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.

Entering the Matrix – the Neuromatrix!

I really enjoyed reading Elyse Fitzpatrick’s, “Idols of the Heart: Learning toLong for God Alone.”  In it she does a really good job of explaining, in very understandable language, what the Bible means when it uses the word “heart.”  That is a word that we tend to use a good deal and you may have even heard people teach about it at church.

The idea is that the word heart in the Bible has an incredibly rich meaning that I can only touch on here.  Please see the book for a more in depth treatment.  Basically the heart refers to our non material self and is loosely described as having:

         

·       Intellect

·       Affections

·       Will

The intellect refers to what we think – and we are always thinking.  We are constantly told in scripture that thinking is very important.  Look at these well known verses:

(Rom 12:2)  Do not be conformed to this world, but be transformed by the renewal of     your mind, that by testing you may discern what is the will of God, what is good and acceptable and perfect.

(Php 4:8)  Finally, brothers, whatever is true, whatever is honorable, whatever is just, whatever is pure, whatever is lovely, whatever is commendable, if there is any excellence, if there is anything worthy of praise, think about these things

As you can see – the Bible teaches that what we think is incredibly important.  What we think tends to show up in our speech and life.  It is not only biblical – it makes sense as well.

Not only do we have thoughts – we have Affections as well.  The term does not refer to nice thoughts as much as it does to our deeply seated emotions and emotional attachments to things and ideas.  We can love the world the flesh and the devil (Eph 2:1-3) in the sense that we have a deep attachment to them.  We can also love the LORD our God with all our heart, mind, and strength (Dt 6:5).

There is always the ever present will.  We always make a decision to do or not to do.  This is perhaps most famously demonstrated in the decision of Adam and Eve in the garden when they partook of the “fruit.”  We see a radically different one made by Jesus when he was tempted by the Devil in Luke 4.  Joshua commanded the people to “Choose this day.”

Compare this with the following picture of the Neuromatrix.  It is the attempt of psychology and pain science to explain the phenomena of pain.  On the left side it shows the input to the neuromatrix.  They use this word to describe the brain.  On the right side they show the output of the brain which is based on the input on the left side.

The left side of the diagram show input from our:

·       Cognitive-related brain areas

·       Sensory Signaling Systems

·       “Emotion-related brain areas.” 

The way this works is that each of these 3 types of input go into the brain/neuromatrix.  Let’s see how this works from this perspective.

The first input mentioned comes from our thoughts.  What we think has a huge effect on what we are going to experience in the realm of pain.  If we are told that a particular tissue is responsible for what we are feeling we get that idea firmly planted in our thinking.  If we saw horrible things happen to someone having a pain like ours we are likely to link that idea in our mind to our own situation.  This goes into the neuromatrix mixing bowl.

The second area on the left input to the neuromatrix is the actual sensory input carried by nerves from our tissues.  There may be inflammation or lack of blood and oxygen to a particular area.  The nerves transmit this information to our brain/neuromatrix – the mixing bowl.

The third input to the neuromatrix comes from our Emotion-related brain areas.  They call this the Limbic System.  Let’s say you saw aunt Sally fall from a ladder and hurt her back. 

She was bed ridden for some time and could only get around in a wheel chair.  When you now fall you remember that feeling – in fact now feel the same way after your fall.  This is a potent addition to the neuromatrix mixing bowl. 

This is all mixed and baked in the brain and the individual ingredients now serve in this mixture to give an output from your brain’s oven of a pain experience.  You may also have an output of movement and stress related chemical soup.

I have read a good deal about the neuromatrix theory from some real sharp atheists.  I don’t know what the developers of the concept thought about the existence of our common Creator.  What I do know is that we all live in the same created universe and that as we look at the same material we are bound to get a few things right.  I believe that the concept of the neuromatrix is in essential agreement with scripture and can be adapted easily to our purposes for pain relief.

The Cognitive concept certainly fits well with the intellectual information that the biblical concept has.  The actual input from our tissue via nerves is in no way disagreed with in scripture.  It is certainly clear from scripture that we have deeply rooted affections.  Jonathan Edwards actually wrote a great book entitled Religious Affections.  It is available at the time of this writing for .99 in a kindle edition and is well worth the read.

The purpose of this post is to give you an understanding of what leads to pain.  In other articles we will discuss what can actually be done for it. We will utilize this information in those posts.  I hope you will seek out the books mentioned here and look forward to the more that is to come!

Pain: How do we understand it - Tom Myers presentation critiqued by Jason Erickson,NCTMB, CMT, ACE-CPT, CES, CAIST, BBA, BA, AA

The following video of Tom Myers was the subject a Facebook thread I participated in.  The information presented was not in any way, shape, or form in accordance with current science based understanding of this issue.  Jason Erickson, NCTMB, CMT, ACE-CPT, CES, CAIST, BBA, BA, AA  gave the response below.  I consider it to be a very thorough refutation of Myers position.  

Myers is not being attacked - but his ideas are.  This is as it should be.  Mr Erickson posted this to YouTube and it was removed.  I consider his response to be of sufficient magnitude that I would like it preserved here for future reference.  I received specific permission from Jason to publish this here.  It is my hope that it will be read and introduce many to real pain science and give a foundation for further learning.

Tom Myers - Why Does Massage Hurt

This video really disappointed me. A while back, I invited Tom Myers to participate in discussions of pain science with people that have serious credentials and expertise in pain science. He didn't participate for long. It now appears that he never did learn anything from the resources made available to him.

He has a personal definition of pain, and it's not accurate because there can be pain without "a motor intention to withdraw". The best current definition of pain used around the world is from the International Association for the Study of Pain (IASP) taxonomy:

"Pain

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

http://www.iasp-pain.org/Taxonomy?navItemNumber=576

I am glad that he acknowledges the presence and role of the free nerve endings in nociception, but he seems to think that nociception and pain are the same thing, as if they are strictly a biological phenomenon. This is also not true.

From the IASP taxonomy:

"Nociception*

The neural process of encoding noxious stimuli.

Note: Consequences of encoding may be autonomic (e. g. elevated blood pressure) or behavioral (motor withdrawal reflex or more complex nocifensive behavior). Pain sensation is not necessarily implied."

Nociception is unfiltered, raw data. It is not a sensation. Some reflexive responses can be triggered locally or at the nerve root, but there is no sensation until the brain interprets the incoming data. Whether or not nociception is transmitted to the brain is mediated at the spinal cord level, and the significance of what the brain receives is mediated by many different parts of the brain associated with memory, cognition, emotions, learning, sensation, motor control, etcetera. If something else demands higher brain priority due to psychosocial contexts, the brain may "ignore" that nociception altogether.

That contextual interpretation of the raw sensory input is a critical part of whether or not the brain generates the sensation of pain. In this video, Tom refers to yoga practitioners experiencing strong sensations that could be uncomfortable/intense but not painful. He also states that those who are "reaching their physiological limits" may experience pain.

Those new to yoga, who have not yet become comfortable with the poses and practices, often lack the contextual learning that would facilitate performing yoga without pain. The practice of yoga (or other strenuous physical disciplines) trains the nervous system to interpret sensory data with a greater discrimination between what represents threat and what does not.

Like Tom, I do not believe in the "No pain, no gain," approach to bodywork. I'm more of a "No pain, more gain," therapist.

I strongly disagree with Tom's unfounded assertion that there are "three types of pain": "pain coming into the body", "pain stored in the body", and "pain leaving the body". He's just stating his personal philosophy and metaphors/analogies/stories... let's look at each one:

1) "Pain coming into the body": Here, Tom seems to think that pain is something that is inevitable from the moment our tissues are affected in some way. No. We have known since the 1960s that pain is not an input, and that the nervous system modulates whether or not we feel pain, and to what extent - that is what precipitated the publication of the Gate Control model of pain. However, even then the authors knew it was flawed and limited, and did not explain many known pain conditions. It is true that nociception can be very important in the processes that result in the sensation of pain, and the term "nociceptive pain" would seem to cover what Tom is talking about here.

From the IASP taxonomy:

"Nociceptive pain*

Pain that arises from actual or threatened damage to non-neural tissue and is due to the activation of nociceptors.

Note: This term is designed to contrast with neuropathic pain. The term is used to describe pain occurring with a normally functioning somatosensory nervous system to contrast with the abnormal function seen in neuropathic pain."

Note the mention of neuropathic pain. Nothing is "entering the body", it's already part of the body. There is much more to be said about it, but I'll leave it at that.

2) "Pain stored in the body": Tom basically says this is experienced as fatigue, malaise, and postural changes... but not as pain. Here he is misinterpreting changes in posture/movement as pain instead of as non-painful co-occurring symptoms. As an analogy, it makes a crude kind of sense, but if we're going to think clearly about our terminology and the underlying processes of pain and altered motor control, then we need to avoid this sort of thing.

A body under stress with a nervous system that is constantly/chronically interpreting threat(s) from incoming somatosensory input will normally make adaptive changes including autonomic physiological responses (altered, often increased sensitivity to sensory inputs, altered hormone levels, circulatory changes, breathing habits, etcetera). These have enormous impacts on how we experience the world. Our postures, habitual movements, gaiting, balance, coordination, etcetera may be impacted as well.

I do tend to agree with Tom that the body often attempts to arrange itself so that it feels less threatened. (He says "pain" but I think I understand what he's trying to say.) These changes in physical arrangement are not always associated with pain, however, and may not be subject to a physical "release". There are psychosocial dimensions that Tom is not addressing here that are at least as important as anything that can be done manually.

3) "Pain leaving the body": This is the least clear portion of Tom's talk. My interpretation is that he is primarily referring to mental/emotional experiences that are uncomfortable, and that he seems to think it's important for a person to have some sort of "remembering" of prior trauma (either as physical sensation, emotions, or whatever) during their treatment(s).

I am very concerned about this part, because he says he believes that people can't be treated for pain without them having some sort of intense physical/mental/emotional re-experiencing of the prior trauma. In my experience, that's patently NOT TRUE, and I would NEVER, EVER plant that idea in a client's head. Doing so may actually make it more difficult to help them, and possibly even make their pain worse by creating a false expectation that might never be fulfilled... and then the client may never recover fully.

Also, massage therapists/bodyworkers should never have the intention of inducing such a mental/emotional response in a client. In doing so, we may actually re-traumatize them. That could make their issue(s) much, much worse. Besides, it is outside of our scope(s) of practice. We are not mental health professionals, and should never seek to pretend otherwise.

Instead, it would be better to never mention this idea to a client, and just work with them. If they have such an experience, just be a caring professional and give them a safe space for it as appropriate. If they have questions about such things, just let them know it happens now and then. Sometimes it's minor, but for some people it can be pretty intense. Keep some tissues handy just in case. Don't make it a big deal. It's their experience, so let them decide how significant it is in their recovery process.

Tom also seems to think that we are walking around holding the collective traumas of all of our ancestors as "stored pain"... but then he veers into historical contexts that are effectively social contributions to how we think, feel, and move... and ends by saying that he thinks personal trainers should help "get the pain out" through exercise. As a personal trainer and corrective exercise specialist who has helped many training clients get through their rehab process, I agree that movement and training can be very effective ways of reducing/overcoming pain.

In some ways, parts of Tom's descriptions of his "three types of pain" correlate with different aspects of the biopsychosocial notion of pain that is rapidly becoming the dominant model for understanding how pain works and how to treat those who have pain. The Neuromatrix Model of Pain, authored by Dr. Ronald Melzack (who also coauthored the Gate Control Model), lays out a rough blueprint for understanding how biological, psychological, and social factors all contribute to how/whether we experience discomfort, and why.

There is a link to a paper "Pain" about pain and the historical development of pain science (also authored by Ronald Melzack, with Joel Katz), in the comments pinned to the top of this page (That was in the original FB post - here is that link:  Pain Article by Melzack & Katz. It's an excellent read, and if you've read this long post, you'll be just fine with that paper.

Though my personal interactions with Tom have been positive, I think there is more value in studying the actual pain science than there is in listening to him talk about pain. I like some of the hands-on methods he teaches, but I think the reasoning demonstrated in this video is severely flawed by lack of modern medical knowledge about pain, what it is, how it works, and why.

This is to Jasons Page Jason Erickson

No Pain No Gain?

A very frequent thing that I hear as a massage therapist is that people really believe that unless it hurts – massage is not going to help.  The message is delivered to me in many ways.  Some people come in and ask for “deep tissue massage.” Others tell me to press as hard as I can – they can handle it.  Many relate positive results of previous treatments with other therapists.

There are many reasons for these requests.  Many believe that their posture needs to be improved and that the only way to do this is to have someone use a good deal of pressure to put things “back in place.” Others believe that their muscles are so tight that only tenderizing them like a piece of meat will work.

My preference in these situations is to ask why they are coming to me in the first place.  They usually mention some type of pain that they want to go away.  They have been to many other practitioners and now they are in my treatment room.  They often give me an overview of their life and health history.  This is where I get some of my best indicators of what needs to be done.

Almost without exception I learn of multiple stresses in their life.  We all know and have lived the litany of problems at home and work, health issues, and whatever maelstrom they happen to inhabit.  Now they are with me. 

At this point I like to point out that I don’t fix people.  Surgeons do that.  I explain that the skin contains nerves fibers that report to the brain.  There are danger receptors (nociceptors) and receptors that tell the brain where they are in space and what is happening to their skin (mechanoreceptors).  My work currently focuses on activating the second group instead of the first.

Some therapists and those who like to see them prefer techniques that activate the danger receptors.  It feels good and both the therapist and the client can testify to the good results.  It’s hard to argue with results.

So why are painful treatments giving the good results?  Why on earth would anyone argue with such a thing as a good outcome?  If everyone involved is happy – why don’t I do the same thing?

I did do the same thing.  I did it for many years.  I treated a huge number of people.  I believe that I do a much better job now.  To understand what I was doing, let’s take a look at how the nerves in the skin send their information.

The type of pressure that activates the danger receptors is usually perceived as somewhat painful.  This is because it creates a little inflammation.  This is one of the ways to activate the danger receptors.  The brain uses this opportunity to release chemicals (endorphins) to decrease the sensitivity of the spine to input from the danger receptors.  This is sometimes called descending noxious inhibitory control.  Endorphins also affect the brain in a number of ways. 

One of these ways is to create dependence on themselves.  People need more and more of a release from this chemical soup to get the same effect.  The effect is very similar to drug addiction.  This is a way in which deep painful massage can feel good but lead to problems over time.  It is why I do not like to give painful treatment.  This link discusses the brain controlling pain: The Drug Cabinet in the Brain

The other receptors respond to pressure and stretch in a good way.  The brain receives information about where the body is in space and of pleasant pressure.  It then takes that information and along with a good deal of interpretation by various parts of the brain that have to do with it’s history and deeply held beliefs and affections – gets to output relief.  This is the effect of activating our parasympathetic nervous system.  This is what massage is justifiably famous for.  This link will discuss how what we believe affects how our brain interprets information:  Why things hurt - the Brain

This is why my treatment tends to entail more gentle pressure and stretching of the skin.  The light pressure approach can be seen to be effective by the flexibility that usually returns to the muscles and the changes in posture that happen at the end of the treatment.  It is not my goal to change posture or increase flexibility.  It is often how your body chooses to respond in response to gentle non-threatening treatment.  It is the result of “First – do no harm.”  

Pain Independance Day - Yours?

I woke up today in what is perceived by many to be a free country.  I can pretty much Do what I want.  At least I can do what I want within certain prescribed boundaries.  I can’t just go out and steal.  I can’t go out and do treasonous activities.  If I do these things there are certain consequences.

This freedom came at a price.  It came at a great price.  The parallels to those in pain and what they can do for themselves have been on my mind today.  I see at least 4 that I would like to mention today.

Decision – Our forefathers spent a good deal of time trying to work out their issues with the crown.  At some point they made a decision.  We call it the Declaration of Independence.  At that point they laid it all on the line and charted a new course. 

People in pain often try a few skirmishes.  These include many things for different people.  In my case I took 8-12 aspirin for about 2 years to deal with the pain that I developed following a hit and run.  I was on the bicycle.  The car was bigger.  At some point I made a decision to do what I needed to do to develop a lifestyle to deal with my issue.  People in pain need to make this decision.  It often has consequences.  One of the better ones is decreased pain and often the ability to do activities that were limited by that pain.

Work – A decision was a good start but work was required.  An army had to be raised.  The colonies had to work together.  It was a formidable task to go against vastly superior forces that were better trained.  People who hurt need to work also.  I have had many clients tell me that they are not willing to do anything that is required in order to get better.  That is why they have insurance.  It is not their fault that they hurt and somebody else better “fix” them.

These people usually don’t get well.  Pain is an output of the brain.  It is a message that we need to do something to change the situation.  Apart from a decision and then active work to deal with the besetting issues there is rarely resolution.  Therapists rarely “fix” anyone or anything.  People need to work toward resolution.  This often means dealing with habits, environments, and underlying thoughts and attitudes.  The Biblical concept of the heart includes intellect, will, and affections.  How this can be applied to pain will be developed in later posts.  I simply want to point out that change in these areas requires work.

Sacrifice – Our forefathers had to sacrifice tremendously.  Many lost all they had.  Many lost their lives.  Others lost friends and relatives.  Those in pain often need to make sacrifices.  The diabetic needs to avoid sugar.  That is hard.  Some people need to avoid gluten.  Others simply need to spend more time in bed – that can be hard.  Entertainments often need to be changed.  All of this can be difficult.  Rarely does relief from chronic pain come without some type of lifestyle change that is perceived initially as a sacrifice.

Recurrence – Our forefathers were not done when the war was over.  It was quickly followed by the War of 1812.  They had to do the same thing all over again.  Those who find relief from pain often find that it comes back.  They need to keep dealing with the issue.  It requires a lifestyle of vigilance.  Habitat and Habits may need to change.

Today is a good day to make a decision to deal with your pain.  Let July 4^th be a day of decision to work and sacrifice to make a change in your pain.  Keep checking here for help.