The Well: Pain

Pain is an inescapable part of living with a nervous system. It is also the most common reason for patient visits at our clinic. Falls, breaks, tumbles, scrapes, sprains, strains, contusions, cuts, burns, twists, accidents, and the like are all fodder for causing suffering in the body and mind. Getting hurt isn't a matter of if, but when and how bad. The only thing we have a modicum of control over in the situation is how much we can prepare ourselves for injury and what we will do about it once it happens.

Prevention is the best medicine

Avoiding severe injury is a matter of two variables--how strong the tissues are and how pliable they are to deformation. The metaphor of a bamboo shoot is appropriate to describe the ideal combination of both. Bamboo is strong enough to withstand daily wear and tear, but supple enough to bend (and not break) when excess force is applied. The same is true with body tissues like muscle, tendons, joints, and bones. Strong is good, but strong and mobile is even better. The best exercise programs will train both strength and flexibility through a full range of motion, and it will do it progressively so that more and more function is gained each time.

Training for function

"Functional training" has become a catch phrase used throughout the fitness community for the better part of half a century now. Applied to everything from Crossfit to yoga, functional training is an umbrella term for anything that increases the body's ability to perform everyday tasks. Not all functional fitness is created equal, though. Hierarchically speaking, adequate strength through the largest range of motion (a.k.a. mobility) is priority number one (and two). If a training program doesn't lead to increases in functional strength over time, then atrophy, restrictions, and overuse injuries can occur.

Pain and training

With any type of pain in the body, training is absolutely essential. Rest is inadequate to completely resolve injury. While training with pain goes against common recommendations that we are accustomed to hearing from others, including most doctors, the field of orthopedics has shifted dramatically in the last few decades. Immediate physical therapy is now medically prescribed for almost every major surgical intervention and pain pattern (the exception being any unset fracture or fresh tendon repair). The reason for this shift in paradigms is related to the importance of maintaining strength and range of motion. Lack of movement can result in worsening of pain because the injured body part is not being challenged to adapt for function.

Training through pain

This brings up the classic question of "when is it appropriate to train through pain?" The answer to this varies case by case and, therefore we must differentiate the type of pain. General stiffness, discomfort, and soreness is indicative of a positive training effect and will typically lessen or move around the body as adaptations occur. Acute pain on the other hand usually means that tissues have been damaged. Usage after injury tends to be self limiting, meaning that pain will prevent us from doing further damage. With acute pain the best results are gained with minimal rest and gradual return to previous activity. Pain that persists for more than three months falls under the classification of chronic pain and requires a different approach. Chronic pain can be particularly debilitating because of the fatigue involved with stress and the loss of muscle mass due to inactivity. Navigating chronic pain requires a shift in perspective.

Chronic pain treatment

So much has been written on the treatment of chronic pain, that to accurately summarize it would exceed the length of this post. Instead, we can simplify the whole discussion by focusing on the goal of treating chronic pain, which is to return the patient to normal activity with no pain or at least manageable pain. "Return to normal activity" is the operative phrase here. However, most Western pain management plans under-reach on their training approach. More often than not, in order for tissues to repair they need a higher than physiological normal dose of loading and range to create adaptations. Twice weekly visits to a physical therapist for thirty minute sessions over a six week period is usually insufficient to make any lasting changes. Instead, a daily focus on movement, posture, and ergonomics, three sessions per week of active training (stretching, strengthening, etc.), and weekly or bi-weekly passive therapies (chiropractic, massage, acupuncture, etc.) would be more effective at resolving pain.

The psychology of chronic pain

Chronic pain is as much psychological in origin as it is biological. The antiquated method of only treating the biological causes of pain with opioids, NSAIDs, and surgery has been proven to be ineffective, often times even more harmful than no intervention at all. Pain is an important signal of the body to repair damaged tissue, but when it is suppressed by medications, the pain pathway is interrupted and healing is stunted. Furthermore, surgical repair of structures will not solve the underlying deficiency of the muscles supporting those structures. It is always the case then, in chronic pain, that the healing process must be restarted, both physically and emotionally. Progressive training to increase strength becomes a way of making both body and mind more resilient. This will not come without some level of pain and fear, which is why proper orientation of the patient's mindset towards the goal of gaining function is crucial. Reduction of pain will follow gains of function, never the other way around. The skilled chronic pain therapist is just as much of a trainer as they are a psychologist, helping patients manage their emotions, fears, and expectations.

Pain and Chinese Medicine

"Where there is blockage there is pain," is an adage of Chinese Medicine. Qi stagnation describes energy that has become stuck in the meridian system, thus producing pain. Luckily qi stagnation can easily be resolved with acupuncture or massage if it is caught early, like in cases of acute pain. However, prolonged qi stagnation can become blood stagnation, which is more persistent and requires more treatment time to heal. If left unattended for even longer, qi and blood stagnation can begin to damage the internal organs and affect the psycho-emotional components of these organs. Worry, fear, grief, anxiety, and anger are all embodied by the Chinese organs, and are always involved in chronic pain patterns. The treatment of the long standing issues must take a multi-prong approach of acupuncture, massage, exercise, meditation, herbs, and psychological intervention.

A world without pain

Pain is a natural and essential part of life. Without pain, growth would not be possible. Without pain, healing would not occur. We can and should minimize the lasting effects that unaddressed pain can produce. First, we must prepare our minds, bodies and spirits to be resilient and flexible in the face of stress. Second, we must respond as promptly to pain as possible to forestall it from becoming chronic. Third, in the case of chronic pain we must shift our paradigm to one that increases function in the face of fear, anxiety, and other emotional coping techniques. Finding someone that we trust in this endeavor is well worth the investment.