once the problem was detected, a long lever technique was applied to release some of the liver’s restriction and an instant improvement was noted in shoulder movement and pain levels.

Applying a bit of science

Here is the key to this thought process.  After ‘playing’ with the liver, we left it alone for two weeks.  The reason was that by addressing only one major variable in this client’s body, we could reasonably expect to be able to attribute any change to the symptoms to that one change.  They were asked to go about their normal life and change as little else as possible.  Had we done heaps to them, and then had a change, we would still be no closer to being able to define WHY the shoulder was dysfunctional.  Why two weeks?  It gives the body time to resolve the myriad compensations required previously to facilitate the liver’s restriction.

In this case four visits addressing only the liver saw a complete and lasting recovery of function in this client’s shoulder as well as much improved breathing and general spinal and chest flexibility.

Everything is connected

Be it by blood, nerve, tendon, ligament or the many other tissues in the body, there is not a single part of the body that is not, in some mechanical and practical way, well attached to everything else in the body.  We are not talking metaphysics here, just good old anatomy!  The fascia that folds to become a falciform ligament from the liver to the belly button continues to form the central (uracus) and median ligaments of the lower abdominal peritoneum, leading to the sacro-genital structures that are key in the functional positioning of the sacrum and lower back function as well as sexual function and fertility.  At the other end, that same falciform ligament of the liver shares tissues with the diaphragmatic passages supported by the various structures of the diaphragmatic crus, the position of the pylorus and duodenum and so on.

We could keep this example going until using just the strong, elastic and contractile visceral fascia and peritoneum until we have joined all of the dots.  We could also do the same with blood vessels, lymph vessels and so on too.

Reductionism’s limitations

The teaching of anatomy in universities must, by the nature of volumes of students, be presented first in reductionism terms, breaking the body into systems and component structures.  What is typically missed is the reconstruction of this structural knowledge into something that approximates a living person, not a cadaver.  This functional training is lacking and whilst certain industry groups influence remains within our teaching institutions, functional applications will remain very much in the realm of post-graduate workshops and controversy.