Chronic Pain
Chronic Pain:
I'm fascinated by the concept of pain. How it manifests in the body, where it comes from, and why some people experience chronic pain long after tissues heal and even when there's no injury, while other people recover from injury without long-lasting pain. The more recent theories in kinesiology utilize the biopsychosocial model instead of the older biological top-down model in injury recovery and physical therapy/corrective exercise. In movement therapy practices we now look at the "whole person" and how other factors such as fear and anxiety can influence someone's experience of pain and injury instead of only the stage of tissue healing and grade of the initial injury.
Pain used to be based physiologically, only on "issues in the tissues", thinking that if there is pain then there is something to fix. That theory is now outdated with the biopsychosocial model of multilayered issues, emotional responses, past experiences, and neurological experiences. Top-down model versus bottom-up. But for a while, that theory got taken to the extreme, telling chronic pain patients that all of our pain is in our heads. Now, while it is true that the brain creates the experience of pain, that doesn’t mean that the pain isn't real and that differentiating factor needs to be addressed with patients. When we feel a sensation it is real. When pain is experienced it can be very painful and restrictive in activities of daily living (ADLs). Pain can be very frightening to experience when someone isn’t aware that pain does not mean there is any damage. Once we understand that pain does NOT equal damage, we can have the confidence to work through sensation without fear, even when we still feel pain. When working through chronic pain it is okay to "bump up into the pain", not push past where it is tolerable, but try to work right along the edge of pain to be able to desensitize and dampen the nervous system reactivity.
There are now many different models in pain reprocessing therapies that include cognitive awareness and a stronger psychological approach to chronic pain such as acceptance and commitment therapy, cognitive-behavioral therapies, and mindfulness-based therapies. All of these approaches share a strong focus on education and understanding of pain, as well as an awareness of and connection to sensation without guarding or avoiding the experience of sensation. Most of the approaches discuss chronic pain as stemming from fear of pain and a misunderstanding of what pain truly means, that pain doesn't necessarily mean damage, and that while the experience of pain is fully real it comes from the brain, not the tissues.
From the latest evidence, it appears that pain education gives patients a better understanding of the mechanisms of pain, reduces kinesiophobia, or fear of movement, and significantly improves the experience of pain for most chronic pain patients.
Chronic pain is extremely complex and multi-layered. Any therapeutic professional that tries to market a program as the answer to pain is selling snake oil. While it is possible that elements from one program can be beneficial to help reduce pain for some clients, everybody is unique and has different needs so no one program works for all. Unfortunately, there is no magic cure for pain. The goal of pain relief modalities is not to be 100% out of pain. Some of us may always be in some discomfort or heightened painful response. What we aim to achieve in pain management is helping clients understand what pain is so that they have the tools to navigate pain, reduce fear and intensity of pain, and eliminate the restrictive feeling pain creates to reconnect with activities they enjoy.
We Can Distract Pain:
Pain is so uncomfortable because it is meant to grab our attention. It's a warning signal. In chronic pain, it's a misfired warning signal.
Can we distract ourselves from pain when its purpose is to grab and hold our attention?
Often when my clients go on a vacation and are able to relax they come back telling me they felt fine while they were away, only to find that when they return back home into the grind of things, their pain returns. This is not always the case, but similar to an annoying mosquito bite, while we may be in major discomfort after being bitten, at times that discomfort disappears. The bite is still there, and the injury may still be there, but when we're distracted the discomfort can dissipate for periods of time. We can be distracted away from pain; it doesn't have to be constant.
By understanding that pain is not always equivalent to danger, we can begin to convince our unconscious protective level of the brain that we're safe by moving with and softening into the pain/stiffness/discomfort. So, when people are on vacation they're happier, relaxed, distracted with exciting fun things on their trip, and may feel suddenly pain-free. However, the opposite may be true and with unexpected issues occurring on a trip, different pillows, plane rides, and jet lag, the body might tense up and create a flare-up of pain.
When we're in new environments, novel experiences, or in the state of flow concentrating pain can be temporarily relieved while the mind is so focused on something else. The old joke is if your head hurts then stub your toe. The new sensory input distracts the central nervous system (CNS).
Just as a change in sensory input can change the experience of pain, emotional and cognitive responses to pain, such as fear, expectations, and daily stressors all impact our sense of pain as well. As previously mentioned, the old way we tend to think about pain is physiological, that pain develops from an issue or injury when the brain signals that there is damage needing protection, with time and rest it heals, and once it heals the pain is relieved. Because of this, we tend to think that if we sense pain there is damage to the body in some way. However, if we look at 100 MRIs a majority of the scans will find issues to diagnose such as herniations, tears, stenosis, degeneration, etc., yet most of those people won't have any pain. Some of the people who do have pain will show a normal MRI, and others showing something to blame the pain on actually has nothing to do with their pain. If someone, whether it is a friend or professional practitioner, says that pain comes from body posture or a scan result that is outdated knowledge.
The fear of damage or pain from movement is called Kinesiophobia. That fear can be stimulated and stoked depending on the individual's personality and personal history or past experiences. When people tell their friends they have pain it's common to hear "oh don't exercise, rest it, don't pick up anything heavy…", but these mistaken suggestions while intending to help, are much more harmful than helpful. Those fear-based suggestions create more fear response and unless there is an actual broken bone that needs to be unloaded for a period of time, the body heals better and feels better with the appropriate dosage of movement.
Pain Management is Daily Hygiene:
For this reason, we must always keep moving to reduce pain and discomfort. I continuously hear the same description from clients, that every day is groundhog's day as if they're starting over again and again with their pain and stiffness, and no matter how much stretching they do one day, the next morning is the same.
It is true, we can feel stiffer in the mornings more so than throughout the rest of the day after we've been in bed laying down and still for a number of hours. The body feels better in movement than after being still, and as movement increases throughout the morning ADLs, synovial fluid moves throughout the body and lubricates the joints, and stretches through the muscles. Watch an animal when they get up from napping. Any time a dog gets up after they've been curled up in a ball for an extended period the first thing they do is reach and do a full-body stretch. Reaching through the body to change the joint angles after sitting in one position is natural and necessary.
To decrease pain and stiffness: move the body. For two minutes a day, move in a different way.
These clients are frustrated with daily sensations of pain and stiffness. They ask me why they have to stretch every day, or why they feel tight every day. Well, we have to brush our hair every day, so why do we think of the body as any different? We have to brush our teeth, shower and brush our hair every day, and just because we've done it once doesn't mean we don't have to continue to do it the rest of the week.
Tension in the body is similar to knots in our hair. Every day we have tangles that happen in our hair, and so we brush it out, and then the next day our hair gets knotted again and we have to repeat. Life happens, hair gets tangled, and we have to untangle it. If we let it go and allow the knots to stay, they get tighter and more difficult to deal with. Eventually, they'll have to be brushed out in some way, and it's always easier to manage smaller issues than waiting until it becomes a bigger problem.
As we move through life we get stiff and sore and we feel these "knots" and tension throughout the body. We get feelings of tissue tension from sleeping, sitting at a desk for a long time, vigorous exercise, or from daily tasks. The body gets knots, and we have to brush them out. But it's not one time and done. We have to manage our bodies daily just like how we have to shower, brush our teeth, and brush our hair. The body is no different.
Pain management is the same as hygiene. It requires work and daily dedication, especially for those who deal with chronic life-long pain. Thinking of pain management as routine, daily tasks can feel more manageable than expecting to do an hour of dedicated stretches daily. Specifically what is needed for pain management changes in different stages of life for each person, but in every stage, we continue to need daily body routines just like we need to always brush and floss each day as well.
Work with a professional to create a personalized, short, daily routine to brush out the knots throughout the body to feel better. Shower, brush your teeth, brush your hair, and do your stretches. Use a regimen of daily stretches and exercises to release tension in the body. There are countless variations and opinions of what to do, but the basic idea is to just keep moving.
The most common excuse as to why people don't keep moving is: "I don't have time to move/stretch/workout". It can be a challenge, but we do have time if we make it a priority. Just say to yourself "my pain is not a priority for me" and then see how you feel about it. If you don't like how that sounds then you know you want it to be more of a priority in your life, so you've got to make it one. We must schedule our daily routine into our daily planner just like we would any other meeting or important task.
Chronic pain relief and healing from injury is a progressive cycle. It will always feel like one step back, and two steps forward, so it needs consistency and patience. We must have the patience to determine the proper process for our own unique needs and learn how to think about pain. It's exhausting dealing with pain but we must stay consistent, make it a priority, and keep moving.
Does Healing = No Pain?
Healing is NOT necessarily about having no pain…it is about learning how to manage and continue on, staying connected to daily life, staying active, and managing as best we can. Healing and feeling capable and confident should be the focus, and we should not have to rely on painkillers. We can have a goal of reducing the pain number if we're measuring pain 0-10, but we shouldn't tell ourselves we won't continue to have sensation. Differentiating between debilitating pain and discomfort or sensation helps us reevaluate what we can handle and what we should expect.
Realize the body is strong, robust, and capable of healing. We are not too weak, too old, or too broken. We do not have to be reliant on any one practitioner, medication, or surgery. Instead, take a proactive approach to movement therapy, continuing our own daily movement routine. There is no magic pill, surgery, or injection.
Pain does not mean we're damaged. Find a practitioner that you can work with to help you navigate the frustrating and complicated journey of chronic pain and healing. I use Pilates-based corrective exercise with my clients as a modality for movement therapy and corrective exercise with the goals of reducing pain and increasing vitality and self-efficacy in their lives. Joe Pilates said it best that "the first requisite for happiness is physical fitness". When we're in pain it's hard to feel content and happy. I always feel best when I feel physically strong and capable, and I always feel better after moving. Just keep moving, in whatever way you like, whatever works for you.
What Should I Do When I Feel Pain?
When we feel that spasmodic pain or old sensations rising it's easy to panic that we're damaging something and that it's going to get worse. But at that moment it's important to relax, start breathing, saying to ourselves "I'm ok, I'm not damaged". While taking deep breaths be aware of the narrative of fear or anxiety that starts spiraling through the mind in response to feeling a muscle pull or spasm. Continue gently moving whether that's pacing around the house, or doing cat/cows and knee hugs, taking the time to consciously tell ourselves we are not breaking, we will be okay.
When the brain believes it is in danger it perpetuates these extreme feelings of fear, overreaction, sensitivity to any sensation, severe reaction to touch, and a sense of impending disability or damage. This is why it is important to learn about pain. Understanding pain is the most effective method to reduce it, putting us back in control instead of being at the mercy of flare-ups. When we know that our pain doesn't mean that we are weak, fragile, or broken we can take a breath to relax in the moment of pain. By recentering and relaxing the nervous system we're teaching the brain that we're not in danger which then relaxes the body and releases fear which dampens the painful response. We don't have to overthink pain or catastrophize when we know pain is most likely a protective response to our lifestyle, habits, environment, and tendencies. Any painful movements that feel like setbacks do not mean we are broken. Pain is complicated, multifaceted, personal and cyclical, and will often recur at times, but we're still strong and can get through it. Knowledge is power.
Books for Understanding Pain :
Explain Pain by David Butler and Lorimer Moseley
The Explain Pain Handbook by David Butler
Why Do I Hurt? By Adriaan Louw
The Way Out by Alan Gordon
