A different lens

I wrote this on a forum called SomaSimple where ideas are challenged regularly and the discussions are regularly about the topic of pain. Since the BPS model includes psychological factors, the overlap seemed to fit well with some of my experience as a trainer. Here’s what I wrote:

“I don’t work in a clinic, I work in a gym. As a personal trainer, it isn’t uncommon for us to have clients who have some kind of ache or pain; if not at first, there’s likely a point where they’ll run into that experience during training. This was one of the main reason I enrolled into a massage program and eventually found DNM and this forum.

In my training career, my clientele has predominantly been female between the ages of 25 & 60. Most clients come to the gym for weight loss (specifically fat loss, but that’s a separate rant) and some of the measures that are taken to work toward better aesthetics are quite extreme (such as using a feeding tube “diet” to lose weight for a wedding).

The extreme measures that can be taken are usually drawn out of something quite emotional. I had one client cry after telling me she was sexually abused and used weight gain to make herself unattractive to her abuser. You can only imagine the road that kind of trauma will take people down when it comes to healthy lifestyle choices.

Much of what training is about is behavior change. Then Jason Silvernail recently posted this great comment on his FB by Bronnie Lennox Thompson. If you can’t read it due to privacy settings, this part of the comment particularly stood out to me:

Quote:
“…, then I get on with helping them do behavioural experiments anyway, because behaviour change WORKS, while cognition/information doesn’t always do the trick.”

I wanted to share what I thought might be some behavioral comparisons or overlap in what the therapist might see in clinic (PT) vs. what I see in the gym with clients (GC):

PT: “I don’t want to bend forward because I’m afraid I’ll do more (perceived) damage.”
GC: We can get a similar statement above, but I commonly hear, “I don’t want to lift weights because I am afraid I’ll get big and bulky.”

PT: Client might cease movement for fear of pain or further (perceived) damage.
GC: Client will cease food intake for fear of weight gain.

PT: Client may try extreme therapy protocols to help relieve the pain.
GC: Client may try extreme dieting or training protocols to help lose weight.

PT: Client may over-analyze diagnoses and split hairs on the little things, like “I hurt because I was sitting too long with bad posture.”
GC: Client will split hairs and over-analyze the little things, like “I didn’t lose weight this week because of that one candy bar I had on Tuesday.”

PT: Client may jump from therapist to therapist or modality to modality.
GC: Client may jump from trainer to trainer or protocol to protocol.

PT: Client may have issues with body awareness (smudging).
GC: Client may have body image issues (perceive themselves as bigger than they are).

This wasn't a part of the original SS post, but we all have those clients who are strong and beautiful, with unrealistic expectations. Image source Tumblr.

This wasn’t a part of the original SS post, but thought it fit well with the emotions behind diet and fitness behaviors I’ve experienced. Image source Tumblr.

If you think I am going a little too far out on a limb, let me know, these were just some random thoughts that were rushing through my head the other day and I wanted to get them out. Also, I’m not picking on women, I know men who have similar body image issues, I just have more experience training women. My thought process is that with the neuromatrix model, the emotions that people experience can be another form of pain that people bring the table, and emotions are a big driver in health and fitness choices and behaviors, making this information just as important for trainers, as well.

Thanks for reading.”

Jeromie

The Lunge

For those who are new to my musings, I started working in a new facility basically right after my wedding. It’s been an interesting 6 months, but I really appreciate that one of my co-workers, Nick, is a talented and experienced trainer. I feel like I’ve learned more from him over the last 3 months or so than I have from many of the courses I’ve taken (words from my wife during dinner conversation). One of the things I recently brought up to him was his opinion on the lunge.

It was this article by Tony Gentilcore that sparked my curiosity. I read the article when it was first posted well over a year ago, which drove me to pay more attention to the lumbar spine during lunges, and Nick agreed, but he brought up another good point. With lunges, the focus is usually on being tall, shin vertical, and taking a relatively big step for a good stretch on the hip flexor of the back leg. The point he wanted to make? The only way to get up out of this position is by pushing off the back leg.

Lunge copy

As you can see by the arrow, related to the post from Tony, there’s some lumbar extension, there’s a big stretch on the hip flexor of the back leg, and the shin is vertical.

This vertical shin position is something I look for in a box squat, and it’s a difficult task to do because of how much emphasis it places on loading the hips. Now take one of your legs out of the equation (the back leg) and try to stand up with a vertical shin – this is basically what is being asked for with a lunge. You have no choice but to push off with the back leg. If you try to slow down your lunge and really focus on loading the front leg, you will have to shift your weight forward some. Which brought up another great point: eccentrically loading the glute on the front leg. When Nick brought this up, I immediately dropped down into a 1/2 kneeling position and slowly shifted my weight forward until I felt a big pull on the tissue in my gluteal region. Once I felt the difference for myself I knew I needed to make that adjustment.

Here’s what I do now:

1. Take a step back (or forward if you’re walking) only big enough to push off as little as you can with the back leg.

2. Make sure to have a little forward lean in your torso so you’re not getting too much lumbar extension.

3. Make sure your weight is shifted forward enough so you feel a nice eccentrically loaded glute, but can also keep your foot flat and not come up onto your toes. You still want a tripod foot position while minimizing shear forces on the knee joint.

It's much easier to load the front leg when I shift forward a tad.

It’s much easier to load the front leg, and I get better glute involvement, when I shift forward a tad. I probably didn’t need to lean forward in my torso this much, either.

For all of the form perfectionists and one-size-fits-all folks, I realize that everyone’s position will probably look a bit different. It will depend on what you as a trainer or trainee hope to accomplish with the movement and if something hurts. And if you or your clients even enjoy the movement at all. This is just something I’ve been playing with and it’s something that a couple of trainers that I respect made really good points with, so I tried it, liked it, and started implementing it.

Give them a shot and let me know how you felt with the adjustment, if it was harder because maybe you were pushing off with your back leg a lot more than you thought, and if you were sore in your glutes in a whole different way.

Jeromie

Quick post: Musings on pain and activity

Pain fascinates me because you can experience pain without having any tissue damage. I’ve been coming across information lately that has me thinking about pain and physical activity.

There are nearly 45 miles (72 km) of nerves running through the body, yet the nervous system only accounts for about 2% of the body. The nervous system is accompanied with a blood supply because of its requirements for about 20% of the available glucose and O2.

I came across and appreciate this picture that I saw via social media and I thought it was really interesting to see the veinous system (both arteries and veins) mixed into the bundles of nerve fibers.

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I found the original source of the picture here.

To add to that, there’s a capillary every 5 cell widths. No wonder sitting is considered the new smoking.

With this in the back of my mind, I see how physical activity can be really helpful in managing pain conditions (especially chronic pain).

“Motion is lotion.”

The more I read about pain, the more I realize it’s not something to fear. Pain is a normal part of living. It’s a signal that’s trying to tell you, “something is wrong, or something might go wrong, so something needs to change.” It’s your body’s alarm system.

Physical activity can help “turn the volume down”, or speed up the recovery process for tissue that is actually injured, so it’s important to move. Move everyday. If you move with intensity, give yourself a break from that kind of activity, but don’t stop moving. Give yourself challenges. Move differently all the time. Play. Just try to utilize the ranges-of-motion that your body feels safe with (that don’t “sound the alarm”), while trying to address movement discomfort with a knowledgable healthcare provider. You’ll feed the nerves, you’ll keep the blood flowing, and you’ll keep your brain happy.

Your body will thank you in the long run.

Jeromie

Memento Mori

Scrolling through social media the other day, I came across a blog post titled: Memento Mori: Art to Help You Meditate on Death and Become a Better Man.

From the post:

Memento mori. Remember that you will die. [emphasis mine]

Us moderns don’t like to think too much about death. It’s a bit too depressing and morbid for our think-positive sensibilities. Our culture is devoted to perpetuating the lie that you can stay young forever and your life will go on and on.

But for men living in antiquity all the way up until the beginning of the 20th century, rather than being a downer, death was seen as a motivator to live a good, meaningful, and virtuous life. To help men remember death, artists created paintings, sculptures, and mosaics depicting skulls, skeletons, and other symbols of death.”

I found a photo very similar to the one below using Google images and now I have it as my background picture on my cell phone.

 

Memento Mori
Image source: click here.

Remember that you will die. I appreciate the use of death as a motivator to live a good and meaningful life. I remember seeing a blog post about the top 5 regrets people had at their deathbed. You can find a link to the post (I don’t think it’s the original) by clicking here. Each regret people had seems like something that would be less of a regret if death was used as a motivator for a meaningful life. #1, for example, is wishing for the courage to live a life true to one’s self, instead of a life others expected of them. There isn’t much that’s more meaningful than a life true to yourself.

With the thought “remember that you will die” being thrown around in my head, I started to write some things down and here are those musings thrown together in one place for the rest of the world to read.

What are some things you’ve decided to not do because of fear?
What have you not spoken up about or stood-up for?
Have you ever held yourself back from anything? If so, what’s held you back (if not fear)?

Now I want you to think about having only 6 months to live: would you still hold yourself back from any of the things that popped into your head after reading the previous questions? What about having only weeks to live? Days? Minutes?

When death becomes a nearing reality, it can be used as a great motivation to do the things you desire. But that’s something most of us assume will happen many years from now. As I sit in a Starbucks lobby writing this, I could drive home later and end up in a fatal car wreck. I could go to sleep tonight and not wake up for reasons unknown. Life is full of “what ifs” and my own life is rather predictable with each day, but that doesn’t make me invincible. It doesn’t make anyone invincible.

Just because you’ll die doesn’t mean you shouldn’t live.

We will all pass one day; what will you be known for by your family and friends? What kind of risks will you have taken? What things will you have spoken up about? Be honest with people. Never give up on your hopes and dreams. Most importantly, don’t hold yourself back.

There are people in my life, myself included at times, who make choices out of fear that may lead them to having those same 5 regrets on their deathbed. They may be big life choices, such as a change in careers, or less significant choices, such as not driving to the next town because of a fear of driving on the freeway.

I’ve not given my all to friendships – I am terrible at staying in touch and could spend much more time than I do with friends and family. I’ve not given my all to employment opportunities – I’ve not gone the extra mile and have failed to follow through on certain things which have disappointed employers or employment opportunities. Most importantly, as this is a movement- and massage-oriented blog, I’ve not given my all to my well-being, and I know many people who likely follow my work or stumble upon my work who feel the same way. You’re not alone. You’re never alone, as much as you may tell yourself those things, and this is your reminder.

This is your reminder to dig deep inside yourself. To stay consistent. To understand that knowing you’ll die is all the more reason to live for yourself, which is a much different feeling than living with yourself. To know that you need to make decisions about your health that are for you and nobody else. To not let fear get in the way of your goals to be a healthy, happy human. Trust your instincts and knock down the walls of doubt. Memento mori.

Jeromie

What sorts of thoughts does this post provoke for you? Let me know in the comments.

SMRT Reads – Functional Anatomy Seminars

I’ve written 5 posts this year and it’s nearly August. For that, I apologize, but my focus has been on working to save for a wedding. Work has slowed down, so I figured I’d throw something together with a few of the posts that I’ve read and have been keeping in my inbox.

Since taking my FR® course, I figured I’d post a few of the articles that highlight the knowledge that has driven me to respect and appreciate Dr. Spina’s systems. And I am taking the Functional Range Conditioning™ course hosted in my home state coming up in January.

Function of Anatomy: the SPINE

This quote sums up the brilliant way Dr. Spina thinks: “At the level of the spine, there is very little relative tissue motion that occurs between each spinal segment (motion segment). The creation of gross spinal movement occurs via the summation of small segmental movements across larger spinal sections. Production of such movement is the job of the more superficial muscle groups that cross several articular segments. For example, when forward flexing the lower spine, movement production is achieved by activation of the larger, stronger, superficial muscles, and the gross movement should be distributed across several lower lumbar motion segments (as well as a significant contribution from the hip articulations). In contrast, when a significant amount of movement is achieved at a single segment, tissue damage often results. We commonly refer to this phenomenon as ‘spinal segmental buckling.’ Because of this, it is more accurate to think of the spine as a single, stiff unit that ‘bends’ rather than as a collection of individual articulations that move independently.”

Muscle…

And his thoughts on muscle: “If you consider ‘a’ muscle to be a single unit that produces one specific function you are grossly underestimating the complexity of its structure.

A muscle is more than ‘a’ muscle as all of the units that make up the structure (myocytes) can themselves be considered ‘muscles’ in their own right, each producing the exact function independently as does the whole. Namely, they draw tension into the connective tissue elements which surround them. From this perspective, each individual sarcomere can also rightfully be thought of as an independent ‘muscle’ whose protein components interact on the molecular level to tension their endomysial encasements. Thus ‘a muscle’ is more accurately thought of as a general name given to a group several thousand functioning structures. Each of these structures produce slightly differing angles of pull and thus create differing angles of tension affecting movement production.”

The secret to health…

This is a post written as a letter to a client: “The fact of the matter is that a general overview of all of the scientific evidence that has ever been published on human health strategies leads to one common conclusion: Being a healthy human requires ongoing effort and dedication.”

“Functional” Exercise??? What do you mean? …

This post is a favorite because it addresses how anything can be “functional” given the context and reason for choosing the exercise: “Two of the most common questions that I am asked on a regular basis (likely due to the names of the seminars I teach) are “what is functional anatomy,” and “what is functional movement.” On the surface these seem like reasonable questions that should have relatively easy answers. For example when considering the first question one might simply say that functional anatomy describes the “function of anatomy.” Or I suppose you could also say that it outlines the “anatomy used as one functions.”

What if you were asked as a follow-up question “what is the most important part of human anatomy?” This question seems more difficult because there really is no single answer. In fact, to answer the question one would need to demand more information as it would depend entirely on the specific function that the ‘anatomy’ was performing at a particular time.

Similarly the question “what is the most important function?” poses a similar problem. The most important function is the one that is needed at a particular time.

How about the second question? What is functional movement? The answer would be that functional movement is movement that achieves a certain function. What then is/are the most functional movements? Again, to answer this question we would require further information as the ‘functionality’ of a movement depends entirely on the goal that it sets out to achieve….”

Be sure to read the entire post, as I just posted snippets from each one. I look forward to what FRC™ can teach me and how I can apply the methodology to get even better results than I am now.

Jeromie

Pain Quotes from Research

As you all may know by now, I am a little fascinated by the way pain works. The way I currently understand it (I say that with the assumption our understanding will evolve with time), pain is the response of an input to the brain and the brain determines whether or not that input is a threat. If it’s determined that there’s threat, there will be pain. If not, there will be no pain. This is why you can have no tissue damage, yet you’ll still have pain, and it’s why you can have tissue damage without feeling any pain at all.

The biopsychosocial model of pain is the latest model that I’m aware of that utilizes multiple factors of a person’s pain experience with less of an emphasis on their biomechanics. This means that it’s less likely for pain to be because of something such as a tight psoas, and more because of cognitive, emotional, and sensory input(s). Does that mean biomechanics don’t play a role? Of course not. The way you move is likely one of the factors under the pain “umbrella”, but it isn’t the whole story. This photo should help that make sense.

Neuromatrix

If you look under the sensory signaling systems under the “inputs” (left-hand side), you’ll notice musculoskeletal inputs play a role. It’s likely only a fraction of what was previously thought to be involved with a pain experience, though. This is one reason why I’ve started to be less aggressive with my manual therapy work and it’s also why I don’t really foam roll or use a lacrosse ball much anymore. If you’ve read my post on Sports Massage, you’ll understand that it takes a lot of force to actually deform tissue. While I probably agree less with what I wrote nowadays, it’s predominantly because of the influence on the nervous system – not on the fact that deep tissue/release work or IASTM is going to alter tissue or tissue function. And my thoughts on the biomechanical approach to pain have especially changed after I read THIS REVIEW of Becoming A Supple Leopard. I think preaching thoughtful, fearful movement approaches is much less effective at reducing threat than thoughtless, fearless movement. Especially when it comes to pain. It’s easier to negatively influence the emotion-related and cognitive-related brain areas in the neuromatrix picture above when you focus too much on the biomechanical approach, because this approach typically leads to using words that create fear, such as: “imbalance”, “dysfunction”, “asymmetry”, and “unstable.”

Some smart folks that I’ve friended or followed were recently tagged in a Facebook post by Lars Avamarie that listed a bunch of research articles and quote from much of the pain science that’s available. Here’s the link to that post: CLICK HERE. Here’s the list of quotes and references from that post for quick and easy viewing (and for me to save for myself):

“You must unlearn what you have learned… about pain…

Start your journey by reading this:

“Strictly speaking, pain is not in any organ, but in the mind, since only that can feel. When any nerve brings news to the brain of an injury, the mind refers the pain to the end of a nerve.” Dr. J. Dorman Steele, 1872

“Pain can no longer be regarded as merely a physical sensation of noxious stimulus and disease, but conscious experience of pain may be modulated by mental, emotional, and sensory mechanisms and includes both sensory and emotional components”

Ref.:
Waddell G. 1987 Volvo award in clinical sciences. A new clinical model for the treatment of low-back pain. Spine (Phila Pa 1976). 1987 Sep;12(7):632-44.

“Pain is not simply the end product of a linear sensory transmission system; it is a dynamic process that involves continuous interactions among complex ascending and descending systems. The neuromatrix theory guides us away from the Cartesian concept of pain as a sensation produced by injury, inflammation, or other tissue pathology and toward the concept of pain as a multidimensional experience produced by multiple influences”

Ref:.
Melzack R., Katz J. (2013), Pain. WIREs Cogn Sci, 4: 1–15.

“Pain is not a simple sensation, and is rarely the result of a disorder in one system only. It is complex, involving multiple interactions. CWPS and FM cannot be considered to be solely a disorder of central pain modulation, and perhaps not even primarily so. Pain is the outcome of a complex interplay between the central modulation and peripheral pain input. ”

Ref.:
Pain Med. 2013 Jun;14(6):777-8. Are peripheral pain generators important in fibromyalgia and chronic widespread pain? Gerwin R.

“The evidence that tissue pathology does not explain chronic pain is overwhelming (e.g., in back pain [11], neck pain [12] and knee osteoarthritis [13]). Yet we continue to avoid the truth that tissue damage, nociception and pain are distinct. I would go so far as to suggest that even the use of these erroneous terms – pain receptors, pain fibers and pain pathways – leaves the patient with chronic pain feeling illegitimate and betrayed, and leaves the rehabilitation team lacking credibility when they look beyond the tissues for a way to change pain.”

Ref.:
G Lorimer Moseley. Teaching people about pain: why do we keep beating around the bush? Pain Manage. (2012) 2(1), 1–3.

“Pain catastrophizing has been associated with heightened pain severity, emotional distress and pain-related disability, even when controlling for medical status variables [2,4]. Pain catastrophizing has also been shown to compromise the effectiveness of pharmacological and psychological pain management interventions. Several studies have shown that reduction in pain catastrophizing is the single best predictor of successful rehabilitation for pain-related conditions [5,6].”

Ref.:
Sullivan M L. What is the clinical value of assessing pain-related psychosocial risk factors?. Pain Manage. (2013) 3(6), 413–416

“Psychosocial factors are important in the development of low back pain and disability.7,8 Depression, passive coping strategies, fear avoidance beliefs (the avoidance of movement or activity resulting from fear of pain or injury), and low expectations of recovery are independently associated with poor outcome.9,10 A clinical guide to assessing psychosocial warning signs (yellow flags) developed in New Zealand has been adopted internationally.11 Patients’ beliefs need to be better understood to improve management of low back pain.”

Ref.:
Darlow B, Dowell A, Baxter GD, Mathieson F, Perry M, Dean S. The enduring impact of what clinicians say to people with low back pain. Ann Fam Med. 2013 Nov-Dec;11(6):527-34.

“Clinicians should not utilize patient education and counseling strategies that either directly or indirectly increase the perceived threat or fear associated with low back pain, such as education and counseling strategies that

(1) promote extended bed-rest or
(2) provide in-depth, pathoanatomical explanations for the specific cause of the patient’s low back pain. ”

Ref.:
Delitto A, George SZ, Van Dillen LR, Whitman JM, Sowa G, Shekelle P, Denninger TR, Godges JJ. Low back pain. J Orthop Sports Phys Ther. 2012 Apr;42(4):A1-57. Epub 2012 Mar 30.

“To understand the way in which a person responds to persistent pain we must look not only at the physical parameters, but beyond to consider factors such as cognitions, coping strategies, life events, and personality. ”

Ref.:
Asmundson GJ1, Norton PJ, Norton GR. Beyond pain: the role of fear and avoidance in chronicity. Clin Psychol Rev. 1999 Jan;19(1):97-119.

“Most education programs for orthopedic patient populations have used anatomic and biomechanical models for addressing pain,4,11-14 which not only have shown limited efficacy,4,11,12,15,16 but may even have increased patient fears, anxiety, and stress, thus negatively impacting their out-comes”

Ref.:
Louw A, Diener I, Butler DS, Puentedura EJ. The effect of neuroscience education on pain, disability, anxiety, and stress in chronic musculoskeletal pain. Arch Phys Med Rehabil. 2011 Dec;92(12):2041-56.

“The traditional biomedical model of sports medicine suggests that every disease process (dysfunction) can be explained in terms of an underlying deviation from normal function such as a pathogen or injury. The model suggests that pathology and symptoms are correlated such that a greater expression of symptoms in the athlete would indicate greater underlying pathology (Fig. 1A).

This model further proposes that a simple correction of the underlying pathology with a treatment (for example injection, surgery, manipulation or exercise) will result in elimination of the symptoms and subsequent restoration of normal function in the athlete (Fig. 1B). Clinical experience and epidemiological data on LBP often tells us otherwise, with many athletes demonstrating physical and diagnostic signs that they have recovered from injury and yet they will continue to experience symptoms/pain (Fig. 2C) (Iwamoto, Takeda, & Wakano, 2004).

Additionally, it has been well demonstrated that many people, including athletes often have significant tissue pathology (arthritis of the spine, bulging discs, bone spurs, etc.), yet experience little to no pain (Fig. 2D) (Alyas, Turner, & Connell, 2007; Waris, Eskelin, Hermunen, Kiviluoto, & Paajanen, 2007).

Ref.:
Phys Ther Sport. 2012 Aug;13(3):123-33. Epub 2011 Dec 27. A neuroscience approach to managing athletes with low back pain. Puentedura EJ1, Louw A.

“Occupations that seem to carry a higher risk are those requiring heavy lifting, maintaining a specific posture, or being exposed to vibrations [5]. However, the factor most strongly associated with a higher rate of reported low back pain is poor quality of relations with coworkers (limited cooperation among colleagues and lack of support from superiors); this association persists after adjustment for physical stress, as shown in a study of over 3000 male workers [6]. Low back pain is significantly associated with repetitive work, concern about making mistakes, and tight time constraints [7]. Other studies found that back pain was associated with common symptoms of work-related stress (nervousness, sleep disorders, and anxiety). ”

Ref.:
Joint Bone Spine. 2005 May;72(3):193-5. Factors involved in progression to chronicity of mechanical low back pain. Valat JP.

“When radiographs are obtained, evidence of degenerative disease should be interpreted critically. Reassurance, with emphasis on the absence of nonmechanical lesions, is far better than a specific diagnosis (osteoarthritis, degenerative disk disease, scoliosis, lumbosacral transitional disorders) that may be interpreted by the patient as evidence that recovery cannot be achieved in the short or medium term.

In a 1995 Canadian study [16], a specific diagnosis (lesion to a vertebra or disk) given within the first 7 days of symptom onset was associated with a nearly five-fold increase in the risk of chronicity, as compared to nonspecific diagnoses (pain, strain, twisting, derangement).

Bed rest until complete resolution of the pain, once dogma, is now recognized as a serious mistake that undoubtedly explains part of the rise in low back pain-related disability over the last few decades. Inactivity, most notably bed rest, has been shown to promote chronicity in several studies con- ducted over the last 15 years [17].”

Ref.;
Joint Bone Spine. 2005 May;72(3):193-5. Factors involved in progression to chronicity of mechanical low back pain. Valat JP.

“The field of pain medicine has shifted from multidisciplinary rehabilitation to procedure-focused interventional pain medicine (IPM). Considerable controversy exists regarding the efficacy of IPM and its more narrow focus on nociception as an exclusive target of pain treatment. This topical review aims to examine pain research and treatment outcome studies that support a biopsychosocial model of pain, and to critique the clinical practice of IPM given its departure from the premises of a biopsychosocial model.

A modern definition of pain and findings from clinical and basic science studies indicate that pain-related psychological factors are integral to pain perception. The clinical viability of IPM is challenged based upon its biomedical view of peripheral nociception as a primary source of pain and the potential of this viewpoint to foster maladaptive pain attributions and discourage the use of pain coping strategies among chronic pain patients. IPM should adopt a biopsychosocial perspective on pain and operate within a framework of multidisciplinary pain rehabilitation to improve its effectiveness.”

Ref.:
Transl Behav Med. 2012 Mar;2(1):106-16. doi: 10.1007/s13142-011-0090-7. Interventional pain medicine: retreat from the biopsychosocial model of pain. Roth RS1, Geisser ME, Williams DA.

“Features of acute pain were examined in patients at an emergency clinic. Patients who had severe, life-threatening injuries or who were agitated, drunk, or ‘in shock’ were excluded from the study.

Of 138 patients who were alert, rational and coherent, 51 (37%) stated that they did not feel pain at the time of injury. The majority of these patients reported onset of pain within an hour of injury, although the delays were as long as 9 h or more in some patients.

The predominant emotions of the patients were embarrassment at appearing careless or worry about loss of wages. None expressed any pleasure or indicated any prospect of gain as a result of the injury. The occurrence of delays in pain onset was related to the nature of the injury. Of 46 patients whose injuries were limited to skin (lacerations, cuts, abrasions, burns), 53% had a pain-free period. Of 86 patients with deep-tissue injuries (fractures, sprains, bruises, amputation of a finger, stabs and crushes), only 28% had a pain-free period.

The McGill Pain Questionnaire was administered to patients who felt pain immediately after injury or after a delay, and revealed a normal distribution of sensory scores but very low affective scores compared to patients with chronic pain. The results indicate that the relationship between injury and pain is highly variable and complex.”

Ref.:
Melzack R, Wall PD, Ty TC. Acute pain in an emergency clinic: latency of onset and descriptor patterns related to different injuries. Pain. 1982 Sep;14(1):33-43

“Consider pain as a model. There is the physical stimulus that causes the irritation and there is the person reacting to the stimulus. The tremendous variation in the way different persons under different circumstances react to a similar pain stimulus is at times awesome and even baflling, Beecher [5) found that men who were wounded at the Anzio beach invasion in WWII required significantly less morphine than civilians who had suffered similar injuries in accidents.

Beecher’s work addresses the reactive component to pain. When an injury was severe enough to save a man from life-threatening combat experience, but not so severe as to impair his function in civilian life, the wound was associated with freedom and survival. The same degree of injury in civilian life was not interpreted as a welcome pathway to survival but rather as an unexpected catastrophe, usually accompanied by anger at whomever or whatever was to blame. ”

Ref.:
Prev Med. 1997 Sep-Oct;26(5 Pt 1):616-21. Nocebo: the power of suggestibility. Spiegel H.

“The description of individuals with congenital insensitivity and indifference to pain provided one of the bases for Melzack and Casey’s (1968) seminal distinction between the sensory and affective components of pain.

In addition, the observation that these people often die in childhood because they fail to notice injuries and illnesses has been viewed as compelling evidence that the ability to perceive pain has great survival value. That is, the sensation of pain protects humans (and other species) from the tissue-damaging effects of dangerous stimuli, and appears to be critical for survival of the organism”

Ref.:
Congenital insensitivity to pain: an update. Nagasako EM, Oaklander AL, Dworkin RH. Pain. 2003 Feb;101(3):213-9.

“Pain catastrophizing has been associated with heightened pain severity, emotional distress and pain-related disability, even when controlling for medical status variables [2,4]. Pain catastrophizing has also been shown to compromise the effectiveness of pharmacological and psychological pain management interventions. Several studies have shown that reduction in pain catastrophizing is the single best predictor of successful rehabilitation for pain-related conditions [5,6].”

Ref.:
Sullivan M L. What is the clinical value of assessing pain-related psychosocial risk factors?. Pain Manage. (2013) 3(6), 413–416.

“Most education programs for orthopedic patient populations have used anatomic and biomechanical models for addressing pain,4,11-14 which not only have shown limited effi- cacy,4,11,12,15,16 but may even have increased patient fears, anxiety, and stress, thus negatively impacting their out-comes”

Ref.:
Louw A, Diener I, Butler DS, Puentedura EJ. The effect of neuroscience education on pain, disability, anxiety, and stress in chronic musculoskeletal pain. Arch Phys Med Rehabil. 2011 Dec;92(12):2041-56.

“Psychosocial factors are important in the development of low back pain and disability.7,8 Depression, passive coping strategies, fear avoidance beliefs (the avoidance of movement or activity resulting from fear of pain or injury), and low expectations of recovery are independently associated with poor outcome.9,10 A clinical guide to assessing psychosocial warning signs (yellow flags) developed in New Zealand has been adopted internationally.11 Patients’ beliefs need to be better understood to improve management of low back pain.”

Ref.:
Darlow B, Dowell A, Baxter GD, Mathieson F, Perry M, Dean S. The enduring impact of what clinicians say to people with low back pain. Ann Fam Med. 2013 Nov-Dec;11(6):527-34.”

 

If you’re interested in learning more, here’s some links via Zac Cupples: Explain Pain Therapy Notes & The Sensitive Nervous System Therapy Notes. Also, his course review of the Dermoneuromodulation course, which I’ve recently attended. Diane Jacobs posted this link today, which makes for good timing: Therapeutic Neuroscience Education: finally, a book that says it like it is. Lastly, I’ve purchased this Pain DVD (the download version), which is a great resource for this information, as Lorimer is one of today’s pioneers in pain research.

Jeromie

Adjusting a Session On The Fly

This is a guest post by Brad Gatens. I’ve been exchanging emails with him about programming and he offered me up this post to use as a guest post as he thought my readers would find value in this information. Also, it’s a way for me to have a place to reference the information. This reminds me of a recent post by Patrick Ward – Click Here. Nothing is linear.

“I couldn’t sleep last night.”
“I feel like I may be getting sick.”
“I had one too many at happy hour yesterday.”

As trainers we need to modify and adapt our client’s workout on the spot.  All that time spent on a well-planned workout program for your client that day is shot.   Gotta switch it up.  We set out with good intentions trying to make an organized plan for the workout, but problems and issues always seem to come up. Planning out weight, sets, reps, exercise selection and order can make our jobs easier when there are no issues with our client.  But more often than not, something is going to come up which throws our plans out the window.

Jon Goodman recently laid out a solid piece regarding this situation (this article wasn’t linked, but I assumed this was the one he was speaking of).  A planning template was presented in his article to provide trainers with a long-term guideline for their clients based off of their goals and needs.  Making use of this type of outline will keep you and your client focused on previously established goals. Creating a long-term periodization plan is necessary, but planning specific individual sessions probably isn’t.

GetUp

It’s up to you and your client to modify a workout when necessary.  What I would like to lay out is strategies to use when a client isn’t feeling well mentally or physically.  Coming down with a cold, feeling tired, under a lot of stress…. Modifying workouts based on injuries and soft-tissue complaints is a whole other topic that might need to be addressed.  Here’s how we can provide a quality training session and still get a training effect even when their having an off day.

  1. Continue as is.  They might surprise themselves and still have a great workout without any modifications.  Remember Michael Jordan playing with the flu against the Jazz?  Sure that’s an extreme example.  But he’s human just like us.  And if he can do something as absurd as that, we can muster up the strength for a couple higher intensity sets.
  2. Adjust the volume or adjust the intensity.   This is going to depend on the individual.  When some feel like crap, some will thrive on high intensity. They may not have the endurance and energy to maintain a normal pace and rest intervals, but they can maintain their strength.  Use this to your advantage as a trainer and program a couple of high intensity sets with long rest periods.  On the other hand, some simply cannot maintain their strength but can keep their work capacity.  As a professional, it’s important to explain this concept to our clients.  Dropping the intensity down does not mean we aren’t,
  3. Beach muscle day.  Arms, abs, some rows, traps for the guys, extra glute work for the women.  Think of this as an accessory day.  Many popular strength programs throw in an odds and ends day.  Single joint movements would work pretty well.  Anything seated would be a plus as well. This workout will provide a nice change of pace and will provide some catch up time on any neglected body-parts.

How do you know which approach will suit your client the best? Based on your history with this person, you should have an idea what the best strategy to take is.  Discuss this with your client.  Let them know that just because the method for the day has been adjusted, it is not going to take away from the workout.  Often times they may feel like they’re not going to get anything out of a “different” workout, but it’s our job as coaches to explain to them why this isn’t entirely true.

All we are doing here is providing a form of self(client)-regulation to our clients.  The best lifters in the world follow some type of self-regulation.  Programs shouldn’t be written in stone for anyone.  Especially when you have a trained professional available in real-time to guide you.  Working with a trainer provides two sets of eyes to monitor and adjust performance.  Use this to your advantage.

Brad

BGats

Brad has a CSCS certification and BA in exercise physiology.  Brad teaches physical education and works with guys looking to build strength and muscle.  Brad has gone from a body weight of 130 to 185, and has recently deadlifted over 3x his bodyweight.