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Stephen Clark, an Atlanta-area physical therapist, sees many patients who suffer from muscle guarding after a traumatic surgery or injury. Muscle guarding, which emanates from the brain, is a physical response to pain. For some, though, protracted muscle guarding can prolong pain and inhibit recovery.
Clark mentioned helping a female patient recovering from a broken ankle who experienced muscle guarding. "If I went to touch her ankle, she would tense up, even though I hadn't touched her yet," he said. The patient's brain made a decision that even the idea of Clark touching her ankle equaled danger.
In muscle guarding, the brain seeks to protect an injured area by subconsciously directing the surrounding muscles to not function, or to lock, ostensibly to defend the body against additional pain or injury.
"Most patients who are in pain have some level of protective muscle guarding," said John Shipley, a board-certified physical therapist with the Johns Hopkins Musculoskeletal Center in Columbia, Md.
Muscle guarding manifests in many ways, including leg muscles that resist movement during physical therapy for a knee replacement, a shoulder that inexplicably "freezes" after surgery or injury, or low back pain that persists long after doctors conclude an injury is healed. Muscle guarding even plays a role in endometriosis, and pain during pregnancy and postpartum.
"It's absolutely built into us after an injury or major surgery that you need to heal, you need to be careful," said Amanda C. de C. Williams, a professor of clinical, educational and health psychology at the University College London, who has studied muscle guarding for eight years. "But the questions we grapple with is for how long, and how much pain should you encounter as you recover?"
Williams and other experts say that anxiety may play a role in chronic muscle guarding, and treatments that help alleviate anxiety may also help lessen pain.
• How our brain reacts to an injury
"The human brain is fascinating and very complex," Clark said. In assessing a situation involving an injured or recovering area of the body, the brain considers several factors: the body's history with the injury or trauma, what the person is doing at the time, what their emotional state is, and whether the perceived threat is expected to lead to pain, he said.
During that split-second calculation, the brain decides that protection is needed, so it signals the musculoskeletal system to safeguard that part of the body. In this initial - or acute - phase, muscle guarding is beneficial because it protects an area while it's healing.
• When acute muscle guarding becomes chronic
The second - or chronic - phase of muscle guarding often frustrates clinicians and patients. The brain stays in overdrive, impeding recovery and often worsening pain.
"The more we clench our muscles, the more the body becomes locked," said Kate Truitt, a Los Angeles-based applied neuroscientist and clinical psychologist. "Clenching can help relieve the pain short term because it's protecting what's hurting, but in the long term, it can lead to more disability because it's getting in the way of recovery. The brain is firing and wiring new neural pathways."
• Anxiety, not pain, may be the culprit
This protection can lead to a vicious cycle. As the brain becomes even more hyper-aware, rewired neural pathways cause it to infer pain, even when none is present, experts said. The brain learns to be in pain, they said.
Any attempt to move that part of the body can lead to anxiety, which puts muscles on even higher alert. Research conducted by Williams and others has concluded that anxiety, and not pain, can be the main determinant in developing chronic muscle guarding.
"To navigate through the anxiety, the stress, the worry, your brain holds on to a storyline of what has happened," Truitt said. "These patients' systems have learned to be more vigilant, in general."
• Painful muscle guarding in other health conditions
Emerging research shows that muscle guarding also plays a significant role in pain associated with endometriosis. The inflammatory condition, in which the uterine lining grows outside the uterus, often causes chronic pain and other serious complications such as infertility.
"Inflammation that comes with endometriosis can be so, so painful, and the immediate response to any kind of pain in your pelvic floor is to guard," said Emily Knell Spaeth, a Portland, Ore.-based physical therapist and certified neonatal therapist who works with patients to overcome muscle guarding in their pelvic floor. "Those muscles are designed to zip up and protect us in times of stress. What happens is they turn on, but don't turn off."
Muscle guarding also can affect pregnant and postpartum people. "When you're pregnant and after you've had your baby, not only is the shape of your body changing, but your center of gravity is shifting," Knell Spaeth said. "Your body is changing so fast, and muscle guarding is common. You can end up creating this tension and tightness because you want to protect yourself and create balance."
• Muscle guarding is not well known or understood
Although patients often struggle with muscle guarding, physicians, particularly surgeons, aren't quick to broach the topic, some experts said. "When I mention muscle guarding to clinical practitioners, there's a little bit of a glimmer of recognition: ‘Oh, I remember learning about that, in class, for maybe 15 minutes,'" Truitt, the neuroscientist, said.
Nick DiNubile, a Philadelphia-area orthopedic surgeon and chief medical adviser of the American Council on Exercise, acknowledged that not taking a proactive approach to rehabilitation is common in surgical medicine. "A lot of doctors take the position: Scar looks good, stitches are out, everything's okay," DiNubile said. "They abdicate the role of ensuring that strength and conditioning are restored."
Williams, the University College London professor said, "Doctors don't always think about what subconscious messages the patient's brain is sending to the body. Muscle guarding isn't under conscious control."
• How to cope with muscle guarding
If you experience stagnated recovery or persistent, unexplained pain, ask your physician about muscle guarding or seek out clinicians well-versed in the phenomenon, experts said.
Treatment may involve a variety of therapies and approaches, including progressive muscle contraction and relaxation exercises, biofeedback, mindfulness and meditation, manual physical therapy and massage, laser therapy, electrical stimulation such as H-Wave therapy, aqua therapy, and getting educated about what's happening and how muscles and the brain interact, which can help the brain and nervous system rewire to the proper state.
For example, Clark, the Atlanta-area physical therapist, said that when he was able to educate his patient with the broken ankle about muscle guarding, her executive function - the cognitive processes and mental skills that allow a person to plan, monitor and achieve goals - took over, and she no longer had a guarded response to the mere possibility of him touching her ankle.
"The brain is in charge, so if we can convince it that we're safe and that we're settled, grounded, and in the present moment, that's the foundation of overcoming muscle guarding," Knell Spaeth said.
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