Coping With Chronic Pain During Exercise : Understanding What It Is, And How To Get Better
I have chronic pain. I have fixed physical pain that has lasted for more than three months. It comes and goes. Some days are moderately annoying while some days are mind-numbingly distracting. Generally pain continuing after 3 months signifies you're in a persistent or chronic pain state. So what's the deal?
Back Story
My low back, after an acute injury surfing, (the initial flare up days before was potentially sparked by barbell RDL's 2 weeks prior), was in daily pain for 1.5 years and would flare up during any lumbar-flexion based activities. Anything that required me to bend down hurt like heck! Now the activities I loved (and that kept me healthy physically and mentally) were off the table. Things like mountain biking, surfing, and even sitting in class.
...PS... Now we know bio-mechanics don't often explain lifting injuries, but don't neglect graded exposure when it comes to putting weight on the bar in your exercise programming. The bro's can laugh at your measly deadlift total, but you're doing the right thing. Too much too soon is a good recipe to throw your body out of homeostasis. This book is a great introduction to the topic of allostasis. There's a decent chance lifting too much too soon caused this little mishap and sparked the subsequent chronic pain.
My shoulder has also been hurting on and off for close to four years, with some days being better than others. I landed on it after falling 10 ft down and casing a road gap on my downhill mountain bike 2 years ago, but first started noticing pain during college water polo.
While an MRI may have been appropriate right after the injury, I didn't feel it necessary. A potential rotator cuff tear, impingement, and the like via MRI don't often adequately explain chronic pain. Check this article out to learn more.
Nocebos Inhibiting Well Being
The precipice and my wanting to write this story is what I heard from a variety of health professionals as explanations for my pain. I had more nocebos given to me than I could shake a stick at. With the ultimate narrative being; something is wrong with you. I thought I was broken. And when you feel your body is broken, your mind can quickly follow suit. I became depressed, anxious, and was having a hard time coping with life.
Nocebo: a detrimental effect on health produced by psychological or psychosomatic factors such as negative expectations of treatment or prognosis.
Nocebos Given by Authority Figures are Strong
As a personal trainer with a passion for rehabilitation and injury prevention (I was physical therapy school bound), I was/am just about sick to death of the PT/DPT/LMT/DC/ATC/MD gurus giving out bio-mechanical “fixes” and explanations that are supposed to make your pain go away. Why is that? Read this.
When someone says you are in need of fixing, that means something about you is broken. It seems the treatment plans for acute vs chronic musculoskeletal issues have gone off the rails. This issue has been outlined in the BJSM article 'Is it time to reframe how we care for people with non-traumatic musculoskeletal pain?' When an acute injury occurs, say a fracture, the bone generally needs to be put back in place. Chronic pain doesn't work like that.
These "fixes" don't really do anything but undermine your self efficacy and autonomy. When you throw off your basic psychological needs:
1) Autonomy
2) Self Efficacy
3) Purpose/Relatedness
You may run the risk of increasing your chances for psychological issues which have the potential to reinforce your pain.
Evidence Based Medicine and the Quick Fix Mentality
To quote Dr. Alf Nachemson “ I've been studying low back pain for 50 years. If anyone tells you they know where its coming from, they're full of shit.”
A study in the BJSM just showed no benefits in shoulder labrum surgery as compared to placebo for type two slap lesions. Rotator Cuff surgery has been shown to be ineffective against placebo for years now. So has surgery increasing the amount of space that the rotator cuff can move between the ac joint, also known as subacromial decompression.
Lumbar surgeries are no longer recommended for herniated disks by NICE; neither are injections. This is due to the large amounts of the human population that have herniated disks and are asymptomatic. Yet these are highly prescribed surgeries that are supposed to fix the bio-mechanical root cause of pain. Why then does pain still persists? Even stranger, why does sham surgery end up resolving the issue?
Dr Baraki in his article titles 'Aches and Pains' explains, "We carefully watch people move as though they were robots, looking for the “bolt” that’s loose, the “screw” that might be a bit too tight, or the “alignment” that’s just a bit off. Unfortunately when it comes to pain, this sort of rigid mechanical analysis doesn’t always lead to a satisfying outcome in musculoskeletal diagnosis."
Pain is highly complex nuerobiology that involves many different factors. Your pain probably can't be fixed quickly because there is no singular fix. There are many different biological, psychological, and sociological factors intertwined that are creating an issue.
So the exercise the guru prescribed won't work, besides placebo or regression to the mean, because there's no structural foundation for diagnosis that said exercise could be interacting with. And the surgery won't work, besides placebo or regression to the mean, because the bio-mechanical structure is not the root cause of the pain. Dr. Hanscom has some interesting thoughts on the topic here.
What to Do?
1) Your first line of defense is to seek out a qualified medical professional who is up to date on pain science. These clinicians seem to be few and far between, but they're out there. A good healthcare provider is educated to take special time to educate you on your issues to make sure you maintain your autonomy and control. Gregory Lehman, Ben Cormack, Barbell Medicine, and Logic of Rehab are all good places to start your journey.
2) Increase your locus of control over the situation. Every time you task someone like a health professional to solely interact with your problem you are undermining your self efficacy, autonomy, and sense of control. As best you can, you want to personally feel in control of your destiny. Painscience.com is a good place to start the journey toward increasing your control over your pain.
3) For me, since I didn't feel there were any significant red flags, I needed to stop my catastrophizing. This can also be grouped in with a pessimistic explanatory style. The stories I was telling myself in my head were very pessimistic:
Make sure you're not doing this. You're not broken, you're not going to feel like this forever; everything is going to be okay. Just take one proactive step at a time and adopt an optimistic explanatory style.
I really enjoyed Flourish by Martin Seligman (and all his other books) and The Upward Spiral to help me understand depression (there-by increasing my locus of control) to effectively wage war on it.
4) Pain involves psychological and sociological factors as well. So my next step was to check in with myself mentally. Turns out things weren't going very well, and to this day I check in with a psychologist once or twice a month to better manage my anxiety and depression. Chronic pain correlates well with these types of issues, and while it's not all in your head; taking care of one issue can be important for addressing the whole.
5) How are you sleeping? Rough guidelines for sleep say you should get 7-8 hours of sleep, averaging out at 7:20 hours a night.
Another issue here, particularly if you wake up feeling tired or snore, is sleep apnea. Sleep apnea can increase your risk for cardiovascular disease, weight gain, and psychological issues. If you don't wake up feeling rested, and already have good sleep hygiene, check in with a sleep doctor. Anecdotally, poor sleep is what correlates best to my chronic pain. Once more, these issues aren't causal but they can be related.
6) Keep Exercising. Now I'm biased, but the research is clear that the development of strength is one the most important physiological factors you can develop and maintain through your lifespan. Strong people live longer - 'Muscular strength as a strong predictor of mortality: A narrative review.' .
If you have physician clearance from a doctor who understands pain science, you should be getting strong with barbells by squatting, deadlifting, pressing, benching, with some added accessory work and conditioning specified towards your goals.
Don't let anyone tell you that you shouldn't be getting strong due to the fact that you could possibly re-injure yourself. No one deserves to be relegated to corrective exercises the rest of their life. Corrective exercises are misused, often ineffective, and nocebo laden wastes of precious time. Read 'The Corrective Exercise Trap'.
Find a trainer that can guide you through this process and can properly program and coach. No exercise equipment or modality is inherently bad, but barbells are certainly the easiest to master and most effective. A trainer's main job should be to get you strong and conditioned safely, question them when they talk about flexibility, mobility, or stability. Make sure a trainer or clinician isn't wasting your time.
7) What does your social life look like? For any chronic issue make sure you are seeking a lot of social support, even if you feel like isolating yourself. Isolating yourself can feel like the best route when you're feeling bad, but it can be the wrong choice when dealing with chronic pain.
Moving Forward with Chronic Issues
I feel blessed to say that after 4 years my pain doesn't give me too many issues. Although when dealing with chronic issues, like pain, like depression, like anxiety - you always have to be ready for another occurrence.
Now you could explain this in a way where you feel bound to your afflictions and cursed, but I see the unique gifts that pain can give you. Without pain there is no struggle and without struggle there is no growth. So while my pain hurts me physically and psychologically, it is always there to teach valuable lessons.
As the stoic philosopher Seneca, has said, "I judge you unfortunate because you have never lived through misfortune. You have passed through life without an opponent - no one can ever know what you are capable of, not even you."
Best of luck with all your opponents,
Jesse
