Here is an excerpt

Pain does not give us a measure on the current state of the tissue.
This has been shown through numerous studies on both animal and human subjects. These data have shown that pain, nociceptor activity and the state of the tissue are not isomorphically related at all but are modulated by a variety of factors.

Nociception is neither sufficient or even necessary for the experience of pain even though it is the most common driver of the pain experience.

Pain is modulated by a number of different factors including those from the somatic, psychological, and social domains.

The influences on pain are varied and seem to be heavily dependent on the context that the noxious input is evaluated under. Some areas that have been shown to modulate pain include:

• Inflammatory mediators.
• Tissue temperature.
• Blood flow.
• Attention (results are mixed)
• Anxiety.
• Expectation.
• Belief.
• Social context.
• Etc…

As pain persists the relationship between the perception of pain and the state of the tissue becomes even more imprecise.
The number of changes that occur in response to activity of the system are large and the list of those identified is growing at a rapid rate. As nociception persists the neurons transmitting nociception and the pain networks in the brain become sensitized. Clinically these changes manifest as hyperalgesia and allodynia not only in relation to tactile stimuli but also movement. This is a key concept in understanding the role of movement in pain. Persistent pain can result in changes in the proprioceptive representation of the painful body part in the primary sensory cortex. This can have implications for motor control since it is known that experimental disruption of these maps results in disrupted motor planning. There is a mounting body of evidence that these changes can become part of the overall issue.
Pain can be ‘conceptualized as a conscious correlate of the implicit perception that tissue is in danger.’
The neuromatrix theory fits our current knowledge of biology and neuroscience and is flexible enough to grow with the research. Two very important components to the theory. Pain is just one of various outputs from the CNS in response to perceived threat and it is this threat perception that drives the outputs – not the actual threat.

In summary, pain changes the way we move and the way our brain interprets the information going to it as a result of our movements. Sometimes (many times), to fix movement patterns, we have to help reduce the level of threat detected by your brain so that your output of pain decreases. That’s all for today!

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1. Prognosis; AKA a reasonable timeframe for resolution:
   • Providers should help you experience some pain relief within 10 visits. Treating pain should not be like renting an apartment you’re not signing up for a 1 to 5 year lease with options for renewal. Unless you’re recovering from a recent injury or major trauma, there should be some positive gains so you an evaluate whether or not the providers’ treatment(s) is/are working. NOTE: your provider should also verbalize this timeframe when they explain to you what their proposed course of care will be.
2. Education:
   • The field of pain science has evolved so much in the last 10 years. Every provider needs to learn the updated explanations for what is going on when you are in pain. It has been said that, “Knowledge is power”; well, in this case, knowledge is medicine. Learning why you experience pain will go a long way towards the resolution of your pain experience.
3. Attention:
   • If you are being treated by a provider who claims they can help you with your pain, expect them to be paying careful attention to you. You will be presenting expert evidence of your current experience and situation. It is important to note that this has nothing to do necessarily with the long story that you’ve developed to explain your pain to the many people who are not really interested in listening. This has to do with someone who is directing their caring attention towards you and noticing cues that you might not even realize that you’re demonstrating. Pain is a very emotional experience. And for this you need help sometimes from another person but they can’t help you if they don’t understand you or pay attention to you and your story.
4. Atmosphere:
   • Because your experience of pain is very much dependent on context (where you are, how you feel, if you’re scared, etc.), the atmosphere you are being treated in also matters. A clean organized treatment space that allows you to remain separate from others, the absence of distractions and clutter are very important. The context of the room is an input to your nervous system, there does not need to be specific decor but the focus should be on reducing the disruptive input to your nervous system (I.e. calming).
5. Empowerment:
   • Your inner locus of control is fundamental to reducing pain (AKA your nervous system’s detection of a threat). At the end of each encounter you should feel more in control and have a greater understanding of your role in the elimination of your pain and how important this control is.
6. Honesty; comfort with uncertainty:
   • Sometimes, exactly what happens physiologically is beyond a provider’s current knowledge level; in fact, regarding pain, it is often beyond everyone’s knowledge level. What you should require from them is that they are honest about this. Too often, providers create a narrative about what their particular therapies are doing or causing to happen in your body; this is often results from being uncomfortable with stating that they don’t know what is occurring. Consider that your provider does not need to have all the answers to be effective. Instead invite them to be someone with great technical knowledge and skill, willing to team up with you and your pain experience. Together you can problem solve, troubleshoot, and work with each other to reduce your painful experience. Also, be wary when providers quickly blame muscles, joints, fascia or other tissue for the sole reason you are experiencing pain; especially if there was no recent (less than 8 weeks) trauma.
7. Encouragement to find movement and move more:
   • There is a saying that is getting rather stale, but is still true, “motion is lotion”. The problem can be that sometimes a provider will get locked into a prescriptive set of movements that they think are the cure-all for everything. Movement is good, exercise is good, but we’re not entirely sure why they work. Also, there are NO magic exercises out there for ANY pain experience. If you’ve read some of my recent (2012 and newer) posts, you know that I am a proponent of novel movements and often have patients use novel movements to help reduce pain. Novel movements (those that you don’t normally do throughout the day), pain education and a very basic knowledge of your nervous system, helps to feed your brain new information so that it can create a new model that is pain-free.
8. A strong aversion to pseudoscience:
   • Many pseudoscientific treatments had their time; and often, people derived benefit from them, this doesn’t mean people should still be using them with patients. Back in their day, science was murky and many who utilized these methods thought they were practicing cutting edge medicine. A good rule of thumb is, if a treatment has little scientific evidence supporting its use with patients, it should be questioned. If there is NO risk involved, it may be utilized, but still be questioned, and probably not the only treatment offered. If there is ANY risk involved, it should not be performed unless it is the only treatment the provider has found to be clinically-effective. Even then, they should be honest with you about the risk and the lack of evidence so you may make an informed decision as to whether or not you want to utilize this type of treatment. If a provider’s primary concern is helping patients get better, it should be totally OK if they discover that what they once learned, is no longer useful or riskier than is warranted.
9. A passion for learning:
   • It is not unreasonable to discuss with your provider about what they have learned recently, regarding pain and pain relief treatments. Ask them about their sources of learning; do they read from a variety of sources? Do they cling to one particular “guru” who they’ve learned all their masterful techniques from. No one person that understands it all. There are many people today doing very amazing research and many clinicians helping many patients with pain relief. Providers should be interested in improving their understanding in some way, this requires that their sources are varied, journal articles, colleagues, continuing education and their own ability to integrate all this are all very important in this process.
10. A willingness to treat pain:
    • In the various physical medicine classes I teach, I have told my students that pain is often one of the major complaints that people present with; in this regard, pain relief should be a primary concern. If you visit a provider because of pain in your shoulder and they spend all of their time trying to increase your range of motion, core strength, or something silly, like balancing a perceived difference in the length of your legs, run away; especially if they mention something like “…I don’t treat pain, I treat dysfunction.” Pain is a reasonable thing to treat first and if any exercise, treatment or movement activity is prescribed, the focus should be in reducing the pain experience. In my opinion, pain is not treated well and soon enough. Do not tolerate a provider who ignores it, If they do not address your painful experience, get out of there.

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Movement, or more specifically, novel movements can be quite useful for pain relief. They are an opportunity to create a new impression in your nervous system. 

There is no guarantee that this new impression will be a favorable one; if you’re not careful the impression may cause an output of pain from your brain. If you’re careful, the impression may help to “convince” your brain and nervous system that movement should not be interpreted as dangerous and therefore, offer some pain relief.

If the impression causes yet another output of pain, there will most likely be some protection, and therefore limited or limiting movement. In order to change things for the better and create a pain-free impression you need to nudge your painless range of motion in the right direction. One way to stack the deck in your favor is to pair the new or novel movements with something that already  has produced a favorable impression by your brain and nervous system.

This is creating context to obtain pain-free movement. Context is important when talking about pain and can be used in your favor.

Do you need to perform specific movements or movement patterns for this to occur? People often worry that imperfect movements create patterns of strain that can cause pain at any moment. In fact there are those in the functional movement camps that insist this will happen (I know, I used to be one of those people).  Is this based on fact? Will “improper” movement cause us to break down, will this result in pain?

Consider these questions and points:

• Why don’t people with cerebral palsy hurt constantly at every joint even though movement is often difficult to control and where movement and postural asymmetry are very common.?
• How do you explain why so many people display these imperfect and asymmetrical movement patterns but have no pain?
• Why are so many of us walking around with herniated discs, meniscus tears, rotator cuff tears, and/or arthritis without knowing it? There is actual tissue damage in these people and yet they don’t hurt. The research documenting all of these findings exists….. in large quantities.
• How can we explain phantom limb pain; even in individuals who were born without a limb?

What about the countless stories of how people (maybe you) have had pain relief by changing movement patterns and/or posture?

Body mechanics and movement are important and useful to consider clinically, but my argument is that I would not be helping my patients by convincing them that their body mechanics and movement patterns are going to lead to them falling apart, injuring themselves and/or leading to degeneration or arthritis. Not only would this be harmful to my patients, but this is clearly not the case in any way.

Now this is  flies in the face of what many in my profession as well as the physical therapy, athletic training and personal training profession, as gospel. Am I denouncing my own profession as well as many others? Well, in this case….. yes!

Body mechanics clearly play a role in the treatment of my patients and I use movement every day to help people with pain. When pain is present, movement and body mechanics can change drastically, but movement patterns and body mechanics are not useful as a pain predictor even though they can be a useful in pain relief.

Regardless of how you move you will all hurt at times during your life and pain may correspond to certain movements. 

Neuroscientist, V.S. Ramachandran said that “pain is an opinion.” Painful movement means that our body is acting on the opinion that we are under threat and should therefore be protected. So, how can we change this “opinion”?

Movement patterns and postures should be thought of as tendencies or movement habits. They develop over time and therefore can give me a glimpse at your movement history. If you do something new, something outside of your normal movement regiment (I will call this novel movement), you give your nervous system something to form a new opinion about. If you perform this novel movement in a non-threatening context, a context of safety, a context of expansion, your nervous system is not likely to come to an opinion hat this is threatening and therefor not output pain.

Pain relief that occurs with postural changes, specific exercises or prescribed movements likely helps to reduce pain because they are all novel movements and is another example of the power of novelty. It likely has nothing to do with attaining perfect posture or perfect movements patterns or reducing musculoskeletal strain reduction, but has everything to do with non-threatening movement variability.

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1. Despite all the impact demolition derby drivers sustain, they have ultra low incidence of chronic whiplash/ crash. It has nothing to do with the forces (they get blind sided too) but everything to do with the meaning and context of what happens. http://www.ncbi.nlm.nih.gov/m/pubmed/15827919/
2. If you treat your body like it is fragile and damaged, it will become more so.
3. Being afraid of the pain getting worse makes you fearful of movement.
4. Working through pain and ignoring flare ups will negatively impact your nervous system. You are more likely to develop chronic pain when your nervous system is not “happy”.
5. You can’t stretch out your pain; strengthening only indirectly affects the pain. So forget about weak muscles and asymmetry as being the cause of your pain.
6. Treatments that are painful are more likely to perpetuate an environment in which your brain outputs pain; meaning, predominantly painful treatments can amplify your pain.
7. Getting imaging like MRIs and X-rays should be an absolutely last resort. Unless there is evidence of serious red flags, chances are any findings on MRI’s, X-rays etc will just cause you to worry about something unnecessarily. Many people have no pain and would have plenty of abnormal findings n X-rays and MRIs.
8. Your brain is in complete control of the pain experience. Pain is produced as a pain experience just like hunger and thirst. Only with pain, it is similar to a smoke alarm. Sometimes the alarm may go off because you took a shower or burnt some toast. With pain, there doesn’t have to be anything wrong for the experience to occur. This one is the most vexing because it feels so real. And it often has a distinct location. You would swear that something is wrong “right there”.
9. Your brain extends throughout your entire body; there is almost 45 miles of nerves in your body. All nervous tissues have their own blood supply and they can get very cranky if they are not well fed. This is where you may need the help of a competent health care provider, and the earlier the better.

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This morning, I find Todd Hargrove’s blog about a pain and performance presentation he gave at a Parkour gym in Seattle, here’s a link Todd Hargrove’s Talk on Threat and Performance

Todd does an excellent job talking about updated information about pain and how it can guide (and negatively affect) your athletic performance. Reducing the threat, or, rather, convincing your nervous system that there is not threat when performing athletic tasks like Parkour, is often the goal with any therapy that touts pain relief; even if the person performing the therapy is unaware of this.

Enjoy Todd’s video and blog post and stay tuned for more recorded talks from me on this subject. If anyone is interested in having me talk about this subject in person feel free to contact me.

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• A better understanding of pain, how important their pain system is, and how it’s not always directly related to anything that’s broken, torn, misplaced, squished or damaged.
• A better understanding of what the therapy can and can’t do.
• Some consideration for their own pain system as an important phenomenon with a past, present and future. This allows it to view every input in the context of past, present and future experiences.
• Hope

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• Through the nervous system, our skin has a plethora of connections straight to your brain
• Skin plays a HUGE role in how we sense where we are in space, where we are going and all the subtle movements in between.
• We (us primates) have a grooming instinct and the responses are programmed in our brains. It’s instinctual to touch, rub and push on things that hurt for pain relief
• When we place our hands on someone else, there is a large amount of activity in both people’s brains.
• When we are in pain, it often requires near-full or full attention, this means that a large part of your brain function is devoted to paying attention to and trying to figure out how to relieve pain.
• Oxygen levels are incredibly important to our nerves, especially the of small nerves in your skin. Gentle contact increases blood and oxygen to these nerves; this decreases any level of threat input to our brains
• Relaxing under the gentle hands of another deepens breathing (very important) and decreases general tension through an interaction between our brains and muscles

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We know that the more variable your heart rate is, the healthier your cardiovascular system is; this is called” heart rate variability”

Well, guess what…. there is a concept called, “movement variability” that seems to be the key component in pain relief for conditions like upper back pain and low back pain.

What is “movement variability”?

It is creating slightly different movements to perform certain tasks. In a 2010 study entitled,  ”People with chronic low back pain exhibit decreased variability in the timing of their anticipatory postural adjustments“, authors found that people with low back pain had decreased movement variability when it came to postural adjustments. In another study (click here), upper back and neck pain was linked to the same decrease in movement variability.

Many clinicians and therapists (myself included) see this as one of the main reasons functional movement, functional training, joint manipulation and mobilization, massage and many other soft tissue and rehabilitative techniques help people in pain. What do all of these treatments have in common? Novel Movements.

Novel movements are movements that vary from those that you produce regularly throughout the day. Movements that exit outside of a stereotypical pattern. Novel movements help to increase your movement variability and also stimulate your brain to produce dopamine. Not only is dopamine a “pleasure” chemical, it is also part of our internal reward system. An increase in dopamine from novel movements and movement variability is  like a messenger to the rest of the brain saying,

“Hey, good job! Everybody, wake up and pay attention, this is something new and good for us.”

Novel movements and increased movement variability creates an opportunity for your body to experience movements that are non-threatening and non-painful; this can help to decrease the pain signals from the brain with chronic pain problems.

We would be correct if we categorized decreased movement variability as our movement habits. To increase our movement variability and therefore, possibly find relief from chronic pain, low back pain, upper back pain and more, we should change our movement habits and introduce novel movements into your daily routine.

In other words, you need to improve your “Movement Diet” (I stole this phrase from Cory Blickenstaff, a PT in Vancouver Washington). Improve the variety of movements in your “movement diet” so that you have options for pain relief and finding comfortable ways to move.

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How many times has your chiropractor or massage therapist told you that you had extensive muscle knots and scar tissue, and that was the cause of your pain? This idea may have caused you to think you had caused some damage to your body. In turn, even sub-consciously, this may have caused you to lose confidence in your ability to heal.

And what was “prescribed” for these “knots”? Probably, lots of massage, chiropractic adjustments, stretching, foam rolling, joint mobilizations and more. Why?

No one knows the answer, it certainly isn’t because all of these things have been proven to help with tender spots in our bodies. Please, read that again…… This last sentence may be a shock to some of you as most providers pass their recommendations off as scientific facts. Try this as an experiment, see what happens when you perform, fun, novel movements within and pain free range without foam rolling, rolling on lacrosse balls, using trigger point sticks, knobs, without getting adjusted and without constant stretching. Chances are, you’ll feel pretty good.

Often, as a health care provider myself, I find that some of my recommendations to patients become obsessions; so I need to be certain that my recommendations are rooted in science. Doctors and therapists can cause patients a lot of anxiety by making them feel like they defects in their body when there is no evidence of them. Many of my patients have been told that their back is “out”, that they have the “neck of a seventy year old”, or that their knee is “bone on bone.” These statements can increase the perception of threat, cause disability and pain, and lead to treatments that are unnecessary or even harmful. Yes, these statements can be interpreted as threatening by our brains and actually cause pain and disability.

I have to share a video that has been circulating recently showing physical therapist Peter O’Sullivan, working with a former client, Jack, about his dramatic recovery from debilitating back pain. The successful therapy involved dealing with Jack’s fears that forward bending was unsafe, which stemmed in part from hearing previous therapists tell him that he had the “back of a seventy year old”, that his back was “in pieces” and that “he couldn’t do nothing.” But O’Sullivan showed him otherwise, and the results were amazing to say the least. This guy went from not being able to ride in a car to digging ditches pain free in short order. I have been showing this to my students lately and hope you too will find it a bit mind-blowing:

The results Jack experienced are pretty amazing and I can tell you, from my clinical experience, his were pretty extreme. I have seen patients leave my office in quite a bit less pain and some, pain free, after a good “dose” of pain education. For more information on this topic and to se some of the pain education tools I use in practice, go here, Pain relief Portland, Oregon

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A common question is, “If a technique helps my pain, it must work right?”

Well, not necessarily. There are many, simple ways that you can live pain free; ways that are not expensive and ways that will empower you and give you back the control you need in your life.

It’s not about disproving these techniques outright. Science is more about what is most likely and what is less/least likely. I cant say with 100% certainty that any technique is not helping your pain. I do not require a machine or special equipment to state that there is doubt surrounding the explanations behind many of the hands-on techniques that one may receive to help reduce pain. Science is about minimizing the number of assumptions we make in our efforts to explain the world around us.

Science does not lead us to a point of absolute certainty. I can not say with certainty. Several studies have cast massive doubts over the reasonableness of some commonly practiced and widely/blindly accepted techniques. Consider the following:

• Myofascial trigger points, their existence, and the therapies that claim to treat them are not based on 100% fact. Their is some doubt in the scientific literature that we can reliably palpate and treat them.
• Various fascial therapies and those who use them are are convinced they can palpate and effect fascia and that fascia is a direct source of pain. This is unlikely, given what we know about pain.
• The Myofascial release crowd are convinced they can palpate and release emotions/memories buried in fascia and muscles. Science is pretty clear on this; emotions are not stored in your fascia or muscles. The definition of “muscle memory” has been corrupted.
• Many chiropractors and physical therapists are convinced they can palpate and effect specific joints and that bones can become “out of place”. This is an idea that needs to be put to rest. Bones do not “go out of place” regularly. Joints may need to be convinced to move better and more freely, but not because a bone is “out of place”
• Those that perform craniosacral therapy are convinced they can palpate and effect cerebrospinal fluid flow/pulses and cranial sutures position and that doing so helps all kinds of ailments. Why does it work? Likely because of light touch and it’s affects on subtle movements in your body. I turn, these novel movements help to decrease pain.
• The core stability crowd are convinced that your aches and pains are caused by muscle imbalances. Well, it’s probably the other way around, situations that cause an output of pain by your brain will likely change also cause a change in muscular control. It is very unlikely that this any perceived muscle imbalance causes pain. In addition, it’s fairly unlikely that we can reliably detect these muscle imbalances.

Probably the best evidence I can present is more of an observation. All of these techniques and more, can help to decrease pain in certain situations. That must mean that there is a common thread to all of them. Well, there is, the common thread is your nervous system.

• Your brain outputs pain as a result of many inputs
• All hands on therapies affect your nervous system through direct contact with your skin and your superficial nerves
• All movement therapies introduce novel movements and novel signals for your brain to interpret. All of this can help to decrease pain and improve function.

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