“I didn’t want to make things worse so I just stopped doing _____” - most patients…most of the time.

Pain deters us from engaging in certain physical activities. That’s sort of the point of pain, it motivates us to avoid behaviors that could make things worse. If gardening, sitting, wearing high heels, or exercising hurts, you probably won’t want to do more of it. Avoiding these activities, in the short term, is protective and essential for allowing the body to heal. However, in cases of chronic/persistent pain, if we avoid activities for a prolonged period of time, it’s likely doing more harm than good.

Activities that are ‘off limits’ because of pain may become scary (even thinking about it might trigger discomfort in your body) and we will eventually lose fitness for that activity…which reinforces the fear, the avoidance and the pain. This is the pain-fear-inactivity cycle and it sucks.

We know that activity is vital for physical and mental health so anything, like pain, that gets in the way is a big deal. Avoiding activity is especially harmful if pain is causing us to avoid:

• a normal, everyday movement like walking, squatting, reaching

• an activity we enjoy doing like gardening, knitting, traveling

• our main form of exercise like running, rowing or weight training

• an activity that’s involved in our social life like tennis, golf, pickle ball, etc.

Movement isn’t just something we do to stay in shape, it’s our vehicle for engaging with the people and world around us. In many ways, it defines our identity - “I am a runner.” If an activity is taken away from us because of persistent pain, it threatens the very way that we see ourselves, “I used to be an athlete but…”

A different animal

The first step to overcoming persistent pain is to understand that persistent pain is a different animal (or beast https://www.youtube.com/watch?v=ikUzvSph7Z4). By definition, persistent pain is pain that lasts more than 3 months, and it’s estimated that between 18-35% of Americans deal with persistent pain https://journals.lww.com/pain/Abstract/2022/02000/Prevalence_of_chronic_pain_among_adults_in_the.31.aspx so this is a huge, costly issue in our society. In contrast to acute pain which may have a more clear cause like injury, overuse, infection, etc. and a more clear timeline to healing, persistent pain is accompanied by massive amounts of uncertainty. Uncertainty about how long the pain is going to last, what ‘caused’ it in the first place and what can be done to improve it. By nature, persistent pain is elusive, so we can’t expect it to respond in a typical way to treatments. Because of this uncertainty, we have think about, approach, and move through it differently.

In most cases of persistent pain, the pain has outlasted the normal healing time for tissue damage - so your brain/body is creating the experience of pain to protect damaged tissues, but there are no damaged tissues to protect. You may get pain every time you garden but it’s not likely that the bending, reaching and lifting in gardening are damaging your back. It’s more likely that your brain has developed an association between gardening and pain.

Breaking the cycle

Your brain/body is constantly making predictions about how situations are going to go. These predictions lead to thoughts, feelings and behaviors that are essentially automated. It’s much easier for the brain/body to predict and automate vs. reappraising every situation as if it were brand new (for more on this, check out neuroscientist, Lisa Feldman Barrett PhD’s work. Here’s an article on the predictive brain - https://www.mindful.org/your-brain-predicts-almost-everything-you-do/). We are constantly being primed for how situations are going to go. Essentially, the brain/body is saying, “I’ve seen this situation play out before and I’m going to help you get ready for it.” When you’re anxious, your system may be primed with butterflies in your stomach or your heart might skip a beat when you’re frightened. The human system might similarly predict an activity to be harmful, so pain emerges. For example, if you’ve had enough repetitions of pain during running or a really significant, memorable episode of running = pain (like after a sprained ankle), the brain can learns to associate the activity with the pain. Again, this pain and activity association helped protect you at one point (if we initially kept running on that sprained ankle, it would make things worse and prolong healing) but may no longer be useful. Given this predictive nature of our experiences, one of the main targets in managing persistent pain is to break/disrupt/violate these unhelpful associations.

To summarize so far:

• Persistent pain is tricky and less straight forward than the acute pain of an injury (i.e. sprained ankle).

• Our brain/body relies on predictions to function in the world.

• In persistent pain, those predictions we rely on may lead to learned associations between pain and certain activities.

• Breaking/disrupting those learned associations can help us overcome persistent pain and resume meaningful activities

Simply knowing about these predictions and associations doesn’t necessarily mean the journey through persistent pain is clear. As with other tricky problems, we need to tinker with different parts and explore different paths in order to get a different outcome. In other words, we need to play with pain to in order change it.

Permission to take a new approach

The number of people I’ve worked with who have completely cut out a meaningful activity due to fear of worsening pain is massive. These are people that completely stop exercising, touching their toes, biking, painting, walking their dog, etc. A new patient last week has stopped walking their dog due to pain and fear of making things worse :(

I want to be clear that none of this fear and learned association talk is to imply that “pain is all in your head” or that the fear of “not wanting to make things worse” should be ignored. All pain is real and all fears are valid. The point is that if you’re stuck in the vicious cycle of persistent pain - we need to zoom out, challenge the assumptions you’ve held on to, reconsider the activities you’ve avoided because of pain and explore a new path forward. This requires both curiosity and courage. Curiosity has to do with the seeking of new information and courage is the strength to do something in the face of pain or something scary.

If someone tells me its hurt every time they tried to touch their toes for the past 3 years, we’ll want to disprove that association and form a new association of touching the toes = safe. After establishing trust and ruling out red flags, we might explore movement, even feared movements (that’s the courage part), as a path to breaking the pain-fear cycle. We don’t know what cue or strategy is going to help break the cycle, so we may have to try out a few different things (this is the curiosity part). We might see what touching the toes is like when we put something under the heels, or go really slowly, or use more hip flexion, or breath out on the way down, or ride the bike for 5 minutes beforehand, do a few sets of planks first, or reach for their toes from a long sit position instead of standing.

Giving someone permission to take a new approach is one of the most powerful gifts we can offer as clinicians. It’s this type of experiential evidence - “Oh wow, I can’t believe I just touched my toes without pain,” that prove they are safe and strong that helps break the cycle.

Compass vs roadmap

You don’t know what every step of the pain management journey is going to look like. It’s more helpful to have a compass than a roadmap on this journey. A compass will generally point us in the right direction but won’t tell us the exact path. We can’t know the exact map of our journey until we take the first step. There will always be roadblocks, speed bumps, detours, etc. Sometimes you have to yield, slow down, sometimes you have clear skies and an empty highway and you can push it a little bit. No one has solved the riddle of persistent pain and it’s likely that no one ever will, we will always have to play/tinker with the system and carry a flexible mindset and treatment approach in order to overcome it.

The human body is complex AF. People bring unique injury and medical histories, life experiences, injury histories, beliefs, fears, etc. Cookie cutter approaches don’t work for persistent pain. That’s hard to hear as a person experiencing persistent pain. And it’s hard to embrace as a clinician that has spent so much money learning techniques, acquiring knowledge. It’s hard for a person of authority to say, “You know what, I’m not exactly sure what’s causing your pain but I have some ideas. Let’s try ______ and see how it goes” The take home message for patients here is to be wary of clinicians that claim to have all the answers.

In the next few articles, I’ll discuss how we can safely play with movement, strength training, aerobic exercise, mindfulness and other active strategies to break the cycle of persistent pain.