In Sickness and In Health (Part 2) – The Pain Game

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In Part 1, i discussed a little about my own pain experience and how i have made a commitment to being free of pain or living with it better.  Today, I am joined by my hubby to help you apply all the information about pain to your situation.

One of the biggest “AH HA” moments for me was when i realised that pain in the body does not correlate well with damage in the body.  If you MRI 100 back, there will be people will disc herniations and inflammation who have NO pain and you will have people with perfectly normal backs who HAVE pain.

This means that pain is not just what is going on in our tissues, but what sense our brain makes of the entire situation.

So, while my SI Joint does show inflammation, that is only one part of the puzzle.  The memories, the fears and my understanding of pain and what it means ALL influence and affect my experience probably more so than the inflammation.  You see, i have had periods of time when my pain was far less (maybe i was really relaxed or i was feeling like my treatment was working) and i had a repeat scan done that showed just as much inflammation as before – yet no pain.  Surely, if inflammation was the cause of my pain, i would have pain all the time.   For me, i think it is much more to do with my emotional state and my beliefs about things like medication, inflammation and what i have seen other people do that all impact on my experience.

To help you, i asked my husband, Dr Jonathan Fass, DPT, to answer a few questions and put together a few “tips” that will push you in the right direction to deal with your pain.  The first step is ALWAYS to learn more.  At the very bottom, i have linked some useful materials that will expand more on this information. It takes time to understand this from a new perspective, so allow yourself that and please let us know if you have any questions. Jonathan will be on hand to help answer them 🙂

Me: In your experience as a Physical Therapist (and research nerd), what are the most common misconceptions about pain?

JFass: Pain seems like a very straightforward experience: If you bump your elbow, you’ll feel some pain; If you break your elbow, you’ll feel more pain, and so on and so forth. The basic story here is damage to your body creates pain. Simple enough, right? You might be surprised that it actually doesn’t work that way at all. Pain is an experience, a signal from your central nervous system that there is a threat to your body’s tissues. Just like the “check engine” light in your car, pain tells you that there is something that is wrong with the machinery, but it doesn’t tell you exactly what or exactly how. Just like that check engine signal, it is a result of a computer analysis (in this case, that computer is your brain) and not a direct result of actual damage: After all, if the engine in your car was already damaged, a check engine signal would already be too late: your car probably wouldn’t be running any longer!

Why is this important? In understanding what the experience of pain actually means, we need to understand where it comes from. Believe it or not, there is a body of high-quality research that shows us when we understand that pain is a signal of distress, not a result of damage, we can actually affect our pain and decrease it, demonstrating greater improvements in pain and function. Our more complete understanding of pain now reflects the inputs not only from our tissues, but how our very beliefs, thoughts, fears and historical frame of reference all work to shape the output of pain. By decreasing fear-based pain beliefs, we can improve our ability to cope and to recover from pain.

Me: As a coach (and as someone who has pain), it is sometimes worrying when i hear someone say they hurt when they do a certain movement.  Most people here love to exercise, but many of them might also have chronic pain. What pain on during movement might mean? For example: low back pain during certain exercises or knee ache?

JFass: It’s important that we respect the pain experience: our central nervous system is trying to tell us that something is occurring that it believes is a threat. When we ignore pain, our central nervous system digs in and “doubles down,” making that pain stronger and more severe over time.

The first step when experiencing pain is to understand where it might be coming from: is there true tissue damage, such as a twisted ankle while playing basketball, or an identifiable disease state, such as an auto-immune disease. It’s always important to have things checked out by a qualified health professional and not just by asking Dr. Google and deciding that your pain is “nothing;” however, when we can identify clear and obvious inputs, such as “my knees always hurt when I forward lunge, but only when I forward lunge,” then we can try to change our form and position to reduce and eliminate that pain. By affecting the inputs to the Central Nervous System – in this case, nerve signals that come from our knees and legs – we can change the experience that is being evaluated by our brain. So if the brain feels that a certain amount of muscle activity at a particular point in your lunge is a threat to your tissue (remember: it does not actually mean that there is tissue damage, although this is certainly possible just not guaranteed), by changing the movement of that lunge (maybe improving the alignment of your knee, maybe by increasing glute activity during the lunge and decreasing the stress on the quadriceps muscles), we satisfy the threat itself. When that is done, the brain no longer “worries.”

Activity and exercise are good things: sometimes we may find that certain activities are provocative of our specific pain complaint, but exercise and movement as a whole is the best thing that you can do for yourself. Do not fear your activities, just seek to understand them. By doing that, we can encourage better, safer and more consistent and pain-free exercise.

 

Me: When i realised that i had  joint that was inflamed, i set about trying all sorts of manual therapy to try to reduce the pain.  Is it wrong for someone to do this right away? What typically follows these misconceptions?

JFass: Manual therapies such as massage, myofascial release, etc can all be very good things. Contrary to what is commonly explained, these therapies almost certainly do not directly change the fascia – our connective tissues that surround the muscles and joints of our body – but instead are more likely to work through altering the sensation and neuromuscular activity through the nervous system. Is this a good thing for pain? It certainly can be; however, what we have come to understand is that since any individual’s pain experience is entirely unique to them, based on their unique physiology and specific influencers – biomechanics, emotional experience, psychological beliefs, cultural education about pain, etc, a “one-size-fits-all” prescription of treatment just won’t work. Based on a proper evaluation which should include a detailed history of your pain, movement assessments and provocative testing, your healthcare provider should be able to identify an appropriate course of treatment which may include manual therapies of some kind.

Me: I typically hear people talk about their doctor’s or therapist’s reactions to hearing about them training when they have been diagnosed with some ligament tear or disc herniation in very negative terms – almost like they have the fear of moving wrongly. What can you recommend to people who have just received a reaction/advice or are about to get scans or investigations into pain – are there any questions we can ask that will help the outcome?

JFass: True tissue damage requires time to heal, and sometimes doing too much too soon can negatively impact that healing process. However, we should never think of any activity or exercise as being “good” or “bad,” but rather assess its value within the context of your situation and potential injury. 

For instance, if you have been repeatedly told that “squats are bad for your knees,” it is entirely likely that this information – false in most circumstances and for an otherwise apparently healthy individual – will influence the threat assessment performed by the brain during this exercise or similar exercise. After all, if you were told as a young child that spiders are dangerous, you might develop an irrational fear of spiders, which is known as arachnophobia. Just like the fear condition of arachnophobia, your pain is very-much real: it is produced by the brain, but that doesn’t mean that it is somehow “all in your head.” It is a real experience based on the information that you believe to be true. What’s worse, just like in arachnophobia, even just knowing that the information that you received – either that spiders are dangerous or that squats are bad – is not true, you will still experience your fear or pain, respectively. The primitive brain isn’t interested in being rational, it’s interested in being alive and out of harm’s reach! 

In order to make sense of any information that we receive, there are a few questions that we can ask, which incidentally are great questions to apply to any information – health or otherwise – in life. 

1. Who says so? Does this information come from a qualified professional, or someone who really has no business in discussing the information. I am much more interested in my mechanic’s information concerning my car than I am about my pain. Further, even if this comes from a qualified professional, how does he/she arrive at this conclusion? Is it an opinion, or does high-quality research suggest that this may be fact? Clinical opinions are valuable, but it is important that we understand that they may also be wrong. Asking your health professional why they believe their diagnosis and on what information they’re using, what other possibilities might your pain be stemming from, and seeking out second opinions are all valuable. Ultimately, if the diagnosis is accurate, we should expect a result from the treatment prescribed from that diagnosis. If we are seeing little/no improvements in our pain, explanations such as “recurring injury process” and “scar tissue” etc, etc are more likely to be a result of attempting to fit your musculoskeletal pain experience into a pre-rendered “box” rather than adjusting the diagnosis and seeking out new possible areas of investigation.

2. Is there information that would make this false? If, for instance, you are told that an MRI has discovered a disc lesion in your spine and that this is the cause of your pain, are there any factors that might make this untrue? For instance, it is well-known that findings of disc damage on MRI and other imaging devices are often false-positives: they are not actually the cause of the patient’s pain. A highly valued study found that ~80% of non-symptomatic individuals – regular people without a history of back pain or current back pain – will have identifiable disc injuries when scanned, yet they will have no symptoms. In other studies, “fake” surgeries for identified knee arthritis produced results just as good as real and actual surgical procedures, indicating that the relief that we experience from these surgeries might in fact be entirely a result of a placebo effect and not the removal of the arthritic tissues! Simply seeing something on a scan is not an automatic or accurate diagnosis for a musculoskeletal pain complaint. Clinical findings must compliment these images, or we risk identifying and treating “problems” that were never actually problems in the first place.

Me: I often see this silly quote circulating online: “pain is fear leaving the body” As if there is a belief that you can run pain out of your body by standing up to it and fighting through it.  I actually got tagged in a photo with this on it and it made me mad! *shakes fist*

Still Me: Anyway, if this is how the fitness “culture” sees pain, how can we improve our understanding?

JFass: Pain is to be respected: we need to remember that most of us are not professional athletes and our income and livelihood do not depend on our performance on the field or in the gym. However, we can also understand that there are different kinds of pain, too. The pain that we experience after a hard workout, general muscle soreness, is a relatively benign pain signal: we shouldn’t continue to push ourselves when we are sore after a tough workout, but we needn’t fear it, either. However, pain that seems to originate in our joints or as a sharp, sudden pain in our muscles needs to be respected and responded to immediately: they can indicate true damage or the real threat of damage and shouldn’t be ignored. If your knees hurt when you squat or your shoulder hurts when you bench press, this needs to be addressed.

If there is any single take-away from all of this, it’s that pain is not something to be overcome and conquered, it is something to be understood. 

Me: Thank you so much for helping us to better understand pain.  For training purposes, it is tempting to do one of 2 extremes in response to pain: either stop moving all together or train through the pain regardless.  I confess, i have done a bit of both.

The lessons i am learning is to be adaptable during your workouts. If something hurts, just try something else. For example, my hip hurt during goblet squats, so i staggered my stance and the pain stopped. I didn’t necessarily have to stop doing the Goblet squat, but i altered my foot position so my painful side was further forward which shifted more effort to my pain-free side, allowing me to continue without “worrying” my brain.

Don’t get stuck in believing it’s “all-or-nothing”. There are gradients and many many ways to enjoy activity.  The biggest problems are our fears and pride. Let them go and be free to enjoy something that doesn’t hurt. Over time, more things will be pain-free and you will be wiser for it 🙂

Here is a list of resources that have helped me:

This video is awesome. Lorimer just has a way of explaining things!

 

So does my wonderful husband in this very helpful Podcast episode he did with Armi Legge.

An article on Back Pain – HERE

Love this wee video. Simple explanation of Chronic pain:

Pain aint so simple. This is great to help show you that each pain experience is unique:

This last one i found very helpful because i am guilty of so much “bracing” and tension that my muscles can’t seem to switch off!

 

Please let me know if you have any questions. Please realise that neither Jonathan, or I can answer anything definitively about your pain from a distance. It must be answered as part of a whole assessment of *you*.  Your pain is unique to you and there is only so much we can do from here.  The great thing is that this information is so empowering – it shows that there is hope and just reducing fear (by increasing your knowledge) can reduce pain significantly.

Cheers,

Jonathan and Marianne 🙂

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7 Responses

  1. […] Fass, DPT in an effort to iron out some commonly held myth-beliefs about pain and injury. Find that HERE and remember to check out the list of resources at the end of that article […]

  2. Marianne, thank you so much for this post! It is full of important information and clarifications. I am especially interested in receiving a copy of/link to any research material which brought Jonathan to the conclusion that “contrary to what is commonly explained, these [manual] therapies almost certainly do not directly change the fascia”. I am an LMT, and the thixotropic quality of fascia and our ability to influence tissue fibrosity, fiber directions and musclotendonous/fascial tissue tensility (etc.) is indeed what we stress as a core benefit of our work (above all in terms of increasing ROM, alleviating muscle-holding patterns, even if only temporarily depending on further sessions as well as the clients’ own work either to strengthen muscles, change posture, improve diet & sleep and seek out inner peace – a holistic process). While I definitely also recognize the impact of nervous system on pain – its existence, its intensity, our very perception of it, but I’d love to be enlightened further as to how Jonathan understands this subject. Your feedback is much appreciated! ~ Miranda

    • Hi Miranda, thanks for your question and I’m glad that you enjoyed the post!

      There are a few concepts here that I think can be scrutinized. “Thixotropy” itself is a concept that largely doesn’t appear to have relevance on the macro level of tissue that any manual therapy would take place in. I like what my friend Paul Ingraham had to say on the matter (his blog is a wonderful source of evidence-based practice directly relevant to MTs, if you’re not already familiar with it) – http://saveyourself.ca/articles/thixotropy-is-not-therapy.php

      The assumption of directly (mechanically) deforming fascia is higly questionable itself, as was concluded in the following (a widely referenced article on the reality of fascial stiffness and its resistance to deformation) – http://www.jaoa.osteopathic.org/content/108/8/379.full. If we can’t mechanically deform fascia, then any influence on the fascia itself – assuming that we have any influence and also that influence is clinically important – cannot occur from direct manipulation, but rather indirect mechanisms through the nervous system. But given the multiple confounders of skin, muscle, joint, nerves, blood vessels, etc all potentially being influenced through our manual approach (and the only definitive influence that can be directly observed, of course, is the skin itself), we cannot confidently determine that any affect that we have on a patient is produced through an assumed interaction with fascia…there are just far too many confounders in that assumption.

      We know that contact with the patient very often is beneficial. However, the previously dominant biomedical theory (and postural-structural model in the manual therapies) often lead our reasoning towards a “purely” mechanistic means of explaining these influences, and fascial explanations were one of these attempts. That doesn’t mean that manual therapies suddenly “don’t work,” it just means that we need to adjust these explanations as new information replaces and updates the old. Fascial-based therapies largely falls into this category, IMO.

      • Dr. Fass, thank you SO much for your detailed reply (and I apologize for taking two months to acknowledge it – I’d checked back a while ago but didn’t see it – I must have gone to the Part 2 comments section!).

        This topic fascinates me – I’m now setting about deciphering the postural-structural biomechanics model better. I’m most willing to accept this current understanding of fascia and thixotrophy. As eager as I am to confirm the benefits of manual therapies, I am equally willing to accept criticisms of it, or at least indications of its limitations. I couldn’t consider myself a professional in this field if I weren’t. Yes, the human body is incredibly resilient, and if our fascia could really be affected as quickly or deeply as those who employ mild heat/manual pressure to affect it often claim, then we’d be in trouble! As a CMT I am known to deliver on deep pressure (no client has ever said that I didn’t give enough), and I sometimes wonder why my clients muscles aren’t turned to jello if I gave so much 😉 What Paul Ingraham explains about circulation is intuitively true for me, and I admit that a solid, usually fairly full-body, workout can be just as if not more effective for me than a session of massage therapy: after I exert my body well, a specific soreness in muscle that has been bothering me often fades or disappears – even if I don’t go and “stretch” that muscle (group) which I think is causing or contributing to the ache.

        Amongst MTs, language like “muscle releasing”, “lengthening muscle fibers”, “changing muscle fiber direction” (such as with adhesions) is standard, and I’ve always been skeptical about the degree to which cross fiber/longitudinal release techniques, for example, can really affect such shifts. Some clients do seem to “respond” better to certain techniques/touch, and I can often palpate shifts in the quality of tissue (including into deeper muscle layers) after working on it. When I observe greater ROM or a release from a postural deviation, I can quantity my value to a certain extent (even if those improvements are temporary and dependent on the client’s active involvement after this point not to prolong poor habits). But in terms of this response and how individuals differ widely in their responses to manual therapies, would you say that an individual’s power to “let go” is key, and that that process is mostly a neurological phenomenon (whether s/he enters into the parasympathetic state during the treatment), while also factoring in the specific severity and underlying complex causes of the local problem (hypertonicity, adhesions, active trigger points)? So, it *might* be easier to affect tissue through manual therapy and to address pain/tension present for individuals whose pain/tension is resulting from recent or comparatively minor injury/poor posture/ and/or superficial emotional difficulty vs. chronic, long-term or deeper physical or emotional-psychologically challenges? I can see that the individual’s trust in his/her manual therapist and manual therapy itself also plays an important role.

        Thank you again for your time!

  3. […] – Been in and out of pain and forced to reduce my training (just read my last blog posts “In Sickness and in Health” Part 1 and Part 2) […]

  4. Robin Morgan says:

    Wow! So much great information. Challenging current beliefs! Love it. SO good to have you back Marianne & to have Jonathan aboard! I am a Personal Trainer branching out into the online world as well, so I loved all the videos. So much to think about & more research to do. Always learning in this industry!
    An open mind is mandatory to survive & succeed. Look forward to more workouts & the forward thinking education to come..:)

    Cheers,

    Robin

  5. Simon B says:

    Hello Marianne.
    Just a note to keep going strong.
    I always followed an active lifestyle including commuting from D’Dee to Holywood and back right through the year by Bicycle until just over three years ago I was hit by a mental wall prob caused by stress. I had never been sick ever and to be bed ridden was definitely a no no. My body just shut down. I currently am still being diagnosed with suspected fibromyalgia. The last few years have been hard trying to push slowly back to some sort of health. I came across your blog in 2012 while looking for some info on kettlebells and have followed it ever since. I just wanted to say keep going strong on your path both mentally, physically and even more so spiritually. Ps are you a vegetarian. Thanks Simon

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