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The Four Seasons of Chronic Pain

Tuesday, January 22nd, 2019

Written By:
Kevin Murray M.A.(pending), CAFS
Movement Masterminds – CEO
Function First – Director of Education
2012 CSEP CPT of the Year

For individuals’ living with chronic pain, the long-range forecast is often filled with metaphorical rain storms, treacherous winds and long, dark nights. When pain is present, the most noticeable characteristic of a client’s changing climate often revolves around biomechanical restrictions and movement limitations. Perhaps not so obvious (yet often just as burdensome) are the emotional and psychological factors involved with experiencing pain on a regular basis.

As such, in order to create a truly unique, multidimensional strategy for individuals’ in pain, expanding beyond the optics of biomechanics and connective tissue principles alone a becomes imperative. Let’s take a walk through the four seasons of chronic pain and examine how you can help your clients transition smoothly through each one.

The First Season – Winter (fear)
Winter is the first season of chronic pain, where the radical change in climate significantly impacts an individual’s emotional and psychological well-being. The narrative chaperoning this season is generally one of fear; fear of movement, fear of pain worsening, fear of the unknown. This fear can reach such heightened states that just the anticipation of pain is enough to steer an individual away from doing the things that matter most to them. Imagine avoiding an activity altogether because of the anticipation of pain, rather than in response to it!

When such avoidance behaviors manifest, it’s clear that approaching the chronic pain demographic solely from a biomechanical perspective is an incomplete approach. The neuromatrix theory of pain proposes that the output of pain is regulated by afferent sensory mechanisms in conjunction with cognitive inputs (Melzack, 2001). These cognitive inputs have the capacity to upregulate and exacerbate states of anxiety, apprehension, depression, self-doubt; all of which fall into the category of psychological/emotional stressors.

It’s these stressors which contribute significantly to winters burdensome climate. To clients in pain, winter’s dark and onerous atmosphere can sometimes seem like it’s going to endure indefinitely. Successfully helping clients’ transition out of winter requires an understanding of one critical distinction; the difference between a clients ‘external’ and ‘internal’ problem.

The Second Season – Spring (awareness)
The melting of snow, dissipating precipitation and the alchemy of animals awakening from hibernation are all welcomed signs that winter’s season is changing. To the health and exercise professional, guiding clients’ towards these more desirable climates lies in understanding each client’s internal problem.

All clients in pain have two global problems. The ‘external problem’ is the biomechanical or anatomical concerns each client reveals during their initial consultation. Consider the client who has been experiencing knee pain for years. That’s the external problem – the knee pain. The ‘internal problem(s)’ however are the area’s in life which hold the most meaning to individuals negatively impacted by chronic pain. The internal problems are the emotional, psychological and social/environmental stressors that are 100% unique to the individual.

For example, consider a husband and wife who spend meaningful time together each day walking their dog. However, in recent months the husband’s knee pain (external problem) has become so problematic that it’s preventing him from participating in the most meaningful aspect of his day, which is connecting with his wife via their evening walk (internal problem).

A clients’ emotional transition from winter into spring begins with his or her health and exercise professionals’ gaining awareness into the clients’ internal problem(s). This awareness then provides an opportunity for both the coach and the client to begin scripting a new, more desirable narrative based on what the individual client values most.

The Third Season – Summer (possibility)
For any seed to blossom and reach its full potential, a conducive climate is required. To clients in pain – fear, anxiety, feelings of hopelessness and negative self-talk are the metaphorical weeds of cognition. If these weeds are ignored, they can uproot any forward progress. During the summer months, the seeds of possibility must be nurtured, and the cognitive weeds must be pulled on a regular basis.

As with any journey, minor setbacks and moments of self-doubt are to be expected (particularly when chronic pain is present). Because of this, granting clients permission to steep themselves in the process of constructing future-oriented, growth-focused possibilities becomes essential.

The Yellow Brick Road refers to this process as a ‘Possibilities Paradigm’ and involves 4-chapters, each designed to amplify and reinforce a clients’ emotional and psychological resiliency & well-being. When successful, these 4-chapters begin to stir hope & optimism back into each clients’ current and future script.

The Forth Season – Fall (self-regulation)
The fourth and final season bears witness to clients’ returning to pain-free living. And while there are a host of ingredients chaperoning any given pain-free transformation (biomechanics included), a clients’ capacity to accurately assess and regulate their emotional states (self-regulation) is a primary contributor in overcoming his or her internal problem(s).

Contrast the experiential difference in self-regulation between a client stating, “oh no, I just threw my back out again!” vs. “my back tightened up, but I know it’s just my body trying to protecting me.” These are two completely different emotional reactions, the former reverberating sentiments of fear and the latter signifying the perception of safety and protection.

Preventing clients from experiencing negative emotions is, of course, not possible. However, as health and exercise professionals, we can strive to cultivate a climate that enhances each client’s self-regulation competence and help them identify and overcome the emotional and psychological stressors that contribute to their pain. Importantly, you can begin this process with your client even before you have conducted his or her biomechanical evaluation.

Reference:
Melzack, R. (2001). Pain and the neuromatrix in the brain. Journal of Dental Education. Vol. 65. 12, pp. 1378-1382.

Health pros interested in learning more about the Yellow Brick Road curriculum through the American Council on Exercise can click on the image

Tags:biopyschosocial, chronic pain, Kevin Murray, lower back pain, pain-free movement specialist
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An Overview of a Function First Initial Visit

Sunday, June 3rd, 2018

We are regularly asked, “what does a visit at Function First look like?”.

Function First founder Anthony Carey takes you through an overview of what that first 2 hour appointment is all about and why it is so pivotal for so many.

Be sure to take note of the differences of how we approach our process compared to what you might experience elsewhere. Even if you are an existing Function First client, this video will be great to share with friends who you know can be helped by what we do.

Please pass along to those that are ready to take a powerful step forward with a movement based program that is backed by science.

Tags:Anthony Carey, chronic pain, education, Function First, The Pain-Free Program
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The Department Store Approach to Pain

Sunday, November 6th, 2016

Written By
Kevin Murray, M.A. (pending)
Movement Masterminds – CEO
Function First – Director of Education
2012 CSEP CPT of the Year

THE SIZING APPEAL

The Small, Medium, Large concept to clothing that all department stores embody seems like a straightforward, pragmatic approach to sizing. If the article of clothing fits, you’re golden; If not, you’re either going up a size, or down. But what about those that fall between the cracks? Or above, or below those labels?

I constantly run into this predicament. Sometimes a small is too tight. Other times a medium drapes off my shoulders, which was a good look for me in the 90’s with skateboard in hand – not so cool anymore. I often wish there was a size “smedium”, right in between at that “sweet spot.”

Perhaps you can relate… maybe your frame deserves a “marge”, right in between medium and large.

ATTENTION ALL “SHOPPERS”:
DUALISTIC THINKING IS OUT-OF-DATE & NO LONGER IN STOCK!

Am I really posting up an article about clothing? As much as I dig fashion, the department store approach is actually a metaphor for the movement industry in many respects, and its modus operandi to complex pain problems.

For example, you may be familiar with conceptualized strategies such as:

• Tight hips = stretch em’
• Weak glutes = strengthen em’
• Noticeable swelling = ice that sh#t
• IT Band irritation = foam roll those puppies

A dualistic, department store approach emphasizes that although all individual’s move differently and come from different backgrounds and cultures, there are essentially only 3-types of people – small, medium and large. Chronic pain on the other hand is complex, embodying dynamic dimensions that encompass myriad variables expanding beyond the optics of biomechanical and connective tissue principles alone. A diverse approach to sizing is needed.

GEORGE ENGEL’s BPS APPROACH:
TAILORED FOR ALL SHAPES AND SIZES – SINCE 1977

Progressing beyond (but not excluding) biomechanics and connective tissue, a 3-dimensional approach to working with clients’ in pain include a vast variety of biopsychosocial ingredients and considerations:

• Systems theories
• Empathetic listening
• Uncovering client’s’ values and beliefs systems
• Establishing client trust
• Providing educational dividends around the context of pain
• Explaining the protective purpose that pain serves

are all in play when considering the Neuromatrix and its influence on how we collaborate with, and coach our clients’ in pain.

SUIT YOU, SIR

Working with the chronic pain demographic is much like being a tailor. Each individual comes in with unique dimensions and constraints; different outcomes and desires. A tailor is seeking to understand where specific attention needs to be placed. A tailor asks questions like:

Why doesn’t their clothing fit?
Have they ever been to a tailor before? If so, what was their experience?
How will we know when a successful amendment has taken effect?
What is their specific outcome?

A tailor considers multiple dimensions into his/her analysis and thought process, outside the shackles of unidimensional constraints. Instead, diversification is personified, driven by the uniqueness of each individual and their articles of clothing.

Individuals’ in pain each have their own unique articles of clothing (yes, we’re still talking metaphorically here) that need specific attention and consideration. If you can meet your clients’ unique needs, much like a tailor does, than you’ll have accomplished something truly special in your clients’ eyes.

Amidst the waves of uncertainty that accompany working with individuals’ experiencing chronic pain and relinquishing a dualistic/department store thought-process, above all remember you’re interacting with another individual – and not a mechanistic instrument. Be kind, be empathetic, and as often as possible seek to understand rather than judge.

“The quality of the therapeutic relationship appears to be more predictive of success than any theoretical approach of the helper.” John Nuttall

Tags:biopyschosocial, chronic pain, Kevin Murray, lower back pain, pain science, program design
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Compartmentalizing Chronic Pain

Thursday, May 26th, 2016

When an individual’s identity and belief about who they are is based around their capacity to be active and athletic, we can predict his or her fears. So what happens when chronic pain no longer permits an active lifestyle?

What happens next is an internal dialog of perception and meaning begin to take root… and how well one can direct their own thoughts, beliefs, emotions and assumptions becomes significant.

Compartmentalization is an unconscious psychological defense mechanism used to avoid cognitive dissonance.
.

The question then becomes “what is Cognitive Dissonance ?”and how does chronic pain fit into the equation?

Cognitive Dissonance “is the mental stress or discomfort experienced by an individual who holds two or more contradictory beliefs, ideas, or values at the same time, or is confronted by new information that conflicts with existing beliefs, ideas, or values.”

For example, no matter how much an individual may believe… if they’re heading east looking for a sunset, that idea and belief will inevitably run up against irrefutable evidence. This naturally will manifest an internal conflict.

In the context of chronic pain, wanting to go to the mountains for an afternoon of skiing with friends & family may be high on an individuals values list. But a belief that skiing will lead to further knee damage or an increase in pain will surely create a conflict. These psychological inconsistencies (dissonance) and the inherent uncertainty they bring can become difficult to manage – overwhelming for many.

Conflicting beliefs and values evenutally feed into an individuals psyche’, establishing negative neuro-associations based around the context of pain that can contribute to the overall pain experience.

What’s more, physical and emotional pain can negatively influence an individuals’ thoughts, feelings and beliefs regarding movement and exercise, inhibiting one’s capacity to remain consistent with how they define themselves – known as their identity.

Our role as movement professionals and coaches is NOT to change an individuals identity or belief structure, but rather create an environment to EXPAND their capacity to understand what pain is and what purpose it serves.

Arming each client with insight and knowledge into the latest in pain science can help them consciously direct their own thoughts, emotions, assumptions and beliefs regarding chronic pain, which can establish constructive psychological associations and increase their ability to effectively compartmentalize chronic pain.

Written by:

Kevin Murray
Movement Masterminds – CEO
Function First – Director of Education

Tags:chronic pain, cognitive dissonance, Kevin Murray, pain science
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Neck pain from your eyes?

Wednesday, April 27th, 2016

Chronic pain is complex, resulting from many inputs processed through the nervous system and the brain. As humans, we rely heavily on our vision to assess and navigate our environment and maintain balance.

Visual references are also one type of input the brain relies on to determine a potential threat to the organism. For example, have you ever found a bruise on your body that did not hurt until you noticed it there?

For those suffering from chronic neck pain, vision provides a great deal of feedback about cervical range of motion along with the mechano-receptors in the joints and soft tissue. The endpoint a person sees when turning his or her head and experiencing pain combines with a cluster of other information occurring at the same time to form the neuro-representation of the pain experience in the brain, or what Melzack (2001) calls a “neuro-signature.”

Harvie et al. (2015) investigated the role of visual feedback on neck pain. The researchers used a virtual-reality apparatus to alter the visual proprioceptive feedback that subjects received during cervical rotation. Subjects were seated with their torsos fixed to avoid contributing motion from the thoracic spine during cervical rotation. Twenty-four subjects with chronic neck pain were assessed for the onset of pain during cervical rotation to the left and right. They were asked to stop when they felt pain and to rate it on a scale of 0-10 at the point in the rotation where pain occurred. Each subject was then fitted with a virtual-reality headset that provided six different visual scenes for six trials. The image below is taken directly from the study by Harvie et al. (2015) and shows an illustration of the set up.

Researchers manipulated the virtual-reality scenes so that the visual cues did not match the actual cervical-rotation distance that subjects achieved on all trials. The virtual rotation provided by the headsets was either:

• 20% more than the actual rotation
• the same as the actual rotation
• 20% less than the actual rotation

This bogus visual feedback of plus or minus 20% made the subjects perceive that they were rotating their cervical spines 20% more or less than they actually were.

The results showed that when rotation was understated (subjects perceived their rotation was less than it actually was), pain-free range of motion increased by 6%. When rotation was overstated (subjects perceived their rotation was more than it actually was), pain-free range of motion decreased by 7%.

This study provides additional evidence to support the findings that pain is not generated solely from tissue damage. The bio-pyscho-social model acknowledges multiple inputs contributing to the pain experience.

Vision is one of many contributing inputs that the brain processes when assessing a threat to the body and therefore produces pain. The association of a specific neck range of motion identified visually, coupled with information from the motor system and proprioceptive system, creates a confirmed reference for past pain experiences. In other words, we’ve always had pain with this set of circumstances (neuro signature of matched proprioception, motor function, vision, vestibular), so we are supposed to have now. Hello pain.

It is plausible that visual input can also influence pain in other areas. For example, if a client has lower-back pain, forward flexion of the spine will bring her eyes closer to the floor, possibly presenting a painful or pain-free experience, depending on the client.

When designing a corrective program for clients where you believe the visual field is a factor, you could vary the visual field to minimize the visual association related to painful movements. Or you could keep the head still and create the motion you want from the bottom up-creating relative movement of the cervical spine in relation to the thoracic spine.

Interested in learning more about how we, at Function First and the Pain-Free Movement Specialists work with the chronic pain population? Enrollment is available only until April 29th here.

Melzack, R. 2001. Pain and the neuromatrix in the brain. Journal of Dental Education 65(12), 1378-82.

Harvie, D.S., et al. 2015. Bogus visual feedback alters onset of movement-evoked pain in people with neck pain. Psychological Science. doi:10.1177/0956797614563339.

Tags:bio-pyscho-social, chronic pain, neck pain, visual reference
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Beyond Biomechanics and Chronic Pain Clients

Thursday, April 7th, 2016

The following video is an exchange between Function First Director of Education Kevin Murray and myself on the critical portions of the bio-psycho-social model. These are aspects of the client that we have to respect, acknowledge and consider when working with those in chronic pain. Understanding the interplay between the 3 pieces of the BPS model help you provide the most effective intervention possible.

Tags:biopyschosocial, chronic pain, corrective exercise, pain-free movement specialist, PFMS
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The Haunted House Effect and Your Chronic Pain

Friday, October 30th, 2015

By Anthony Carey M.A., CSCS, MES
Founder of Function First

(all photos are property of Nightmares Fear Factory http://www.nightmaresfearfactory.com/)

We’ve all heard the saying “frozen with fear”. It’s that brief but profound period of time where something is so shocking or terrifying that one can’t move. The body does not respond because the brain is overwhelmed with the danger at hand.

Or consider what happens to your body and your mind the moment you have the fright of your life in a haunted house. The image above is from the web site Nightmares Fear Factory. They are hugely popular images on the internet of visitors caught at a moment of time inside the Nightmares Fear Factory’s haunted house.

If we got a little “sciencey” here and thought about all the things that happen to the body as this photo is taken and for the short time thereafter, we would observe:

1. A huge dump of stress hormones enter the blood stream
2. The heart rate and blood pressure spike
3. Blood vessels dilate
4. Breathing gets rapid and shallow
5. Muscles all around the joints contract and stiffen the body
6. Posture instinctively goes into a flexed protection mode
7. Ensuing movement is guarded and apprehensive

Now let’s imagine these events happened within the first 5 minutes of a scheduled 30 minute tour through the haunted house. They still have 25 more minutes to take part in an experience where the tone has been clearly established as frighteningly intense.

So what happens when they approach that next corner that they can’t see past? Are they relaxed and at ease? Absolutely not! Their body will reproduce the identical events it did from the first scare. Except all of those responses will happen BEFORE they even get to the corner.

As they cautiously approach the blind corner and their body is in full anticipation mode-anticipation of the next blood curling scare-they ultimately see that there is nothing there. No threat exists at this corner. Yet their body and mind went through all the same events as if the next big scare actually took place. That pattern continues through the remainder of the tour with each anticipation of the scares almost as physically and mentally real as a scare itself.

The source (which we can’t see) that created those responses in the photos is not the only part of that scare experience. Although likely not as obvious to those in the photos, the entire experience includes the people they are with, the smell of the room, the temperature of the room, the sounds and even how their clothes fit. And as the remainder of the tour continues, they all become part of the biological, psychological and social contribution to that experience.

So what has this got to do with someone dealing with chronic pain? The scenarios can be almost identical except replace “scare” with “pain”. Let’s say for example that after a long flight you felt a pop in your back as you lowered your carryon from the overhead bin. You begin to feel your back tighten up and you experience the pain ramping up as you exit the plane. Beginning with the “pop” you felt, you would begin to experience those same 7 traits listed earlier. And whether you realized it or not, the physical pain itself is not the only part of the experience. The people you are with, the smell of the airplane and then the terminal, the temperature, the sounds and even how your clothes fit all become part of the biological, psychological and social contribution to that pain experience.

These combined elements begin to form a neuro signature or neuro representation in your brain. Over the next couple of days as you are recovering from this episode, you experience those 7 traits any time you anticipate potential threat to your back. This could be something as familiar as putting on your socks. Some movements may in fact provoke pain but others may not. Yet the net result is very similar in terms of your physical and mental response.

You can clearly see how patterns emerge that are counterproductive to your long term goals. And the reality of this is that we can’t and you can’t explain your way through process. Yes, you need an understanding but your body and brain also need proof. This is where a strategic and structured corrective exercise plan can create the movement confidence you need to no longer anticipate a threat when the threat is not valid.

Pain is a very complex experience for everyone. And many people will attempt to chase one aspect or another of their pain. The science now tells us that we have to look at the entire bio-pyscho-social context from which chronic pain is experienced.

Don’t live your life waiting for the next ghost or goblin around the corner.

Happy Halloween!

Tags:apprehension, chronic pain, fear, haunted house
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Are Biomechanics Still Relevant for the Client in Pain?

Friday, May 29th, 2015

This video shows a powerful sequence of 3 corrective exercises that we use at Function First that can positively effect lumbo-pelvic-hip function.

Here is the second installment of the “Understanding Pain” series

We hope you’re enjoying our Understanding Pain Series thus far.

Have you ever had a client in pain present no biomechanical “red flags”? What course of action did you take? How did you help them? Share you thoughts in the comment box at the bottom of the page.

Tags:chronic pain, corrective exercise, hip function, lower back pain, pelvic alignment
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Lorimer Mosely on Chronic Pain

Wednesday, November 13th, 2013

The understanding of pain mechanisms-in particular chronic pain-has taken a quantum leap in the last few years. This is a rare case where the research is much further ahead than how patients/clients are treated day to day.

What we do at Function First is always evolving as we are exposed to more and more science. The good news is that much of what we have always done continues to work. The better news is that we have a clearer picture on why the Function First Approach works so well for so many.

This video is a TED talk from one of the preeminent researchers in pain science. I have shared this with many of you in the past and wanted to be sure everyone in the Function First family had an opportunity to watch. The best part of this video is that Dr. Mosely is an extremely engaging and entertaining speaker. As someone who often speaks on difficult topics, it is refreshing to see a man of his background provide such an enjoyable presentation.

Tags:chronic pain, Function First Approach, Lorimer Mosely, pain, TED Talk
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The 3 Pitfalls that Lead to Chronic Pain

Thursday, May 29th, 2008

It is the time of year many people ramp up their activity levels. The warm weather is upon us and longer days have will have people outside taking on all kinds of physical challenges they have no business doing.

As their body exits from its winter hibernation, I sometimes think they left the mind sleeping. What makes a person think that riding for 20:00 a day, three times a week on a stationary bike prepares them for getting yanked out of the water by a speed boat while holding onto a tow rope? Or that playing 18 holes twice a month gets them ready for 72 holes over 3 days while on vacation?

If you’re currently suffering from an injury that is keeping you from exercising or requiring you to modify what you do for exercise, chances are that you didn’t get to this point overnight. Overuse injuries and injuries that end with “itis” (meaning inflammation) are often chronic issues that have become acute. These injuries are usually tied to a number of small incidents that have occurred over a period of weeks, months and even years.

Most people don’t stop and think about their bodies when they sustain a mild to moderate injury. Minor injuries especially, are rarely given the time and consideration that they deserve. It’s often the minor injuries that turn into major problems down the road.

After working with people with musculoskeletal pain for more than 17 years, I’ve identified three steps that lead to long-term musculoskeletal issues:

Denial

Most people deny the seriousness of their injury, especially when it’s something like a sore elbow from a couple of sets of tennis. If it’s not broken or gushing blood, then it’s nothing to worry about, right? Wrong. Thinking that your sore elbow is no big deal or that it will clear up on its own is a mistake. Denying that there is anything seriously wrong enables you to miss a very important window at the onset- the very beginning is when you can do so much to avoid compounding the injury.

Pain avoidance.

We all know that the body doesn’t like pain, so when we experience pain we begin to change our habits and mannerisms in order to avoid it. People who have chronic lower back pain are prime examples of this. When they stand for a certain period of time, or garden, or walk, it hurts their back. What do they do? They start to avoid activities that are going to hurt them. Eventually, any movement or activity that is similar to those that initially caused the discomfort will cause pain as well. It’s a snowball effect that gradually gets worse.

If the stairs hurt your knee, you stop doing step aerobics. The next sacrifice is to cut out squats and lunges. At a time like this is where many folks reach their threshold. It is here where they will seek therapy, surgery or medications for relief.

Shortsightedness.

When people finally do take action against their pain, it is often only enough to mitigate the current symptom. Just enough therapy to calm things down. Or a surgery to repair the damaged part or pills to mask the pain for now….. Unfortunately, this does nothing for all the factors from the previous incidents leading to the major pain.

Don’t blame your aches and pains on the easy cop out, “I’m getting older”. I tell my clients, “it’s not that you’re getting older, it’s that you’ve been doing things WRONG longer”. And pain is the price that is paid.

The cumulative mechanical stress that the body has experienced demands cumulative action to first slow, then stop and finally reverse the damage. Equally important is to recognize that it is never too late to change and it is never too late to recognize what is happening today and keep it from haunting you tomorrow.

A corrective exercise program designed around your specific needs can literally teach your body to move and function differently. Bad old habits can be replaced with good new habits. This gives the body a chance to restore itself instead of breaking down more over time.

The body has a tremendous capacity for healing when given the right environment and provided the right tools. The right exercise, proper nutrition and a healthy mind can work miracles.

Tags:chronic pain, pain avoidance, sports injuries
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