Acute hamstring strains, which typically present as pain in the back of the thigh…
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 Hurt. It’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.
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
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 exercise13,14,25 – 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).
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 therapy6,15-21 – 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 mobilization6,26
l. Modalities –
m. Yoga22,27 – 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 meditation23,27 – 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. Humor27 Laughter has been shown to decrease the negative effects of stress (calms the alarm system). Crying certainly has is place and is highly therapeutic. That being said, none of us are here for very long in the grand scheme of things, so we might as well laugh as much as possible. I personally love Judd Apatow’s Funny People, with Adam Sandler, although the crude humor is not for everyone.
p. Aquatic Therapy24
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)6,15-21 – See the “Manual therapy” item above.
u. Spinal stabilization6,25,26 – 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.
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.
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