I am helping drum up enrollment for this great course in Toronto June 13-15, 2014. I am a fan of this approach and am looking forward to taking the course and hope to see a lot of people there.
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
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
In 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
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
This brief post has two main points:
Static stretching is not going to kill your performance
Static stretching is not a cure-all
Further, nothing in this post is even remotely new.
Purpose: To list a number of gait adaptations that you can make that might help you run injury and pain free.
I’m of the opinion that running is rehab. Here are some running rehabilitation thoughts that justify changing your gait during a return to running and some things you might want to keep in mind. Please remember, this is not comprehensive and should not be viewed as the only things you do to rehab injuries or run pain free. This is one aspect. Please see a professional for help.
1. Pain does not equal injury – keeping running while you are injured helps keep your fitness but can also decrease the threat and fear associated with the injury. In the picture below there are three lines. The first is your injury threshold. This can be breached when you do too much too soon and don’t give your body the time to adapt to the stresses you place on it. The second line is your pre-injury or pre-pain experience pain threshold. This the point in terms of physical stress where you used to start feeling pain. This line is your warning line created by the brain. The third line is your new pain threshold. When you have pain/injury you often start to feel pain much sooner. It is like a habit and you get better at feeling pain. We want to break this habit. Running as rehabilitation lets you just “gently poke the bear”. Your goal is to change the threshold of where you start to feel pain. You are NOT hammering through pain. You are just going to the edge and then backing off. By exposing your body and brain to running again we slowly creep up that pain threshold line. This occurs through physical adaptations but also neurological plasticity (i.e. changing that pain habit through graded motor exposure).
2. Don’t run through pain – run just to the edge of pain. If you feel pain start to walk for 30-60 seconds. Run again for a little bit. Keep increasing your exposure slowly.
3. Add variety – remember pain is more than injury. Pain is very context related. Ever heard about Vietnam veterans being hooked on heroine in Vietnam, coming home and having no cravings but when the go back for a visit they are jonesing for a fix. This is context. Pain is a habit and can be triggered by context. Change your running context. Different shoes, different paths, times of day, don’t run perfectly straight, veer, weave and changeis. your form (more on this). A lack of variety continually stresses the same tissues but can also activate the same neurosignature associated with the pain you feel. Lets avoid this.
Gait Modifications you can make
We have biomechanical justifications for many of the recommendations below. The research is mixed but we can say that you will experience different tissue stresses when you make these adaptations. Many professionals will suggest that the adaptions address a specific deficit or flaw in your form - this may be true but there are also more general and less reductionistic explanations. We we can also argue that merely changing something about your running is enough to create a stimulus for your tissues to adapt, to change the stress on some neurally irritated areas and to break the pain habit with variety and graded exposure. But I digress, here are things that you can do.
1. Don’t overstride
Be conscious of where your foot lands in relation to your body. Film yourself on a treadmill. Is your foot way out in front of you? Is your lower leg far from being perpendicular to the ground? Is your knee straight at impact? Work on feeling like your foot is landing behind you (I recognize that this is impossible as is having it land underneath you but still attempt this and in the attempt you will get your footstrike closer to your center of mass).
2. Increase your cadence
This is strongly related to not overstriding and is another way to work on having your footstrike closer to your body. I don’t believe in any magic number as I feel that cadence is strongly linked to speed. If you are running slower than a 6 minute/km pace than it will be tough for you to get higher than the supposed magical 180 steps/min. So don’t worry about it. Just try to take lighter, quicker steps. A general rule is an increase of 5-10%. Increasing this excessively will most likely influence your running economy in the bad way.
3. Pull with your glutes
Again, many of these are inter-related. The idea behind this is twofold:
a. this may decrease overstriding by increasing your hip extension (i.e. how much your thigh goes behind you). See detailed review here.
b. this may decrease how much your pelvis drops side to side and the amount of knee valgus that occurs during ground contact. These variables are often linked with knee pain in runners.
What you do is you tighten your butt when your foot hits the ground and feel that your are pulling your leg backwards while it is on the ground. Feel like you are even pulling the ground. Do this for 30-60 seconds out of every 600 to 1000 meters.
4. Modify the impact of your running by running softer.
My favorite running researcher is Irene Davis. Much of what I know I owe to her body of research over the past 15 years. Dr Davis has recommended for years that one of the simplest ways to change the loading rate (or tibial shock) in runners is to simply instruct them “To run softer“. Isn’t that awesome? Just let the runner figure out a way. Some runners might shift to a forefoot strike, some might heelstrike but they will find a way to make less noise and run softer. See a minor review of ways to change impact loading here.
5. Change your footstrike
I don’t believe in any ideal foot strike. I have advised runners in the past to try running with a heelstrike yet a forefoot and midfoot striking gets all the positive press and the heelstrike is deemed a faulty wanker. I think they can all be beneficial and appropriate at different times. If you are having trouble with your calves or your metatarsals then maybe trying to run with a light heelstrike for 30 to 60 seconds out of every three minutes is right for you. The inverse is also true. Been having knee and hip pain? Try shifting to a forefoot or midfoot strike for 30 seconds out of every three minutes. Increase over the course of a few weeks the amount of time you spend forefoot striking. See a review of form, footwear and footstrike here and a review of barefoot and footstrike styles here.
6. Change your speed
Michael Fredericson recommended this more than a decade ago after noticing that many ITB painful patients felt better when running with increased speed. The key again, is variety and sharing the load across different tissues and changing context. Do 15-30 second pickups every kilometer.
7. Run with your feet slightly wider apart
Running with your feet just 2 inches wider has been shown to change the tension on the ITB (abstract here)and on the amount of pronation at the foot (abstract here). Again, the mechanism for this being helpful is that it is different and thus has novel stresses on the tissues.
Remember, variety is good for injury. If you run a factory that builds cars the best way to injure your workers is to have them do the exact same thing thousands of times a day. The safer method is to have them perform a lot of different tasks through out the day. Training can be seen much the same.
As an aside, this is also why I am not a fan of the ideal sitting posture. Throw that 1950s stenographer posture out the window. Slouch, lean one way, then the other, cross your legs, feet on the desk, head tilted back, trunk rounded, trunk straight, arm rests, no arm rests –Variety, novelty, tissue load distribution. We aren’t built to do the same thing. Forget the ideal, go for variety.
In part one of this post I very simple reviewed some of the ideas behind core stability and how I questioned their relevance to a patient’s pain presentation. In this follow up post I will briefly review how people with pain have different function than those without pain and give an opinion on how core ‘stability” exercises may help with patients in pain in a manner that has nothing to do with stabilizing the spine.
Nutshell summary: People in pain have spines that function differently than those not in pain. Many treatments can influence pain. The spine stability model of low back pain does not explain how people have pain and takes an overly mechanical view of the pain experience. No test has ever shown that a spine is unstable or how “increasing stability” would lead to a decrease in pain. Thinking that our spines need more stability or control may be the completely wrong path in explaining how people have pain or how our exercises help them. Our treatment “corrections” occur not via one specific “corrective” mechanism (e.g. improving stability) but rather through global non-specific mechanisms that our better explained by our understanding of pain neuroscience. Making the shift from believing that “stability” is the issue with pain can thus free up to choose completely different exercise programs. Exercise and treatment prescription thus become simpler. We have preliminary evidence to support this view with the clinical studies that show benefits with the various exercise conditioning programs that train different schools of thought on stability or the just as effective programs that completely ignore any concepts of stability.
Purpose: I recommend a lot of hip exercises and consider variety and novelty important for people in pain and for athletic injury rehabilitation. This is just a catalog of pictures. Please don’t do them and don’t consider these to be the be and end all for exercises. Many other exercises can also be chosen to achieve your goals. Below is a catalog of a number of exercises that you can use to train/stress your hips. (more…)
Purpose: To explain my treatment approach to Persistent Pain Problems.
Overview of the Treatment Program:
- Pain Physiology Education
- Movement (Graded exercise/activity exposure)
- Manual Therapy (more…)
A recent article in BMJ by Deb Cohen entitled “The truth about sports drinks” got a lot of people very excited, me included. The article seemed well written to me but I don’t know enough in this area to be legitimately critical. And that was the problem with the article. Most of us know relatively nothing about an area but read a seemingly good article in a well respected big medical journal and its easy to take everything at face value when perhaps it shouldn’t be. Fortunately others know better about sport drinks and have started to write rebuttals. Of course, these rebuttals or counterpoints should have been included alongside the original piece – that lets us be the informed consumer of science. There are two sides to everything in this grey, gray, not black, not white world of body science. Below is the original article and some responses from the involved and often maligned parties.
Deb Cohens initial piece ” The truth about Sports Drinks”
Dr. Stu Phillips from McMaster University initial response here
Dr. Michael Sawka interesting response here
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…)