Pain Education

What Pain, Legos, and your Mom have in Common

Simple analogy for one of the most often questions I'm asked on a daily basis. "Why did (insert body part) get hurt when I didn't really do anything to cause it?

Watch to video below to learn more.

It's about recognizing what needs work, and picking 1-2 things that are most efficient at addressing it to help prevent "stepping on the lego". If pain is present, then finding 2-4 things to do which are most efficient and do them often until the mess is cleaned up.

My job is to find what it is that will be most efficient to helping you clean up the mess and keep in cleaned up for the future.

Ann Arbor, Mi

About the Author: Dr. Greg Schaible is a physical therapist/strength coach specializing in athletic performance. He attended The University of Findlay, graduating in 2013 with his Doctorate of Physical Therapy (DPT). As a Track and Field athlete, he was as a 5x Division II All-American and 6x Division II Academic All-American. Greg is the owner of On Track Physiotherapy in Ann Arbor, Mi. You can stay up to date with helpful information and news on Facebook.

Does Gaining Range of Motion Really have to Hurt?

Not all physical therapists are created equal. Nor does gaining range of motion have to be extremely painful! Unfortunately there is this idea among the public that physical therapy has to hurt to be effective. In most cases, nothing could be further from the truth. Sadly enough there are plenty of physical therapists out there who also believe "no pain, no gain" to be true.

Before we go any further, I need to clarify that pain is very different then a "stretch", "pull", "pressure" or "fatigue/workout soreness". Just because I don't believe in "no pain, no gain" doesn't mean I'll vouch for laziness or sub-par effort.

So here is why gaining range of motion does not have to hurt:

–  When the brain starts feeling ‘stress’ it goes into protection mode.  A pain response results in signals sent to muscles, fascia, and joint capsule to literally tighten down to protect the painful structure.  So the entire time your PT is cranking on your new rotator cuff repair, knee replacement, or you are cranking on it at home per their instructions. Your brain is busy fighting back.  The result is lots of pain and minimal progress.

– Pain fires up your sympathetic nervous system, the part of the system that handles ‘fight or flight’ situations.  To complicate matters, research has found that a lot of people are already in this sympathetic state even at rest. These individuals tend to exhibit increased stress hormone levels that result in poor sleep patterns and poor recovery from workouts and games (If you are coming off of surgery, I would argue that you are already in this state to some capacity anyway).  This elevated level of stress over the long term can have some serious effects and implications on rehabilitation.

Balance is good!

The moral of the story here is that increased pain levels correlate with increased stress levels which can delay healing and recovery.  Some pain is going to be present when you’re dealing with an injury or surgery, but your therapy should not be making you consistently feel worse! Increased pain is not an ideal situation for someone trying to gain range of motion, strength, and returning to work or athletics.

So how do we avoid the "no pain, no gain" philosophy! For starters, you still need to put forth maximal effort. Laziness will not get you out of pain. If you are post surgery then you should expect some type of "stretching" or "pulling". It is very important to distinguish between this and actual pain. The surgical limb has to move (when appropriate) and move frequently in order to start improving and building back up normal tissue resiliency. However, you want to avoid jamming your limb through further ranges of motion putting yourself into a further stressful (sympathetic) state then you already are post surgery.

Taking this a step further, in both surgical and non surgical folk we want to consider other areas which could be contributing to your overall dysfunction and pain on movement. This means looking at the joints above and below the injured area to make sure they are functioning optimally. Assessing the difference between active and passive movements also plays a role on distinguishing between actual soft tissue restriction or just lack of motor control or coordination in those end ranges of motion.  Muscle strength, endurance, work capacity, and timing are all important factors as well.

Next time you go through a physical therapy treatment, or any treatment for that matter, ask yourself if all these things are being assessed? If your program feels like a cookie cutter program then it probably is! Find a provider that understands pain and will take the time to assess/reassess movement. In most cases, there are better ways to gain range of motion and strength than trying to push through restrictions and pain.

(Part 4) The Setback, The Comeback, and Staying On Track!

Learning The Value Of Physical Therapy – A Patient’s Perspective

Let’s Recap:  Last week you heard about my successful experience with physical therapy, and how I was ready to ride off into the sunset. You can read Part 3 HERE (or maybe you missed Part 2 and Part 1).

This week I talk about how I thought I was good to go, acted like I was invincible, needed a reality check, and finally put an end to all the madness!

Prior to what I refer to as “The Setback”, I had taken big steps to improve my overall health. The PT I worked with was also a fitness trainer, and I didn’t’ hesitate to hire him for this venture. He understood my ability and history of injury, and took this into consideration when developing a fitness regimen. Everything was going great for about six months. I had lost 50 pounds, gained a lot of strength, and was feeling awesome! This was the best shape I had ever been in, and I was starting to feel “invincible”.  I started doing too much, too often, and taking things too far………

The Setback

After a few weeks of being “invincible”, I woke up one morning feeling a very familiar pain.  My right arm was aching and I felt some pain in my back and neck area. I didn’t panic right away….. but then three days passed and the pain was still there. Now I started to panic. The thought of re-living that pain was terrifying to me. My anxiety went from 0-100 in a matter of days, and the pain started to increase. I saw the physical therapist, and he did a brief evaluation. He didn’t seem overly concerned, and thought I had just overdone it with exercise. He encouraged me to do the PT exercises and stretches again for a few weeks.  This calmed me down, but that would be short-lived. I did what he told me to do, but I was full-on freaking out and things started to get worse. The pain was similar to before…….but different…… not as consistent in level or location, and I didn’t have any weakness……. but range of motion in my neck was decreased (the pain I had before was constant and unrelenting). My fear and anxiety about the pain returning took over, and I threw myself back in the ditch!

I went back to the physical therapist and insisted I had another herniated disc. I had been in pain for over two weeks, and was starting to feel like I was in a vicious circle. He agreed that my range of motion was decreased and something was going on, but not for the reason I thought. I argued with him about my previous MRI, cervical disc problem, and my pain. He had me sit down to try to explain something to me……. but I didn’t get what he was saying.  All I heard was “Your body has an alarm …. blah blah blah…. brain thinks there is a problem……blah blah blah……not a herniated disc.”  It sort of sounded like he was saying the pain was all in my head. I was certain it was caused from the disc issue, and I didn’t have a clue why he would be thinking anything else. Did he not believe me?

I got home and started thinking about what he said, and of course went on the internet. I found myself on websites that talked about something called “pain science”. I didn’t grasp this concept, but I was intrigued.  I saw him again for another appointment, and we talked more about pain science. He explained that he DID believe that I was having pain, but my clinical symptoms weren’t consistent with a herniated disc. He used some different analogies that made more sense to me, and went into more detail about this “alarm” going off. I still was having a hard time with the concept that this pain wasn’t necessarily coming from the area I was feeling it, but I was determined to find a way to understand this.

The Comeback

It was time to move on to getting me out of trouble yet again. This PT was standing there by the ditch, but he wasn’t going to pull me out this time. He was going to throw me a rope, and make ME pull MYSELF out! He gave me a “reality check” and said I needed to get my fear and anxiety under control if I wanted to change what was happening. He gave me more information on pain science, as well as reputable websites and professionals who had written about it. I read some very good books on the subject, and realized that I was the person in the books……..and the light bulb turned on!

My pain was definitely real, but was being magnified by my brain “thinking” I was in danger, and not from an acute injury. My prior injury had “sensitized” my neurological system, and pushing myself too far with exercise alerted my brain that I may be in danger, thus setting off this alarm. This was why my pain was so inconsistent and would wax and wane depending on what I was doing, or my emotions (and also why no weakness was present).  Sometimes the brain can be a little too protective and respond with pain even if there is not an actual injury, this is because it remembers the previous injury. (Pain science is a whole other blog post!)

Grasping the pain science concept and knowing that I didn’t have an acute injury reduced my symptoms significantly, but there was still work to do. My neurological system had gone haywire, and it would take some trial and error to reset it. I did the exercises and stretches, got my anxiety under control, and the PT did some manual therapy.  Before I knew it, I had pulled myself out of the ditch and turned the alarm off.  It would still take a little time until I got the hang of this “alarm” in my brain. My neurological system was really sensitive now, and I had to be careful not to flip the switch.  I tried going back to my fitness routine, but every time I did, it would trip the alarm and the symptoms would return.  I finally realized I needed start over and do what the PT said and what I had read in the pain science books…….“graded exposure”. I needed to start out very slow, take small steps, and work my way back up. This drove me crazy, because I had no patience and wanted to be back to the level of fitness I was at prior to the setback.  It took an entire year, and there were bumps along the way, but I finally got there!

Staying On Track

It took me almost two years to fully appreciate the value of physical therapy and how it improved the quality of my life. There are so many lessons learned, that I have lost count! This experience forced me to develop patience, which I definitely needed. I learned to understand my body, how it works, and that I need to listen to it when it is trying to tell me something.  I learned that doing things the right way might take longer, but I will get a better end result. I learned that anxiety and emotions can have a big impact on me physically. I learned that I need to participate in my own healthcare, and what I want in a healthcare provider. I learned that physical therapy is an excellent choice as a first-line treatment for pain and movement problems, and it will ALWAYS be the first place I go before considering other interventions.

I could waste time thinking about what I should have, could have, or would have done differently, but I’m not going to do that. The fact of the matter is, there are a lot of times that “You don’t know.....what you don’t know”.   You find out things along the way that help you make better choices. You can’t go back, only forward, and use what you have learned in the future. I wouldn’t go back and change any of the events that happened, because then I wouldn’t know what know now.

I ended up meeting that physical therapist by happenstance, and I feel like I dodged a bullet because of it. There are several different unpleasant scenarios that could have played out here. I could have had an unnecessary surgery gone wrong.  I could have ended up dependent on prescription pain medications or injections. If I hadn’t learned about pain science, I may have ended up as a chronic pain patient, living in a terrible vicious cycle. Instead, I went to physical therapy and met a smart PT who helped me learn how to help myself. I am very grateful for that, and now I have a healthcare professional I trust who I can use as a resource.

If I have to be totally honest here, I’m pretty sure I initially went to physical therapy out of pure spite towards that neurosurgeon, because he said it wouldn’t work. This will probably be the only time in my life where being spiteful actually worked in my favor! Regardless of how I got there, I made it to that first appointment, continued going, and learned the value of what physical therapy can do for a person.  I may have shown up on that PT’s doorstep looking like a “train wreck”, but I left that experience with the information, education, and tools that are going to help me stay “on track”……..and the rest is history!

Stix and stones may break bones but words CAN hurt you

Interactions between health care providers and patients have a huge impact on a patient’s recovery. Unfortunately not all Doctors, Physical Therapists, Chiropractors, Insurance company’s realize how their words positively or negatively can impact a patient.  How a musculoskeletal or physical problem/injury is described to a patient has a great impact on how much pain is perceived. Pain is ultimately the body’s output to a perception of threat.  The way an injury is described to a patient often has a profound impact, either increasing the perception of threat or decreasing the perception.  Countless times I have heard patients say that Doctors have told them their MRI or X-ray is the worst they have ever seen.  Countless times I have heard patients say that a Physical Therapist told them that my “nerve is pinched” or “bending forward is terrible for the back.” Countless times I have heard patients say that their chiropractor told them their spine was out of alignment. What do all these conversations do? Increase fear of movement and increase avoidance of activity.  Never once do I hear a patient tell me that anybody actually took the time to explain to the patient what pain actually is, and how it relates to their injury.

pain-bear.jpeg

First understand that all musculoskeletal injury has the capacity to heal no matter if it’s bone, muscle, tendon, ligaments, discs, etc. These are all human tissues that physiologically heal in time. Much like when you were a kid and scraped your knee outside playing, physiological damage to tissue occurred and the skin healed in time.  Inflammation is normal, it is how the body starts to heal itself. The nerves being sensitive is a GOOD thing. If you stepped on a rusty nail, wouldn’t you like to know about it?  The nerves are just doing their job. The increased sensitivity to movement is only because the nerves are “pre-warned.” Much like sunburn on the shoulder increases the sensitivity of the skin when you get in the shower. The water is not actually burning the skin, it just feels that way because the skin is very sensitive at that point in time during the healing process.

Movement stimulates blood flow. Movement done frequently, in a non-threatening manner reduces sensitivity. Threatening descriptors such as “bad back”, “blown disc”, “bone on bone”, or “torn a muscle” increases sensitivity.

Here is a link to a post by a colleague. It also does a great job of explaining everything mentioned above. The post also contains a very interesting MRI photo demonstrating how words can impact pain. Take a look HERE!

 

Pain, Productivity, and Happiness

Understanding your brain and how it operates can impact your health on multiple levels. The video below talks about how our mindset should match how the brain operates. Watch it! It's comical and you'll thank yourself for listening to it. http://www.ted.com/talks/shawn_achor_the_happy_secret_to_better_work

In case you are lazy, here are some quotes.....

“90 percent of your long-term happiness is predicted not by the external world, but by the way your brain processes the world.”

“25% of job successes are predicted by IQ, 75% of job successes are predicted by your optimism levels, your social support and your ability to see stress as a challenge instead of as a threat.”

“If I work harder, I'll be more successful. And if I'm more successful, then I'll be happier.” “Every time your brain has a success, you just changed the goalpost of what success looked like. You got good grades, now you have to get better grades, you got into a good school and after you get into a better one, you got a good job, now you have to get a better job, you hit your sales target, we're going to change it. And if happiness is on the opposite side of success, your brain never gets there.” “But our brains work in the opposite order. If you can raise somebody's level of positivity in the present, then their brain experiences what we now call a happiness advantage. Your brain at positive is 31% more productive than your brain at negative, neutral or stressed.”

My Two Cents.....

We know from pain science that our brain is naturally attracted to negatives or threats, this is a primal/survival mechanism that humans have developed. All inputs that the brain receive are either positive inputs or negative inputs. From a survival standpoint, positive inputs are seemingly useless to the brain. For example: Let’s say I’m camping in a tent in the middle of the jungle. I look around and I don’t see a tiger (positive input from visual system). I’m happy, I feel safe, there is no tiger.  However, if I listen to my previous knowledge (negative inputs). Which are telling me hey dummy, your in the jungle, there is probably a tiger around somewhere. This negative input then becomes a survival mechanism because I can now prepare for the life threatening scenario of meeting a tiger face to face.

As a protective mechanism your brain prioritizes negative inputs over positive inputs. When your body is in pain, the brain feels threatened from one or more likely a series of negative inputs. The body then becomes sensitive or highly altered of other potentially negative inputs.  The only way to reduce the sensitivity and break the cycle is to apply a positive input for the body. However because a positive input is not as significant as a negative input, this means we must bombard the body and brain with positive messages so the system no longer feels the need to prioritize all the painful experiences of the past.  If this is not accomplished, it can often be the reason why pain lingers around much longer than it takes for tissue to physiologically heal.

Get PT First

Often times when a patient walks through the door, I’ll ask them “How are you doing today?”.  Many times I’ll get the response “fine”, “feeling better”, or something else that leads to a nice conversation. Sometimes the response is much more blunt however “Well if I was good, then I wouldn’t be here.”Touché! Hopefully your medical professional has some sense of compassion and empathy toward your situation.

We’ve all had those moments when things just don’t seem to be going right.  It doesn’t always have to be a health related issue.  Maybe it could have been that your car broke down and you had to take it into the shop.

Is it convenient? No

Do you need your car? Yes

If your check engine light comes on, you have two choices. Ignore it and hope for the best, or address the problem. If you have a leak in your plumbing, you find a plumber.  If you have a toothache, you go see a dentist. If you want to win a bobsled race, you need a good driver.

Do you dig where I'm coming from?

As a Physical Therapist we have the expertise and knowledge to treat a variety of musculoskeletal disorders.  Pain is much like a check engine light, it’s signaling to your brain that your body is perceiving a threat to the system.  The cause of this threat is often related to multiple different reasons. The underlying issue could be big or small, and if ignored it could lead to much greater problems.  As a Doctor of Physical Therapy, we are uniquely trained to assess and treat many of these issues. We are also trained to recognize red flags which may signal to us that we need to refer to another medical professional with a different expertise.  Your body is the vehicle that drives you, and I encourage you to pay attention to the “signals” that your body is sending.  Unlike a car, you cannot trade your body in for a new one when it breaks down.  Find a health professional that you trust and be proactive in your health.  Take care of your body.

 

When Pain Happens

Here's a riddle. Nobody wants it, but everybody has experienced it at some point in time. It acts oddly and seems to come on for no rhyme or reason.  It is vastly misunderstood by the general population as well as healthcare professionals from all fields.

You guessed right, the answer is pain.

If you are reading this post and currently in pain, I genuinely am sorry and have empathy for your situation.  But understanding pain is the first step in combating it, so you are in the right place.  My goal is to educate people on pain. In my profession I deal with pain every day, so in order to treat it, I need to do my best to understand its complexity. I have learned a great deal about the subject of pain from books by David Butler and Lorimer Moseley. These two guys are at the forefront of the research on this subject.

So what is pain?.......  A short but loaded question.

First let's get some context. The body is constantly gathering information from sensory receptors about the body's internal and external environments.  It is also interpreting how these two environments are interacting and how they relate to one another. All these signals are ultimately sent to the brain to make heads or tails of the information. These inputs can range from actual tissue damage, chemical changes, past experiences, emotional/psychological distress, lack of sleep, hunger, your mother yelling at you, or seeing a snake on a plane.

Snakes on a Plane

The brain's job is to then interpret all of these signals and determine if a threat is present. If the body perceives there is a threat, a number of different responses are possible.  One of the possible responses is pain.

Pain is felt as a survival mechanism to encourage you to take action. However, it does not always mean damage has actually occurred.

Consider this example Lorimer Mosley gives: A fractured wrist is often very painful until it is put in a cast. Once casted, the pain is almost always gone quickly thereafter.

Interesting!

The problem with this is that we know that bone will take 6-8 weeks to fully heal (depending on age and other factors).  Yet, pain is no longer present, and in some cases instantaneously gone once placed into a cast.  So why is this? Very simply, the need for protection is now gone because the cast acts as an external protective device.

In this example the pain is gone but damage is very much still present. The opposite can also be true. The body can be in pain, but no longer damaged.

We must consider other factors such as social influence, past history, fear, future consequences, stress to name a few. All these signals can trigger the body to feel it is under threat and notify you via pain. For this reason you can experience pain with no tissue damage at all.  I’m sure you have heard the term phantom limb pain.  Even though the limb is gone, the body still has the ability to sense pain in this area.  This reinforces the fact that if you can experience pain without a body limb, then tissue damage is not necessarily a prerequisite for pain. Furthermore, just because you are experiencing pain in a particular area does not mean that is in fact the source of the pain.  This is why it is important to find a clinician who does not focus solely on the area of pain, but looks for other areas of dysfunction which may contribute to the brains overall perception of threat.

Another possibility is that tissue damage could have very well occurred which initially started the pain cycle.  However, because the body is great at healing itself at the cellular level. It is also possible that the tissue may have healed. Yet the brain still has the perception of threat because non-threatening inputs were never sent up to the brain to override the previously painful threats.  This may explain why people often feel pain long after normal tissue healing time has passed. This is also why it is important to not treat pain with pain.

Here is some research that backs the theory: tissue damage does not equal pain. Jensen and colleagues performed a study titled: MRI of lumbar Spine in People without Back Pain. They found that 52% of people without back pain had at least one bulging disc or MRI abnormality.  Templehof and colleagues performed a study titled: Age-related prevalence of rotator cuff tears in asymptomatic shoulders.  The authors found that 23% of people with asymptomatic (non painful) shoulders actually had a rotator cuff tear. These are just two examples. Numerous other studies could be cited to help support that tissue damage does not have to cause pain.  

So the next time you experience pain, please understand that there may be a number of contributing factors. Remember that pain is perfectly normal, it’s your body’s alarm system. Pain can be present with or without tissue damage. Providing the body with novel non-threatening stimulus's to remove the body’s need to produce a protective response is a great place to start if you are currently experiencing pain.

Let's take the example of elbow pain, lateral epicondylitis a.k.a tennis elbow. It's not uncommon for lifters to experience elbow pain. I have noticed it becoming more prevalent now as people spend more time on their tablets using their fingers instead of a mouse.

Holding a tablet in one hand, and constantly using your fingers to swipe, type, navigate, etc. will place your wrist/elbow musculature on constant stress. Over a prolonged period, this can be perceived as a threat to the brain. Especially if you are lifting heavy weight in conjunction and require a high volume of grip strength for your workouts.

So applying the knowledge we learned about pain, and how it may or may not relate to tissue damage.  Here is a very simple and extremely effective solution to a lot of cases.

1st) Reduce the threat. In this example altering body mechanics while using a tablet and modify your workout routine with less grip intensive activities for the time being.

2nd) Provide a novel and nonthreatening stimulus.  In this example, I will use a wrist extensor stretch.

While this exercise may not seem like much, it's very effective when applied correctly.  Flexing your wrist and turning it to the side obviously places a stretch on the outside of the elbow or to the wrist extensors.  In addition, you are also placing some tension and loading a nerve which flosses through the tissues at the elbow called the radial nerve.

So we now have our novel/nonthreatening stimulus.

3rd) Here is the kicker. You can do all the above, and get zero results unless you get this third step correct.  You MUST perform the novel/nonthreatening stimulus frequently.  To the tune of every 1-2 hours for best results.  Here is why it's so important.  When the body is in pain, it is very good at making memories of pain.  This is because the body is very protective over itself, and rightfully so.  The only way to reduce the threat is to perform a stimulus frequently enough that if no longer feels the need for protection.

This example can be applied to many other pain scenarios as well if you follow the steps correctly. 1) Remove as many threats as possible while in pain 2) Pick a novel/nonthreatening stretch or exercise 3) The exercise should be simple enough so that you can perform it frequently throughout the day (in some cases every 1-2 hours).