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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The Advantage Of Active Rehab

In the wake of hiked ICBC rates due to an uncontrollable flood of payouts as well as an audit into unethical professional fees to do with claims, it has been a thought of mine recently that there is something not quite working with an insurance system that should be easily covering its costs due to the nature of what it is.

Now, there are many directions to point the blame. One of the articles above discusses how much autobody shops are milking the insurance company with hiked rates, and I'm sure there are therapy clinics who aren't much better in terms of ethics. There's the increase in legal fees as well, due to ICBC's fight against offering higher and fairer initial settlements. We won't even get into the political discussion of what role certain provincial parties may have played in creating this mess.

Whatever the reason, I'm mostly concerned with solutions to the problem. One way that I can see it - one that would save much in terms of time and money on the side of both the insurance companies, the legal teams, and the clients - is the shift towards more active approaches to injury rehab.

I don't often feel the need to talk about the importance of exercise for recovery since, to myself, it's a no-brainer. However, I remind myself that the world we live in isn't necessarily one that's focused on exercise and movement the same way that an Athletic Therapist is. But I digress...

It's easy to find evidence for my case. Studies are easily comparing the difference between active rehab (which includes movement and exercise prescription) to passive rehab (which is treatment-centered only) and consistently shows an improvement in client-condition and function when you get people moving.

The implications of this are easy to figure out. With more control of recovery being given to clients - by way of prescribed home exercises - the result is more-optimal recovery through means of fewer appointments and thus, less money! 

So while saving ICBC from paying a few less $70 appointments isn't quite comparable to the thousands of dollars that car shops might be milking, if the trend catches on, it can make a difference. And obviously, this doesn't solely apply for motor vehicle injury claims; individuals paying out of pocket for their recovery would of course appreciate paying a little less.

The advantage is clear. Exercise rehabilitation is the way to go!

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I Don't Know It All

I admit it! I'm not perfect! While I wish I could know every minute detail about human anatomy and physiology to a "T" and call myself an expert on everything that is rehab, the reality is that this is not the case.

Don't worry, this isn't me going on a depressive rant and feeling sorry for myself. (That's what Valentines Day is for.) This is a productive admittance of the limitations that all medical professionals have but don't always like to verbalize.

We also don't always like to admit our Valentine woes, either.

The thing is, there is a LOT to know about the body, and as humans (Yes, therapists are humans! Gasp!) we can't perfectly log, file, and access that information without flaw like computers. Speaking for myself, I'm probably pausing every fifth or so new assessment that I do with clients in order to check a reference. (If you follow my social media, you've probably seen my textbook collection. And to tell you the truth, it's a very small collection compared to others out there.)

Yes, I need another bookshelf. Nerd problems.

Thankfully, I've been gifted with clients who are perfectly fine with me, as their clinician, taking a minute to check a reference. In their words, they're happy to know that I'm absolutely sure on what I'm doing rather than just trying to guess, and the anecdotal message I get is that they wish more medical professionals (doctors included!) would do the same more often.

Frankly, my opinion is that any clinician who claims to always be 100% sure without a fault and never needs to reopen a textbook probably, in fact, knows the least. (Or is just being irresponsibly stubborn.)

What's more, this piece of humble pie goes a bit further. What if that textbook doesn't give me the answer that I need? Well, it sometimes hurts to have to go to my client and say it, but ethically, I have no choice: "I am not entirely certain on what this is."

At least it tastes like cherry!

The saving grace here, again, is the trust that this level of honesty instills in my clients. Knowing that I'm not going to feed them false information, I'm often allowed the chance to have the client return to, at the very least, see if whatever treatment I performed worked. If it does, then we know that we're on the right track and can keep plucking away. If not, it's time for a referral.

To sum it up, no Athletic Therapist, chiropractor, nurse, or even doctor can have the answer 100% of the time. Perhaps some people there expect us to, but I feel like the majority of the population understands the raw amount of information out there. As long as we clinicians are honest with our limitations of knowledge, it seems like the public will accept that as a sign of integrity and be willing to work with us.

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Happy World Spine Day

October 16 is World Spine Day! Today, organizations and people, worldwide, join together to raise awareness of spinal health and illness.

Listed below is a compilation of back health-related articles written both by myself as well as outside sources. They're all very informative and easy to read, so please take a look and empower yourself with some knowledge!

Cain Exercise Rehab Posts

Core Strength And Why Sit Ups Will Hurt You

One of my earliest posts outlining the basic functions of the core as an "anti-movement" system and the reason why the medical community is vigourously recommending against sit-ups.

Core Before, Not Abs After

It's common for weightlifters to fit their ab workout at the tail-end of the session following training another area. However, here's my reasoning on why it's beneficial - for the long-term and for the workout - to do a few sets of core exercises before the rest of the workout instead.

Core Strength And Hyperextension

A short article (with video) on how to train your core to stabilize during the much-neglected range of hip-extension for when you walk or run.

Weight Lifting Belts - The Gym-Goer's Crutch

Weight lifting belts are a crucial element for weightlifters who are pushing those heavy one-rep maxes or doing fatigue-sets. However, what happens when a person becomes over-reliant on the support?

Do You Need Traction?

Traction is an extremely popular alternative treatment for back pain, but here's a short discussion on whether or not there are sound benefits for the long term.

Why Planks Are Not Enough

Planks are what the media is currently pumping out as the solution for spinal health and tight abs. However, this is more out of the simplicity of the exercise for the purpose of quick explanation. In reality, planks are only going to get you so far.

X-Ray and MRI Results: How Concerns Your Should (Not) Be

This may be one of the most important articles to read! If you have had imaging that revealed degeneration or other concerning problems in your back, click this link!

Source

External Sources

If You Keep Texting, Your Head Will Fall Off

You've probably seen some variation of this headline in the past. However, rather than fear-mongering for likes, this writer dug up the research debunking the claims of "text neck".

Why All Those Back Pain 'Cures' Just Make It Worse

Dr. Stuart McGill discusses many popular forms of back pain treatment and why they're likely ineffective - or even counterproductive! Don't worry, he also gives solutions to the problem.

Chronic Back Pain? Journalist Investigates What Works And What Doesn't Work

An investigative journalist scours the research to come to her own conclusions on what is actually proven to be beneficial for the spine and what is not.

Behind Tiger Woods' Arrest And Pain Meds Lies A Problematic Surgery

Spinal fusion is still commonly prescribed by doctors much too early in the process of finding a solution for back pain. More often than not, it only results in more problems down the road.

What This Biomechanics Professor Wishes People Knew About the Real Causes of Low Back Pain

One more article from Stuart McGill as he debunks the most common back pain myths and offers helpful alternatives to address your pain and injuries.

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Let's Talk Mental Health

Yesterday was World Mental Health Day.

It's my job, as an Athletic Therapist, to take care of the physical side of health, but through that, I run into the overlapping cases of depression, anxiety, eating disorders, self-confidence issues, and more. Often, my clients trust me enough to open up to me, and hopefully we, as a society can continue to do so more and more.

Below is a quick compilation of mental health and psychology-related posts that I've written in relation to my Athletic Therapy work as well as sport and fitness in general.

Athletic Therapy and the Opioid Crisis

I didn't write on the mental health aspect of addiction, but with addiction being a mental illness itself, I'm including this post to talk about the benefit of active rehab measures in order to avoid these negative outcomes.

Coaching Sport, Coaching Confidence

A passionate article I wrote about the importance that I discovered when it comes to building confidence and ability in youth for the benefit of their mental health in future years.

Positivity in the Clinic Space

I discuss the importance of careful language when treating clients. When reeling from the mental distress of an acute or chronic injury, it's vital to not cascade the issue with poor word choices.

Identifying With Pain

Discussing some of the mental health changes that occur when it comes to chronic pain that may impede the recovery process.

Central Nervous System Fatigue

Fatigue of the CNS can easily result in detrimental changes to the physical body. What's more, we are finding more and more than mental illness, among other things, can propagate this central fatigue, highlighting the importance of mental health for the sake of the physical.

Pain Tolerance

Again, I talk on another factor that mental illness can affect. While pain tolerance can be affected by mental health, we cannot consider these effects to be all "in your head".

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Random Thought On Exercise Adherence

As an Athletic Therapist, I'm obviously always concerned with how to keep my clients adherent to their exercise plans in order to accelerate their recovery. It's not always easy, especially when that client's motivation was low enough that they barely made it to my office in the first place.

It's funny, though, some of the methods we employ to try and keep ourselves motivated. One common thing I've noticed that people attempt to do to keep themselves true to healthy habits is bargaining the use of passive habits in order to achieve them. Allow me to explain..

Once in a while, I see a client who floats the idea of adhering to their rehab plan by doing their exercises during "down-time" to make it easy, such as while watching television. Unfortunately, not a single client who has said this has been able to maintain their routine. Where is the disconnect here?

I'm too snuggly-wuggly comfy to exercise right now!

Well, it could simply be the fact that using those passive activities is only going to motivate our psychology toward more passive habits, rather than the other way around. When it comes to exercise in general, our brain is going to activate these exercise-related habits when it experiences related stimuli that normally goes along with them. (ie: When the "switch is flipped" when you walk into a gym or get up early for your run.) Since your brain is going to have trouble associating passive activities, such as television, with activity, the chances of developing those habits are slimmer.

As well, this is speculation, but perhaps trying to bargain passive methods in order to stay healthy is a sign of poor self-efficacy. Maybe someone who attempts to use these tricks, in reality, has poor confidence in the first place that they will adhere. And as we know, self-efficacy is vital when it comes to lifestyle changes and without that sense of control, success rates are low.

In short, the clients of mine that are the most successful are the ones who are intrinsically motivated enough to set aside time to, well, get'er'done!

Does this mean that a person is a lost cause if they're not one of these go-getters who's ready to go guns-out and balls-to-the-wall with their recovery, however? OF COURSE NOT!

This article was written based on topics collaborated on with of Sasha Tanoushka, owner of Verus Systems Therapy. Sasha is a member of the BC AMFT and AAMFT  ( American Association of Marriage n Family Therapists  ). She's completing her MA in Marriage And Family Therapy through Northcentral University. She's worked extensively with families and individuals over the years in both community sports, martial arts, kids' clubs and ladies' community groups.

She has a particular interest on neuropathy and works with several therapeutic modalities but has a particular leaning towards Satir, Bowen and Gestalt.

Follow her on Facebook!

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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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