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.
I’ve taken on a lot of clients who have been told by a Health or Medical Practitioner that they should not run ever again. Usually it is due to chronic knee pain with some evidence of structural change- like some cartilage degradation for example. This may not sound shocking, but it should.
“So Mr. Wood, every time you run, your knees pull up sore. Running is very hard on the knees, and your knees aren’t exactly in show-room condition. I recommend that you cease running from now on”.
If this news was delivered to me it would be analogous to a shotgun blast to the guts.
“Don’t run any more? But I love running!” “Get yourself a bike, bike riding is great for the knees”. “But what about when I have kids, I won’t be able to kick the footy in the park with them?” “Not if you don’t want a knee replacement in 5 years time!” “Well what if I am being chased by an axe wielding maniac, can I run then”. “Well, in that instance yes, but don’t blame me when your knees are killing you the next day!”
This is pretty clear cut. And that is the problem I have with this type of delivery. By being so definite in the stance that running (without pain) is not possible in the future, they are effectively saying this.
“On behalf of all Medical Experts and Conservative Health Care Providers, I state that it is impossible for you to run in the way that you want to without aggravating pain and accelerating degeneration of the structural features of the knee.”
Now I know some pretty bloody awesome people in the above mentioned fields, but I wouldn’t think anyone has the right to speak on behalf of every Medical and Health Practitioner both currently alive and those to come in the future.
Instead, why not just word it like this: “I don’t know how to help you run”.
Simple, and absolutely more true than the previous example.
And imagine if you were given this perspective instead. What would your reaction be? Mine would be:
“Ok, thanks for your honesty. I’ll search for someone who can”.
The reality is that it is quite possible that for some people, running without pain is impossible. But who has the right to make that conclusion. If my clients want to run, it is my job to help carve out a pathway to make that possible. I’m not always successful, but I’d like to think I am humble enough to own my shortcomings rather than deem the goal impossible.
If you’ve been told that you can’t run any more, maybe you can’t. But maybe you can.