Understanding Pain When Dealing With Injuries

THIS ARTICLE IS SCHEDULED FOR AN UPDATE IN JAN 2017


 

There are two main components that need to be addressed when dealing with pain.

One is the physical aspect of rehabilitation, and the other is the psychological aspect of healing. The latter for most people depends on the extent of the injury, if it impairs them from activities or sports they enjoy, and how long the injury has been present.

We will talk about these two aspects especially in dealing with the concept of pain and how it should be cared for in rehabilitation.

This is a semi-excerpt from the upcoming bodyweight strength training book.

The physical aspect of rehabilitation

There are two prevailing popular methods of thought out there in regards to common injuries. The first I am sure that everyone know is “no pain no gain.” While this applies great to aspects of training such as metabolic conditioning, it does not scale well with injuries. The other line of thought is rest, rest, and more rest. While rest is good it depends on what kind of rest is implemented. Often the truth is somewhere between each of these two lines of thought.

Let’s take a step back and look at movement in general. Why is it so good for us?

I think the most underused example is the use of mobility in the context of how good it is for our joints. Take for instance the fact that hip replacement is becoming extremely common in the United States. Joint replacements occur because our joints become “unhealthy” in that they start to develop arthritis and other painful maladies.

The main occupational thing that has become prevalent with people working jobs in the US is desk work. That is to say that people are sitting down 8+ hours per day and not moving their hips at all. When you compare this to Asian cultures such as the Japanese who eat on low tables and have to constantly get up off of the floor to use their hip joints you see a remarkable contrast in the amount of hip replacements between the ethinicities.


Hip replacement rates // Photo from this study: http://ard.bmj.com/content/62/3/222/suppl/DC1

Anyone can tell you that what happens when you break a bone and you are put in a cast that your muscles start to atrophy, joints start to become stiff, and your connective tissues become weaker. The same thing occurs with self imposed semi-restrictions such as with padded shoes (akin to soft casts), and restrictions just imposed by working such as sitting. This is why I have much on this topic.

Movement in general is good for our joints, connective tissues, and muscles. We always want to be moving our injuries – albeit non-painfully – because that helps to start to loosen up tight muscles, get the blood flowing to the area, etc.

When you stub your toe or hurt your finger the first thing you do is move and take it to its full range of motion as possible. As long as it doesn’t hurt more the movement and other rubbing that we do helps to tell our nervous systems that everything is relatively fine, and it does not need to impose any restrictions on movement or dial up our pain sensations to prohibit us from potentially damaging the tissues more.

However, we are taught that we generally should not be moving other injuries and it is definitely detrimental to our overall health. Do not get me wrong there is some times where movement restriction is necessary such as after surgery or where the pain is made worse by movement and a doctor should be checking you out but these are more rare cases and you will tend to know when these cases present themselves because you will probably be going to the emergency room.

Regardless, if I were to put a number on it I would say that movement and/or exercise in general should be used in healing about 90-95% of injuries. Ice, heat, anti-inflammatories, ultrasound, e-stim, etc. are all well and good, but most of the time they are not needed (or can be used in the context of helping speeding healing in some cases).

I don’t think I have to elaborate on why pushing through pain is a bad idea. Our bodies have pain to tell us when we are damaging things. If you want to make an injury worse the best thing to do is push through pain. There are some exceptions, but generally they should only be done under a qualified medical professional or physical therapist during rehabilitation.

Gate control theory

If you are having issues is pain soft tissue work and non-painful mobility work is extremely important. One of the major factors in eliminating pain is the gate control theory of pain. The gate control theory of pain shows us how to help dull down the pain so the body can heal itself better.


Gate control theory of pain. Photo from health.howstuffworks.com

All of the fibers under ‘gate control’ are sensory afferents from the skin, muscles, ligaments, and joints. The large fibers specifically are the ones that travel fastest – alpha and beta fibers (Ia and II, and Ib respectively) – in humans these are golgi tendon organs and muscle spindles. The small fibers tend to be smaller afferents responsible for nociceptive (pain) input including Adelta and C fibers.

The theory goes that stimulation of the large alpha and beta fibers can interfere and help dull the body’s sense of pain from the smaller delta and C fibers. What stimulates alpha and beta fibers? That’s right: soft tissue work and movement.

Many people have probably experienced this phenomena but did not know it. Have you ever injured yourself during exercise? For instance, possibly a skinned shin during a deadlift or clean and jerk? Or you were running and hit a limb or toe on something but it didn’t hurt? Or been so hyped up for something that you did not feel the pain such as in a fight or flight situation?

Since there is so much feedback from the faster fibers from movement and/or exercise or total body sympathetic response it literally drowns out the pain fiber sensations that are sent to the brain. And you don’t feel any pain.

Edit: Thanks to Anoop for referring to Neuromatrix theory of pain which expounds upon Gate control theory while integrating more sensory, processing, and output modalities. See the above PDF for a bit more details if you are interested.

Like with programming you don’t need to understand a more complex model if it is not applicable to your specific case(s) so understanding the simple model is fine in some instances.

How much is too much?

Generally, movement is good as long as the pain, inflammation, swelling, are improving or at least staying neutral. Most of the time if you are focused on movement or mobilizing a joint you should end up feeling better than when you started.

This is important for any stretching, mobility, or prehabilitation work as well.

Acute injuries are a difficult topic to discuss directly which is why you should always talk to your physical therapist about rehabilitation progression and planning.

It is important not to progress too fast as it clear that injured tissues are vulnerable to reinjury more than healthy tissues. However, it is important not to baby injuries such that they lead to functional impairments or compensations that interfere with normal activities or sports.

Any questions during the rehabilitative phase should be addressed to the appropriate health care professional. If they cannot answer your questions then you may want to search for a new one. Although “it depends” may not be the answer you’re looking for which is often the case, but most health professionals if they are good should be able to give you a decent time frame or progressive plan or alternatives if you ask.

The psychological aspect of rehabilitation

Chronic pain also presents an interesting case. After about 3-4+ months most of the damage from injuries are healed. While there may be some restrictions in movement via things such as scar tissue, if there is chronic pain present without damage to the soft tissues why is it still there?

The answer lies in our nervous systems. Our brains can interpret stimuli any way it wants and there are a lot of disorders such as aphasias where our brains incorrectly process what we hear and how we understand and speak out our response. The same is true of chronic pain after injuries.

When it all comes down to it and we have chronic pain after 6 months and it continues we can almost always know that our brains are interpreting almost any sensation or movement that gives feedback to the nervous system as pain.

There are many keys to rehabbing chronic pain, but I think the best approach is the graded response which can be approached from two directions. First, the ‘fear” response (or phobia) psychology where people are gradually introduced to things they fear such as spiders and is continually progressed such that they eventually see that they really have nothing to fear of that. This can be introduced with proper gradation in movements starting from simple movements building up to more complex or greater movements.

The second approach is through somatosensory experience. If we take people through a variety of sensory experiences even near painful and demonstrate that on normal tissues the same near pain or pain response is not normal we can start to get the brain to realize that it is incorrectly interpreting these responses. After all, if someone thinks that even placing a hand on a painful area is going to hurt are they not going to tense up all their muscles and have a fear avoidance reaction of trying to move out of the way at all costs? The key is to introduce the sensory experiences gradually just like with exercise such that we limit the fear/pain/sympathetic responses and help restore proper activity within the nervous system.

I think that both of these techniques (and there are probably others that I do not have time to cover) are very useful in understanding that our bodies are not just based on musculoskeletal factors. We need to understand that movements and developing mobility is actually a combination of neuromuscular and musculoskeletal factors including even some primary neurological factors as well.

After all we know that some people even with hours of stretching can never get any flexibility. Why?

Muscle spindles (gamma motor neurons) govern a muscle’s length. The nervous system controls these fibers. When they are “tightly wound” the muscle does not respond very well to length increases and stays tight.

This can happen for a variety of reasons but the most elucidating is when you have spinal cord injury or stroke. When upper cerebral control is cut off from the spinal cord, the inhibition that the cerebral cortex puts on these gamma motor neurons is lost. Thus, they become overactive and the muscles tend to get extremely tight and hypertonic. You can this in the synergistic patterns where the a lot of the flexors tighten up and the arms, legs, and body start to move into the fetal position as they all start to contract.

I made this point just to say that flexibility and mobility are not just about lengthening the muscles and connective tissues. We have to take into account how the nervous system responds to these exercises.

What to do?

Tough question.

Gate control theory tends to be variable at this point. Sometimes the feedback from the muscle movement activates pain sensations when it should not with chronic pain. Sometimes it helps. If movement HAS pain, but does not increase it then it is generally best to move even if there is pain. It will get better as the body relearns how to sort out the sensations coming from its fibers.

Conditioning or graded response will also work. You have to take these things slowly and introduce the movement back. Preferably as stated before the small amounts of movements and mobility work will only have lower levels of pain or stiffness. However, as the body begins to learn again how to differentiate between them you can increase the movement.

It has been shown in studies that “chronic pain” is less in countries where there is no such thing as time off work or workers compensation. The mindset of the person is very critical to overcoming any type of chronic pain, so you really have to believe that you can do it along with the other protocols.

For a more in depth discussion of some of these concepts see Anoop’s article on pain here. I honestly do not see this as a revolution (in his words) at least in the injuries world, but information is not as widespread as other types of treatment and application for acute injuries.

Also, here is an interesting article from Todd Hargrove on how taping can help with pain and/or injuries. Theory behind it is similar to gate control on the effects of movement.

Author: Steven Low

Steven Low, author of Overcoming Gravity: A Systematic Approach to Gymnastics and Bodyweight Strength (Second Edition), is a former gymnast who has performed with and coached the exhibitional gymnastics troupe, Gymkana. Steven has a Bachelor of Science in Biochemistry from the University of Maryland College Park, and his Doctorate of Physical Therapy from the University of Maryland Baltimore. Steven is a Senior trainer for Dragon Door’s Progressive Calisthenics Certification (PCC). He has also spent thousands of hours independently researching the scientific foundations of health, fitness and nutrition and is able to provide many insights into practical care for injuries. His training is varied and intense with a focus on gymnastics, parkour, rock climbing, and sprinting.