Pain - How is it affecting you?
By Jane Wake MSc
I can remember the first time I experienced back pain. I was a personal trainer in my 20's and I was helping some one in a gym with their bench press. They lost control, the weight slipped and I reached to grab it, bending forward and to one side in a sudden movement. I didn't feel pain immediately but over the next few days it multiplied. I went to see a physio who advised I should rest. This was the worse news for me. I couldn't teach, I couldn't work, I couldn't train. My livelihood and more was suddenly taken away from me. I slipped into a big pool of rubbish-ness. I went for a second opinion, seeing an osteopath who clicked and shifted me around, saying this and that was out. "I still had no idea what was wrong. Could it have been a pulled muscle, a torn ligament, God forbid, a 'slipped' disc? The answer was highly unlikely to be any of these, although all were thrown into the conversation, adding to my discomfort and pain. What was the most likely cause? Probably the fact that I was running through in my head "how am I going to work?"
Was that pain genuine pain?
You bet it was - I thought my career was over.
What I was suffering from was non specific back pain. According to the World Health Organisation (d.2020), 619 million of us suffer from lower back pain and that number is likely to increase to 843 million by 2050. 90% of cases are attributed to non specific lower back pain, i.e. we don't know what's causing the pain, or to look at it another way - where we feel the pain is not because that body part is damaged, just where the pain is appearing.
So when I leaned forward to grab the weight, in a movement that was a) uncomfortable, b) something I had been told was 'bad' for me, my body sense danger. I felt pain. This did not mean, as was assumed by myself and every practitioner I saw, I'd damaged tissues in the area where I felt pain. It's far more complex than that.
So where exactly does pain stem from?
Pain is the result of multiple brain processes which can be physical, i.e a signal from 'Nociceptors' - nerve cells in our tissues. When we touch something hot, these cells send a signal via the spinal cord to different areas of the brain such as the Midbrain and Thalamus - our sense of danger is alerted. This is our most primal yet over-riding use for pain. It's how we have evolved. Pain is a danger signal.
Pain however is multifaceted, not only in how it manifests but also in type. It can be acute i.e of short duration, often tissue damage that heals over time. It can be chronic - lasting for 6 months or more, recurring or cyclical. There's also neuropathic pain which is damage or disfunction of the nerves themselves plus radial or referred pain.
There is no one clear structure or classification for pain. Is this because pain just isn't like that? You can't distinguish it? It's a bit of a mish mash?
For years we were taught that there was a root cause, and if we found that root cause and healed it, all would be well. Much of the teaching within exercise is still based on this simple model - you have a pain in your hip, therefore there's probably something going on in your hip that we need to release, strengthen, balance out or align? Often these methods work. I know this, I've helped so many people this way! But do they work because of the specific release, alignment, localised strength given or do they work because of the calm, the reassurance, the confidence and overall strength also gained?
Acute v chronic pain is easier to understand, but chronic pain becomes so complex, hence the term 'non specific lower back pain'. Which sounds a bit vague and nonchalant, as if it's a throw away term of little interest - something for which we don't care. Except we do, because it affects so many of us.
We still don't know the exact mechanisms for pain but we do know that it's by no means a simple physiological response. It can be driven through psychological or environmental or social issues, plus it's connected to our endocrine & immune as well as nervous systems.
A recent study (May 2023) from University of California (UC) has taken new steps to look more deeply into the brain, in relation to chronic pain. The study was very small but included someone experiencing so called 'Phantom' pain, e.g pain where a limb no longer existed. By implanting electrodes in the brain they found, in response to chronic pain, activity was centred in the orbitofrontal cortex.
It seems we are still learning much about the orbitofrontal cortex's role. Amongst many other things, it's been linked to our somatosensory system. This is our conscious perception of touch, pressure, pain, temperature, position, movement and vibration. It's also been linked to our reward value, mood and emotions and could play a key role in understanding depression. What I find most fascinating is this link to reward value, belief and self esteem. What has this got to do with our pain? I have no idea! And I don't even pretend to vaguely understand the neuroscience behind all of this. But it does make me question it. Whether you are a looking at this as a practitioner who is working to help people with their pain or, if you are suffering from pain, that self efficacy, i.e. our belief in ourselves is as important to work on as our tissue healing, inflammation, neuropathy and strength .
It's complex! Even the experts don't know everything and new research, like the above, is emerging all the time. This is not because this area is particularly understudied. It's because it's so vast! And it just reiterates how wonderfully complex and amazing we all are.
I have worked with many people suffering from chronic pain who have been advised to exercise. They are often looking for answers, have gone through numerous treatments and seen high level consultants. Nothing is working or at least not permanently. Even nerve treatment that desensitises or removes the nerve connection thats creating the pain, so in theory the signal is removed, doesn't always eliminate the pain, or at least not permanently.
This tells us something quite amazing about how it all works . Our nervous system has plasticity. It can rewire or change from one moment in time to the next.
As much as this means it can create more pain signals, doesn't that also mean it could go the other way? Think of it like a volume switch - what if, when it gets dialled up, we have tools up our sleeve to dial it right back down?
I'm also fascinated by the link to memory which is well cited in literature. Whenever I have had back pain, it comes back in that same place I experienced it in my 20's. I can describe the exact point to you right now! If my initial pain had been tissue damage, e.g. a sprain/tear in muscles, ligaments, a disc bulge, research tells us that these tissues commonly heal in 3 - 6 months. So when pain re-occurs in the same area, is it really the same? The phrase often repeated, "My back has gone again!" Suggest to us that there is tissue damage - but is there? Perhaps there is some kind of weakness or vulnerability? Is this our brains way of telling us to be careful? It's something I always suggest to clients to be conscious of and to act positively with. In this instance - could we see this as a positive form of pain?
Whilst this is all quite complex, when we understand the matrix of that complexity, just that, just knowing that your body has this pain response - that it's real, it exists, it's your unique map of everything thats going on from hormone to immune system to muscle response and every reaction and interaction in between and that with that map comes more understanding, tools and solutions...
... Is there not something calming in that?
You better believe it! Research shows that when you understand the science of pain, you get less pain!
Language is important also. We live in a medicalised environment built on language that is often misogynistic and/or based on practises that pre date modern pain science. Being conscious and aware of this, discussing and being open about it can have a positive impact on our pain.
I am constantly fascinated by my neurodivergent children who are as different to each other as they are to me in how they react and respond. With one child I have to communicate via text, the other with voice messages. Their body language varies to mine as it does to each other. Can I learn to understand and respond better to each of them? Yes I can! Pain is another form of communication. It's unique to us and it is totally something you can learn to understand.
So what can we hold onto in all this?
Perhaps that should read - So what can we let go of? May be it's a little bit of both?! This new piece of research from UC I think sheds light. When you look at how the brain controls how we remember and react to certain things and how totally unique that is, we can start to think about what that means for us as individuals. What I Iove about it is that it's so unique to you. You are the only one who can truly understand it, and by the nature of that, it means YOU hold the key! This is powerful stuff.
There is a simple example right here in this article. Look at the picture at the top of the gymnasts. How does that picture make you feel? What is your response to it? Does it make you wince? Smile? Perhaps trigger a pain response? Can we train ourselves to respond differently? Yes we can.
You are not alone in all this. There are plenty of people who can help and support you. Looking at therapies such as CBT is one way in which you can do this. Most of the exercise programmes I provide offer mentoring. That's not to say we talk more than we move, but that element of what we do is an important part of your journey. I have always felt that my role as a trainer/coach has been as much about the mental side of your movement as it has the physical. The reason I have introduced mentoring sessions is because I feel that element has been lost in much of the online training now being provided. .
There is a wonderful book that I have recently read called 'Pain is Really Strange', by Steve Haines. It's written like a graphic novel and so easy to read - you can read it in a matter of minutes, yet it's jammed packed with useful information that's all backed up by research. Haines, through some wonderful pictures and statements, is able to explain the many processes of how pain works. There is a style and sensitivity to the book that makes you feel grounded - a feeling that everything is going to be ok.
"Pain is so much more than signals of danger from tissues. It is also much more than blocked emotions and belief systems - in fact the experience of pain can depend on anything that can effect you" (Haines)
So where does exercise come into all of this? There is plenty of research to show how movement can help with our pain but its results are not nearly as effective as when they are combined with other factors that consider us as a whole. There is a big focus on psychological considerations, social and environment as well as physical. Pilates and Yoga are often cited as magic pills that will rid you of pain. The research however doesn't side with any one movement. Let's just think about that individual pain matrix. How can one form of movement or set of exercises work for all? There are key elements to consider - mindful focuses, language, how the movement is taught, environment and social factors. All of these come into what makes movement work when it comes to pain. If you are a movement leader, your fluidity in being able to incorporate all this is how you help people - not by using a set of movement rules or particular exercise methodology.
Pain is weird! It's our own form of quirkiness! But learning to understand it is really can mean you don't have to live with it quite as much as you have.
Jane Wake is a health and fitness leader with 35 years experience specialising in women's health. She has a Master of Science degree in Sports Management. Her research focused on the sociological implications of exercise provision for women.
References;
Pain Is Really Strange by Steven Haines https://amzn.eu/d/2Li3mEq