guest article by Rob Carruthers and Ash Berry
There are so many old expressions that spring to mind when we are talking about pain, particularly in relation to exercise. ‘Pain is weakness leaving the body’ is the classic one I grew up with in the rugby sheds of New Zealand. These expressions usually revolve around the fact that being in pain creates the opportunity for us to experience growth and pleasure. Now this may have been true to those who originally made those statements, but if we are talking about pain in relation to the human body and movement, there are a few extra things to consider before pushing through to the glory we’ve been promised.
What exactly is pain?
At its most basic, what is pain? I’ll reflect on a lecture we recently had at Movementality from Dr Della Buttigieg, an osteopath and pain science specialist: “Pain is a mutually recognisable somatic experience that reflects a person’s apprehension of threat to their bodily or existential integrity”(1). This differs from nociception, which is the chemical signaling we experience in relation to a potentially harmful stimulus. So in layman’s terms, we are perceiving an array of signals from our brain that something potentially isn’t right. The important word here is ‘potentially’. Pain can signal tissue damage or trauma, but it can also send off these signals way earlier to warn us of potential damage which most likely hasn’t happened yet.
I always find it helpful to remember that pain is the result of pre-programmed and developed reactions in our psychology and physiology that have to be triggered and transmitted via chemical reactions. Why is that important? We already know that the body becomes accustomed to things it experiences and does a lot. So, if your brain is constantly firing off signals that you’re potentially in danger, then it becomes predisposed to expect to be in pain. Similarly if you have injured a particular area in the past, your system’s tolerance for stress to that area drops significantly and so your brain will fire off warning signals to stop long before there is any risk of actual injury. This is what often leads to what many classify as chronic pain. I will add that this can occur at both the physiological and psychological level, both impacting and playing off the other to create a cycle which is often hard to break out of.
The in’s and out’s of pain are far too complex to pull apart in a single article, and there are a bunch of amazing practitioners out there who have already put together excellent resources around the topic. Specifically, check out the work of Butler and Mosely if this is your first venture into this topic, and their book Explain Pain. Next we’ll touch on how we work with pain at Movementality to give you some tools to work with it in clients of your own.
Relax and Breathe – it will be ok.
The first thing you can do to disarm the body against both acute and chronic pain is to create a space for the system to relax and breathe. The very first stop to this is creating a space where you can build trust with your client. Now that seems obvious enough, but it’s something we find a lot of people are missing out on. There are often unconscious expectations we have as practitioners about what someone should be able to do with their body – and these expectations can put a client on guard straight away. If the client doesn’t trust that you’re okay with them as they currently are, and that they might not be able to do what you ask of them, then they will likely struggle to do what you are asking as they won’t be focusing internally.
The next stop is to teach your clients to breathe and pay attention to their body. We are aiming to move our clients from a fight or flight response (where their pain receptors will be firing like crazy) to a parasympathetic relaxed state. Ask them to notice sensation, as opposed to pain, as they are not the same, and often asking someone to feel more deeply into their body will reveal to you as the practitioner, more information on what other things might be going on for them
It is your job as a practitioner to meet them where they are ready to be met, and then provide the space for them to be able to grow into what they are able to. Simple strategies to do this start at the conversational level, by asking open questions about how they are, how their week has gone, what they’ve been able to achieve and what’s allowed them to do this – basic rapport building skills that show you actually listen and care. Once they start opening up, the trust is there and half the battle is won.
Now that they’re relaxed, it’s time to move!
This is where Pilates apparatus is fabulous. Regardless of whether pain is acute or chronic, the best starting point is to show the person that they have a body that can move pain free. The more positive movement experiences they can have in their body, the more likely they will be able to find pathways out of pain over time. The easiest way to provide these experiences, is to let the equipment do the work for them, taking their joints through passive range of motion. By passive, I mean that they have to relax the joint as much as they feel they can, and then you can start to gently move the focus area either with your hands, or through the use of the apparatus. For example, if we’re talking about shoulders, one excellent move is to take a rope off the reformer, and hang it over the cadillac bars. They can sit on the caddy, threading their arm through a loop or strap, while their uninjured arm holds onto the rope. The uninjured arm puppeteers the sore shoulder through small ranges of movement, completely passively – see picture inset. When pain signals start to fire off, you pause – wait and see what happens. If they can relax, you may be able to go further, or it may be time to back off. But every time you show their brain that they can move pain free, you’ve proved to them that movement in that area is possible – another battle won.
Pain free movement? Load them up
Once they have experienced pain free movement in a passive way, it’s time to load them up a little. The best way I find to do this is with isometric holds. Start in pain free positions, adding a level of load they can maintain for 10-20 seconds without compensating in other areas of the body. Gradually test the range – even by just doing a isometric hold, then moving the joint passively through it’s range again to show the brain that with the load initially stabilising the joint, it’s okay to relax even more as they have more strength than they realised. Then you can start to load them up in different ranges – be careful to keep going between safe and testing zones though. If you keep pushing and pushing, you’ll over do it. We find the ‘less is more’ approach often helps organise the body at a deeper level, rather than a ‘push push push’ approach which can create unnecessary compensations you have to then try to undo later down the track.
Celebrate the wins!
Because pain isn’t just a physiological experience, it’s important to openly celebrate the wins when they come, particularly when working with chronic pain. Highlight to the client that what they’ve learnt is not just an exercise or two, but a safe strategy that they can trust. Most importantly, make sure they acknowledge that they are the ones who made it happen – you didn’t fix them, you facilitated an opportunity for them to make the change.
Don’t beat yourself up, as there will be setbacks, especially initially as they try to navigate what is possible. Use positive reinforcement and language and remind them regularly that they can trust their body to look after them by re-highlighting all those times that they did have a win. The rest comes down to considered and clever programming. In regards to programming, keep it simple. Aim to gradually increase range and load, and build in variety of movement to help build their robustness. Keep the feedback coming and leverage off it to provide more options around how they can keep building on their safe strategies. Their everyday life will do the fancy stuff for you in terms of building reflexes if you build solid, foundational movement patterns that they can trust such as breathing, crawling, squatting, lunging, twisting and hanging.
Pain is a tricky beast, and there is no single way to help clients through it. What we’ve outlined is what’s helped us significantly and consistently, but even within that there have been rogues and non-starters who just don’t want/can’t improve for any number of reasons. When it comes to those clients, remember that it’s not on you – they have to want to get better, and be willing to put the work in to improve their own situation. If they don’t, the best thing you can hope for is to not aggravate them, and to build in joy during the sessions and eventually they’ll be ready to tackle their pain head on. You just keep the space open and friendly, keep asking the right questions and celebrating the wins where you can.
Rob Carruthers and Ashleigh Berry, PAA members and Directors of Movementality, Richmond VIC
(1) Cohen, Milton; Quintner, John; van Rysewyk, Simon. Pain Reports: March 05, 2018. Doi: 10.1097/PR9.0000000000000634
Dr Della Buttigieg is an Osteopath in her own business, Melbourne Osteopath, a Pain Science lecturer at Victoria University, as well as affiliations with numerous pain science resources.
The exercise pictured was originally shown to Movementality by Bruce Hildebrand.