Chronic pain management through exercise and massage therapy
At Stephen Tongue Fitness, I work with many clients to prevent and rehabilitate injury, manage long term medical conditions and cope with long term pain using exercise and massage therapy. For that reason I recently gave up a Sunday to head down to Hertfordshire in the hope of learning more about the weird and wonderful world of pain.
The workshop came about after I attended a lecture earlier in the year by an Osteopath namely Andrew Nicholletos. Andrew opened my eyes to the mechanisms, and the management of pain in a way that none of my tutors had in the past. Andrew presented both new content and treatment strategies that captured my imagination. Driven as I am to deliver cutting edge service to my clients I could not pass up an opportunity to learn more about the modern science of pain.
A change of perspective
For a long time I was of the opinion that the science behind the exercise and massage therapy techniques that I use was best kept from my clients. I believed I should only reveal such information in the simplest form as the process was irrelevant and the end result was of main concern. At the pain workshop Andy expressed that the first step to helping someone with long term pain was to educate them about how pain works, he gave the following analogy which completely altered my opinion.
Imagine I was your coach and I told you the solution to your problem was to drive from Nottingham to Tower Bridge, London. I get in the car, drive you there and your problem is resolved. I then explain that should the problem return you should drive back to Tower Bridge of your own accord along precisely the same route. Had I informed you of that detail from the beginning you would have probably had a very different, more attentive thought process throughout the whole journey. That change of perspective would likely increase your chances of success in the future.
This story struck a chord with me and I realised that informing clients of the process of getting results actually created better results. I also noticed that many clients were more motivated and genuinely interested when it came to understanding how and why change was occurring and what my intentions were when training and treating clients.
How pain works
Let’s take a deeper look at how pain works…
Pain is Protective
Pain is a very natural and useful tool. Pain is designed to protect us from injury, we often feel pain just before or just as an injury is about to happen to give us chance to react. For example if you touch something hot or sharp unexpectedly you will get a sudden pain, this may be a different experience if the heat or sharp edge is expected. If you do become injured your brain will create pain in order to 1. Encourage you to take action to promote healing 2. Protect the injury from further damage.
Pain is Processed
All pain is produced by your subconscious brain. Your brain uses all of your senses and experience to assess any given situation. The brain then processors all information before making a decision on how much pain you should feel and where. Touch, sight, sound, smell, taste, memory, rational and emotion all contribute to pain experience and are all considered before a decision is made about the pain you should experience. This processing starts developing from when we are born and memory and experience play a key role, have you ever seen a child fall and then look to their parents to see how they should react. Have you heard of individuals bleeding whilst being oblivious to their injury but then experiencing pain on the sight of their blood. Your subconscious will only allow you to feel pain if it is of biological advantage, self preservation is a high priority.
Pain is Contextual
Let’s take an ankle sprain as an example. If three individuals become injured with identical ankle sprains their pain experiences could differ dramatically. In this case I will use an office worker, professional footballer and an individual in a burning building…
It is likely that the footballer would be in most pain as the injury is a huge threat to their career, livelihood and identity. The subconscious brain perceives that the injury has dramatic consequences and so it creates a pain experience that cannot be ignored and promotes action to be taken.
The office worker may perceive the pain to a lower degree. Although structural damage is identical to the other injuries the threat to the office workers existence is not as dramatic. They will experience pain but perhaps not to the degree of the pro footballer.
An individual that has sprained their ankle in an attempt to escape a burning building is likely to perceive the least pain. Their senses, experience and logic can all recognise that the surrounding fire is more threatening to their self preservation than the ankle sprain. Creating ankle pain at this point would impede escape and likely result in more serious injury or death. It is probable that this individual would begin to feel more pain once they had gotten to safety.
It’s known that lack of understanding of an injury can make the injury more painful, so three conflicting diagnosis of pain can make pain worse. Even the company you keep can change perception, during pain experiments men felt less pain when tested by women. Similar to that classic scenario when you visit the dentist and your toothache has miraculously vanished, your sub conscious brain is satisfied with the action you have taken.
It is remarkable how complex the world of pain is and easy to see how so many people have such differing experiences of pain. So you now know that pain has a great purpose, it is not necessarily related to the degree of tissue damage and can be a different experience based on the environment. Understanding how pain works is key to long term pain management.
Dealing with long term pain
I am going to help you identify the difference between acute and chronic pain and help you to understand that it is possible to have chronic pain without even having an injury present. You will also learn some simple steps to help combat chronic pain for good.
Acute vs Chronic Pain
Acute pain is defined as pain felt for a period of 3 months or less. Chronic pain therefore is pain felt for a period of 3 months or more. The 3 month benchmark is significant because it is the time frame in which one would expect soft tissue damage to heal. Pain beyond this time period is increasingly less likely to be caused by structural soft tissue damage and is more likely to be a neural (nerve related) protective mechanism produced by your sub conscious. The lack of structural damage however does not make the pain any less real, the pain feels and indeed is very real.
Our soft tissues can deal with force and mechanical stress to a point but they have a limit at which they fail and experience damage. The soft tissue limit may differ from one person to the next based upon genetics or fitness. To protect us from this point of soft tissue failure we experience a protective buffer. This is a point at which pain is felt before the soft tissues experience damage, this mechanism is of course protective and gives us chance to react to prevent actual damage occurring.
Soft tissue damage is often sustained very quickly and before we have adequate time to react such as a fall or a car accident. On occasion soft tissue damage may occur more slowly but this is usually during a period of distraction such as working. Once soft tissue damage has occurred it may take up to 3 months to repair and it is likely that following the injury the repaired tissues will be weaker and therefore have a relatively lower point of failure when compared to pre injury tissue health. This new lower soft tissue limit has a knock on effect which increases your protective pain buffer meaning you will experience pain at a much lower level of force or mechanical stress compared to your pre injury limits.
Pain Becoming Chronic
Let’s take the example that a soft tissue injury has occurred whilst performing the lifting of boxes in the work place. Pre injury you may have been quite confident in lifting and moving boxes of up to 20kg time and time again without giving it thought. Following the lifting injury it is likely you will experience less confidence in your ability to do this and you may have even become fearful of performing this activity. To add to this your now relatively lower tissue tolerance and pain protection buffer levels mean that if you were to perform the same lifts you performed pre injury, you may now experience pain in instances that would have previously been pain free. It is worth highlighting at this point that the pain experience is not linked to actual tissue damage but rather the threat of tissue damage and knowledge that the activity has caused damage in the past.
As discussed in the previous article your environment has a big impact on the amount of pain you feel. As the injury occurred at work you may well notice that similar lifts at home or in the gym don’t hurt at all or certainly not as much as lifting boxes at work. The stimulus of the work environment in this case can be significant in the pain experienced during the lifting motion, this is because the sub conscious remembers the scenario and perceives it as an injury threat.
When living with chronic pain it is not unusual for individuals to become frustrated with their pain. They may try to ignore it and work through it, this rarely helps the situation. Ignoring the pain buffer and pushing yourself closer to the tissue tolerance threshold can trigger a protective response which you may recognise as a flare up. If the sub conscious recognises the same scenario that caused injury in the first instance it may react by repeating the same steps it took to promote healing and prevent further damage upon becoming injured. This may include protective muscle spasm, limping, limited movement and increased pain. This reaction may be stored as a default program which is triggered when the injury scenario is repeated, this is known as a Neurotag. It is important to highlight once again that although there maybe no actual tissue damage, the individual will be exposed to the same pain experience they felt after the initial injury. This Neurotag remains banked deep in the subconscious and can be repeated years after the initial injury if the same injury threat is perceived.
Beating Chronic Pain
The first step in beating chronic pain is recognising and respecting your limits. It is important that you move and work within a pain free threshold to begin with; the greater the intensity of the activity and the pain you experience, the greater the threat perceived by the subconscious. It is this perceived threat that can trigger the neurotag and cause a flare up.
Moving and working in the same environment that the injury occurred, but without pain, helps that threat perception reduce. As that threat perception reduces so your tissue tolerance and pain buffer thresholds rise. This means over time you can work within the environment that the injury occurred with increasing intensity and reduced pain experiences. This may be a long slow process and an incremental approach should be taken; progressing too quickly can result in a flare up. Aim to progress step by step and gradually raise your thresholds.
Using the example of lifting the boxes at work – if the injury occurred whilst lifting a 20kg box and now even lifting a 10kg box is painful, try not to lift any boxes heavier than 5kg. Over time you should aim to gradually increase the size and weight of the boxes you lift. If it starts to become painful take a step back and again build up gradually.
So if you suffer from chronic back pain and have regular flare ups, you now know that it may not be injury related, your nervous system is just going to extra lengths to ensure you don’t sustain the same injury again. You should also take note that in this situation you can re-educate the subconscious to demonstrate that the exaggerated pain experience is no longer needed.
Exercises to defeat pain
Until now we have covered the theoretical aspects of dealing with long term pain so let’s identify practical applications to improving chronic pain. Earlier I introduced various concepts including the brains virtual map of the body, the fact that pain can change based on context and the acknowledgement of pre stored physical reactions to injury threats known as Neurotag’s. If ignored, these concepts may work against you, however if embraced they maybe integrated into your rehabilitation.
The following is a list of exercise techniques which can be used in unison to create a plan that can help to reprogram your brains influence on chronic pain. As discussed in part 3 incrementally increasing the intensity of these exercise techniques without the presence of pain is the most effective approach to take. Each technique should be adapted to the individual based upon the physical function that creates their pain.
If a particular movement or activity frequently triggers a pain Neurotag (initiating a pain response) a great place to start reprogramming the motion is mental rehearsal. Imagining yourself perform the movement that creates the pain or even observing somebody else doing it stimulates areas of the brain which would create that movement but without the presence of pain. In severe cases even mental rehearsal may initiate a pain neurotag in which case the movement you are imagining should be scaled down until a pain free rehearsal is possible. An example of a painful movement might be imagining lifting a box from the floor, a motion which perhaps usually creates back pain for instance.
Adapting Orientation to Gravity
Under most circumstances during the day we are upright with gravity creating force vertically through our structure from the top down. An upright position is often the position we experience chronic pain in. Changing the orientation of gravity for example lying on your back so that gravity passes horizontally through our structure alters the direction of force and obliges our tissues to react differently. For instance a forward flexion of the spine may create pain whilst standing, however a forward flexion of the spine from lying maybe pain free. This helps to reeducate both the physical and virtual representations of the body in the brain and identifies that the usually painful movement can be pain free.
Balance and Stability
Gradually increasing instability as the movement progresses can help with the remapping of the virtual body. As suggested previously it is important that this is done incrementally and without the presence of pain. A forward flexion movement pattern could progress from a chair, to a ball, to standing with support, standing with no support, standing on one leg and so on.
Visual Feedback Variations
Visual feedback can add to the brains sense of threat to injury. Performing movements with eyes closed can influence pain level. This can then be progressed to looking at the painful body part move and on to watching the whole body perform the movement in a mirror from various positions.
The fact that pain is contextual means that the environment can have a large impact on the pain you feel. If you perform the painful function under the same circumstances in which the original injury occurred for example it will likely induce pain. Take yourself to a very different environment however and pain may be reduced. A great example of this would be a swimming pool where sights, sounds, smells and feelings are all very different. You may consider other enviroments like outdoors or in the home.
Moving Through Moods
Levels of stress can effect pain and flare ups of an injury may occur when individuals are angry or anxious for instance. Performing rehabilitation exercises whilst your in different moods can help to prevent this in future. This helps the virtual body experience the usually painful function without pain regardless of mood.
Thinking about pain or risk of pain whilst exercising can potentially help to induce it and so adding distraction is a welcome tactic. You could for example sing or count, possibly even create a game that involves the function you are looking to improve. Using the example of forward flexion again you may decide to chalk a drawing on the floor, as long as you are not thinking about your pain coming back distraction will be of use.
Overcoming Fear of Function
Don’t completely avoid activities which may encourage the use of the movement which you are fearful may cause injury. In the long term to overcome chromic pain you need to reprogram the nervous system, it wont be able to learn pain free motion if that motion is avoided. Plan to do activities that in the past you may have avoided but take care to control intensity. If lifting heavy boxes used to create pain begin with light boxes and progress form there, build your levels of tolerance.
Create a Movement Matrix
Performing your function using varied joint positions builds your tolerance to painful motions and teaches you to control and tolerate the motion from various angles. In a forward flexion pattern you may bend with one foot in front of the other, with your feet wide or narrow and possibly turned inwards or outwards.
Reduce Mechanical Tissue Stress
Avoiding putting weak joints into positions where they are under a lot of force can prevent you overloading pain sensitive areas. If forward flexion feels like it creates a lower back stress for you begin by stepping on to a low step and reaching part way down. Movements can be designed based on the function you wish to improve.
Avoid Motion Compensation
Your body is great at identifying movements that require the least effort and reflect the least pain. If you are to reprogram your movement, compensatory movements must be identified and gradually corrected. People that have experienced long term pain often have well rehearsed movement habits that they are unaware of. In forward flexion for instance you may see the hips kick sideways and the hands support the back on the knees.
As you can see form the above list the variables in your rehab plan can be vast. There really is no right or wrong activity rather the fact that if your not experiencing pain and your movement looks something similar to the function you would like to improve then your are making progress.
The one thing I will reiterate is that you should begin with very low intensity and progress gradually. if your progressions create pain you have taken a step too far, it is likely you will make such mistakes but each time you do you will be more aware of your tolerance level and approach it more cautiously the next time around.
Working alongside a professional that understands movement and has a good imagination when designing exercises specific to your function is invaluable. Have a positive attitude to rehabilitating chronic pain as avoidance and fear will only feed it.