chronic pain

Pain Science for Runners

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This post is mostly the same as my recent article in CompetitorRunning.com. I discuss several exercises in the article designed to help runners overcome common painful issues related to running. For this post, I include pics and videos of the exercises. Here it is.

Pain Science for Runners

Acute vs Chronic Pain

Chronic pain is frustrating. Painful feet, ankles, knees, hips, and low-backs are common in runners. Chronic pain may bring fear that you’re broken, weak, and fragile. Thus you avoid many meaningful activities. You may obsess over your pain. This is the fear-avoidance cycle and it fuels itself.

Chronic pain is different from the pain of an acute injury such as a bone fracture; dislocation; or a cut, scrape, burn, or puncture. Chronic pain lasts long after an acute injury has healed.

Pain serves a valuable purpose but with chronic pain, the pain remains after it has served its purpose. Chronic pain comes from a “broken pain system,” akin to a car alarm that goes off for no reason. Fortunately, you can overcome chronic pain and start running again.

Pain science reveals several important points regarding chronic pain. Most important is that pain rarely equals harm or damage. You can be hurt and strong at the same time. (You can also have damage with no pain. Ever find a bruise but have no memory of how it got there?) Chronic pain is the result of a sensitized nervous system aka central sensitization (http://www.instituteforchronicpain.org/understanding-chronic-pain/what-is-chronic-pain/central-sensitization). Contributors to sensitization include:

  • Beliefs such as you’re broken and further activity (running) will break you more.
  • Lifestyle factors: job stress, relationship stress, lack of sleep, poor diet, lack of exercise
  • Coping strategies: Avoiding running out of fear which drives you deeper into despair and further sensitization.
  • Emotions: catastrophizing, fear, anxiety, anger, rumination
  • Tissue stress: Tissue stress can definitely contribute to pain. Remember though, tissue damage is typically a minor contributor to sensitization.

All of the above factors may be kindling for a pain fire. One too many stressors may spark the fire. You feel pain when the accumulation of stress exceeds your brain’s perceived ability to cope. There are two ways to tackle pain. One way is to decrease the stress that contributes to pain. Another way is to increase your resilience and get strong.

Confront your pain

You can lower nervous system sensitization in several ways:

    • General physical activity
    • Talk with a counselor
    • Various therapeutic techniques: massage, foam rolling, manual therapy, hot, cold
    • Consistent sleep schedule
    • Improve your diet
    • Load and strengthen the place that hurts.
    • Resume running

Your bones, connective tissue, joints, and muscles are very strong and they respond well to loading. If you’ve been guarding and resting part of your body then it gets weaker. Structures like the Achilles and patellar tendons need strength, not more rest. Physiotherapist, chiropractor and pain expert Greg Lehman favors gradual strengthening as one of the best ways to reduce pain.

Get strong – Load it!

Loading strengthens muscles and connective tissue while and provides an analgesic effect. Physical activity boosts your mood, builds self-efficacy, and shows that you’re not broken. By engaging in exercise you break the fear-avoidance cycle. Here are several exercises to help with several conditions. A comprehensive guide is beyond the scope of this article.

Isometrics:

Isometrics work well to calm pain. Contract and hold with no motion for 30-60 seconds. Perform isometrics frequently throughout the day.

  • Right: Heel raise loaded with a kettlebell for Achilles and plantar

    Heel raise

    fascia pain. Use a bent or straight knee.

  • Below: Wall sit for patellar pain. Progress from two to one leg.

    Wall sit

     

 

 

 

 

 

 

 

  • Below: Straight-leg bridge for glute/hamstring pain. Progress from two to one leg.

Straight-leg bridge

HSR (Heavy Slow Resistance) training:

Exercises should be exhausting in 5-10 slow, deliberate reps. (Most of these can also be done as isometrics too.) Start with bodyweight then add weight via barbells, dumbbells, kettlebells, weight vests, machines, or rubber tubing/bands. Persist into pain no higher than a 4 on a 1-10 scale.

Heel raises for Achilles tendonitis can be done with a straight or bent knee.

Loading the knee and hip reduces knee pain.

Band knee & hip extension

Band walks

Side bridges target abs and hip

Band leg press (A squat can be done in a similar way.)

IT Band syndrome

1-leg squat

1-leg bridge

Band leg press (A squat can be done in a similar way.)

Resume activity

Exercise is medicine. If you’ve avoided running for a while then it’s time to run! A little bit of running will help you understand that you’re not broken and the physical activity will help calm your nervous system. You’ll use the process of graded exposure. Add work gradually, keep pain at a minimum, and you’ll increase your capacity for activity.

Try a run/walk protocol like this:

  • Week 1: 1 min. run/3 min. walk, repeat 10x
  • Week 2: 2 min. run/2 min. walk, repeat 10x
  • Week 3: 3 min. run/1 min. walk, repeat 10x
  • Week 4: 40 min. run

Perform each workout twice per week on non-consecutive days. Pain should be no higher than a 4 on a 10-scale (1 = no pain, 10 =  very painful) and pain should not alter your running form. Don’t push through severe pain.

Flare-ups

It’s not uncommon for pain to flare up after activity. Don’t be alarmed. You haven’t done more damage. You’ve pushed a boundary and your nervous system has overreacted. Reduce your activity level a little bit next time you exercise.

Finally

You may need more information beyond this article. A physical therapist or other medical professionals can help guide you through recovery. Injuries such as stress fractures definitely need to be unloaded and rested. If your pain gets worse with activity then seek medical care.

 

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Here’s What’s Right With You.

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We typically visit a doctor, physical therapist, chiropractor or some other medical professional because we hurt. We go to be fixed. As part of the diagnostic process, he or she may tell us what’s wrong. Similarly, many personal training assessment protocols have the trainer take clients through some sort of movement assessment and we get to tell our new client where they’re tight, where they’re immobile, and what movement skills they lack. (Often the movements that make up these assessments are highly unusual to most people and they have little resemblance to anything we do in real life. No wonder so many people don’t score well.)

By framing the discussion in terms of “what’s wrong,” we enter into a negative state of mind. We may have walked in feeling fear, hesitation, shame, and pessimism about our inability to get out of pain and get in shape. When we’re labeled as “dysfunctional” then we will only feel worse — yet we came in seeking help! There’s a better way to discuss patent and client health.

Movement optimism

Physiotherapist, chiropractor, and strength coach Greg Lehman advocates for being a “movement optimist.” In his seminar Reconciling Biomechanics with Pain Science, he suggests a better way to help our clients and patients is to start by telling them what they can do rather than what they can’t. People come to health and fitness professionals to feel good, get out of pain, and be strong. Our words matter. We can have a tremendous impact by setting the stage for success.

Lehman’s optimistic outlook mirrors some ideas from physical therapist Gary Gray. He advocates that in working with clients we start where he or she is successful. That means we find a movement with which they’re comfortable. We start where it’s easy. Then we progress gradually toward more challenging or painful movements.

For instance, if someone can’t balance well on one foot, we allow him or her to hold on to something or use their other foot to help with balance while he or she performs a movement task. Or, if someone feels knee pain with a forward lunge, but has no knee pain in a lateral lunge, then we start with lateral lunging and gradually progress to the forward lunge. If we start with success then we build confidence. If we allow the nervous system to move without pain then we help calm fears about pain and we facilitate more pain-free movement.

Research: Positive self-talk works.

Movement optimism isn’t just for clinicians and trainers. Patients, clients, and athletes have the power to help themselves. Research on positive self-talk shows that it has a measurable positive effect on strength and endurance.

Greg Nuckols of Stronger by Science discusses the effects of positive self-talk on strength athletes in this edition of his newsletter, MASS. Scroll down to page 75 to read the details. Greg writes:

“Adding mental training to your current program will likely boost your strength gains and may even decrease markers of physiological stress. Positive self-talk and first-person kinesthetic mental imagery absolutely don’t replace slinging around heavy iron, obviously, but they can help you get larger gains from your training program.”

Positive self-talk also helps endurance athletes. Alex Hutchinson has discussed research on cyclists:

“Take 24 volunteers and have them do a cycling test to exhaustion; give half of them a two-week self-talk intervention; and then do another cycling test to exhaustion and see if they’ve improved relative to controls. In this case, the answer was yes: the self-talk group lasted 18% longer (637 to 750 seconds) while the control group stayed the same. The rating of perceived exertion (RPE) on a 10-point scale also climbed more slowly in the self-talk group; in other words, they were able to convince themselves that the exercise felt easier.”

Hutchinson also discusses the effect of smiling (yes smiling!) while running:

“A new study in the journal Psychology of Sport and Exercise from Noel Brick and his colleagues at Ulster University explores precisely this question. They had 24 runners complete a series of four six-minute runs and measured their running economy (an efficiency metric based on how much oxygen you consume at a given pace), as well as perceptual outcomes, like effort. During the runs, the volunteers were instructed to smile, frown, relax their hands and upper body (by imagining, for example, that they were carrying potato chips between their thumb and forefingers without breaking them), or just think their usual thoughts.

“The results more or less supported the benefits of smiling. Running economy was a little more than 2 percent better when smiling—an improvement that’s comparable to what you see in studies of weeks or months of plyometrics or heavy weight training.”

(A note to curmudgeons: Your act is tired and childish. It’s a cry for attention that helps no one. Enough with the nonsense! Try something new! Do something that works. Or don’t…)

The brain is central to everything I’ve discussed. Pain science tells us that we are less apt to hurt if we feel relaxed, confident, and safe. In contrast, we’re more likely to feel pain if we’re stressed, anxious, and fearful. Clinicians and coaches have a huge opportunity to help people if we communicate in a positive way. Patients, clients, and athletes have the same opportunity when they communicate with themselves.

 

 

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Biomechanics and Pain Science Seminar with Greg Lehman

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Poke the bear. (But don’t hump the s%it out of the bear.

I’ll get to the above statement in a moment. (Mom, I apologize but blame Greg for it. I’m just quoting what he said.)

I recently attended Reconciling Biomechanics with Pain Science, a two-day seminar with chiropractor and physiotherapist. Greg Lehman. (There aren’t too many people schooled in both disciplines.) The course was superb! I recommend the course to anyone involved in helping people move and get out of pain, whether you’re a trainer, coach, massage therapist, chiropractor, physical therapist, etc.

This is the cutting edge of pain science. The information may challenge what you hold near and dear as pain gospel, most importantly, pain doesn’t always equal damage. Nor should painful movements always be avoided. In fact, engaging in painful movement is part of getting past the pain and back to living.

This was another big dose of information with which I was familiar. Much like reading a book for the second, third, or 19th time, it’s always useful to revisit and re-examine important information. I came away with a deeper understanding of how pain works and how to work with it.

I’ll discuss what I learned and how I’ll apply this information to over the next several blog posts. Here’s my first takeaway:

You’re free to poke into pain

One of the best ways to overcome pain, regain function, and have fun doing what you love is to load the affected area. Does something hurt when you move it? If so, do the movement slowly and safely to the edge of your ability. Add a little more work over time. Work to the level of pain that you can tolerate. Load the movement to your tolerance. The idea and the expectation is that your tolerance will increase, your pain will decrease, and your life will improve. It may take time, but it’ll happen. This is called graded exposure. Pain is the bear that was mentioned at the top of the post. The concept is that you are free to gradually work to a tolerable level of pain but don’t grind and bash your way into severe pain. You shouldn’t limp, flinch, or recoil from the pain. No white knuckles, please.

If it’s a sore knee, then we’re going to use those parts and make them work. We may do squats, lunges, one-leg squats, hopping—whatever is tolerable. By poking into pain you can habituate to it and decrease the severity. Same with a sore ankle, shoulder, back, etc. Some other examples of pain that diminishes upon exposure:

  • You sprain your ankle and you “walk it off.” It hurts but you move it, load it, and resume activity to a tolerable level and you’re fine. The ankle might be sore so take it easy but don’t just rest it for days or weeks without using it.
  • You step into a hot shower and—Wow! It’s hot!—but it feels fine in a few moments. You accomodate. Similarly…
  • You get into a swimming pool and—Whoooo! It’s chilly!—and you’re fine in a few minutes. You adapt. (Strangely, the same process happens when you step out…)
  • You start a bike ride or a run and you knee bugs you a little. The pain vanishes in a few minutes. Did you suffer an injury that suddenly healed? No, but you had pain and your nervous system changed and then there was no pain. You’re fine.

Movement is a great way to desensitize the nervous system! Anyone who’s gone through post-surgical rehab for something like an ACL tear (me) has gone through this process. We’ve had to work through a certain amount of pain and discomfort as we progressed out of the injury and back into normal living. The crucial point is this: PAIN DOESN’T EQUAL DAMAGE. You’re not broken.

*****IMPORTANT DISCLAIMER***** I’m not talking about loading an acute, severe injury. If a bone is fractured, if you have a dislocation, if you suspect organ damage or if you’re bleeding then please don’t load it. In this case, you ARE damaged and you need medical help, not a trip to the gym. These conditions should be obvious.

I have vanquished the foe!

In my case, I’ve had some foot and heel pain which has been severe at times. I’ve curtailed my running and I’ve had to face the prospect of missing several big races this year. I’ve spiraled down a drain of negative thoughts and dread.  Most runners have faced this overflowing toilet of fear, self-hate, and psychological nastiness. All that stress has only contributed to my pain. What will I do with this crisis? Can life go on???

On the first day of the lecture, I started loading those hurt areas. I sought out the sore spots and made them work. I did both isometric contractions and heel raises with bent and straight knees. I worked various angles and speeds. I worked to the point of local fatigue. My pain started to recede before the lecture was over. My nervous system was changing and my pain was retreating. My hurt spots hurt less.

The next day before the second lecture I went for an easy run. I continued with heel raises and toe work and I added weight to the exercises. My symptoms have only improved. Two days later I did a hard hill workout, a workout that would’ve been seriously painful and nearly unthinkable prior to my new hopeful mindset.  I’m not broken! In fact, wouldn’t be surprised if I was made of vibranium… Maybe adamantium. You probably are too!

 

 

 

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Posterior Tibialis Tendinopathy = Aggravation x 10

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The upside to adversity is that I get to learn something. If that’s true then I am an expert genius on problems with my left foot and lower-leg. I’ve fought various aches and pains in my left foot region and the war continues! I am grateful to be on the very tale end of a successful battle against posterior tibialis tendinopathy (PTT).

Ouch.

Ouch.

Why does a tendon hurt?

The injury mechanism is that the tissue has been stressed beyond its ability to recovery. Too much stress/too fast/too often is the problem. Thus, the tissue must be unloaded and rested enough that it heals. Tendons, compared to muscle and skin, don’t get much blood flow so they need longer to repair than blood-rich tissue.

Time off?!?!

I took the whole month of January off. Every runner — probably every athlete or fitness enthusiast in any discipline — shudders at the idea of taking time off, especially a whole month. “I’ll get out of shape!” or “But I have a race in X-number of weeks!” we say. Well, here’s some news for you: If you’re injured then you’re out of shape. Let’s say that together: IF YOU’RE INJURED THEN YOU. ARE. OUT. OF. SHAPE! You’re busted. Broke. Lame. Dead in the water. Out of the race. It’s the agonizing truth.

If you’re injured then you’ve dug your way into a hole. Trying to run your way out of a running injury is like trying to dig your way out of a hole.

You get what I’m saying? 

If you don’t want to prolong the condition, if you want to get back to serious training (as opposed to piecemeal, sporadic, painful, crappy training) sooner rather than later, then STOP RUNNING RIGHT NOW! Bite the feces-covered bullet and prepare to take several weeks off. This is a test of your discipline. You may think you’re disciplined because you do all this running but discipline isn’t doing what you like to do, discipline is doing what you need to do.

Or, just like me and a bunch of other runners, you can believe you’re the exception, you’re made of magic, you’re different from all the other humans and your PTT will resolve in miraculous fashion. I took a few days off, tried to keep running, and I was still hurt. I did that a couple of times. Reality, in all its brilliant, gruesome glory was sitting on my chest, trying to kill me. But January was a better month to take off than all the other months coming my way and I decided it was time to stop being stupid.

You’re a grownup. You’ll make your own decision but guess what: At some point you’ll stop running. You can either make the choice or it’ll be made for you.

(I’m an expert at dispensing this type of advice but it’s as painful and difficult for me to follow as it is for anyone else. Let me make the dumb mistakes so you don’t have to. Also, for a big pile of woe, read the Let’sRun.com forum on PTT, where you can read about people who’ve dealt with this curse for months and years. My bet is they haven’t taken sufficient time off. But if you read about those who overcame PTT, you’ll see most of them took a significant break from running.)

Fortunately, I could bike and lift. Those aren’t perfect substitutes for running but what is? I was able to keep my body in decent shape. I found peace of mind, and a sense that I wasn’t helpless. The good news is I improved my cycling and my numbers went up on the weights. Hooray me.

Some useful resources

Dr. Nick Studholme is always helpful when I’m hurt and can’t figure out why or what to do about it. He showed me how to use Dynamic Tape to help unload the tendon. He also provided me with the following two resources.

Return to Running Rules of Thumb – Are you ready? This contains specific bench marks that you should be able to hit before you return to running. Some of the terminology may not be familiar to you if you don’t have an education in kinesiology. Do your own research, contact me, or contact a physical therapist for help understanding this information. If you pass these tests then you’re ready for…

Zeren PT Return to Running Program. I like the specific, progressive instructions here. Even though I’m a fitness professional, it helps if I get outside guidance and rules to follow. As the saying goes, “The lawyer who represents himself has a fool for a client.” Might as well replace “lawyer” and “represents” with “coach” and “coaches.” If left to my own guidance then I’ll tend to do too much too soon too fast and I’ll get hurt again.

4 Ways to Prevent and Treat Posterior Tibial Tendonitis is from Runnersconnect.net. This is a thorough, well-researched article. In it you’ll find various strategies to address PTT including pictures, exercises, and specific exercise protocols. I used a lot of the information here.

Below is a taping strategy that can help unload the posterior tibialis and support the arch. Dr. Nick Studholme used Dynamic Tape on me. I’ve been taped with KT Tape and Rock Tape before and I can say for certain that Dynamic Tape provides more resistance than either of the other two and it stays on longer. Also, I tried doing it on my own and it doesn’t work. Get a friend to help or have your physiotherapist do it.

Running technique

In the past, fixing my technique was the key to overcoming a collection of running-related problems and pains. I believe a regression in my technique is what brought on this PTT. I know how to run. I help my clients regain good running form — but I’m not perfect and I can’t watch myself run. My technique slipped and I didn’t know it until I got some expert eyes on the case.

I’m enormously grateful for the help of my new running coach, Andrew Simmons of Lifelong Endurance. Through his guidance I’ve shored up my technique. The first time we met he videoed me running and we saw some faults. I won’t go into the specifics here but he helped me bring awareness to what I was and wasn’t doing correctly and now I’m running better. I believe good technique will help keep my tendons healthy.

If you’re dealing with nagging running injuries then perhaps the way you’re running is the problem. I highly recommend time with a coach. You don’t know what you don’t know. The right coach does know. It’s money and time well spent.

Up next…

My PTT was similar in some regards to achilles problems I’ve had in the past, but it was different in its tenacity and response to treatment efforts. In the next post I’ll discuss my rigid arch and why I believe it has contributed to my foot problems. I’ll also demonstrate a mobility drill, foam rolling techniques, strength exercises that helped, and some running technique points.

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Activity is Better Than Rest for Overcoming Lingering Pain

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I’m glad to see Outside Magazine delivering a message that may be very useful to anyone suffering from pain. (This is from 2009, but I just saw it.) The article mirrors my recent experience with my ACL rehabilitation. The Real Heal: Overcoming Athletic Pain says two things essentially:

  1. Rest usually doesn’t cure what hurts us. (In fact, too much rest makes us deconditioned and contributes bad feelings in general.)
  2. Moving and using our sore parts–confronting the pain–is essential to getting rid of pain.

The writer discusses his journey following a bike crash which hurt his knee (an acute injury). He rested and took pain medicine. He states (emphasis is mine):

“It turns out my belly-up approach was dated. New research is proving that the best way to treat nagging pain is to eschew pampering in favor of tough love. Doctors at the University of Pittsburgh are doing ongoing research showing that stretching irritated tendons actually reduces inflammation. And the principle extends beyond rickety wiring. Every expert I spoke with told me variations of the same thing: ‘Rest and ibuprofen cure few injuries,‘ said Dr. Jeanne Doperak, a sports-medicine physician at the University of Pittsburgh. ‘During rest you’re in a non-healing zone,‘ offered Dr. Phelps Kip, an orthopedic surgeon and U.S. Ski Team physician. ‘The body was designed to move.'”

Pain is very much a psychological thing. I can relate to this:

“And it just so happens that tendinopathy chronic tendinitis is the most diabolical of recurring injuries. Give me a broken foot over tendon trouble any day when something snaps, at least you know what you’re in for. My injury dragged on into winter, deep-sixing my mood. This is not uncommon: The link between pain and depression is so well established that sports psychologists use a tool called a Profile of Mood States to monitor injured athletes. (This is a graph evaluating tension, depression, anger, vigor, fatigue, and confusion. People in pain score extremely high in every category except for vigor.) I was five years removed from being a college athlete and I was Long John Silvering it up stairs at work. Strange questions crept into my head: Could I consider gardening exercise?”

I like the overall message of the article but I don’t agree with all the information:

  • The writer says, “… or imbalances in the body’s kinetic chain of movement (a weak core can cause lower-back pain).”

Though this is a popular concept, there is significant evidence that “core strength” (which can be defined and measured in a multitude of ways) has nearly nothing to do with back pain.

  • For runner’s knee, the writer suggests this: “Lie sideways on a table, legs straight, and slowly raise and lower the upper leg ten times. Do three sets. Easy? Ask your PT for a light ankle weight.”

I think this might be part of an effective strategy to address runner’s knee (if the problem is rooted in the hip which it often is; however it could be rooted in poor control of the foot and ankle), but there are several dots that I think need connecting between this exercise and full-on running. This exercise is very different from running in which the foot impacts the ground and the runner must control motion at the foot, ankle, knee and hip. If this is the only exercise given to a runner’s knee patient then I’m skeptical that the runner will fully overcome the issue.

  • A caption under a photo reads, “Preventive Measures: Recovering from a nagging injury? Next time you go for a run or a ride, try taking ibuprofen beforehand. As long as you’re cleared for activity by your doctor, inhibiting swelling prior to a workout can dramatically reduce post-exercise inflammation and pain.”

This is an interesting idea but I have strong reservations. Pain is a signal that should be respected. Even though pain doesn’t equal injury it’s still a message from our brain that there is a perceived threat that needs to be addressed. The pain could be signaling a threat related to poor movement control and tissue stress is leading toward injury. By taking a pain-blocking drug, we might simply be turning down that signal as we continue with what may turn into an acute injury. I would compare this to driving a car with a damaged muffler that needs replacing and instead of replacing the muffler, we turn up the stereo loud: No noise!!–but have we fixed the problem?

On the other hand, I understand that even if the movement problem is addressed, we may still feel pain. Taking a drug may help the brain experience the new, better movement in a painless way which might help break the chronic pain cycle. I’m curious to what degree this has been method has been investigated.

For me, as a personal trainer, I would never suggest someone take a drug and just keep going. Rather, I would speak with the person’s PT. If he or she OKs it, I would then advise someone to move and work below the pain threshold or at a very manageable level of pain.

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Pain, the Brain and ACL Recovery

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A few weeks ago I had a very interesting experience regarding my ACL rehabilitation. It’s very similar to an experience I had with Achilles tendon and heel pain. Here it is.

A perceived setback

I had ACL reconstruction on May 1, 2014. I have been very aggressive with my rehabilitation and I felt it was going very well. My PT and I agreed on a strategy and he approved of the process in general. I knew that sitting and resting was not the right way to go if I wanted to regain full function. For people like me, laziness wasn’t a problem; an overly aggressive approach might be though.

I knew that I could be in trouble if I did too much work too fast and stressed the knee too much. I worried that I’d drifted into this territory when at almost nine months I experienced more pain than I expected. I had a final appointment with my surgeon and she expressed some concern at my symptoms. We agreed that I should back off my activity and rest a bit. Seems perhaps I had reached the point of “too much of a good thing.”

I backed off lifting, running a cycling. I didn’t stop my activity completely but I cut it back significantly. After a couple of weeks I realized the knee wasn’t feeling much better. I continued to experience frequent pain; not debilitating but somewhat worrisome. I decided a visit to the PT was in order. I wanted to get some guidance and make sure I hadn’t damaged the graft.

The long and the short of the visit was this: The graft and my knee were fine. I needed more strength in the leg and around the knee. I needed to do more work, not less! Eureka! (My previous PT had moved on to another position and I had to meet with a new one. Unfortunately, the “bedside manner” of this PT left much to be desired. Right off the bat she was rude, dismissive and she interrupted my answers to her questions. I became very frustrated and it was work to keep my yapper shut and listen to what I needed to. Fortunately I got the information I needed.)

From here, I was ready to rock ‘n’ roll.

Goodbye fear. Hello confidence!

My experience was a very clear experience of what modern pain science has been finding recently. Here are some important points:

1) Pain doesn’t equal injury: In Reconceptualising Pain According to Modern Pain Science, neuroscience researcher Dr. Lorimer Moseley has made several points about pain. Two are pertinent here:

  • pain does not provide a measure of the state of the tissues
  • The relationship between pain and the state of the tissues becomes weaker as pain persists.

Yes I had an injured knee and yes I had surgery in which part of my patellar tendon was cut out in order to make a new ACL. This was all very disruptive to parts of the knee and was clearly part of the pain I was feeling. It takes about six weeks for the graft to heal. The reconstructed ACL is pretty much healed at six months which would’ve been October for me. In other words, my knee was/is healed and any pain wasn’t from tissue damage.

2) Fear is a significant obstacle that must be addressed: Fear is a powerful part of our pain. Overcoming that fear is major part of a successful rehab and return to activity. The pain in my knee caused me to worry that I’d re-injured it and it led me to avoid a lot of activity that I enjoyed. This condition is known as fear-avoidance. The International Association for the Study of Pain (IASP) describes fear-avoidance this way:

Psychological factors play a key role in the development of chronic musculoskeletal pain, in particular dysfunctional beliefs about pain and fear of pain. Fear of pain leads to avoidance of activities (physical, social, and professional) that patients associate with the occurrence or exacerbation of pain, even after they may have physically recovered. Whereas this response is adaptive in the acute phase—rest promotes recovery—it leads to disability and distress when avoidance behavior is continued after the injury has healed.

"Fear-avoidance model" by LittleT889 - Own work. Licensed under CC BY-SA 3.0 via Wikimedia Commons - http://commons.wikimedia.org/wiki/File:Fear-avoidance_model.jpg#mediaviewer/File:Fear-avoidance_model.jpg

“Fear-avoidance model” by LittleT889 – Own work. Licensed under CC BY-SA 3.0 via Wikimedia Commons – http://commons.wikimedia.org/wiki/File:Fear-avoidance_model.jpg#mediaviewer/File:Fear-avoidance_model.jpg

When I learned that my parts were solid and strong and that I wasn’t broken, I felt the fear drain away like water down a toilet. I was a happy dude!

Another of Moseley’s points is important here: that pain can be conceptualised as a conscious correlate of the implicit perception that tissue is in danger.

Big words. What does that statement mean? I’ll let Moseley explain (emphasis is mine):

“First, there are other central nervous system outputs that occur when tissue is perceived to be under threat, and second, that it is the implicit perception of threat that determines the outputs, not the state of the tissues, nor the actual threat to the tissues.“

In even simpler terms, we may feel pain absent any damage but we feel pain when our brain perceives a threat–even when there is no threat. I compare this to a car alarm that is set off by the wind. There’s no break-in occurring yet the alarm signal is going off due to the alarm sensing a threat.

3) Patient education is vital: Very interestingly, an effective strategy in treating chronic pain is patient education. This strategy of patient education is supported in several studies that are discussed in a review in the Archives of Physical Medicine and Rehabilitation, and it’s further discussed in an article titled Can Pain Neuroscience Education Improve Endogenous Pain Inhibition? Literally, knowledge of pain processes can reduce pain. (Pain is weird!) I believe that my experience supports this phenomena.

(To be clear, it’s not that I received education on how pain works. I received the message that my knee was solid, not injured and that it could be worked very hard.)

Keep this in mind.

Dr. Moseley discusses pain education in Pain really is in the mind, but not in the way that you think. I like what he says here:

“The idea that an inaccurate understanding of chronic pain increases chronic pain begs the question – what happens if we correct that inaccurate piece of knowledge?

We’ve been researching the answer to this for over a decade, and here’s some of what we’ve found:

(i) Pain and disability reduce, not by much and not very quickly but they do;

(ii) Activity-based treatments have better effects;

(iii) Flare-ups reduce in their frequency and magnitude;

(iv) Long-term outcomes of activity-based treatments are vast improvements.”

Most of us outside the medical community probably still equate pain to damage. Many inside the medical community still think that way too. (Blame Rene Descartes.) We now know better. Rather than address pain from a strictly biomechanical approach, therapists would be well advised to study and adopt what’s known as the biopsychosocial model for pain. This model is explained very well here and discussed in-depth here. We patients will be well armed in a fight against pain if we understand this model too.

 

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“Body Talk” Lecture Series by Rick Olderman

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If you’re in Denver and you’re either in pain or your a trainer/therapist who’s interested in helping people who are in pain, then I highly suggest you attend one or more of the following lectures from Denver physical therapist and certified personal trainer Rick Olderman.  I’ve mentioned Rick before (here, and here) and his hugely important role in helping me recover from back pain and regain my running ability.  Without question he’s one of the main reasons I was able to resume running and run my first marathon last year.  He’s part of the Body in Balance physical therapy office. The information here will be practical and probably very powerful in helping you or someone you know get out of pain.  And it’s free!

  • Neck Pain & Headaches: Innovative answers you’ve been missing.
    Tuesday, 4/9, 6pm
    Presented by Rick Olderman MSPT, CPT.
  • Trauma, Pain, and the Brain: How to use your brain to fix your pain.
    Saturday, 4/13, 1pm
    Presented by  Rick Olderman MSPT, CPT.
  • 3 Patterns Causing Back Pain and How to Change Them.
    Tuesday, 4/16, 6 pm
    Presented by Rick Olderman MSPT, CPT.
  • Accidents and Chronic Pain: Why you’re not getting better and how can you change your outcome.
    Saturday, 4/20, 1pm
    Presented by Rick Olderman MSPT, CPT.
  • How You Walk Can Fix Your Back, Hip, Knee, and Foot Pain.
    Tuesday, 4/23, 6pm
    Presented by Rick Olderman MSPT, CPT.
  • Stretching: Is there a better way to lengthen muscles?
    Saturday, 4/27, 1pm
    Presented by Rick Olderman MSPT, CPT.
  • Core Performance Versus Core Strength: Common mistakes with abdominal strengthening.
    Tuesday, 4/30, 6pm
    Presented by Rick Olderman MSPT, CPT.
  • How Does Walking Contribute to Chronic Foot and Ankle Pain?
    Saturday, 5/4, 1pm
    Presented by Rick Olderman MSPT, CPT.
  • Carpal Tunnel Syndrome and Thoracic Outlet Syndrome: A unique approach to solving pain.
    Tuesday, 5/7, 6pm
    Presented by Rick Olderman MSPT, CPT.
  • Running Injuries: It’s more than just foot-strike patterns.
    Saturday, 5/11, 1pm
    Presented by Rick Olderman MSPT, CPT.
  • Dry Needling: How is it different than acupuncture and how can it help you?
    Tuesday, 5/14, 5:30pm
    Presented by Aline Thompson PT, MSPT, OCS.
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Chronic Pain Lecture at Cherry Creek Athletic Club, Denver

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For anyone who’s interested in learning more about chronic pain and how to use the Z-Health Performance System to start overcoming chronic pain, I’m giving two lectures next week at the Cherry Creek Athletic Club in Denver.  Both members and non-members are welcome.  The lecture is free.  Dates and times are:

  • 5:45 pm, Tuesday, December 6th
  • 9:30 am, Thursday, December 8th

This is an interactive lecture so you will be moving around.  It’s not a full-on workout by any means but please wear clothing that will allow you to move comfortably.

For more information call the Cherry Creek Club at 303-399-3050 or you may email me at DenverFitnessJournal@Gmail.com.

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Recognition of Chronic Pain as a Disease

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If you’re suffering from chronic pain, then understanding how pain works is key to overcoming it. The New York Times has a pertinent article regarding this very strange issue from which so many suffer.  Giving Chronic Pain a Medical Platform of Its Own highlights a growing understanding of chronic pain by some medical professionals (and a misunderstanding by many more medical pros).  The main points are these:

“Among the important findings in the Institute of Medicine report is that chronic pain often outlasts the original illness or injury, causing changes in the nervous system that worsen over time. Doctors often cannot find an underlying cause because there isn’t one. Chronic pain becomes its own disease.

“When pain becomes chronic, when it becomes persistent even after the tissue and injury have healed, then people are suffering from chronic pain,” Dr. Sean Mackey, chief of pain management at the Stanford School of Medicine said. “We’re finding that there are significant changes in the central nervous system and spinal cord that cause pain to become amplified and persistent even after the injury has gone away.”

We see now that in many many cases, pain DOES NOT equal injury.  (If you fall and bang your knee, cut your finger, or touch a hot stove then yes, the pain is quite indicative of an injury.  These are acute injuries, not chronic pain issues.)  Read the rest of the article for some of the latest ideas on pain science.  If you want more excellent information on the very strange subject of pain, check out Body In Mind, a blog by pain researchers based at the The Sansom Institute for Health Research at the University of New South Wales in Australia.

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Gluten & Pain

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Several Sources of Gluten: Top: High-gluten wheat flour. Right: European spelt. Bottom: Barley. Left: Rolled rye flakes.

Gluten and ailments related to gluten such as celiac disease and gluten sensitivity have received a lot of press over recent years. It seems that more and more people are experiencing some sort of adverse reaction to gluten. Symptoms vary from mild to severe and may include various digestive issues, breathing issues, skin irritation, joint pain, and lethargy.

Recently I’ve been experimenting with getting the gluten out of my diet.  I believe cutting gluten gluten has played a strong role in reducing in my various aches and pains, particularly my Achilles and heel pain. Are You Too Sensitive? is a recent article in Outside Magazine that provides some anecdotal evidence to support my observations.

As I mentioned at the start, gluten seems to cause some degree of distress and inflammation in a good number of people. This may not rise to the level of severe illness but it may be perceived as a threat by the nervous system. So now we’ve got dietary stress. Let’s add that to any number of the other stresses we have including job stress, money stress, or even the normally good stress of exercise. Maybe we’re not sleeping all that well–oh and our seasonal allergies are getting to us.  At some point all this stress builds and the nervous system senses a building threat. We’ve got a threshold below which we don’t feel pain. Once our stress hits that threshold, things change. The nervous system which is always looking out for our best interest (survival) wants us to reduce this threat level. The result may be pain–an action signal–that will alert you to reduce your stress. And what better way to get our attention than via a nice efficient pathway such as our old back pain, knee pain or foot pain?

And gluten is everywhere! Bread, pasta, anything with malt or barley like beer, pancakes, pastries…  Gluten is often found in sauces, ketchup, marinades, soy sauce and ice cream.  It’s often found in processed meat.  (Have a look here for a big long list of gluten-containing products.) So we’re swimming in gluten.  While this stuff may not be so bad in small amounts, if we’re constantly consuming it then it may build to a toxic level. This chronically elevated gluten may well then contribute to chronic pain.

In addition to reducing my heel and Achilles pain, I believe getting the gluten out has helped me recover after tough workouts and bike rides.  I noticed this maybe a week or so after eliminating gluten.  Typically it was easy for me to either lift, ride or run to the point that I’d be sore to some degree for a couple of days.  The result was my next workout would be inhibited. Now I can say with certainty that I’m simply not as sore as I used to be.  This observation is echoed in the Outside Magazine article:

“That’s old news to Robby Ketchell, the director of sports science for the Garmin-Cervélo pro cycling team. Since 2008, riders have experienced improved post-ride recoveries, which Ketchell attributes to the team’s gluten-free diet. ‘When our guys ride, they’re tearing muscle fibers, and that creates inflammation in their bodies,’ says Ketchell. ‘We need to get rid of that inflammation so they can ride strong the next day. The last thing we want is something that causes more inflammation.'”

So if you’re struggling with chronic pain and you’ve tried many methods to address it, addressing your nutrition–and particularly your consumption of gluten–may be a way to move forward.

 

 

 

 

 

 

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