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.