Being Active with Pain – Being Smart About It.

In our busy society, we do not take time to care for ourselves as much as we should with things like relaxation, getting together with friends, and exercise. When we do get the opportunity to do something important for our well-being like exercise, we often expect our bodies to operate at full capacity and without complaints. This is quite unrealistic and can often lead to aches, pains, and possibly injury. Often when these things show up, we don’t take the time to properly care for them, rather we continue to exercise the way we normally do, and expect the aches and pains or injury to resolve on its own – and sometimes it does. But what if it doesn’t?

The goal of this post is to help you better understand how to stay active while dealing with pain. We will cover the different views of pain, highlight the contemporary view of pain, as well as discuss how to interpret your pain and work with it.

"However, training to improve performance it is always a matter of balancing enough stress to create physical improvement, but not so much that we cause injury."

"However, training to improve performance it is always a matter of balancing enough stress to create physical improvement, but not so much that we cause injury."

3 views of pain:

The Old View of Pain – In the old view, pain meant damage to a body part. It was thought that the body sent a pain signal to the brain informing it of damage. This can lead to a mentality of “always listening to the pain.” We now know that the body actually does not have any pain receptors, nor does have the ability to send pain signals to the brain. Instead we have receptors which tell us about potential harm (nociceptors), but these can’t tell the difference between potential and actual harm.

Sport & Performance View of Pain – This is the “No Pain, No Gain” attitude that is commonly found amongst athletes or die-hard exercisers, and is often accompanied by the belief that “pain should be ignored.” However, training to improve performance it is always a matter of balancing enough stress to create physical improvement, but not so much that we cause injury.

The Modern View of Pain – We now know that pain is an OUTPUT of the brain. It is a behavior modifier, meaning that your body and brain are trying to get your attention! As an OUTPUT of the brain, pain is influenced by all our senses, past experiences, and stress/emotional level, which all reside inherently in the brain. As an example, professional violin players will report pain in their pinky finger at a lower temperature and pressure than the rest of us, demonstrating greater sensitivity as their little finger is vitally important to playing the violin and to them as a whole person (Zamorano et al., 2015).

To put it simply – Pain is complicated! However, this modern view that has emerged from 'Pain Science' demonstrates that “pain should be respected, and can be worked with.”

To put it simply – Pain is complicated! However, this modern view from ‘Pain Science’ demonstrates that “pain should be respected, and can be worked with.”

Bottom Line on Pain – Pain is good in that it serves a purpose! It is the messenger that gets your attention, BUT it is just the messenger and not the problem! Pain is your brain and body’s assessment of your own health, and it can be influenced by many things. Your pain should be respected, but it can and should be worked with to help you improve. This is the idea of training and being active intelligently!

How to be active with pain:

Respecting Pain – The first question that you need to ask when you are learning to deal with pain is how is it behaving? Is it always there (constant)? Is it only there sometimes (intermittent)?

Constant Pain – Here I mean truly constant, as in the pain never goes away even for a second. There are a few reasons for constant pain, but the one that we are most familiar with is after an acute injury. If you have an acute injury, you will know it. There will have been something you did that led to pain immediately and you will see signs of inflammation such as redness, heat/warmth, swelling, pain, and loss of function.

Look for redness, heat/warmth, and swelling – if these are all there, this is likely an acute injury and it deserves to be cared for. This is when protection, rest, ice, compression, and elevation, or PRICE, is the thing to do.

Intermittent Pain – This is great news! It means that there are some things that are perpetuating the pain and some things that are relieving the pain. This pain can be worked with!

  1. Determine which things cause your pain, and then minimize these for a short period.
  2. Keep pain after activity down(i.e. irritability). Here are some helpful guidelines to assess your pain with activity, think of it like a traffic light:
    • Green Light – the activity helps my pain; I should do more of this.
    • Yellow Light – I feel my pain while I perform the activity, but when I stop it goes                   back to normal in less than 5 minutes
    • Red Light – My pain is aggravated by this activity and stays aggravated for more than 30 minutes or I have notable pain the next morning.

The big take-away here is that pain does not always mean damage and, while it should be respected, you can work with it if you know how. Hopefully now you know a little more of the “how.” Think of pain as the messenger that the brain and body uses to get your attention. This messenger is meant to change your behavior, so don’t ignore it…work with it! Finally, if you continue to have difficulty or pain, reach out to your physiotherapist (book an appointment here). We can help with some hands on treatment, exercise and education to help you get moving better and pain-free again.


Zamorano, A. M., Riquelme, I., Kleber, B., Altenmuller, E., Hatem, S. M., & Montoya, P. (2015). Pain sensitivity and tactile spatial acuity are altered in healthy musicians as in chronic pain patients. Frontiers in Human Neuroscience, 8. doi:10.3389/fnhum.2014.01016

Vitamin D and Menstrual Cramps

Dysmenorrhea, the medical term for menstrual cramps, is a common problem affecting over 50% of menstruating women of all ages. 

The term “dysmenorrhea” is derived from Greek, meaning “difficult monthly flow,” thus referring to the pain experienced by women during their monthly cycle. Pain is often experienced just before or during the first two days of the menstrual period and will usually ease as the period continues. The pain can be in the pelvic region, lower back or may even radiate down the thighs.  For some women, nausea, vomiting, fatigue, headache, increased urination and diarrhea may accompany the pain.  It can be so debilitating for some that they are forced to take time off work or school, disrupting social and family life. 

It is estimated that 10% of women who experience menstrual cramps are rendered incapacitated for one to three days each month.

Menstrual cramps can be classified as primary (physiological problem) or secondary (caused by underlying pelvic abnormality such as uterine fibroids or endometriosis).

It is estimated that 10% of women who experience menstrual cramps are rendered incapacitated for one to three days each month.

Primary dysmenorrhea starts after the release of inflammatory compounds called prostaglandins from the endometrial cells inside the uterus. And therefore, target treatment is often focused on the suppression of these prostaglandins.   Treatments may include non-steroidal anti-inflammatory drugs (NSAIDS), herbs, nutritional supplements and/or hormonal contraceptives.

Vitamin D has received much attention in the past few years regarding its role in calcium balance, bone health, and immune function. Vitamin D can also reduce the expression of the inflammatory compound cyclooxygenase-2 and can therefore regulate prostaglandin production, exerting anti-inflammatory effects in the body and endometrium.

Vitamin D has received much attention in the past few years regarding its role in calcium balance, bone health, and immune function.

Vitamin D has received much attention in the past few years regarding its role in calcium balance, bone health, and immune function.

A randomized double-blind placebo controlled clinical trial was conducted on 60 women with primary dysmenorrhea and vitamin D deficiency.  Women had to have at least four recent consecutive menstrual cycles with painful cramps during the previous 6 months.  Women also had to have a serum vitamin D level of <50ng/ml.

Women in the treatment group received 50,000 oral vitamin D once per week for 8 weeks, while 30 women received placebo once a week for 8 weeks.

In the vitamin D treatment group prior to treatment, pain was mild in 3 (13%), moderate in 16 (69.6%) and severe in 4 (17.4%) of the women.  After treatment (2 months), 22 (95.7%) had mild pain, 1 (4.3%) had moderate pain and none had severe pain.

Pain intensity significantly decreased in the treatment group after 8 weeks of treatment, with a significant difference in pain intensity between the two groups.

Vitamin D may be a useful and inexpensive strategy to reduce primary dysmenorrhea along with lifestyle and dietary recommendations.



Moini A, Ebrahimi T, et al.  The effect of vitamin D on primary dysmenorrhea with vitamin D deficiency: a randomized double blind controlled clinical trial.  Gynecological Endocrinology 2016, Early Online: 1-4.

What to do about Spinal Stenosis

Spinal stenosis is a condition that affects about 10% of all people over the age of 65. 

Spinal stenosis is a condition that affects about 10% of all people over the age of 65. 

I’m always impressed by how active people can be in their later years and what a positive impact this activity level can have on their health and function. As a Physiotherapist, I’m fortunate enough to be given the opportunity to assist these people with maintaining and improving their physical abilities and a common condition that interferes with day to day activities is spinal stenosis. 

Spinal stenosis is a condition that affects about 10% of all people over the age of 65. Typically, patients with lumbar spinal stenosis present with pain, numbness or fatigue that radiates down either one or both legs. The symptoms are typically relieved quickly by sitting down or bending forward. Symptoms are believed to be the result of a narrowed spine secondary to changes over a lifetime. This narrowing puts pressure on either the spinal nerves that supply the legs or the blood supply to these nerves. Standing and bending backwards tends to narrow the space where the nerves and blood vessels reside and brings on symptoms. Conversely, when we sit, the spinal canal opens up and takes pressure of the nerves, leading to a quick improvement in leg symptoms. An x-ray can help confirm the diagnosis but isn’t definitive; approximately 20% of all seniors have stenosis on imaging without experiencing any symptoms.

Approximately 20% of all seniors have stenosis on imaging without experiencing any symptoms.

So, what are your options if you are diagnosed with spinal stenosis and want to improve your function and decrease your pain? It used to be that surgery was thought to be the only effective treatment for spinal stenosis. Some of the more recent research suggests that spinal stenosis surgery can be effective for a few years but at eight to ten year follow-ups, patients who undergo surgery are no better than those who receive conservative treatment. A more recent clinical trial took patients with lumbar spinal stenosis that had been slated for surgery; half the patients proceeded ahead with surgery while the other half received Physiotherapy. At two year follow-up, patients who received Physiotherapy did just as well as the surgical patients. These facts are not meant to dissuade people for pursuing from receiving surgery for spinal stenosis but rather to suggest that the first option for a spinal stenosis patient is a thorough course of conservative treatment that includes physiotherapy.

At two year follow-up, patients who received Physiotherapy did just as well as the surgical patients.

What should your rehabilitation treatment consist of when you attend Physiotherapy? There are a number of different interventions that can be used for spinal stenosis, and they should be custom designed based on each individual’s presentation. Generally speaking, flexion-based exercises can be used as a tool for pain relief as it helps open up the area where nerves and/or blood supply are compressed. People with spinal stenosis tend to have limited mobility in not only the low back, but also the hips, mid back, knees and ankles can be stiff. Improving movement in these areas through manual therapy and exercise can help improve spinal stenosis symptoms.

There is also some good research suggesting that cardiovascular exercise can help decrease spinal stenosis symptoms. The problem is that most older adults use walking as a form of exercise and spinal stenosis tends to aggravate symptoms when walking, so patients often come in a deconditioned state. If this is the case, water based exercise and stationary cycling can be good options. Finally, general strengthening and exercise to improve trunk musculature is beneficial for everyone.

If you are suffering from spinal stenosis, Physiotherapy can help and should be a first line intervention.

We can help!

The Head Game of Concussion

One of the most challenging things about concussion is that you can’t see it; there are no scars, no broken bones, very few, if any, outward signs of injury. We hear a lot about common symptoms of concussion such as headaches, sensitivity to light and sound, balance or vision issues, and memory and attentional impairments, but we don’t often talk (openly) about the psychological symptoms.

When it comes to concussion, I’ll begin by emphasizing that everyone is different and each experience is unique. Psychological and emotional symptoms present differently in each person. That said, there are a few more common symptoms that we tend to see. Here’s a short list, along with a few strategies to help you work through them:


There is no shortage of things to worry about post-concussion. How long will this last? When will I be able to go back to school/work/play? What will others think of me? Will I ever be the same again?

Excessive worry never seems to do much good for anyone, especially if you’re worrying about things that are beyond your control. When you’re injured, your physical, cognitive, and emotional resources are limited. Ask yourself this: is there anything you can do right now to help the situation? If the answer is yes, then do it. If the answer is no, then direct your energy toward more productive avenues. Focus on the 3 S’s: Strengths, Solutions, and Safety. 


Getting back to “normal”, financial concerns, work or social commitments, physical and cognitive limitations, the list goes on. 

Test out some strategies to manage your stress.

Test out some strategies to manage your stress.

Being injured is stressful, no one should deny that, including you.  The first step is acknowledging your stress and, more importantly, identifying your “stressors”. What are your “yellow light” and “red light” things that signal stress? Know your triggers, acknowledge them and decide in advance how you’d like to deal with them. Test out some strategies to manage stress like deep breathing, meditation, light physical activity, or just spend time with a friend or loved one. Everyone deals with stress differently, the key is knowing what works for you and deciding in advance how you’re going to deal with it. 

Depression/Low mood:

You’ve been told you should rest, limit your screen time, limit your physical and cognitive strain, you can’t do your regular duties or activities, you’re missing out on other commitments, and you generally don’t feel all that good, physically or mentally. 

Optimism and hope matter. You will get through this.

Optimism and hope matter. You will get through this.

Concussions suck. Period. But they are not uncommon, and one has happened to you. While that can be pretty scary and overwhelming, it isn’t permanent. We hear all about the ‘worst case scenarios’ in the media, but we don’t often hear about all the people who successfully recover from concussion (the vast majority) in a reasonable amount of time (a few weeks to months). Again, everyone is different, but those with a positive outlook tend to experience positive outcomes (ref). Look for the good things, no matter how small they are, and choose to focus on those. What are you able to do? What are you learning from this experience? How is it making you stronger? Make a list and refer to it often.


Flashbacks, nightmares, negative thoughts, avoiding certain places or activities, avoiding thoughts/feelings, fear of re-injury.

You’ve been through something significant and when that happens your subconscious mind can sometimes take advantage of your vulnerability. Talk about it. Grab a close friend, family member, or a professional, and talk it out. Sometimes this can be scary and uncomfortable, but better out than in, as they say. Once you feel a little more comfortable talking about it, try to gradually reintroduce some of the things that make you uncomfortable. For example, if concussion is a result of a car accident, the idea of driving might be stressful for you. Start by simply spending a few minutes per day just sitting in the driver’s seat of a parked car. Put your hands on the wheel. Maybe even turn the car on and adjust some of the radio or mirror settings. Eventually, once you feel comfortable (and that might take days, weeks, or months), take a slow ride around your block or on quiet side street, and then build from there. By gradually reintroducing some of these things in a safe and controlled environment, you allow your body and mind to build some confidence to reengage in those activities or experiences.  


He was driving too fast and not paying attention, the turf was too wet we shouldn’t have been playing on it, I should have been more careful, he back-checked me on purpose!

It happened, it was scary, but it’s over now and your energy is best spent in the here-and-now.

It’s human nature to want to understand why bad things happen and it can feel cathartic (at least temporarily, anyway) to assign blame. The problem with that is, when we assign blame to others, we remove our control over the situation; we become victims. In some cases, it can even be tempting to blame yourself. The problem is, the blame game can take a serious toll on your recovery. Blame requires a focus on the past (what happened, why did it happen, who was involved, etc.) but at the end of the day, how can you expect to move forward and recover if you’re spending your limited resources dwelling on the past? It happened, it was scary, but it’s over now and your energy is best spent in the here-and-now. What are you going to do today to help yourself move forward? What is your goal and what steps can you take to bring yourself closer to achieving it? 

To summarize, this is very much a simplified explanation of the psychological and emotional side-effects of concussion paired with a few tidbits of advice, but be well-aware that there really is a lot more to it. These symptoms can be difficult to acknowledge and challenging to work through – no one is saying it’s easy – but around here we like to operate guided by optimism, positivity and, of course, the evidence. What that tells us is that with the right attitude, a lot of hard work, and maybe a little guidance, you really can feel better, get back to school, work, sport, and life, and thrive once again.

The 4 Myths of Massage

The 4 Myths of Massage

We live in an exciting age of information wherein anything we need to know is only a couple of clicks away; knowledge has never been more within our immediate grasp. There's only one problem: along with this easily accessible information comes an abundance of misinformation. This is perhaps most prevalent in the health and wellness industry and, more specifically, in the realm of massage therapy. Far-fetched claims are infinitely plentiful on the internet, everything from clearing bad energy to correcting poor posture.

So, I’ve decided to make a short list of some of the most popular myths surrounding this profession as follows:

1)    It has to hurt to be helpful. 

Nope. No truth to that statement. Although it’s not surprising this belief has permeated our culture. Therapists can become famous (or infamous) for the excruciating treatments they perform…sigh. 

Massage doesn’t work by pounding muscles into submission, it doesn’t work by stretching or deforming fascia, and more pressure does not equal a more therapeutic effect. So how does it work? We don’t really know exactly, but we do know a few things. Basically, your brain controls your thoughts, emotions, how you move, and your level of muscle tension. It also has an amazing capacity to either turn-up or dial-down the intensity of pain you experience. When you are touched, nerve endings are stimulated in the skin, messages are sent to the brain, and if the brain likes these messages good things can happen.

So, if massage is to be effective, it is through the successful engagement with the patient’s nervous system, i.e. brain. And since pain is like an alarm system to alert us to any potential threat, giving a painful treatment may keep that alarm ringing.
Protecting us from threat is a high priority for our nervous system and pain intensity can increase when we feel unsafe. Inflicting pain doesn’t usually make a person feel safe. A painful treatment can have the opposite effect of what is intended. A good massage may take you to the edge of pain, but hurt is unnecessary.

2)    It releases toxins, or detoxifies the body.

Detoxification - sounds good, doesn’t it? Sometimes it can feel like toxins have been released after a good massage. Maybe that’s why for decades this has been a prevalent belief in massage therapy culture. However, there is no research to suggest this happens. 

A plausible explanation on the mechanism of which these toxins are supposed to be eliminated eludes us. Are they squeezed out of muscle like water from a sponge? And what, exactly, is meant by toxin? There are some vague ideas out there. Some would say it refers to environmental substances like BPA (we all remember the great plastic water bottle scare of the late nineties). Others say toxins refer to metabolic waste such as lactic acid. Regarding the former, no amount of pushing on muscles will squeeze toxic chemicals into the bloodstream, this is not scientifically plausible. And as for lactic acid, there is research suggesting that massage might actually impede its elimination. Interesting article here.

You don’t need to worry about toxins accumulating anyway, our liver and kidneys take care of that.

3)    It breaks down scar tissue.

Ah, the ubiquitous scar tissue. It’s at the root of all mysterious pains. There are many who make this claim, and no shortage of techniques and instruments to break down this apparent scar tissue. And once it’s gone all pain will vanish and life will return to normal. What a neat and tidy story. Too bad it’s not true.

There is no evidence to suggest our bodies are riddled with scar tissue and no convincing story telling us how we would acquire it. Even if it were true, how do we know this causes pain? It doesn’t make sense; the scars on our skin caused by cuts and abrasions don’t usually hurt. Scar tissue is pretty fibrous stuff; it’s made strong to protect us from further injury. The only way to break down this stuff is with a very sharp instrument, i.e. scalpel.

If your therapist tells you he’s breaking down scar tissue, you can be sure he is more in tune with pseudoscience rather than science.

4)    A relaxation massage isn’t therapeutic.

Therapeutic: causing someone to feel happier and more relaxed or to be more healthy

There is a negative connotation associated with relaxation massage; namely that it is only appropriate for spas and cruise ships, that it’s only purpose is to pamper the privileged. I frequently hear patients say, as if ashamed, that they are not seeing me for relaxation, for it is therapy they need, not relaxation. However, the two are not mutually exclusive.

Here are two definitions of therapeutic: 

From the Cambridge Dictionary- “causing someone to feel happier and more relaxed or to be more healthy”

And from the Oxford Dictionary- “having a good effect on the body or mind; contributing to a sense of well-being”

It seems to me like the word, therapeutic, describes a relaxation massage perfectly. 
Why are people so down on relaxation? It can lead to many great things such as: improved sleep, more energy, increased concentration and a higher tolerance for annoying things in life, like pain. And let’s not forget about stress. Being more relaxed definitely enhances our ability to cope with stress. It would be ridiculous to suggest that relaxation has no therapeutic effects considering excessive stress is linked to almost all chronic diseases. 

It is clear relaxation is an important part of massage therapy, if not the most important part. 

In conclusion, I would advise looking at all claims about massage therapy with a skeptical mind. There is no such thing as a magic bullet in this industry, and if it seems too good to be true it probably is. Thankfully, massage doesn’t need grandiose claims. There is only one claim that matters: the general effects are plain to see; people feel better after massage.