Pain Psychology - Identifying With Pain

As I continue into my practice as an Athletic Therapist, it fascinates me on how much of a mind-game rehab is; not simply a body one alone. It's not as easy as rubbing a client's sore muscle and telling them to exercise. If it was, my job would be way too easy.

Pain has a large impact on our physical as well as psychological state. Inversely, both physical and psychological factors play a role in its onset, frequency, severity, and more. Over multiple posts, I plan on discussing just a few of the many psychosocial factors that influence pain and some of the tools that I use to help clients past them.

One major phenomenon that all therapists run into with clients, especially those who live with chronic pain, is the circumstance of individuals who identify with that pain. In the same way that a person can identify as - and revolve their life and their psyche around - being an athlete, a mother, or an academic, it's equally possible to do the same with pain.

To my understanding, this occurrence is one that allows people to turn the situation around and, in their minds, making the existence of their pain "ok". Patients have been observed using this principle to keep the blame and ownership for their own pain away from themselves, potentially treating it as simply a "fact of life" in order to cope and make the sensation easier to handle. To complicate the matter, it's suggested that patients can end up relying on their pain for self-identity, creating a crisis if pain is, in fact, remedied.

So here's the challenge. When clients who come in who are so used to and accustomed to pain that it's a part of their entire identity and if taking their pain away risks causing an identity crisis, what do I, as the clinician, do?

A lot of the process comes down to classic first-year psychology class methods, believe it or not. Visualization and imagery is crucial, as pain-sufferers need to be able to envision a future outcome that involves an improved condition (even if it's not a complete recovery). Doing so prepares them for what could be considered their "new identity", creating a pathway for the transition after pain is gone. Following the creation of that long-term end result, shorter-term goals need to be established in order to make the process of reaching the outcome seem plausible. (Sound familiar, everyone who went to college ever?)

We'll never use any of this stuff.

Past that, there are too many other skills and methods used to assist clients along their recovery process to fit into one post, but what I've written here offers a good start. For all of what I've said, this is the reason why my appointments tend to be so chatty, but those psychological barriers need to be addressed if there's to be any hope of treatment success.

When it comes to treatment, exercise, and rehab, "just do it" doesn't quite cut it. Sorry, Nike.

This topic was written with consult and collaboration with Alison Quinlan, a Sports Behavioural Consultant in Victoria, BC who is also pursuing continued education in dietetics. Follow her on Twitter and visit her website and blog to see some of her own authored articles. 

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Specific Adaptations to Imposed Demands

There was one principle that was commonly reiterated to us all throughout school. 

SAID: Specific Adaptations to Imposed Demands

Whether it's for rehabilitation or for fitness, this is a very important thing to note about the body's reactions and adaptations to the stresses we place upon it. Beneficial changes cannot and will not occur if we don't give them a reason to happen.

So, in the same way that you won't gain muscular size if you don't work out, you also can't expect tissue to properly heal following injury if we don't exercise it in the manner that we need it to function.

Why aren't I in shape?

Essentially, you use it or lose it. I can't tell you how many times I've heard potential clients decline starting rehab in their acute phase of injury because they think that they need to rest and wait first for partial healing to occur on its own. This is especially rampant among elderly demographics who simply feel unsafe attempting any sort of exercise too close to their injury.

It doesn't always have to come to this!

Unfortunately, young or old, too much rest is more detrimental than anything. Immobilizing injured tissue results in it healing in a way that typically doesn't allow for optimal return to activity, as the tissue was not stressed with any of the demands that replicate it's intended function.

I cringe every time someone tells me that their doctor recommended nothing but bedrest; something that is still painfully common. Inversely, when an injury occurs on an athlete whose team I work with, I get to witness the increased speed that they bounce back completely from injury. Just by jumping on top of exercise and range of motion immediately during the acute phase, we're able to seriously cut down on their recovery time.

I'm being real; I'm not expecting you to box jump and power clean directly after blowing your ACL. There's always some sort of movement that is possible, though, and something is always better than nothing.

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Cross Syndrome Is Not A Disease

I've spoken to several people lately who have been very concerned with their "cross syndrome" and have sought my advice in correcting it.

For those not in the know, cross syndrome is a term coined by Vladimir Janda in the 80s for a series of muscular and postural imbalances. It signifies the criss-cross pattern of shortening and lengthening of muscles that results in postural imperfections, such as the classic forward shoulder position from tight upper traps and pecs combined with weak neck flexors and lower traps.

These cross patterns occur through both the upper and lower body as termed by Janda. Similar principles exist through the entire kinetic chain overall, not being isolated with just the aforementioned saggital (front and back) planes.

I take issue with the name "cross syndrome", though, as I find that it's regarded with more fear than it should. The term "syndrome" is mistaken by many individuals (usually ones that are self-researching for their own health or working in fitness) to be synonymous with "disease". This is absolutely not the case.

I wrote before about how textbook posture is an unrealistic achievement and a largely-unnecessary goal. These cross patterns (as I prefer to call them) are often correlated to injury, yes, but not causative to them.

Many, many people will walk around with forward heads and rounded T-spines their entire lives and never experience shoulder pain. Anterior pelvic tilt does not automatically signify lower back pain. We need to not fear these postural imperfections and think that they always need to be corrected for.

Obviously, these patterns are something that we pay attention to if there is pain, because they provide the rehab practitioner a good place to start in terms of relieving the symptoms and the mechanics that caused the injury. In absence of a symptomatic dysfunction, though, there's very little to gain by trying to address the "imbalance".

All in all, there's no real problem with wanting to train yourself to stand taller, but we shouldn't be concerned when we look sideways in a mirror and notice "upper cross syndrome". If it ain't broke, don't fix it. If it doesn't hurt, if it doesn't impede your performance or day-to-day activity, it's probably functional.

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Fascia: Not Your Enemy

Fascia spent many decades with status as the "forgotten system". Indeed, we got very used to only ever thinking of the body as a neatly-compartmentalized container of separated organs. Fast forward, though, and the past few years have seen fascia blow up as hot topic among medical and fitness professionals, bringing to light how these system keeps the body so closely interconnected and supported.

However, with awareness of fascia came this strange demonizing of it. Fascial pain, myofascial release, foam rolling, trigger point release, and more. I hear so many people attempting to boil down all their pain and dysfunction to fascia and trying to roll it out and stretch it cellophane-thin in order to address it.

 

But let's try to remember that, like all other systems of the body, the symptoms of fascia are a product of your lifestyle and habits and that all of your systems are being affected together. It's irresponsible to try and narrow down all of your problems to just the one type of tissue; if there's pain or dysfunction in it, it's absolutely being caused by overall mechanical issues being contributed to by multiple other structures.

For instance, I had one client who had confusing knee pain symptoms that kept bouncing around to different areas around the knee and occurred bilaterally. When the pain was clearly not purely muscolotendinous, I considered it to be fascial. To test this theory, we went up the chain to the neck and treated the muscles that were fascially connected to the painful areas of the knee (the superficial front line pictured below) and then reapplied stress to the knee. What do you know, the pain had alleviated!

The superficial front line

Does this signify the fascial involvement in my client's pain? Yes. Does this mean that all we have to do is treat his fascia? Definitely not. We still have to consider the muscular restrictions that may be causing secondary fascial tension. We need to address the reasons why that anterior chain is experiencing shortening and tension in the first place to allow the fascia to adhese in the way it is. Whether myofascial involvement is the primary, secondary, or tertiary issue, you have to touch on it all.

In short, we need to stop treating the topic of fascia like it's the enemy that's causing all of our problems or that treating it is the end-all-be-all solution. Healthcare and fitness professionals alike know that we need to treat the body as a whole, but sometimes even we need a good reminder to not become hyperfocused on one aspect.

Fascia, it's not an enemy. It's a victim.

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