Thursday, April 23, 2015

Science Says I May Not Be Crazy!

Many people have the experience of going to the doctor with some type of pain.  The doctor often orders tests to try to make sense of the complaint.  We want that.  At least we want that until we have been to doctor after doctor and they can’t seem to find a problem.  That is when we get the psych referral and are told that the problem must be in our head.

We resent this.  We feel the pain.  We know that we have a problem and that if we just see the right person – they will listen to us, run the right test, and finally fix our problem.
It really starts getting to us.  We have bad feelings toward our caregivers.  Many of us begin to mistrust the medical profession.  We blame big pharma, the insurance company, and the government.

Our life begins falling apart.  No one sees any blood, cast, or wheel chair and they too often begin to wonder – is it all in their head?  The saddest part of this is that deep down – we often begin to wonder about that as well.

A Way Out – Understanding!

 I would like to offer a way out of this mess.  It is only possible to do this by helping you to understand what we now know about both you – and your pain.  I will start with a definition.

An unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage.

This definition comes from International Association for the Study of Pain. [i] It is the definition that is followed by most health care practitioners.  It is really good to have a definition like this because in its absence we really have no accepted way to have a discussion about it.  We are simply left with opinions.  This is a helpful definition.
Tissue damage is not a requirement for a person to have pain!  This is very important because all of those tests that get used to find out what is wrong with the tissue are looking for – you guessed it – TISSUE DAMAGE!

This means that just because the tests are negative that you can still have a legitimate pain problem.  If you are complaining about pain or experiencing it – you probably actually have it regardless of the outcome of any number of tests.

This became clear when people began complaining of phantom limb pain.  There was no limb to have pain in and yet many people in the absence of those limbs consistently complain about pain.  One of my favorites is the rubber hand illusion  where a person can be taught that a rubber hand belongs to them and they can actually feel pain when it is struck with a hammer!  People did not even have to believe the hand was theirs in order to be benefit from acupuncture or TENS in this abstract at the World Confederation of Physical Therapy.

This may all sound a bit strange.  We have pretty much assumed that pain is an input from our tissues since the time of Descartes.  Yet the science seems to be pointing in an altogether different direction. 

In the picture above we see the view of Descartes in the left hand corner that we have nerve receptors in our skin that go directly to the brain and carry pain signals.  The problem with this traditional view is that there is no such thing as pain to sense. 

Think about it.  If you get a cut - did pain leak in?  Did you put some pain on a slide in high school and view it under a microscope?  Have you ever seen, heard, or tasted pain?  If you answered no you are in good company.  We are all in the same boat!

The reason the rubber hand illusion works and why people who have lost limbs can feel pain is that you don’t need a body to feel pain.  You just need a BRAIN!  The big finding of modern neuroscience is that pain is actually an output rather than an input of the brain.  Let me explain.

Pain researchers have found that the brain takes everything into account regarding our beliefs and attitudes as well as the sensory input from the surface of the body when a potentially bad issue exists.  It asks the question, “How dangerous is this?”  The answer to that question determines what you are going to feel.

Here is how this looks in real life.  You have a minor fender bender.  There is a slight scratch on your bumper.  No big deal.  It was low impact.  The complicating feature may well be the emotional attachment you have to the idea of an accident.  If you know someone who suffered serious pain from an accident and that influenced you a good deal – you may be set up for a pain experience.  If you have been studying disability statistics for a paper and have really focused on the bad outcomes you may well have set your thought processes up to cause a pain experience.  Your brain takes all of this information and if it answers the “How dangerous is this?” with – dude, you are in big time danger – then you may well have a horrible pain experience.  This could be in the absence of any tissue damage and a minor scrape on your bumper.

All of this gets registered in various portions of your brain.  Related pieces of information are stored all over in your cranium.  As you go through life you create these connections and reinforce them.  In any situation the activation of a number of these pieces of information (called neurotags) may lead you to experience pain – even in the absence of tissue damage.  

My favorite is the memory I get when walking through the mall and I smell cinnamon.  I immediately see the living room from when I was a kid waiting for my mother to bring her newly made cinnamon rolls.  Some people drive by where they had an injury and can feel the pain – even after the tissues have healed.

At This Point Things Get Really Interesting

 If you are having a pain experience and your tissues are healed why would you be continually treating your soft tissues?  Most scar tissue is formed by 2 months. At this point the issue is pretty much a brain issue.  People often continue to get expensive treatments for pain.   These are based on the idea of fixing issues in the tissues that have healed long ago.

What really needs to happen is to realize that a more effective and sensible approach is to deal with the sensitization of the nerves that has occurred.  You need to deal with the neurotags.  Your nervous system can change.  That will soon be the subject of another post!


Monday, April 20, 2015

Am I Strong Yet?

My Roots

We all have to start somewhere.  My earliest experiences with strength training had to do with high school and was often connected to my love of wrestling.  Strength was a key element of the training and we worked really hard.  I was on a team in one school where almost the entire team consisted of state champions – no,  I was not one of them.
What was evident to me was that people who were stronger seemed to do better.  They were no pinned as easily and could often break holds.  I could see it’s importance but it was not something I particularly worked at unless the coach was making me do something like push-ups or sit-ups.  I do have to admit a more than passing interest in Charles Atlas and his dynamic tension.  I just never made enough money to buy his product.  It still sells for about $50!

And Then Came the Army…

I joined the Army to study Physical Therapy.  In my mind it is still one of the most important things that I have done.  I learned a good deal about the body and specifically about how therapy is done.  I was expecting to learn massage and exercise.  

What I actually learned was about 3 hours of massage and exercises for particular issues that are regularly seen in a military setting.  It was a very good foundation but it only emphasized the shortening aspect of exercise.  We specifically focused on strengthening muscles for the purpose of returning a soldier to duty in the shortest amount of time.  We were considered miracle workers by many due to the way we were able to get people out of the hospital so quickly.

One of the things that is burned into my mind is the amount of pain often experienced with our approach.  Many people told me that they really dreaded coming in for their treatment.  PT was said to stand for Physical Torture.  No Pain – No Gain was our slogan.

What I Learned as a Trigger Point Therapist

 I went to school to study Trigger Point Therapy.  It was not like today where one goes and learns to incorporate treating trigger points into a massage session.  This was actually studying Trigger Point Therapy as an actual discipline.  There are not many who actually do that.

One of my favorite memories is of a teach asking us periodically in class – with no time to think about an answer – How we were similar to and different from other specific disciplines.  She asked me about Physical Therapy.  My reply – PT sees a person in pain and asks, “How can I teach that person to exercise and increase their strength to get out of pain.”  A Trigger Point Therapist would ask, “How can I lengthen that person’s muscles to get them out of pain.”

Those 2 perspectives differ greatly.  In my experience I saw more people respond positively to pressing “Trigger Points” than I did to “Strengthening” muscles.  In fact, the strengthening approach often increased the pain so much that people often quit therapy before it was over.  The other really interesting thing is that I found people had more strength after the lengthening process and that it was an instantaneous improvement.  The patient did not have to exercise for weeks or moths to see the improvement!

The strengthening approach has grown in recent years into a movement in PT  Athletic Training that is called Core Strengthening.  It seems to make sense that if we strengthen the muscles most responsible for maintaining posture that we should be able to help more people.  The story about posture is pretty well debunked in my post, “Confessions of a Recovering Posture King.” There are numerous studies that actually show that core strengthening is now really effective at all and was implemented by good marketing instead of by good science.

 I really liked, taught, and used the lengthening approach for many years.  Now I think differently.  It’s time for the rest of the story.

The Rest of the Story

When a person is experiencing pain they learn to avoid it by not using the area.  Our brain, for some reason, has decided that it is safer to shut down and avoid movement in order to protect itself.  In long term pain we learn to guard or hold ourselves long after the injured tissue has actually healed.

This lack of activating the muscle shows up as weakness and we assume – often incorrectly that the body’s defense is actually a defect. This defect must be corrected by strengthening or lengthening – depending on the view adopted by your therapist.  

But……What happens if we simply remove the sense of threat?  What if we could convince the brain that there is nothing wrong with the tissue and that nothing bad is going to happen when we move it?  This is what modern pain science is indicating that we should actually do.

The there are those pesky 95 lb. weaklings with zero pain. They don’t need strengthening to avoid pain.  They may need help opening a ketchup bottle though!

You Can’t Replace Something with Nothing!

If the brain is experiencing a sense of threat when there is no actual threat – What can we do?  There are a number of specific things that we can do.  Here we are simply going to mention a few of them.

We can show the brain that it is safe.  This can be done in a number of ways.  I often do this by passively moving a joint to show the person that it is safe to do so.  I then explain that pain does not necessarily indicate damage to tissue.  If there is redness warmth and swelling – indicators of actual inflammation – there may well be a problem requiring actual medical intervention.  If it is an acute injury it is usually a good idea to have the injury checked out – just to be safe.

You can also move the area where you feel pain.  I encourage people to move the area to the edge of pain and to practice doing that.  With practice – the initial point of pain is passed and greater movement is accomplished.  This is illustrated here by a PT.  He calls it Edge Work.

I often touch the painful area and then stay there as I distract the skin from another location.  This actually fires of stretch receptors in the skin and tells the brain that it is sage.  You can do that with a medical tape such as kinesio tape that is sold in drug stores.
These things commonly lead to strength increases without exercise and without pain. They are things that you can do for yourself.  There is almost always something you can do to help pain.

Friday, April 17, 2015

Confessions of a Recovering Posture King

The Culture

I always enjoy a good parade.  The floats are often amazing and there is always a great display of talent.  I like to see the various people as they pass by.  What tends to strike me is the way the people in each of the groups all try to look the same.  The Military people stand erect with stomachs in and shoulders back and they stare straight ahead.  The dance school groups come by and have a very characteristic posture that just can’t be missed.  The people watching are often just as entertaining as the actual members of the parade!

We often see people or even look in the mirror and comment on how good or bad someone’s posture appears to us.  We seem to have an innate understanding of how each other is supposed to look - in our culture!  We often work hard to hold ourselves in uncomfortable positions just so people won’t look at our bearing and criticize.  We know they will because we do it ourselves.

I have to admit that as a therapist I was rather horrible at postural evaluation when I first started.  My wife worked as my receptionist and would often come beck and tell me what she saw in a person’s posture and movement.  This was invaluable to me because I just did not see it.

Then I Learned About Posture

Then I attended a workshop where a local DO taught us how to evaluate posture.  He mentioned during his demonstration that we could use this new tool to see if our clients were making progress.  I light went off in my mind – perhaps I could evaluate the posture and then create a treatment that would intentionally alter it!

I eagerly applied my knowledge of muscles and their areas of attachment and developed a plausible theory of what to treat and what order to do it in.  I made it all up as I went along.  The results were amazing.  I was helping people that I had not been able to help previously.  It was an exciting time.

I even wrote an article about how to do it and got it published in a medical journal.  I had people come up to me at professional meetings and thank me for my work in this area.  I was even asked to demonstrate it for my national association as a major contribution to our discipline.

Another doctor – this time a DC added a substantial missing piece to my puzzle.  I was especially thankful for his input and developed his material to suit my own needs.  I eventually taught this in the school where I worked for 18 years and in seminars to therapists all over the country and even internationally.

This section has contained a good deal of what I call “Blowing and Glowing.” There is a reason for the overrated build up.  I think that most of what I did is wrong.  This is my public retraction.  To set the record straight – I was a Posture King.  I was wrong.


I helped a lot of people utilizing the approach that I developed.  I now believe that those successes resulted from other factors that were not directly related to my postural understanding.  I see a number of problems with my previous approach. 

A lot of people with poor posture don’t hurt.  This is readily apparent.  Just look at the people who you know with less than stellar posture and ask them if they hurt.  Many of them do not.  If posture is directly a cause of pain we should find that everyone with poor posture also has a pain complaint associated with that particular postural fault.  It simply is not the case.

We are not simple machines – in fact scripture teaches that we are “fearfully and wonderfully made.”  If we were a simple machine it would make sense that a lift under a short leg would balance everything and our pain would just disappear.  I have put lifts in shoes and under heels for years and can confidently state that many people remained in pain.  They did so because we are a flesh and blood creation and have our very own nervous systems.  A machine would have been fixed.

Fixing the posture rarely works long term.  I could often make a posture look rather stellar but it was often a short lived thing.  I saw those who were helped long term but unless they followed through on a number of other things I had them doing - those were a minority. 

Anatomical variation is hugely apparent in people – often in the same people from side to side!  In a recent study the pelvis was compared for symmetry from side to side in the same person.  The sides were clearly different.  There is great variability in studies when therapist attempt to describe what they see posturally in the same person.  This is in the literature and I have seen it numerous times myself in settings where I have tried to teach postural assessment.

Freeze, Fight or Flight is something we have all heard of.  Simply stated – When we have a sense of threat we tend to curl up in a ball to protect our “tender vittles.” In our homes and work places we tend to live in this constant curled up little ball.  No amount of bodywork is going to correct our posture if we live under a constant state of threat and stay curled up in a tight little ball.

Why Did It Work?

To hear me tell the story above about how I learned of the importance of posture and how to treat it successfully you are probably wondering why I have come to believe my approach was wrong.  I did give those reasons in the last section but of course the question remains – Why did it work in the first place? You can bet I asked that question myself.  It’s the stuff insomnia is made of.  I have a few thoughts on that subject.

I not only started dealing with posture – I also began doing a number of other things at about the same time.  One of the biggest things was that I really lightened the amount of pressure I was using.  I really thought that in order to be effective that I had to cause a good deal of pain during the treatment session.  Once I lightened my pressure it really helped the process.

I also began to look into the ergonomics of my clients at home and at work.  I showed them how to vary their routine and encouraged them to move frequently.  This had the effect of allowing the blood to be supplied to the nerves and to lower the threat level experienced by the brain.  More blood to the nerves is generally a good idea.

I also started talking more with my clients about things that tend to perpetuate pain.  I recommended books and began to give a good deal of movement for them to do between sessions.  Those who did these things  seemed to improve more quickly.  I believe these are a few of the things that made people feel better and I credit them rather than my attempts to correct posture – with helping their posture!

Another Way

I now have an entirely different focus when I treat people.  I generally look for signs that a person is in sympathetic mode (that’s a fancy way of saying Freeze, Fight, or Flight).  There are a few indicators that are especially helpful.  
  • ·       Upper Chest Breathing
  • ·       Feet that point to the ceiling
  • ·       Cold hands and feet

I see these as indicators that their nervous system is on overload and I work to calm them down using a variety of massage techniques.  These are often performed on the neck.  It is very common to see a pelvis untwist and the shoulder drop after a few minutes of this.  I am trying to calm down the nervous system and as the person begins to relax they begin to uncurl from that tight little ball and the posture does actually change.  The difference – and this is a BIG DIFFERENCE – is that I am not forcing my will on the person and trying the change their posture. Instead, I am supplying novel input to their nervous system and it is adapting itself to the new information gleaned by its receptors in the skin that I am touching. 

There are a number of other ways of getting our nervous system out of this condition of sustained irritation.  Believers can be seen doing these things all throughout the scriptures.  Here a few of them.

Theologians in the Presbyterian tradition often speak of what they call the “Means of Grace.” These are enumerated as:
  • ·       The Word of God
  • ·       The Sacraments
  • ·       Prayer
Let’s look at these and see how they apply to our subject.

The Word of God is identified as the Scriptures contained in the Old and New Testament.  When we hear it preached, taught, or when we read it the Holy Spirit often uses it in our lives.  We deepen in our love for our Triune God as we see his plan of redemption, Christ’s death and resurrection for our sin, and as the Holy Spirit applies it to our lives.  This happens in many ways.  We begin to think about him and the focus and meditation of our heart is on him and his person and work.  We rise above this world and adore him.  It is not uncommon for our cares to roll away.  I have seen shoulders drop and people rise changed.  It’s hard to be in Fight or Flight when adoration of our God is occurring.

The sacraments of the church are identified as Baptism and the Lord’s Supper.  These are done in community.  People in pain often tend to live in isolation that increases stress.  In worship we not only adore God but we pray for each other and try to meet each other’s needs.  This often gets the focus off of us and our problems and can be incredibly effective in lightening our cares.

There is nothing quite like prayer to get out thoughts off of us and onto God.  We pray to him as Christ taught us.  We pray acknowledging who he is and what he has done.  We bring our requests to him and we trust him with our needs.  Talk about stress relief.  The Creator of the universe loves us and asks us to ask him.  Burdens are lifted.

There are other things that can also help in dealing the stresses that curl us into little balls.  Learning certain breathing techniques is a great way to bring us into a calmer state.  The way I like to have people train their breath is to have them breath in to a count of 4.  Hold for a count of 1. Exhale to a count of 6.  The longer exhale puts us into a more relaxed or parasympathetic state.  It should be done for about 3 minutes.

Nutrition is a big thing also.  Studies seem to indicate that stress uses up our B vitamins and that supplementing with a good B complex can keep our nervous system from being as irritated.

Regular massage therapy is also an ideal way to keep our nervous system happy.  As a massage therapist I recommend it highly.  Exercise is another great way to help your nervous system.  These are a number of ways to keep out of that tiny stressed out little ball – and maybe even improve your posture as a side effect!