The Pain Map ebook is up!

What if we didn’t see our pain as an antagonistic villain, but as a teacher and friend; not as an enemy to be avoided, but a partner in crime? This article provides a map for reshaping our relationship to pain. It is a map providing you reference points within a complex territory. The goal is not that you walk away with some information you can store in your back pocket for trivia night, but that you have the understanding for thinking critically and deeply about pain & injury, for knowing what kinds of questions to ask inside of this territory.

Download the ebook "Pain Map: A Mindbody Perspective"

Pain Map by Sean Nicolle is licensed under a Creative Commons Attribution 4.0 International License.

Map drawn with Gravit Designer (www.designer.io). Thank you!

Interviewed by "Back | Pain | Movement"

Sean was recently interviewed by “Back | Pain | Movement” (Simon Schmidt) - talking about pain, movement, psychology, democratizing science, observations from our movement community and teaching in Miami, and personal own background (bulk of the pain discussion comes up at the end - around 38:50).

Link: .iTunesShoutEngine

For those intrigued by pain, we’re almost done with the pain map/resource that will provide the blueprint for changing the relationship to pain

Pain is prediction

Pain is the experiential corollary to the brain's prediction of threat to the physical body, as it is mapped and represented in the brain. Let’s break down what that means:

1. Pain (first described by Aristotle to refer to an emotional, not an physical, experience)
2. is the experiential corollary to (is the other side of the coin of) the…
3. brain’s prediction of threat (the brain is taking in countless inputs from various systems, including cognitive, sensory, and emotional)
4. to the physical body, as it is mapped and represented in the brain. (there is a representation of the body, within the brain, that is being used to model and decide if there is threat)

Converting the last two pain lectures into a “map” that will lay out the territory of pain. Stay tuned. It will be shared here on our blog. .

Tendinopathy

Note: This document is a “living” document. It is likely to grow and change in response to new research and personal experience.Tendons are a fascinating structure in the human body. We think of them as boring rubber bands connecting muscle to bone, but in truth, they have some very unique structural properties. In addition, they have a capacity for adaptation, vital to their long-term and proper function. When this capacity is disturbed, tendons can become “sick.”

Sick Tendons

Tendinopathy is an umbrella term for diseases (pathologies) of the tendon. If you have pain localized to the tendon, you have “tendinopathy”. But tendinopathy is an umbrella term. It actually includes both tendinosis and tendinitis.Tendinitis: Tendinitis is inflammation of the tendon. Most people know this. What most people don’t know is that the condition of tendonitis is actually quite rare in people presenting with tendon pain (tendinopathy). This is shown by looking at the blood, where inflammation “lives”. It’s simply not there in most people who present with tendon pain. This would explain why inflammation-oriented treatments are not effective for dealing with most cases of tendon-pain.Tendinosis: Tendinosis is degeneration of the tendon, often taken to be caused by failed healing. It’s characterized by stiffness, a localized pain that seems to match the load placed on it, the warming up effect (pain is less when you’ve warmed up), and being sensitive to touch (8). Does this sound like you?It is often taken for granted that tendinopathy arises from overuse. But simply high amounts of repetition is not enough to predict tendinopathy (3). The truth is, as of the writing of this document in 2014, there is a scientific consensus that the cause of tendinosis (and thus of most tendinopathy) is unknown. Load is an important factor, but definitely not the only one.Though we don’t know what causes tendinosis, we DO know what tendinosis looks like, compared to healthy tendons, and that’s mainly an issue of tendon adaptation.“These data clearly indicate that painful, overuse tendon injury is due to tendinosis” Khan and Cook (5).

Tendon Adaptations: the Good, the Bad, and the Ugly

Tendons normally adapt to load by stiffening, without changing thickness. In the case of the onset of tendinopathy, however, tendon adapts by thickening. “These initial changes...may occur because quick adaptation is necessary until longer-term change in either structure or mechanical properties (true adaptation) happens.“These observations suggest that if you increase stress on the tendon beyond the primary (“good”) adaptive capacities of the system (such as increasing tendon stiffness), the system will engage in a secondary (“bad”) compromised form of adaptation (such as increasing cross-section area of the tendon).These compensatory / pathological adaptations are less efficient than the primary adaptations. As a result, they are also likely to fail to keep up with load demands, and true tendon degeneration occurs: tendon cells begin dying (the “ugly”).Something to keep in mind about these different kinds of adaptations: normal/good adaptations take 20 days to happen; compensatory/bad adaptations happen in days. (3)When demand exceeds the capacity of normal ("good") adaptive mechanisms, secondary ("bad") compensatory mechanisms take up the slack. But these inefficient adaptations eventually result in ("ugly") tendon degeneration .

Tending Your Tendons

The most highly supported modality for treating tendinopathy is eccentric loading (1). Eccentric loading involves resisting a muscle/tendon as it is lengthening. In addition to eccentrics, some studies have shown that basic prehab-type work reduced symptoms of tendinopathy (2). We describe some sample protocols below.One major difference between studies showing success vs. no success with eccentric protocols is that success was associated with pushing through pain (6). Consider this along with a study demonstrating that concomitant rehab and continued training are as effective as rehab alone, when pain was not allowed to exceed 5 on a 1-10 scale. (8)Although the research is still looking for an explanation from the perspective of cellular adaptations of the tendon, by looking at neuroscience of pain, we can come up with a concise explanation. By repeating the movement in a pain-free manner, we begin to dissociate the movement with notions of injury. In a sense, we re-define how we view the movement itself. Simultaneously, we provide the stimulus necessary for proper healing.“Do I need to stop training while rehabilitating tendinopathy?”No (8). Just make sure pain wouldn’t exceed 5 on a 1-10 scale.“No negative effects could be demonstrated from continuing Achilles tendon-loading activity, such as running and jumping, with the use of a pain-monitoring model, during treatment. Our treatment protocol for patients with Achilles tendinopathy, which gradually increases the load on the Achilles tendon and calf muscle, demonstrated significant improvements.” Silbernagel et al. (8)

Sample protocols

While we wait for the empirical research to validate the most effective protocols, we can begin to improve our functioning by experimenting with what works. Here are sample protocols based on research and experience, for dealing with various tendinopathies.These protocols combine eccentric work (1-3 sets of 5-10 repetitions) with high volume prehab (3 sets of 20+ repetitions)KneesEccentrics: Squats (consider elevating the heels to bias the quadriceps)High volume prehab: Misalignment work, such as knee rotationsElbowEccentrics: Chin-ups (or barbell curls)High volume prehab: forearm pronation/supinationAnkleEccentrics: Calf-raises on a step, through a full range of motionHigh volume prehab: Misalignment work, such as walking on inverted and everted feet.

NSAIDs? Stands for: No sir, altogether I dislike.

NSAIDs are not shown to improve long-term outcomes (1), and are associated with various side effects. In addition, they interfere with the healing process, and are known to increase incidence of injury/tendon rupture (4). The same can be said of corticosteroids (such as cortisone) (1).Return to Resources

References

1. Andres, B. M., & Murrell, G. A. C. (2008). Treatment of Tendinopathy: What Works, What Does Not, and What is on the Horizon. Clinical Orthopaedics and Related Research, 466(7), 1539–1554. doi:10.1007/s11999-008-0260-12. Bang MD, Deyle GD. Comparison of supervised exercise with and without manual physical therapy for patients with shoulder impingement syndrome. J Orthop Sports Phys Ther. 2000;30:126–137.3. Cook, J. L., & Purdam, C. R. (2009). Is tendon pathology a continuum? A pathology model to explain the clinical presentation of load-induced tendinopathy. British Journal of Sports Medicine, 43(6), 409–416. doi:10.1136/bjsm.2008.0511934. Ferry ST, Dahners LE, Afshari HM, et al. The effects of common anti-inflammatory drugs on the healing rat patellar tendon. Am J Sports Med 2007;35:1326–33.5. Khan, K., & Cook, J. (2003). The painful nonruptured tendon: clinical aspects. Clinics in Sports Medicine, 22(4), 711–725. doi:10.1016/S0278-5919(03)00035-86. Maffulli, N., & Longo, U. G. (2008). How do eccentric exercises work in tendinopathy? Rheumatology, 47(10), 1444–1445. doi:10.1093/rheumatology/ken3377. Rio, E., Moseley, L., Purdam, C., Samiric, T., Kidgell, D., Pearce, A. J., et al. (2014). The pain of tendinopathy: physiological or pathophysiological? Sports Medicine, 44(1), 9–23.8. Silbernagel, K. G., Thomeé, R., Eriksson, B. I., & Karlsson, J. (2007). Continued sports activity, using a pain-monitoring model, during rehabilitation in patients with Achilles tendinopathy: a randomized controlled study. The American Journal of Sports Medicine, 35(6), 897–906. doi:10.1177/0363546506298279

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Explain Pain

When I recently was dealing with an elbow problem, my teacher Ido Portal mentioned that I look into the neuromatrix model of pain. It's had a powerful effect reorganizing how I think of pain. Here's a short description of recent developments in pain and injury research. In an effort to protect against the “But” people (as Ido calls them), yes, of course this is not the only scenario. But it’s a hugely relevant one, one which might dominate the majority of cases of pain.

Nociception

There are no pain receptors. There ARE specialized receptors in your body called nociceptors, which detect potential threats to the body (in the form of temperature, pressure, chemicals, etc). These receptors project this information about potential threat to the brain’s center for sensory integration (the thalamus), where these signals are integrated with other information (related to threat: fear information, emotions, visual perception, etc.) to be projected to the cerebral cortex where they result in the subjective experience of pain.Stimulation of these nociceptors is NOT enough to cause pain. Why? Because the experience of pain is an integration of all that information. You must perceive a threat to experience pain. (If you don’t notice the cut, however traumatic, on your leg, it doesn’t hurt.)Likewise, pain can occur in the absence of the stimulation of these receptors. This is best demonstrated by the rubber hand illusion: we can stimulate feelings of pain by "injuring" pretend body parts which the brain temporarily believes, due to visual misinformation, is actually part of us. This occurs despite the absence of nociceptive input.

Chronic pain

Another important thing to consider is that chronic pain (e.g., low back pain, tendinopathies such as golfer’s elbow, climber’s elbow, achilles tendinopathy, patellar tendinopathy) is very poorly correlated with structural damage. There is chronic pain in the absence of structural damage, and there is structural damage in the absence of pain. It is well documented that a) extremely large percentages of asymptomatic people have herniations as well as b) many cases of tendon ruptures occur in the absence of pain.So why chronic pain in the absence of structural damage? It is suggested that it’s a hypersensitivity of the nervous system. It over-reacts to small stressors (let’s say, a small strain of a muscle, nothing serious, or just a twinge in the joint, again nothing serious) which should not cause pain, or even does so in the absence of these stressors. Possibly, this hypersensitivity arises from a previous and quite real structural injury, one which has resolved but which you continue to internalize a fear of.

Why would the brain do this?

Most people psychologically/cognitively associate various somatic experiences with structural damage. We have a tendency to assume we’ve hurt ourselves when we “feel” things in our body. We’ve come to the point where we panic over every physical anomaly, whether structural or sensory. Part of this is the result of an emphasis on medicalization of our experiences. We think in terms of structural damage. We think the strain in the low back is a “pulled” muscle, and we vividly (thanks to the medical industry) project an image of damage fibers and injured tissue. We create illustrations in our mind of the inflammatory response, of lactic acid burning through our tissues, and so on and so forth.These higher level perceptions are integrated as well into the experience of pain (people who don’t hold these thoughts experience less pain, for example). In many cases, higher level systems override lower level systems in cognition. Many of us have experienced this personally.Extrapolating to the experience of chronic back pain, you’d have to be crazy not to experience pain if you simultaneously felt strain in the low back while thinking you had damaged your back muscles. It would be anything but adaptive otherwise. Problems arise when we form false cognitive beliefs. We’ve used the higher-level system, which can override lower level systems.

Top-down / cognitive approaches

It turns out the most effective treatment for most of these chronic pains is actually a form of cognitive re-education, a "top-down approach" teaching the individual about the nature of pain. It’s more effective than bottom-up approaches: corrective exercises, drugs, surgery, even manual tissue work. Why? Because it removes the fear upon which your pain is contingent: a fear that you’ve damaged yourself.This isn’t to say we don't experience pain; of course we do, but a large part of that pain is the interpretation of non-damaging strains of the musculature, and projecting “injurious” narrative on it. "Oh, I feel something in my elbow, I must have done something to it”.So why do we do corrective exercises? I think the minor physical adaptations are only part of the equation. Good corrective exercises actually contribute to the top-down approach: teaching you that a range of motion is safe, to dissociate that movement from pain. This idea is supported by the observation that eccentric versions of painful exercises are probably one of the best treatments for tendinopathies.And what about soft tissue work? I think this kind of work reduces those intra-muscular stressors, the signals that are being sent to the brain. You haven’t actually reduced the hypersensitivity of the nervous system, but you’ve reduced the inputs which trigger it’s over-reaction.So soft tissue work is actually a bottom-up approach.

Application

The application of this knowledge doesn't imply that you should train through pain. Even if you spontaneously believe that there is no structural damage in your tissue, your nervous system does not. It still has the association of pain. These things are not under direct conscious control. This could do more harm than good, since that fear might (this hasn’t been shown empirically, but it seems rather likely) trigger local stress responses which degrade tissue quality. It has been shown, however, that continuing training while rehabbing an achilles tendinopathy did not impair recovery (compared to just rehab), so long as the pain did not exceed 5 on a 1-10 scale.Even in the case of a legitimate injury, this effect is going to be at play. It’s not some miscellaneous phenomenon, or some minor illusion. This effect is always at play.

Need further convincing?

Pain scientist Lorimer Moseley talks about "Why Things Hurt" (TED Talk)Exercise physiologist (and good friend) Anoop Balachandran on "What Should Fitness Professionals Understand About Pain and Injury" (Article)An article regarding "The Real Reason You Still Have Back Pain" (Article)

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