Chronic Pain: The Kinesiologist's Role - Part 2

In Part 1 of my blog, I discussed chronic pain and it's effect on the brain and nervous system. For Part 2, I'll explain the role of a Kinesiologist and how we can help.

Now, diving right back in to my observation about guarding and and/or compensation. Two things have happened here:

1)      Pain from an ailment or physical trauma has imprinted messages to the body regions on the brain map thus creating some behavioral guarding to the area ie: not wanting to stress or elongate the area

2)      Any pain that may exist emotionally, whether related to the cause of the pain or not, can further the perceived physical pain.

The emotional component comes with it’s own body behavioral pattern. Example: the head protruding forward or down along with tight and elevated shoulders is commonly seen. Everyone knows this look. It’s a classic. Any type of pain can and likely will result in this posture. There are numerous subtle changes as well that a Kinesiologist would identify but that’s a big one.

The intervention of exercise when it comes to chronic pain influences these objectives:

  1. Postural changes; not allowing the muscles to behave as if they are in pain
  2. Achieving more range of motion; again, not letting the muscle tissue stay guarded and contracted
  3. Length/tension relationships; building strength where appropriate

The head forward, rounded shoulder case will typically have a tight chest and therefore a decent amount of strength there by virtue of the positioning. Does chest strength matter to a Kinesiologist at this point? No. Creating mid-back strength to open the chest and complimenting that with chest stretches is more appropriate. This is one simple example of imbalances that Kinesiologists will deal with regarding chronic pain. By training the body to present or behave in a way that is void of pain, the feedback loop for the nervous system can be intervened. The mapping can be re-trained. In other words, our brains can influence our behaviors but our behaviors can also influence our brains. The mapping effect and the regions in how they are situated on the brain allow us to understand how our behaviors can influence our brains. Body positioning is huge! It’s becoming more and more appreciated but I still often see it overlooked. If your body is able to achieve non guarded movements and utilizing postural muscles appropriately, this re-mapping can begin.

In other words, our brains can influence our behaviors but our behaviors can also influence our brains.

Once the re-mapping out of pain has begun, we typically see specific patterns. Almost always, the reported wide-spread pain will alleviate (the “de-mapping” down of unnecessary body parts) and what will linger is the focal and often milder pain that represents the original injury area. It’s like a cycle has been broken and the neuron messaging has become less efficient so it goes back to the most paved path -- the original one. 

Another aspect of the feedback loop is that if more and more movements are not guarded or accommodated, we notice over time that overall muscle tension goes down. Guard perpetuates more guard. If someone is still in pain but has learned to un-guard, it’s only a matter of time before the re-mapping relieves the overall pain. Outlying influences take part in this loop as well; clients often comment on how the pain doesn’t wake them at night (there’s the sleep centre being influenced) or get them down as much (there’s the emotional centre). Longer term posture training will continue to have benefit. Envision the map of the brain only receiving a minor pain stimulus for the original injured area. At this point, clients will say that they barely notice it and they are able to return to their old lives. I often hear that the area still feels different but they aren’t bothered by it because it’s a huge improvement from where they were.

The big take-away that I want to emphasize is to never stop working on your posture. Injured or not, the brain will read the body positioning.  Know that working on your posture will help you feel better regardless if you suffer from an injury but ESPECIALLY if you are suffering from an injury or any type of pain for that matter.

Chronic Pain: The Kinesiologist's Role - Part 1

Almost everyone that I see is dealing with pain of some form.  Some present as acute but the most common is chronic. A lot of chronic pain sufferers come with a history of motor vehicle accidents, osteoarthritis, spinal stenosis, fibromyalgia, or recovery from a total hip or knee replacement. In my experience, there appears to be two components of chronic pain that must be dealt with in the kinesiology model:

1)      Address the pain by prescribing movements that will improve strength and range of motion to correct the pain, specifically that speaks to the cause of the pain.

2)      Address the guarding and accommodation that has not only resulted from the pain but is perpetuating more pain.

The second item listed is the one I will focus on in this post.  Number two is often the barrier from moving forward into progress; the ball and chain that is keeping someone in their pain state. It goes beyond the physical injury or trauma that may have initially occurred to create the pain. It’s a behavioral state that has both conscious and unconscious aspects. Moving past this barrier is by far the most difficult task in dealing with clients as no two people are the same in how they recover from chronic pain. Some of the overall behaviours are common among individuals but the way to intercept is different with each person.

Our nervous system is trainable. Our nervous system is adaptable. Yes, pain can be trained in very easily; BUT, it can also be trained out!

If you deal with chronic pain, know this:

1)      Your pain is real

2)      Your pain is treatable- often through movement

No one, these days, needs to be convinced that exercise is good for you. The information available is overwhelming. Weight loss, cardiovascular, strength, conditioning- all results of a consistent exercise regime.  However, what is it about exercise that addresses pain? We know that it helps alleviate pain, but why? How?

Brain and Behavior

In the last 20 years, there has been some excellent research on the topic of the brain and the nervous system. The last 10 years has resulted in a very steep learning curve for researchers and professionals in the understanding of our behaviours, our bodies, and particularly our pain. Studies are determining that rather than focusing on the exchanges of messages in the brain to explain pain, the brain can be geographically mapped with the physical parts of the body in a particular geographical region. These regions receive stimulus in and can transmit stimulus away. Applying a stimulus of touch to the lower leg will result in the “lower leg region” of the brain map to light up and respond. Continual stimulus of that region will result in a refinement of the neurological route or highway that the incoming stimulus travels on.  That route becomes a very efficient, well-oiled machine. When our brain regions receive such a strong, efficient input over and over, they look at nearby regions that are receiving less stimulus and move in on their air time. Yes, if the lower leg region is getting a great deal of incoming message, it will look at the knee or ankle and move into it. In other words, the message “spills over”. What does this result in? The perceived pain will travel from the lower leg of the person and “refer” to the upper or lower regions around that physical area. This re-mapping that happens on a high center in the neurological chain has helped explain referred pain and phantom limb pain. I think it sheds a huge amount of light on chronic pain. Especially in cases where the original injury has long healed but pain in the region or other regions persists.

Now, let’s consider other regions of the brain- we’ve got areas for mood, emotions, impulses, urges, hunger, and sleep. For the chronic pain sufferer, the signals are so strong and efficient that they can influence these other regions. Pain signals from the body can become pain in others aspects of wellbeing like emotions (e.g. depression) or disrupted sleep. This signal can play out in the reverse effect as well. Studies have shown that emotional pain can translate to physical pain; a region of the brain map can become so efficient with stimulation that it begins to be opportunistic and take over the brain tissue occupying or representing a physical part of the body such as the back or the shoulders.

What does this tell us? Our nervous system is trainable. Our nervous system is adaptable. Yes, pain can be trained in very easily; BUT, it can also be trained out!

Stay Tuned for part 2, which dives into how Kinesiology can train your pain away.

Massage Therapy and Persistent Pain

There’s not many of us who don’t appreciate a good massage. Rubbing and kneading our muscles is our “go-to” when we’re experiencing pain. It feels good, if for only a small amount of time. It can decrease our pain and give our brains something else to focus on when we hurt. In this blog post, I will try to answer two questions:

1.      What can massage therapy do for those living with persistent pain?

2.     Is there anything else patients can do to achieve lasting results?

The answer to the first question is simple: massage can help make pain more manageable. This is possible because of the remarkable capacity of our nervous-system to turn-down the intensity of pain we experience. Something profound happens when we are touched. There are many complex effects in both brain and body that contribute to that magical feeling of relaxation and rejuvenation that occur after you have had a massage. These effects are beyond the scope of this blog to describe. Let’s just say, that by adding sensory input to our nervous-system, it has a chance to change its output or, in other words, decrease pain intensity. A perfect example of this is when you bump your shin and it hurts like heck until you reflexively start rubbing it. This is kind of like the brain receiving competing messages simultaneously but can only hear the loudest one. Of course, receiving a massage is a lot more complex than that. For one thing, no one receives a massage devoid of context. A warm room, peaceful music, and comfortable bed, coupled with an attentive and caring therapist will help turn down the nervous-system’s fight-or-flight response. This, in turn, can help decrease pain. This is called hypoalgesia, a fancy word for "less pain". And this is what most people are hoping for when they seek massage.

 

We know massage can decrease pain, but what else can it do? Something less obvious, is the effect of massage on how we move. It makes sense that when our pain becomes more manageable, our movement becomes easier, leading to increased confidence and resilience. This means getting back to the activities we love to do, making us happy and decreasing stress. And less stress will have a positive effect on almost everything in our lives. So, we could say the benefits of massage have a cascading effect reaching many facets of our lives.

Something I often hear from patients is that they feel great after the massage, but within the next day or two, their pain returns. Why is this? Well, for starters, there are 168 hours in a week, and probably only one of those is spent having a massage. The other 167 hours are spent doing all the things that got us seeking massage in the first place. Our beliefs and established neurological patterns probably play quite a large role in the persistent pain experience. We all have habitual ways of moving, sitting and standing that may not always be optimal for us. These things do not change overnight. For someone who has been experiencing pain for a short while, one hour of massage may be enough for their nervous-system to make a change in how they feel. Kind of like a car veering off the road needing just a little nudge to get back to centre. But for those with persistent pain, their nervous-systems has established a baseline that includes pain, and it may take more than just an hour of massage to make any lasting change. This scenario is more like a car that has veered off into a ditch and will need more than just a nudge to get back up on the road.

But for those with persistent pain, their nervous-systems has established a baseline that includes pain, and it may take more than just an hour of massage to make any lasting change.

So, what can we do to extend these short-lived benefits? Well, we can start with education. Knowing a little more about what is really happening when we are in pain has been shown to have benefits (ref). A common belief is that when we’re in pain, there must be something damaged inside our body. Or worse, the pain is an indicator of some seriously ominous disease. So, it’s not surprising that, for most people, pain of an unknown origin can lead to fear and stress; fear of living in pain the rest of their lives, unable to do the things they love, unable to live life to the fullest. Research suggests that these feelings can actually make pain worse (ref). However, it is possible to decrease the fear surrounding the experience by learning the basics of pain science.

The key point here is we don’t need physical harm to experience pain. Just like your car doesn’t need to have its window broken to have the alarm go off.

This starts by acknowledging that pain is a survival mechanism and exists to protect us. Without it, we wouldn’t live very long. It is a response by our nervous system to any threat, real or perceived, and doesn’t necessarily mean we are damaged. The key point here is we don’t need physical harm to experience pain. Just like your car doesn’t need to have its window broken to have the alarm go off. If we can just wrap our head around this concept, it can shift the way we view pain and, subsequently, decrease threat. This is not always easy and requires diligence on the part of both therapist and patient.

The concept of pain education has inspired a slight modification of the very popular saying: “no pain, no gain”. This has never been one of my favorite maxims. However, if we just add a couple of letters, it looks like this: “know pain, know gain”. I like this one much better, it’s more truthful, and less painful. Unfortunately, pain education is by no means a magic bullet. But, by adding it to massage and good movement, we can increase the chances of a positive outcome.

But knowing is not enough, we have to put what we learn into practice. You can spend hours learning exactly how to shoot a jump-shot, but without putting time in at the gym, shooting ball after ball, proficiency will be elusive. It’s the same for those with persistent pain. Learning how to move with confidence takes time and practice. It’s one thing to know that nudging our movement towards ever more challenging feats will build confidence and resilience, but to actually keep with it through all the ups and downs requires dedication and maybe some active cheerleading from family, friends, and your therapist.

Here’s a quick summary:

  •  Massage feels good and can help make pain more manageable.
  • Our nervous-system has a remarkable capacity to lessen the intensity of pain we experience.
  • Less pain means easier movement.
  • Good movement takes practice, and nothing changes overnight.
  • Pain doesn’t mean we are damaged and learning this can help decrease the fear surrounding the experience.
  • Know pain, know gain.

Thanks for reading.

To Orthotic, or Not to Orthotic?

There are many options out there in the world of orthotics: off the shelf, custom made, custom-moulded.

There are also many questions: which option is better for my needs? Do I actually need them? And, um, what are they, really?

How do orthotics work?

Orthotics are a tool to manage how stress falls through the bones and tissues, primarily in the feet, and in so doing they impact how stress falls through the knees and, to some degree, the hips.

Similar to using a brace, it’s very common for people to notice immediate relief from foot and knee pain when they start to use orthotics.

However, and unfortunately, this doesn’t mean that the underlying problem is fixed.

Rather, it indicates that the irritable structures are being shielded. Sometimes this stress-shielding gives the tissues the rest they need to heal, in which case treatment with orthotics can be curative.

In other situations, one needs to wear the orthotics consistently on an ongoing basis to avoid symptoms.

While this solution works for some, many folks don’t like the idea of orthotic-dependency.

The way to side step wearing orthotics indefinitely is to perform some corrective exercises and movement training, which improve the function of the feet and lower extremities. Wearing orthotics while you go through this course of exercises and treatments will improve or fix the mechanics of your foot, so that you no longer need to wear them.

How do you make custom orthotics?

At Tall Tree, we are unerringly thorough when it comes to creating orthotics.

We start with a musculoskeletal assessment consisting of an analysis of movement during gate, standing, changing directions, etc. The assessment also includes orthopaedic testing of the joints, ligaments, muscles, and nervous system of the lower extremities and feet.

Following this assessment, we do a state of the art scan of your feet and generate a digital replica of how your foot contacts the ground while walking. This data gives us diagnostic info and the foundation design for the corrective orthotic: measuring your foot posture during the movement of walking provides more relevant information than measuring a foot at rest. 

Then, we are able to make adjustments, additions, and accommodations based on a physical exam of the foot. This covers all the bases in creating an optimal foot orthotic.

How do I know if I need them?

Just because we can make you an awesome pair of custom orthotics doesn’t mean you need them.

A good first step is to determine if your condition is one that would benefit from orthotics. An assessment with a physiotherapist, chiropractor, or family physician will give you direction.

Once you’ve determined that you would like to get orthotics, it’s often worth trying the off-the-shelf variety first. These are less expensive and you can find them most local pharmacies and running stores. Sometimes these are enough to adjust how load falls through the foot and decrease symptoms. If they don’t do the trick, custom orthotics may be your next step.

At Tall Tree you can meet all your orthotics needs under one roof - come and see one of our chiropractors or physiotherapists, then drop by the orthotics office for a consultation with our kinesiologist, Jeremy. We'll help you take the next step - with or without orthotics in your shoes.