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Your cranky nerves: A primer for patients to understand pain

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Published on: June 10, 2013

Audience: Patients with any type of pain or injury

Purpose: to learn a little about pain and convince you that pain is not in your head even though your brain plays a big role

Why? Understanding pain helps decrease pain and helps us make better choices in the treatment of injury

Some brief pain information tidbits

  • you don’t need a leg to feel pain in that leg (e.g. phantom limb pain)
  • you always need a Brain to feel pain
  • pain can become a habit – and like all habits lots of factors help keep it going
  • Changes in how we feel pain can also come from changes in the brain and the nervous system
  • tissue damage or degeneration does not have to lead to pain – but it certainly can

Damage does not always equal pain

220px-Lagehernia
This herniated disc does not always hurt

The idea that lots of pain equals lots of damage is a very difficult concept to shake.  It is entrenched in how we think about pain, arthritis, surgery and injuries.  When we have pain we want to know what is causing it. We assume there must be something damaged and that causes our pain.  The problem with this is that the majority of us are walking around with some degenerative joint disease, disc protrusions, tears in our shoulder rotator cuff and all kinds of things that look like damage YET we have no pain.  Conversely, you can have a lot of pain and all the imaging shows that there is no damage.  This can be extremely frustrating for someone in pain. Take a look at this rather dry post that details a number of research studies showing the poor relationship between joint damage and pain.

However, sometimes damage certainly does lead to pain.  If you break your arm it will hurt.  But in a week, that arm will still be broken but you can be out of pain.  I also know, that many people with hip degeneration are in a lot of pain, they then get a hip replacement and they are out of pain.  This is wonderful.

So why does some damage end up leading to pain and other damage doesn’t?

Several factors can contribute to our experiencing pain.  The leading theory on pain is the Neuromatrix Theory.  In a crude nutshell, it suggests that the brain ultimately decides how much pain you will feel.  The brain takes in all kinds of information and then makes a decision.  With a recent injury we think that you feel pain, swelling, weakness, tightness, guarding all because the brain is trying to protect you.  The area of the injury will get more sensitive and your brain can get better at producing pain.  The brain thinks that pain is a good thing.  Unfortunately, pain can persist for a long time after the pain is useful.  For whatever reason the brain, your nerves, your muscles, your immune system, your endocrine system all stay sensitized.  Its now easier for you to feel pain.

But none of this is all in your head.  In fact, this is how athletic excellence works

The brain learns and you become a better athlete/guitar player/knitter

np_overviewIn some ways we can think of pain as habit.  Our nerves and brain get better at making pain.  Now, I know this sounds like I am saying this is psychological because I’m talking about the brain.  But would you ever say its psychological when you get stronger after working out for 6 weeks? Of course not, but after exercise training much of the reason we get stronger or perform better is because the brain and nervous system become better at the task.  This is similar to what happens with pain.  We get sensitized and better at producing pain.

Pain is neither a barometer or a GPS

The pain we feel gets out of whack with any damage we have.  The pain becomes the bigger problem than any wear and tear.  Pain is now a poor guage of how much injury there is.  Pain is also horrible for telling us where the problem is.  Where do people feel pain when they have a heart attack?  Their arm, neck, chest and back.  There is nothing wrong with their arm.  This is how we need to think about pain.  It is just an alarm that goes off.

The overly sensitive alarm

NO! Don't make me do crunches!

If a fire alarm goes off in a building we have no idea if the alarm is due to a large fire, lighter held underneath a sensor, a little bit of smoke or even some problems with the wiring.  We can even put of the fire and the fire alarm will still go off.  This is how we can think about the pain alarm that goes off in our body.  It can stay on long after any damage has healed. You can even think of pain as a cranky toddler.  The pain or response of the toddler is often out of proportion to their injury.  At an unconscious level this is what can happen with our body.  A disconnect between damage and pain and we are left with screaming joints or muscles.

Again, the pain is not in your head

You might ask why I keep talking about cranky nerves and a cranky brain when you know that there are problems with your muscles and your joints.  I would probably agree with you.  When we have pain for awhile we move differently.  We can get weaker, we can get stiffer, muscles can compensate, you might slouch or limp or move poorly.  All of these things can either be caused by your pain or can be contributing to it.  Addressing them can be helpful but surprisingly it is not often necessary.  Often, we can change your pain immediately and you will have immediate change in strength or range of motion.

Treatment is about decreasing the sensitivity of the system

You have threshold to where you feel pain.  Treatment is about increasing this threshold.  This can be done a number of ways.  Good treatment should try to address as many different factors that influence pain.

The significance of everything above means that you can have damage. You can have joint degeneration and certainly can have the normal wear and tear associated with arthritis.  Whats great is you can change the amount of pain that you feel without ever changing the amount of arthritis, wear and tear or even damage in different body parts.

Treatment helps turn down the sensitivity of our nervous system.

See here for a description of my treatment approach.  But what we need to remember is that since pain is influenced by many factors many things can influence the pain we feel.

Related Pain Links

1. Pain videos

2. painphysiotherapy.ca

 

Golf swing kinematics ebook. Implications for performance, training and injury

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Published on: January 26, 2013

A lot of my previous research (much unpublished) was on golf biomechanics and its the only sport that I am better than average at yet I never write about it.  So to rectify that I have attached an ebook.  Its nothing special, this information is out there, but it does bring a lot together for those interested.

I did a talk last year on this topic and have some of the rough notes I used.  Below is 40 page ebook on the lecture.

The majority of the graphs are my copyright from 3D kinematic data we collected on a study 6 years ago looking at the influence of static stretching on pelvis and thorax kinematics during the swing.  Please feel free to use my pictures however you see fit.

The ebook is a simple overview of how the spine moves during the swing.  It also reviews the academic literature on what kinematic variables of the swing are related to performance and what individual golfer variables are related to performance.  Last, I touch on injury but this is a murky area and I mostly avoid it.  We don’t have a lot of good research on injury mechanism (like most areas) so feel free to make up whatever you like like everyone else does. :)

Here it is:  golf biomechanics ebook compressed

A related link is at the mytpi.com (Titleist Performance Institute) website.  This is one of the best golf biomechanics/fitness websites around.  They have a huge amount of free information and its mostly very good – especially their biomechanics.

A review of Charlie Weingroff, his course and the SFMA

Purpose: To provide a very selective review of Charlie Weingroff’s course and how it actually fits with a neurocentric view of pain and function.

Audience: Therapists and strength coaches.  Patients who  have trouble sleeping.

Related Links

1. Jeff Cubos discusses SFMA, DNS and Lorimer Moseley and they inform his practice style

2. My and Bret Contreras’ minor critical analysis of the Joint by Joint Approach

 

Overview

I took 2 days out of Charlie Weingroff’s course, Training = Rehab, Rehab = Training course here in Toronto from MSK-Plus.  MSK-Plus is a  continuing education company run by Dr. Glen Harris.  Dr. Harris has brought in a lot of great educators over the years and this course was not an exception. (more…)

This physiotherapist’s approach to treating Persistent Pain

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Published on: October 30, 2012

Audience: Patients and other health care providers

Purpose: To explain my treatment approach to Persistent Pain Problems.

Overview of the Treatment Program:

  1. Pain Physiology Education
  2. Movement (Graded exercise/activity exposure)
  3. Manual Therapy (more…)

The relationship between functional tests and athletic performance: Part I – The single leg balance test.

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Published on: July 26, 2012

Background: Testing and assessing an individual is popular.  There is an old saying that if you aren’t assessing than you are guessing.  The assumption here is that the tests and assessments you do are somehow relevant and meaningful yet I would suggest that the majority of tests and the information gleaned from them hardly change (10% ish) a therapeutic approach once you have heard your patients history. I can have a patient with knee pain and run them through 30 different tests and the results of those tests may hardly change my treatment.  Tests have to provide us meaningful information that we can do something with. (more…)

Postural correction and changing posture. Can we treat our patients like puppets?

Audience: Therapists and Strength Coaches

Purpose: To justify the use of a variety of exercises (even general exercises) for training, rehabilitation and injury prevention and question the application of movement specificity principles.

The Gist of this Post: Specificity of training is an important component of rehabilitation and strength and conditioning but I think the application of specificity can be taken too far when we attempt to mold our posture. (more…)

A critique of Janda’s prone hip extension test

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Published on: April 13, 2011

Audience: Therapists and patients with too much time on their hands

Purpose:  Provide a mild critique of the utility of the prone hip extension test

 

Background

The prone hip extension test (or prone leg extension – PLE) is a very common clinical test in use for more than 20 years.  Two influential clinicians have advocated its use although for slightly different reasons.  Both Vladmir Janda and Shirley Sahrmann have described its use for decades.  This blog will focus more on the clinical rationale that Janda proposed.

(more…)

Shoulder Pathology – a diagnostic algorithm and summary of dysfunction

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Published on: March 28, 2011

Audience: more for me but anyone interested in the shoulder can read it.

Purpose: quick reference card for thinking about a functional shoulder diagnosis

The algorithm below is from Ann Cools work:

(more…)

What is injury treatment? The judicious use of stress.

Categories: physiotherapy
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Published on: March 5, 2011

Audience: Patients

 

What is this about:  Injury Treatment

 

Injuries can be treated a number of ways and many different ways are often successful. But if I am asked to be very simple about what treatment is I start with one basic assumption.  THE BODY ADAPTS TO STRESS.  (more…)

Chronic Pain – Do therapists contribute? An unsolicted rant

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Published on: February 9, 2011

Become invisible and walk into a Chiropractic, Physiotherapy or Massage Therapy office one day. Watch them speak with a patient who has back pain or maybe a little bit of knee pain. You may hear the following:

-you need stability exercises
-these muscles are very tight
-you need therapy as you don’t want this degeneration to progress
-no more running or arthritis will certainly flare up and you will have real problems down the road
-you have dysfunctional movement patterns
-your glut muscles don’t turn on
-oh, it hurts here (pressing on upper traps). There some adhesions in the muscle
-I need to see you 2-3 times a week for the next 4-6 weeks.

All of the above statements are from good, well meaning people. And some of these statements might even be appropriate under certain conditions. These statements typically are not from the quacks and crooks that look to exploit anyone who has been in a car accident or might have fallen off their bike when they were six (and therefore their spine is permanently in trouble because of this “trauma’).

My concern is how all of these things sound to our patients – which is different from what we hear. If you tell someone they need stability exercises they probable assume their spine is unstable. That probably does not sound good to a patient with an incredible amount of pain. When we poke on areas that are “tight” or “sore” in everyone (e.g. the upper traps, you can’t find someone who is not tender there) we catastrophize, comment on how tight it is and reinforce a pain belief with our poking and create beliefs in people that there is something wrong with their muscles.

Not encouraging patients to resume their normal activities and to keep active contributes to fear and movement avoidance.

Telling patients that the way they move is dysfunctional based on an arbitrary standard of how someone should move again creates the belief in people that something is seriously wrong when there is usually no serious dysfunction.

Seeing someone 3x/week for 6 weeks for whiplash or a simple backache. Come on. Common sense says this is bad practice even though it is somehow in many guidelines.

The bottom line is we  need to watch our words.  I am no exception,  I catch myself doing this too often.  An unstable spine means something completely different to a therapist than it does to a patient. The phrase degenerative joint disease should be banned – they have a joint that is changing like everyone’s joints  and most minor symptoms have nothing to do with those normal changes.

Just some thoughts,

Greg Lehman

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