Today we are happy to have a contribution by Mari Gish PT, Founder of Tokyo Physical Therapy, Minato City, Tokyo. She kicks off a two part series exploring management of chronic pain, from both the physiological and psychological perspectives. 

Thank you Mari Gish for your contribution and insight!

Chronic pain is defined as pain that has persisted for more than several months. In my physical therapy practice, I often encounter many patients who fit this category, and in fact, many have suffered much longer, even years. Most commonly these relate to shoulder pain, neck pain, headaches, radiating pain (into limbs or chest, for example), joint pain, pelvic pain, genital pain, foot pain, jaw and other facial pain, or any combination of the above.

When dealing with pain for lengthy periods, there is bound to be significant psychological and emotional stress, which in turn magnifies the pain response.

A traditional treatment approach for treating chronic pain in physical therapy has been to utilize stretching, strengthening, various manual therapy skills and modalities to restore pain-free movement and function.  It is important in this process to take a holistic approach, considering the whole body and their history to determine the root cause of their pain.  Someone’s neck pain might be related to an ankle sprain they had several years ago, which started a cascade of altered body mechanics, ultimately leading to changes in their posture, muscle length and strength imbalances.  Then one day there is an unpleasant event at work or home, and suddenly they wake up with excruciating neck pain and cannot turn their head.

Take another example of someone I saw who started having neck pain 2 years ago.   This progressed to numbness and tingling down his arm and he later started to wake up with both hands very weak.  He started to worry that he was becoming paralyzed (or another common fear for many is cancer), and started to have panic attacks.  He was diagnosed with mild bulging discs in the neck and prescribed muscle relaxants.

However, his symptoms continued and soon there was pain radiating into his chest and jaw which increased his anxiety.  He was prescribed sleeping and anxiety meds.

Because of his symptoms, it becomes extremely difficult to tolerate work which involves sitting at a computer all day.   Another 4-5 months later he started to have lower abdominal discomfort, urinary urgency, and genital pain.  He could not tolerate wearing anything tight around his waist and had to wear very loose sweat pants to work.  He was given multiple blood tests, urine tests, abdominal X-Ray and CT scans, and everything came back negative.  He was prescribed antibiotics and later prostatitis meds.  Now he has to wear his pants so loose, they fall down whenever he stands up! Then to make matters worse, one morning he wakes up and has pain in the arches of his foot.  One can imagine the emotional strain caused by this progression of events. He sees another orthopedic doctor and diagnosed with plantar fasciitis and is recommended to physical therapy….   So where do we start?

Over the years, I have found 2 treatment strategies particularly helpful for these types of systemic pain.  One is called PRRT (primal reflex release technique).  This technique influences the sympathetic nervous system (SNS), which is commonly known as the “fight or flight” mechanism of our autonomic (involuntary) nervous system.   With pain, anxiety and stress, the SNS can get too excited and also get stuck in this state.  There are telltale signs that can be checked from head to toe in a few minutes which can indicate that the SNS is up-regulated.  If so, the treatment to relax the SNS utilizes primal reflexes that are involuntary responses to quick stretches or tapping, much like when a doctor taps below your knee with a reflex hammer.  In fact, for some areas I actually use a reflex hammer to tap on tendons.   The effect is involuntary, quick and pain-free.  This can lead to a relaxation of muscle guarding and spasms, increased circulation and a significant increase in freedom of movement.

The second strategy is the Trager Approach, which is a psycho-physical method named after the late Dr. Milton Trager who pioneered this new form of therapeutic treatment. It utilizes a variety of techniques to relieve the body of trapped movement patterns and pain.

Current medical research into chronic pain, such as Lorimer Moseley and David Butler’s work on “Central Sensitization”, is showing that once someone has been in pain, anxiety and fear long enough, then real physiological changes often occur in the body.  The brain starts to interpret non-threatening stimuli as an acute danger, causing exaggerated feelings of pain in the body.  These pain disorders can drive psychological symptoms such as depression and anxiety.  This becomes a vicious loop.

The Trager Approach works by introducing pleasurable and pain-free movements which are passively administered by the therapist. The approach also includes active movements combined with an emphasis on mental awareness. This helps to replace the negative and painful habits and movement patterns one has acquired.  The ideal outcome is that the threat of painful stimuli is reduced, and patients learn to release the need to control, guard and tense against pain. Once the neural drivers are calmed down with these 2 techniques, I am often able to continue the rest of the physical therapy treatment much more effectively.

Many who suffer under conditions of pain and anxiety can begin to lose hope that their problem is a fixable one. They believe that the root of their pain stems from a particular area whilst simultaneously experiencing no improvement, or experience fear that it’s all a concoction of the mind.  I am here to tell you that, in my experience, solutions to chronic pain are often readily available and may be realized through a holistic and team approach. Once a better understanding of the condition is achieved and the necessary tools for improvement are applied, there is hope to end the vicious cycle and start the road to recovery.

  For any questions, feel free to contact Mari Gish, PT

Physical Therapist

Certified Trager Practitioner

[email protected]


  1. “TEDxTalks-Lorimer Moseley-Why Things Hurt”
  2. “Home.” Primal Reflex Release Technique,
  3. “United States Trager Association.” United States Trager Association,
  4. Tragerjapan,
Check back into the blog shortly for the part 2, written by TMH’s own Ryota Sakurai, MA.