Central Sensitization, Chronic Pain, Favorites, Pain Neurophysiology Education, Pain Science, physical therapy, Treatment Approaches

The core message of pain neurophysiology education

In the traditional model of physical therapy, the physical therapist prescribes stretches and exercises for the patient in order to improve function in one part of his or her body.

For example, if you have back pain, your PT will probably give you strengthening exercises to build up the muscles in your back and your core.  If you have a knee injury, she’ll  probably give you exercises to strengthen the muscles around the knee.  This is why when most of us picture physical therapy, we imagine a patient grunting and sweating in a gym while the therapist looks on.

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Pain neurophysiology education, however, draws from a different treatment model.  This model is not based on the idea that the patient’s pain is coming an injury in one specific part of the body.  Instead, it targets the sensitized nervous system directly as a source of pain.

The best way I can try to describe this is with graphs.  The first graph below shows the way most people imagine pain to work.  It also shows what most physical therapists are imagining when they prescribe stretches and exercises to improve a patient’s function:

acute pain graph

You can see how, as the intensity of the injury diminishes (represented by the black line) the intensity of the pain diminishes as well (represented by the red line).  This matches our experience of pain in most minor situations: getting a tooth drilled, pulling out a splinter.  When the stimulus goes away, the pain goes away.

However, in situations involving chronic pain (generally defined as a painful experience that lasts for at least two to three months) the pain response works differently.  Prolonged exposure to a painful stimulus actually produces changes in how a person’s nervous system works.  It’s as if it sets off a feedback loop in which pain signals continue to be produced independently of the level of injury.  For this reason, pain persists even after the initial injury has healed:

chronic pain graph 2

This second graph is an accurate representation of the state I was in when I was first introduced to pain neurophysiology education by my physical therapist Tim.  I had a very high level of pain, but it was not correlated with a high level of injury in my body.  This is why I hadn’t seen much improvement with any of my past physical therapists– my pain was coming from my nervous system, not from a specific injury in my body.

“If pain is the patient’s primary symptom, then pain relief should be the primary goal of treatment.”

I once read something along those lines in a blog comment section, and it really stuck with me.

Most physical therapy programs are designed to improve function of a certain part of the body.  But when your pain isn’t coming from a problem with a certain part of your body, you can stretch and strengthen until the cows come home.  It still won’t change your level of pain.

This is why none of the physical therapists I had seen before had been able to help me.  They were all stuck on the idea that I needed to strengthen my back; strengthen my abs; strengthen everything.  Of course, in some ways they were right.  I wasn’t in the greatest shape.

But what Tim was able to identify is that there was a common denominator behind all of the pain I was experiencing in different parts of my body.  Rather than looking at each one as unrelated, he recognized them as the symptoms of an overactive nervous system, or, as he taught me, body alarm system.

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The goal of PNE is basically to help the patient’s body “remember” what an accurate pain response is supposed to be.  There are a few ways to accomplish this, and I will be discussing them in upcoming posts.  But the general goal of these various techniques is to help the patient’s nervous system get back in touch with with the reality of what’s happening in his or her body.

This graph shows the general goal of treatment:

input to nervous systemThe blue arrows represent the input you want to give to your nervous system.  You’re basically saying to it, “Hey.  Hey you.  You are freaking out for no reason.  This is reality, and it’s over there.”

The role of the physical therapist is basically to help the patient’s nervous system realize it doesn’t need to be on high alert all the time, and to slowly help it calm down.  The idea is that as time goes on, the discrepancy between what the person’s nervous system feels and the actual level of dysfunction in his or her body will slowly shrink.

Now, to be honest, I’m not sure you will ever be able to fully reverse the process of central sensitization.  It’s probably possible, but it hasn’t happened yet for me.  That’s why I didn’t draw the red line going all the way back down to the bottom.  An overactive pain response will always probably be somewhat of a factor for me, but it is a million times better for me now than it used to be.  I’d much rather have the red line close to zero than soaring way up high, totally out of touch with my physical reality.

P.S. I adapted this post from Part 3 of my series on my own patient experience with pain neurophysiology education, entitled “How a physical therapist helped me through my lowest point.”  I’m experimenting with different ways to present information, to find out what works best for people.  Definitely check out that series if you’d like to know more!  I would love to hear any comments or questions you might have.

Photo Credits:

  • Strength training equipment pic: colonnade
  • Balance training equipment pic: kbrookes
Central Sensitization, Chronic Pain, Pain Neurophysiology Education, Pain Science, physical therapy, Treatment Approaches

What is pain neurophysiology education?

In a nutshell, pain neurophysiology education is the type of treatment for chronic pain that changed my life and inspired me to become a physical therapist.

I’ve mentioned it in passing on this blog, but I decided it’s high time I give the topic its own post.

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In my series “How a physical therapist helped me through my lowest point,” you can read the story of how my life had ground to a halt because of chronic pain, until I finally met Tim, a physical therapist who had studied with Neil Pearson.

Tim treated my pain in an entirely different manner than all the physical therapists and doctors I’d seen previously.

He explained to me that after all my body had been through– running 45 miles a week, only to develop compartment syndrome and barely be able to stand, to live like that for two years, and then to undergo surgery– my nervous system had gotten confused.

All the pain doctors hadn’t been able to explain– it wasn’t because I was crazy.

In fact, the reason I was feeling all this pain was because my body was trying to protect me.

My nervous system had decided the world was a dangerous place.  It was tired of me taking chances– it didn’t want to have to deal with another injury.  So it was making everything hurt.  It was making me feel as though I were made of glass.

But I wasn’t made of glass, Tim assured me.  My body was strong; it was capable.  And this attempt on the part of my nervous system to protect me had over-served its purpose.

Tim explained that the surgery I’d had for compartment syndrome had been successful, and despite how much my legs might hurt at times, I wasn’t going to be able to bring it back just by walking down the street.

***

The pain neurophysiology approach worked when nothing else had, because it gave me a real explanation for the pain that actually made sense.

Before that, all the physical therapists I’d seen (and I’d seen a lot) had taken one of two approaches:

A) You have some underlying soft tissue problem or scar tissue or whatnot that we have to fix with a special treatment, or

B) I can’t really find anything wrong with you, so the pain must be in your head and you should probably see a psychologist.

Neither of these approaches ever made a difference for me.  The “special treatments” for the hidden, subtle issues in approach A never fixed anything or reduced my pain (except temporarily, because I felt like I was doing something).  And approach B never fixed anything, because ultimately these problems were not reflective of my overall mental health.

Instead, I learned, my pain was the result of a specific phenomenon that occurs within the nervous system: central sensitization.  Basically, the underlying principle here is that the more practice the nervous system gets at sending signals, the better it will get at sending those signals.  And that is true of pain signals, along with everything else.

***

Tim didn’t really use the words “pain neurophysiology education” while I was seeing him for treatment.  Instead, I first found this phrase while I was looking through Neil Pearson‘s website, as Tim had urged me to do.

From there, I discovered the names of other physical therapists and researchers who had contributed to developing pain neurophysiology education, or PNE as I’ll be referring to it in the future.

Names such as David Butler of the Neuro Orthopedic Institute, and Lorimer Moseley of the research group Body in Mind.

From there I have discovered so many interesting resources, and articles, and interesting people doing work on the subject.

***

For 2017, I’m trying to get back to my roots on this blog.  I started blogging to educate people on the science of chronic pain, and I really enjoy doing that.  So I’m planning to start channeling more energy towards that again.

So I’m going to start fleshing out this section of the blog again.  I’ll be providing a lot more explanations, linking to great resources, and also quoting excerpts from articles that I think explain things really well.

And I’ll be telling my own story, when it comes to my struggle to understand my body, and learning to deal with central sensitization.

***

For now, I want to leave you with two posts I wrote on some of the main concepts I learned through my experience with PNE:

Understanding pain as your body’s alarm system

Understanding pain as an overprotective friend

These posts tie in a couple of anecdotes from Neil Pearson and Lorimer Moseley that I found particularly helpful.  (Let me say, once again, that I am so, so grateful for their work!).

***

I hope you find this post, and the related articles I linked to, to be helpful!  I’m really excited about the things I plan to write about in the future, and I hope you stay tuned!

Treatment Approaches

Breaking up muscle knots, without completely breaking your budget

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Sometimes, there’s nothing like a good massage.  Exercise and stretching are incredibly important, but sometimes you really just need someone to dismantle the knots that have taken over your muscles, and give your body a “reset.”

Unfortunately, if you’re dealing with a chronic condition, the cost of things like massage, acupuncture, and other bodywork can add up quickly.   How you can you pay for these things without completely ruining your budget?

Here are some of the best strategies I’ve learned over the years for using your money as effectively as possible to get the help you need.

*Before booking anywhere, look the place up on Yelp to see if other people had a good experience there.  This is especially true if you’re following my next tip:

*Check websites like Groupon and Living Social.  Many massage therapists post deals on these sites to try to bring in new clients.  I’ve saved a lot of money and met some interesting, helpful people this way.   I’ve also seen people start to post deals for other types of therapies, such as acupuncture and chiropractic.

*Check the massage therapist’s or business’s own website.  A lot of places offer a discount to first-time customers, or a monthly special.  (Many also offer a discount for people who book multiple appointments, but leave that until after you’ve had at least one massage there).

*Check to see if your insurance company will help you pay for massage.   Some companies, at least in the US, will pay for about 15% of the cost of your massage, if you go to someone that’s in-network.

*Ask if there is a sliding scale.  Sometimes people in the helping professions offer a “sliding scale” to those with financial difficulty.  It isn’t something they always advertise, however, since they (quite understandably) don’t want to be taken advantage of.

This is sometimes an awkward conversation, but if it’s the difference between you getting help or not, it can be worth asking.

*Try to find a massage school near you that runs a student clinic.

Massage students have to perform a certain number of hours of massage before they can be licensed.  Most massage schools operate a student clinic where members of the public can come and get a discounted massage performed by a student.

This probably won’t be a spa-like experience.  You might end up sharing a room that has multiple massage tables in it with other people.   But it is a way to get a low-priced massage, without having to book too far in advance.  (Thanks to Jezzybel for this suggestion!).

*See if you can find a physical therapist who specializes in massage. 

Unfortunately, not all physical therapists consider massage to be an important part of treatment.   Some PT’s haven’t had very much training in it.  Others are discouraged from performing massage on patients by the companies they work for because insurance companies do not reimburse as much for massage.  But once in a while, you’ll find a PT who considers massage to be an important part of treatment, and whose place of employment allows him or her to perform it.

I am currently seeing a physical therapist who specializes in massage, and it’s incredibly helpful, convenient, and cost-effective, as my insurance company pays for most of it.  But it took me forever to find her.

Unfortunately, there is no obvious way to find a physical therapist like this.  I would suggest looking for someone who mentions manual therapy or soft tissue release among their techniques.

*Check out Community-Oriented Businesses

I’ve come across a few really awesome places over the years which follow a slightly different model than the traditional spa or health center.

Many of them have had the word “community” in their name, and they place an emphasis on being affordable and accessible to everyone.   These types of places generally offer a sliding scale upfront—everyone pays what they can.

I make it a policy not to post the names of businesses I currently frequent.  (Maybe I’m being paranoid, but the internet freaks me out).

I am, however, comfortable posting the names of businesses in places I no longer live, so here is a place I went for acupuncture when I was in college.  You can check this out as an example of a community-oriented business, and see how it’s a little bit different from other places.

http://amherstcommunityacupuncture.com/welcome.html

Many businesses that follow the community model offer other services, such as massage, counseling, and nutrition therapy.

*Self-Help Techniques for Muscles

Of course, there are plenty of things you can do for yourself to help ease muscle pain and prolong the length of time you are comfortable between appointments (for example: ice packs, heating pads, and self massage with a tennis ball and other tools).  However, there is so much to say about this that it will have to wait for another post!

Thank you to Foundry Park Inn for the use of the above photo!

Healthcare, Interesting Articles, psychology, Treatment Approaches

“Science-based” vs. “evidenced-based” medicine

Over the years, I’ve seen the words “evidence-based” used to justify a lot of concepts I find dubious.  (Trust me– I saw some pretty ridiculous things during the time I worked in a mental health group home).

This article from Paul Ingraham at PainScience.com in favor of moving from evidence-based to science-based medicine was music to my ears.  I realized that, although I hadn’t consciously thought of it in those terms, advocating for that shift has been one of my motivations for working on this blog.

A lot of the treatments for fibromyalgia sufferers might be “evidenced-based,” but that doesn’t mean they shed any real light onto its causes.  For example, an “evidenced-based” course of treatment for someone with chronic pain or fibromyalgia might be cognitive-behavioral therapy.  It’s true that multiple studies have shown CBT to be helpful for patients with these conditions.

However, I don’t believe it’s reasonable to infer that because CBT has been shown to benefit fibromyalgia patients, those patients must have had an underlying psychological problem in the first place which contributed to their fibromyalgia.

To me, that’s confounding variables.

It makes perfect sense that someone with chronic health problems is going to appreciate having a sympathetic person sit with them, listen to them, and teach them new coping strategies.  However, this does not mean that fibromyalgia or related conditions are caused by depression or anxiety.  It simply means that therapy helps patients feel better.

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What I try to do on this blog is to present the scientific evidence in favor of what I’m arguing.  That’s why I am always linking to academic articles.  Even though I know people don’t always have time to read them, it’s important to me that the citation is there.

It blows my mind that there are still practicing medical professionals out there who are unaware of all the research that has been done on the complexities of the nervous system, and how people experience pain.  In my opinion, the research that has been done on the process of central sensitization is a lot more convincing than the research that has been done on the overlap between mental health conditions such as depression and anxiety and fibromyalgia.

For one thing, it makes sense that you’re going to find a higher rate of depression and anxiety among the chronically ill.  I don’t know why anyone is surprised by this. To me, it makes perfect sense that those suffering in chronic pain and discomfort would experience an impact on their mental health.  It’s a chicken and the egg problem, and I find those studies relatively meaningless.

For another, the people who write these studies apparently don’t know anything about the process of central sensitization.  They appear to be completely unaware of the ways our nervous systems can physically change in response to chronic pain, in a way that is beyond our control.  Physical abnormalities have been found not only within the brain but within the spinal cord of chronic pain sufferers.

To say that depression and anxiety are responsible for chronic pain is to focus on only the tip of the iceberg.  If the people who published these studies would at least acknowledge the rest of the iceberg, I would be able to take them more seriously.

But it seems that academic knowledge is too compartmentalized.  Some people go into psychology and study people’s moods and thoughts.  Some people go into neurology and study the nervous system.  Even the people within neurology end up specializing.

This is why I am inspired to see people beginning to criticize the concept of “evidenced-based.”  I’m tired of people throwing those words around as though it means what they are doing is automatically great.  There is a difference between evidenced-based and science-based.   When you can see physical abnormalities in the brain of a chronic pain sufferer under a fMRI, that is science.   Assuming that people with fibromyalgia must have a problem with depression because psychotherapy makes them feel temporarily better is not. 

Anyway, that was a bit of a rant (but I’ve been told my rant-y posts are some of my best!).

Do you agree with me? Disagree? Let me know your thoughts!

Digestive Issues, Treatment Approaches, Women's Health

Beware the Red Herring

One of the reasons I sometimes take a critical tone towards alternative medicine on my blog is not always that I think these approaches have no merit.  But I do think that, too often, people are drawn to and waste their time treatments that are simply “fads.”

When I look back on everything that led up to my losing an ovary, I can’t help but feel my digestive problems are to blame.  I wasn’t sure I wanted to talk about my digestive issues on this blog, but what the heck.  I have issues with IBS and chronic constipation, made worse by the fact that I have a pelvic floor disorder.

I am so used to feeling discomfort in my abdomen that I didn’t rush to the hospital the moment things began to hurt.  In retrospect, that was critical time in which my ovary was being deprived of blood supply, and although the doctors and nurses I talked to didn’t want to come right out and say it, there is a chance I could have kept my ovary had I gone to the hospital sooner.

When I look back, I can see that some of the symptoms I associated with my twisted ovary were actually building for months.  I had this weird feeling in my right side, a feeling that something was where it shouldn’t be, for almost a year.

It’s so infuriating to realize this, because I talked to two gastroenterologists about the feeling that something new was wrong on my right side, that somehow things were getting worse.  I told my most recent doctor– who actually published a book on digestive issues in women– that I felt as though the right side of my abdomen always seemed to be a bit swollen (for lack of a better word). That my right side was always aching a little bit, that it was simply bigger than my left side.

This doctor basically told me not to try too hard to diagnose myself; that I shouldn’t go by how things felt from the outside.  I tried to explain that I wasn’t, but our appointment time was over and she had mentally checked out.

I am so frustrated now, because I wish she could have pointed just out that ovarian cysts can have many of the same symptoms of IBS.  Perhaps she could have said something like “Gee, I have no idea why that area is bothering you, perhaps you should try seeing someone in a different specialty.”

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I also wish I’d tried harder to get an answer.  It’s funny because, a few days before the pain really started up in earnest, I knew things were getting worse.  I didn’t have the horrible pain in my right side yet, but the feeling that something was there, that something was stuck, was really getting on my nerves more than usual.  I remember saying to my mom “I have to deal with this problem.  I can’t keep taking no for an answer.  I have to find a new gastroenterologist.”

Almost a year had gone by since I had seen a new doctor.  The last time I saw my doctor, which was almost a year ago now, she had offered to put me on Amitiza, a medication for chronic constipation.  I was reluctant to start a medication without exhausting every other possible option, so we decided that I would try going gluten-free first to see if it helped.

My doctor had said that sometimes it can take a long time for the gluten free diet to help.  She also said that it won’t necessarily work to just reduce gluten; you might have to eliminate it completely to really see an improvement.  So I spent the past year waiting to see if this would help.  At some point over the course of that year, my right ovary began to twist, and I did not aggressively pursue answers for the new pain I was feeling.

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Now, I am sure that a gluten-free diet has helped many people.  But at the same time, gluten-free diets for non-celiac sufferers is not something that has actually been proven to have any scientific merit (as far as I’m aware).

I think it was a mistake for me to have endured so much discomfort, for so long, waiting for something with so little evidence to help me.

When I look back over the years, I can actually see how sometimes, being stoic and just enduring the pain and discomfort has not served me well.  I’m sure certain family members of mine will get a good laugh out of this statement, but I wish I had complained more, not less.

Being stoic is not always good.  And neither is being too open to new ideas.  I had a very real, very diagnosable problem in my abdomen.  But I was content with no answers, for too long, because I was waiting to see if something that is basically a fad was going to help me.

Of course, I don’t mean this in any way to be a criticism of those who are on gluten-free diets.  If it helps you, that’s great.  I might even try it again in the future if my digestive symptoms don’t improve.

But it’s about proportionality.  When I look back, it just doesn’t seem logical; the idea that I could fix extreme discomfort by no longer eating something I had eaten comfortably for most of my life.  I can see why my doctor would have recommended a gluten-free diet for a more subtle condition.  A subtle treatment for a subtle condition.

But there was no proportionality between the persistent, nagging feeling that something was stuck in my abdomen, which bothered me day in and day out, that kept me awake when I tried to fall asleep at night… and gluten.  If gluten-free diets could clear up this kind of discomfort, I’m pretty sure they would be in medical textbooks by now.

So, these were my mistakes.  The first: a lack of proportionality.

The second: being too stoic.  I waited far too long for something with very little scientific credibility to help me, instead of insisting that a doctor understand exactly how miserable I am.

Let’s not be strong all the time, people.  Sometimes, it’s really important to just let yourself complain.

Treatment Approaches

The Scam of “Muscle Energy Testing”

muscles of back

I’ve seen numerous “alternative medicine” providers perform something they call “muscle testing” or “muscle energy testing” many times as part of their sales pitch.  They tell you to put one arm out in front of you, and then push down on your arm.  Your arm sinks immediately.

Then they ask you a question, or put some kind of substance or herbal remedy in your opposite hand, and repeat the “test.”  Your arm always stays up better the second time.  The explanation the quacks will give you is that your body “knows what is best for it” and that your arm is somehow “in tune with the universe” enough to know that what you’re holding in your opposite hand will help you.

As this video points out, none of this is true.  The reason your arm does a better job of resisting the force the second time around is simply because your body has learned what to expect.  As John Duffy, the physical therapist in the video, points out, this represents “simple motor learning.”  In the video, he uses his “magic pen” as a joke to represent the “treatments” that some unethical “alternative health” providers con people into taking using this test.

This video was originally posted on the Phoenix Rehabilitation and Health Services, Inc. Facebook page.  I am including the link to view it on the blog Forward Thinking PT because that is where I originally viewed it, and it seemed to come out in a higher quality there.  (Although I have to admit that this may have more to do with the fact that my computer is ancient than anything else…).

Thanks to EUSKALANATO on Flickr for making the above photo available.

Interesting Articles, Treatment Approaches

Ugh… way too true

I just found this really great article that cut close to home.  It’s about the tricks people use to con others into thinking they’ve got some great new alternative healing method.  I hate to admit it, but over the years I’ve definitely been taken in by some of the tricks the author lists here.  Looking back, I was particularly susceptible to Number 3 (Add a dash of pseudo-science) and Number 4 (Don’t forget a dose of ancient wisdom).

I thought I got off to a good start on explaining how to avoid scams in my post on alternative medicine, but this article really takes the cake.

Oh man:

Q: Your treatment can cause considerable harm; do you find that responsible?

A: Harm? Do you know what you are talking about? Obviously not! Every year, hundreds of thousands die because of the medicine they received from mainstream doctors. This is what I call harm!

Q: Experts say that your treatment is not biologically plausible, what is your response?

A: There are many things science does not yet understand and many things that it will never understand. In any case, there are other ways of knowing, and science is but one of them.

Yup… I fell for this line of thinking repeatedly between the ages of 19 and 23.

If you are considering trying a new form of alternative medicine, I suggest reading this article first.  If the person pushing this method gives you too many of the talking points Ernst lists, stay clear!

Edzard Ernst– How to Be a Charlatan

Chronic Pain, Treatment Approaches

Why you should learn a little anatomy

Fellow pain sufferers, as well as anyone who likes to learn about the body, I can’t stress enough how learning about anatomy and physiology has helped me.

First of all, it makes such a big difference when you can begin to understand medical terminology.  Once you start studying anatomy, you’ll see that medical terminology, with all of its Latin routes, is kind of like a second language.  But it’s a fun second language and it’s not as hard as it looks, because many words share the same Latin roots.  It really ends up being the roots that you memorize, and the rest comes naturally after that.  For example, the suffix -itis indicates inflammation, whether this is tonsilitis (inflammation of the tonsils), tendinitis (inflammation of a tendon), or appendicitis (inflammation of the appendix).  So you know any word that ends in -itis refers to some kind of inflammation.

It doesn’t take that much to learn these terms, and once you do you’ll find you can actually hold your medical records in your hands and understand about 50% more than what you previously would have been able to.  I’m not saying you have to be your own doctor, but at least for me, understanding these words greatly contributed to my own sense of confidence.  Also, a little background knowledge can make little boring things like having a cold slightly more interesting.  You can think to yourself, “oh, the white blood cells are doing this…” etc. etc.

Secondly, a basic background in anatomy will help protect you from falling prey to healthcare scams and misinformation.  Anyone who’s suffered from chronic illness knows how desperate we can get at times for answers, and this is where a lot of enterprising people try to swoop in and sell you supplements, health counseling, and God knows what else.  There are so many ridiculous, snake-oil cures for sale on the Internet, I can’t even bring myself to do a Google search right now.

As I wrote in a previous post, a lot of people with chronic pain believe they have a problem with inflammation.  I used to think this too, and I was always reading about all of these New Age cures that could supposedly fix the problem (herbs, special diets, etc.)

When I took an anatomy class, I learned about how the inflammatory response works, and I also learned about the various blood tests doctors can order to check and see if a patient has an inflammation problem.  (Examples are sedimentation rate and complete blood count).  Then I went home and looked at my medical records and realized my doctor had actually ordered those tests multiple times over the years.  My results had been normal every time.  Suddenly I realized why she had never seemed to take my concerns about having a problem with inflammation seriously.  I mean, it certainly would have been nice if she could have taken the time to explain all of this to me, but I guess after you spend all that time in medical school you forget how foreign those concepts are to someone who’s never heard of them.

In addition, I have found a huge amount of value in developing an understanding of the part of my body that hurts.  Pain is basically your body’s alarm system, and it’s there to keep you from doing things that your body thinks is dangerous.  Of course this is a totally unconscious process.  But I have found that when I can learn more about a part of the body that’s hurting me, and get to a point where I feel I have an accurate and precise mental model of that area, my pain level actually starts to decrease.  Nobody likes uncertainty, and the more you can develop a sense of certainty about what’s going on, the better you are likely to feel.

Of course, this is not true in every situation with every injury.  I really hate when people take these mind-over-matter theories too far.  You can’t use one theory to explain everything that can happen to people.  But I’ve been able to reduce the level of pain I feel many times by using this technique.

Lastly, a basic knowledge of anatomy will help you to protect yourself from future injury because you will start to know a little bit more about how the body is supposed to work, and you will be less likely to perform your exercises with bad form.

Now I realize that not everybody is able to just sign up for a high-school or college course.  The good news is that there are some ways to get this information on the cheap.

A few suggestions:

  • Try auditing a class.  It’s cheaper than taking it for credit.
  • ExRx.net also has some interesting anatomy information.  Check out this list of muscles.

I know I talk a big talk, but the truth is that it was a lot easier to learn all of this stuff when I was enrolled in a class.  I had some really great instructors and I was buoyed up by their enthusiasm, as well as that of my classmates.  So if you have the opportunity to take a class, I do recommend it.  Knowing you have a test coming up is a great way to force yourself to cram this information in, and assuming you have a good teacher, you will probably learn more that way.  I always check Ratemyprofessor.com before enrolling in anything.

But if you can’t, then definitely check out the resources I suggested.  I definitely think it’s one of the best things you can do for yourself, one that might end up saving you time and money in the end.  Good luck!

Treatment Approaches

Have you ever tried yoga?

This is one of the first questions people ask me when I tell them I’ve had problems with back pain, and I always feel a little embarrassed when I have to tell them that yes, I’ve tried it, and no, I didn’t really like it.

It’s awkward because the person asking is usually really enthusiastic about yoga, and because it has such a great reputation.  After all, yoga has connotations with not only physical but emotional wellness.

For me, yoga has been painful because I have always been inflexible.  I managed to keep it at bay during my running days by stretching religiously, but in shape or not, it is next to impossible for me to stretch without doing some kind of cardiovascular warm-up.  (These days, when I say stretch, I’m talking about doing little movements that a pain-free person probably wouldn’t even notice.  Some days tying my shoes counts as a stretch).

I once attended a pain clinic at a very prestigious Boston rehabilitation center.  The whole experience actually sucked (we’ll talk about that later), but the worst part of it was the four times a week yoga class.  All of the other eleven pain patients and I would end up in more pain by the end of every class.  By the end of my three weeks there, we were unanimously convincing the instructor to teach us an extra tai chi class every time the schedule said it was time for yoga.  We actually liked tai chi because it involved motion, which turned out to be much easier than holding one static pose.  We also probably liked it because it helped get our circulation going.

At any rate, I tried to keep my dislike of yoga on the DL among non-pain-afflicted people.  That is, until I saw this:

New York Times: How Yoga Can Wreck Your Body

Now I don’t want to offend anyone who loves yoga, because I’ve only tried it with two different teachers, and I’m aware there are different schools of thought and ways to do yoga.  But for me, this article touched upon a lot of the things I’d been wondering about.

The article is based largely on interviews with Glenn Black, a yoga teacher who’s been practicing for four decades. Black’s basic point is that while yoga has some applications, the rate at which its popularity has grown in this country has not kept pace with the numbers of qualified teachers, and it is not always taught with enough care.

Some of the most telling quotes:

“Not just students but celebrated teachers too, Black said, injure themselves in droves because most have underlying physical weaknesses or problems that make serious injury all but inevitable. Instead of doing yoga, ‘they need to be doing a specific range of motions for articulation, for organ condition,’ he said, to strengthen weak parts of the body.

“‘Yoga is for people in good physical condition. Or it can be used therapeutically. It’s controversial to say, but it really shouldn’t be used for a general class.'”

In other words, yoga shouldn’t be one-size fits all.  Someone with any kind of injury shouldn’t be going to a class of fifteen people and trying to keep up.  Black says,

“’Today many schools of yoga are just about pushing people… You can’t believe what’s going on — teachers jumping on people, pushing and pulling and saying, ‘You should be able to do this by now.’ It has to do with their egos.’”

The article tells of yoga teachers who tore their Achilles tendons by holding Downward Dog for too long over too many years, and even of a very small number of people who suffered a stroke due to the extreme neck movements that occur during some poses.  Black talks about instructors who had been teaching yoga for decades who’d hurt their backs and hip joints so badly that they now taught classes lying down on a mat.

I know there are a lot of people out there who really love yoga and have had a totally different experience than me.  I guess what I’m saying is that the expectation that everyone will totally love yoga and find it a transformative experience is probably  bad.  That’s what leads beginners to pull muscles during class, because they went in with some kind of underlying structural weakness and tried to keep up with everyone else.  That’s what leads the master teachers to continue to teach even after their doctors have warned them that some of the poses they’re doing can be damaging to their hips.

I think it’s possible that I would like some forms of yoga if I could do things my way.  I would have to do a real warm-up first, and I would probably want to be alone with a teacher or with a very small group of people.  Someone with chronic pain especially needs to take things at his or her own pace.  (Trust me– you can’t rush through things when you’re living with chronic pain.  Things have to take as long as they need.  If you try to ignore your gut feeling and rush, it ends up backfiring every time).

Then again, I know I am partly just saying that as a concession to my friends who actually like yoga.  Part of me is genuinely curious why people enjoy it so much.  But it’s also very hard to admit that you’re that narrow-minded person who doesn’t like yoga.