Nociception and personal training- part III

*This is the final blog in a three part series on proprioception, interoception, and nociception. To read blogs I and II, please click here and here.

Before I delve into this topic, I want to share some thoughts about this particular piece. I am not a pain researcher or scientist, and I am not in any way attempting to give advice regarding pain (one of my pet peeves is sensationalized pieces that claim “these three exercises will cure your back pain!” Really? How can you be totally sure? And in some cases, I bet those three exercises make it worse). If you work in the movement field, there is a good chance that at some point you will work with someone that has some sort of ache or pain. Sometimes that pain will be acute with an obvious cause; once in a while, you might get an individual that suffers from longer lasting pain, one that “flares up” occasionally. I am hopeful I can shed some light on ways to work with both types of individuals in a post rehabilitative fashion, as well as explain in a simple manner the physiology of the normal healing response. If pain science is something you are really interested in, there are some resources listed below to websites and individuals that are much more knowledgeable about this subject than I. Onward.

When I first graduated from college and began working full time as a personal trainer in a country club setting, I naively thought everyone that wanted training would be perfectly healthy. I quickly realized working with individuals with life experience meant there would be little things that cropped up. Tendonitis in the elbow. A small rotator cuff tear that was never fixed. Low back surgery 4 months ago (It was early in my training years that this happened. I experienced mild anxiety coupled with heart palpitations due to the fact that, not only had he recently had low back surgery, he was also a lawyer. Needless to say, I did my homework). This began a career long fascination with how to effectively work with people with aches and pains in an effort to a) not make their conditions worse and b) understand some of the psychology, word choice, and methods I could utilize to empower individuals and keep them doing the activities that they enjoyed. Along the way, some of them moved past their original aches and pains (for reasons I will discuss in a moment). Others, through improved interoception and proprioception, began to understand how their physical responses to stress affected their bodies, leading to a more mindful, less painful, way of being. There were bumps in the road as I learned to navigate working with people with a “pre-existing condition” (e.g., people experiencing increases in pain after workouts, not recognizing fatigue soon enough, and learning how to program for people living in a high stress environment). I am hopeful others don’t need to make my mistakes, especially with the information that exists in the wonderful world of the online universe.

Nociceptors are nerve cells that send information back to the brain about potentially threatening situations (Nelson, 2013). They are located in various parts of the body and respond to many different types of stimuli, including changes in temperature, pressure, pinching, cutting, and irritating chemicals. In the presence of inflammation, nociceptors are on high alert and will send information to your brain that even the smallest movements are threatening. This is a normal part of an acute injury, and ensures healing can take place by letting you know what movements are currently threatening to the injured area.

When you sprain your ankle, the ankle swells, or experiences inflammation. The damaged ankle ligament releases pro-inflammatory mediators including prostaglandins, serotonin, amines, nerve growth factor, and cytokines, among others (Butler, 2000). These all have specific roles and aid in the healing process. One of the things they do is try to prevent further harm to the injured ligament. If you were to try and walk normally with your freshly injured ankle, for instance, the nociceptors in your ankle would send information up to your brain that placing load on the ankle might make the situation worse. As soon as you placed a little bit of weight on it, these warning signs would cause you to take the weight right off of it. This would go on for a few days. Eventually, the inflammation will decrease, and gradually you will be able to place more and more weight on the injured leg. Assuming you have a healthy mindset regarding your injury, eventually you will wake up one morning and trust your ankle completely. It has healed and you can go on with your normal life. 

While this sounds like a fairly simple process, the reality is sometimes a little bit tricker. A systematic review of ankle sprains by Hubbard and Hicks-Little (2008) found it took anywhere from 6 weeks to 3 months for ligament healing to occur. In addition, ankle instability was an issue for some individuals up to year after sustaining the original injury. This speaks not only to the fact things don’t heal overnight, but to individual variability with the healing process. It would be easy to speculate why some experienced a sense of instability even after the tissue had already healed (severity of injury, lack of movement, psychological experiences at the time of injury), but it would be just that- speculation. I worked with a woman once who had sprained her ankle years before. She never did physical therapy for it, and never fully trusted it. It took gentle ankle and foot mobility, gradual balance work, and eventually more dynamic movements for her to fully embrace her ankle as “healthy.” When we finished with our time together, she was so grateful that “I” had given her the confidence to hike, wear heels, and trust her ankle. Really, I didn’t do anything except in a very safe and slow manner introduce her ankle and leg to weight bearing movement.

Acute injuries happen. Even if you create the strongest, best balanced clients, falls, slips, awkward carrying of groceries, and other life events cause tweaks that can take a while to heal. These types of injuries follow a fairly standard healing process. Inflammation, which I discussed above and is necessary for healing, lasts 2-3 days, assuming blood supply isn’t compromised (Baechle and Earl, 2008). Once inflammation subsides, the repair phase begins, scar tissue is formed, and collagen is laid down. This can last as long as two months. Finally, during the remodeling phase, the weakened tissue is strengthened, collagen production decreases, and newly formed tissue increases in strength, structure, and function with proper loading. In individuals following this normal healing trajectory, pain free movement should be encouraged. If a client insists on coming in after an acute injury, we don’t use the area in any significant way, though we might do some gentle mobility work in a pain free range of motion, not approaching end range, and focusing primarily on the areas above and below the injury site. Mobility work continues as the inflammation dies down, always working in a pain free range of motion. Gradually, isometrics are introduced at pain free angles (you are probably noticing a theme), and eventually, we work back in to normal strength and mobility exercises. 

Connective tissue contains several different types of cells including fibroblasts (Stecco, 2015). Fibroblasts play an important role in maintaining the structural integrity of connective tissue, and fibroblasts are continuously degrading and proliferating when mechanical loading occurs, such as during the course of most movement. High rates of stretching (which occurs during many forms of exercise), can result in overstimulation of fibroblasts. This is one theory behind the mechanism of repetitive use injuries. 

When a client presents with a history of a repetitive use injury, I am careful about force distribution during exercise. For instance, I have a client that struggled with tennis elbow several years ago. I make sure when we do pressing movements (including push-ups), load is distributed evenly from his arm into his shoulder. I pay careful attention to shoulder blade stability, and we do a lot of mobility and stability work in his upper extremity. A month ago, he came in with his elbow irritated. The last time it had been an issue was several years ago. I gently asked what he had done since the last time I had seen him. He had gone skiing for the first time in 4 years with his sons. He was gripping the ski poles and elevating his shoulders for stability while on the mountain. We worked on his neck, thoracic rotation, shoulder blade mobility during reaching, and integration of the shoulder blade and arm. By the end of the session, he reported his pain was gone. I encouraged him to try a looser, more relaxed grip on the ski poles. I briefly explained the goal was to make sure force gets distributed all of the way up the arm into the torso; gripping as hard as possible with his predisposition to elevated shoulders was preventing even distribution of force. Once the elbow is no longer aggravated, we will work on gripping exercises, with an emphasis on feeling the effort of gripping all of the way up into his shoulder, teaching distribution of load.

Sometimes, injuries never fully heal. What I mean by that is the individual still experiences pain in the area years after the original injury occurred, giving the person the sense the body part is “bad.” “I have a bad back,” or “I have a bad knee,” are both statements I have heard from clients when we begin our work together. This can happen for a number of reasons, one of which is a nervous system that decides despite the fact the tissue has healed, there is still the potential for danger. The brain sends pain signals to ensure the person in question doesn’t cause harm to the area (Nelson, 2013). Again, this isn’t exactly cut and dry because a heightened nervous system can be caused by many things including stress and sleep issues. Research demonstrates sleep problems correlate to long-term onset of musculoskeletal pain in adults (Bonvanie et.al, 2015). While sleep is currently getting a lot of press, it is outside the scope of practice for personal trainers and movement specialists to address. The same is true of stress. To be clear, it isn’t stress that is bad. There are physiological differences in the stress response based on whether the person perceives stress as a threat or as a challenge (Epel et.al, 1998). While the trainer is not in a position to address the psychological well-being of a client (that’s what therapists are for), a good trainer or coach is well-equipped to create an environment where movement tasks are deemed challenging rather than potentially harmful. This is done through properly regressing movement and exercise, and working slowly with individuals that are prone to anxiety. Asking the individual to focus on the task at hand and sense how he is performing the task creates a  mindful, non-threatening environment and allows the client to create a mindfulness practice within his exercise program. 

It is impossible to cover every “what if” scenario for nociception that might arise when working with individuals in a one on one setting. Below are guidelines for the things I most commonly see. I have found that understanding anatomy and biomechanics, breath mechanics, and therapeutic, somatic modalities allows me to work with pre-existing conditions in a much more effective way.

Acute pain:
Client falls on knee while walking to a car after lunch with friends. Knee swells up. Client e-mails you this has happened but wants to come in anyway. (Client scheduled doctor appointment, but appointment isn’t until later in the week).

Session: 
Knee is still swollen when client walks in. She’s limping a little bit, and says the pain is tolerable. We work on mobility in the shoulder girdle, access breath in supine with knees bent (I instruct her to bend the injured knee only as much as she can in a pain free manner). While there, we work ankle and hip mobility on the uninjured leg, and ankle mobility on the injured leg, again, staying pain free. I spend about 15 minutes on the table with her, and then we move to a seated position on the bench so she can extend her leg if it’s more comfortable. I set up the bench so I have easy access to the Freemotion and tubing. We work on arm patterns, pushing, pulling, Pallof presses. We do leg slides on the uninjured leg, play with some seated cat cows focusing on moving from the pelvis first, breast bone next, and finally the eyes. We do seated thoracic rotation, pelvic rocks to find the sitting bones, and finish with some isolated biceps and triceps. This takes 40 minutes. She is happy, because she got a workout in and for the 55 minutes we were moving, she forgot about the dull ache in her knee.

Goals with acute injury: Don’t aggravate the injury site. Work around it, make sure you have open communication with the client and the client feels comfortable enough to say, “this doesn’t feel right.” Get creative. This is easier if you study multiple movement modalities. The session briefly described above utilized methods and exercises I adapted from PRI, Feldenkrais, FRC, Gyrokinesis, the web, and trial and error. 

A brief note: In the hypothetical situation above, the client had already contacted a health care professional. This isn’t always the case, and I encourage using good judgement to know when something requires further medical attention. I have found most acute injuries that aren’t serious feel significantly better within one month’s time. This doesn’t mean the tissue is fully healed, as noted above, but the sense of pain will have decreased. If this is not the case, the individual should be encouraged to see a doctor (I only had this happen once, early in my training career, when a client’s shoulder began bothering her. I eliminated painful movements, but after three weeks of no improvement, I encouraged her to make an appointment with her doctor. It turns out, she had torn a rotator cuff muscle). 

A client that has “stuff”:
During initial phone conversation with client, he reveals he has low back pain, has done physical therapy, has a full MRI and x-rays he will bring with him his first appointment. The MRI describes disc degeneration in the lumbar spine and bulging at L3-L4. Client is 67, so none of this is terribly concerning,* and the pain is worse with sitting for long periods or standing still. He also gets occasional flare-ups, which he feels is due to postural issues. His low back has been a problem off and on for approximately 6 years, and he has done two rounds of physical therapy. The exercises help, but he would like to gain strength. He feels he has a bad back, and is cautious with all lifting movements.

Initial consultation and assessment:
Client moves stiffly, with no thoracic rotation or arm swing while walking. He is a belly breather, with no apical expansion in his chest. His feet turn out a little bit while standing, and he lives in his heels. He appears disconnected from his body; when asked to squat, his knees shoot forward and there is no hip initiation. He is unsteady on one leg, and has very little ankle mobility.

Session plan:
While posture is not necessarily indicative of low back pain (Pope, et al, 1976), when movement options are limited for an individual experiencing discomfort, this indicates perhaps the current options could be improved upon with a little variety. My solution is to look for ways I can increase his options. This generally occurs in the form of controlled mobility, dynamic stability, and eventually strength. My first four sessions with this individual would consist of teaching different breathing options emphasizing rib mobility, gentle thoracic rotation using somatic principles in supine, ankle mobility, assisted shallow squats and/or quadruped rock backs to understand hip versus knee and low back movement, straight arm lat pull down, shallow step-ups with an emphasis on weight transfer and controlled movement, and foot awareness. I would consistently cue rib position for each exercise, so he begins to improve overall proprioception and awareness of where his center is located. Gradually, we would move into more strength and balance based work as body awareness and motor control increased, with consistent cueing to improve body awareness. 

For homework, I would ask this individual to notice throughout the day how he is standing. If he notices he is standing far back in his heels, I would ask him to shift his weight more to the center. I would also give him supine breathing exercises to perform before getting out of bed that bring awareness to how the ribs expand during the inhale, and come down and together during the exhale.

Goals with recurrent pain:
It is extremely important to minimize flare-ups after the session. The goal should be to allow movement to be a vehicle for confidence in the body’s abilities. If there is pain after the session, this reinforces the threat of exercise. As a result, less is more when starting these individuals on an exercise program. A small study, comparing healthy subjects to subjects with chronic non-specific low back pain (CNSLBP), found less adaptability during various flexion and extension tasks in subjects with CNSLBP (Mokhtarinia, et.al, 2016). What this suggests in a practical setting is slow progression with these individuals is important. If you do too much, too soon, there is a chance a system overload might occur, where the tissue isn’t prepared for the movement, the nervous system isn’t prepared for the movement, and what results is discomfort. The body is extremely adaptable if you go slowly and make sure the client listens to his body both during and after the session.  If a flare up after a session happens, look at your programming and see if you either introduced a new movement, increased load, or increased time under tension. If you did all three of these things in the same session, it is going to make it difficult to tease out which sent warning signs to the nervous system that danger was imminent. Slow is better. 

Word choice used during coaching doesn’t invoke images of “bad” or “injurious” movements (Butler, 2000). This includes not deeming a movement “dysfunctional” or declaring any particular movement “bad.” Catastrophizing commonly occurs when one is frequently in pain. If clients believe there is a “right” or a “wrong” way to move, this feeds into the idea that movement might be harmful. It has been my experience this isn’t helpful for the client, and can lead to muscle guarding. Exercise and movement should be encouraged, and while checking in regarding a person’s current physical state during a session is necessary, it shouldn’t be dwelled upon. Pain free movement does wonders for a person’s psychological and physical well-being; word choice and coaching should reinforce this idea. 

These are just two examples, loosely based on clients I have worked with over the years. Experience has taught me that cues and movements which work extremely well for five people might not work as well for the sixth; as a result, it is important to be fluid when working with the experience of nociception. I always have a plan and an end-goal in mind, but sometimes detours are necessary to overcome hurdles of body awareness the ability to access various areas. It is extremely important to understand pain can be caused by a myriad of factors. It isn’t always mechanically based (an excellent example is given in Douglas Nelson’s book, “The Mystery of Pain.” A young woman with chronic low back pain was eventually diagnosed with an intestinal disorder. The source of her discomfort wasn’t muscular or mechanical in nature; rather, it was an undiagnosed physiological problem). It is often multi-faceted and tends to do well with a team approach. As personal trainers, yoga teachers, or movement professionals, we can’t guarantee we can “fix low back pain with these three exercises/asanas/or movements.” What we do know is pain is individual and can often be helped with gentle, mindful exercise. I have watched people become pain free under the guidance of a carefully planned exercise program; I have also referred people out that I was unable to help within my limited scope of exercise modalities. From a practitioner’s point of view, knowledge of anatomy and physiology is extremely beneficial, as well as paying attention to a person’s patterns, of movement, of mood, and of self awareness. Aristotle is credited with saying, “For both excessive and insufficient exercise destroy one’s strength, and both eating and drinking too much or too little destroy health, whereas the right quantity produces, increases, or preserves it. So it is the same with temperance, courage, and the other virtues…” Pain is a warning sign, sometimes a prolonged, annoying one. It shouldn’t be ignored, but it also shouldn’t be the loudest voice in the room. To successfully work with pain, listen to the person, know when to refer out, know when to progress, but also know when to regress. As Gray Cook says, “ First move well. Then move often.” Hopefully, with the examples given above you can begin to see improving motor control begins with improving self awareness (interoception) and how the body moves in space (proprioception). There are no cookie cutter answers, but using common sense, understanding the principles of movement and applying those principles in a mindful way are invaluable tools. The right amount of exercise applied in a thoughtful, progressive way has the power to change someone’s life.

Yours in health and wellness,
Jenn
References:

Nelson, D., (2013). The Mystery of Pain. London: Singing Door.
Butler, D.S., (2000). The Sensitive Nervous System. Adelaide, Australia: Noigroup.
Baechle, T.R., & Earle, R.W., (2000). Essentials of Strength Training and Conditioning.     Champaign, Ill: Human Kinetics.
Stecco, Carla, (2015). Functional Atlas of the Human Fascial System. London: Churchill Livingston.
Hubbard, T.J., & Hicks-Little, C.A., (2008). Ankle ligament healing after an acute ankle sprain: an evidence-based approach. Journal of Athletic Training, 43(5), 523-529.
Bonvanie, I.J., Oldehinkel, A.J., Rosmalen, J.G., & Janssens, K.A., (2015). Sleep problems and pain: a longitudinal cohort study in emerging adults. Pain, http://www.ncbi.nlm.nih.gov/pubmed/26684726
Epel, E.S., McEwen, B.S., & Ickovics, J.R., (1998). Embodying psychological thriving: physical thriving in response to stress. Journal of Social Issues, 54(2), 301-322.
Pope, M.H., Bevins, T., Wilder, D.G., & Frymoyer, J.W., (1976). The relationship between anthropometric, postural, muscular, and mobility characteristics of males ages 18-55. Spine, 10(7), 644-648.
Mokhtarinia, H.R., Sanjari, M.A., Chehrehrazi, M., Kahrizi, S., & Parnianpour, M., (2016). Trunk coordination in healthy and chronic nonspecific low back pain subjects during repetitive flexion-extension tasks: effects of movement asymmetry, velocity, and load. Human Movement Science, 45, 182-192 (abstract available only).


*In a research review that included 3110 asymptomatic adults, 96% of 80 year olds had imaging consistent with disc degeneration (compared to 37% of 20 year olds). This suggests disc degeneration is not uncommon, and isn’t necessarily indicative of pain. (Full text can be found here: http://www.ajnr.org/content/early/2014/11/27/ajnr.A4173.full.pdf).

**If you would like to read more thoughts on pain, check out Todd Hargrove’s blog (https://www.bettermovement.org), Greg Lehman’s blog (http://www.greglehman.ca/category/blog/), or anything by Lorimer Moseley (http://www.bodyinmind.org/who-are-we/)