With all the uncertainty in the world, this months blog takes a broader view of health and wellness. I hope you get some value out of it and would appreciate any feedback in the comments section below.
Warning !
Pain can be coming from a red flag sign - things like a broken bone, inflammatory arthritis, cancer or organ disease.
Please ensure you have a full and thorough examination with your doctor and continue to follow up if your symptoms have not improved or don’t make sense to you.
Another warning….
This blog is very long.
It could well have been a short book.
And I did consider dividing into 3 parts.
But in the age of Netflix binging, I decided to keep it as one long one.
Up to you if you want to read all in one go or break it up a bit.
The 1 Minute Summary:
you may be noticing more pain than usual lately since the COVID pandemic
pain is related to the perceived threat of tissue damage, not actual tissue damage
once a threshold of perceived threat is reached, pain is produced
perceived threat can come from physical, mental and emotional sources
just understanding and becoming aware of this process can be enough remove a significant part of your stress response and keep you under the threshold of pain
Who this blog is for:
Full disclosure, this blog isn’t for everyone.
But,
If you are someone who:
experiences ongoing pain flare-ups and confused as to why
experiences ongoing widespread muscle tension e.g. neck, back, jaw, hip flexors
you’ve tried every stretch under the sun, and continually still feel tight
had a thorough medical screening with your GP with no sign of any red flags
is curious to learn the about the deep causes of ongoing pain and want to empower yourself with knowledge
previously had a severe episode of pain and want to learn how to avoid in the future
has seen many health care professionals over the years and only ever get short term relief from your symptoms
has ongoing headaches, and especially if related to monthly cycles
Then please read on, the following information may help you steer back in the right direction.
One more thing…
**As usual, this blog is for general information purposes and everything written below may not apply to your situation. If you have any specific questions, please talk with your health care professional for more specific advice.
Why you might be feeling more niggles than ever
…(grab yourself a cuppa!)
My road to learning about more about pain
In 1997 I began studying Physiotherapy at the University of South Australia (yes…feeling a little old right now!).
Since then, my interest in the human body has grown exponentially. One thing I can say for sure is that we are incredibly well designed creatures.
The way everything works in harmony most of the time, without our awareness is a genuine miracle.
If you ponder the billions of processes that are going on to keep us healthy and alive, it really is amazing.
“There are two ways to live your life. One is as though nothing is a miracle. The other is as though everything is a miracle.”
It’s quite the humbling feeling when, the more you learn and experience, the more you realize how much you don’t know in the vast scheme of things.
“Sell your cleverness and purchase bewilderment”
And this thing we experience called pain is an amazing, complex and curious feeling that can help protect us from many dangers.
The feeling of curiosity about what is actually happening in your body can evoke a life changing journey of transformation.
Townsville
I am so old, this picture was taken in black and white!
My first job in private practice was up in Townsville.
I loved the work and thrived on the adventurous outdoors lifestyle, spending the weekends exploring the North QLD region.
I also meet lots of cool people - one of the them ended up being my wife!
Starting out in private practice is a steep learning curve for most Physio’s.
The undergraduate degree has a very broad education, so there is a lot to learn in your special area of interest after you graduate.
Back in the day, the teaching was mainly centered on a biomedical medical that focused on the tissues. I studyied at UniSA, where Geoff Maitland’s model of care, (based on manual therapy) was considered best practice.
I loved turning up to work everyday… and thank-fully most of my patients seemed to get better.
But there was a certain percentage of people who I wasn’t able to help (or even made worse).
People presenting with ongoing, complex pain made me feel completely out of my depth.
I felt frustrated and confused. This led me on a journey to learning more specifically about pain.
At the 2008 Australian Physiotherapy Conference in Cairns, I vividly remember plonking myself down in the audience, near the front of the stage, for the keynote speech on Day 1.
Lorimer Mosely was them first speaker and in under an hour was able to blow us away with his new and exciting on research about pain and how we can best serve our patients.
In then attended David Butler’s Explain Course at the Adelaide NOI headquarters. Again - some career changing information I learnt and helped give me the tools to have better understand complex pain presentations.
NOI headquarters in Adelaide, South Australia - one of the coolest Physio clinics you will ever visit
In 2019, I was fortunate to hear Lorimer speak again at the Physio Conference in Adelaide and it was great to hear him reflect on the journey of explaining pain - the highs and lows which I’ll touch more on later.
The things I have learnt about pain have changed the way I approach Physiotherapy - and provided a greater understanding of how the nervous system processes injury, disease and pain.
But it’s also helped me personally when I’ve had various pain episodes over the years.
This blog post is an attempt to articulate some key messages about pain to help you.
Full disclosure
Our current current scientific understanding of pain doesn’t have all the answers.
I certainly don’t either.
In fact I am a huge skeptic and critically analyse all information that is out there.
Nonetheless, we have to act on a certain level of uncertainty, based on the best current available evidence.
I will be regularly updating this blog, as relevant comes to light, so feel free to check back here regularly.
The current problem with pain
1 in 5 people live with persistent pain.
Less than 10% get the help they need to recover.
Aside from the staggering numbers, chronic pain has a visceral affect on our daily lives, in the form of lost social connections, missed days work, inability to play with grand-children and reduced physical and mental vitality.
Ongoing pain creates uncertainty about the future and can lead to increased feelings of anxiety and depression.
So then, where does Physio fit in?
When you have ongoing pain, it is confusing to know who you are supposed to go and see.
There are lot’s of options -
GP
Physio
Chiro, Osteo, Acpuncturist, Massage therapist
Psychologist
Pain specialist
Yoga, pilates, personal trainer e.t.c.
To make things even more complex, when you go and see a Physio, there is no standard specialty training for helping people with persistent pain.
Which means that each individual Physio has their own unique interests, biases and approach.
Essentially there are three main areas of Physiotherapy focus:
manual therapy
strength and conditioning
education / pain science evidence based
Nowadays, many Physios have a specific focus on only one of these specialties, meaning that you may not be getting the most appropriate approach for your individual needs. If you’ve this blog before, you would see I’ve written about manual therapy/dry needing and building capacity.
So this blog post is focused squarely in the education section…so here we go…
Top down vs bottom up
Education could be considered a ‘top-down’ approach, compared with addressing the tissues directly with manual therapy and exercise - that would be considered a ‘bottom up’ approach.
Like with anything, if we can address an issue from multiple perspectives, we can usually reach a better outcome.
Learning about pain is so important because our mindset can be a powerful contributor to our experience.
“Accurate knowledge is the greatest pain and stress liberator”
Most of us have around 60,000-80,000 thoughts per day (less if you follow Port Power 🤣 ).
If you are carrying around inaccurate or outdated beliefs, you may be carting a lot of unnecessary baggage, without even realizing it.
Carrying around unhelpful beliefs can really start to wear you down after awhile!
I am sensitive to your current beliefs and this blog is attempt to become more explicit in expressing some of the concepts I’ve been trying to make sense over the past 20 years.
Pain is always a very personal experience.
It’s always real.
Talking about contributing factors to pain can be one of the most difficult conversations and challenging topics to address, without being disrespectful or condescending.
When beliefs are challenged, one of the first reactions is to put up a wall of defense.
When you’ve had pain for long enough (and nothing else has worked) sometimes this can force us into becoming a bit more open to hearing about new concepts.
If you’re able to read, digest and reflect on some of the concepts presented, and see how they fit into your own life, I would be really happy with that outcome.
Ultimately, you know your body best…trust and have faith in it.
“Absorb what is useful, reject what is useless, add what is essentially your own” - Bruce Lee
Know pain, know gain
A basic knowledge and understanding about pain is something I believe everyone should have.
In particular, it is much better to know about pain before you have an episode of pain.
As once you’re in the eye of the storm it can be difficult to find your way out sometimes.
“Everybody has a plan until they get punched in the mouth”
Studies have shown it’s really hard to learn when you’re in pain, stressed and anxious - not really the ideal situation to learn about important topics like pain.
Understanding pain changes how we experience pain.
Knowing about pain changes how we think about it, talk about it and ultimately how we go about treating it.
When learning takes place at a deep level, you can feel a lot more confident in your ability to handle all of the challenges that life throws at you.
Letting go of the war on pain
One thing needs clarification from the outset.
Pain is a normal and (mostly) rational experience.
It’s an important motivator that gets our attention and helps us to act to protect ourselves.
People who don’t experience pain can end of doing damage to their bodies…not ideal!
So the first step in healing is to fully accept your pain.
Your body is well meaning and is always trying to protect you, but as we’ll find out, sometimes it can be a little over-protective.
Fighting your pain only increases stress and anxiety and puts you at war with yourself.
So please be kind, gentle and patient with yourself.
We are powerful healing machines
Take a moment to think about the last time you cut your finger.
For me it was just last week, slicing a piece of salmon as I was about to throw it on the grill.
It was a deep cut. Luckily my wife was close by and she was able to get a band-aid and strap it up nice and tight.
Without ever thinking about it, three days later - I took the band-aid off.
The deep cut in my finger had completely healed.
If you stop and think just for a moment how amazing our bodies are at healing.
There are powerful processes working day and night to effectively heal us when we injure ourselves.
Injuries can take various lengths of time to heal, but generally 3-6 months is the longest it takes to fully heal (see table below).
We are incredibly resilient creatures
As more research is being done, we are finding out that our bodies are incredibly resilient.
Something I find fascinating is that we can have all manner of structural and degenerative changes in our bodies and not ever know about it, because it never registers as a painful feeling.
For example, the picture below shows the percentage of people who went in for an MRI scan of their body and were found to have structural issues - but absolutely no pain.
For example:
43% of adults aged over 40 have signs of knee osteoarthritis on MRI but have no pain
19% have a tear in the knee meniscus and have no pain
87% of people have some form of disc bulge with no pain
96% of us have shoulder abnormalities and have no pain
68% have hip labral tears and have no pain
This indicates that many of these features—particularly when found incidentally — should not be considered pathological and instead be regarded as normal age-related changes.
Another study showed degenerative disc disease was found in 40% of Olympians in the 2016 Rio Olympics.
But how could people with so many structural issues be able to perform at the highest level, and not feel any significant pain?
I am fascinated by this question, and the rest of this blog will explore in more detail.
We’ll giving you some practical examples and also dive into some philosophical talk.
Like in the movie The Matrix, I’m about to give you the red pill.
Grab yourself a stiff drink…you will need it!
Assuming you’ve seen The Matrix?
Old school thinking
Our old way of thinking involves a direct linear relationship between tissue damage and pain.
But this line of thinking is not fully accurate.
Our experience of pain is way more complex than that.
In fact, the longer your pain is present, the weaker the relationship with the tissues.
Here are true stories to get you thinking…
Some curious stories about pain
There was a story published in the British Medical Journal about a man working on a construction site.
He had an unfortunate accident where a nail ended up going straight through his boot.
Understandably he felt incredible pain and was rushed to the emergency department.
He was in a world of agony and required intravenous sedation.
The interesting thing was once the doctors pulled off his boot, they discovered the nail had passed right between his toes - and there was absolutely no damage at all.
The man’s agonizing pain was elicited solely by his thoughts about what had happened.
Another story…
My kidney stone
Back in 2014 my wife and I were living in New York City, I was getting a lot of ongoing back pain. My doctor decided to order an MRI.
On the report, the MRI showed a likely kidney stone that was around 10mm in diameter. They suggested a follow-up ultrasound to confirm.
Unfortunately I was traveling the following week, so I had to wait until I was back to get the ultrasound.
Let me tell you, that was one of the longest and most uncomfortable weeks of my life!
Being relatively young and healthy, I wasn’t too sure what the deal was with kidney stones and so I jumped on ‘dr google’.
I was horrified….
According to all reports, to pass a kidney stone was likely be an extremely painful process.
And my only other memory of kidney stones is when Kramer had one in Seinfeld.
I used to lie awake at night doing more research and scaring myself half to death. The thing that really concerned me was, how could this happen to someone so young?
I was confused, scared, angry and in a hell of a lot of pain.
The the follow-up ultrasound came around.
Good news the sonographer said.
“There is no kidney stone”.
Upon reviewing the scan, another doctor pointed out that the object they thought was a kidney stone turned out to simply be a knot in the gown I was wearing.
What do these stories tell us?
You can have pain without a tissue injury
The point here is you can experience full blown pain without any form of tissue damage.
The reason for this is that pain is not an accurate measure of tissue damage.
In fact it would be more accurate to say pain is a measure of threat of damage.
For example, violinists who injure their fingers are more likely to feel pain than non-violinists because they feel threatened their livelihood is at stake.
Phantom limb pain
Another interesting example of feeling pain without tissue damage is a thing called ‘phantom limb pain’.
In this case, people with amputations can feel severe pain in a limb that is not even there.
This gives us a very clear message that pain is a product of our nervous systems, not the tissues themselves.
On the other hand,
You can sustain an severe injury, and feel zero pain
Have you ever discovered a bruise or a cut that you didn’t feel?
This is the most common example of experiencing tissue damage without pain.
Nail in the head - a true story
This report in the USA Today mentioned a construction worker who had unknowingly shot himself in the head with a nail gun (see pic below).
Somehow, he was unaware of the injury and thought it was just a toothache.
He presented to a dentist (6 days later!), where the cause of the ‘toothache’ was discovered.
Other examples of when, despite serious tissue damage, there is no feeling of pain:
1989 footy grand final - Dermot Brereton getting hit in the opening seconds, sustaining 2 broken ribs, a bruised kidney and internal bleeding and managing to play on and kick 2 goals.
These stories fascinate me - examples of people undergoing severe stress and reporting no pain whatsoever.
With the above stories I hope I have convinced you that the relationship between pain and tissue damage is shaky, especially the longer you’ve been in pain.
I’d love to know…do you have a story that show pain and damage aren’t always linked?
I’d love to your story in the comments below.
The biology of pain is never really straightforward, even when it appears to be
As pain persists, is thought more to do with a sensitive nervous system than the tissues themselves (see graph below).
“The longer the pain persists, the weaker the relationship between tissue damage and pain intensity”
How the nervous system really works
Before we any further, I’d like you to take a look at the image below.
What do you see?
Are the circles REALLY moving? Look a little closer!!
If you are like most people, you can see the circles moving.
But when you look closely, this is an optical illusion and there is actually no movement happening.
This is an example of our brains making extremely quick decisions, based on the their perception of what is going on.
The brain is right to a certain extent - its reality is spinning circles.
But can you see how our brain can create an experience that isn’t actually there?
Some more examples:
How many circles do you see?
Pain and our nervous systems - Perception becomes reality
In these above visual examples, our brains take the information coming in from the eyes and then creates a story out of it (the visual illusion) in a split second, beyond our conscious awareness.
The human brain is essentially an anticipation machine.
In chronic pain (that has persisted more than 6 months), this be a part of what happens.
The brain receives information from the bodily tissues, and creates the feeling of pain, based on the perception of threat in an instant in order to protect us.
The pain you feel ultimately comes back down to the amount of perceived of threat.
Beyond our conscious awareness, our nervous systems weigh up all of the credible evidence for safety and credible evidence for danger and makes a decision about whether to produce pain.
Persistent pain (beyond normal healing times) is an example of our brains perceiving and creating a reality that isn’t 100% accurate.
I would like to stress at this point, that pain is always real, but it is not always directly correlated to the damaged tissue. Rather it is a reflection of a heightened state of sensitivity in your system.
For optimal healing, you need a balance of sympathetic and para-sympathetic time
Sensation vs Perception
Our brains are continually receiving millions of sensations from our internal structures such as muscles, tendons, nerves and skin e.t.c.
Thankfully, 99% of the time, we aren’t aware of these sensations.
Importantly, we can have structural issues such as joint degeneration, tight muscles, cuts, bruises, disc bulges and nerve compression that are all feeding sensation back in the spinal cord and brain, and we don’t have any idea about them.
Here is where it gets interesting!
At the level of the spinal cord, there is a switch that can amplify the sensations coming into the brain.
What amplifies our sensation is dependent on the state of our nervous system.
And by nervous system, we are specifically referring to the autonomic nervous system that is made up of the sympathetic (fight or flight) and para-sympathetic (rest and digest).
When our sympathetic nervous system is activated to certain threshold - we feel an amplification of the incoming sensation - that is often felt as the feeling of pain (see picture below).
When our nervous systems are in a calm state - we will most likely still feel some pain from an injury.
But you would perceive it as a mild sensation, without fearing it and gradually return to normal life fairly quickly.
But when we our fight or flight system has been triggered, we can become more fearful of the pain, stop moving and become de-conditioned quickly.
If we get a scan early on after our injury, we can easily attach our pain to structural changes on our scans. Obviously this is very important for acute, traumatic injuries, but for persistent pain the lines becomes blurred.
It can sometimes be very hard to ‘un-see’ a scan and erase this pattern of negative belief about our bodies being damaged, vulnerable and weak.
Sensitive Alarms
To understand chronic pain more simply, think of a house with a security alarm set up.
After the house was burgled a few months ago, the owners decided to set the alarm’s sensitivity to high so they could detect an intruder.
Instead of an intruder though, every time the wind blew strongly it would - setting off the alarm system.
The owners woke up to the alarm and prepared for a ‘fight-flight’ situation.
But each time the alarm went off, they didn’t find anything wrong.
After an injury, the body is biologically wired to act like a sensitive alarm system - magnifying small normal niggles.
This is a normal and healthy protective response.
For some people though, while the original injury can heal (normally taking no longer than 3-6 months), this protective response (highly sensitive alarm system) can remain in place indefinitely.
This can lead to overwhelming sense of anxiety and fear, that can turn into a downward spiral of inactivity, de-conditioning and eventually more pain.
Pain spiral
Fearing structural damage can lead to a fear of movement, as every movement hurts.
Lack of movement leads to reduced blood flow.
This can lead to an imbalance in neuro-transmitters (no pain relieving endorphins) which can make you feel pretty lousy.
De-conditioning sets in quickly and it can lead to a loss of confidence.
A spiral is created and can sometimes spin out of control.
Some people turn to stronger and stronger medications that can help short-term, but long term have quite adverse outcomes.
A scary but very real documentary about the addiction to opioids can be viewed here (warning - footage is disturbing).
OK, we’ve introduced some rather heavy concepts, let’s lighten things up a little…
Have you ever felt ‘hangry’?
At the 2019 Australian Physio Conference, Dr Tasha Stanton gave the example of what happnes when you get cut off in traffic.
In normal circumstances, you will feel a bit peeved off, but brush it off pretty quickly.
But if you haven’t eaten for a few hours and you’re ‘hangry’ (hungry + angry) then all of sudden you really lose your temper and find yourself revved up for the rest of the drive home.
Obviously you’re not a bad person when you’re hangry.
It’s just that your system is on edge and sometimes a small trigger can make us explode.
The feeling of pain is much the same.
So back to our original question - why do some people feel pain in the presence of normal degenerative changes and others do not?
We know that it’s not the age-related changes in bodies that is the real issue.
An initial injury may have sparked a spot fire, but in people with ongoing pain, it is differences in their physiology (over-active sympathetic nervous system) that fuels the the raging fire.
The modifying factor is the state of the nervous system.
And ultimately, things hurt more when you aren’t sure if you’re safe.
What triggers the sympathetic nervous system?
The brain is constantly monitoring the internal and external environment for signs of danger.
The sympathetic nervous system becomes activated when the sum of the perceived threats reaches a certain threshold.
So what could be increasing perceived threat?
This is where it gets really interesting (see graph below).
Never forget this picture!
An overflowing bath tub
Imagine a bath tub that is full to the brim with water (your current life stress).
Then you add a bit of water that makes the bath overflow.
In terms of pain, the extra bit of water may have been a minor injury such as picking up something off the floor or sitting in the wrong chair. The underlying issues have been building up and often it’s the straw the breaks the camel’s back.
Unfortunately though many of us get distracted by the extra bit of water, rather than seeing the bigger picture of the underlying issues that may have been building up over months or years.
Our perceived stresses all add up
Sometimes it’s lots of small perceived stresses that add up or it can be one very large one.
Below are some examples of things that can activate the stress response.
Please be aware that uncovering some of your stresses may bring about some unwanted negative mental states. If feel you like need some support, please speak with your GP or call Lifeline on 13 11 14
Physical stress
over-exercising causing an injury
lack of movement - sitting too much
sudden spikes in training load (too much or too little) can freak out the tendons - they hate change
inadequate nutrition (lack of protein, carbohydrates or skipping meals causing low blood sugar)
other nutritional deficiencies
ill fitting clothing or equipment e.g. wearing overly worn or unsupportive footwear
poor sleep is known to decrease pain threshold
anemia
taking medications such as opioids (can cause a long-term increase in pain)
smoking
inadequate core stability - the nervous system will perceive this a potential threat and tighten up your muscles instead
poor aerobic capacity
sub-optimal gut bacteria colony
auto-immune dysfucntion
Mental stress
feeling anxious about an injury - fear of doing more damage
confusion of diagnosis - many different opinions leading to fear and anxiety about what is going on
consulting Google with a minor niggle, and freaking yourself out with all of the extreme things that it could be
scan findings not given in context (giving you the false belief that faulty structures are the cause of your pain). It is important to talk with your health care provider about the difference between a serious pathological change on scan vs a age-related change
being told your hips are out of alignment or your ‘spine is out’ making you feel fragile and afraid - unfortunately there is a word for this and it’s called a ‘nocebo’. Be careful who you listen to. Well meaning clinicians can unknowingly set you up to fear moving your body.
being told be a health care professional to strictly avoid certain movements e.g. never sit relaxed in a slump position. This can lead to constant ‘over-protective’ behaviour such as sitting up straight rigidly, overloading the muscles in the back
fear your current injuries will get worse as you get older
Lorimer Mosley at the 2019 APA conference was humble enough to admit the attempt to educate people on pain can back-fire e.g. after hearing a pain science education talk, a man was heard to say despondingly, “the disease has got into my brain now”. Not an ideal outcome at all. Words are extremely powerful and the stories we tell ourselves can have a huge impact on the quality of our lives
over-worked - no time to hear the messages your body is trying to communicate
no down-time
caring for young children or elderly parents
parent or friend who had a similar injury and you’re worried about ending up in the same boat
personality traits - e.g. perfectionism, type A personality, people pleaser, stoic, anxious, low self-esteem
going on holidays - have you ever noticed your niggles seem to go away when you have a break from all of your daily stresses?
Emotional stress
Lack of social connection
poor quality relationships
passing of a loved one
divorce
etc
Our ancient biology
We must remember our history and that our nervous systems are ancient.
We have bodies and minds that have evolved over 2 million years and have been shaped by the natural environment.
Imagine our human ancestors being plonked into our modern world and the stresses that are placed on them.
As Daniel Liebermann explains in his book, The Story of the Human Body, there is a mismatch between what our DNA is designed for and how we live our lives. It is not hard to be overwhelmed with stress and tension that presents itself in many different ways.
The rapid and severe changes in our environment in the past 200 years have no doubt made our lives more livable.
But that has come at a cost of increased stress on our nervous systems:
technology all pervasive
increased work, lack of connection with nature
highly competitive capitalistic society
convenience of cars, elevators e.t.c meaning we are generally less active
junk food and many toxic chemicals in our environment
All of these add a tax of load that must factor into the equation as to why we have a chronic pain epidemic going on in our society.
We have to over-ride our instincts here and know even like it looks like the circles are moving, they are not.
When it comes to pain, everything matters
Pain can become persistent because perceived threats can often lurk in hard to find places.
Even memories can trigger a stress response.
For more info, I would encourage to read the excellent book, The Protectometer.
Let’s take a pause for a moment…
How are you feeling? Please take a moment to reflect and write down anything you have learned.
I know it’s a lot to take in.
We are on the home stretch, I promise…
deep breaths!
Why you are feeling more pain during COVID
Back to the point of this blog - the current situation with COVID is increasing our perceived threat levels to a huge degree, sensitizing our nervous systems so that mild niggles turn into more intrusive pain.
In terms of COVID, it’s not hard to see how we have had a spike in perceived stress and threats which may include:
social restrictions - not seeing friends and family
financial hardship and job insecurity
relationship stress - higher divorce rates
24 hours alarmist news cycles
constant adaptation to new changes in our lives
fear of becoming seriously ill with a virus we can’t see
One study suggests the number of people displaying symptoms of anxiety, stress and depression in the community have risen between 13 and 21 per cent, while the other finds roughly one person in every five is now experiencing clinically-relevant depression symptoms.
Going back to our graph our above, we can see that this additional block of perceived stress puts our nervous systems ‘on edge’.
You can see how our normal niggles can re-appear, even if we haven’t changed anything else.
And if you happen to sustain a new injury, there is a chance you will be feel more pain than usual.
Let’s take a look at one of the biggest perceived threats that have come about since the COVID lockdown…
People feel more pain when they are feeling lonely
“To the brain, social pain feels a lot like physical pain”
Social connection is huge, and many of us have had to socially isolate for extended periods of time.
Studies have shown social isolation sets off responses in the body linked to survival tactics from thousands of years ago, proving that our bodies perceive loneliness as a life or death situation.
Having strong social bonds is as good for you as quitting smoking.
Connecting with other people, even in the most basic ways, also makes you happier—especially when you know they need your help.
Social connections are as important to our survival and flourishing as the need for food, safety, and shelter.
“To be kept in solitude is to be kept in pain”
Other medical perspectives
When we look at some traditional medical perspectives, they can seem like they had this stuff figured out a long time ago.
For example, in Ayurvedic medicine which is 2000 years old, it is thought the nervous system correlates with the vata dosha being out of balance.
According to this research paper, the vata dosha correlates with fear, anxiety and pain.
Ayurveda links a healthy vata dosha with functions governing basic survival and homeostasis.
If you are unfamiliar with ayurveda, I would recommend you investigate some more, as it can be very interesting to see the body from a very holistic perspective. There’s a great book, Ayurveda and the mind, written by Dr David Frawley.
Becoming aware of when you are in sympathetic dominant state:
Signs of increased sympathetic activation can include:
widespread, ongoing pain and muscle tightness
jaw clenching
neck and back pain with no relief from treatment
inability to feel relaxed
upper chest breathing, fast and shallow breaths or holding breath sub-consciously
poor sleep - waking during the night and having trouble getting back to sleep
IBS, immune related issues
typical emotions in the early stages —> stressed, nervous and anxious
typical emotions in the latter stages —> depression, mood swings, irritability, anger, frustration
social withdrawal
fatigue, memory changes, poor concentration, brain fog
core and glute muscles stabilisers become inhibited
tinnitus, vertigo and poor balance
Is there more to pain than damage?
Our nervous systems are originally wired to equate pain with tissue damage.
Think about when you are very young and first touch a hot surface - your nervous system reacts with a split second spasm to protect you.
From an early age, the nervous system is conditioned to think there is a direct link between tissue damage and pain.
So it can come as a surprise to learn that the pain you feel is often not due to tissue damage.
Here are three examples:
Muscles
This is a big topic, and will be a the subject of a future blog, so I will be brief here…
The muscle system is the largest single organ in the body and measures around 50% of our body weight.
When we’re in a sympathetic dominant state, our muscles are prepared to ‘fight or flight’.
We have 2 types of muscles:
the fight / flight muscles that become full of tension preparing for battle. These would include the traps, hip flexors, lower back, ITB, jaw, pecs, SCM
the deep stabilisers that aren’t really important in an emergency such as the deep core muscles, glutes and shoulder stabilisers tend to become inhibited
When our fight or flight muscles are contracted for ongoing periods of time (e.g. when the sympathetic system is continually being activated), then they start to tighten up and remain tight.
This eventually leads to a lack of blood flow and oxygen that sensitizes the muscle and can quickly lead to a spiral and pain and tightness.
Muscle tightness can be very painful, but it is completely harmless, as there is no structural damage, only a decrease in blood flow and oxygen, causing the pain.
“Pain from the muscles is an often neglected but major cause of pain and dysfunction in the largest organ of our body ”
Professor Janda originally proposed the theory of crossed syndromes (see below).
Diagnosis of muscular imbalances can follow basic patterns such as above.
But everyone has their unique movement signature, based on all of the subtle (and not so subtle) muscle system's reactions to injury, pain and activities over their lifetime.
A personalised assessment is the fastest way find about your particular patterns and get on the road to transfomation.
Inflammation
Inflammation around joints - especially the knees, ankles and shoulders can be a very common cause of pain.
It is quite amazing, even if you’ve had knee pain for some time, if you are able to decrease the inflammation by using ice and compression around the joint how you decrease the amount of pain your are in.
Stiffness / lack of blood flow
The belief that you are structurally broken or somehow defective lies at the heart of the chronic pain sufferer.
No wonder why you would be afraid to move, if every time you believe you might be somehow contributing to more structural damage.
Unfortunately not moving enough leads to stiffness in the muscles and joints.
And if you do decide to start moving again, it’s probably not going to be a very fun experience.
And most importantly not moving because of fear sends a strong message to your nervous system that you have to be even more careful and I mentioned already a spiral can develop.
Lack of blood flow means reduced oxygen to the muscles, nerves, organs and brain.
Getting moving again
One of the most powerful things you can do if you are in pain is to get creative and find a way to get moving.
The WHO recommends 30-60 mins of aerobic exercise / movement per day and this would be an excellent goal to gradually build towards.
It doesn’t matter what body part is affected.
There is always a way you get moving to get some blood flowing (and here is where you might need the guidance here of an experienced physio to help you choose an appropriate activity).
Here is where some appropriate guidance around pain during activity comes in handy.
Some people expect to feel no pain ever, and that can be a huge barrier to return to normal.
As you’re getting back into some activity after a break, we expect you to feel some niggles as the muscles and joints kick back into gear.
Using a traffic light analogy can be helpful:
RED LIGHT: STOP / ADJUST 7-10 pain level (0-10 scale). Danger zone. Potentially damaging to tissues and delay rehab. Pain can persist after you stop for hours, days or weeks. Get checked out immediately with health care professional.
ORANGE LIGHT: CAUTION - SLOW DOWN - MONITOR 4-7 pain level during activity (0-10 scale). Often done too much, too soon. Monitor the 24 hour response and if symptoms worse you may need to adjust intensity or volume. If no increase in symptoms over 24 hours, continue the course. Be prepared to use flare-up plan e.g. ice, rest, physio. Stay positive as entering this zone means you are making progress. Avoid negative words and thoughts.
GREEN LIGHT: CONTINUE 0-3 pain level (0-10 scale). Normal everyday niggles during activity. No worse over the 24 hour period. Safe to continue or gradually increase load.
Endorphins
As you increase your activity levels (with hopefully something you enjoy - with friends and perhaps some cheesy motivational music on spotify), all of a sudden you get a surge of endorphins.
Eye of the tiger…CRANK it!!!
Endorphins are your happy hormones and are actually much stronger than opioid medication (without the side effects).
Access your endorphins also helps to burn away the stress hormones such as cortisol and adrenaline that can keep you in a state of fight / flight.
There is hope
Here’s the thing - once you understand your pain, you can remove a large chunk of stress. And in an instant put you under the threshold of experiencing pain.
Confusion about your symptoms can cause a lot of fear, anxiety and stress.
Receiving an adequate explanation for why you hurt can instill emotions such as understanding, acceptance and clarity.
Where to from home - 3 key take away messages:
Understand that our experience of pain is gloriously complex and involves many systems, not just purely injured body parts. The context of injury is important as well as what you think, feel, say and what you do in your environment
Identify all the perceived stresses your life and deal with them as best you can. Sometimes it can be overwhelming when we initially learn about all of the stresses. Be patient with yourself and seek guidance - there is support out there.
Most importantly, just becoming aware of your stresses and how they impact your pain levels can decrease the perceived threats and get you out of a chronic pain state.
It’s the perceived threats that are living in hard to find places that can do you the most harm. These are often best explored with an experienced clinician with experience in this area.
With guidance from your Physio, gradually increase the physical activity you are doing - WHO recommends 30-60 mins of aerobic exercise daily and x 2 strength sessions per week. This will help keep your body moving, fit and healthy.
“Respect pain, don’t fear pain”
Pain and the nervous system
The curious thing is just becoming aware of how your nervous system works and knowing that you are structurally OK can help get you our of a chronic pain state.
Sure, identifying all of your perceived stresses and trying to do something about them can help.
But quite often we can’t do much about our daily stressors- for example if you parents to new children or caring for elderly parents, or in a stressful work situation everyday.
So you don’t have to get rid of them - just knowing about the real source of your pain and knowing that you are safe to move is important.
Here’s where a well rounded doctor and physio can work with you as part of your support team to properly educate you and gradually get you moving again to re-build your confidence and capacity.
There’s an old saying, “Whatever doesn’t kill us makes us stronger”.
We’re never going to be completely stress free.
But as long as we are aware of what is really going on, the pain we feel can have less power of us and most importantly still allow us to pursue our strongest values in life.
I want to stress again the importance of getting yourself fully checked out and examined for any red flag signs if you have any ongoing symptoms.
Damaged tissues are an important part of the story, but it’s not the full story.
In summary our old definition of pain might sound something like this:
“Pain is a distressing feeling often caused by a damaging stimuli”
And our new definition more like this:
“Pain is not a sensory signal or marker of tissue state, but an inference based on many factors - a feeling produced by the brain to make you take protective action”.
The purpose of pain is protection of tissues, not detection of tissue damage.
When you can ‘re-think’ your pain, you can re-engage with high value activities such as building physical capacity.
Then you can get a genuine sense that recovery is back on the table.
I am hoping you’ve found this blog useful and possibly even had a few ‘aha’ moments.
Congratulations if you made it this far, I know I tend to ramble and not make much sense sometimes.
In all fairness, most of this has been written in short bursts in the time of COVID lock down with 2
(slightly crazy) toddlers running around the place.
If you have any questions or concerns, please leave them in the comments below, I’d love to hear from you.
Part 2 of this blog will look at other strategies to help calm a sensitive nervous system.
Recommended reading
Can the vagus nerve serve as biomarker for vata dosha activity?
