How Specific Do Treatments For Pain Need To Be?

Specific; On TargetPain is what drives people to consult a medical professional more than any other symptom.

The vast majority of pain is benign, somatic (musculoskeletal) in nature, though some somatic pain has a visceral component.

Most of the time, complex examinations and treatment rituals are performed, in order to diagnose and treat said pain.

Patients feel like they are getting good value, practitioners feel like they are providing it.

But is it necessary to go through all these examinations, and aim for all these specific hands on, taping and exercise techniques to help people get better?

I’m going to argue, that no, it isn’t.

Can We Be Specific With Assessment?

A typical assessment of someone in pain consists of the following:

  • History
  • Neurological and orthopaedic testing
  • Active movement
  • Passive movement
  • Palpation/provocation

It can also include

  • Functional/task specific assessment
  • Capacity testing: strength, endurance etc

Based on all of this, a clinician then formulates a diagnosis, which dictates a management plan.

However, and this is a massive “however”, it could very well be that we are wasting our time.

Let’s have a look at each of those components, and see how specific they can be.

History

The clinical history is probably the most important part of an initial consultation. Combined with general information about a patient (age, occupation, family status etc) and how they carry themselves, a clinician can hypothesise a working diagnosis prior to any further assessment, which usually serves to confirm or refute the diagnosis.

For certain presentations, the history is quite diagnostic.

For example, neuropathic pain occurs when there is damage to a nerve, causing it to have what’s called an ectopic discharge. Without going into too much depth, when patients complain of burning, lancinating pain, often that will point us towards a diagnosis of neuropathic pain.

On the flip side, a recent study questioned whether commonly held true concept of clicking in the knee being related to meniscal damage. It was shown that equal numbers of people with and without meniscal injuries experience things like clicking and catching. (1)

Neurological and Orthopaedic Testing

The neurological examination consists of things like a cranial nerve examination, reflex testing, sensory testing and motor/strength testing, along with neurodynamic testing.

Unfortunately, neurodynamic testing often yields false positives (so not that specific).

Strength testing, at least the manual version, is very unreliable, and thus not specific.

Isokinetic strength testing is more reliable, however most clinics do not have this equipment. Some clinics have hand-held dynamometers, which increase reliability of strength testing. (2)

Additionally, strength testing only tells us there may or may not be a weakness, not why. Additionally, strength is not related to pain, though it is important for both injury risk and activities of daily living.

Sensory testing is helpful, while reflexes don’t really tell us much except that reflexes are there or not.

Orthopaedic tests, those which clinicians use to rule in/out certain tissue based injuries are notoriously unreliable. Even those which have demonstrated high sensitivity and specificity are subject to error as a result of neurological changes when we are in pain.

Active Movement

Okay, by now you should be sensing where I’m going with this.

Active movement tests the ability to perform that movement. Yes, certain tissues/structures are involved in certain movements, but that doesn’t mean that movement is a specific test.

For example, raising your arm out to the side as high as you can involves multiple muscles acting at the shoulder joint. If it hurts to do so, it implicates all these muscles involved, as well as the tendons, ligaments, joint, nerves etc.

Is it helpful to know? Most of the time.

Is it specific? No.

Passive Movement

See above.

Yes, passive movement takes muscles out of the picture, at least from a contractile point of view. That doesn’t mean that if active movement hurts, and passive doesn’t, that the problem is with a muscle.

Thus, not specific.

Still valuable, but not specific.

Palpation

Most practitioners, especially osteopaths, believe their palpation skills are reliable means of assessment.

They’re wrong. (3)

Palpation is not reliable, and thus definitely not specific.

Still valuable, but not specific.

Can We Be Specific With Treatment?

The short answer: it depends on the treatment.

Let’s look at my common methods of treating pain:

  • Education
  • Manual therapy
  • Graded exposure
  • Movement therapy/exercise rehab

Can any of them be specific?

Education

Education can address specific themes and topics, but the challenge with education, as is the case with any communication, is that what is heard and understood is not always what is intended. We are at mercy of the interpretation of the receiver. Language is more than words. It is influenced heavily by our social circles and our cultural experiences. (4)

But because teaching people about their pain, how to manage it and how to prevent future flare ups is a hugely important part of practice, this means these are simply challenges to be overcome.

I’ve said before, that education is the only thing that stays with a patient after they finish working with me. The caveat to this is, education that is effective. Saying things is not educating. Helping someone understand is educating.

As important as it is, I think it is a stretch to say it has a specific effect on pain. We can’t measure the effect it has, and say what amount of pain reduction was attributable to what amount and type of education.

Manual Therapy



I’m going to upset a lot of my colleagues by saying you can’t be that specific with manual therapy.

But it’s true.

Think about it, all we can truly touch is the skin. Not muscles, not ligaments or tendons, and not bones. The skin.

We can direct force to deeper lying tissues, like those mentioned previously, but this depends on the magnitude and direction of the force, as well as where the target tissues are situated.

Physics dictate that the only force that can be efficiently transmitted to bone has to be perpendicular to bone. Any horizontal or tangential force is dissipated by the frictionless interface of the skin/fascia. (5)

Another strike against the blow of specificity is the way the body is innervated. No one section is supplied by a single neurological level. Hence, because of convergence of multiple levels, we end up with less specificity.

Finally, when it comes to spinal movement, there is a plethora of research showing that you cannot isolate movement to a single vertebral level. Even neck manipulations, which allow the best contacts compared to thoracic and lumbar manipulations, result in movement of adjacent interverterbal joints.

So strike specificity off the list of things manual therapy is.

Graded Exposure

What about graded exposure? Many people conflate graded exposure with exercise rehabilitation. There are similarities, in that they are both (should be) progressive. However, graded exposure borrows from psychological research, and in theory, addresses psychological factors relating to pain and activities just as much as the physical factors. It’s kind of obvious when you think about it: gradually doing the things that hurt, or that you are worried about hurting makes it easier to do them over time.

Worried about bending over to garden all day? Let’s start with kneeling for a short period of time. Then you can gradually (the graded part) do more (the exposure part) until you are bending over gardening all day

There are two arguments about whether graded exposure is specific:

  1. It works for the specific task/scenario, hence it has a specific effect
  2. The same can be achieved in other means, hence it doesn’t

In my experience, the former holds true more so than the latter.

Here’s an example:

A patient of mine who was very active injured himself playing hockey. The injury came about because he wasn’t physically prepared for the demands of hockey, despite being physically fit and active. That and plain old bad luck – he simply moved in a way that loaded his back too much, which was in part due to the circumstances of the game at that moment.

After history and assessment, I was able to narrow it down to a diagnosis of “acute low back pain, without referred pain” (remember, we can’t really be that specific).

Treatment was manual therapy (didn’t really make a big difference), stay active (kind of hurt, but didn’t make things worse), some gym work for posterior chain (was able to train, but didn’t help pain), time (definitely made a difference) and gradually increasing hockey load (really helped).

Does that mean it (graded exposure) has specific effects that cannot be achieved any other way? I really don’t know. Let’s call this a maybe, at best.

Movement Therapy/Exercise Rehab


Like manual therapy, the fact that so many approaches can work holds the answer: if everything works, then nothing works. 

Or less cynically (and this is my position, because we know this works for many pain presentations), if everything works, the effects are non-specific.

Honestly, aside from the specific adaptations of exercise, which can definitely be important to an individual based on their capacity (power, strength, endurance, mobility etc), or lack thereof, when it comes to pain, the most important thing is to do something, do it appropriately (not too much, not too little) and continue to do it (consistency).

This can shatter the hearts (and wallets) of professionals who espouse a specific approach as “the only approach”. Of course it works. But not because of the reasons you say it works.

Do We Even NEED To Be Specific?

So here is the big question, or rather two questions:

  1. How specific do we need in order to be effective?
  2. Can we be that specific?

We could argue that currently, we are not very effective at treating low back pain, for example. Most of the time we can help people manage it, and the condition takes it’s natural history, which for most, is a resolution over a long enough time-frame.

But could we be more effective if we were able to be more specific?

There is still so much unknown about pain, that it is very difficult to answer.

We do know that pain typically has a blend of biological factors, including local tissue factors and central nervous system factors. We also know that pain consists of psycho-emotional-social components, which play a large role in the nature and course of pain.

We can’t measure the exact contribution of each, and nor can we isolate tissue factors – even evidence of tissue damage on imaging or surgery is at best, correlated with pain. Sacreligious? Perhaps, but, if we go “full academic”, you can’t separate the non-tissue factors from the resolution of pain. For years, surgeons thought sub-acromial impingement improved because of surgical decompression (it didn’t) (6). Same with arthroscopic surgery for arthritic knee pain (7).

Clinically, I have seen people with total and partial knee replacements still experiencing pain, more than 12, and in some cases 24 months post surgery. This doesn’t mean there is no effect of the surgery, but we aren’t 100% sure what it is.

Anyway, I digress.

With most non-specific pain presentations, by nature, we can improve people with non-specific interventions.

Neck pain for no apparent reason? Here’s a scientific valid approach:

  1. Rule out serious pathology.
  2. Rule out tissue injury (via history and assessment).
  3. Rule out complications/comorbid factors.
  4. Educate.
  5. Provide coping strategies
  6. Neuromodulate with chosen intervention, if desired (see above).
  7. Improve function (see above).
  8. Let time and physiology do the rest.

We can apply this concept to nearly all non-specific pain and be evidence based.

In fact, you can apply this to many instances of specific pain too.

Let’s Get Critical

Earlier this year a study on managing lateral hip pain (gluteal tendinopathy/trochanteric bursitis) was published in BMJ:  Education plus exercise versus corticosteroid injection use versus a wait and see approach on global outcome and pain from gluteal tendinopathy: prospective, single blinded, randomised clinical trial (8)

 After critiquing this study, you could easily come to the conclusion that there was a lot of confirmation bias taking place in how much effect these interventions were having, and how much of that effect was due to the specific nature of the intervention (there was no general exercise arm as a comparison).

The methods of intervention were pretty generic:

  1. Education (basically, avoid compression of the tendons by not sitting and moving in certain ways) and exercise (a standardised hip exercise protocol) was one group
  2. Corticosteroid injection was another
  3. Wait and see was the third

Everyone got really excited on social media when this was published, because “exercise works!”, and “I do exercise with my patients” so there was lots of back patting and confirmation bias all around.

However, in my opinion, the interventions didn’t result in that much improvement over a wait and see approach in the main outcome measure (Visual Analogue Scale or VAS, a numerical pain scale). In fact, average pain intensity (score out of 10) changed from 5 to 3 in the wait and see group, while the intervention groups (education + exercise or corticosteroid injection) improved from 5 to 2 on average (there was only a minor difference between the two groups).

Consider the cost for that 10% improvement over wait and see:

  • The education + exercise was 14 sessions, which, if we take an average of $80 per consult, is $1120.
  • A corticosteroid injection under ultrasound guidance, ranges from between $150 and $300 on average.

So was all that effort of exercise, expense of education and injections worth it? Yes, in the short term, there was a big difference at 8 weeks over wait and see. However, if you told someone they had to spend $1000 over 8 weeks to end up 10% better than doing nothing at a year, how many people would still take that option?

Now let’s look at the other main outcome measure, the Global Rating of Change or GROC. The GROC is a single-item instrument that asks each patient to indicate whether and to what extent they perceive change has occurred, typically relative to the date of the initiation of care. The GROC uses a Likert scale to indicate the direction of change (ie, worsening or improvement) and the extent of change (ie, “tiny” to “very great”).  (9)

However, there is contention that the GROC doesn’t reflect functional changes (9), as it is a subjective assessment, but unlike the VAS it isn’t assessing pain, which is subjective, but the participants perception that something has changed. The problem with this, is the recency illusion and the availability heuristic inherently skew the results.

So when we look at the GROC scores: we see that at 8 weeks there is a big difference between the education + exercise and wait/see group, which makes sense, because the education/exercise program was 8 weeks long. But over time that difference was reduced, which is explained as follows:

Our data showed that a patient’s current FS exerts a strong bias on perception of change, even for short recall periods (fewer than 30 days), and this effect increased as transition time lengthened. (9)

So where does that leave us? Time to draw some conclusions.

Conclusions

That was really a long winded way of saying, no, we don’t need to be specific, because even when we try, we can’t be.

The constituents of good care are listed above. This much is clear, though some will debate the manual therapy aspect, others debate the exercise aspect, the moderates will say these 4 interventions are all good in various degrees.

What is emerging, is that what you do isn’t as important as how you do it, and who you do it with (the therapeutic alliance is a big predictor of outcomes in pain). It is also important to not do the wrong things – i.e. those that are clearly ineffective, but moreso, those that actively do harm.

Nick Efthimiou Osteopath

 

This blog post was written by Dr Nick Efthimiou (Osteopath), founder of Integrative Osteopathy.

This blog post is meant as an educational tool only. It is not a replacement for medical advice from a qualified and registered health professional.

 

 

Rehabilitation Is More Than Just Exercise

Exercise is NOT a magical pill – it is great for many things though.

There is a current trend to treat painful problems with exercise, conflating it as rehabilitation.

Before I elaborate, let me make a few things clear:

  • Done correctly, exercise is a good thing, for most people
  • Exercise can be part of the recovery process from pain and injury
  • Exercise has many health benefits
  • I promote exercise actively – if you follow my social media accounts you’d see that

However, exercise is not therapy, nor is exercise rehabilitation.

Yes, exercise can be part of rehabilitation, but it isn’t the same as rehabilitation.

We must keep in mind, however, that motor skill learning and exercise are not synonymous. – Stevans and Hall, 1998

I teach a workshop that talks about using kettlebells for rehab.

In it, I present this argument that performance training and rehab are on the same continuum, with health somewhere to the right of middle.

A slide from my Kettlebells for Rehab Workshop

My point is this:

Performance training is aiming to maximise performance of a particular task.

Rehab is aiming to improve physical performance in one or more aspects.

The principles of stimulus and adaptation still hold.

What doesn’t hold is that you can use performance training to achieve a rehab goal, if the deficit is not performance related.

There is a saying that you can’t put fitness on top of dysfunction.

That’s not completely true, but nor is it true that simply adding load makes things better.

Solely focusing on resolving dysfunction (whatever that means) and solely focusing on building capacity (performance) are both inadequate.

So what happens when rehabilitation is inadequate?

  1. Presenting issue (often pain or injury) is not adequately resolved
  2. Increased risk of future injury
  3. Impaired performance (be it at sport, work or activities of daily living)

Strength Training Is Not Rehabilitation

I have a weak back.

I need to train my core.

My knees aren’t as strong as they were.

Almost every day I hear stories from patients correlating their pain with weakness.

There is a meme floating around about the relationship between strength and pain that is growing in power and becoming really hard to undo.

If there was a direct link between strength and pain, we would not see strong high level athletes suffering from chronic pain.

But we do.

The main reason I suspect we see this link is two fold:

  1. Visually, strong people fill our idea of health and fitness.
  2. Simplicity: it is easier to blame on weakness, teach somebody how to strengthen the so called weaknesses and then use strength as an outcome measure.

Strength training can definitely be part of a rehabilitation program.

But getting strong alone is not the reason we see improvements in pain.

Strength training, done properly, improves movement quality, load tolerance and builds confidence. All these contribute to improving pain in certain conditions.

Stretching Is Not Rehabilitation

The second common issue is “tightness”.

People often feel tight and cite this as a reason they need to stretch.

Therapists then perform an assessment.

They say this feels tight, this is weak. Stretch this. Strengthen that.

If only it were that simple!

Stretching is a valuable technique. I use it as part of my own personal exercise programs, and often prescribe stretching to patients.

Stretching has value beyond lengthening muscles (which it actually doesn’t do*), like improving body awareness (interoception) and relaxing both body and mind. All of this can help people in pain improve.

But alone, stretching is not rehabilitation. In fact, changes to flexibility are not associated with improvements in pain.

Oh and by the way, feeling tight doesn’t actually correlate with being “stiffer”. This has been shown in research. One is a perception of the body, the other is a physical property.

“Cardio” Is Not Rehabilitation

Whether it is going for a run, stationary cycling or walking – all these forms of exercise can have positive effects on health, pain and function.

However, again, is it rehabilitation?

Time again we see improvements with these (and other) cardio activities, which do not correlate to improvements in fitness or endurance.

Again, this isn’t to say cardio exercise has no value in a rehabilitation program, it is simply saying, that cardio in and of itself is not rehabilitation.

What Is Rehabilitation?

Comprehensive rehabilitation should involve restoring optimal function to both the sensory and motor systems, in a manner that builds resilience and enhances adaptability.

Huh? Does that sound complicated? It kind of is. We are talking about the body, which still remains a mystery to us.

We don’t know it all.

But what we do know, is that rehabilitation should be tailored to the individual, and process based.

It should include education and a graded exposure that takes context into account.

It should have objective outcomes that measure improvements in function, but should also focus on resolving the presenting pain or injury as best as possible as well.

Exercise can definitely (and usually should) be part of this process, but I have seen many fit and “dysfunctional” people over the years, along with many people who have “rehabbed” themselves to become stronger and fitter but still suffering from their initial complaints.

There of course, is a balancing act – it’s not always about the pain – and often improving function in spite of pain is the best outcome, but that doesn’t make exercise alone magically turn into rehab.

How Do You Do It?

Educate, Educate, Educate

Without properly educating someone about what they are doing and why they are doing it, rehabilitation lacks meaning. When things lack meaning we don’t give them appropriate focus, which leads to lack of results.

This is why the who treatment encounter should be centred around education from the beginning.

Create the appropriate context, and then each intervention fits into that context.

Sensory Rehabilitation Should Precede Motor Rehabilitation

When somebody has referred pain down their arm or leg, I will test their reflexes.

A reflex tests both the sensory and motor function of the related nerves.

The body has to sense the stimulus (the tap of the reflex hammer on the tendon) and then respond to it.

If you have impaired sensory function, but your motor function is fine, then you won’t demonstrate normal reflexes.

Rehabilitation is similar.

If you have impaired sensory function, your motor function (movement, strength etc) will not be at the level it should be.

Initially, rehabilitation should aim to restore sensory function – this can be achieved in many ways with manual therapy/taping (sensory nerve stimulation), body awareness exercises (enhancing interoception), mobility/flexibility exercises (enhances sensory input), motor control exercises (enhances proprioception).

If someone displays poor sensory awareness, improving this will often develop their motor qualities concurrently, as outputs are a product of inputs and processing.

This is why simply exercising doesn’t always improve things. It’s not just what you do, but how you do it.

Rehabilitation Should Be Contextual

Soldiers in the army face numerous challenges when deployed. An uncertain and continually changing environment, unpredictable tactics from enemies, and the threat of death create extremely high stress situations.

In these high stress situations, our brains go into survival mode – thinking decreases and insinctive behaviour increases – unfortunately, what is instinctive is often dangerous, so these behaviours must be stopped.

As a result, training for soldiers involves as real as possible simulations, to cause an adaptation to the brain.

As the soldiers are exposed to realistic threatening scenarios, they become less and less sensitive – their brains do not enter survival mode as easily – allowing them to think and act intelligently, even under extreme stress.

With pain, our brains are protecting us from a threat, real or perceived. If you experience pain while you are working, and you work in a fast paced financial office, rehabilitation in a calm clinic room only goes so far.

Rehab should progess in context, from safe and secure to challenging and confronting, to allow the brain to adapt its response.

This is one of the most overlooked aspects of rehabilitation, in my opinion. It is why education is so important, and also one of the hardest things to do.

Rehabilitation Shouldn’t Be Based Solely On Sets and Reps

Fixed set/rep schemes work great in theory.

However, given the dynamic nature of the human body, some days we can do more, some days it’s less.

Creating an environment or set of parameters that allows you to “fail forward” is usually more optimal than grinding out movement to achieve a number.

One of the ways this can be achieved is with self-limiting exercises.

Another is with auto-regulation using a “rating of perceived exertion” (RPE) scale. This requires good sensory awareness. See earlier point.

While exercise is often focused on achieving a number, to ensure progression, rehab is slightly different. Numbers can play a role, but shouldn’t be the main focus. Quality and feelings should, at least in the beginning.

Conclusions

Exercise is definitely an important part of the rehabilitation process, but what we have learnt in recent years is that it doesn’t matter as much what you do, but rather that you do something and how you do that something.

When we frame exercise in terms of capacity (load, volume, range of motion etc) without paying attention to the contextual factors involved in someone’s presentation, we are missing a large part of the problem at hand.

And while it is easy to measure strength and endurance gains, it is much harder to measure gains in body awareness, confidence and resilience.

I myself have been guilty of defaulting to the former many times, purely because patients often demand something tangible, and this is what I am familiar with.

The challenge for everyone involved in rehabilitation from pain and injury is to bring the bigger picture into focus, and to really shift the emphasis towards rehabilitating people, not problems.

 

Nick Efthimiou Osteopath

This blog post was written by Dr Nick Efthimiou (Osteopath), founder of Integrative Osteopathy.

This blog post is meant as an educational tool only. It is not a replacement for medical advice from a qualified and registered health professional.

 

 

11 Important Things To Know About Pain

As someone who spends his life thinking about how to better understand pain, I have reached the point where I have amassed a great deal of knowledge on the topic.

The problem with knowing a lot about a topic is, it is easy to fall victim to the curse of knowledge.

The curse of knowledge is best explained by this example:

In 1990, a Stanford University graduate student in psychology named Elizabeth Newton illustrated the curse of knowledge by studying a simple game in which she assigned people to one of two roles: “tapper” or “listener.” Each tapper was asked to pick a well-known song, such as “Happy Birthday,” and tap out the rhythm on a table. The listener’s job was to guess the song.

Over the course of Newton’s experiment, 120 songs were tapped out. Listeners guessed only three of the songs correctly: a success ratio of 2.5%. But before they guessed, Newton asked the tappers to predict the probability that listeners would guess correctly. They predicted 50%. The tappers got their message across one time in 40, but they thought they would get it across one time in two. Why?

When a tapper taps, it is impossible for her to avoid hearing the tune playing along to her taps. Meanwhile, all the listener can hear is a kind of bizarre Morse code. Yet the tappers were flabbergasted by how hard the listeners had to work to pick up the tune.

The problem is that once we know something—say, the melody of a song—we find it hard to imagine not knowing it. Our knowledge has “cursed” us. We have difficulty sharing it with others, because we can’t readily re-create their state of mind.

I, like many health professionals (and experts in every area) often struggle to convey our knowledge to our patients. This is a huge problem, as education (transferring knowledge), is one of the key strategies we can use to help people.

We say one thing, and with it we are thinking of many other things implicitly, based on our years of accumulated knowledge and experience. Unfortunately, patients only hear what we say, and not everything else that we are thinking of when we say it. To make matters worse, patients will often hear all of what we say, but truly understand even less.

So what’s the solution? How do I make this information as clear as possible?

Simple:

  • Use concrete, not abstract, language.
  • Use examples that relate to you.
  • Repeat the key concepts, over and over, until they stick.

With this in mind, here are 11 important things to know about pain.

1) Pain does not equal tissue damage

This is the most important thing to understand about pain.

Pain is not a marker of tissue damage.

Yes, it does occur with injuries that involve tissue damage. That is not in dispute. However, there are countless examples of people experiencing tissue damage and not feeling any pain. There are also many examples of people experiencing very minor or no actual tissue damage and a lot of pain.

Think about stubbing your toe. Often there is no discernible tissue damage, yet stubbing your toe hurts, a lot. However, after you look down and examine it, often the pain quickly subsides.

Or what about the examples of people who have been shot and don’t realise this until later!

Additionally, the intensity of pain we experience is not a direct measure of the severity of what is wrong. A paper cut hurts immensely, at least at first, but it is hardly a serious injury. On the other hand, many people with life-threatening cancers feel little no pain, especially in the early stages of the disease.

So if pain is not a measure of tissue damage, what is it?

2) Pain is protective

Pain is a protective “feeling” we experience with our conscious awareness.

Huh?

Well you can’t be unconscious and experience pain, by definition. That’s how anaesthetics work.

I’m going off on a tangent here, back to the point. Pain is protective.

Whether it is protective of an injured body part or protective of a threat to our brain’s concept of self pain is a biological process that is meant to keep us safe.

 

Imagine if, instead of being told that her sore knee is because of wear and tear, a doctor tells her patient that her knee pain is because her NERVOUS SYSTEM is being PROTECTIVE of it. ~ Imagine this doctor then tells her patient that to deal with the pain she needs to become more ADAPTABLE and RESILIENT, and that she can do this by improving her flexibility, strength and endurance with EXERCISE and ACTIVITY. ~ Imagine if this doctor also told her patient that STRESS and FEAR makes her PAIN WORSE, and that she not only needs to become more physically adaptable and resilient, but more MENTALLY as well, and that this is possible because even into older age, the BRAIN and nervous system CAN LEARN and CHANGE for the better! ~ #integrativeosteopathy #osteopathy #osteo #pain #neuroscience #exerciseismedicine #positivevibes

A post shared by Nick Efthimiou (@integrativeosteopathyau) on

That sentence is complicated, so read it again, and then I’ll break it down.

Pain can be protective of an injured body part. Most of us would have experienced this, but as I said above, it doesn’t measure damage. Pain can protect a previously injured body part too, often way before it is at any risk of being injured again. This is what happens when people talk about having a bad ____ (insert body part here).

Pain can also be predicatively protective. That is, we feel pain in anticipation of something happening to us. I see this lots with people who have low back pain – before they even move they feel pain, even though nothing has happened except a thought!

Finally, pain can also be protective of our concept of self. Our concept of self is the idea of “I”. It is who we think of when we think in the first person. The concept of self has been discussed anddebated in religious and philosophical circles for millennia.

The self is an individual person as the object of his or her own reflective consciousness – Wikipedia

When you understand this, you can see how pain that comes on for “no reason” can be explained as being protective of the self.

If you experience pain after intense periods of stress, then this is an example of your brain (we’ll get to that) deeming that stress as “threatening”, and along with the corresponding changes in a biochemistry during periods of stress, producing pain to get you to change your behaviours

3) Pain is produced by the brain and localised to the body

You don’t see with your eyes.

Your eyes have cells in them that respond to stimulation by light. Once stimulated, these cells send the information signal, via the optic nerve, to the brain. It is the brain which composes the “image” that we see. Interestingly, our brain doesn’t always produce an objectively accurate image. Unless we are really paying attention, it will often give us a generalised image, that is predictive, based on previous experiences. This is why eye-witness testimony is not considered reliable enough to convict as a stand alone evidence. It is thought this is to save energy.

The same goes for all our sensory experiences. Our brains produce a conscious experience based on input from the sensory nerves.

 

Most people are familiar with taste, touch, smell and hearing, which along with sight make up the “5 senses”. However, our brain is also receiving sensory information from many other nerves throughout the body. This gives us interoception (our sense of our internal body) and proprioception (our sense of our body’s position).

Along with the sensory stimuli mentioned, we also have sensory stimuli we are unaware of.

Nociception.

Nociception is “noise” from the body. Sensory nerves that respond to thermal, mechanical or chemical stimulation are constantly sending signals to the spinal cord. Most of this is blocked, because it is just that – noise. However, when when those nerves are stimulated to a greater degree – think an injury, or contacting a hot surface – then your brain becomes aware of the change to the noise levels.

Think about how you can hear your name spoken at a noisy party.

Your brain, not knowing exactly what is going on, will respond by producing pain, and will decide to protect the area where the increased nociception is coming from.

How does it do that?

With pain of course!

To make matters even more complex, we can have pain in the absence of nociception – think of amputees with phantom limb pain – but the majority of pain people experience is either the result of increased nociception or decreased inhibition of nociception.

More on that later.

4) Chronic pain is different to acute pain

Acute pain is usually a response to either a tissue injury or other immediate threat, it subsides as the injury or threat does.

Chronic pain is the result of changes to the nervous system which make it more sensitive. This means the nervous system and brain become “hyper protective”, generating pain with little or no provoking stimulus.

Whether you or someone you know has chronic back pain, arthritis, headaches or some other chronic pain condition (like fibromyalgia), it is important to know that in cases like this, the problem is pain, and it is the same mechanisms that are involved across the board.

How can this be? How can low back pain be the same as a headache or arthritis?

The changes that take place in the nervous system, predominantly take place in the central nervous system (brain and spinal cord). This is like the central control room for our nervous system. Thus if something is wrong with the central control room, then everything linked to it (which is everything), can be affected.

Of course, there are local (or peripheral) factors involved, which contribute to the pain being localised, but there is often a large central nervous system component to chronic pain.

As a result, chronic pain needs to be addressed as a problem in its own right, and not treated like acute pain.

5) Recurrent pain and multisite pain are both forms of chronic pain

Some people experience recurrent pain. That is pain that “comes and goes”.  They will often think that each episode is a discrete event, that is, it is the same problem happening over and over again. It gets better for a while, then it happens again.

Others experience pain in multiple body regions. They might all be one sided, or they cross midline and are above and below the waist. There may or may not be a pattern (often this pattern is explained in biomechanical terms by well meaning practitioners, but that’s another issue altogether).

This is not the case.

Both recurrent pain and multisite pain are forms of chronic pain, and need to be managed as such.

Often multisite pain starts as a single site, and progresses to multisite, chronic pain. In these cases it can be considered a progression of the same condition. It is important to understand the distinction between these presentations of pain, because chronic pain requires different management to acute pain (see no. 4).

6) Pain is never simple, even when it seems so

It may seem like some pain is simple.

You twist your ankle and it hurts.

Or, you drink lift too much and end up in pain.

We think like this because our brains like linear “cause and effect” relationships.

However, pain is not linear. It is emergent.

A linear process is when one thing progresses to another. In simple terms, it is when A + B = C.

An emergent process is when two or more things combine to form something that doesn’t share the properties of the things that make it up.

Because of this, and all the invisible and unconscious factors that contribute to us experiencing pain, we can never say that pain is simple.

When you twist an ankle, all the associations with twisted ankles you have ever experienced that are buried in your brain are activated. The meaning and context of the ankle twist comes into play (a soccer player who will miss the final will experience different feelings to someone who gets out of duties they didn’t want to do because of the injury). Sometimes the nociception doesn’t represent tissue damage at all, but spikes due to a sudden increase in load.

Why does this even matter?

Because chronic pain starts as acute pain, and in some cases, it was considered “simple”.

7) Pain is not caused by “poor posture”, weak muscles or being “out of alignment”

 


If you have understood everything up until now, this should make sense.

However, many people still think of pain being caused by these things, because we observe these things when people are in pain.

It is the common error of attribution: correlation is not causation.

When you experience pain, you might be weak, or stand/sit differently or even look and feel like you are twisted or bent. There is no disputing this.

But it doesn’t cause pain.

More likely, these things are caused by pain.

They are defensive, or protective behaviours.

8) Osteopaths (and other practitioners) don’t “fix” pain

You might think this is a strange statement to make.

Why else would you pay to see an osteopath then?

Well, there are lots of reasons, but when it comes to pain, the resolution can only come from within your own body and brain.

<

A good osteopath will do everything in their power to help remove the barriers to recovery, and facilitate the physiological and psychological processes that need to take place, but no one can change you on the inside from the outside.

Even pain relieving drugs can only work if you are in the right context – morphine doesn’t always help, while sometimes a placebo pill works better than the real thing.

So if you are looking to be “fixed”, it is unlikely to happen as you want. This is probably the hardest thing to accept as both a patient and a practitioner.

9) Everything can “work”

There are claims from therapists, doctors and other kinds of healers about all kinds of treatments for all kinds of pain.

It’s likely all of these people have numerous success stories to confirm that what they do works.

But just as an osteopath can’t fix someone (see no. 8), everything can work for pain.

This is because the brain has the ability to produce pain relieving chemicals, in the right circumstances.

These pain relieving chemicals are extremely powerful, and when the context is right – belief, expectation and ritual all come into play – then the brain, in anticipation of what’s to come and in response to what has happened sends out all these amazing substances to help you deal with pain. This process is called descending modulation (or inhibition).

This is not a bad thing at all. It is actually the goal of many therapies, including osteopathy and exercise rehabilitation.

The problem comes, when interventions are sold in misleading ways, i.e. they are sold as doing something unrealistic or impossible.

In simple terms, if something sounds too good to be true (amazing success rate, top secret, revolutionary) or can only be done by a particular person, it is unlikely that the intervention is really doing what is claimed.

That’s not to say it doesn’t work, only that is doesn’t work because of what is claimed.

10) Inflammation is a good thing

Many people take anti-inflammatory medications for pain without a prescription. They don’t work (at least for low back pain).

Many others use ice after sustaining injuries.

The majority of people doing this don’t know why they are doing it. If you asked them, they might mention something about stopping inflammation.

If you asked them why they want to do this, they might say it helps with pain and recovery.

Now what is more likely?

Our bodies have, over thousands of years, evolved highly effective mechanisms for dealing with injury, part of which is the inflammatory process, or this process is an error of biology and must be stopped?

Inflammation is the body’s way of healing.

Yes, it can be painful, but pain is a protective response. And you know what needs protecting? Injured tissues.

That is not to say you need to completely rest an injured tissue by the way. It is simply saying that suppressing inflammation (particularly with drugs) can impair and delay healing.

Finally, chronic inflammation is not a good thing. However, it is usually the result of other issues, and while suppressing it relieves the inflammation, it doesn’t address the reasons why it is happening. Like chronic pain, chronic inflammation needs a different approach to acute inflammation.

Oh and one more thing,

11) How you live is more important than what you do

 

Most people in pain are looking for a fix.

Be it medication, treatments of various kinds, a specific exercise or even surgery.

The issue here, is that for many pain problems, these interventions all have low effect sizes. That means, they work, but not by very much. Hence the cost and risks often outweigh the benefits.

What is most important, particularly for sufferers of chronic pain, is living well, despite your pain.

Healthy lifestyle habits contribute to healthy bodies and brains.

Healthy bodies and brains experience less pain overall, and when they do experience pain, respond better to interventions.

That is not to say all treatments for pain don’t work.

Nor is it to say how you live can solve all types of pain.

It is simply saying, that your lifestyle plays a large role in your likelihood of developing and recovering from pain.

Think about it. If someone leads an unhealthy, high stress lifestyle, barely sleeping and consuming lots of drugs and alcohol, do you think it matters what kind techniques an osteopath uses, or what type of exercise they do?

Do you think it will make any difference in the grand scheme of things?

Conclusions

I consult with people in pain on a daily basis.

I work with them to try and help them feel and live better.

Sometimes, their pain goes away. Sometimes it doesn’t. Sometimes it gets worse. We are not predictable like a machine.

It is a really hard job, and while many practitioners love to talk about their success rate, I think if you take a big picture view, it is unlikely any single practitioner gets results above and beyond what the statistics say they should for the patient base they work with.

I do believe there are practitioners who would do worse, simply because this information about pain is still not common knowledge, even among health professionals, but to do better is unlikely.

Thus, if someone has a long waiting list, it doesn’t necessarily mean they are the best therapist, it simply means they have a lot of people waiting for their services.

When you choose a therapist to help you, it is less about what kind of therapist they are, and more about how they work, and whether that suits you. A good way to know if they are up to date with the research is to ask them about some of the topics above. They don’t have to agree, but if they have no idea, or dismiss things outright, that might be a hint.

Pain is a mystery, but that doesn’t mean you can’t reduce it, or live well with it. After all, it’s not just about the pain.
Nick Efthimiou Osteopath

 

This blog post was written by Dr Nick Efthimiou (Osteopath), founder of Integrative Osteopathy.

This blog post is meant as an educational tool only. It is not a replacement for medical advice from a qualified and registered health professional.

 

 



 

 

References

The Curse of Knowledge

Self

 

It’s Not About The Pain

Being a good osteopath involves being good at communication.

Being good at communication involves being good at listening.

Being good at listening involves understanding, not only what was said, but what wasn’t said.

This is because:

People don’t seek your help because of their pain, they seek your help because of the pain their pain causes.

When We Start, We Don’t Know Where We Will End Up

When I was a teenager, I was lucky enough that my dad, for whatever reason, bought a copy of a book called Smart Sport, which is essentially a book of sports science for lay people.

I read that book multiple times, developing an interest in exercise physiology and sports performance.

Indirectly, that has lead me into my current profession, but that is not what this post is about.

Because of my interest in exercise physiology, I became interested in cycling, and if you were interested in cycling at the turn of the century, you were interested in Lance Armstrong. Say what you want about him, but the man made cycling exciting!

Part of his appeal was his back story, which he detailed in a book titled It’s Not About The Bike.

The book outlines Lance’s struggles in life, and with cancer, as well as his comeback from the brink of death. It peaks when Lance is on the recovery trail and is climbing a hill in Colorado, when he realises his life is meant to be a struggle.

Which brings me to pain.

Pain Is Good, And Bad

None of us is entitled to be pain free, all the time.

[Note: This actually wouldn’t be a good thing either, as people with congenital analgesia (genetically can’t feel pain) tend to have shorter lifespans than average.]

Most of us are lucky in that we only experience pain in a positive way. That is, short term pain that is protecting us from something obvious (or not so obvious); a broken bone, a strained muscle, too much exertion in too little time.

However, some people experience constant, chronic pain, which we could say is not positive at all, but rather negative.

This pain is still protective (all pain is), however it is also pathological.

It occurs when the nervous system has changed, both in structure and function and become hyper protective. This type of pain is negative, because in the vast majority of cases it doesn’t correlate well with any tissue damage needing protection, and becomes a big hurdle to living a full life.

What we (as a population) have to understand is, some pain cannot be resolved.

We just don’t know enough yet. And even if we did, perhaps some pain is not meant to be resolved?

So if you are suffering from chronic pain, you have to ask yourself:

If this pain never went away, can I still live a good life?

And to me, as an osteopath, the answer is always yes. Mind you, many people will actually experience their pain decreases as they learn how to manage it better, but more on that later.

If you have have chronic pain, and you cannot fathom a way to live a good life, then you need help.

You need a team of health professionals who understand pain, who can work with you on reshaping your expectations, improving your management and helping you get as much out of life as possible.

#TheStruggleIsReal

Back to Lance. This is what I think he was talking about: life is all about the struggle.

We all struggle.

Our struggles vary, but to the person struggling, as the internet says “the struggle is real”.

But this struggle defines us.

It is because we struggle that we become stronger people.

It is because we struggle that we rely on others, building relationships that add to the richness of life.

It is because we struggle that we can help others who share the same struggle.

Perhaps, if we can learn to find meaning in the struggle, the struggle isn’t so much of a struggle, but a journey. And like every journey, some have it harder than others. Some don’t even make it. It’s not fair, but it is life.

Knowledge Is Power

I have talked about pain over the last few years, using tens of thousands of words to try and help people understand what pain is, how it works and how to move, think and live in order to overcome pain and achieve optimal health.

But overcoming pain doesn’t always mean getting rid of pain.

It means overcoming the adversity that pain brings.

It means understanding the key points of pain science education, as my friend and colleague Alison Sim outlines:

  • Pain does not equal tissue damage
  • Focus on function, not pain
  • Use physiology to underpin management (i.e. manipulate physiology with exercise and pyschological techniques to reduce stress and anxiety)

Mostly, it means understanding that it’s not about the pain, it’s about living as well as possible given the circumstances.

Nick Efthimiou Osteopath

 

This blog post was written by Dr Nick Efthimiou (Osteopath), founder of Integrative Osteopathy.

This blog post is meant as an educational tool only. It is not a replacement for medical advice from a qualified and registered health professional.

 

 



 

 

How To Recover From Any Injury

Image credit: Marcus Needham

Pain is a complex, emergent experience.

Tissue injuries are not.

Tissue injuries occur when the loading on the tissue exceeds its capacity.

This can be an acute issue – think of a sprinter suddenly straining their hamstring mid race – or a chronic issue – think of a builder developing elbow pain over time.

In both circumstances, the principle is the same.

The formula for managing an injury is fairly simple on a macro level:

  1. Decrease the volume, intensity and/or frequency of aggravating activities to manageable levels
  2. Improve biomechanical efficiency
  3. Increase capacity with progressive overload


What is challenging is how to achieve these objectives in living, breathing humans who have needs, wants and annoying things like emotions that make us behave irrationally.

This is where a clinician needs to have excellent listening and communication skills, be a master of persuasion and thoroughly understand the physiological and biomechanical aspects of movement, stress and adaptation.

This post is going to outline a few of the methods I use to achieve the above outcomes.

Decrease Volume/Intensity/Frequency of Load

The most obvious thing to do when we are injured is often the hardest.

Why?

  • Necessity. We all need to continue working, caring for family or performing our activities of daily living (ADL). It can be hard to offload your injured body part when there is a baby crying or a load of laundry that needs doing. Let alone when you have a work deadline to meet.
  • Desire. This is an emotional issue. Many of us desire to continue doing something as it brings us pleasure, status, or allays a negative emotion like guilt or fear. For example, it is common for people to want to continue to push themselves exercising whilst they are injured because of body image issues.

However, in most cases, an all or nothing approach is not required.

You don’t have to stop something completely to reduce the loading effect.

Here are two examples from a patient who has lateral hip pain that I’ve diagnosed as a gluteal tendinopathy. In these cases we are reducing the volume of the load primarily:

  • Use the fitness tracker in her phone to estimate her daily activity level. Work out at what activity level her symptoms flare up. Stay below that activity level while gradually building up during recovery.
  • Track her walks accurately (pace/duration) and work out at what level her symptoms flare up. Stay below that activity level while gradually building up during recovery.

Here is another example of how I reduced the intensity of the load in a builder with elbow pain. He couldn’t stop working, and a lot of what he did (using tools) aggravated his injury.

  • Use tennis grip tape to wrap around the handle of his hammer. This increases the circumference of the handle, which reduces the mechanical leverage of the forearm muscles, taking the load off the tendons at the elbow.

In most cases, there are ways to continue doing what you need or want to do, with some modifications. And in most cases, this is actually better than complete rest.

Improve Movement Efficiency

Everybody knows Roger Federer. You don’t have to be a tennis fan to appreciate his skill and technique. He makes things look easy.

As we improve our skill at a task, we become more efficient as well. It takes less effort and as a result we tend to load our body less.

Roger Federer demonstrates this – his supreme technique has helped him accumulate very few injuries in his career, despite a demanding schedule and advancing age.

However, we don’t need to look to elite sport for examples of movement efficiency.

Think of your local pizza parlour. If it has been around for a while, watching the chefs put a pizza together is a picture of movement beauty (okay, I really love pizza). Every time I try and replicate this at home I just end up tired with a very messy kitchen bench.

Or let’s keep it closer to home. When I was younger, I didn’t know how to iron a shirt well. My mum could iron all of my dad’s and my brothers’ shirts in the time it took me to do one. All that effort, all that time under load. It’s easy to see how my inferior ironing skills could lead to more load on my body. Even though my mum was doing more total work, her body was adapted to it, and she did it in a way that was smooth and effortless. Contrast that to me, not adapted to ironing (still not) and very tense and inefficient.

When it comes to rehab for an injury, it’s not just the capacity of the tissue that we have to worry about, but the efficiency of movement, which affects the loading on that tissue for each movement/activity.

Improving movement efficiency is a topic in and of itself.

My approach is based on the following formula: 

The input is related to sensory information from the nervous system. The better the quality of sensory information, the better the output. This is why rehab should begin on the sensory side. Sensory input can be improved with manual therapy, which is likely one of it’s biggest roles in modern practice.

Processing is based on cues and context. We can change both, but we have no idea how it will affect the processing. I’m not a big fan of the word processing, as it sounds to much like a computer, and we are not a computer or machine.

I discuss this in more detail here, and also here.

Increase Capacity

Remember at the start of this post when I said:

Tissue injuries occur when the loading on the tissue exceeds its capacity.

Well it makes sense that as well as reducing the load on the affected tissue(s), we increase the capacity as well. This has two benefits. No, actually, it has three benefits:

  1. Loading tissues helps with repair.
  2. Loading tissues that are painful helps (re)build confidence in the injured tissue.
  3. Increasing tissue capacity protects against future injury.

I like to use a two pronged approach here:

  • A targeted exercise approach
  • A graded return to activity approach

This isn’t revolutionary. It doesn’t have to be. It just has to be done well.

In the targeted exercise approach, I use a simple progression. I like someone to be able to (where possible) perceive the tissues properly (sensory awareness) before we work on the following:

  • Isometric to dynamic
  • More stable to less stable
  • Simple to complex
  • Less task specific to more task specific

There is some evidence to suggest local loading, particularly with isometrics has a pain relieving effect, which is why I start there.

More stable positions allow people to focus on the movement or activation required, without the extra motor and sensory demands of stabilising their body in space.

Starting simple allows more mental energy to be directed to recruitment patterns, while progressing to complex reinforces these patterns in different contexts.

Finally, starting less specific to the task allows for the load to gradually be progressed as tissue capacity increases.

Graded Return to Activity

This is an expansion of the first topic, reducing the load.

Put simply, we simply reverse the process, gradually increasing the load until the tasks can be performed normally again.

A good rule of thumb is to progress no more than 10% per week, to allow the person and the tissues to adapt. You cannot go too slowly, but you can absolutely go too quickly.

Conclusions

This is my current approach to treating tissue injuries.

You have to remember that not all tissue injuries present with pain, and not all painful presentations are related to tissue injuries.

When pain is the primary problem, we can use a similar approach if localised tissue sensitivity is deemed to be the main contributing factor.

Finally, we know that past injury is a big predictor of future injury. So while the pain from an injury subsides as the tissue heals (the tissue will heal if you give it a chance, regardless if you rehabilitate function or not), if you want to minimise your chance of re-injury in the future, it pays to be thorough.

 

Nick Efthimiou Osteopath

 

This blog post was written by Dr Nick Efthimiou (Osteopath), founder of Integrative Osteopathy.

This blog post is meant as an educational tool only. It is not a replacement for medical advice from a qualified and registered health professional.