Now understanding what pain is and how it protects us is useful, but now I would like to use this information to give some practical tips to reduce pain.
In Part 1 of this blog series we learnt that we need pain to survive, to avoid danger and protect us from injury. However in Part 2 we learnt that the protective response from an injury, such as muscle tightness and weakness can persist long after our tissue has healed. This can lead to pain being present for much longer than needed.
So if your pain has persisted for longer than the usual tissue healing time (around 3-6 months), then it might be useful to read below:
Tips to reduce pain:
Find movements that you feel comfortable with and progress slowly.
We know that pain is the result of our brain feeling as though we’ve pushed our tissue tolerance above a certain threshold (Butler & Moseley, 2013). So it’s firstly important to know where that threshold is at and gradually challenge this over time. For example, if your back gets sore after 10 minutes of continuous walking, start with less. Then you gradually build this up minute by minute until you get to an amount you’re happy with.
Now please understand, you will experience flare ups from time to time. However, it’s important not to worry about this. Unless there has been another injury/trauma (you will generally feel this at the time), these flare ups in pain are just a way of your brain telling you that you need to pull it back a bit. Go back to what was previously comfortable and then progress slowly once more.
Train your brain before you train your body
At times movement may be too much. You may know what types of movement give you pain. Quite often these movements are very similar to the movement that may have created your injury in the first place. So why not start with imagining the movement?
Motor skills studies show that just by imagining movements you can improve them. One in particular showed that basketballers who imagined free throws improved just as much as those that physically performed the task (Richardson, 1967).
Now when it comes to pain it’s important to imagine the movement pain free and in a relaxed state. Sometimes just thinking about an aggravating movement can make you feel anxious. It may bring up emotions that you need to recognise to move on. In this case you may need to relax yourself once more before you return to imagining the movement.
Distraction can be a great way to reduce pain
Our levels of pain are amplified in the brain when we focus on them. It makes sense that when we add other stimuli it gives your brain more to process therefore it decreases the pain stimuli (Schreiber et al, 2014).
Distraction is a great way to do this. Some things to consider while you exercise are listening to music, changing your visual input (closing your eyes or using mirrors), performing cognitive tasks (like crosswords/sudoku), adding balance (standing on one leg or moving on an unstable surface), and changing your environment (try outdoors, indoors or in water).
Find an aerobic exercise that suits you and perform it regularly
Now I understand that sometimes when you’re in pain it’s hard to find an aerobic form of exercise that is tolerable. However, research shows that if you can tolerate it (even if it produces a 6/10 pain level), doing it regularly will reduce your pain. This is because aerobic exercise has been shown to reduce your central immune response via the glial cells (Cobianchi, et al, 2017). People with chronic pain can quite often have a hypersensitive central immune system. When this system is always on it creates an inflammatory response, even when it’s not needed. So when you exercise is down regulates this response, leading to less inflammation and in turn reduces pain.
Choose fun, enjoyable activities with people you love!
Finally, one of my favourite pieces of advice is to find activities and movements you love! Not only will this help you reduce pain, we know that people who have hobbies and activities they enjoy typically live longer (and happier) than those who don’t (Fushiki et al, 2012).
In our brainstem we have certain areas that pick up pleasure and displeasure. Interestingly the area of displeasure is closely associated with areas of the brain that detect and produce pain. The pleasure centre does not have this relationship but is closely related to movement and attraction. So let’s use this to our advantage and find activities you actually want to do. It may even help you stay motivated to doing things that aren’t as pleasurable (such as the homework exercises your exercise physiologist gives you), so long as you can relate it to the activity you love (for me this activity is trail running!).
So there you go. Hopefully I’ve given you some practical ideas to reduce your pain and help you get back to doing the things you love doing. Obviously if you need any help with any of the tips above, we are alway here to help you with your journey free of pain.
Cobianchi, S., Arbat-Plana, A., López-Álvarez, V. M., & Navarro, X. (2017). Neuroprotective Effects of Exercise Treatments After Injury: The Dual Role of Neurotrophic Factors. Current Neuropharmacology, 15(4), 495–518. http://doi.org/10.2174/1570159X14666160330105132
Fushiki, Y., Ohnishi, H., Sakauchi, F., Oura, A., & Mori, M. (2012). Relationship of Hobby Activities With Mortality and Frailty Among Community-Dwelling Elderly Adults: Results of a Follow-up Study in Japan. Journal of Epidemiology, 22(4), 340–347. http://doi.org/10.2188/jea.JE20110057
Following on from the great work from my colleague Dr. Nathan Harten’s last blog; I will continue educating you on the latest neuroscience on persistent pain.
You may have been allluded to our brains wonderful capacity to protect to a ‘perceived’ threat.
Perceived you say?
Lets delve into this further…
There needs to be credible evidence of danger over safety for a pain experience (1).
Let’s pause and reflect on that for a moment…
Danger or safety in pain circumstances
It is advantageous to have fast acting danger messages to make us pull our hand away from a hot pan right? Danger over safety is highly relevant here. What about an ankle that had been sprained ten months ago? That ankle is still hurting to load, difficult to localize the pain, and you have exhausted Google & the pharmacist for an answer. Not advantageous at all is it?
Pain is not a true marker of tissue damage…
Let’s pause and reflect again on this statement…
Pain is an output constructed by the brain (1), by many contextuals. Contextuals ranging from:
Is this pain going to interrupt my job?
Is this what an ankle sprain feels like?
Can I still play in the football grand final?
How long am I going to be out for?
Should I just rest?
All of these constructs add to a pain experience (3); storing memories, emotions and motor patterns in a highly organised network, AKA your central nervous system. Even your immune cells (microglia) and endocrine system (HPA axis) are activated! (3) plus more!
Persistent pain is more than just where it hurts
So you see pain isn’t all just about where it hurts. Especially persistent, chronic pain (1). Somehow, your brain is still warning you. It still wants to protect you from a perceived threat and make you hurt.
This may sound like a rhetorical question, but is this protection advantageous at all?
Please take the time to reflect on your own experiences of pain…
Maybe the threat of losing your job is adding to a pain experience?
What if you are a professional athlete, trying to protect your pain from the coaching staff, perhaps because your contract is up at the end of the year?
Are you still blaming the driver who hit the back of your car?
All of the highlighted words are ‘threats’, and thus the brain will scrutinise all of the aforementioned and will decide whether it’s important or not to let you know; and to make you hurt.
Becoming aware of perceived threats and dangers are so important to understanding your pain (1, 3).
I hope now you think of pain as a biopsychosocial paradigm (Bio meaning the biological tissues, psycho meaning thoughts, feelings and beliefs; social meaning the environment) and not just about the tissue that hurts (2).
So I challenge you to challenge your beliefs on pain. This may be a line in the sand that you are willing to make.
Address what threats are in your life (work, financial). Learn how your stress system works. All of this is great at assisting you in the short term, but it can get a bit much if it’s 24/7 (think of having to listen to your car alarm all day!). However this is a topic for another day and another blog!
Feel free to seek help from someone else! Know that you are safe to move when you are experiencing chronic pain (even better with an exercise physiologist!).
Finally, know that we are neuroplastic and bioplastic… meaning that you can heal!
Now in part one of this blog we learnt that pain is a vital part of our survival but sometimes it can persist for longer than we need. So now I’d like to share with you some of the longer term changes that can occur as discovered by pain scientists (Hodges & Tucker, 2011). These adaptations give us a road-map on how to use exercise and movement to free ourselves from pain.
Pain leads to changes in the way we move
Think of a time when you may have hurt yourself and you were in pain. A very common occurrence is twisting your ankle. Sometimes this doesn’t create much tissue damage but it can have a very significant pain response. What you’ll notice is that you’ll limp, maybe just for a little while, as the pain changes the way we move so that we don’t load the affected area too much.
Our muscles around the area will “splint” to stiffen the area up and we’ll subconsciously take load off of the affected side. Now as I stated in part 1 of this blog, this is really useful during the first few months of tissue healing. But long term this can have other consequences. Some common examples are that if we were to injure a joint (let’s stay with the ankle). It can increase the load in joints further up the chain (such as the knee or hip). Alternately, let’s say that we injured our right ankle, if we don’t correct the way we are limping, we’ll place more weight through our left side making it work harder. This could then make the left leg more predisposed to injury.
Now many of these changes in how we move are subconscious. A lot of people don’t realise they are limping long after their initial injury. So sometimes we need to retrain our body to move freely and more evenly again. This is where specific corrective exercise can be useful.
Pain changes the way our muscles fire!
Not only does pain change the way we move, in doing so it also changes the way our muscles fire.
Some muscles will become facilitated
That is, they increase their tone to help protect and splint a particular area. Again while this might be useful for the first few months, these muscles tend to get tight and overworked in the long term.
They also become over-sensitised to pain to the point where even a gentle stretch, well below the threshold that would create tissue damage, creates a pain response. This is where it is important to get these muscles moving freely again, even if it is a little uncomfortable at first. In doing so we are retraining our protective response. Over time our brain no longer deems the use of these muscles as threatening and our pain will gradually decrease.
Some muscles will become inhibited
Now interestingly, while some muscles increase in tone others will “go to sleep”. These are quite often called inhibitions and the long term consequence of these muscles not firing properly can place undue stress on other tissues.
I don’t know whether anyone really knows why this occurs. Perhaps it is part of our short term protective response to prevent us from using a particular area and allow for healing. However we do know that in the brain the areas that fire a particular area become “smudged”. That is when we try to fire a particular muscle we might get a whole group of muscles firing (quite often the protective facilitated ones).
What we find is that we need to “wake up” these inhibited muscles which are quite often muscles that are important for the long term use of our past injured joints. And it is not until these muscles are firing properly again that our pain will subside.
Everyone’s protective pain response is individual
Finally, and most importantly, what we know is that our response to an injury and pain is unique and individual. How we move after an injury depends on what we were doing to cause the injury. How we splint and what muscles tighten up is very individual. And what muscles go to sleep and lose their capacity to fire can be different as well.
Interestingly, all of these people though may have the exact pain in the same location. So it is important that we don’t just focus on the area of pain. In fact, sometimes this can just feed our pain response as it make this area even more sensitive. We need to assess the way you move to see if you are still protecting an area long after it has fully healed. And we also need to identify what muscles are not firing appropriately and what muscles are still stiff and tight trying to protect.
Now this detective work is not always straightforward, particularly if like many of use you’ve accumulated multiple injuries over the years. But unraveling this tangled rope might be one of the best ways to do this and it is probably why good quality movement and exercise is shown to be one of the best ways to free yourself from pain.
Quite often when we injure or hurt ourselves we tend to go back into our shells and stop our usual activities to prevent pain. This can often mean limiting our movement and exercise, as doing so creates more pain. This is normal and something that shouldn’t be feared.
Pain is a protective response to keep us alive!
Let’s think back to our hunter and gatherer days when our main goals were to eat, sleep and procreate. Back then our survival was dependant on how successful we were in finding our food. This, of course, required a lot of movement. In fact, modern day hunters and gatherers such as the !Kung and Ache tribes average 15-20 km per day. (Cordain et al, 1998). That’s over 20,000 steps a day!
Now obviously if we were to injure ourselves this would severely limit our capacity to hunt and gather. So our in built pain response was designed to allow for tissue healing and conserve energy while our capacity to get food reduces. This protective response in our paleolithic environment was vital to keep us alive. Now pain science can get a bit heavy so I’ve tried to reduce some of the key points for us to understand:
1. Pain tags the brain with the circumstances that lead to creating it.
A toddler only needs to touch a hot stove once to remember that it is not safe to do so again! Back in the hunter and gathering days this might have included the location of dangerous terrain or the time and place of an aggressive animal. Research has shown that the pain response will improve our memory of these specific details.
2. Pain prevents us from moving the affected area for a short period of time.
This is incredibly useful as depending on the tissue that has been injured. It can take around 2 to 12 weeks for the area to heal. Pain can prevent us from loading the particular tissue too much and too soon and allow for recovery.
3. The protective pain response triggers metabolic responses in the body to conserve energy.
Inflammation and cortisol (part of the stress response) both have been shown to increase insulin resistance. This both triggers the body to increase your blood sugar levels for energy and also store your body fat. This is a perfect response for when you didn’t know if or when you would get your next meal. Unfortunately today food is at an abundance and many of us put on weight after an injury. So nowadays we don’t find this too useful!
Pain has short term benefits but can have longer term consequences
As I stated above our protective pain response is really useful for those first few months after the initial injury. However, for many of us pain can go on for much longer than that or we may not have actually had a trauma to create an injury. Long term pain is quite often diagnosed as non-specific pain as doctors can not find any tissue damage or pathology. Sometimes this pain might be the remnants of a past injury that has fully healed. But for some reason our protective pain response remains.
Going into the scientific reasons as to why this occurs is not something we can quickly delve into. However, in part 2 of this blog I’d like to share with you some of the longer term adaptations that occur to us. These adaptations will give us a roadmap as to how to best free ourselves from pain for good.
Now as a disclaimer of sorts, I am going to straight out say that the following is purely qualitative & subjective. One is sure The New England Journal of Medicine won’t be calling to publish the following…
We are born to move!
Neuroscientists have hypothesized for years that we humans are prediction machines, we are born to move! Movement can even be seen in the early stages of gestation. The child learns by observing the mother’s facial expression(s) & fine motor cues, and learns from making errors.
But still, movement is regularly neglected as a first line agent for pain & even metabolic conditions. Often replaced with pharmacological interventions. Now, one can understand that a hypertension patient would be prescribed a angiotensin converting enzyme. But, we know MORE can be done!
Motivation for this blog is due to seeing more knee pathologies, and especially how correctives have been neglected for surgery as a frontline intervention. Now, I am not trying to put your ACL into excessive anterior translation (get it?). And I don’t need to discuss any sham stories.
Let me explain… Check out the schematic below
Without needing to be Wilder Penfield, you can see the highlighted blue & green regions in the cerebral cortex. This is your motor and sensory regions in your brain! Now, it doesn’t seem like your motor & sensory areas represent a huge amount of your cortex. But if you knew (or you may already know!) that the gyri & sulci (plural) are densely packed with neuronal cell bodies, millions in fact! And if I direct you to the tonotopic organization of the motor & sensory cortex; you can see how much dedication and richness there is to regions such as the hands & lips et cetera.
So, now you have brushed over some neuroanatomy…
What’s the big deal?
My argument is that are motor & sensory cortices are highly neglected as a conjunctive therapy to other modalities. One can manipulate another’s motor & sensory system to drastically improve pain, especially if there is maladaptation which is oftenly seen in chronic pain, but somehow neglected.
Don’t get me wrong, touch (which is somatosensory) is fundamental for the healing, learning process.
However, as humans, we are prediction machines. We hypothesize, use our narratives to justify our cognitive biases, plan, make executive decisions.
Sprinkle a little dopamine in the Ventral Tegmental Area and 3..2..1..GO!
As someone who gets the opportunity to coach people on a daily basis, I work hard to get my clients moving with the best technique possible.
Why is technique important in resistance training?
Moving with poor or inefficient technique can lead to altered load distribution, and subsequently increased stress placed on the passive structures of our body. This can lead to an increased risk of injury (both acutely and chronically), which is obviously not ideal. Furthermore, training with poor technique can lead to muscular imbalances. This in turn leads to postural deviations, movement impairment, and again, an increased risk of injury.
Fortunately for us as coaches, technique is one of the few things we have a huge amount of control over. We have the opportunity to educate individuals on the importance of proper technique, and develop quality movement patterns through the use of appropriates exercise progressions and regressions. With this in mind, we can also improve poor or limited movement through a variety of corrective exercise strategies. In short, we have the necessary knowledge and ability to ensure that each and every one of our clients are performing a given movement well.
But, it is important to note that movement technique is entirely individual!
Is there such thing as a perfect technique?
Despite what some internet warriors might like you to believe, there is no such thing as perfect technique. Everyone has different anatomy(this includes not only limb lengths, but also things like joint depth and stiffness). All of which can significantly change their range of motion at specific joints. It is for this reason that some people can squat to a full depth with their feet barely apart, while others need a wider stance just to squat to parallel. It may mean that a conventional deadlift is out of the question for you, and a narrow sumo stance is your best option. For others, it may mean that a conventional deadlift is ideal.
Everyone is different. And it is important to reiterate that none of these techniques are wrong. In actual fact, in both cases they may actually provide the ideal position for that individual to complete a given movement. But in the same light, each technique is different – and none of them are perfect.
As coaches it is our job to find the best position possible for you as an individual to perform a given movement safely and effectively. While this position may be slightly different, there are number key things we can look for to ensure that this position is found and trained correctly.
Firstly, you need to be able to maintain a neutral spinal position for the movement’s duration. While this is true for almost any exercise, it holds significant importance for lower body dominant exercises. Think squats, deadlifts, and their single leg variations. This is becuase these movements place significant compressive and shearing forces on the spine. These forces are actually a good thing when a neutral spine is maintained, as they teach the muscles of the trunk to resist these forces. This is essential to building a strong and healthy spine.
BUT! When this position is lost, and the trunk moves (flexes or extends) under these heavy loads we can become susceptible to injury and dysfunction. As a result, we need to play around and find the best position for the individual. This tends to be where an individual has maximum joint range of motion, while also being able to maintain a neutral spine throughout that range of motion.
How do we determine ideal technique for an individual?
This can be done by assessing passive and active joint ranges in different positions. We can also reduce the range of movement to ensure that you can maintain a neutral spine. For example, we could use boxes or blocks to reduce a movements range.
Secondly, we need to sure that the joints remain ‘stacked’ on top of each other throughout the full movement. This essentially means that the knees and the hips are kept aligned throughout the movement’s duration. Thus limiting any potential shearing or rotational forces placed on your knees (think the knee collapsing inwards during squatting movements). Once again, suitable exercise regressions OR utilising principals of reactive neuromuscular control are utilised to ensure safe positions are maintained. Think bands pulling the knee into different positions during a split squat to teach the body to resist these forces.
Everyone is different, and as such there really is no such thing as perfect technique.
Despite this, we need ensure that each movement can be performed with the best technique possible given your individual anatomy. We try to focus on maintaining a neutral spine throughout the movement. This guarantees that the joints remained stacked on top of one another. We can regress our exercises if needed to encourage proper positioning. This can also be extremely beneficial to keeping a movements within a safe range of motion.
Remember, there is no right way to perform a given exercise. However, we can find an ideal way for a given individual at a specific point in time.