Got Pain? Don’t Stretch, Strengthen.

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If you’re like many runners, stretching is your first course of action when you feel pain. Sore Achilles tendon? Stretch the calf. Sore knee? Stretch the quads or the IT band.

The problem is, tight muscles are rarely the root cause of pain, so stretching rarely solves the problem. A better solution for chronic, training-related pains and injuries—one with more evidence behind it—is strength training.

Read the rest of the article, my latest for PodiumRunner.com.

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.

 

My Race Schedule & I’m a Professional Writer!

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Time to trail run

Springtime is hurtling our way and that means it’s time to trail run! I’m working up to what is for me a pretty giant bite of a trail race this fall. I have several races on the schedule as I work up to the final big event in September. They are these:

  1. Dirty 30, June 3, Golden Gate Canyon, CO – I’m running the 12-miler
  2. Under Armor Mt. Running Series, July 14, Copper Mountain, CO – I’m running the 25k (about 16 miles).
  3. Pikes Peak Ascent, August 18, Colorado Springs – 13.32 miles. I’m not running the full marathon, I’m only “running” up to the top.
  4. The Grand Traverse Run, September 1, Crested Butte to Aspen – 40.7 miles!? My god, is that right?! Amazingly, 40-ish miles is sort of small potatoes in the world of ultra-running.

The best part of this is that I love trail running and I love the process! I love the training I did last year for the Imogene Pass Run. Being in the mountains is… exquisite. Language doesn’t suffice… It’s more than fun. Trail running is a deeply spiritual thing for me. I have enormous enthusiasm toward the preparation for the Grand Traverse, and I’m grateful to get to do it.

Time to suffer

I’m reading Endure by Alex Hutchinson. It’s an excellent book. An ever-present concept, maybe the foundation of the whole book, is the experience of suffering. Suffering defines endurance. We don’t have to endure that which doesn’t induce suffering.

As it pertains to my races: There will be suffering…. especially in the Grand Traverse. I’ve suffered in two marathons and the Imogene Pass Run. I suffered through a bad half-marathon. I’ve biked up Mt. Evans twice. There’s some suffering. Two-a-day football practice in the Texas summer = suffering. The Grand Traverse is almost 41 miles, about 6200 ft. of climbing and 7000 ft. of descending. That equates to more suffering than I’ve ever experienced. I will suffer for many hours. Every bodily fiber from my toes to my eyebrows will be in agony. I will despair, get angry, and maybe feel hopeless. I’ll want to quit, maybe multiple times. How do I get through that?

Hutchinson discusses the idea of preparing to suffer. How will I react? Will I succumb to negative thoughts? Or will I employ a strategy like positive self-talk, a touchy/feely sort of thing that actually has quantifiable positive effects on performance? Maybe I’ll deliberately smile to myself which has been demonstrated to reduce perceptions of effort.

One thing I won’t do is try to ignore the pain. It can’t be done. Research has shown a more effective way to manage pain and suffering is to inspect your pain in a clinical way and have a calm conversation about your suffering. There’s a difference between pain and the emotions we feel about pain. Awareness and examination of this divide can help lower the perception of pain and suffering. I am in control of my thoughts on pain. This will help.

Much of Endure compares “mental” vs. “physical” endurance. (In truth, there is no difference between mental and physical. It’s all atoms and molecules. It’s all connected. There should be no delineation. Try having a mind without a body or vice versa. Rene Descartes was wrong. Maybe it’s useful to say “psychological” vs. “mechanical” endurance to indicate the perception of pain by the brain vs. the muscles’ inability to generate high force.) I’m learning about the multitude of ways and the degree to which the brain generates feelings of effort, pain, and suffering during exertion. The best athletes don’t suffer less than everyone else. They are able to suffer more and manage their suffering better than the rest of us. Hutchinson gives evidence that we are probably capable of far more effort than we believe possible. Based on my learning, I plan to make my difficult runs very difficult. I plan to push myself harder than I have in the past when the time is appropriate. The idea is to get intimately acquainted with a high level of suffering That’s not to say most of my running should be grueling. That’s not the right way to train. But when it’s time to push hard, I’m going to push hard. I’ll be testing this strategy in the races leading up to the Grand Traverse. I need to find out how hard I can push, how hard I can suffer.

Oohhhhhh this is good… Ultra-Marathons: The 15 Stages of Suffering tells it like it most certainly is. It conjures up explicit memories of prior suffering. I’m nervous, and I can’t wait to do it.

I’m being published

Also, in 2-3 weeks I’ll have an article appearing on Tnation.com — and they’re paying me for it! I’m not sure I’ll win the Pulitzer but I’m very excited that I can technically call myself a professional writer. I’ll post a link to the article here when it comes out.

Got Shoulders?

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The shoulder joint is the most mobile joint in the body. That’s a good thing! When combined with good spine mobility, our shoulders allow our arms to reach, throw, pull, and push from all sorts of angles.

A consequence of being mobile is the possibility of being highly unstable. Instability, or the inability to control a limb, may lead to the common aches and pains that many of us experience in our shoulders, elbows, and possibly even the wrists. Why might instability and pain happen? (My answer will be limited to chronic pain, not acute injuries such as fractures and dislocations due to falls and other accidents.)

My belief is that shoulder problems (and most other movement problems) are rooted in a use-it-or-lose-it dynamic. Our modern lifestyle is characterized by limited movement. As adults, we rarely crawl on the ground. As modern humans, most of us don’t have to climb trees or pick up heavy things and put them overhead. We typically sit with our arms in front of us as we type on keyboards, drive cars, and operate TV remote controls. Thus our movement skills stagnate. Our brain and nervous system loses the ability to coordinate the many movements available to us. But then we might decide to swing a golf club, swim, lift weights, attempt pull-ups, pushups, throw a ball, or reach into the back seat from the front seat. Unfamiliar movements—especially if done with high force, high speed and/or done at end-range—may be too much to ask of our deconditioned shoulder complex. Then we get pain.

The following videos are designed to help restore mobility and stability to the shoulders. Pay attention to how you move as you do them. Don’t speed through them. Always be in control of the exercise, don’t let the exercise control you. If it hurts then back off or stop. None of these drills are guaranteed to fix any specific problem you may have. You may need to see a physical therapist or some other injury rehab specialist.

For the corner stretch, keep you eyes up a little bit. Don’t let your head and neck flop forward.

For the rotator cuff complex, use high reps, maybe 15-20 reps.

The halo can be varied in some ways not shown in the video. Try the halo while in a hip-hinge or deadlift-like position. Use a light weight.

Pain vs. Discomfort

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Everyone and anyone who’s been in a gym has heard the phrase “No pain, no gain.” What does that phrase really mean? Do we want our clients exercising in pain? What should effective exercise feel like?

In my experience, clients often interpret “No pain, no gain,” as “Pain is inevitable and it should be ignored.” I believe that for the good of our clients’ health, trainers should examine this misunderstood statement with their clients. This is a vital conversation, especially with clients who are new to training.

Pain & discomfort defined

I don’t recall if it was in a seminar or an article, but someone smarter than I once discussed pain vs discomfort. I’ve stolen the idea and used it ever since. (If you made this description and you’re reading this then thank you! It’s been highly valuable to me and my clients.)

My clients should understand that in order for exercise to do the things we want it to do — if we want to create favorable adaptations to exercise — then a client must exercise to the point of exertion and fatigue. The client must work hard. He or she might sweat, grunt, groan, and work to the point of fatigue and discomfort. A description of the D-word:

Discomfort:

  • Often a burning in a working muscle or muscles.
  • Comes with a feeling of fatigue.
  • Doesn’t alter the way you move (compared to a limp, for instance)
  • Is usually symmetrical if for instance you’re squatting, swinging a kettlebell, doing pushups, running or cycling.

Discomfort is a sign that we’re working near your accustomed limits. That’s a good thing, and that’s how you get in better shape.

I also tell my clients about pain. We don’t want pain. (Some minor, intermittent pain may be OK. More on that in a moment.) Some characteristics of the P-word

Pain:

  • Often felt in a joint, not a muscle
  • Sharp or electric
  • May not accompany fatigue
  • Severe pain alters your movement: Knee pain causing a limp or low-back pain altering how you bend down and pick up something
  • It’s often asymmetrical: Knee pain in one knee when squatting, shoulder pain in one shoulder during pushups or bench press, low-back pain on one side of the low back

If a client feels pain then we stop and we evaluate. Persistent, serious pain should not be a part of our day-in-day-out experience at the gym. Pain is not something to be ignored or masked with pain pills. Pain is a signal from the brain that something isn’t operating as well as it should be.

Color-coded pain

In another case of I-forgot-where-I-read-it disease, I read about a physical therapist’s color-coded, traffic-light guide to pain. I’ve adopted it and it helps guide me as to when to when or if I need to alter an exercise for a client due to pain. It goes like this:

GREEN: Everything feels fine; no discomfort anywhere. Client is ready to rock ‘n’ roll!

YELLOW: Minor, sporadic, or short-lived pain during the exercise but it’s not bad enough to stop or alter the movement pattern. We keep going as long as it doesn’t get worse.

RED: It hurts. We stop.

If pain becomes more intense, and/or more frequent, and/or lasts for more than a week then it’s probably time to seek medical care of some sort. Trainers should have a physical therapist, chiropractor, or some other licensed medical professional to whom he or she can refer clients.

I like this code system in that it’s rare that everyone is going to feel 100% perfect all the time. It’s not uncommon for us to feel something that is less than optimal but not so bad that we need to stop entirely. With the yellow reading, we can keep going through some minor pain, and we can avoid catastrophising around pain. If a client can experience a little bit of pain yet continue working then I think we can build resiliency in the client and protect against what’s known as fear-avoidance of certain movements. If we get to red then we can always stop and change things.

The fear-avoidance model. You don't want to be caught up in it.

Fear-Avoidance Model. Avoid it.

 

Unfamiliarity: Is it pain or discomfort?

Exercise newcomers may have no idea what it feels like to work hard. Their experience with muscular discomfort may be sporadic and in the distant past. Unfortunately, many people experience all uncomfortable feelings the same whether it’s joint pain or the normal sensation of hard work. They are different and our clients should learn the difference.

A classic example is low-back pain/discomfort. The epidemic of low-back pain is a unique pain in our culture. It is widespread and debilitating for many thousands of people. For those who suffer low-back pain there can be tremendous fear of recurrence. At the same time, exercise is an effective antidote for many forms of pain in older people, and for chronic (but not acute) back pain.

Numerous muscles attach in and around the low back. The glutes, erector spinae, lats, obliques, and other spinal muscles live and work all around the low-back area. Just like any other muscle, if you work these muscles hard then you’ll feel it. Exercises such as squats, deadlifts, kettlebell swings, and bent over rowing can cause serious — and totally normal — discomfort in the low back. Yet for many clients, any sense of low-back discomfort can be bad and scary. Thus it’s very helpful and reassuring to a client if a trainer can discuss the issue of pain vs. discomfort.

The spirit of “No pain, no gain”

The knowledge behind that phrase is well-informed and comes with good intentions. Plus, it rhymes! It sounds good. But clearly it can be misunderstood. (If I ruled the world, I’d change the phrase to “No discomfort, no pain.”) The truth is, no one will increase his or her physical capacity by sitting comfortably. Anyone who wants to get in better shape must work hard. At the same time, pain, as I described above, isn’t a normal part of working out. Pay attention to it. Get help if it doesn’t go away.

Health & Fitness News: Pain Science, Breakfast – To Skip or Not to Skip?, Carbs vs fat (Whither protein?), 8 Glasses of Water Mythology

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Several articles have grabbed my attention. One is a concise summary of the current understanding of pain. Another discusses breakfast and the flimsy evidence supporting its importance. Next, science looks at the efficacy of reducing carbs vs fats for weight loss. Finally, drinking eight glasses of water a day is based on nothing.

Pain and lifting

The issue of pain is a continual theme in this blog. I’ve dealt with periodic bouts of lingering pain. The upside to this is that I’ve learned a lot about pain. Whether we’re an athlete or not, most of us will encounter non-acute or chronic pain.

It can be scary and depressing to us especially if it limits our ability to train. Interestingly, learning about how pain works can actually help us feel better (low-back pain in this case). Pain is NOT simply an indication of tissue damage. It’s very much a product of the brain. How we perceive our bodies (damaged or strong), our pain (threatening and scary or just a nuisance) and our expectations (“I’m broken and ruined,” or “I’ll be fine.”) are major influences on the pain process.

In that direction, Elitefts.com has a worthwhile article called 3 Things Lifters and Coaches Need to Know About Pain. It’s concise and fairly easy to understand for non-scientists. I think this information is useful for coaches and trainers who will certainly come across an athlete or client in pain. It may also prove helpful to you if you’re in pain. Here is a summary:

1. You are not your MRI or your X-Ray. Many people have tissue damage or degeneration on imaging but walk around without pain everyday. If you’re dealing with pain or an injury, get a thorough medical history and functional examination done by a qualified health professional, preferably one that works with athletes and lifters (they are out there).

2. Understand that pain (particularly chronic pain) isn’t purely related to biomechanics or injury. Biological and psychosocial factors both contribute to a person’s pain experience.

3. When working with clients, don’t create fear or a nocebo effect by berating your clients on their lifting technique, posture, or movement capabilities. Instead, work through your client’s issues with positive coaching and cueing to build a great training effect.

Read the article to get more detail.

Breakfast and weight loss

“Breakfast is the most important meal of the day.”

You’ve heard it. You believe. I’ve preached it to clients. It seems the earth rotates around this statement. But, is this bit of gospel based on anything of substance? Not really.

In The science of skipping breakfast: How government nutritionists may have gotten it wrong the Washington Post discusses research that shows the following:

“In overweight individuals, skipping breakfast daily for 4 weeks leads to a reduction in body weight,” the researchers from Columbia University concluded in a paper published last year.”

Another golden idol knocked from its pedestal! How can this be? Why would the USDA Dietary Guidelines for Americans tell us something that isn’t supported by good evidence?

The Post article does a good job of discussing the answer.

One of the key pieces of evidence, for example, examined the records for 20,000 male health professionals. Researchers followed the group for 10 years and published results in 2007 in the journal Obesity. They showed that after adjusting for age and other factors, the men who ate breakfast were 13 percent less likely to have had a significant weight gain.

“Our study suggests that the consumption of breakfast may modestly lower the risk of weight gain in middle-aged and older men,” the researchers said.

The advisory committee cited this and similar research, known as “observational studies,” in support of the notion that skipping breakfast might cause weight gain. In “observational studies,” subjects are merely observed, not assigned randomly to “treatment” and “control” groups as in a traditional experiment.

Observational studies in nutrition are generally cheaper and easier to conduct. But they can suffer from weaknesses that can lead scientists astray.

One of the primary troubles in observational studies is what scientists refer to as “confounders” — basically, unaccounted factors that can lead researchers to make mistaken assumptions about causes. For example, suppose breakfast skippers have a personality trait that makes them more likely to gain weight than breakfast eaters. If that’s the case, it may look as if skipping breakfast causes weight gain even though the cause is the personality trait.

It’s a reminder of the very important rule: Correlation doesn’t equal causation. Just because one detail appears alongside another detail, it doesn’t mean the one detail causes the other. (Tall people play basketball. Therefore one might conclude that playing basketball makes people tall. Is that right?)

Similarly we’ve seen a recent revision on dietary fat and cholesterol guidelines. We once thought that fat (particularly saturated fat) and cholesterol were the most evil of edible substances. Based upon flawed science, we were told to replace fat with carbohydrates and we’d all be well. Upon further review, it seems we may have been very wrong.

Low-carb vs. low-fat

Sticking with the diet and science theme, there’s been a lot of discussion on a recent study in Cell Metabolism that looks at low-carb vs. low-fat diets. This was a six-day study in a carefully controlled lab environment. The study had the same group of 19 obese participants spend six days on either a restricted-carb or restricted-fat diet. They then went home for several weeks for a “wash-out” period where they resumed their normal eating habits. The participants then returned and they were switched to the other diet. The same number of calories were cut from both diets, the difference being the calories came specifically from either carbs or fat. The participants were observed in a metabolic chamber and their caloric expenditure was very closely monitored. It was a well-designed study.

The result? The low-fat group lost more fat. Discussion over right? If you saw most of the popular-press headlines you’d think so. But there’s more to the story.

First question in my mind is “What about protein?” Though the jury is still out on some aspects of high-protein diets, several studies (here, here, here and here among others) suggest that high-protein diets can be useful for weight loss. The study doesn’t mention protein at all. Seems odd to me in that carbs, fat and protein are the main macronutrients in food. Why would we want to manipulate and study the effects of just two?

A good discussion of the low-carbs vs. low-fat study can be found at Examine.com. Really-low-fat vs somewhat-lower-carb – a nuanced analysis goes into some of the limitations of the study. This article is quite detailed. Read it all if you’re up for it. I won’t go into all of it but here’s a little bit.

One point to remember that this low-carb diet could be called a “lower-“carb diet in that some low-carb diets go much lower than this one. The Examine.com article says:

“The carb levels ended up being 352 grams for Restricted Fat versus 140 for Restricted Carb, and the fat levels 17 versus 108. In other words, (moderately lower carb than typical diets) versus (oh my goodness I can count my fat gram intake on my fingers and toes!).

This trial wasn’t designed to explore a real-life 100-gram-and-under low carb diet and especially not a ketogenic diet. Rather, it was a mechanistic study designed so that they could reduce energy substantially and equally from fat or carbs, but without changing more than one macronutrient. If they lowered carbs much more in the Restricted Carb group (like under 100 grams), they’d then have to go into negative fat intake for the Restricted Fat group. And negative fat intake is impossible (*except for in quantum parallel universes). One more note: all participants kept dietary protein constant and exercised on a treadmill for an hour a day.”

So it’s possible that if carbs were lowered further, we might see a different outcome of the study. Also, this was a six-day study. We must wonder what might happen over the course of six weeks, six months or six years.

Another very important point to remember is that this was a very tightly controlled experiment. It didn’t reflect the real world in which people trying to lose weight have to make their own food choices. Examine.com says:

And to repeat a very important point: this study was not meant to inform long-run dietary choices. In the long-run, the choice between restricting fat or restricting carbs to achieve a caloric deficit may come down to one thing: diet adherence.

While preference for certain foods may dictate which diet is easier to adhere to, this isn’t always the case. For instance, it seems that insulin-resistant individuals have an easier time adhering to a low-carbohydrate diet. Nowadays, new dieters often pair low-carb with higher protein, the latter of which can boost weight loss. And since there are plenty of high-sugar but low-fat junk foods (see Mike and Ike, et al.) but not so many high-fat but low-carb junk foods, low carb intakes can sometimes mean an easier time staying away from junk food when compared to low fat diets.

So we should remember that the dietary rubber meets the road when someone seeking weight loss can modify their diet in any healthy way and then stick to it for the long haul. If it’s less fat then great. If it’s fewer carbs, also great. If it’s some other improvement to the diet then wonderful!

Eight glasses of water a day is arbitrary

Another sacred cow of health and longevity is the admonition to drink at least eight glasses of water a day. That bunk has been debunked but much like a bell that’s been rung, it’s hard to change people’s minds once they’ve heard this information. The New York Times gets into this topic in No,You Do Not Have to Drink 8 Glasses of Water a Day. This one is simple. If you’re thirsty then drink. If you’re not then don’t. (How else would we have made it to the year 2015 if we didn’t have some sort of very good water gauge built into our physiology? Do my cat or dog think about the measured quantity of the water they drink?)

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 rehabilitationThe 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.

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.

 

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)

Can Yoga Be Harmful?

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“With it went my belief, naïve in retrospect, that yoga was a source only of healing and never harm.”
– William J Broad, NY Times

If you haven’t read or heard about it, the New York Times recently ran an article titled How Yoga Can Wreck Your Body.  It’s far from the perfect article.  For one, it’s full of anecdotal evidence.  Second, many of the examples given of yoga causing injury consist of people doing rather extreme versions of a pose or movement.  I think the article does bring up valid questions: Can yoga cause harm?  Is it always safe for everyone?

I’ve had a couple of harsh experiences with yoga.  Once I had a teacher that thought since I looked big and strong I could do some sort of headstand.  I figured I would follow the teacher’s lead and give it a shot.  Without question I was not ready for this pose.  I left the class with a very painful shoulder.  This instructor had been teaching for years and was very highly sought after at the gym where I worked.  I was in another class where an instructor all but insisted that I move deeper into a pose and I simply couldn’t do it.  My nervous system was trying to protect me by preventing further movement into this position and she had me trying to force my way into a deeper range of motion.  Again, by the end of class, I was in a bit of pain.  This is not what I was after.

My observation is that yoga is often championed as a panacea cure-all for any number of ailments: back pain, knee pain, mental stress, possibly even digestive issues.  I can’t say everyone says this type of thing but in every gym setting where I’ve worked yoga is discussed and presented in this glowing fashion. But is yoga really any different from any other type of exercise? Might there be a few risks?

First and foremost, yoga is movement.  So is running a 100 m sprint.  Driving a golf ball is also movement.  The power lifts are movements.  Typing on a keyboard and watercolor painting?  Also movement.  Guess what: Movement can cause injury!  (By the way, try NOT moving and see how healthy you become.)  Further, yoga is a lot of very different movements.  One may be quite safe, another quite unsafe.  All parts of yoga can’t be viewed fairly as the same thing.

We can probably agree that movement is essentially necessary and usually healthy.  We can probably agree that walking is typically safe and healthy.  But what if we have a sprained ankle?  Or a damaged vestibular system such that we can’t tell which way is up?  Then even walking might be quite harmful.  Lifting weights is similarly healthy in most cases.  If we have a herniated disk or if we use bad technique then lifting may be very unhealthy.  Why would we view yoga as any different?  If we have poor kinesthetic sense then moving into any number of poses could cause pain and/or injury.

Further, we as Americans often have the view of “If a little bit is good then a BIG WHOLE LOT must be great!” More is better in other words. I’ve heard some yoga people speak proudly of not only how deep they can move into a pose but also how quickly they can move from one pose to another.  Sounds a lot like the talk in any weight room.  Just substitute weight and reps for poses and depth of motion.

Glenn Black is an experienced yoga teacher who’s interviewed for the Times article.  He speaks to other yoga teachers and practitioners on the issue of injuries.  He talks about ego.  (I think the popular image of yoga is that it is an ego-less type of thing.  But what human activity is free of ego?)  Black says, “My message was that ‘Asana is not a panacea or a cure-all. In fact, if you do it with ego or obsession, you’ll end up causing problems.’”  This seems a very wise statement, and I’m pleased that this article may start to shed light on the idea that yoga should be evaluated the same way as any other type of exercise.