Don't Chase Your Pain

Wrist pain that has nothing to do with your wrist? Elbow pain that's doesn't stem from a structure of the elbow? Hand pain...well, you get the picture.

Many of our clients see our therapists for pain that just can't be traced to the area where the pain is perceived. Classic examples of this are symptoms in the elbow, wrist, and hand that we find rooted from the neck and shoulder.

It's not at all uncommon for nerves, as they travel from their origin to the spine, to cause pain at the furthest extremities. In the shoulder, for instance, the bundle of nerves leaves the neck and travels through a pathway in the shoulder before innervating the rest of the arm. 

At both of those locations do we often see a restriction of the nerves, whether it's from muscular tension, poor mobility between joints, or anatomical bone structure. That restriction can then result in pain, numbness, tingling, or other neurological symptoms.

However, nerve pain is interesting in that it follows trends, but not rules. Individuals often expect that they need all of the symptom criteria in order to identify the cause as a nerve. Radiating and electrical pain is a classic sign, as is the numbness or other sensory changes throughout the arm.

Neuropathies do not follow strict guidelines, though, and can easily present as localized sensations, resembling muscular soreness, tendinitis, or arthritic pain.

For this reason, we cannot simply point to the pain and assume that that's the spot that we need to rub and exercise. Our therapists will ensure to rule out the joints above and below the site of pain to narrow down, exactly, where those symptoms are originating from. (Fun fact, it could be MORE than one place. Fun.) With that being said, to the carpal tunnel or tennis elbow clients out there that seem to have found no relief, it may be time to seek an additional opinion to make certain that the right area is being addressed.

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Air Quality and Pain

If you're reading this from anywhere on the West Coast, you're likely aware of the smoke conditions we're experiencing due to the record-breaking forest fires. The amount of smoke and toxins in the air had BC pegged as having some of the worst air quality in the world!

Obviously, there have been the obvious health concerns of this occurrence, mostly in regards to asthmatics, COPD, and even cancer in the long term. However, is there a link between air quality and musculoskeletal pain as well?

I had a client this week who I've been treating for shoulder pain involving nerve entrapment between the shoulder and neck. After weeks of improvement, she came in on Monday frustrated over a severe relapse in her symptoms. The relapse began on Wednesday of last week with no apparent trigger.

I thought for a minute. In Victoria, I remembered Wednesday as being one of the peak days for smoke in the air.

So I doublechecked her intake form for health conditions. There it was: asthma! Upon questioning, we were able to come to the realization of how irritating the smoke has been for her, resulting in persistent coughing and tightness throughout her chest. Thus, reaggravation of the nearby structures regarding her injury and the return of her pain! With that in mind, we were able to treat appropriate and reassure my client that this relapse was temporary with no true set-backs; only speed-bumps.

This being said, this is a good lesson in how things such as air quality and smoke can be a cause for pain, even when it's not completely obvious. If we look at COPD patients, we can easily find a prevalence of upper back pain. I wasn't able to find statistics, but from here, it's not a difficult leap when considering similar effects that might plague individuals who live in areas that experience smog or industrial workers with regular exposure to toxic fumes.

Could there be links between air quality and pain that aren't purely mechanical as well, though? There isn't a ton of research on this subject, but we do have findings of air pollution having neuroinflammatory effects that, while are mostly looked at in relation to central nervous system disease, is likely transferable to neuropathic (chronic) pain as well. More specifically, airborne chemicals also are linked to neuropathy in painters and the exacerbation of neurogenic pain in smokers.

This information shouldn't be taken as something to scare you, but hopefully it makes everyone think and be cautious. Whether it's your outdoor environment, your job, or another type of exposure, protect yourself and save yourself some pain! Hopefully this forest fire issue will resolve soon, cigarette smokers can clue in and change their habits, and for those in highly-polluted areas...I don't know, vote?

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Why Do Muscles Get Tight?

Tight muscles? You gotta stretch!

Wait...

Ok, so maybe aggressive stretching isn't the answer to muscles being tight, and I've delved into some alternative methods for helping to increase flexibility in the past, but why do muscles get tight in the first place?

Does tightness occur simply due to high amount of use? True, muscles may become stiff when they become conditioned to high demand, such as your spinal muscles or the calves of runners, but let's make sure we realize that stiffness is one thing and that the sensation of a muscle being tight is another.

For the record, muscles require stiffness to function and that stiffness should not be a cause for discomfort. If you disagree, go ahead and try to loosen up your neck and come let me know how it's working for you if you achieve it.

For this reason, I try to avoid even using the word "tight" when in practice, as it sends the message that any tension and stiffness is a negative thing. But if we were loose all over, we'd be pretty useless meatsacks.

So when things DO feel tight, what's happening? Well, that is usually due to muscle tone.

We now understand that flexibility is a mechanism driven by the nervous system and has to do with the level of passive contraction that the muscle is holding when at rest. That level of contraction and tone will change based on the body's physical condition, work demand, and also simply by what it's trained to do.

"Tight" muscles occur when the nervous system is given a reason to hold an excessive amount of tone. These reasons can include acute injury, of course. However, they can also include the muscle simply not being strong enough to do it's job, resulting in increased tone to compensate. This being said, when I find a particularly tonic and tender muscle on a client, while I do treat it for that tension, my immediate next step is start exercising it. (Not stretching it!)

The sensation of tightness, I find, also occurs in those who specifically condition and train themselves to avoid stretching a muscle into certain ranges. The classic example is individuals who religiously avoid any spinal flexion, whether it be due to injury or training in the gym, resulting in the tense feeling through the back by the time they do happen to bend over.

If we can understand the messages that our bodies send us, then it helps us to remedy the discomfort that we are in much more effectively. Targeting the symptoms of tightness often gives us some relief, but mindfulness about addressing those root causes is equally or more important.

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3 Lifestyle Influencers Of Pain

Posture? Training error? Mechanical form? Many people think that physical, musculoskeletal factors are the only ones involved in the creation or persistence of pain. Let's take a look back on some past discussions, however, and remind ourselves of some of the lifestyle situations that may be exacerbating the way that we feel.

Smoking

Understandably, the research of nicotine's effect on pain is much less thorough than on its effect on other annoying health concerns such as LUNG CANCER. However, I digress...

Despite the number of people who use smoking as a coping mechanism for their body and head pain, lets remember that pain sensitivity is going to be increased by nicotine withdrawal in the first place. Even so, some individuals report increased pain tolerance in general, but this could actually be attributed to nicotine causing damage to the nerves themselves.

What's more, if you suffer from any kind of neurogenic pain or fibromyalgia, you pain may be made even worse without even the option of being dulled by a cigarette.

Sleep

In our busy world of one in three Canadians not getting adequate amounts of sleep, this is an important aspect of life to look at.

While sleep deprivation does definitely correlate strongly with increased perceptions and sensitivity to pain, the relationship is actually a little indirect. Rather, that sleep deprivation can increase depressive symptoms and anxiety which are mental factors that more-directly effect pain sensitivity themselves.

And you can also consider the fact that increased pain increases sleep disturbances as well, further affecting this spiral.

Stress

It's easy to understand that stress has a massive effect on the body's functions, from cognitive to immune and everything in between.

The stress hormone, cortisol, is released during periods of stress to assist the flight or fight response. When cortisol levels are heightened for a prolonged period of time, however, individuals will begin to experience a decreased pain threshold and increased pain sensitivity.

On the bright side, aside from physical rehab alone, this also opens the doorway for mental health treatments, even those as simple as meditation, to have positive impacts on helping individuals recover from pain.

As suggested when it comes to stress, pointing out these lifestyle influencers on pain isn't meant to show how hard it is to subvert it; rather, it opens avenues for us to address when physical treatment alone isn't enough. Support for quitting addictive behaviours, careful consideration of sleep, and proper management of stress are all extra tools that can be used in order to help win the battle against pain. All in all, this demonstrates the importance of looking at pain and other lifestyle health factors as a closely-related cascade rather than separate entities.

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Do No Harm - Treatment Intensity And Consent

"This other therapist I saw just beat the crap out of me."

People seldom expect to see an Athletic Therapist, physiotherapist, RMT, or chiropractor without experiencing some level of discomfort during the treatment. After all, we, as the clinicians, are applying manual pressure into your body to exert some kind of physiological change. Things could get tender!

However, I hear, time and time again, stories of individuals who see practitioners that seem to have a particular level of sadism for making their treatments as excruciating as possible.

As I've covered before, pain tolerance is a very individualized factor when it comes to any treatment. Some people will be able to handle more pressure and discomfort than others, and as a result, those few may actually require a more intense treatment in order to attain the desired desensitization effect from it.

Inversely, if someone has a much lower tolerance to pain, they do not need to - nor should they - receive any treatment method that is more intense than they can handle. Remember, any therapeutic treatment is targeting the nervous system only, rather than causing any true physical change to the tissue. That being said, a client should only need to be taken to their personal threshold for the intensity of a technique to have an effect. What's more, exceeding that threshold may actually result in heightening that person's pain sensitivity.

With that in mind, I cringe when I see these photos - from both clients and clinicians - who are proudly showing off their treatment bruises. "More pain, more gain," is not a principle that applies to healthcare, and taking these extremes is unnecessary at the best and damaging at the worst!

In my view, these mistakes are being made both intentionally and unintentionally. While even the professionals may be prone to forgetting that higher intensity may not be necessary, there are definitely those cases out there where the clinician is trying to use that "more pain, more gain" belief as a placebo or a means of creating some sort of dependency for return-visits. (What can I say? Workers with shady ethics can be found in every field.)

So as a message to other clinicians, be mindful of your treatment and make sure to follow the first rule of your field by doing no harm! To clients, you have a right to tell your therapist to ease off, and if they're too insistent that, no, they need to go that hard, then you also have the right to leave their office. No one has a right to cause you pain without your consent.

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The Sixth Sense You Need For Injury Prevention

In broad, obvious terms, we have five senses. Touch, taste, sight, smell, and hearing. In reality, however, the body actually has many more sensory systems than that. Thermoreceptors in the body detect temperature; chemoreceptors detect chemical changes (such as what your immune system requires); equilibrium from your inner ear handily lets you know if you happen to upside-down or not.

And then there's proprioception, which happens to be one of the most important senses that our bodies have in order to move, function, and avoid pain and injury.

Proprioception is the sense of where a body part is in space. For instance, if you close your eyes and raise your arm into the air, you will, no matter what, be aware that you arm is above your head.

Where is it? WHERE IS IT?

Those proprioceptive sensations can be much more subtle than that as well, though. Take, for example, single-leg standing on an unstable surface. It's your body's ability to sense minor changes in position and weight shift that contribute to your ability balance. That proprioception that you have for the joints in your leg provide the feedback that your brain needs to coordinate the muscles in this case.

With that in mind, it should be easy to understand how a lack of well-trained proprioception can result in a higher risk of injury. Lacking proprio in a joint certainly affects its overall stability, increasing the chance of tissue failure when the body can't properly adjust for a stimulus.

From observation and speculation in the research, there's also a link between a lack of proprioception and chronic pain in absence of true tissue damage. Lower back pain patients, for example, are demonstrated to have this sense impaired basically across the board! It may be that the body's inability to accurately reposition itself as needed could be resulting in increase muscle-guarding activity and heightened pain sensitivity as a protective response.

This being said, proprio is a vital system to retrain when rehabbing clients. It's not as easy as simply strengthening some muscles and increasing flexibility in others, as the body still won't be receptive to letting go of it's protective responses if it can't effectively sense those changes in joint position. In fact, I've had incredibly strong clients with no significant weaknesses remain plateaued in their recovery simply due to this fact! Given that proprioception can be lost as a result of injury, surgery, and even growth spurts, being mindful of this domain is one of the most crucial aspects of an effective recovery program.

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Flexibility Is Driven By The Nervous System

Flexibility is a common concern for the health-conscious population. Right or wrong, stretching a tight muscle is often a main focus. However, what causes a lack of flexibility? How does that lengthening and shortening of muscular tissue work?

Well, you may be surprised to know that a lack of flexibility is not a structural issue. Often, we think of tissue like an elastic band. It seems like a good metaphor, as we'd like to stretch out that band enough to a point that it remains lengthened.

How we visualize muscle on stretch.

HOWEVER, the reality is that flexibility is, in fact, a neural mechanism, not a structural one. Just like the shortening of fibers occurs when you contract a muscle, the nervous system initiates similar contractions in response to stretch. (It's this response that we condition or decondition by lifestyle, rehab, or training.)

In other words, when you try to reach for your toes, your hamstrings experience a reflex that cause a contraction against the stretch.

You can't think of muscle shortening or lengthening like an elastic band. You have to think of it like a second person pulling back on a rope when you try to pull it in another direction.

What's really happening.

If you think about it, it makes a lot of sense. If you've ever pulled a muscle in your back or slept funny and have a kink in your neck, you can feel the sudden lack of flexibility in the area. Your muscle tissue didn't just magically and suddenly decrease in length (which would mean decreasing in size) in that time. Rather, the muscle is contracted and guarded.

This being said, getting muscle to lengthen and remain like that is not as easy as simple as performing prolonged stretching. If inflexibility is a nervous system reflex in response to stretch, that reflex needs to be trained out. Whether that be teaching the muscle to relax under tension, addressing a reason for excessive muscle guarding, or some other type of conditioning, it always comes back to making the nervous system happy and willing to let go.

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How Getting Past Pain Relapses Is Like Quitting Smoking

We made it to February!

How are those New Year's resolutions coming....?

Mmmhmmm!

Stepping aside from New Year's-specific goals (as you already know my opinion on them), let's discuss the realistic situation of regression.

Across the board, regressions and relapses occur in every type of behaviour or lifestyle change, whether it's recovery from pain, smoking, or weight loss. While the ideal is that we persevere through the road block or speed bump and continue on through the recovery process, often, hitting a point where pain returns, a cigarette is lit, or a few pounds are gained back are enough to shatter motivation and derail progress altogether.

One research group categorized pain relapse responses into four possibilities, some less ideal than others.

1) An unpleasant mystery that leaves negative feelings towards oneself and the situation.
2) A fact of life that should just be ignored.
3) A reminder to keep within physical limitations in order to avoid a future relapse.
4) An indication to change your behaviour to avoid another relapse.

You can probably assume that the first option is the least constructive, likely resulting in an ever-increasing level of negativity regarding the pain and loss of motivation to pursue further recovery.

The second option, ignoring the pain, is dangerous, as it may result in the individual becoming too content with their pain to the point of identifying with it.

The third possibility is good to a point. During a more acute phase of healing, learning to stay within limitations is vital, and sometimes the reminder is necessary. However, avoiding behaviours for too long can end up in a person simply using avoidance as a long-term coping mechanism.

Lastly, the fourth option is the most ideal in the long term. Understanding triggers or becoming aware of an increased need for self-work for your health is the most productive response to have if reexperiencing pain. However, sometimes coaching (whether it be self-coaching or help from a therapist) is necessary to reevaluate a relapse in order to maintain a positive foreseen outcome on the situation.

As it turns out, you can closely relate behaviour change relapses between health behaviours fairly well across the board! For instance, these tips of quitting smoking are amazingly applicable to this very process!

1) Focus on the next 24 hours:
Manage the acute phase of the relapse. Modify the environment so that further aggravation doesn't occur. Understand that this was an acute occurrence only and that you shouldn't become down on yourself and treat all the work up until this point as a failure.

2) Talk to someone:
Seek advice or support as needed. Seek your therapist or even consult a doctor if it puts your mind at ease that this wasn't a complete reset to square-one.

3) Analyze what happened:
Did you decide to get too aggressive with the weight you were squatting? Did you take a week off of your rehab exercises in too-early of a stage? Try and ask yourself exactly what may have caused this relapse to happen so that you can use that knowledge for future recovery.

4) Build a new plan:
This one is built straight into the basic rehab process. We're always modifying and changing pain-management and prevention strategies as needed, and having this relapse happen is a bit of a blessing in disguise, as it can help you and your therapist to further progress your long-term plan.

I try my best to ensure that my clients are ready for the possibility of their pain returning at some point, whether it's simply next week or a sudden reoccurrence in five years. Yes, it may happen. No, it is not the many steps back that you may think it is. And yes, there are steps that you can take to get right back on the train and continue to always get better.

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Life Doesn't Mirror Gym Movements (And Doesn't Have To)

No, I'm not telling you that the gym is bad and that you should stop going. There are many fantastic reasons why the gym is awesome.

However, there's a certain phenomenon among many of my clients that I'm noticing. Fear of movement.

The best example is the rounded-spine position. On one hand, many individuals who experience back pain are told by doctors, therapists, and more to absolutely avoid bending down and rounding their backs; that doing so will result in more pain. Having this fear of that movement instilled, however, does little to remove their pain, as these positions are, to say the least, inevitable. As a result, the nervous system, essentially, becomes primed and ready to guard against those movements, causing pain in those ranges and positions when pain wouldn't normally be a necessary response in that case. 

We call this kinesiophobia, the fear of movement due to pain which actually works to prolong pain and disability.

Here's the surprising thing. Active and healthy individuals experience this too! I've also seen this in very disciplined gym-goers who, for all intents and purposes, have nothing mechanical going on to suggest that they should be in pain. However, due to the immense emphasis on "good form" that active and athletic individuals may be bombarded with, I've been witness to the exact same avoidance-triggered pain. These are clients who are under the impression that it's necessary to square-up and keep a neutral spine curve every time that they so much as bend down to tie their shoes. And again, this belief that any other type of position is harmful is so strong that, just the same, they experience guarding and pain. Even so-called functional training isn't devoid of instilling these messages.

The takeaway from this is that the body has very natural movement patterns that it likes to use that don't necessarily reflect the strict and controlled form of the gym. Absolutely, if you're at the squat rack, moving in a single-plane only, and are loaded up with multiple plates per side, then you should definitely be observing "proper form". However, whether you're an active or inactive individual with or without formal training, the body is built for free and fluid movement. Don't let anyone, including Instagram personalities, magazines, or even doctors to tell you that dropping form as you live your life is a dangerous thing.

Credit: Greg Lehman

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The Stressful Effect Of Stress On Pain

It's the New Year! I hope your holidays were fantastic. However, now's the time for all of us to buckle down and get back to work. Don't let the stress get to you!

Stress! GAHHHHH!

If you read even the occasional post from myself, then by this point you know that pain is not a response that's simply caused by a physical lesion alone; it's a complex phenomenon with massive psychosocial and neurochemical contributors as well.

And just like how poor sleep can (indirectly) cause an increased sensitivity to pain, perhaps mental disstress can as well.

We all know negative stress as causing potentially negative effects on the body. Many of you may also have heard of cortisol, the stress hormone. Or, to get technical, the hormone released by your body in response to stress to take part in the fight-or-flight response, regardless of how major or minor.

Well, cortisol also has this interesting effect on pain, with several demonstrations showing an decreased pain threshold and increased sensitivity while subjects were under mental strain.

This can have huge implications from a rehab perspective, especially in chronic pain cases. Even as tissue heals and rehab programs are followed, negative stress can certainly interfere in the regression of pain symptoms. This is largely why conditions such as fibromyalgia are commonly looked into, at least in part, as a stress disorder.

This could be particularly problematic with progressive pain and stress before intervention occurs. As we are finding, chronic pain clients typically have an elevated cortisol level even when looking at them in absence of stress-specific factors. This implies that the body may be pumping out even more stress hormones simply in response to pain (as seems reasonable), resulting in a potential cycle of pain and cortisol continually causing one another to spike. (Hmm, haven't we seen a cycle like this before?)

Fortunately, this opens up more avenues of treatment as well. Simply doing mental relaxation exercises and activities is showing positive effects on many chronic pain conditions. This goes to show the importance of stress management when it comes to long-term or complicated pain cases. We often overlook this mental side of physical pain, but disregarding it means overlooking a crucial avenue for recovery.

Relax man!

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The Nocebo Effect - Why Belief In A Treatment Is Vital

We all know what the placebo effect is. It's the very real-world phenomenon of the body responding positively to an otherwise ineffective treatment or stimulus caused by the belief that there will be a positive outcome. The placebo effect is, in reality, a large reason for many success stories in the therapeutic world, believe it or not. In fact, some modalities actually rely on a patient's belief that it will decrease their pain.

Source

BUT.. did you ever stop to consider the opposite effect being a possibility as well?

The "nocebo" effect is classified as when a negative expectation results in a negative outcome, whether it's to do with movement, nutrition, a clinical treatment, or virtually anything else. Truly, it's the other far-side of the spectrum from the placebo.

This ties directly in with my past topics about how language selection and expectations of pain can propagate and cause more pain. Like I've said before, mental state has a huge effect on driving the body's outputs, whether it be pain, inflammation, or more.

This being said, the nocebo has a massive influence on the effectiveness of a therapy treatment. If a client does not believe in a certain type of treatment or modality or they think that it will cause them harm, then it absolutely can interfere with the treatment outcome!

For this reason, I do my best to thoroughly educate my clients in exactly what kind of processes are occurring in their body before, during, and after any treatment I provide in order to help them understand the targeted effect and increase the probability of success.

If a client simply doesn't believe in a modality at all, then that's ok! Therapists work for the client, not the other way around, and the client does not HAVE to subscribe to every philosophy. However, in absence of that belief, gears need to be switched with either a new approach or a new therapist, otherwise we're charging that client continually for treatments with no outcome. And that's where responsibility on the clinician's side comes in.

The brain is a funny thing, but it's the boss. We gotta work with it.

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Removing Pain - An Example Of Pain Expectation

I had an awesome experience regarding pain psychology and coaching this week. I've already written before about how pain can be amplified purely due to expectations of pain, but it's always great to have some real-world examples rather than only scientific studies.

I had a chronic-pain client come and see me in the past week after a particularly-stressful time period. As a result, her pain sensitivity through her neck and upper traps was through the roof, and she recoiled from only very light pressure from my hands.

Knowing that it wouldn't be productive to simply try and force my way into her muscle tissue and use physical means to get my client to relax, I instead did some education on pain.

I used this great example from Dr. Jarod Hall, on Facebook where he talked about how he experienced a splinter poking him in the back in a sauna. However, due to being in the hot sauna, his nervous system interpreted the "poke" sensation as "burning" due to the expectation of what kind of a sauna would typically cause. Yep, the body can be that easy to trick!

With that being said, I was able to use that experience to teach my client on how it's unnecessary to expect pain, especially when the oncoming stimulus isn't an appropriate one. By coaching her through self-talk to convince her that the pressure from my hands, while perhaps not being the most comfortable, wouldn't cause her any physical harm or damage, her pain sensitivity decreased dramatically. And just like that, without any other physical intervention, I was immediately able to apply more pressure to those sensitized area than ever before!

Remember, pain isn't all in your head! But the head sure can affect things!

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Brain-Body Trust

Here's another scenario:

You're an avid weightlifter who hits the gym five times per week. You regularly do squats, deadlifts, and many others of those exercises that gym rats know and love.

Gains.

However, despite your ability to deadlift twice your bodyweight, one morning, you simply bend down to tie your shoe and you completely put out your back. You're in excruciating pain for the rest of the week which lingers to a lesser extent for the next month or so before you go and get it treated. All the while, you've been doing what you can at the gym but have been avoiding deadlifts and have been extra cautious when bending over to pick anything up on a daily basis in order to protect your back. Every time you try to bend down, you recreate that most-painful sensation and it needs to be avoided. Finally, you decide to go get treated. (Perhaps even by an Athletic Therapist!)

Promotionpromotionpromotion.

Treatment goes great. After one or two sessions, the constant pain is no longer a bother. You have your homework to condition and strengthen your core and protect your spine. You go on your way out of pain - except when it occurs the next time you go to deadlift again. Although your therapist told you that the tissue is all healed and the inflammation is gone, that bending motion, alone, still elicits tension and pain through your back as soon as you square up to lift heavy.

So here's the question: Even after receiving treatment and home exercises, after the tissue is healed and the inflammation is gone, once you've gotten strong enough that you core should be stabilizing your back without a problem, this one movement still causes you pain. Why could that be?

Pain science is a fascinating field and I'm not about to go into the neurobiology and in-depth psychology of pain today. However, I will quote the Pain Science Podcast that I listen to in this.

"Pain is a conditioned response," and "Pain is an output, not an input".

If you know of the Pavlov experiment, this is like how he was able to trigger salivation in dogs every time he rung a bell. Essentially, all physiological responses, pain included, can be conditioned to occur whether the stimulus is appropriate or not. This is related to when I talked about pain avoidance habits and how they can propagate pain rather than prevent them. After such a prolonged period of time of an individual telling their nervous system that bending down is going to cause pain, the nervous system is now trained and hyper-reactive, sending out pain signals every time that movement is performed even after healing has occurred.

Not kidding. This picture is how pain can work.

This is actually a common occurrence. Clients who should be out of pain are still experiencing it due to their nervous systems, basically, working against them. In a way, although there is not actually anything wrong with those tissues anymore, the brain no longer trusts that particular movement pattern and will have a sympathetic response every time that it's attempted.

Stupid nervous system!

This case I'm discussing is, in reality, actually one of the more simple ones. In severe chronic pain cases, those inappropriate pain triggers can extend to nearly every movement and even light touch to the body!

In any of these cases, careful rehab considerations to both the physical and psychological side of the recovery are required. It's the responsibility of the therapist to guide the client through those movements - or other stimuli - very carefully to progressively allow the nervous system to adapt and trust the pattern again. At the same time, coaching a client away from expecting pain is important, otherwise it may leave a barrier that the individual might never overcome. 

Pain is a funny thing and pain patients are kind of like the Murphy's Law of healthcare: Expecting the worst can cause the worst to happen. However, responsible therapists can recognize these barriers; no person should be trapped by their pain.

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Pain Tolerance - It's Not All In Your Head

"When you asked me to rate the pain, what happens when someone just has really, really high or low pain-tolerance?"

This was a question posed to me by a new client, and a very understandable question at that. If a client has really low pain-tolerance, does that mean we need to ignore their pain level when treating them in order to make progress? If tolerance is high, are we doing more damage to them by pushing too hard without them being able to set proper limits? Again, if tolerance is low, is that person just being soft?

"I'm smiling. Are you smiling?"

The quick answers: No, pain tolerance is not all in your head. No, you're not a wimp. And no, we are not risking going too hard or too soft with treatment and exercise because you're tolerance is higher or lower than the average person. I digress...

What Affects Tolerance?

There are too many things that affect pain tolerance to try and go in depth to them all. There is a slew of cultural differences when it comes to perception of pain which can be affected by age, sex, or race alone!

Psychological factors also affect this tolerance. Again, I'm not saying that the perception is all in one's head. Rather, certain aspects of one's psychology, such as perception of control, depression or anxiety, and expectations of pain can all cause physiological changes within the nervous system and propagate pain sensitivity.

Finally, looking at a more at the peripheral sites of pain within the body, the reactions occurring at the nerve endings, during inflammation responses, and communications between the immune system and nerve cells all affect pain sensitivity and can become more or less reactive, depending on a person's condition. It's complicated. I spent an entire night trying to make sense of the biochemistry of it in order to summarize it in my blog and ultimately had to give up. I promise that the science is there, though!

Need-to-know!

The Affect on Treatment and Rehab

So with that being said, we circle back to the question about the effectiveness of rehab and treatment when pain sensitivity and tolerance are higher or lower. If pain is preventing us from massaging a muscle hard enough to make a change, where is the benefit? If a client is insisting to keep going harder when you're already, essentially, on top of them with all of your weight, are we not going to hurt them more?

Well, as I covered in the past, the system that these treatments target isn't the muscular one. When we massage, when we exercise, we're addressing the nervous system itself, and so we're doing the body a favour by working within those limits (or lack thereof) of sensitivity and pain tolerance.

To a limit. Please don't actually try to break
someone's back because they asked you to..

With that being said, if someone is highly-sensitive and can only tolerate very light touch, then those are the means that we'll stay in. By treating or exercising within that high level of sensitivity, the goal is to try to reverse some of those physiological changes contributing to it in order to, gradually, decrease the sensitivity and allow the client to eventually be able to accept more pressure.

On the flipside, if someone is highly-tolerable to pain, then yes, the treatment does become a bit tougher and more aggressive to try and meet their needs, but you don't have to worry about causing damage. Like I've noted before, the amount of force you would require to actually deform or damage tissue would be roughly the equivalent of a steamroller.

Don't try this at home.

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Plantar Fasciitis (And The Nerves That Imitate It)

I thought that this would be a good post to make, as I've now encountered a handful of clients with this issue. Individuals have come to see me with complaints about plantar fasciitis that has been persistent to any amount of stretching or foot massage.

In these instances, my typical process was to assess the injury but have difficulty replicating their pain using any ranges of motion or muscle testing at the foot, ankle, or knee. Pain with pressure was common, however.

After attempting to treat the plantar fascia with no benefit, I had to flip switches and try something different. Having some experience with this before (and with the wonderful handiness of the internet) I zoned in on testing a couple nerves instead.

Most people assume that nerve pains follows the trend of always beginning centrally near the spine and extending down the length of the limb. However, it is only a trend, not a rule. If entrapment of the nerve occurs further than the spine or in several, less severe areas separately, then the symptoms can absolutely manifest at only the end of the limb, like in these "plantar fasciitis" cases.

Both the sciatic and the saphenous nerves have the potential to cause plantar pain that many people may think to be fascial. (Both can be dull, diffuse, or burning pain.) However, upon proper testing where we put the nerve itself on stretch, we were able to determine the root of the cause. Without fail, after treating these clients up at their hips or back instead, we were able to relieve the pain.

Just a good example that therapy and rehab isn't as easy as chasing the pain. Often, you have to go quite a ways up the chain in order to find the cause. In these cases, finding that cause can be a hard thing for clinicians to do, considering that protocol wouldn't normally involve having to rule out joints as high as the spine in cases of foot pain. However, therapist or client, it's important to keep in mind that the body works as whole.

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