Does How You Think About Your Pain Affect Your Pain?

Low back pain (LBP) is extremely common, and is globally ranked as the leading cause of disability in adults (1). LBP is often a source of confusion for healthcare practitioners and patients alike. Where is the pain coming from? Is there a serious issue that needs to be addressed? Fortunately, bouts of pain often resolve on their own with time and appropriate behavioral responses, and the majority of time do not represent a serious underlying pathology. However, too often back pain becomes a chronic problem that begins to impart major impacts on one’s comfort, quality of life, and mobility.

Chronic LBP should be investigated through a biopsychosocial lens, as it is a multifactorial issue that cannot be reduced to one cause. (See our previous blog, A Holistic Approach to Pain Science) There are many factors that can influence the cycle of chronic pain, and among them are cognitive factors- how we think about the pain. How we think about our pain affects how we react and respond to the pain, both on a physiological and a behavioral level. The meaning we assign to our pain can either act as fuel to the fire of chronic pain, or water to dampen its rage.

A danger alarm gone awry

Oftentimes, when it comes to chronic LBP, the bark is worse than the bite. Pain can be considered as a “danger” signal from our nervous system that is indicative of a threat to our safety. However, when pain becomes chronic, part of the problem is in the sensitivity of the danger alarm itself, rather than only issues in the tissues. In chronic pain, learning has time to occur, and this learning is not always helpful. The nervous system begins to amplify pain signals associated with certain activities, and we begin to avoid certain activities, thereby weakening or changing the physical structures that must be used during these activities, creating a negative feedback loop that is consistent with disabling chronic LBP (2).

Consider a home smoke detector.  Can you recall the last time you were cooking, and perhaps had the heat just a little too high for a little too long? Tendrils of smoke begin to float up from the pan, and the next thing you know, the smoke alarm is blaring at full blast, causing you to drop everything, turn off the stove, turn on the fan, open the windows, and apologize to your neighbors. While house fires exist and are a huge threat, there was no fire in this case, and the smoke alarm might have caused more of an inconvenience than the smoke itself. Now, imagine that each time this happened, the “sensitivity” dial of the smoke detector turned up just a little bit, the volume of the alarm got a little louder, or perhaps the detector itself somehow started getting closer and closer to the stove. These changes would be maladaptive, and would lead to more situations in which your eardrums get pierced, stress hormones flood your system, and your neighbors start to question your sanity. You might even begin to avoid cooking. Or perhaps you take a more active approach and call a mechanic to help fix some of the issues you are having with the detector. 

Cycles of chronic pain can behave in a similar way. Your brain’s pain “alarm” can change overtime, becoming hypersensitive to lower levels of pain input (known as hyperalgesia), or respond by generating pain in situations where normally there would not be pain (known as allodynia). This nervous system plasticity that occurs with chronic pain is known as central sensitization, which is a well-researched phenomenon within pain neuroscience (3). We know that the brain is plastic, and we can learn fear, amplified pain responses, and unhelpful appraisals of our pain. We can also unlearn these maladaptive changes, and begin to relearn safety, comfort, and control. 

Changing Your Response to Pain

Amplifications of this danger alarm can occur if we believe that our pain is indicative of severe threats. These beliefs can stem from previous encounters with health care providers, uninformed health messages from society (e.g. our spine is a weak, vulnerable structure), and can even root back to childhood and one’s parent’s responses to pain. If we believe that our pain is not within our control to change, it is more likely to persist.

Try to be with your pain, feeling into it at that exact moment. What is the little person in the control center (your nervous system) trying to communicate? Show your nervous system there is no danger by finding a comfortable, safe environment, slow down your breathing, and engage in some gentle movement of the tissues that are contributing to the distress. Comfort, joy, safety, and pleasure are the opposites of pain, fear, and danger. The sooner you can get yourself into this place, the more likely the smoke alarm will turn off and you will reestablish a state of tranquility. 

Asking For Help

In order to make significant, lasting changes to chronic pain, therapeutic interventions are required that we provide at the Wellness Station. A multifactorial, individualized approach is warranted in which bio, psycho, and social issues are addressed. We strive to provide informed care where we can see the intersection between mind and body, the psychological and the structural. Dysfunctional movement patterns are what we look for, and are reflective of protective tension, fear-avoidant behavior, and muscular weaknesses. These patterns may be detected in the way you walk, breathe, bend, reach, turn over in bed, and more. They can also be detected through passive movement, in which we as the therapist move you while you intend to stay relaxed and not help. Addressing these movement patterns are key to bridging the gap between issues in the mind and in the tissues, and will help you make lasting changes in your ability to change and respond to your cycles of pain. While pain is part of being human and it is not realistic to be “pain free”, we can move towards our pain being the occasional pebble thrown into a pond with quickly fading ripples, rather than constant boulders creating tidal waves.

Written by Jacob Tyson, DPT - Physical Therapist, Yoga Instructor and The Wellness Station Team

References:

1. Vos T, Flaxman AD, Naghavi M et al.. Years lived with disability (YLDs) for 1160 sequelae of 289 diseases and injuries 1990–2010: a systematic analysis for the Global Burden of Disease Study 2010. The Lancet. 2012;380:2163–2196. 

2. O'Sullivan PB, Caneiro JP, O'Keeffe M, Smith A, Dankaerts W, Fersum K, O'Sullivan K. Cognitive Functional Therapy: An Integrated Behavioral Approach for the Targeted Management of Disabling Low Back Pain. Phys Ther. 2018 May 1;98(5):408-423. doi: 10.1093/ptj/pzy022. Erratum in: Phys Ther. 2018 Oct 1;98(10):903. PMID: 29669082; PMCID: PMC6037069. 

3. Latremoliere A, Woolf CJ. Central sensitization: a generator of pain hypersensitivity by central neural plasticity. J Pain. 2009 Sep;10(9):895-926. doi: 10.1016/j.jpain.2009.06.012. PMID: 19712899; PMCID: PMC2750819.

Images:

1. https://www.google.com/url?sa=i&url=https%3A%2F%2Fonlinelibrary.wiley.com%2Fdoi%2F10.1111%2Fjabr.12125&psig=AOvVaw1JHcqoPV34D_evHNqFIGOP&ust=1676907126933000&source=images&cd=vfe&ved=0CA8QjRxqFwoTCNCv9P7zof0CFQAAAAAdAAAAABA8 

2. https://www.google.com/search?rlz=1C9BKJA_enUS933US933&hl=en-US&sxsrf=AJOqlzWV_WK2FOcZC4qGZmRvZWSM8YYdWw:1676301748365&q=danger+alarm&tbm=isch&sa=X&ved=2ahUKEwivlf3R5pL9AhUcGFkFHQDBDmIQ0pQJegQIHhAB&biw=1366&bih=905&dpr=2#imgrc=AwpaQLmgKUDIqM 

3. https://encrypted-tbn0.gstatic.com/images?q=tbn:ANd9GcQBzpLWrips6ax-khNB59gPoCtJ8A7E4qshPw&usqp=CAU 

4. https://www.google.com/search?q=a+pebble+in+the+pond+with+ripples&rlz=1C9BKJA_enUS933US933&oq=a+pebble+in+the+pond+with+ripples&aqs=chrome..69i57j0i512l3j46i512l2j0i512j46i512j0i512j46i512.3906j0j4&hl=en-US&sourceid=chrome-mobile&ie=UTF-8#imgrc=1JB3ecM7OTxY7M 

Your Spine is Not “Out of Alignment” - A Holistic Approach to Pain Science

Have you ever been to a practitioner who assured you that the cause of your pain was one of the following, or some combination of these very technical sounding terms? “Your ____ (spine, hips, etc) is out of alignment.” “Your pelvis is twisted.” “Your SI joint is jammed.” “Your pain is because of your leg length discrepancy.” The list goes on and on.

These types of claims are not helpful, and can be downright destructive due to the nocebo effect.

First of all, joints don’t go “out”. If your joint was dislocated, it would be a medical emergency that you would be well aware of, and warrant a trip to the ER. Additionally, structural explanations for pain (aside from acute pain due to tissue injury) are generally unsupported by evidence. These claims (e.g. joints being “out”) have extremely low interrater reliability, meaning two different clinicians would almost never agree on them.(1)

By teaching people that these minor asymmetries are “serious”, clinicians are over-medicalizing normal human conditions. We all have asymmetries, and we do not have good evidence that asymmetries will lead to pain and dysfunction. By believing that your pain is structural, it is taking you out of the healing equation, and will consciously or subconsciously rely on external sources for healing, including surgeries, injections, and frequent chiropractic adjustments. 

Fortunately, the human body is not like a car. Because issues as complex as pain are not due typically due to structure alone, they typically do not require a structural solution. Unlike a car, the human organism has a nervous system, an immune system, and higher consciousness that allows us to think, feel, move, make decisions, and change our beliefs and behaviors. It may be convenient for some clinicians to blame structural issues as a scapegoat, as it can be easier and quicker to explain than the other contributing factors, and can also be an effective business model. Also, many patients may also be looking for some structural issue to blame, as it can be extremely frustrating and distressing to be in pain for a long time and not understand why. However, it is crucial for clinicians to educate patients on the real causes of pain, and move away from teaching people the body is a machine that breaks down, inevitably leading to pain. We need to lean in to educating people on the messier science, including physiology, neuroscience, psychology, as well as social and lifestyle factors. 

The truth is, pain is multifactorial. Sometimes it is very simple, sometimes it is extremely complex. Simple cases tend to be acute- you stub your toe, the nociceptors (pain receptors) fire, your brain registers the sensation as pain, and you say “Ow!”. However, chronic pain is a different beast. After pain persists and the initial injury is gone, brain changes tend to be what keeps the pain cycle alive. Our nervous system can get a bit confused, and the helpful pain perceiving pathways can start to run awry. We begin to get overly sensitive to stimuli that normally wouldn’t cause pain (known as allodynia), and perceive that pain is more intense than we normally would (hyperalgesia). It is very hard to turn that sensitivity back down, and it requires neuroplasticity (brain change). 

So how do we change our brain to affect our pain? We have to address pain biopsychosocially, meaning we address the biology, the psychology, as well as social factors.

Biologically (or physiologically), we rehabilitate the physical body through movement and exercise, improving efficiency of movement, decreasing unnecessary tension, and improving fitness. This might mean gradually desensitizing our body to painful movements or activities. We also want to make sure we are sleeping well, eating healthful foods, staying hydrated, and being very mindful regarding consumption of certain substances.

To address psychology, we must challenge our beliefs, improve our mental health, find appropriate coping mechanisms for stress, and change our relationship to our pain to become less reactive and more responsive.

To address the social factors, we have to make sure we are surrounding ourselves with the right people, participating in activities that bring us joy, and seeking support rather than battling with pain alone. 

Hopefully, this path to healing does not seem overwhelming. By addressing these biopsychosocial factors, we can take control of our lives and make decisions that better ourselves and improve our quality of life. We can take an active role in our own healing, and won’t be as reliant on expensive and harmful procedures. While the healing journey is not linear and will come with challenges, it is the direction to go for all of us, with and without chronic pain. 

It is our job at the Wellness Station to take the role as educator, detective, and coach. We strive to teach you about the science of pain, figure out the greatest contributor factors, and provide guidance, encouragement and support as you begin or continue your healing journey.

References:

1. https://www.painscience.com/articles/structuralism.php

Written by Jacob Tyson, DPT - Physical Therapist, Yoga Instructor and The Wellness Station Team

The Power of Belief: Saying No to Nocebo

As the fields of cognitive science, psychology, and new biology continue to develop, the scientific community is beginning to understand more about just how powerful our beliefs are. The way we think affects our behaviors, our mood, our perceptions, and even the way we move and experience pain. Most of us have heard of the placebo effect- this is a beneficial effect that occurs after a particular stimulus that cannot be directly attributed to the stimulus, but rather to the belief that the stimulus had a positive effect. This occurs due to both expectancy and conditioning. We expect something to happen, perhaps because it has happened for us in the past, or because someone has planted the idea into our heads that something will happen. This expectation has a neurophysiological effect, which activates particular circuits in the brain that will actually contribute to the expected effect.

The specific neurophysiological mechanisms of how thoughts can impact our physiology are not fully understood, partially because our understanding of consciousness is still extremely limited. However, it is clear that our thinking can impact our body. If you have any doubt about how thoughts can impact our physiology, consider this thought experiment. Does imagining yourself biting into a lemon trigger any kind of physical reaction? Why might that be? 

While the placebo effect can certainly be used for good, we must be wary of its dark cousin, the nocebo effect. The opposite of a placebo, nocebo is a stimulus that creates negative expectations that result in negative health outcomes.1 This might be done intentionally, but more often it is an unintentional adverse effect commonly experienced through interactions with healthcare providers. Ever have an experience in receiving imaging (an X-ray, MRI, etc.), and the provider makes a comment such as … “Wow, no wonder you have pain! Your spine is a mess!” Or another favorite, “Geez, your knee is bone-on-bone! I’m surprised you can still walk! Time for a knee replacement…”. After hearing this information, the nocebo effect can occur, and one may actually begin to experience more pain. It can also impact behavior- perhaps by believing that one’s knee is bone on bone and walking should be difficult, one might stop walking as much, or may begin to compensate while walking. This can lead to actual tissue changes such as deconditioning, excessive tension in various muscles, and more. The negative belief that resulted from imaging and the subsequent conversation with the doctor ended up resulting in a greater experience of pain as well as impaired function. 

How can we use the power of belief to support our health and function? For starters, question negative beliefs, whether these are personal beliefs or from someone else. Anyone who receives imaging should be well informed that structural abnormalities found on imaging do not correlate with pain or function. While people with low back pain may have some abnormal findings on their MRIs, so do asymptomatic people.2 If 100 random people were taken off the streets and underwent imaging, there would be plenty of people with abnormal results with no pain, as well as people with crystal clear imaging who are in severe pain. If people attach too much value to their imaging results, they give up on their belief in themselves to get better. “I have stenosis and arthritis in the spine… physical therapy certainly can’t fix that!” Someone who maintains this belief is deciding that their situation is not in their control, and they are less likely to believe that they will get better. They will be less likely to participate in therapy, more likely to experience pain and dysfunction, and may seek more aggressive treatment options. 

In addition to questioning negative beliefs, create your own positive beliefs! Evidence shows that the use of positive affirmations can lead to improved performance, well-being, and more.3 The use of positive affirmations is a prime example of using the placebo effect to trigger positive health outcomes. By changing our beliefs about ourselves, we can change our behavior and function. This can be very helpful for those of us experiencing pain. A simple exercise could be creating several positive affirmations to repeat to yourself morning, afternoon, and night. The affirmations could be phrases that you don’t currently believe, but what you wish your life was more like. For example, consider the following positive affirmation: “I am strong. I am resilient. I am at peace with my body.” For someone experiencing chronic pain, it can be very difficult to experience peace with one’s body. However, having a sense of peace with oneself can have extremely beneficial effects, including downregulating tension in the body and decreasing the affective components of pain. As we continue to repeat these positive affirmations, they will gradually shift our mindset, beliefs, and experience of life. Ever try to force a smile while upset? Similar to the use of positive affirmations, simply smiling will bring about positive changes in mood, as our brain associates the mechanical act of smiling with happiness.

1. https://journals.lww.com/painrpts/fulltext/2017/03000/nocebo_and_pain__an_overview_of_the.2.aspx

   2. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6118107/ 
   

   3. https://www.mindtools.com/pages/article/affirmations.htm

Written by Jacob Tyson, DPT - Physical Therapist, Yoga Instructor and The Wellness Station Team

Osteoporosis and Osteopenia: A Healthy Movement Practice

Are there any special considerations for a movement practice for someone who may be at risk of osteopenia or osteoporosis, or perhaps is already diagnosed with a condition of impaired bone density? 

Absolutely! One size does not fit all when it comes to movement, especially when it comes to protecting the integrity of our bones. At the Wellness Station with our Feldenkrais-inspired approach, it is our job to address osteoporosis and osteopenia with individually-crafted lessons that are unique for every individual. Factors that are important to consider throughout therapy are how to maintain and increase bone density, improve muscular strength and responsiveness, body awareness, and help prevent the risk of a fall or compression fracture.

Here are some key considerations when engaging in yoga or any movement if you are aware that you have decreased bone mineral density:

1. Communicate effectively with your body: 

When we move, we are engaging in a dialogue with our body. We initiate the movement, and it is our job to listen to how our body responds, and modulate our movement based on that response! In other words, what are the subtle signs that we can pick up when we are putting our body through strain? Do we notice when we are doing a forward fold that we feel uncomfortable pressure in our abdomen? Do we notice that the way we pick up a heavy object from the floor causes us to hold our breath and feel a sense of distress? If so, we have to change the way we are moving.

2. Modify movements that put excessive load on the front of the spine or neck of femur: 

The most common osteoporotic fractures are of the front vertebral bones in the low or mid back. Notice in this image the location of the compression fracture is in the front of the spinal bone towards the middle of the back. There are many types of movements that increase load on these bones, such as bending forward at the waist, as well as twisting and turning the body when bent at the waist. When engaging in movement that involves compression of the front spine, consider the load that is going through these bones, and be careful not to push or strain if any discomfort is felt.

Consider a forward fold. Especially if the hamstrings are tight, the spine may become very rounded in this pose, which can put extra load through the front vertebral bodies, especially if we are straining to try to get the hands to the ground.

When modifying your movement practice, consider the intention of the movement, and modify to match the intention but in a safer and more effective way.

The intention of a forward fold is to experience lengthening and relaxation throughout the back of the body, including the hamstrings, gluteals, and muscles of the low back, and the fascia (connective tissue) that runs down the back of our body.

Notice that in this movement sequence, these same intentions are met, but the spine is fully supported by the ground and we are able to move dynamically without increasing the load on the vertebral bodies.

The neck of the femur just below the hip joint is also a common fracture area. Be cautious about poses such as pigeon, as this position subjects that bone to a high amount of load. Many people practice pigeon in a very passive way, which is not helpful for strengthening the bones and the surrounding hip musculature.

Consider these hands and knees variations of pigeon pose. Notice that by performing this “wagging the tail” movement, we are bringing suppleness into the whole spine, and also challenging the weight-bearing leg (the leg that is down on the ground). Notice that “sitting back” into the weight-bearing leg is very similar to the “pigeon” position, but it is a dynamic rather than a passive movement. This challenge can stimulate bone density as well as improve strength and responsiveness of the supportive hip muscles including the gluteals and piriformis.

After you get the hang of wagging your tail, try to make circles! Notice the engagement of the entire body with this dynamic movement pattern.

3. Prioritize extension postures rather than flexion postures

Flexion-based movements such as forward folds are when the spine is bending forward, which puts more compression on the front of the vertebrae. Extension-based movements do the opposite. Also known as backbends in yoga, extension-based postures are very safe for those with bone density loss. Spinal extension helps to reverse the compression on the front of the body, and helps to strengthen the muscles that promote healthy posturing. 

Notice these extension-based movements performed while lying on the belly. This is an excellent way to build strength and awareness of the back side of the body. Notice the balance and stability that is created by performing these diagonal movement patterns  in which the right upper body moves with the left lower body, and vice versa.

4. Challenge your balance with ease and support 

Yoga can be an excellent tool for improving balance, but it is important to be able to maintain stability and ease throughout your standing practice. There is no point in practicing feeling unbalanced, so modify your practice to meet yourself where you are. If you are feeling too challenged and at risk of falling, then this is not doing you any favors. Maintain stability and ease by modifying and using props. My favorite props for balancing poses are the wall, chairs, and even the kitchen counter. By gently contacting one of these props with a hand, we can maintain groundedness, and correct ourselves more easily if we begin to lose our balance.

Notice the use of the wall as a prop to perform this standing side bending and circular movements. This sequence is the same as what we did on hands and knees, but now in a standing position. As balance is a dynamic process, adding movement is more helpful for improving balance compared to holding a static position such as tree pose. Additionally, the weight-bearing leg is being stimulated in a way that will help improve bone density and strength. This is also a great way to warm up the body before further activity such as going on a jog.  

At The Wellness Station, we will help you become aware of habitual movement patterns, yoga poses, and lifestyle factors that may be affecting your bone density and risk of fractures. We will help you develop or modify your movement practice with considerations of your individual needs, medical history, and goals. Every day is an opportunity to get to know your body on a deeper level in order to stay active, healthy, and strong, even with osteoporosis.

Unlearning Fear of Movement

Kinesiophobia, or fear of movement, is an issue that affects far too many of us. Often
times, people with chronic pain or a history of injury to a particular body area will develop a fear of movement. Kinesiophobia can exist on a macro or micro level, affecting both overall physical activity levels, as well as movement of specific joints and patterns of muscular activation. Kinesiophobia is often outside of our conscious control, as the fear circuits of our brain (e.g. the amygdala) are involuntary and affect our movement without us necessarily being aware.

How does this happen? Individuals with kinesiophobia may associate certain activities with pain, as this activity may have caused pain in the past. An activity that is a common trigger is bending down towards the ground, perhaps because this movement may have led to an injury in the past. The internalized association between movement and pain will contribute to fear-avoidant behavior, and the individual will continue to avoid this activity due to fear of pain or re-injury. Over time, even after the original injury heals, the individual will still have this same fear embedded in them and will avoid bending down. Now the motor pathways, muscles, and joints responsible for bending down will atrophy, and it will be far more likely to cause injury if the individual were to bend down in the future! The irony is that the fear is what contributes more so to the dysfunction, rather than an issue in the physical tissues of the body.

What can we do about this?

Because fear is a learned behavior, we must "unlearn" the fear, as well as create new neural pathways that teach us that movement can be safe, easy, and pleasurable. Your physical therapist at the Wellness Station will quickly identify what is contributing to your kinesiophobia. Along with providing education about anatomy, biomechanics, and pain neuroscience, your therapist will teach you how to gradually engage in safe movement patterns that will help you gently progress towards your functional goals. It is important that this process is done slowly and gently, as our brains will not be receptive to learning if fear is still present. The tissues of your body will slowly adapt, and your nervous system will gradually learn that previously feared movement patterns can be safe and even easy.

Written by Jacob Tyson, DPT - Physical Therapist, Yoga Instructor and The Wellness Station Team