We’ve all heard the phrase “It’ll get worse before it gets better.” Many times we apply the phrase to difficult life situations, but it can also be especially applicable to the healing process. Medically, the period of “worse” is known as the Jarisch–Herxheimer Reaction and is also referred to as a Healing Crisis colloquially. This is a time in the body’s healing where a client may experience an exacerbation of their symptoms as toxins (dying bacteria in the case of disease and most likely excess metabolic waste in the case of massage) are released from the tissues faster than the body can eliminate them. These symptoms usually last for only a 2 to 4 days, but can sometimes persist for several weeks ranging in severity from mild to high and occurring right after the client feels his or her best. Unfortunately, many of us think that the increase of symptoms means that the treatment we have chosen is ineffective or even worsening our complaint. This belief often leads clients to discontinue the protocol. Stopping a course of treatment which sets off a healing crisis, however, is actually a disservice to yourself as this is a sign your body is actually healing rapidly. In fact, Adolf Jarisch and Karl Herxheimer – the doctors for whom JHR is named – observed that those who had the most severe reactions recovered from their illness the fastest.
For clients seeking massage for medical benefit it can be disconcerting that a gentle, relaxing therapy can cause a flare of distressing symptoms. Because your goal is to relieve your pain, it can be scary and counter-intuitive to continue a course of action that appears to inflate your condition. But it is important to ride out the crisis phase to complete your healing. To illustrate this, I offer examples of two clients who came to me to resolve chronic low back pain. To respect their privacy and health information, I will not use either of their names.
Example A
I began working with our first example client in May of 2017. This person presented with lower back pain which interrupted his sleep and prevented him from working. He felt that most of the pain stemmed from his left hip which radiated (in his words) “nerve pain” around the entire thigh and into the low back. This client suffered a meniscus tear to his left knee in previous years which correlated with the onset of his symptoms. For months he saw a physical therapist and a chiropractor, both with limited results. He was extremely diligent about self-care, maintaining a daily routine of the exercises he learned in physical therapy.
During the course of our treatment plan he continued to see the chiropractor and reached out to the physical therapist for glute strengthening exercises on my recommendation. The treatment plan on which we agreed was a weekly 90 minute session for 4 weeks working exclusively on his back, hips, abdomen, and thighs with some attention to the knees. After this period we would evaluate our progress and adjust strategy if necessary. We measured his pain levels on a 1 to 10 scale in which 10 is the worst pain he could feel.
Immediately after our initial session, he told me his pain was still about a 3 which was the same as before we began the session. However, when I called to check in 2 days later, he reported experiencing either no pain or pain he rated a 3 or less which was highly unusual as his pain flared consistently to a 7 or 8. Our second session was an even bigger success as he saw 4 days of little to no pain after treatment! The area over which this client felt pain became less generalized as well over the two week time period; the sensation traveling down his inner thigh and up his outer thigh decreased and the low back pain condensed toward his sacrum. His chiropractor also noticed a difference in the ease of which adjustments were made and an increase in the length of time those adjustments held.
The third session, however, did not go as well as the trend would have suggested. The client got off the table with slightly more pain (4) than at the start of the session (a 3). He informed me the pain was centered on his sacrum which felt out of place. I chose to work with him for an extra five minutes during which we were able to realign his sacroiliac joints (the place where the sacral bone meets the ilium aka hip bone) and completely relieve the pain much to his delight and astonishment.
About three days later I received a call from this client. He wanted to cancel his appointment. When I inquired why since we were making such great progress, he informed me that about 4 hours after our session the pain in his sacrum returned. He had been experiencing a higher level of pain - he did not quantify it for me - ever since. This had entered a healing crisis. Unfortunately, he saw this increase in symptoms as a sign of failure instead of progress. While I have not seen him again, we left off with him seeking what he termed “more aggressive” forms of therapy through his insurance company which I assume included more physical therapy and possibly surgery.
Example B
Our second example client began working with me in June, 2017 after 8 months of increasing discomfort which prevented her from playing soccer with her children, exercising, and driving her car for extended periods. She complained of pain across the top of her sacrum and hip bones that occasionally spread down into her hips and glutes. She also noted a taut, pulling sensation across the back of her shoulders and into her neck as a side concern. As her symptoms began after a car accident, she had seen doctors to rule out any serious medical concerns. Finding nothing, they advised rest and time for the pain to dissipate.
We agreed to work together twice a week for two weeks and then reassess. Due to scheduling conflicts, we were actually able to see each other three times in those first 2 weeks after which I recommended we meet twice more over the next two weeks. So overall she came in for 5 sessions over 4 weeks. All treatments were 60 minute in length. These focused solely on her abdomen, hips, low back, and thighs. The first two treatments also included work on her shoulders and neck. Her pain was measured using the same 1 to 10 scale as the first client.
On average, this client reported a pain level that lingered around a 6 in her low back. After her first session, she was pleased to note an overall sense of balance as well as about a fifty percent decrease in pain and a difference in feeling when walking. When she returned for her second massage she told me she continued to feel great for about 4 days. The following week, she happily announced that she was able to play soccer with her kids and that she was able to perform a slightly more vigorous exercise routine under the supervision of her personal trainer.
Upon returning for the fourth session, however, she was a little concerned. In both of the previous sessions, she returned with pain registering at a 2, maybe 3. This session the pain was back at a 5. The reprieve she had been enjoying from the discomfort was also cut from 3 to 5 days in the previous weeks down to 2 days after the third session The client also had to cut short her workouts to keep her flaring back and hip from worsening. As you can guess, she had struck her healing crisis. We agreed the benefit she received from the previous sessions warranted at least completing the current session. When the session concluded, she got off the table with no pain at all. At this point the client’s muscles felt as though they were resetting themselves efficiently, but I asked her return one final time to make sure those changes held. She returned for her final session reporting no pain and having regained the quality of life she had been missing since the car accident. She has not needed to return for back or hip pain since.
The Take-Away
It is impossible for me to say what would have happened with 100% certainty if the first client we discussed stuck with our massage protocol. I also have not heard back from him regarding his current condition or the other treatment options he chose to pursue. However, the massive progress he made combined with the results the second client experienced with my massage suggest that his quality of life could have skyrocketed and his pain significantly decreased if not entirely disappeared had we worked together for just another two or three massage sessions.
The point I would like to make here is that it is easy to be discouraged by setbacks, especially in the case of a chronic pain condition. This is normal and you have a complete right to feel upset by the return of symptoms. But if you are undergoing a plan from which you benefited, stay the course through the storm. Remember that this is probably the “worse” before the “better” and once the crisis passes, healing is on the other side.