Category Archives: Chronic Pain

Critical Decision Making and the Healing Process: Part 3

7. Healing is a Process, Not an Event

Healing tends to be like a roller coaster rather than a straight line.  Having the expectation that your problem can be resolved overnight is typically not realistic, which leads to increased frustration and disappointment (and often more healthcare visit, procedures, money, etc.).  This causes increased stress which causes your brain to release more stress hormones that negatively effect the healing process.  Furthermore, the belief that your problem can be “fixed” with one simple intervention directs people to focus on passive interventions (medications, surgeries, new/popular machines, creams/oils – something that is being done to your body by someone or something else).  This is as opposed to active interventions, which are ways that you can help yourself such as critical decision making, exercises or self treatments targeting your specific deficits, postural changes, and determining aspects of your life that may be contributing to your problem.  These active interventions take time to get dialed in and are ever evolving.  Using your healthcare guides (physical therapists, physicians, surgeons, psychologists, massage therapists, yoga and Pilates instructors, etc.) as tools to gather information and options allows you to speed up the process by not reinventing the wheel.

Ask a lot of questions, use the tools that work for you, and discard the rest.  Its a more challenging path, but one that leads to greater overall gains with a better understanding of your problem and life, which gives you more control of your situation.

8. A Note on Chronic Pain

I plan to elaborate on this fascinating topic in a separate post for those who are looking for a deeper understanding of the neural and physiological changes that occur when pain becomes chronic.  For anyone with chronic pain or those with a family or friend with chronic pain, I highly recommend Adriaan Louw’s book Why Do I HurtIt’s short, easy to read, and helpful…you can’t beat that.  Much of the information in my articles about this topic come from Dr. Louw’s research and the research he sites in many of his continuing education courses.

I’ve mentioned before that in almost all cases, our bodies have the ability to heal themselves.  We just need to create the environment to allow the body to do what it knows how to do.  Chronic pain occurs when this natural healing process does not occur.  The most important points are 1. what happens at a general level when your pain doesn’t go away, and 2. what do I do about it?

I. What happens when my pain becomes chronic instead of resolving?

Your nervous system is a group of structures in your body that send signals throughout your body to provide information about the state of your body and the environment.  The brain and spinal cord (central nervous system) and the nerves that exit the spinal cord and travel to the rest of your body (peripheral nervous system) are constantly sending signals back and forth.  These signals are being interpreted and modified by many parts of the brain in order to determine what to do next.1-4  Imagine the map of the flight routes in the back of the airline magazine on your last flight.

Your Alarm System
With permission from Adriaan Louw, PT, PhD

In relation to pain, think of your nervous system as an alarm system.  The body has a normal baseline level of sensation.  If you think about it, you can feel the pressure from the chair you are sitting on.  The brain knows that specific sensation isn’t important so its not something in your general awareness.  However, if you are walking barefoot in your backyard and you step on a bee, that normal baseline level of sensation rises to a “what the heck was that!” threshold level as the  nerves from your foot send an immediate signal to your brain and the brain says “danger!”.   You remove the stinger, attend to your wound, and eventually that elevated level of sensation returns to the original baseline.   Your nervous system is protecting you with that initial “danger” signal and the subsequent sensation of pain while you heal in order to prevent you from performing activities that irritate the injury whereby slowing the healing process.1-4

Unfortunately there are times when that baseline level is not reached and your nervous system stays in a hypersensitized state.  This starts out as feeling more intense pain than a given stimulus should be provoking and can lead to feeling pain from a stimulus that shouldn’t be causing pain at all (the touch of your sheets in bed, for example).  Your nervous system is still trying to protect you by keeping the alarm system cranked up.  Think of a home alarm system.  Its supposed to go off if an intruder breaks a window.  Now its going off when you open the fridge.1-5

Hypersensitive Alarm System
With Permission from Adriaan Louw, PT, PhD

There are many reasons your nervous system might stay in this elevated state.   Pain is stressful in many ways.  It obviously doesn’t feel good.  You can’t do what you want.  It can affect your finances if you can’t work.  It can affect your relationships if you can’t perform your normal duties and you have negative interactions because you’re irritable from the pain.  Maybe your family or friends think you should be better by now.  You may have received numerous explanations for your pain from physicians, surgeons, PTs, massage therapists, family, friends, etc.  All of the explanations are different and none of them seem to help.  You may have tried numerous treatments with minimal success, some of which may have even made things worse.  You may have been told some form of “there’s nothing wrong with you”.  All these stressors can create fear and anxiety which crank up the part of the nervous system that controls the alarm system.  This all leads to decreased sleep and mobility which further escalates your problem.

II. What do I do about chronic pain?

The key is to use interventions that gradually and progressively calm the central nervous system, and thus your alarm system, and restore it back to the original set points. There are 22 treatments that have been studied which can help to  resolve this ramped-up state that your nervous system is currently in.12  Below, I’ve added some notes to the ones that may be easiest to implement.  Of these 22 treatments, there are 4 “pillars” that are the most beneficial and that must be done.12  Those 4 are:

a. Pain education – Understanding what is happening with your nervous system has been shown to decrease pain and improve function.3,4,6-11  Check out Adriaan Louw’s book Why Do I Hurt? and stay tuned for my upcoming article specifically about chronic pain.

b. Goal setting – You have to know where you want to go in order to figure out how to get there.  Write down your goals and keep a journal.  Try writing not just about your goals, but how you feel about what’s happening throughout the process.

c. Aerobic exercise13,14 – Start slow and listen to your body.  I frequently tell people to start by literally leaving your front door, walk for 5 minutes, and come back.  If you can’t do that, start at 1 minute.  Just get started.  If you walk for 10 minutes and it puts you on the couch for the rest of the day, try 5 minutes the next time.  If you can’t walk, try a stationary bike or swimming.  Consider keeping a log to track your progress and boost accountability.

d. Sleep hygiene – Check out my evidence-based handout for sleep hygiene tips and Matthew Walker’s Why We Sleep.  My article The Role of Sleep Loss in Healing has additional information and references.

The additional treatments that have been shown to be beneficial are:

e. Diet – Consulting with a nutritionist is highly recommended.  This is a lifestyle change which means the changes should be realistic above all else.  You may want to gradually implement small changes into your diet to make it easier to maintain long term.

f. Breathing – Check out an option here.   The simplest way to start is to ignore the pelvic floor part (add this pelvic floor part back in for problems with incontinence and core strengthening).  Focus on expanding the abdomen and bottom of the rib cage, like an umbrella slowly opening, on the inhale.  You can add 4-7-8 breathing to this, where you take 4 seconds to inhale, hold for 7 seconds, and exhale for 8 seconds (as described in some of Dr. Andrew Weil’s books).

g. Biofeedback

h. Graded motor imagery

i. Safe, healing environment – Do you have a healthy support system?  If family members, friends, or work colleagues are less than supportive, consider talking with them about it.  Invite them to read this post.  Consider limiting your time with the folks and situations that add stress to your life.

j. Manual therapy15-21 – There are many forms of hands-on treatments.  Myofascial release (sometimes called trigger point release) is a gentle and effective way to treat yourself.  Some resources for this are The Trigger Point Therapy Workbook and my book Beyond Tape.

k. Neural mobilization

l. Modalities – 

m. Yoga22 – If you are new to yoga, check out a restorative yoga class or call the instructor, tell them a bit about your limitations, and ask them if they have a low level beginner class that they would recommend.

n. Relaxation and meditation23 – An easy way to start this is through the breathing option stated above.  Find a quiet place for 5-10 minutes.  Focus on the breathing.  As your mind drifts off to other things (which it will), take note without analyzing or judging and bring yourself back to the breath.

o. Humor

p. Aquatic Therapy

q. Medication

r. Social Interaction

s. Coping skills – There are no doubt excellent psychotherapists in your town who can guide you with this.  We learn new skills much faster through guidance.  I have personally benefited greatly from several therapists, as well as through my own reading/study/practice, throughout my life.  As with anything else, this is a process, not an event.

t. Soft tissue/trigger point therapy (myofascial release)15-21 – See the “Manual therapy” item above.

u. Spinal stabilization – These are exercises that strengthen your core (muscles surrounding your midsection).  It would be beneficial to get help with fine tuning a routine that’s right for you.  I typically start folks on a “floor routine” with some form of the dead bug, bridge, and bird dog and then transition into more functional exercises, such as squats and lunges.

v. Journaling

w. Stretching

x. Posture

It is not necessary to do all of these (except for the 4 pillars).  Its important to not get overwhelmed by trying too many things at once.  Trying one thing is better than not trying at all.  You may be able to run through the list right now and pick out options that seem the easiest to implement.  Periodically check back in with the list to see if you can try out 1 or 2 others.  Each person is different, so there will be some options that resonate with you and some that don’t.  Its important to not get discouraged if one of the options doesn’t work for you.  Move on to the next one.  This is a process, not an event.

 

Check out Beyond Tape: The Guide to Climbing Injury Prevention and Treatment for more information about warming up, stretching, and other climbing (and non-climbing) injury related topics.  Like my facebook page for updates and more information and rate/review Beyond Tape on my website or here My primary motivations for Beyond Tape and any of the posts are to:       1. Check out the most relevant and up-to-date research for each topic in order to dispel myths, sift out conflicting views, and help people to prevent or heal from injuries – letting me know about new research or opposing views is helpful and greatly appreciated       2. Contribute to the local and global communities by donating 100% of my net profits from Beyond Tape to service-based non-profit organizations, such as Rotary International, Doctor’s Without Borders, Access Fund, etc.

1Gifford, L. Pain, the Tissues and the Nervous System: A conceptual model. Physiotherapy
Volume 84, Issue 1, January 1998, Pages 27-36.
2Moseley, L. Reconceptualising pain according to modern pain science. Physical Therapy Reviews 12(3):169-178 · September 2007.
3Louw A1, Diener I, et al. The effect of neuroscience education on pain, disability, anxiety, and stress in chronic musculoskeletal pain. Arch Phys Med Rehabil. 2011 Dec;92(12):2041-56.
4Louw A1, Nijs J2,3, Puentedura EJ. A clinical perspective on a pain neuroscience education approach to manual therapy. J Man Manip Ther. 2017 Jul;25(3):160-168.
5Neblett R1, Cohen H, et al. The Central Sensitization Inventory (CSI): establishing clinically significant values for identifying central sensitivity syndromes in an outpatient chronic pain sample. J Pain. 2013 May;14(5):438-45.
6Moseley L1. Combined physiotherapy and education is efficacious for chronic low back pain. Aust J Physiother. 2002;48(4):297-302.
7Louw A1, Butler DS, et al. Development of a preoperative neuroscience educational program for patients with lumbar radiculopathy. Am J Phys Med Rehabil. 2013 May;92(5):446-52.
8Louw A1, Farrell K. The effect of manual therapy and neuroplasticity education on chronic low back pain: a randomized clinical trial. J Man Manip Ther. 2017 Dec;25(5):227-234.
9Louw A1, Zimney K. The efficacy of pain neuroscience education on musculoskeletal pain: A systematic review of the literature. Physiother Theory Pract. 2016 Jul;32(5):332-55.
10Van Oosterwijck J1, Nijs J. Pain neurophysiology education improves cognitions, pain thresholds, and movement performance in people with chronic whiplash: a pilot study. J Rehabil Res Dev. 2011;48(1):43-58.
11Moseley GL1, Nicholas MK, et al. A randomized controlled trial of intensive neurophysiology education in chronic low back pain. Clin J Pain. 2004 Sep-Oct;20(5):324-30.
12Louw A. Recorded Webinar: The “How-To” of Teaching Patients About Pain. Medbridge
13Busch AJ, Barber KA, et al. Exercise for treating fibromyalgia syndrome. Cochrane Database Syst Rev. 2007 Oct 17;(4):CD003786.
14Kuphal KE1, Fibuch EE, et al. Extended swimming exercise reduces inflammatory and peripheral neuropathic pain in rodents. J Pain. 2007 Dec;8(12):989-97.
15Ajimsha MS1, Daniel B2, et al. Effectiveness of myofascial release in the management of chronic low back pain in nursing professionals. J Bodyw Mov Ther. 2014 Apr;18(2):273-81.
16Arguisuelas MD1, Lisón JF, et al. Effects of Myofascial Release in Nonspecific Chronic Low Back Pain: A Randomized Clinical Trial. Spine (Phila Pa 1976). 2017 May 1;42(9):627-634.
17Ceca D1, Elvira L, et al. Benefits of a self-myofascial release program on health-related quality of life in people with fibromyalgia: a randomized controlled trial. J Sports Med Phys Fitness. 2017 Jul-Aug;57(7-8):993-1002.
18Castro-Sánchez AM1, Matarán-Peñarrocha GA, et al. Effects of myofascial release techniques on pain, physical function, and postural stability in patients with fibromyalgia: a randomized controlled trial. Clin Rehabil. 2011 Sep;25(9):800-13.
19Castro-Sánchez AM1, Matarán-Peñarrocha GA, et al. Benefits of massage-myofascial release therapy on pain, anxiety, quality of sleep, depression, and quality of life in patients with fibromyalgia. Evid Based Complement Alternat Med. 2011;2011:561753.
20Yuan SL1, Matsutani LA, et al. Effectiveness of different styles of massage therapy in fibromyalgia: a systematic review and meta-analysis. Man Ther. 2015 Apr;20(2):257-64.
21Haller H1, Lauche R, et al. Craniosacral therapy for chronic pain: a systematic review and meta-analysis of randomized controlled trials. BMC Musculoskelet Disord. 2019 Dec 31;21(1):1.
22Sutar R1, Yadav S1, et al. Yoga intervention and functional pain syndromes: a selective review. Int Rev Psychiatry. 2016 Jun;28(3):316-22.
23Cash E1, Salmon P, et al. Mindfulness meditation alleviates fibromyalgia symptoms in women: results of a randomized clinical trial. Ann Behav Med. 2015 Jun;49(3):319-30.

Critical Decision Making and the Healing Process: Part 2

5. Internal vs. External Interventions 

External interventions (or passive treatments) are things that are being done to you (surgery, injections, medications, manual therapies, etc.).  Internal interventions (or active treatments) are things you are doing, or not doing, to help your body heal (exercises, self manual treatments, addressing stress, sleep, nutrition, etc.).  There is a place for both and the internal interventions should always be a component to your healing process.  In fact, the goal is to transition away from external interventions and be able to focus solely on your home program of exercises, self manual treatments, education, postural and ergonomic alignment, sleep, diet, etc.  You may require occasional “tune ups” or additional information in order to fine tune your self care.

If “fixing” your body (or mind) was like taking your car into the shop, it would be easy.  You take your car in, have a faulty part replaced, and drive off good as new.  Your body is much more complex, intricate, and interconnected than a machine.  The word “fix” signifies an event that happens, but healing is a process.  A process of physiological phases and lifestyle changes that occur over time.  Additionally, various environmental factors can alter those physical processes.  Those factors can be things such as nutrition, belief patterns, prior experiences, stories you’ve been told, things you’ve read, job issues, family issues, fear, etc.  Without critically thinking about these factors, the healing process can be slowed or stalled as we all tend to go off of autopilot.  More importantly, critical thinking about contributing factors can’t happen without awareness.  Awareness comes from first knowing how these contributing factors can negatively affect the healing process (see the chronic pain section in Part 3) and then listening to the signals your body sends to let you know which ones may be involved for your individual case at this particular time.  Signals such as pain, anxiety, and depression are ways your body communicates to you that something is wrong and should be addressed.

Gaining awareness is also a process, not an event.  Over time, it leads to greater and greater intuition or pattern recognition.  Daniel Kahneman wrote an interesting book called Thinking Fast, And Slow about much of the research he did with his partner Amos Tversky regarding cognitive biases.  In a nutshell, we make many decisions on autopilot, without critically thinking about them.  These decisions are largely based on a culmination of our prior experiences (things we’ve read, have been told, and that have happened to us).  We are sometimes lead down an unhelpful path with these autopilot decisions for various reasons (transferring information from one unique situation to your current situation).  Kahneman was firm in his belief that intuition should never be trusted.  Interestingly, he was open to considering a different view and collaborated with Gary Klein, who believes strongly in the power of intuition.  In the end, they concluded that using intuition is in fact beneficial if 1. the system you’re working with is predictable and 2. the person is able to figure out the patterns that make the system predictable.1   So, in our case, healing is a predictable pattern in that the body sends signals (pain, anxiety, depression) to tell you what to do and not do in order to heal.  Gaining a keen awareness of these signals allows you to see the patterns that lead to healing.

6. Believing vs. Not Believing You Can Heal

The concept of believing that you can heal works on many levels, from the esoteric to the concrete.  From a logical standpoint, when you think the disorder you have is permanent and you can’t get any better, you can imagine understandably reacting in 1 of 2 ways.  You may attempt to do whatever activity you want even though it causes pain.  This can be due to a deep need to continue with your current lifestyle.  It can also be due to fear of progressively sliding downhill and becoming incapacitated if you don’t keep moving.  The second mode of action is to do virtually nothing.  This can be due to an overwhelming frustration that leads you to give up.  It can also be due to fear of making things worse.  In both of these cases, you might stop searching for ways to help yourself and disregard recommendations for exercises or other self treatments, because what’s the use if your problem is hopeless.

Our bodies have an amazing ability to heal themselves in almost all cases.  As you’ll see in the section on chronic pain in Part 3, there are many factors influencing this healing process and lots of ways to gradually restore the body’s natural healing ability.  The first step is to gain as much knowledge as possible, whether through second opinions or your own research.  The second is to determine which of that information is applicable to your individual case.  The third is to implement those interventions.  The fourth is to constantly tweak your current plan to make it better until you reach your goals.  The last is to create a long term maintenance program to prevent recurrence.  Ask lots of questions so you can understand what you’re doing and why.

Doing virtually nothing can be seen as one end of a spectrum with the other end being continuing to plow through pain.  The key is to find the balance by listening to your body.  This takes time.  Healing is a process, not an event.

A final note on the power of belief is the placebo (and her meddling brother, the nocebo) effect.  For an in depth look at these topics, check out the fascinating book Suggestible You by Erik Vance.  Most folks have heard of the placebo effect, which has largely been studied with regards to taking an inactive substance (a sugar pill for example) that produces the same effect as a medication.  There are numerous studies showing that a significant number of people (from 30% to as many as 80%) show the same benefits from taking a placebo as those taking the actual medication.  This effect has been shown for disorders including pain, depression, Parkinson’s, irritable bowel syndrome, and asthma, among others.  The reasons are much more fascinating and complex than simply saying a person’s symptoms were not real or were “all in their head”.  It turns out that when a person believes they are taking something that will help them heal or to have less pain, their brains actually produce the chemicals that allow healing, decreasing symptoms, and/or lessening of pain to occur.2-5  Aside from medications, this effect has also been shown with information and education.  People with chronic pain, for example, experience decreased pain and increased function after receiving education about their pain and nervous systems.6-13  Knowledge is power…and healing.

An important concept to be aware of is the nocebo effect.  This occurs when negative expectations regarding a treatment or disorder cause a more negative outcome than would have occurred without the negative expectations.  Check out the information in Part 1 regarding the results of studies on imaging (MRIs and Xrays).  The “abnormal findings” are frequently not the cause of a person’s pain and dysfunction.  You can imagine that hearing some form of “wow, your spine is a mess” can create much fear and anxiety which can negatively effect the healing process.  If you find yourself in this situation, start by focusing on a belief that you can heal.  The answer is out there somewhere.  Figure out the questions you need answers to that will allow you to create a plan for healing.  Gather information, listen to your body, and focus on providing your body with the environment it needs to do what it naturally knows how to do…heal.

Stay tuned for the 3rd and final part of Critical Decision Making and the Healing Process!

Check out Beyond Tape: The Guide to Climbing Injury Prevention and Treatment for more information about warming up, stretching, and other climbing (and non-climbing) injury related topics.  Like my facebook page for updates and more information and rate/review Beyond Tape on my website or here My primary motivations for Beyond Tape and any of the posts are to:       1. Check out the most relevant and up-to-date research for each topic in order to dispel myths, sift out conflicting views, and help people to prevent or heal from injuries – letting me know about new research or opposing views is helpful and greatly appreciated       2. Contribute to the local and global communities by donating 100% of my net profits from Beyond Tape to service-based non-profit organizations, such as Rotary International, Doctor’s Without Borders, Access Fund, etc.

1Kahneman D1, Klein G.  Conditions for intuitive expertise: a failure to disagree.  Am Psychol. 2009 Sep;64(6):515-26.
2BEECHER HK. The powerful placebo. J Am Med Assoc. 1955 Dec 24;159(17):1602-6.
3Pacheco-López G1, Engler H, et al. Expectations and associations that heal: Immunomodulatory placebo effects and its neurobiology. Brain Behav Immun. 2006 Sep;20(5):430-46.
4Moseley JB1, O’Malley K, et al. A controlled trial of arthroscopic surgery for osteoarthritis of the knee. N Engl J Med. 2002 Jul 11;347(2):81-8.
5Jensen KB1, Kaptchuk TJ, et al. Nonconscious activation of placebo and nocebo pain responses. Proc Natl Acad Sci U S A. 2012 Sep 25;109(39):15959-64.
6Moseley L1. Combined physiotherapy and education is efficacious for chronic low back pain. Aust J Physiother. 2002;48(4):297-302.
7Louw A1, Butler DS, et al. Development of a preoperative neuroscience educational program for patients with lumbar radiculopathy. Am J Phys Med Rehabil. 2013 May;92(5):446-52.
8Louw A1, Diener I, et al. The effect of neuroscience education on pain, disability, anxiety, and stress in chronic musculoskeletal pain. Arch Phys Med Rehabil. 2011 Dec;92(12):2041-56.
9Louw A1, Nijs J2,3, Puentedura EJ4. A clinical perspective on a pain neuroscience education approach to manual therapy. J Man Manip Ther. 2017 Jul;25(3):160-168.
10Louw A1, Farrell K. The effect of manual therapy and neuroplasticity education on chronic low back pain: a randomized clinical trial. J Man Manip Ther. 2017 Dec;25(5):227-234.
11Louw A1, Zimney K. The efficacy of pain neuroscience education on musculoskeletal pain: A systematic review of the literature. Physiother Theory Pract. 2016 Jul;32(5):332-55.
12Van Oosterwijck J1, Nijs J. Pain neurophysiology education improves cognitions, pain thresholds, and movement performance in people with chronic whiplash: a pilot study. J Rehabil Res Dev. 2011;48(1):43-58.
13Moseley GL1, Nicholas MK, et al. A randomized controlled trial of intensive neurophysiology education in chronic low back pain. Clin J Pain. 2004 Sep-Oct;20(5):324-30.