Pain

What is pain? Whenever I refer to this reoccurring question in my field, I remember a line from a cartoon movie I watched as a child; The Mighty Ducks, the details of the scene are blurry, but as the hero character goes to punch an object as he exclaims, “Pain is an illusion.” After he punches said object, he replies to himself, “An illusion that really hurts.” That is a wonderful way to explain physical pain we perceive from our body. It is only a signal, from our body, to our brain. A signal that, in fact, really hurts sometimes. Pain science is a large area of interest in the Physical Therapy field at the moment and I have heard many analogies, stories, and metaphors attempting to rationalize the enemy that PT’s have forged battle with since the inception of our field. I will share a few that make particular sense to me. If you are interested, there are far smarter people than myself that may help you to understand it better (Peter O’Sullivan for example). As far as I know, these are true stories; however, they are just my recount of them without direct referencing…

A construction worker is using a nail gun, he shoots the nail gun, misses the target, and the nail pierces through his work boot. He screams in terrible pain and is rushed to the ER to prepare for treatment. When the boot is removed, it appears that the nail did not pierce the man’s skin. The man assumed he impaled himself with his nail gun. The brain responded appropriately and the man experienced pain relative to that of a nail piercing through one’s foot. Pain can lie to us, and our brain can be tricked into believing that we have pain when there has been no harm done to our physical self.

(https://www.youtube.com/watch?v=MG22iFL-VgE - another interesting example of this phenomenon).

A lady was walking along the side of the road and a window shattered. The woman was hit with the debris from the crash and had a large piece of glass stuck directly into her head. When the doctor at the ER asked if the woman was okay, the woman responded that she was, in fact, not in any pain and was unaware of the piece of glass that was stuck into the side of her head. This woman was struck directly through the part of the brain that is responsible for nociception (the response to pain signals) and was therefore was in no pain and unaware of her life-threatening injury. Pain can be an important defense mechanism to provide safety and protect our well-being.

The final story comes from a man walking across a railroad track. He trips over the track, falls, and severely sprains his ankle. He is writhing in pain, thinking to himself that he may have broken his ankle. Then, he hears the horn of a train and when he turns and looks, the train is streaming down the track towards him! He quickly jumps up and off the tracks, out of harms way. After the adrenaline rush from escaping certain death subsides, he begins to realize that his ankle is still hurt and needs attention, but for the few short moments that he was scared for his life he had completely forgotten about his injured ankle. Pain signals can be turned off in the event of a more important or life threatening situation. This indicates that environment absolutely has at least some influence on the pain that we feel. We may have limited control on the pain we are feeling, but we can control the environment around us that could be contributing to our pain.

Pain is something we perceive based on information given to us. No different from our vision or our hearing we gather information around us and perceive our reality based on the information available. Pain can be useful in protecting our well-being, but it can also be overwhelming and a significant life burden to some. What we need to develop is a healthy relationship with our pain and use it as a guide to explore our movement through this physical world.

Our Ever Changing Physical Self

We change every single day that we are alive. We grow older, yes of course, but more than that, our cells are constantly responding to external stimuli from the food we eat, activities we take part in, the air we breathe, sleep that we allow ourselves, etc., some things we can control more than others. The important thing to focus on are the things we can control and for the scope of this site we are going to focus on the physical activity we choose to take part in. The activity we take part in today will send signals to our body to use our resources (food) to prepare our bodies for the challenges of tomorrow. For example, if we take part in an exercise program today our body will respond to that stimuli by allocating its resources to building up the boney structures, developing the neuromuscular system through hypertrophy (gains!) and neural efficiency, build up our cardiovascular system in a number of fascinating ways! The positive benefits of exercise is well-documented and hardly requires defending at this point.

The same concept applies to the recovery or rehabilitation process. A metaphor that I like to use when explaining the recovery process to patients is to compare an injury to the musculoskeletal system to a cut of the skin. The way the cut needs time to scab over and heal is similar to the way muscle/tendon/bone/joint heals. It is important to give our injured body part time to recover as we gradually return it to normal use. Taking part in activities that aggravate our injury is like picking a scab before the wound is fully healed.

There are three groups of people when it comes to their physical activity. The first group are the couch potatoes. The never exerciser, usually overweight, but not always. These people need to gradually incorporate physical activity in their lives. Starting gradually, and working to find a consistent, healthy amount of exercise to achieve the lifelong health benefits without burning out or causing injury. The form and type of exercise is less important (although some types may be better suited than others) but the consistency is the key. These people need some form of physical activity that they enjoy enough that they will continue to do consistently week after week, year after year.

The second group is on the other side of that coin. The exercise addicts. Physical fitness is a part of this group’s self-identity and without it there is a negative impact on their mental and/or emotion well-being. This can lead to a problem, especially when there is an injury that restricts this person’s ability to perform physical activity. With this group it can be difficult to take time to recover from injury and gradually return them back to the exercise they love. The benefits of exercise are well documented, but over-exercising can lead to dangerous depletion of our body’s resources and a small injury that is not cared for and allowed to heal can turn into a bigger problem.

The last group is the happy medium group. Those that enjoy exercise, perform physical activity consistently, but do not derive their happiness from their fitness.

I will finish this post with an analogy that I particularly enjoy. We are all floating out in the ocean that is life. The tide is gradually pushing us to shore (the shore representing death in this analogy). Exercise is, in a way, like swimming against the tide. The tide is still stronger than the hardest we can swim, but if we swim against the tide we can prolong life and spend more time in deeper, healthier water before, inevitably, coming to shore. <3

The Right Fit

Okay, so we have established that exercise is important and to reap the benefits we have to exercise consistently. But what kind of exercise should I do? Does it matter? Is one exercise better than another? According to the ACSM, you should perform a minimum of 150 minutes per week of moderate-intensity cardiorespiratory exercise. This recommendation can be met by completing 30 to 60 minutes of moderate-intensity exercise on approximately five days per week. As an alternative, you can perform 20 to 60 minutes of vigorous-intensity exercise on approximately three days per week. The ACSM stresses that the required daily amount can be broken up throughout the day. That tells us how much exercise to do, but it does not answer the question of what kind of exercise to do. In my opinion, the answer to that question is different for everyone depending on a number of variables.

I think it is important to start with, “is the exercise appropriate and safe for you?” The picture above is of my mother and I. A lifting program that incorporates high level plyometrics and Olympic lifts would be appropriate for me, but would likely be too dangerous for my mother to participate in. Depending on a multitude of factors including age, medical history or current status, and personal preference all factor into choosing an exercise program that is right for you. 

In a perfect world, an exercise program would have some level of cardiovascular (cardio) exercise for our heart and lungs, some form of resistance training for muscles and bones, some flexibility/stretching for soft tissue, and some form of meditation for our mind. A combination of these through the week make up an “ideal” exercise regime. This could be a spin class, weight lifting class, and a yoga class (stay for the meditation!). Some people might enjoy this variety, but others might prefer just one program that fills each of those buckets to some varying degree.

Sticking with just one program is totally acceptable, as long as that program does in fact address cardio, strength, and flexibility in some way. What I do not recommend is something I hear a lot and was the motivation behind this article. “I walk my dog a few times a week for exercise.” First of all, this is totally fine and if this is what you enjoy doing as your cardiovascular exercise, in my opinion, that is perfectly acceptable. The problem is that your musculoskeletal system will be susceptible to whatever the rest of your normal day looks like. And for most people that looks like sitting. Sitting behind a desk, or in a car, or maybe hunched over a pottery wheel for hours on end. The construction worker, mechanic, and other manual labor people will argue that they are immune from the sitting disease. This may be true, but there are other problems with these occupations that I will address in another article on another day. On the opposite end of the dog walking spectrum I do not recommend cross-fit type intensity for the older population or even a younger person who is new to exercise.

The key to a lifelong relationship with exercise and fitness, in my ever-so humble opinion is, finding a routine that is 1) enjoyable, if you do not enjoy the exercise, you will eventually find an excuse to stop doing it. Is 2) appropriate and safe, if you become injured consistently you will not be able to make progress in your fitness. Finally 3) comprehensive and fills all of the physical buckets to some degree (cardio, strength, flexibility). If you are able to check these three boxes, I believe you are on the right road towards a lifetime of good health and mobility.