brain function

The Final Victory Against My Heel Pain Part II: The Brain and Pain

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This piece about my heel pain was in the works prior to my ACL mishap. It was great to banish my heel pain! I’m still happy about it! Now I just have to overcome this latest speed bump and all will be well.

In Part I of this post I discussed my consultations with coach Mike Terborg and therapist Nick Studholme. We were trying to figure out how to resolve some very persistent heel/Achilles tendon pain that had been with me for several years. Their work was biomechanical in nature. They helped me to move better, run better and unload the sensitive tissues.

Here in Part II I want to discuss another important component to pain management, one that has less to do with biomechanics and everything to do with how we think about pain. Z-Health is where I first learned about these concepts. I drifted away from Z-Health a bit but I’ve returned to my learning about the realities of pain.

Key points

  • Pain is in the brain.
  • It’s a blend of nociceptive (danger) signals, attitudes, beliefs, past experiences, knowledge, social context, sensory cues.
  • It doesn’t equal tissue damage–particularly in chronic pain cases like mine.
  • Pain is a response to a perceived threat.
  • Reduce the threat and we reduce the pain.

Obviously there’s a lot of subconscious stuff at work when we experience pain. If we want to tie our shoes or turn the ignition key of a car, we have to consciously take action to make these things happen.  In contrast, we don’t have to think at all in order to feel pain. We feel pain without having to consciously do anything. However, research into pain reveals that we can often actually reduce our pain via cognitive processes.

One of the most powerfully fascinating aspects of pain management involves consciously considering pain and whether or not we’re actually under threat. Emerging research strongly indicates that pain management can be made more successful by educating a patient about the whole pain process. Understanding the process at work and recognizing that pain DOES NOT equal injury and that it IS NOT a threat to our health or life can be hugely powerful. For instance, there’s this analysis of research titled. Patient education interventions in osteoarthritis and rheumatoid arthritis: A meta-analytic comparison with nonsteroidal antiinflammatory drug treatment. The conclusion is this:

 Based on this meta-analysis, patient education interventions provide additional benefits that are 20–30% as great as the effects of NSAID (non-steroidal anti-inflammatory drugs) treatment for pain relief in OA and RA, 40% as great as NSAID treatment for improvement in functional ability in RA, and 60–80% as great as NSAID treatment in reduction in tender joint counts in RA.

Here, patient education offers benefits beyond that seen with drug treatment alone.

Exercise Biology explains pain:

Exercise Biology is a fantastic, very thoughtful site full of very useful information. It’s written by Anoop Balachandran. He’s gone to admirable lengths to include only evidence-based information and science. It’s not just opinion. One of the best articles on his site deals with pain science. It’s called What should fitness professionals understand about pain and injury? and it does a great job of breaking down a complex subject digestible pieces. (Todd Hargrove at Better Movement also does a great job discussing pain in a similar way.)

Very pertinent to my experience is Anoop’s discussion of how to desensitize or calm down a nervous system that is overly sensitive to a perceived threat that no longer exists. He describes the top-down vs. the bottom-up (find-it-and-fix-it) approach:

Top Down: Basically, means changing your attitude, beliefs, knowledge (neurophysiology of pain) about your pain and in turn, lowering the threat value of pain. People get hurt, they experience pain, healing follows, and they recover. But in some folks the pain lasts forever. And why is that? According to one of the most well-accepted models – the fear-avoidance belief model –  people who have heightened fear of re-injury and pain are good candidates for chronic pain. Lack of knowledge or incorrect knowledge, beliefs ( hurt always means harm, my pain will increase with any activity and so forth), provocative diagnostic language and terminologies used by medical therapists like herniated disc, trigger points, muscle imbalance, and failed treatments can further heighten this fear or threat . So education to lower the threat is THE therapy here. We now have some very good evidence to show that just pain physiology education or the top-down approach is enough to lower pain and improve function 5.

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Bottom Up approach: The bottom-up approach is what we see around us: surgery, postural fixing, trigger point, muscle imbalance, movement re-education, manual therapy, acupuncture and the list keeps growing. Almost all treatments out there are trying to lower the nociceptive drive without much consideration to the top-down approach. This is solely because these treatments are based on the outdated model of pain. We now suspect that positive effects of manual therapy may be due to neural mechanisms than the tissue and joint pathology explanations that is often offered. So even the bottom up approach is working via de-sensitizing the nervous system. Although not intended, there are top-down mechanisms clearly at work even in bottom up approaches( like the placebo effect, a credible explanatory model, the belief in the therapist) .

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So what we you need is a combined approach that takes into account the “entire individual” and that’s where the biopysycosocial model of pain treatments walks in. The bio psycho addresses the biology (nerves, muscle, joints), psychological ( beliefs, thoughts, fear) and social aspects (work, culture, & knowledge). 

Pain self-talk: “I’m not in danger.”

My Achilles started feeling a lot better once my running biomechanics were cleaned up (the bottom-up strategy.) I still had some sporadic discomfort though. In reading up on pain and the brain, I realized it was time to apply the top-down method. I had several internal conversations with myself. I said something like this: “I’m not under threat. My Achilles is strong. It won’t break. I’m safe and strong and I’m ready for anything that comes my way.”

I started feeling a little like Stuart Smiley as I gave myself these pep talks–but guess what!–they worked. Literally within 48 hours my residual pain was gone! This conscious thinking process seemed to influence the unconscious pain process to a very favorable result.

The pain neuromatrix

This model is known as the pain neuromatrix. and it is very powerful stuff. It may sound odd this idea that pain and injury aren’t the same, and that pain can be changed literaly through education. I haven’t made any of this up though. This is what the researchers are finding.

My ACL injury and pain

 I sustained an acute knee injury that includes a torn ACL. Did it hurt? Oh yes! It was a sudden change that my brain rapidly assessed as a significant threat. The result of the injury is instability in my knee and I can’t move as much or as well as I could prior to the injury. From an evolutionary standpoint, I’m at a disadvantage for survival. Pain is helping me avoid further damage. I will most likely undergo an ACL reconstruction (I hope to know for sure next week.) with plenty more pain to go along with it. But I’m not worried.

I went through 10 years of weird chronic pain (primarily low-back pain) that didn’t have an obvious cause. I obsessed over it and dreaded the pain constantly. I missed out on perhaps my best potential years as an athlete. I overcame it though.  (Much of my relief came from the bottom-up approach of fixing a lot of biomechanical issues–which ultimately reduced the threat level to my brain.)

Now with that perspective and my current knowledge, here’s how I see my knee injury:

  • I’m highly optimistic that I can be fixed and that I can return to all the activities I love.
  • I’m exercising as much as possible while at the same time avoiding pain. In this way I’m calming my brain and minimizing any feelings of depression, 2nd guessing, or any “woe-is-me” thinking.
  • The threat level via my knee will be high. Therefore:
    1. I must be patient and diligent with my rehab. I will!
    2. To reduce threat, my return to exercise (particularly Olympic lifting, trail running and skiing) must be gradual and non-threatening.

More resources:

Lorimer Mosely is one of the foremost pain experts on earth. Here he lectures on pain. Around the 7 minute mark he discusses his own experience with a very dangerous yet painless wound. The whole thing is fascinating but perhaps a bit long for some. If you’re in pain though I strongly suggest you watch it.

Also, here’s a link to an interview by Bret Contreras with physical therapist Jason Silvernail. Many good questions are asked and very well-informed answers given. Again, it might be long for some of you but the information is just hugely valuable.

Remember, learning about pain can help you overcome pain! Reading and listening to those who understand pain can be hugely beneficial to anyone who suffers. Below are more resources.

Informative sites:
www.somasimple.com (excellent forum)
www.bodyinmind.org
www.forwardthinkingpt.com
www.bboyscience.com
www.saveyourself.ca
www.bettermovement.org
www.thebodymechanic.ca

Excellent books:
Beginner Level

  • Explain Pain by David Butler & Lorimer Moseley (This is a must read)
  • Painful Yarns by Lorimer Moseley

Intermediate Level

  • Pain by Patrick Wall
  • The Challenge of Pain by Ronald Melzack
  • Sensitive Nervous System by David Butler
  • The Back Pain Revolution by Gordon Waddell
  • Topical Issues in Pain by Louis Gifford
  • Therapeutic Neuroscience Education: Teaching patents about pain by Adriaan Louw ( a book on how to do the top down approach)
  • Pain by Lorimer Moseley (DVD)
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Health & Fitness News: Sit-to-stand test predicts mortality, Kids who walk or ride bikes to school concentrate better, Further evidence against gluten

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Getting up off the floor predicts mortality

Several stories may be worth your reading.  First there’s an interesting test that seems to fairly strongly predict mortality risk.  It involves getting up from the floor using a minimal amount of assistance and support.  A Simple Test Assessing Ability to Sit Up From the Floor Predicts Mortality come from Medical News Today.  It discusses research from Brazil published in the European Journal of Cardiovascular Prevention. Here’s the pertinent information:

“They told the participants to try and sit up with the least amount of support that they believe necessary, and not worry about their speed. They scored the participants’ ability to both sit and rise out of 5. For each time the participants used support from their hand, knee or other part of their body the researchers would subtract a point. A total composite score out of 10 was assigned to them which would determine which category or group they belonged to (C1, 0-3; C2, 3.5-5.5; C3, 6-7.5; and C4, 8-10).

A total of 159 people died (a 7.9% mortality rate) at the end of the study, with significantly more deaths occurring among people with low test scores. They found that the rates of mortality between the four groups differed by quite a great deal, even when controlled for gender, age and body mass index (BMI). Those belonging to group C1, which had the lowest score range, were 5-6 times at higher risk of death than those in group C4. This difference suggests that the sitting score is good predictor of all-cause mortality.

Participants with scores below 8 had mortality rates 2 to 5 times higher than those with scores ranging from 8-10. The authors noted: “‘a 1-point increment in the [sitting-rising] score was related to a 21% reduction in mortality.'”

Watch the video below to see an explanation of the sit-to-stand process.  Try it out.  What’s your score?

Kids who walk or bike to school concentrate better

An article in the Atlantic tells us a) kids who move around more think better and by extension, b) there really is no division between the mind and the body.  The Link Between Kids Who Walk or Bike to School and Concentration discusses Dutch research that indicates the following:

“The survey looked at nearly 20,000 Danish kids between the ages of 5 and 19. It found that kids who cycled or walked to school, rather than traveling by car or public transportation, performed measurably better on tasks demanding concentration, such as solving puzzles, and that the effects lasted for up to four hours after they got to school.”

Niels Egelund is the researcher who conducted the research.  I love what he says about moving and sitting (emphasis is mine).

“I believe that deep down we were naturally and originally not designed to sit still,” Egelund said. “We learn through our head and by moving. Something happens within the body when we move, and this allows us to be better equipped afterwards to work on the cognitive side.”

I’m going to go way out on a crazy limb and say that if movement is good for cognition in kids, it’s probably just as good for adult cognition.  And we see here that the concept of a division of the mind and the body simply doesn’t exist.  The health of one depends on the health of the other.  The evidence shows that the French philosopher Descartes got it wrong with his idea of dualism.

More on gluten

Going gluten-free is probably the biggest, most discussed issue in nutrition these days.  By eliminating gluten, are we improving our health or are we just following the latest fad?  The jury is out.  Certainly if someone has celiac disease then it’s vital that gluten be eliminated for good health.  But it’s unclear if everyone else will benefit from avoiding gluten.

There is a lot of anecdotal evidence out there to support the health benefits of cutting gluten, but anecdotal evidence isn’t terribly powerful evidence.  Gluten-free whether you need it or not comes from the New York Times Well Blog.  The article discusses all of these details.  It doesn’t come down firmly on any side but it provides evidence that perhaps the anecdotal evidence supporting gluten avoidance is worth further investigation:

“Crucial in the evolving understanding of gluten were the findings, published in 2011, in The American Journal of Gastroenterology, of an experiment in Australia. In the double-blind study, people who suffered from irritable bowel syndrome, did not have celiac and were on a gluten-free diet were given bread and muffins to eat for up to six weeks. Some of them were given gluten-free baked goods; the others got muffins and bread with gluten. Thirty-four patients completed the study. Those who ate gluten reported they felt significantly worse.

That influenced many experts to acknowledge that the disease was not just in the heads of patients. ‘It’s not just a placebo effect,’ said Dr. Marios Hadjivassiliou, a neurologist and celiac expert at the University of Sheffield in England.”

Something else caught my eye in the article. Experts who caution against everyone going gluten-free have suggested the following:

“They also worried that people could end up eating less healthfully. A gluten-free muffin generally contains less fiber than a wheat-based one and still offers the same nutritional dangers — fat and sugar. Gluten-free foods are also less likely to be fortified with vitamins.”

Okay, here’s the big revelation: EAT FEWER MUFFINS!  Anyone worried that gluten-free muffins don’t offer the same nutritional benefits of wheat-based muffins is looking at gluten-free grains of sand on the beach and ignoring larger issues.  To me, the big picture is still one in which we’ll have better health if we reduce processed food consumption.  Eat less stuff that comes out of boxes, bags and cartons.  That includes all kinds of stuff that contains gluten: bread, crackers, chips, cereal, etc.  Eat more plants.

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Strengthening the Brain, Compliementary Training

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I have an interesting article and website to share with you.  If you’re a reader then congratulations, there’s lots to read here.  If you’re an exercise professional who’s also a reader (Do exercise professionals who don’t read exist?) then even better.  If you’re a fitness enthusiast with a hungry brain, then fantastic as well.

Can You Build a Better Brain?

First, an article from Newsweek called Can You Build a Better Brain? speaks to much of what we discuss in Z-Health.  Brain and nervous system function are at the “heart” of everything for us.  Pain, performance, and obviously cognition are all rooted in brain function.  The question is, how best can we improve brain function?  Various means have been proposed to improve brain fitness.  But from puzzles, vitamins, fish oil, antioxidants, non-steroidal anti-inflamatories (NSAIDs), to the Mediterranean Diet, very few strategies have been shown to provide any benefit when studied rigorously.  I won’t go into the whole article but there are important points I’d like to share with you.  First, from the article:

“The rule that ‘neurons that fire together, wire together’ suggests that cognitive training should boost mental prowess. Studies are finding just that, but with a crucial caveat. Training your memory, reasoning, or speed of processing improves that skill, found a large government-sponsored study called Active. Unfortunately, there is no transfer: improving processing speed does not improve memory, and improving memory does not improve reasoning. Similarly, doing crossword puzzles will improve your ability to?.?.?.?do crosswords. ‘The research so far suggests that cognitive training benefits only the task used in training and does not generalize to other tasks,”’says neuroscientist Yaakov Stern of Columbia University.

The holy grail of brain training is something that does transfer, and here there are three good candidates…”

And what are these magical activities?

  1. Physical exercise
  2. Meditation
  3. Some video games

The article concludes:

“Few games or training programs have been tested to this extent, and many of those that have been come up short. Those with increasing levels of difficulty and intense demands on attentional capacity—focus as well as switching—probably do the most good … as does taking a brisk walk in between levels.”

Further indication that there is NO difference between the body and the mind.  We need a new word that encompasses both concepts.  What should that word be…?

Complimentary Training

There’s quite an impressive if also quite technical blog I’ve come across called Complimentary Training.  It’s written by Serbain coach Mladen Jovanovich.  His sports background is basketball, soccer, volleyball, martial arts and tennis.  I’ve just started digging into it.  It’s packed with a lot of technical information, much of it on periodization.  It looks like a very useful resource.  Dig into it if you dare.

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Injury, Re-injury & the Brain

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Many of us have experienced recurring injuries.  From Achilles tendon pain, low-back pain and whatever else-type of pain, we often feel great only to have the maddening issue return–often for no clear reason.  Anyone who’s experienced this pattern knows how crushingly disheartening it can be when after a layoff,  you feel good and with great joy you’re able to return to your chosen activity… only to fall back into the same injury pattern as before.  It’s more than just physical pain.  It’s a highly emotional and psychologically challenging obstacle to overcome.

To this point, the Peak Performance newsletter features an excellent article called Once Injured, Twice Fearful.  (Peak Performance is an great resource.  You can register for free and access many well-researched and well-written fitness and performance-related articles.  For a fee you can access more of Peak Performance.)  The main issue is how our brain is affected by an injury.  We may reach a point where our tissues are healed yet mentally we aren’t yet prepared to return to our sport.

Most interesting to me is the discussion on the pain neuromatrix.  What is the pain neuromatrix?  Well, there is no easy answer.  This is a theoretical construct that sort of consists of our perception of a threat and whether or not the brain decides that the threat is sufficient to create pain.  For instance, we sprain an ankle.  The damaged ankle is literally a potential threat to our survival (Not so much in 2010 but for most of human existence a sprained ankle may indeed have led to our starvation or death from the elements or predators.)  The nerves in the ankle send a status update to the brain, the brain then interprets this information as damage and thus gives us pain.  Why?  Pain gets our attention.  Pain will cause us to alter our activity so that we don’t further damage that ankle, thus we should survive longer.  (In contrast, if we sprain an ankle while we’re running away from an erupting volcano, the brain may say “That volcano is a far bigger threat, so no pain for you–KEEP RUNNING!!!“)  This is a fairly complex thing.  Here’s a brief explanation.  For further information, read Ronald Melzak’s paper on the topic.

Once injured, our brain pays particularly close attention to the damaged area.  The neuromatrix keeps close watch so that we don’t re-injure ourselves.  If all goes well, the tissue heals, we start moving normally and pain free, the neuromatrix senses no threat and the pain is gone.  However, this close scrutiny by the neuromatrix may sort of get stuck in the “on” position.  The tissue may heal but the athlete may still feel pain and anxiety at the prospect of re-injury.  This often results in poor performance because the brain is focused on monitoring the area of injury and thus can’t devote full attention to sport skills.

So what’s the solution?  First, simply explaining this psychological model to the athlete can be quite helpful in calming anxiety.  His or her knowing that pain doesn’t necessarily equal injury can be very reassuring.

Next, we must modulate the threat as it’s perceived by the neuromatrix.  If for instance a soccer player sustained a major injury on the field, simply returning to the field in soccer cleats may be perceived as a threat and pain and/or anxiety may be the result.  Certainly then running, cutting, dribbling, etc.–playing soccer in other words–may be a huge threat.

(A more overt example of this type of situation can be seen in war vets suffering from post-traumatic stress disorder.  Though the person may be safe and the actual threat long gone, any number of minor events may trigger extreme reactions such as panic attacks or violent behavior.  The sound of a book dropped on the floor or trash bag in a yard may cause the sufferer to react in a way that’s vastly inappropriate relative to the actual threat posed by the event or object.)

The player must be gradually re-introduced to the movements and environment of soccer.  Brief, easy jogging on the field; simple ball handling drills, and slow- to moderate-speed agility drills may be introduced as a way to ease the player back into the sport.  Variables may be added as the player feels more confident.  Speed, duration and predictability of drills may be adjusted.  Opponents may be introduced.  Playing surfaces may be changed.

A key part of this process is movement reeducation.  An injury doesn’t only include tissue damage.  The connection between the brain and the injured region (let’s say it’s the ankle) is also disrupted.  Such a disruption means the ankle tissue may heal but control of the ankle may remain deficient.  This sort of thing may cause pain–but it may not be ankle pain!  A poorly moving ankle may cause pain at the knee, hip, back, anywhere along the spine, shoulder, even the jaw.  Such is the nature of this highly interconnected system we live in called the body.

The Z-Health system has by far helped me more than anything in addressing my own pain as well as my clients’ pain.  R-Phase is the introduction to Z-Health.  With R-Phase we start to relearn the ABCs of movement.  We reestablish control over every joint in the body: feet, ankles, knees, hips, spine, shoulders, elbows, wrists, hands, fingers, jaws and even the eyes.    Through methodical, mindful movements we can very effectively reduce pain and increase performance very quickly.  Here we recreate and reinforce the foundation for all our more complex movements such as running, stair climbing, shooting baskets, swinging a golf club, etc.  We can then safely reintroduce our favorite sporting movements and activities.  It’s a very powerful and exciting system.

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Practice Makes Perfect: An Analysis

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We know that skill building and retention of skills involves practice.   We practice swimming, typing, putting, free throws, dance moves–all with the expectation that we’ll improve those skills.  I think most of us would agree that swimming probably won’t do much to improve our putting.  Nor will practicing our cursive handwriting improve our soccer skills.  In other words, we need to practice specifically those skills and tasks that want to improve.

To that point, we in the exercise field are familiar with the SAID Principle, or Specific Adaptation to Imposed Demand.  It means we adapt to the stresses and stimulation which we’re subjected to.  It’s the SAID principle at work when a swimmer swims and thus gets better at swimming.  Or why a boxer improves his skill through boxing.  In order to improve a skill then we’d better practice that skill.  A new study however tells us that if we’re willing to deviate just a bit during our practice sessions then we’ll probably learn better.

Why (Smart) Practice Makes Perfect comes from Science Daily and Athletic Edge: Does Practice Really Make Perfect comes from Time Magazine.  Both pieces profile research done by USC and UCLA neuroscientists.  The study featured six groups who practiced an arm movement pattern that mimicked a pattern on a computer screen.  The more accurate the subjects’ arm movements the better they scored.   Three of the groups practiced the arm movement only while three other groups practiced the arm movement plus other arm movements that were similar to the target movement.  The groups were then tested 24 hours after their practice sessions.  The variable practice group scored significantly better than the rote practice group.  Why?

“In the variable practice structure condition, you’re basically solving the motor problem anew each time. If I’m just repeating the same thing over and over again as in the constant practice condition, I don’t have to process it very deeply,” said study senior author Carolee Winstein, professor of biokinesiology and physical therapy at Herman Ostrow School of Dentistry at USC.

“We gravitate toward a simple, rote practice structure because we’re basically lazy, and we don’t want to work hard. But it turns out that memory is enhanced when we engage in practice that is more challenging and requires us to reconstruct the activity,” Winstein said.

“While it may be harder during practice to switch between tasks … you end up remembering the tasks better later than you do if you engage in this drill-like practice,” Winstein said.

This research is particularly fascinating as it coincides very much with a book I’m reading,  Norman Doidge’s The Brain That Changes Itself. In it, Doidge profiles various individuals with brain injuries and diseases and describes their efforts at rehabilitation.  Often these people have lost use of language skills, thinking or cognitive skills, and/or their ability to move or their motor skills.  They must focus to learn anew skills that are common to most of us.  It is through intense concentration and focus that these individuals are able to regain these damaged brain functions.  It seems a key aspect of this process isn’t just the learning of new skills–but it’s the very act of concentrating that brings success.

What might this mean for fitness enthusiasts and athletes?  It means that if you’ve tuned out during your workout then you’re probably not getting all that you could be getting out of your effort.  It means that doing the same workout over and over will yield fewer benefits than adding challenging variety to your routine.

In gyms, I see a lot of people who tuned out long ago.  They sit on the same bicep curl machine and curl the same weight the same way they did the last 1000 times they came in to workout.  Or they’re on the same elliptical machine going at the same pace for the same amount of time as they’ve always done.

Clients often struggle with new exercises.  They may be very comfortable with certain movements but try and add something new and it can be a bit of a battle sometimes.  Our brains aren’t always happy about making our limbs move in new ways! Kettlebell and Olympic lifts for instance, require more skill and coordination than calf raises or pec deck flyes.  But if we look to this latest research it may make sense that just as lifting the barbell is healthy for our bones and muscles, the challenge of learning these new complicated tasks is in fact just as healthy for our brains.

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