Defense or Defect?

One of the most important questions a therapist can ask of every area of perceived tissue restriction is this: Defense or Defect? Is the distortion I see or the tension I feel the real problem, or is it in response to a problem elsewhere? As an example, let me share the following story.


One of my friends is in a yoga therapy training program. One of the people taking that training had very unlevel shoulders, with one shoulder much higher than the other. As a class project, they decided to take her postural distortion and create a treatment strategy designed to level her shoulders. This person had no real shoulder pain, but did have some rather annoying neck pain. The neck pain was thought to be a response to her shoulder height discrepancy. Numerous strategies were employed to lower her elevated shoulder through stretching. In addition, stretches were designed to lengthen the depressors of her lower shoulder. Sounds good, right?

Unfortunately, instead of improving, the young woman’s condition slowly worsened. The shoulder height changed a little bit, but not much. Because progress was slow and she was the class project, she increased the frequency and intensity of her stretches. The annoying neck pain escalated to far more than annoying, now it was serious. She also had bouts of searing pain down her arm. Everyone was perplexed and frustrated.

As it turns out, this young woman had a rather serious cervical disc issue that was the underlying cause. This is the important point- her shoulder height discrepancy was in response to her disc problem. The shoulder discrepancy was defense, not defect. Carrying her shoulders unevenly unloaded the disc, which is a good thing when the disc and nerve root is inflamed. Leveling her shoulders without addressing the discal inflammation turned out to be a disastrous strategy.

When we therapists see or feel tissue tension, we must move beyond the “what” question to the “why” question. Is the tissue tension we feel the real problem, or is it protective for something else? What is the greater context? It isn’t just “what” we feel, we must ask “why”.

This contextual viewpoint can conflict with treatment philosophies that regard restoring symmetrical structural symmetry as the answer to all musculoskeletal pain. Experienced clinicians will often see people with noticeable asymmetries than have no symptoms and are relatively pain-free. Other people have lots of pain and a quite symmetrical structure. At the same time, other clients have been enormously helped by restoring their structure to a more symmetrical presentation. How can this be? This is obviously much more complicated than originally thought. We must be careful about adopting rigid treatment philosophies. Like good investigators, we must listen and learn, being careful about our underlying assumptions that can cloud our judgment.

What clues can we use to decipher if the distortion is defense, not defect? Here are three steps that might be useful. First, we must listen to the whole story as relayed by the client and not be quick to assign meaning.  In the aforementioned case, this woman described having rather constant annoying neck pain. The assumption from the therapist was that the shoulder height discrepancy was the cause of the neck pain. The reality, however, was the other way around.  Second, assess the response speed. If the tissue is not responding as quickly as you would expect, consider that there might be some stimulus that keeps it from quieting down under your fingers. Third, assess tissue reactivity dynamically. If you palpate the tissue while gently lengthening it, you should feel tissue slowly lengthening in direct relationship to the movement. If you sense an over-reactivity, it is likely that this is protective for some underlying injury.

In the end, like so much in life, symptoms can be bi-directional. Form can determine function, yet function can also determine form. Our job as a therapist is to listen with care and wisdom, gently interacting with the system to uncover which direction will be the most efficient and effective way to restore balance and health.

Douglas Nelson