The Role Of Movement In The Treatment Of Pain

Movement

What is the role of movement in the treatment and management of pain?

We know physiotherapists have long time incorporated exercise(s) into their practice, but now osteopaths, chiropractors and other remedial therapists have started introducing exercise and movement as part of their treatment approach to pain.

Does this improve outcomes for people in pain?

As someone who has an exercise background, and a practice based in a gym (with a large number of patients who are active themselves), I’m a big proponent of empowering people with active management strategies to both help manage pain and improve health and fitness.

Large scale research projects have confirmed that an active, movement based approach is superior to a passive treatment approach for the management and treatment of many pain conditions.

Whilst the many benefits of exercise and movement are commonly known and widely promoted, the message can be misconstrued when context is not provided.

To understand the role of movement in the treatment of pain requires an understanding of pain.

Unfortunately, many people do not learn about pain when they seek treatment for pain, which leads to incorrect ideas and beliefs, that can make their pain worse.

The Dark Side of Exercise Therapy for Pain

In general, encouraging people to take an active role in their recovery from pain is a good thing.

Problems arise when exercise and movement is billed as being the treatment or “fix” for pain.

Unfortunately, nothing can “fix” pain, not manual therapy, not exercise, not medication, not surgery.

The reason being, pain is not a thing, pain is an experience, an active process. All of those methods create a change within your body and brain, so that your brain can resolve things.

So, as always, the context in which anything, including movement, is performed to help with pain is paramount.

What’s the big deal?

Many times, I have seen people who have been told to stand/walk/move in a certain way, because if they don’t “their pain will get worse”.

Others, rightly or wrongly, interpret their failure to improve as their fault, if they have been made to believe that exercise is what is needed to fix their pain, due to poor compliance. I often view poor compliance as not as the fault of the client, but of the therapist.

If someone can’t do something, then what has been given to them is too much for them at that point in time.

And yes, people still need to take responsibility for their actions, but the job of a health practitioner is to show the path in actionable steps, not unload a volume of information onto their patients (they could use google for that).

What’s In A Name?

Throughout this post, I have used “movement” and “exercise” interchangeably.

Whilst it is true that exercise is movement, it is also true that not all movement is exercise.

Exercise is purposeful physical exertion/activity performed to create a physical adaptation.

Movement is a preferred term, because it doesn’t have the connotations to exertion.

You shouldn’t need to exert yourself (physically) to overcome pain.

Mechanisms of Movement in the Treatment of Pain

We don’t actually know exactly what happens when pain resolves.

To clarify, we know that pain is an emergent property, that is, it has biological, psychological and social/environmental components, but it is not any one of these, nor does 1+1 = 2.

This means, that treatments for pain can be specific only up to a certain point.

Why does spinal surgery improve outcomes for some people, but not all? If pain were only physical, then surgery would always work, but we are not bodies, but people, and this needs to be considered in the treatment of pain.

That’s not to say we have no idea what helps pain, we do, generally, but what helps pain for any specific person at any specific time is going to vary.

One thing we do know, is that “all pain is neurogenic”, that is, all pain originates in the nervous system.

So for any intervention to help in the resolution of pain, it must have some effect on the nervous system.

Thankfully, we know that movement has a great effect on the nervous system.

Novel Input

Our brains crave novel sensory input. It is why we are generally attracted to “new and shiny”.

When we experience pain, it is an output of the brain, based on all the current sensory inputs from both the body and the brain itself (confusing? read this).

In theory, by providing novel sensory inputs, we can alter the outputs, including pain.

With movement, if we can “show” the brain a different way, then sometimes that is what is needed to “teach” it how to produce the desired output.

For example, let’s say you experienced low back pain that hurt when you bent forward.

If we change the context of your bending by having your feet in a split position and bending to the side, that might be enough of a different sensory input to change the output of pain.

Cortical Mapping

Our body is in our brain. We have a “map” of our body within our brain, such that when certain peripheral nerves are stimulated, a corresponding brain area is activated.

Conversely, stimulating that brain area with electrodes will cause a vague sensation in that region of the body.

When we have pain, we know that our “body map” is impaired. That is, we can’t clearly recognise our affected body parts like we can the unaffected ones.

Deliberate movement can help with cortical mapping, once again, by increasing the amount of information coming from an affected area.

Touch can help, but we seem to have a better response to active movement, likely because more brain areas are involved, resulting in a more pronounced stimulus.

Neural Mobilisation

This is little bit easier to understand for many people, because it is more of a direct mechanical effect.

Nerves are everywhere in our body. We have km’s of them.

They pass through “tunnels” of soft tissue all over the body.

They can get stuck or deformed.

When they are stuck of deformed, they will fire more rapidly and strongly.

Movement, can either directly, or indirectly mobilise the nervous system, freeing up your nerves to slide and glide freely, which is exactly what they want to do.

Descending Modulation

Our brains are pretty cool.

In addition to being able to recognise a bunch of pixels lit up on a screen into shapes (letters) as meaningful, they can produce a whole host of chemicals that can block pain at the level of the spine.

Aside: there are 3 levels where you can block pain. Peripheral, spinal and brain.

Movement can facilitate the production of pain relieveing chemicals, like endogenous opoidids. Much better than buying them at the pharmacy, because your brain is never going to get the dose wrong.

Improved Mood

There is a correlation between mood disorders like anxierty and depression and pain.

Regular and meaningful movement is correlated with improved moods, as is exercise.

You can probably see where I’m going with this.

So Movement is Medicine After All?

Definitely.

But just as taking the right medication, in the right dose for the right problem is paramount, using movement as an intervention for pain is the same.

More is not better if all you are doing is reinforcing the same behaviours that lead to or maintain your pain.

Think of it like this: there is the skill to perform a movement, and the capacity to perform it. If you have the skill, but limited capacity, you need to improve your capacity and vice versa.

Conclusions

Movement is important in treatment of mechanical pain.

Active movement is superior to passive movement in most cases.

The mechanisms of how movement affects pain are not specifically known, but there are plausible ideas, all of which must involve the nervous system.

These effects are what would be called “non-specific effects”. Whilst there are potentially “specific effects” occurring as well, we don’t know enough as yet to harness these more precisely.

In terms of pain: inputs + processing = output (pain).

To change pain, we are attempting to change our inputs, be it movement, education, cognitive behavioural therapy, manual therapy or something else.

Whatever it takes to get a change is what “works” for that person, in that moment.

 

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

Coming soon!

A Simple Mind Hack To Reduce Pain

Neurons

Neurons

Pain is the conscious correlate of perceived threat. – Lorimer Moseley, Professor of Clinical Neurosciences and Chair in Physiotherapy, Uni SA

Pain is only pain if we are consciously aware of it, if you aren’t aware of pain, you don’t have pain!

Knowing this, if we can shift our awareness away from pain, we can reduce it.

In medical terminology, this is described as distraction therapy.

Distraction therapy is an effective pain management strategy, and it’s something you’re likely to be familiar with.

If you’ve ever spent any time with children, you’ll have seen them hurt themselves. Sometimes, after a minor fall/scratch/scrape children make a bigger fuss than warranted (tears and tantrums), mostly for attention. Many clever parents use simple distraction techniques to take a child’s mind off the pain they are experiencing. It usually works a treat.

This is distraction therapy.

How Does It Work

There are 2 inter-related but separate mechanisms that are at play.

The first, and probably the coolest, is that distraction therapy leads to the secretion of pain relieving opoids by the brain (1).

These opioids, termed endogenous, as opposed to exogenous opioids that you consume (codeine, oxycodone etc) act within the central nervous system to reduce pain.

The second involves competition for attention between an important sensation and consciously directed focus (2).

This is because the conscious mind can only focus on one thing at a time.

Sure, we can rapidly alternate our attention between two or more things, but at any given moment our attention can only be on one thing.

And going back to the opening quote, “pain is the conscious correlate of perceived threat”, if our consciousness is focused elsewhere, then it cannot focus on pain.

How Do You Use It?

The great thing about this, just like with children, you can use this to help reduce your pain.

It’s important to understand that distraction therapy is not magical. It is simply a pain management technique that is free, easy to implement and accessible to all.

Distraction therapy can work with pain of all different causes, but you can’t ignore the underlying issue:

  • If your pain is caused by a medical condition, see a doctor!
  • If you are suffering pain due to injury, the injury must heal first before the pain goes away.
  • Likewise if you have pain related to movement issues, they must be resolved.
  • Finally, please understand, that persistent or chronic pain is considered a disease in its own right, it’s also not considered to be curable, instead, focus on finding effective management strategies.

 

So how do you do it? The beauty of distraction therapy is that there is no one way.

The most important thing is to use an activity that is interesting and meaningful to you. One that is comfortable and immersive.

You can’t think to yourself “I’m doing to distract myself from the pain by doing this” while you are doing it, because that means your attention is on your pain and not on the activity.

Doing this causes you to engage in a state of flow, and given that your brain will want to remain in this state, it will secrete opioids to modulate your pain.

That’s a win-win. You get to do something that is important to you and reduce your pain at the same time!

There is no limit to how long this will work for, it depends on how strong your concentration is.

Intention and Distraction: The Next Level?

Whilst the research on distraction therapy focuses on the immediacy of performing a task and the subsequent physiological response, here at Integrative Osteopathy we have used similar principles to help patients throughout their entire day.

This is not, strictly speaking, distraction therapy, but the principles are similar – namely that the conscious mind can only give attention to one thing at a time.

Not only does this technique help with pain management, but it can improve your mood and even your life.

The technique is called setting your intention.

It simply involves a short period of quiet contemplation in which you focus your attention on your intention.

What is your intention? It is another way of describing your focus.

If you look back through time, pretty much all cultures had periods of quiet contemplation built into their lives.

Whether it was prayer, meditation or spiritual rituals, these practices allowed people to process events that had happened and the associated thoughts and emotions, and find a place of comfort, if not clarity.

It is part of the reason mindfulness/meditation is gaining such traction in recent years – our attention is being attacked from every direction, distracting us – mindfulness helps with finding clarity again.

To add in quiet contemplation to your life, it need not be complex. In fact, it’s better if it’s not.

How To Set Your Intention

Setting your intention starts with quiet contemplation. A great time to implement it is in the morning, as it sets you up for the day ahead.

Pick something you habitually do, like taking a shower or brushing your teeth, and immediately before/after, close your eyes, slow your breathing and spend a few minutes alone with your thoughts and feelings.

Focus on the one thing, above all else, that you want for the day. This is your intention.

 

Your intention needs to be framed in a positive way. Your brain doesn’t recognise negative words. To illustrate, make sure you don’t think of dancing elephants while you’re reading this sentence.

Once you have the elephants out of your mind, get back to setting an intention.

This focus will govern all your actions for the day, both consciously and unconsciously.

After you have set your intention, you can create an intention card (3). Write your intention down on the front of small card, in one word. Then, on the back of that card, write out a prompt question.

Usually, you would frame it like this:

A. Statement of the intention
B. A question prompting the action which leads to the intention

Here’s an example:

Imagine someone who always feels stiff.

They might set their statement of intention as this: Fluid movement.

Then their question might read: what do I have to do to experience more fluid movement?

Instead of thinking about how stiff they feel, this question prompts somebody to get up and move, to stretch, to avoid prolonged positions and a whole heap of other things, all from a positive outlook. In essence, it’s distracting them from the problem whilst prompting a solution.

 

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

(1) Attention Modulates Spinal Cord Response To Pain – http://www.sciencedirect.com/science/article/pii/S0960982212003934

(2) How Does Distraction Therapy Work – http://www.ncbi.nlm.nih.gov/pubmed/15745617

(3) Intention Cards – http://www.authenticeducation.com.au/intention-cards/

Rethink Pain: Moving Beyond Muscles and Bones

Classical Anatomy

This is the first post in what will be a series about “re-thinking pain”, or rather, re-conceptualising it.

The aim of the series is to help you move from a tissue based understanding of pain to one based in neuroscience, which is more accurate and more correct (although a better term would probably be “less wrong”, as there is still so much to learn).

Why is this necessary?

  • The language we use around pain shapes the way we think about, and experience pain. Using tissue based descriptors of pain reinforces the idea of a “bottoms up” model of pain, which is wrong, and can often make things worse in the long term. Moving towards a neuroscience approach helps move away from this model.
  • Chronic pain is a massive problem in Australia (and around the world), affecting millions, costing billions and growing worse every year. Chronic pain often starts as poorly managed acute pain. One of the most important management strategies of any painful condition is education.

The Problem

To begin to understand how we have ended up with such a problem regarding pain requires tracing back through the centuries of medical and philosophical history.

In short, we used to describe pain as “coming from the tissues” up to our brains, where we felt it.

What is now understood, is that pain is a brain output, with many different “filters”, that are unique to each and every one of us, being applied before we are consciously aware of it.

Despite having this knowledge, we can see that even within the official definition of pain, the problem exists.

An unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage.

The definition of pain above has been put together by a group of highly intelligent people (International Association for the Study of Pain), who have spent a large portion of their lives studying pain, it’s effects and how to treat it.

Unfortunately, there is one small problem, and it has nothing to do with the definition itself, but rather, the fact that pain is “described in terms of such damage”.

When we explain all pain in terms of tissue damage we paint a picture in people’s minds. Unfortunately, when it comes to pain, this picture is not only incorrect, but harmful.

One can assume this became part of the definition because of what takes place in the real world:

  • Your back hurts, people say you have strained a ligament/joint.
  • Your knee hurts, people say it must be arthritis.
  • You have a headache, must be wear and tear of the head. No, that last one doesn’t sound quite right.

So how exactly is this harmful?

When pain is described in terms of body tissues alone and combined with the type of language typically used (words like torn, strained, scarred, degenerative) to describe tissue based pain, irreversible damage in the form of nocebo* can be caused.

This can lead you to think that something is wrong with your body that needs to be fixed, when things are in actual fact, completely normal.

Additionally, thinking in terms of body tissues leads to a mechanistic view of the body, one that wears out over time and the association of this “wear” with pain. The body is a biologic organism, one that is always adapting as best it can, it doesn’t “wear out”, but rather fails to adapt. There are lots of reasons for this failed adaptation though, it’s not just the result of “getting older”.

Check out this Facebook post on from September:

"It's probably just WEAR AND TEAR"My oh my, does that saying get tossed about. Usually, it goes something like this:…

Posted by Integrative Osteopathy on Wednesday, 30 September 2015

*Nocebo, is basically the opposite of placebo, ie causing harm when no harm has been done.

The Solution

We need to rethink pain, to conceptualise it as a dynamic process, arising in the nervous system and governed by our brains.

Yes, pain is often a result of tissue damage. However, there are many cases of severe tissue damage with no pain experienced at all and vice versa.

Additionally, the intensity of pain is very poorly correlated with the severity of any tissue damage.

Finally, when tissue damage has occurred, there are three scenarios.

  1. It is quite severe and needs medical intervention at a hospital. Think of compound fractures, 3rd degree burns, deep cuts etc.
  2. It is not severe enough to require medical intervention beyond basic first aid.
  3. It is somewhere in the middle.

In all 3 cases, with time, the body will heal as best it can.

As long as there is adequate rest, nutrition and then re-loading of the tissues in a progressive manner as governed by the condition and individual requirements, you’ll get as full a recovery as possible.

So initially, once the need for medical intervention is ruled out, the important thing to do is treat the pain.

This goes against almost all manual therapy and allied health advertising to “treat the cause of your symptoms”.

Alleviating pain will, in many cases, sort out a lot of associated “findings”, the so called causes of your pain, and then beyond that, allow your body to heal.

If you came to us for treatment, here’s how we might do that:

  • Explain all of this information about pain, in a way that makes sense to you, so that you aren’t as stressed or anxious about it anymore.
  • Have a look at you stand and move and suggest ways that might make standing and moving less painful.
  • Get hands on and apply some really pleasurable manual techniques. There is no need to dig in deep for the sake of it. The goal isn’t to change the tissue, it’s to change the perception and get the brain releasing pain relieving chemicals.
  • Do some breathing techniques to help you relax. You’d be surprised at how poorly most people breathe, even when they are concentrating on doing it properly.

All of these techniques are based on the same principle – once the threat is reduced to an acceptable level, the brain will stop protective behaviours, which include pain and altered movement.

So to summarise a blog post in a sentence:

Pain is all about threat perception, it doesn’t mean damage and body tissues can’t produce pain, only the nervous system can**, so we must focus on the nervous system, including the brain, when describing and treating pain, so as to not cause further complications via nocebo.

 

 

**Yes, the nervous system is a body tissue, but for the sake of the argument we are using simple language.

 

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

Integrative Osteopathy is an osteopathic practice located in the heart of Fitzroy North, within the reputable Healthy Fit gym. For all inquiries, call 0448 052 754, or to make an appointment online, click here.

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.

 

Pain Science Made Simple

Scary Unkown

When the primary complaint is pain, treatment of pain should be primary. – Barrett Dorko, P.T.

At Integrative Osteopathy, one of my core practices is to empower people through education, so they feel better both in the short term, and the long term as a result of resilience and independence.

A hugely important part of this process is pain and neuroscience education.

Whilst this may sound daunting and perhaps even irrelevant to you, research shows that neuroscience (including pain science) education has a positive effect on pain, disability, physical performance as well as anxiety and stress.

In addition, not learning about pain early on can lead to the rise of chronic pain conditions later, by not alleviating the fear that is often associated with pain (consciously or unconsciously)

Considering how effective this intervention is, and the fact that pain is the number one reason people consult an osteopath in Australia, it’s a no brainer to ensure a thorough teaching about pain precedes any other treatment.

What is pain?

Any teaching about pain must start with exactly what pain is, and currently, the definition put forward by the International Association for the Study of Pain (IASP) is:

Pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage.

Now that seems straight forward enough, but let’s look at it a little deeper.

What exactly does this mean though?

Pain is more than just a physical phenomenon

Most people associate pain with injury and damage, and whilst this is often a component of pain, pain is much more than damage.

This is why the word potential is used, it implies something else is at play – we don’t need tissue damage to occur in order to feel pain.

Pain is an alarm, not a damage meter. This can be one of the hardest things to grasp when first learning about pain, and will be explored in more depth later in this post.

Pain is an emotional experience

If you have ever experienced pain, you will likely recall not being yourself, you may have been “short” with people, or become more introverted, or demonstrated any number of changes to your normal demeanour.

That’s the emotional part.

Every person’s pain is unique

We commonly use words like sharp, dull, throbbing, aching, burning, stabbing and shooting to describe pain.

This helps communicate each pain experience in a more “universal” manner, allowing clinicians and patients alike to identify certain attributes of pain, potentially helping with diagnosis or coping.

However, what this doesn’t allow for is the uniqueness of pain.

The use of the word experience in the above definition, suggests the individual nature of pain.

We all feel differently and what we feel depends on many factors – our genetics, our current situation in life and our cultural upbringing are just a few of the contributing factors to how we experience pain.

Pain is an output of the brain

Understanding the broadness of pain and the fact that pain is not reflective of tissue damage, the next step is to grasp the concept that pain is an output of the brain, rather than an input to the brain.

To understand what this means, let’s use a simple analogy.

On a computer, we can use a mouse or keyboard to provide an input. This input is then processed, and then, depending on the program in operation, and output is displayed.

Currently, I’m typing in a word processor, which means when I hit the “w” key, w appears on the screen. However, if I were playing a game, that “w” key might move my character in a certain direction.

Same input, different output.

When it comes to pain, we experience it when our brain decides, unconsciously, that the sum of information it is processing is “dangerous” and we realise this danger consciously – the feeling of pain.

Regarding the inputs to the brain, there are 3 main sources (in no particular order):

  1. Cognitive (thoughts)
  2. Affective (emotions)
  3. Physical (messages from the nerves)

What’s interesting, is that only one of the three inputs is regarding the status of the body.

If the sum of all this information is perceived as “dangerous”, then we experience pain, changes to movement and posture, a heightened stress response etc.

So really, pain is a broader part of the nervous’s systems operations to keep us safe. Though sometimes it goes wrong, for the most part, it’s a pretty good system. If it wasn’t, we wouldn’t be here today.

Nociception and pain

We are really diving deep into this pain stuff now, but this is quite an important part of the pain experience.

Nociception is simply the reporting from the peripheral nerves to the central nervous system (brain and spinal cord) on the status of the tissues.

There are 3 main kinds of nociceptors:

  1. Thermal (reporting on heat/cold)
  2. Chemical (reporting on chemical irritation, like inflammation)
  3. Mechanical (reporting on tension and compression)

There is always some nociception occuring, that is so our brain knows what’s happening with our body. However, this doesn’t necessarily turn into pain.

When nociception reaches a certain threshold, then the nerves fire faster, which can alert the brain to something happening. It doesn’t mean there is damage – but only that there is more stimulation of those nociceptors.

This only becomes pain, if, when combined with the other inputs mentioned above, your brain decides the information means “danger”.

Acute versus chronic pain

Acute pain is a completely normal response to dangerous stimuli. It usually follows some form of tissue irritation, which may or may not include damage to the tissues.

This is the pain we experience when we bump into something, strain a muscle or cut ourselves. It serves a protective purpose – alerting us to the incident and getting us to change our behaviour accordingly, so we do no further harm. It usually subsides when healing has taken place – often before (think of a cut, it doesn’t hurt all the time, only in the beginning).

For some people, pain does not resolve after the acute phase, and it becomes chronic pain, which is a problem in and of itself.

Chronic pain occurs due to changes in the nervous system, which make it more sensitive.

Whilst too deep a topic to cover in a short section, the most important thing to grasp about chronic pain is that the longer it has been present, the less correlation there is with tissue damage, and the more sensitive the nervous system has become.

Chronic pain is manageable, but it needs a very different approach to acute pain.

Conclusions

Pain can be thought of as an alarm bell. A highly sensitive alarm bell that often rings for no reason and sometimes keeps ringing despite people cutting of its power supply.

Understanding the complexity underpinning the pain experience is an important step to resolving or managing pain, and one that pays long term dividends.

This post can only touch on the basics of pain, but it is enough to give you an overview of the main components.

 

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

Burke, S.R., et al, A profile of osteopathic practice in Australia 2010-11: a cross sectional survey, BMC Musculoskeletal Disorders 2013, 14:227 [http://www.biomedcentral.com/1471-2474/14/227]

Louw, A., et al,  The effect of neuroscience education on pain, disability, anxiety and stress in chronic musculoskeletal pain, Arch Physical Med Rehabilil, 2011 Dec;92(12):2041-56 [http://www.ncbi.nlm.nih.gov/pubmed/22133255]

Melzack, R. and Katz, J. (2013), Pain. WIREs Cogn Sci, 4: 1–15. doi: 10.1002/wcs.1201