Five Strategies to Help Your Pain (Part 1)
My chronic back pain is no secret. In fact, it was one of the reasons I started to exercise. I was told I had Ankylosing Spondylitis (albeit a mild form) and that exercise would “stop your spine from fusing”. The doctor did a good thing encouraging me to move more, it’s just a pity he also didn’t explain how pain works. Perhaps I can use my experience with pain to help others who have pain in a way I could never have done before. What I am going to share over the next few weeks aren’t just 5 things that have helped me (although they have); these are quite possibly some of the best options out there to help your current pain or any future pain.
Before I begin I want to underline something very important: these methods don’t work overnight and ought to become part of every day life so that you can begin to change how you think and respond to pain. When I first saw some success from these methods, I was filled with hope and confidence in them and I felt “cured”… but what I hadn’t adequately prepared for was the occasional relapse. It is during the “bad” days that you need these strategies to be well ingrained and for that faith in the process and the journey to keep your nerves “intact” (pardon the pun). It’s very easy to allow the distress of pain to rob you of hope in the bigger picture and for you to fall into the trap of assuming that you have regressed to square one and you no longer believe that the strategies are working. That is why it is so important to always count your blessings and remember each improvement and set your mind on positive things, rather than always on thoughts like “am I still in pain?”.
I wanted to make this one blog post, but after writing out the first strategy, I realised it might be better to split this information into smaller parts to help you assimilate it all. It can be a lot to take in.
1. I learned more about pain
For years we have heard from Doctors, Physios, Chiros, Massage Therapists, and even Trainers (and I am guilty too) of spreading misinformation about the causes of pain.
“Your leg length is off”
“You have flat feet”
“Trigger points”
“Your pelvis is out of alignment”
“you’ve blown a disc”
“Your back is a ticking time-bomb”
“I just have to look at you squat and my knees hurt”
“Watch you don’t wreck your back when you deadlift”
“Your diaphragm is dysfunctional so all your pain stems from there”
“You have bad posture and that’s why you have neck/ shoulder/ back pain”
“Oh, you have back pain? Your Glutes are weak and you have tight hip flexors.”
The list of things I have heard is endless.
Basically, what seems to happen is that therapists correct what they think is “off” and pain might initially improve. So they rationalise this like so:
– You have pain and X is tight
— Work on X’s tightness
— pain improves
—-therefore X was the cause of pain
Bingo!
Hmmm, NOPE!
There is a rather large body of evidence that now shows us that posture, structure and biomechanics are poorly correlated with pain. Meaning, they are unlikely causes of pain and improving or “fixing” these play less of a role in healing pain than was believed for a long time. And, if someone tries to explain your pain’s origin as a tightness, imbalance, weakness, poor motor recruitment, poor breathing, poor alignment – close your ears. Treating said tightness etc might help, but that is not proof that it was the cause!! This is very important to remember. Think of it this way: Are you sore because you’re all twisted up or are you twisted up because you’re in pain?
Being somewhat lazy and a little rusty on how to reference properly, here are a few blog posts that have great authors who did that work for me. If you’re anything like me, you might appreciate reading a blog article that is making sense of the research, rather than reading the research itself.
– The Real Reason You Still Have Back Pain
– Does Posture Cause Back Pain?
And, of course I enlisted the help of my very smart and handsome husband, Dr Jonathan 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 too.
Yes, there are other resources, but I like these ones because they cover all the basics. And that is always the best place to start. Lay the foundations and build the rest as you begin to understand it.
So what is Pain?
I felt it was important to talk first about what pain isn’t (a signal that comes from the muscles, joints or bones) so that we can better grasp what pain is (a signal that comes from the nervous system, and is governed by the brain). Pain is not always indicative of tissue damage/injury, and it is not proportional to damage. If you have more pain today than yesterday, this does not mean there is more (or any) damage. When you have pain, your brain has received danger information from one or many locations within your body (via the vast network of nerves) and has decided that it warrants some pain to change your behaviour and protect you from something that is *perceived* as a threat.
And I get how confusing that is!!!
When I first heard this stuff (a couple of years ago) I failed to assimilate it because I got defensive and thought it was suggesting that my pain was all in my head (as in, imagined). But actually, *all* pain from is the brain (and nervous system) – even if it’s just a stubbed toe.
At this point I want to highlight something so that you don’t misunderstand me. I am not saying that pain is somehow not physical. It is physical, but these physical changes and responses happen within the nerves and brain. Before, I always thought pain came from damaged tissue and it told my brain it was in pain, but this is not the case. The nerves deliver a message about what’s happening (toe got stubbed on the table) to the brain and the brain then decides whether pain is needed. However, sometimes this system doesn’t operate as we would expect.
For example:
You stub your toe just as a lion jumps in the room. Are you going to have pain in your toe? NO WAY! Your brain will delay that until you are safe enough to tend to your toe.
And there are many other times when the brain and nervous system respond in ways that really do not make sense if all pain is from injury:
Have you ever discovered a cut or bruise that you didn’t know how you got?
Does your pain get worse when you’re stressed?
Does your pain get worse when you’re tired?
Ladies, do you feel more pain before or during your period?
So, pain is a response (like an alert) from the brain to a danger signal from the body. BUT, the “alert” may be very very quiet (only a little pain) or VERY VERY loud (lots of pain). And if you’re like me, and your pain seems to get worse for no apparent reason, it can be very disconcerting and cause much unnecessary confusion and angst. This is why knowing how the nervous system interprets information will help reassure you that when you get a bad pain, it may not be because something has gone seriously wrong.
So what amplifies that “alert”?
Now consider each of these things potentially “ramping up” your nervous system’s alarm sensitivity, making that alarm ring a little bit louder:
– Not knowing about how pain works and what it means
– Stresses (family, work, money, health worries or fears)
– Thinking the worst (catastrophising)
– Fearing movement because you believe it is causing damage
– Depression and lack of sleep (this can be a vicious cycle for someone who already has pain)
– Loss of motivation to train (maybe because of fear or depression or hopelessness – or being told not to train by a well-meaning physio or doctor)
– More pain
– Fear of pain itself
– Beliefs about your pain and/or diagnosis
– Oh and even hormones, temperature and your immune system can contribute to your pain *experience*.
There are more things that could potentially go onto this list, but you get the gist.
Factors like these can play some sort of role in your pain experience. Even if you do have an acute injury, it is still helpful to understand why some days your pain may seem worse, even when healing is under way. Pain does not mean something isn’t healing. The body is very good at healing its tissues, but sometimes after an injury the nervous system becomes more sensitive as a way to guard from a repeat injury. After all, if anyone has ever been in severe pain, you’d do anything to prevent it happening again, right? So, depending on your circumstances, your beliefs, your history etc etc your pain experience will differ greatly compared to someone else. But you also have a lot of control over many of these factors – and that is great news! And even if you can only influence your knowledge about pain, that has been shown to help pain.
Pain as an experience.
No one has the same experience of pain because there are so many factors involved in pain’s creation: memories, beliefs, smells even. But guess what? That means *you* (the person dealing with pain) have more control over it than you may know. It is quite helpful to become proactive about your pain triggers – without obsessing on them. If stress is a trigger, then you can use some of the other strategies to help with that. If beliefs are an issue for you or fear, then this educational strategy will really help.
For years I expected someone else to fix me. Either by massaging away my tight fascia, teaching me “good alignment”, correcting my “dysfunctional breathing or movements” or by prescribing me better medicines. These strategies are called “bottom up”. While many of those things can help pain, they don’t get to the root of it and you often end up seeking more treatments and getting more investigations, which don’t have as much success long-term. Since pain is governed by the brain, then surely we ought to focus our attention there to see what can turn down the alarm. The best pharmacy, after all, is right between your ears.
By using the next 4 parts of this series, you will learn a total of 5 “top-down” strategies (education is also a “top down” approach) to radically influence your pain.
Life and death is in the tongue.
Do I still have pain? Yes, but it is MUCH better than it was, but the main thing is that I don’t respond the same as I always did – which was the belief that there was something wrong with my tissues, joints, posture, breathing etc. I thought I was broken and I was at odds with my body. But now I see that my body is healing and movement is good. Avoiding movement (and this happens if you begin to believe that some movements or postures are “bad”) can actually cause you to have the very pain you are trying to avoid.
Which brings me on to another issue that comes from the words and reactions of therapists, doctors, trainers, and even the beliefs within a society about pain. There is a good amount of research into something called the nocebo effect (the opposite of placebo). Basically this means that the beliefs you have about your situation can make things worse. For example: If someone is told they have “blown a disc”, how do you think that will affect their beliefs about their back? It could potentially make them fear moving their back (because they believe pain = damage) and this fear increases the alert which increases the brains output of pain to protect that “weak” and “vulnerable” area. Pain is protecting against a false danger. This person could live for years in chronic pain because they started to fear moving their back. And they may actually begin to get other pains (in their hips, down their legs or their sides) because they have become so stiff and “braced” in order to support their back that these muscles never stop bracing. Can you imagine clenching your fist all day every day? That would eventually hurt, right? So these words can have real negative effects on people’s lives. Instead of being told that discs herniations are very common, that they heal and movement is good, they are told never to lift or flex their back again. Plus backs are strong and the disc may have had very little to do with their original complaint.
But don’t take my word for it – read the articles and set yourself free from believing all pain is caused by tissue damage.
Here’s another little list from smarter people than me who have listed the research.
– Nocebo Effect: Your Power of Suggestion May Harm Clients
– Spinal Discs, osteoarthritis and degenerative joint disease with pain
– First, Do No Harm – language can harm!
Now you have 1 major tool to help you reduce your pain. Just understanding pain has been shown to reduce it.
Pretty awesome, right?
I expect there will be a few questions after reading through some of this material. Feel free to ask and I will try my best to clarify anything.
Also, if you want references for anything I have said, I will be happy to provide them in the comments.
Additional Reading Material:
– Therapeutic Neuroscience Education (2013) by Adriaan Louw
– Explain Pain (2013) by David Butler and Lorimer Moseley
October 9th, 2014 at 2:02 pm
Thanks for a great article. I’ve read Dr. Sarno’s “Healing Back Pain: The Mind-Body Connection” and can understand that the brain sends out messages even if there isn’t damage. However, I’m not so sure that it can or should always be dismissed which is basically what I’ve taken from that book. Last year, I was fused from C4-C7. I’ve had more pain since surgery than I ever did before. I still run (though not nearly as much as before surgery), use kettlebells (and am only now not feeling guilty because I don’t use anything more than a 25 lb bell), do yoga, hiit strength training and cardio kickboxing. There are times I push my body too far and have to pull back a little and slow down. I’m trying to listen to my body within reason…not always easy. And yes, I have the fear of injuring my spine even further. Is it the fear that cause my pain? Pushing too hard? I don’t know. I look forward to the rest of your articles!
October 9th, 2014 at 5:01 pm
Hi Michele,
I think you are perhaps misunderstanding pain being “in your mind” with “in your nervous system”. Or perhaps you are still combining injury and pain in your own case. We can feel, perhaps because our own pain is so much a part of our lives, that we are the exception to the rule, or we fear that something is being missed and so even when we intellectually understand that not all pain = injury, we hang on to the possibility that our pain is caused by injury. I’m not saying that is what is happening with you, but I wanted to throw it out there in case it makes sense to others.
The “mind” part of pain plays into the nervous system part, but the nervous system part is always true. Pain is always a reaction to threat/danger within the brain and nerves. So the experience of pain comes from the information of tissues being damaged or perceived as vulnerable to damage (which may or may not be the case). Pain can both come from and be made worse by fear of pain/injury. In both situations the nerves are still being “instructed” to respond the same way as if there was tissue damage, if that makes sense. This is why so many people present with pain and have no findings on their X-Ray or scan. This is also why phantom limb pain exists: there are no limb tissues and no limb nerves, but the brain map of that limb still exists and that is why pain is still experienced as if the limb was still attached.
Is fear causing your pain? From what you have said, it could be contributing to it. After all, tissues heal (even when you have a fusion). If pain is worse only sometimes, this does not mean that the damage is worse, this means that the sense of threat (within your nervous system) is very sensitised and certain circumstances trigger it. This threat level can therefore be influenced by your fear, beliefs etc, fatigue, stress.
Pain should never be “dismissed”, but it should be understood and put in perspective, which is the point of this article. From the research, we know that back injuries and spinal problems (like disc herniations) are poorly correlated with pain. And as a result, spinal surgery frequently has poor outcomes *for pain treatment*. Why? Because that pain never originated from those tissues. The pain originated from the brain’s assessment of the information that was gathered about the entire situation (for example: what’s happening or what has happened at the area that is in pain, what are the memories and beliefs of this, and even what happened the last time you did Y exercise). In your brain, that areas of your spine has become “an area of special observation” (whether because of the surgery, previous pain, worry or whatever) and so your brain recruits more information-gathering cells. This also means that information that used to be ignored (because it was not interesting) has become VERY interesting and as a result there is now more potential for information to be perceived as potentially dangerous. Which is why more things now trigger pain that didn’t before.
Your statement: “I have the fear of injuring my spine even further” brings me to ask, does it matter if more damage occurred without pain (which we know is very possible)? In fact, we know that there is not a 1:1 damage-pain ratio. Perhaps what you are fearing, rather than more injury, is more *pain*. Which is more relevant because that is what these strategies will ultimately help. You can use “bottom up” treatments and techniques to help reduce injury, but that still won’t guarantee less pain. So in that sense, we actually should never dismiss this side of the equation (as has been done so often before) because that is where the key to pain lies, not injury.
Injuries heal. Pain can persist. And it is the belief that pain=injury that needs to be resolved.
I hope this helps 🙂
October 9th, 2014 at 2:24 pm
Much needed read this morning. Thank you!
October 10th, 2014 at 12:22 pm
Thanks for your reply. It does help! I’m sure I am still combining pain with injury. Last year was very traumatic for me as I did not have many symptoms related to my herniations. For me, it came out of nowhere. I originally went to the doctor because of numbness and tingling in my thumb and index finger. I had zero pain and had full range of motion. My MRI showed significant herniation from c4-c7 with c-5/6 indenting my spinal cord at an ap diameter of less than 5mm and also showed possible myelomalacia. I went to pt and they couldn’t believe I did not present with pain and could move freely. It was all scary and from MRI to surgery was only 3 months. While I was told that surgery was absolutely necessary, it has created new pain issues as well as range of motion. I really do need to learn to understand my pain. Thank you!
October 10th, 2014 at 12:39 pm
I am so sorry that happened, Michele. Do you mind me asking why they told you surgery what “absolutely necessary”? Did your symptoms significantly worsen in 3 months? Did PT not help?
October 10th, 2014 at 7:53 pm
My neurosurgeon told me surgery was necessary as I was crushing my spinal cord. Both neurosurgeons that I saw told me a hard fall or small car accident could sever my spine. Well, that terrified me. I have two small children (4 & 8) when this was happening. I want to always be able to physically interact with them – touch them, hold them, walk, run and play with them. I know this surgery is considered to be elective but it certainly didn’t feel elective to me. PT didn’t hurt or help. I was touched very gingerly as they had seen my MRI and I think I made them nervous. Everyone from my personal physician, PT, neurologist and 2 neurosurgeons told me that herniations that large pushing in to the cord would never resolve itself on its own. I did not have surgery for pain. I wanted the herniations off of my spinal cord. However, during that time, my anxiety grew by a lot and I was having all sorts of new pain, numbness and tingling. My blood pressure was high for several months and I know now that I wasn’t truly having new issues but my anxiety caused me to feel like it.
I still have a lot of work to separate my pain with an actual injury or potential injury. I should go back and re-read my book on the mind/body connection. I also look forward to your next installment on pain.
October 10th, 2014 at 8:54 pm
Thank you for explaining. What an ordeal! It makes a lot of sense to me why you now have pain and I wholeheartedly believe that you will find relief from these strategies. You are a perfect candidate, so to speak.
October 11th, 2014 at 7:48 pm
I have been searching for someone like you for over a year. I am almost 69 yrs old, female. 14 months ago, I suffered some kind of injury after coming in from the pool. Horrible pelvic pain which lasted for about 30 minutes. It then settled into what I thought was my rectum. Pain severe to where I was suicidal. All test imaginable. Nothing wrong. Pain management Dr. saved my life by giving me Neurontin and tramadol. After a time, they no longer worked. Now off of those. Take Cymbalta for anxiety due to fear of pain, .50 klonopin middle of day and .25 Xanax at bedtime. These are anti-anxiety meds, not pain meds. Two months ago, the pain moved to the left buttock. Had MRI: bulge at L34, bulge at L45 with tear, bulge L5s1 with tear. First 2 listed as moderate, last listed as severe. I had read the Sarno, Schecter,, Shubiner books, did all the repressed memory work, read how their patients got well in just a few weeks, but I didn’t. Couldn’t figure out what I had done wrong or was not doing. That’s why I like your approach so much better. It doesn’t make me feel like a failure. Neurologist wants me to have injection into back. PT after 2 wks of uploading said it was not going to work. So here I am trying to sort all this out. I used to play racquetball, lift wts, walk, swim. I have resumed swimming, wts, Cant walk because of burning in small toes on left foot. Love what you said about pain room and blessings room. Would love any input you could give. Thanks for this blog.
October 21st, 2014 at 3:08 pm
Hi Marion,
Sounds like you’ve really been through the mill. Perhaps you will find this article of interest, too: http://www.bettermovement.org/2014/a-systems-perspective-on-chronic-pain/
October 13th, 2014 at 6:59 am
[…] ” Five Strategies to Help Your Pain.” By Marianne […]
October 15th, 2014 at 6:25 am
This is REALLY good stuff.
As someone who is struggling to overcome chronic low back pain, it’s refreshing to hear someone who knows what they are talking about. I just finished reading a book about chronic pain, and the author (an orthopedic surgeon) mentioned something I thought was a little bold but really interesting nonetheless. He said every patient he has worked with who is trying to overcome chronic pain, is angry. Whether or not the anger preceded the pain, or rather was a cause of the pain, he was pretty adament that anger (amongst other things like anxiety, depression etc.) had to be addressed before anyone would see sustainable change.
He told a few stories about clients who refused to believe they had anxiety, depression, anger etc. He provided several examples of patients who would yell at him, run out of his office, and a few that would later commit suicide.
I can only speak for myself, but everything written in the book is entirely true of my situation. While I still struggle quite a bit with pain, learning more about it has helped quite a bit. Being more cognizant of your thought patterns, and simply being more mindful of how you are feeling, has made a difference. I’m not sure why the mechanical model of pain is so prevalent, or why it got started to begin with, but it simply makes very little sense. It took me a while to realize it, but I’m glad I at least have a better idea of what is going on.
October 21st, 2014 at 3:04 pm
I can certainly see how anger would correlate with being in pain. But remember that anger, anxiety and depression are part of being human. There are physiological reasons why anxiety and depression are highly correlated with chronic pain so, while it will help to address them, it’s important to remember they are part of a non-linear system. Here is another great read on this topic: http://www.bettermovement.org/2014/a-systems-perspective-on-chronic-pain/
It seems like you have a great understanding of the emotional and physical aspects of the pain cycle and I hope you continue to get better 🙂 Thank you for commenting!
February 5th, 2016 at 1:37 pm
Thank you for publishing these posts! I also especially liked the article you referenced on chronic pain.
October 24th, 2014 at 10:21 pm
The only problem I have with this article is when you say “here’s another little list from smarter people than me.”
You are one of the strongest critical thinkers I’ve ever met, and I can’t imagine there are many who are smarter!
This article has had a profound impact on my opinions, thank you. Can’t wait for the whole series to be available.
October 29th, 2014 at 5:47 pm
[…] to practice what I am preaching, eh? And also learning way more about the physiology of pain. In Part 1 I discussed how the nervous system is the place where pain happens and it is influenced by many […]
November 17th, 2014 at 10:54 pm
Hey Marianne! I’ve been keeping up with your posts on your SI Joint issues and pain as I have also been to doctors, physical therapists, read all the biomechanics stuff on posture/alignment (a lot of Katy Bownman) and have been told no dead lifting at all, that one leg is longer than the other and that my SI joint issues are the result of hormones and pelvic floor/diastasis recti problems. Wondering what your hubby has recommended you do to strengthen/help/heal these issues or any other wise advice that you are heeding and /or incorporating in your workout and lifting routine. All this conflicting information is quite overwhelming and not very helpful! ps. Your writing, as a fitness professional and also as a Christian woman is so amazingly refreshing. : )
November 23rd, 2014 at 3:49 pm
Heidi, sorry to hear about your confusion about what you should do/not do etc. I totally understand that! My husband’s advice is to find someone who specialises in Chronic Pain, rather than structural disciplines. He said that you need to speak to someone who is up to date in the pain research so they can treat you as a whole person, not just parts. No person’s pain is purely Biomechanical and no person’s pain is purely Psycho or Social. But each has a different role to play in each person’s *experience* and sometimes these things change at different times.
Sometimes my own pain can be more Bio than psycho or social but i still “treat” it as a combination by remaining calm and positive, enjoying what movement I have and by remembering it will get better.
Where do you live?
December 3rd, 2014 at 8:15 pm
[…] to read these five strategies in order, but if you want to, you can read the previous ones here: Part 1 and Part […]
February 12th, 2016 at 12:49 pm
[…] Five Strategies to Help Your Pain (Part 1) […]