Pain: A Complex Matter

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When will this end?!

Anyone who’s experienced chronic pain knows it can be a very mysterious issue.  Chronic pain presents very different characteristics and patterns when compared to acute pain such as a skinned knee or a sprained joint.  It may start for no clear reason and progress with no clear pattern.  A long-ago healed injury may continue to hurt even though the tissue is no longer damaged.  Oddly enough even amputees and paraplegics may experience pain emanating from missing or non-working limbs.  Chronic pain seems as if it’s driven by a very mysterious force.

The issue of hope–or hopelessness–can be a truly crushing burden in the quest to resolve long-term pain.  Typical methods in addressing chronic pain may include drugs (ibuprofin, steroid shots, muscle relaxers), heat, ice, physical therapy, chiropractic adjustments, massage (Active Release Therapy, myofascial release, Rolfing, and others) and acupuncture, and then if none of the above works then we often resort to what certainly must be the final sure cure: surgery.  These methods often provide temporary relief at best.

This past weekend I attended the first half of the Z-Health R-Phase certification.  Pain and resolving pain was the overarching theme.  I learned a tremendous amount about the issue.  As many people have observed, pain doesn’t always equal an injury.  Pain sometimes feels better with movement: someone with a slightly sore shoulder may feel better as he or she moves the arm around.  In contrast, pain often does indicate an injury.  If I break my leg and I continue to walk, then the pain will increase with every step.

A key issue we discussed is that the site of pain is rarely the site of the problem.  Pain is often a symptom of dysfunction elsewhere in the body (Or sometimes even outside the body.  More on that in a moment.)  For instance, absent a blow or violent twist of the knee, knee pain is rarely a knee problem.  Knee pain is often rooted in hip or foot dysfunction.  Similarly, shoulder pain is often rooted in poor spine or hand movement.  As the renowned neurologist Karel Lewitt said, “He who treats the site of pain is lost.”

Emotions are often overlooked when we deal with pain.  Again we often think of pain as strictly a bodily thing.  Still a lot of us have noticed that our pain increases during times of stress.  This is an indication that we must consider our mind and our emotions when we’re trying to resolve long-term pain.  It may be that our “physical” pain is rooted in the conditions that surround us.  In fact what happens in many cases is that the pain itself causes us such distress that it becomes a self-perpetuating situation in which our fear of pain drives only more pain.  It’s an enormously complex matter when we start to look inside our head in order to address pain; but if we’re not considering the inside of our skull then we’re probably missing the mark by a long shot.

One of the books Z-Health creator Eric Cobb suggested we read is David Butler’s Explain Pain. Butler is an Australian neurologist who specializes in pain research and treatment.  His blog on pain is called Explain Pain.  If you’re currently in pain or if you’re in the business of treating pain I highly suggest you look into it.  Pain treatment professionals should also look into the Neuro Orthopedic Institute.  The NOI site describes their mission as such:

“The nervous system is our prime focus, integrating neuroscience, neurodynamics and manual therapy into patient management.  NOI’s core philosophy is to provide progressive, current material, always challenging existing management protocols, to promote professional reinvestment, and to ensure that course participants benefit from the most recent research in a fun way.”

Z-Health Day 1

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Yesterday was the first day of the Z-Health R-Phase certification here in Denver and I found it very informative and enjoyable.  We learned a tremendous amount about the nervous system and why doing joint mobility drills can relieve pain.  (I started the day with some low back pain.  We progressed through only a few drills: foot/ankle drills and knee drills.  Soon after there was no back pain and I still am pain free this morning as I type this.) It sounds strange I know, but the ways of the body and nervous system are often less than obviously logical.

The class of about 20 students is the most diverse class I’ve seen at any sort of exercise course.  In addition to personal trainers there’s a physical therapist and a PT school student in attendance, a yoga instructor, a school teacher, and a nurse.  One man is  a client of a Z-Health trainer who’s simply been impressed enough by the results that he wants to learn more.  One woman has seen her elderly mother go through hip and knee surgeries with poor results.  She said she didn’t want to get old in the same fashion.

I don’t want this to sound like some sort of a weird cult thing or blind devotion to some oddball system.  Z-Health creator Eric Cobb has drawn on a wide variety of sources in developing the system.  Much of what informs Z-Health is neurological research and an understanding of what pain is, how the brain views pain and they myriad ways we can address pain.  Cobb urges students and Z-Health trainers to read a lot and learn as much as possible about these issues.

One criticism of Z-Health is that it’s hard to explain.  People ask “What is Z-Health?” and those of us who’ve been exposed to it often can’t give as succinct an answer as we wish we could.  I think the Z-Health web site should give a better explanation of what Z-Health is and how it works.  The course I’m taking is called R-Phase.  “R” stands for restore, rehab, and re-educate.  There are other phases but R-Phase forms the basis for the other phases.  I’ll do my best to give an explanation.

The driving concept is that the nervous system is the key driver of of every facet of the body.  Absent an acute injury like a broken bone, cut or dislocation our pain is a movement problem.  For example “My knee hurts when I climb stairs,” or “My shoulder hurts when I reach overhead.”  Those are movement problems.  The nervous system drives movement, not the muscles, not the bones, not connective tissue but the nervous system.  Thus is if we want to eliminate pain then we must address the nervous system in order to improve movement.  (Interestingly, if any movement pattern is compromised–ankle movement for example–then it may create pain and/or weakness in other regions such as the neck or a shoulder.  It’s sort of similar to the way a storm in Seattle may impair air traffic in Miami.)  The way we do this is by moving each joint one at a time through its full, pain-free range of motion.  We do this very precisely under strict control.  In this way we improve the brain’s map of the body (the homunculus).  We increase the nervous system’s recognition of these joints and limbs thus we improve movement and control of the body.

That’s the brief, non-technical explanation!  I wish I could put it more briefly.  Medical and body work professionals may still prefer a more thorough explanation.  Z-Health looks somewhat like tai chi.  In fact Z-Health draws on martial arts, tai chi and dance for various mobility drills.

For anyone wanting more information I suggest you call the Z-Health offices.  The people who work there are very much willing to discuss Z-Health and answer any questions.  They’re a very helpful and well informed staff.

Achilles Tendon Issues: Help from Dr. Ivo at Summit Chiropractic

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My wife and I just recently enjoyed a long weekend in the mountains full of skiing/snowboarding, sleeping in,  and wishing we had a condo near the slopes.  Part of that weekend included a visit with Dr. Ivo Waerlop at Summit Chiropractic in Dillon, CO.  I went in hopes of 1) getting help with my sore left Achilles tendon that’s been bothering me for months, and 2) get some of his thoughts on barefoot running.  The visit was very helpful and enlightening.

Dr. Waerlop was featured in a Denver Post article on barefoot running.  My wife looked up his web site and it grabbed my interest.  Dr. Waerlop is involved in the biomechanics of cycling, running and skiing (three things I love), and he’s involved in barefoot running.  In fact, he’s a biomechanics advisor for Vibram.  He’s also an accupunturist.

I won’t go into every detail but his asessment of my gait was very precise and his explanations very thorough.   He assessed my feet, legs and trunk; observed my gait; and presecribed several exercises for me plus a sole lift for my shoe.

Most importantly we focused on attending to the causes of my problems (faulty biomechanics in the feet and toes) rather than the symptoms (pain in the Achilles–oh yeah, and my low back and my left shoulder).

He also advised me on barefoot running.  I probably won’t ever be a full-on barefooter but I likely will be doing some barefoot running in the near future.  (Gotta take it slow!)

There’s more.  Dr. Waerlop is part of the Homonculus Group.  (What is the homonculus?  Excellent question.  Click on the word to find out.)  This is a group of physicians and sports performance/injury rehab professionals who are “committed and driven to better understand the problems of pain and movement impairment in this world (basically the aches and pains that ail individuals.)”  The Homonculus site is rich with podcasts, articles and discussion threads (though it appears their discussion board has received a lot of spam which should be removed.  Go to page 1 of the discussion board for legitimate information.)  Finally, Dr. Waerlop is one of the Gait Guys whose lectures on gait assessment are found at Youtube.

I am very excited to dig into the articles and podcasts.  If you’re a trainer, coach, or injury rehab professional–or if you’re just a fitness geek with some spare time, I highly recommend you investigate some of this material.  I can’t get enough of this stuff!!!

Counterpoints to Barefoot Running

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I think it’s important to analyze any trend or issue from several viewpoints.  In the world of fitness and nutrition we see all sorts of fads come and go.  Today barefoot running is gaining in popularity.  I’ve posted recently on some of the research that suggests barefoot running may be healthier for the joints than shod running.  So, I believe it’s worth considering doing some barefoot work whether it be gym work such as weight training or agility work; or perhaps very short runs on a soft surface such as grass.   It may in fact be beneficial to work toward a full transition from shod running to barefoot running.  That said, it’s vital to consider other views.

First, the Science of Sport gives us Barefoot running – new evidence, same debate.  One notable point the writers make is this:

“I guarantee that the media are going to be all over this and they are going to tell you that you should be running barefoot or in Vibrams.  You will hear how science has proven that being barefoot will prevent injuries, and that those of you who are injured should blame your shoes as you lob them into the garbage bin.

(This sort of observation can go for just about every new study that’s reported in the press.)  I think it’s entirely likely that runners may latch on to barefoot running thinking that it’s an instant magic cure for whatever is bothering them and the results may be disastrous.  (Then what will the press, physical therapists, and podiatrists say?  “Barefoot running is the worst thing in the world!  No one should do it ever!  Then we’ll have discarded a potentially helpful tool from our toolbox.)

The article goes on to give an example of what happens when the pendulum swings too far and runners adopt something very new and very different into their training:

“And I will illustrate this with our own insight into footstrike and injury.  When the Pose research was done in Cape Town, athletes basically had their footstrike patterns changed through 2 weeks of training in the new method.  The biomechanical analysis found lower impact forces (sound familiar? Same as the Nature paper), and even less work on the knee joint.  This was hailed as a breakthrough against running injuries, because lower impact plus lower work on the knee meant less chance of injury.  Jump ahead 2 weeks, and 19 out of 20 runners had broken down injured.  Why?  Because their calves and ankles were murdered by the sudden change.  And the science showed this – the work on the ANKLE was significantly INCREASED during the forefoot landing.”

Thus we get the very clear point that barefoot work must be added gradually into your routine.  A rapid switch in running technique is probably a very bad idea.  DO NOT move rapidly to replace all your shod miles with barefoot miles.

Over at the Running World According to Dean you can read Another Barefoot Running Story.  He seems a bit skeptical on the issue of barefoot running.  Owen Anderson at Educated Runner has presented two posts on barefoot running: Barefoot, Nearly Barefoot and Bearfoot Running; and Barefoot Running: What the Harvard Study Really Said.  Both articles are again somewhat skeptical of barefoot running and running in Vibrams.  Anderson’s second post is most valuable I believe in that he points out some of the limitations of the study “Foot Strike Patterns and Collision Forces in Habitually Barefoot versus Shod Runners” that appeared recently in the journal Nature.

Anderson makes this point: “The Nature investigation did disclose some interesting information about the effective mass of the foot and shank (which we won’t discuss here), but it offered no other information about the potential links between barefoot running and either injury or performance.”

He’s correct.  This study was not a long term study.  The study indeed showed lower impact forces at the ankle, knee and hip during barefoot running when compared to shod running, however the runners were not observed over the long term.  Thus we only know what happened during the short duration of the study.  This situation is indicative of most barefoot running studies.   Nor did the study investigate which method–barefoot or shod–results in the fastest performances.

Further studies should be conduced looking at several points.  First, long-term studies should look at injury rates of shod runners compared to barefoot or minimally shod runners.  Second, we need to move beyond injury issues and look at racing performance.  In other words can we run faster barefoot/minimally shod or in shoes?  Third, it might be interesting to see how many people have tried to convert from running shoes to barefoot running but were unsucessful.  What happened to these people?

From my point of view, none of these other posts or viewpoints have changed my thinking that some degree of barefoot work is very likely healthy for a fair number of people.  It’s not necessary for anyone to permanently discard their running shoes for bare feet, but perhaps it would be valuable to consider taking the shoes off from time to time and letting the feet behave like feet.

More Magic Fitness Nonsense: Part I

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I love this stuff!  From somewhat questionable vitamins, to goofy “health” food, to the out-and-out fantasy Cookie Diet, we continue to search for a way around eating right and exercising.  The latest magic potion to come out of Fantasy Fitness Land is a pill which has been developed by General Nutrition Centers (GNC) and tested by Oklahoma University.  (I’m glad the Sooners took on this strange project instead of the University of Texas.)  You can read all about it at Science Daily in an article titled Weight-loss supplement has potential to burn fair amount of calories

It seems this substance contains three things: black pepper, caffeine, and capsaicin–the stuff that makes hot peppers hot. 

(Now, as it turns out, I actually created this combination some years ago and I’ve been consuming it roughly once a week in the form of a morning meal known as breakfast.  I eat an omlette, sprinkle on some black pepper, splash on some hot sauce, and drink two cups of coffee.  Too bad I didn’t patent the whole process. )

The article is fairly brief and doesn’t give much information but I can forsee this new weight loss pill flying off the shelves into the hands of people who desperately want to lose weight but who refuse to take on the tried-and-true guaranteed methods to healthy weight loss–that is eating right most of the time and working hard often.  I’ll post more information on this type of snake oil.