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The Pain Game: 4 pain questions answered

The Pain Game: Get 4 Responses for that Bothersome Pain

By  Spencer Earnest , PT, DPT

This blog post is a sequel of previous blog posts from Spencer about the importance of pain,the effects of short term pain relievers, and the ties between activity and recovery.

What if I’ve been recovering but the pain doesn’t seem to calm down?

Sometimes you can do all the right things to rest and recover but the pain in those areas don’t want to calm down. It’s ok to seek medical attention, I don’t want to make you feel like you should never seek medical attention. There are times for whatever reasons that specific tissues have a hard time calming down and recovering on their own.

Sometimes tissues need some help.

There are two ways of calming down over-active musculoskeletal pain. Let’s compare over-active muscle tissue to an over-active child. That child is just go-go-go without any hope of giving up. Passive method- give them a cell phone, works like a charm- for a little bit. After that treatment the child is no less tired and if anything might be more hyped up and even more agitated.

Passively treating something will never lead to a long term outcome.

The active method- what do you think would happen if that child ran a couple laps around a track? That child would be exhausted and would calm down. When possible, this is the best method. Remember- our tissues need activity and recovery. If we only give our tissues passive recovery tactics then we are missing out on the more beneficial way to recover. Passive treatments are beneficial and do have a place in medicine. As long as you know how to respond to passive treatments.

Passive treatments will never change the tissues ability to tolerate activity.

What happens when a child experiences pain? When a child falls, runs into something, smashes a finger in the door, and/or gets hit by a sibling- that child experiences pain. Pain is the body’s way of saying “stop doing this.” Now, a child cannot prevent any of the above-mentioned things from happening the first time, but pain prevents them from continuing those things. The fun is over once the child starts crying in pain-the body's way of ending potentially harmful activity.

Even so, a child is only in pain for as long the body is sending the warning signal to stop that activity.

That is why a child overcomes their pain so quickly-the body stops sending the pain signal because the child stopped the activity that the body viewed as dangerous or harmful to it. Pain is a warning signal to stop or modify potentially dangerous activity being done to the body. It is not meant to be long term by any means-unless we don’t stop the activity that warranted the warning signal in the first place.

What would happen if the child got injured enough to warrant healing? Does the child scream in agony for the entire duration that it takes for the broken bone to mend? No, the body isn’t in danger while the bone is casted and healing.

So we now know the body doesn’t have to experience pain during healing.

If the child accidentally used the broken bone during the recovery process-the body would absolutely send a painful experience to that child-warning them of the potentially dangerous activity being done to tissues that are not ready for such activity.

Most people with LBP/neck pain have the hardest time recovering. They think rest and avoidance of activity will help. Have you asked yourself-what is the role of those muscles in that area of my pain? Muscles in our back are primarily stabilizers. Otherwise known as postural muscles. Patients will constantly report experiencing pain with prolonged positions such as sitting/standing/lying down with these areas. Knowing the role of those specific areas of your pain will help you know what they need, and don’t need.

By “resting” those areas you are actually giving them the hardest workout of their life. I put “rest” in quotations because most people have a very difficult time resting/turning off their postural muscles when they’re awake. And it’s for good reason. Our postural muscles are built to endure the duration of our day. But when they become involved in one way or another, their capacity to fulfil their function diminishes-making it difficult to last the entire day without increased symptoms, often pain.

So what can we do with these annoying areas of pain that seem to never “release!?” Gentle activity and movement is often the easiest way to calm down the neck and LBP. Why? Because other muscles become the primary activators of the body, giving your postural muscles a break. Don’t be afraid to move when you have back pain, be more afraid not to move!  When pain occurs-react, don’t analyze. 

 

Is there a list of do’s/don’ts activities when I have pain?

No! This might go against most of the common beliefs and MDs orders but it’s true (unless referring to post-operative patients).  Think of it this way instead- it’s not about what I can and can’t do- it’s about how much my body, and specifically the area of my pain, can tolerate at this current time. If you remember the activity vs recovery principle you will avoid overdoing it.

If running has caused you pain in the past, and your MD told you to stop running, you’ll have to begin cautiously. If your normal distance was 10 miles maybe start off with one mile. I say maybe because there isn’t a finite system to this. Everybody’s conditioning level and tolerance to activity varies. So learn what your body can tolerate and start there. If there’s pain in the first couple seconds when you start your run then you’ll have to perform lead up exercises.

MODIFY where you need to.

If an activity is too much to handle (and it’s the brain's job to send a warning signal if it is, ie- pain) then either lessen the resistance/decrease the reps/sets/duration/ or decrease the range of motion required to perform that exercise or activity. I’d recommend seeing a physical therapist if this is the case, they can direct your program to help you accomplish your specific movement goals.

If you keep this simple rule in mind you will find it difficult to “over-do” it- begin cautiously and increase gradually.

 

How to overcome chronic pain?

Persistent and repetitive motions. Convincing the brain that movements are not harmful to the body and should therefore no longer send a pain output is easier said than done. The body has already tricked itself that non harmful movements and activities are harmful and thereby result in pain.

This is defined as allodynia.

For example- a person who’s pain and nervous system has increased so much that even a light touch becomes painful. While taking a feather and rubbing it gently on someone's arm is not harmful, the nervous system has rewired itself to believe it is. So while we know there's only a feather touching the arm the nervous system acts like it's a blowtorch blasting the arm.

While this is a very real example, it's also the extreme.

Please apply this principle to your life, if you suffer from chronic pain. If you are in control of your actions and movements, there's a safe bet that you are not causing harm to your body. Repeat these gentle, controlled motions as often as you can; CONVINCING your nervous system to rewire itself to send the correct outputs for these actions.

Please note- those in chronic pain create a very real deconditioned and most likely atrophic state for those areas of pain.

The tolerance to activity will be low. So please begin with gentle activity and movements and progress from there.

For example- a person suffering from chronic LBP (not a far fetched example), may have significant pain every time they bend over. This person should start with laying on their back and bringing one knee up to his chest, then both knees to his chest, then gentle standing hip hinges-progression from there until bending over completely within the limits of their tissues (I’m 6’6’’ and can’t even get close to touching my toes).

Just a moment ago I had a patient who suffers from chronic pain and displays allodynia constantly. He had shoulder surgery months ago and the pain has only increased since then. Today, I sat him down and asked him to move his shoulder in a way that’ll cause pain. He attempted to move the shoulder into abduction (away from his body) but was only able to get a trace of movement (around 1mm of movement) before wincing in pain. I then convinced him that that movement is in no way shape or form causing harm to his shoulder. He believed me. I then asked him to do that same movement 20 more times.

Believing something and doing something can be two different things.

I can tell he was nervous but he did it anyway. His first attempt after believing the movement wasn’t harmful was very painful again. WHY?! I explained that his nervous system is hard wired to react this way. It’ll take many, many, many attempts to rewire it. He bought in again. He then winced his way through 5 more times. Then winced less for the next 5. The final 10x he no longer was wincing. He rewired his nervous system for that movement. The nervous system no longer saw that movement as harmful to the body and no longer sent the pain output accordingly. I sent him home with homework to continue these gentle movements and attempt other gentle movements as well.

With the mindset of repeating them until they are no longer painful. Is he cured of pain? No. Is he on the path to restore function and rewire the nervous system to send the correct outputs for non harmful stimuli to the body? Yes. He will continue this process and increase range of motion, activity level, and resistance training until full function is restored.

Please note- he will most likely experience pain throughout all of these steps, as each progression will require rewiring. But he’s on the path to taking control of his life again, rather than letting the pain control his life. 

The question is not why does the person THINK it hurts so much, the question is why does this hurt so much.

Pain does not depend on what is actually happening to its tissues, it depends on what the brain THINKS is happening to the tissues.

Pain doesn’t exist in the body. It never has and never will. It’s an output of the brain. It’s all about meaning. When we have pain for a long time the pain begins to spread, change, move. If we don’t understand the complexity of the brain and plasticity we automatically conclude that our body must be damaged. 

You have to know the pain you feel is 100% real. But it no longer accurately signals damage and harm being done to the body. That system has been altered. We can use brain exercises to help convince the body and retrain the brain to regain precision. 



Will I have to deal with pain the rest of my life?

I'm saddened by those people who think they are going to have to deal with LBP the rest of their lives, like it's a different body part than the rest of their body (or whichever body part has become chronic for you). Meaning- their low back doesn’t respond the same as the rest of the body to injury and recovery. Bones, joints, muscles, tendons, ligaments make up the lower back. You might be shocked to find this same makeup is found all over the body as well.

So why do we put so much emphasis into our lower back being unable to heal and not our ankle? When we sprain our ankle we know the prognosis and the process of rehab and there is a clear belief that we will be able to recover. The ankle is made up of bones, joints, muscles, tendons, and ligaments just like our lower back. So why do we believe the ankle is so much more capable of recovering from injury?

It is our culture.

There is a culture of belief that has been built over many years that some injuries are more chronic than others. Please stop this. The body heals and recovers and is capable of rehab in every mechanical part of the body. Are there injuries that will never return to the way it was before? Yes. If you were to lose a limb the body would not be able to regenerate a new one for you (come on scientists!). But the body would be able to recover and rehabilitate to a life WITHOUT PAIN again. Which is what this whole thing is about anyway.

The LBP you are experiencing is not a life sentence of pain. Start viewing your LBP as an ankle sprain that is just in your lower back. Modify your activity the same way you would with a sprained ankle.

We need to stop holding different expectations for different parts of the body when we are injured.

It seems like we don’t allow our back to be in pain like we allow other parts. If we sprained our ankle and it hurts when we walk on it, we accept it as normal. When we have an episode of LBP and we go to bend over and experience pain- we think our back is broken. Let your back be “ankle-sprained” and modify your activity as you would with any other injury. Even if that injury came in a way that we didn’t realize. “-but nothing injured my lower back??” The “ankle sprains” of the lower back come much easier than more parts of the body.

Don’t be surprised if you strain your lower back muscles without you noticing it. Accept it and move on to the recovery phase.

Here are 7 things to do in Vegas if you don't have low back pain!!

Reach out to a physical therapist to help with gentle ways to increase your activity level.

Spencer Earnest works at Optimal Therapy an Affiliated Company on Paseo Verde.

The address is 1358 Paseo Verde Pkwy #200 Henderson, NV, 89012

To schedule an appointment call 702-564-6712 or click here to see a list of our locations.


Portrait of Optimal Therapy physical therapist Spencer Earnest   Spencer Earnest was born and raised in Laguna Niguel, California, spending his time playing  sports and hanging out with his nine older siblings.

  Spencer earned his Bachelor of Science degree at Utah Valley University and went on to get his Doctorate degree in Physical Therapy at Touro University, Nevada. He has a passion for physical therapy and helping his patients achieve their functional and rehabilitational goals.

  Spencer describes himself as being married to the most wonderful girl in the world and they have three amazing children. He loves spending time with his family and playing any and all sports.

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