We are living in an era where often disparate fields of medicine, rehabilitation, pain science, and strength & conditioning can communicate freely and openly, ultimately improving human performance. This post is an example of such. I am happy to share an open letter from Leda McDaniel - a bright, thoughtful CrossFit athlete and coach I recently met - who has dealt with several orthopedic injuries and the pain that ensued. After reading her thoughts on this subject, I felt compelled that she share it on this site. This letter (in my opinion) applies to not only healthcare providers but coaches and athletes as well, with the intent to stimulate a more open discussion on chronic pain and managing it in our athletes. 

How to read this post: 1) a little more background on Leda, 2) her open letter, 3) a few of my thoughts on the subject.

Leda McDaniel played basketball and ran track/cross country at Trinity University, a Division III school in San Antonio, TX. She has been involved with CrossFit both as a coach and athlete, competing in the 2010 South Central Regionals and 2011 NorCal Regionals. She graduated in 2008 with a degree in psychology and is currently applying for physical therapy programs.

A Letter About Pain: A Patient’s Request for Open Dialogue 

I am writing with the intention of creating a better standard of care for future orthopedic patients. More specifically, I am interested in stimulating a constructive dialogue between patients and caregivers around the issue of pain. I believe that managing and trying to explain this sensation, for patients, is integral to successful rehabilitation from injury. Furthermore, I feel that there is a real need to acknowledge the mental and unconscious factors influencing pain. Through my recovery, I have found that compartmentalizing physical pathology or injury with the exclusion of a psychological component will lead to mediocre treatment at best and iatrogenic effects at worst. 

For the past year, pain has become a daily truth for me as well as a source of continued anxiety. The pain was initiated when I tore the ACL in my left knee playing soccer. I had reconstructive surgery, a patellar tendon autograft, and experienced post-operative pain. This was expected, of course, and I tried to manage this with medication, and the standard dosing of R.I.C.E., however, the pain has persisted and become chronic. In my search for health, I have sought treatment from orthopedists, physical therapists, chiropractors, massage therapists, psychologists, herbalists, and an acupuncturist. 

Throughout this process, I’ve had mostly a bipolar response from the healthcare community on what to do about pain. These two responses have been:

1- The “deal with it” approach

(i.e., The pain you’re experiencing is normal post-operative pain), you need to regulate it better and/or tolerate it)

or

2- The “listen to your body” approach

(If it hurts, don’t do it. You need to avoid pain-inducing movements)

The problem with these two approaches is that they infer that pain is a pure case of sensory and perception signal transmission. This is a commonly held view and it was a fine explanation for me up until the onset of chronic knee pain. You see, I had experienced pain with injuries and that pain had subsided as those injuries healed. I even had the same ACL reconstructive surgery on my other knee (right knee) a number of years ago and felt post-operative pain and its gradual decline with healing. I thought I knew that pain was a reliable indicator of injury or tissue damage. This view, according to pain researcher Patrick Wall, is incorrect. Pain does not necessarily indicate damage. There are instances of tissue damage without pain (those with very serious injuries, in shock, reporting no pain) and there are instances of people in agonizing pain without any obvious tissue damage (most chronic pain conditions, e.g., fibromyalgia).  

If tissue damage isn’t the culprit, then what is the cause of chronic pain? Well known pain researcher, Louis Gifford explains it like this: there is mechanical pain (reflecting tissue damage/injury) and learned pain, which refers to sensitization of tissues and can be a cause of chronic pain conditions. 

Obviously, pain is more complicated than just an indicator of injury. I am not asking medical professionals to know exactly what is going on, but I am asking that they make an effort to learn more about pain and communicate with their patients about it. After all, it is a big part of why patients seek treatment in the first place and, I contend, why patients follow the instructions of those in the medical community. If prescriptions and treatment plans are followed and pain does not dissipate (and there is no explanation for why or what pain is all about), trust in the person delivering that treatment erodes very quickly. 

The two approaches that I’ve encountered have been unhelpful for me for a few reasons. First, the idea that “you’re going to feel pain, so just deal with it” suggests a level of helplessness surrounding the pain but also a complete dependence on symptom-relieving analgesics (e.g., pain medication) instead of alterations in activity or a deeper understanding of the meaning of pain. This can lead to negative outcomes like: engaging in physical activities that can ultimately be more damaging (i.e., pain is indicating further trauma) or the development of maladaptive cognitive coping strategies such as learned helplessness (i.e., the belief that “nothing I do can free me from pain, therefore I won’t try to get out of pain”). Learned helplessness factors into the high co-morbidity seen with depression and chronic pain. Okay, so clearly, there are problems with ignoring pain or even dealing with pain purely from a “deal with it” symptom relief perspective.  

The alternative view, “If it hurts, don’t do it,” has problems as well. These have to do with the process that Gifford describes in which tissues and nociceptors can become hyper sensitive to stimuli and create pain signals that are not reflective of actual damage, but just a misfiring of the system. Lorimer Mosely describes this phenomenon as “central sensitization,” and uses metaphors to explain this idea to patients who are entrenched in the common structural-pathology paradigm. This was one of the most ideologically shattering ideas for me as someone experiencing pain. Do you mean that pain does not necessarily equate to bodily harm/injury? Just learning that pain could be due to hypersensitive nerve tissues and not be signaling damage decreased my anxiety and fear A LOT. 

So, if the pain is not harmful, how do we deal with pain that doesn’t reflect physical injury? It can’t just be ignored. As Physical Therapist Gray Cook says, “The first rule of movement is this: pain changes everything.” Our bodies institute unconscious compensatory behaviors (e.g., muscle tightness or stiffness) to protect the painful area. Just because our brain logically understands that pain may not be harmful does not make our body react differently. Gifford eloquently describes one approach to this type of pain, saying, “The thinking has shifted from mechanical fault-fixing to ‘desensitizing’ – using movement, or mechanics, to alter pain processing that’s stayed sensitive too long.” The approach he is advocating for is the gradual introduction of movements that elicit little pain and retrain movement patterns as “safe.”  I have since realized that my experiences in physical therapy have reduced some of my pain, utilizing this powerful tool of desensitization. 

Finally, without a more in depth discussion of pain, the patient is left feeling helpless, frustrated, and distrustful of medical professionals who may dismiss the pain as “in your head” or “normal”. Again, I think it is very important to note that pain is neither purely physical nor purely psychological. The first attribution dismisses the validity of past experiences on present felt pain and the second trivializes a person’s very physical feeling of pain by labeling it, “psychosomatic.” Furthermore, there is no such thing as “normal” pain. In his book “Pain: The Science of Suffering,” Patrick Wall contends that pain is a conscious experience that necessarily includes an unconscious evaluative component. This is a view shared by researcher Lorimer Moseley and expressed in his book, “Painful Yarns: Metaphors and Stories to Help Understand the Biology of Pain.” 

My hope is that we can use this complexity of pain to better communicate to patients the idea that they have agency to change potentially pain-inducing behaviors with the equally important message that the pain they are experiencing is not their fault.   

I truly believe that there needs to be more open discourse on pain between patients and practitioners. The perpetuation of pain as a taboo topic is a nonscientific approach. Pain should be discussed openly and the intricacies of pain acknowledged. Only when patient and practitioner can speak about pain honestly and intently will the shame, frustration, and stigma dissipate. The more we can all learn about this construct, both scientifically and within felt experience, the closer we will be to finding more effective treatments for pain. I hope that your reading of this was relatively pain-free and I thank you for taking the time to read and keep an open mind. 

Sincerely,

Leda McDaniel

Seth's thoughts: Fantastic piece, Leda! I agree there are plenty out there who do not understand, or are unaware of, the various pain constructs and their impact on daily and athletic life. It is critical that we acknowledge the fact that there really is no such thing as "normal pain". Clinically, many athletes I see report normal pain during or after their sport - this is not okay, people. It means that movement has already lost its integrity and often represents a threat to tissues and/or the nervous system, whether that threat is real or perceived. Furthermore, sensitization fundamentally changes movement patterns even after the painful stimulus is gone. 

So if pain changes movement as Leda described, perhaps changing the movement pattern may modulate pain. As Gray Cook states: "perception drives movement behavior and movement behavior modulates perception". It's no surprise that a graded exercised program can improve function and quality of life in those with chronic back pain because, in part, it changes how the brain perceives movement. Lorimer Moseley discusses movement as the brain's perception of the demand and the capacity to meet it - we can change that capacity by retraining safe movement patterns.

Coaches are often the catalyst here as we see pain often at its earliest prior to going to the physio or MD. We all need to educate ourselves and our athletes/clients on the importance of pain because it ultimately keeps us from realizing our potential. We are much better off understanding and respecting pain than pushing through it - it's our ultimate protective device. If you don't understand the athlete's issues refer them on - we can't screw around with this stuff. 

Pristine movement without pain is, or should be, the goal of sport and performance. 

HUGE thank you to Leda for sharing this - you can contact her at ledamcdaniel1@gmail.com.

- Seth

P.S. Watch this fantastic lecture by physio Lorimer Moseley on pain. His group has some of the best stuff going right now:

We've already discussed how to increase performance with breathing and bracing strategies during movements (I highly recommend checking out Part 1, Part 2, and Part 3 to get the whole picture), but what about when the training, competition, mission, or workday is over? An inability to shut down, sleep, and recover is not only frustrating to that individual which further amplifies the stress, but is also untapped potential for performance gains. Recovery may be the most important part of your workout. 

Stress, both physical and emotional, is powerful when appropriate as the heightened state of the sympathetic nervous system (the "Fight or Flight" state that gets your heart pounding) can increase short-term physical performance. However, those who are in a chronic amped state due to work, rigorous training, competition, or even battle are often unable to efficiently regulate this system and shut it down when necessary. Even chronic pain patients suffer from this. This causes an imbalance between the sympathetic and parasympathetic nervous systems in which athletes are persistently yoked-up and unable to sleep and recover. We have to get out of this reset baseline in which abnormal starts to feel normal. Self-medicating to sleep is NOT normal.

In normal diaphragmatic breathing, the heart rate accelerates when breathing in and decelerates when breathing out. This Heart Rate Variability (HRV) is a glimpse into the balance of the nervous system. When athletes are in a constant state of sympathetic dominance, the heart beats like a drum and does not have a normal variability. This is exacerbated by heavy upper chest and neck breathing (discussed in detail in Part 1) and poor diaphragmatic activity resulting in chronic over-breathing. Loss of HRV is even found to be predictive of mortality in those with heart conditions.

The harder we train or stress about work, the less variable this system becomes as the sympathetic state dominates and our athletes and soldiers cannot down-regulate and adapt to these stressful stimuli. The result is what you really care about: poor adaptation and recovery, disrupted sleep patterns, fatigue, and ultimately poor performance.  By the way, notice how much these symptoms look like (and are likely correlated with) overtraining.

One way we can help better balance the nervous system and down-regulate for adaptation is thru better diaphragmatic breathing. In Part 2, I discussed how breath-holding and prioritizing inhalation during max effort can up-regulate the sympathetic nervous system and increase force output. Similarly, prioritizing exhalation via the diaphragm can down-regulate the sympathetic nervous system for better balance. 

To help shut down and recover, try this for 5 minutes per day preferably before bed: 
1. Lay on your back with knees bent, one hand on abdomen at the bottom of the rib cage and one on the upper chest.
2. Take a breath in thru the nose and breathe into the belly, feeling the hand on your abdomen rise. The hand on your upper chest should not rise - only the diaphragm and lower ribs should move. There should be no pause between inhalation and exhalation.
3. Breathe out in a slow, controlled motion - this should be completely passive. Take twice as long to exhale as it took to inhale. 
4. Time yourself and aim for 8-10 breaths per minute, this may take time to accomplish as the athlete may feel some air hunger indicating a reset system (abnormal is now normal) where they've been chronically over-breathing - which is why this feels weird. Concentrating on the exhalation should help. *Obviously breathe if necessary, don't be a knucklehead about this and pass out - breathing should always win.

Diaphragmatic breathing takes practice but can be extremely effective at helping down-regulate this sympathetic breathing state and promoting recovery and a balanced baseline. Break the stressed-out loop and start PRing - we need to better manage and maintain homeostasis with the tools that we have. 


"If breathing is not normalized, no other movement can be" Lewit

- Seth

*If you need more than self-management for this, then find a local provider. Breathing always wins.
**Kelly Starrett has some good stuff on this, as do the DNS and PRI groups if you yearn for more.

Last week we discussed 3 common mistakes athletes and coaches make that destroy training sessions and decrease performance. We have gotten you to stop sitting, encouraged (mandated) goal implementation for every training session, and improved your warm-up. But what about during and after the training session? The goal for this week's post is to fix some common errors during and after the workout that are killing efficiency and productivity.

1) Missing the details. When it comes to training for performance, not paying attention to how you or your athletes are moving is a common and crippling mistake. Proper exercise prescription and progression is an art and science that takes experience and knowledge (as well as some trial and error) and can be difficult even for experienced physios, coaches, trainers, and athletes. Often if someone is struggling with a particular exercise, the response is "that guy/girl must be weak, let's load up the weight". That's borderline moronic. Increasing load or reps will only serve to exacerbate the athlete's poor movement. In the rush to "strengthen" in an attempt to fix the ugly movement, we miss what is staring us right in the face - how the athlete is moving!
        The fix: Watch the athlete move! The manner in which someone moves is the best way to deduce why they are struggling. The problem is almost always staring us right in the face if we just take the time to figure out why. It may be a mobility problem (unable to achieve appropriate position due to joint and/or soft-tissue restrictions) or a motor control deficit (unable to simultaneously stabilize and control a movement). If someone has poor motor control increasing the difficulty of the task will only serve to make them more unstable. Poor mobility and increasing load will just put them in an untenable position that is destined to fail. Both of these deficits can and do lead to injury. So take a step back and look at how the athlete moves. Knees come in when landing from a jump? They may lack hip internal rotation or they may have poor control of their glutes and posterior chain. Unable to tell in real-time? Slow it down, man, and film it. Coach's Eye is a great app that allows video analysis in slow-motion and is very effective at making the invisible become visible. Not sure what's going on? Find a good physiotherapist (contact me for some help) to get on the right track. Proper exercise progression should be based not just on load, speed, and other quantities but on quality! The goal here is to pay attention to the details, unload the movement, and do some problem-solving. Perfection is in the details and will propel you or your athlete to higher performance.

2) Improper recovery habits. Taking a training session seriously is just not enough to significantly improve performance. Multiple variables are either forgotten, ignored, or misused in recovering from workouts. These include improper nutrition and hydration, ignoring or mistreating post-workout soreness (DOMS - delayed onset muscle soreness), and improper sleep habits. Screw these up and they neuter your best efforts in training (and in rehabilitation - often these variables are forgotten by physios and patients when they are needed most).
           The fix: Nutrition - poor caloric and protein intake is critical to recover from training. If you are involved in strenuous exercise and are not eating adequate amounts of protein, it's counterproductive. Muscle damage needs repaired and protein (specifically amino acids which make up protein) is the constituent that needs replenished. Current NSCA recommendations are for 1.5-2.0 g of protein per kg of bodyweight. Protein supplementation is likely necessary though a majority of it should come from high quality, animal protein. Get a portion of this protein immediately after exercise and at least every 4-5 hours thereafter. Eat clean, eliminate inflammatory foods (gluten, sugars), and perform better.
        Hydration: drink half of your body weight in ounces per day and throughout the day (not all at once - a large bolus of fluid will flood the kidneys and prevent appropriate uptake). Hydration is so important for not only muscle suppleness, but also joint surfaces (via glycosaminoglycans) which draw water into the synovium and maintain joint hydration, reducing friction. Get hydrated and take it seriously.
        Handling post-workout soreness: How are you dealing with soreness now? Waiting for it to go away while you limp up the stairs? Don't be that guy. Soft-tissue work is a must in this situation: foam roll or lacrosse balls applied (sometimes aggressively) to the offended tissues provides tissue mobility and better intra-muscular sliding which prevents them from becoming matted down, ugly messes. Don't ride your muscles hard and put them away wet. A 5-10 minute cool-down will also aid in post-workout recovery. You can try tart cherry juice for some relief, check out this study in runners. Thinking about ice and ibuprofen for your soreness? DON'T! Friends don't let friends take ibuprofen. Read this and watch:

        Sleep: Multiple studies are coming out regarding the increased risk of injury in those who are sleep-deprived, including factory workers and athletes. In fact, adolescent athletes who slept more than 8 hours per night were 68% less likely to get injured. The exact mechanism is unknown (decreased reaction time, poor healing?) but the benefits for injury prevention are real. Appropriate sleep also improves retention (crucial when learning a new skill) and is necessary for growth hormone to be secreted - a potent anabolic hormone. Bottomline: get your 7-8 hours. I suspect one of the causes of high injury rates in college and professional sports is due to sleep deprivation - take your sleep seriously!

Bottomline: when determining exercise progression, determine if it's appropriate based on the quality of the movement not just on the numbers - pay attention to the details! Trust your eyes and don't be afraid to unload the movement and get to the "why" of the problem. And take recovery seriously. As you can see from last week's post and this week's, performance is 20% training and 80% what you do outside of the actual physical part of training.

-Seth

We must always treat, train, and move with purpose. So why should the way we manage musculoskeletal injuries be any different?

True or false: you use and trust the mnemonic RICE (rest, ice, compression, elevation) when dealing with injuries?

True or false: after a hamstring strain or ankle sprain, ibuprofen or aspirin (common NSAIDs - non-steroidal anti-inflammatory drugs) are popped like Skittles?

The truth of the matter is, despite what we all have learned, RICE may not be such a good idea if the goal is promoting adaptation and tissue recovery following injury and/or intense muscle soreness.

In a healthy person with a normal functioning system, the Inflammatory stage is paramount to healing. In fact, the inflammatory process must be initiated for the body to progress to the Repair stage (collagen is laid down and scar tissue begins to form) and finally the Remodeling stage (collagen is realigned and strengthened).

Now, the inflammatory stage does create swelling which causes fluid pressure to build. The pressure from swelling blows out free nerve endings causing pain and inhibiting muscle contraction. So swelling, NOT inflammation, is the real problem here. By icing or taking NSAIDs we are retarding, and potentially eliminating, the natural inflammatory response and not letting the body go through the necessary steps for tissue repair. The body does a great job of healing itself if we quit being bozos and get out of the way! Our GOAL is to promote tissue repair and create the perfect healing environment, not just numb the area with ice and ibuprofen - which does nothing to reduce the swelling, by the way.  Don't get me wrong, we take injuries seriously and continuing to irritate a hot and inflamed joint will stall the healing process but we have to look beyond ice and ibuprofen to promote repair.

I know this is tough to deal with considering everything you've been told about the benefits of ice and NSAIDs so below is some hardcore evidence (the peer-reviewed kind - NERD ALERT):

“Is Ice Right? Does Cryotherapy Improve Outcome for Acute Soft Tissue Injury?”
Abstract: Aims: The use of ice or cryotherapy in the management of acute soft tissue injuries is widely accepted and widely practiced. This review was conducted to examine the medical literature to investigate if there is evidence  to support an improvement in clinical outcome following the use of ice or cryotherapy.  Conclusion: There is insufficient evidence to suggest that cryotherapy improves clinical outcome in the management of soft tissue injuries.
    Journal of Emergency Medicine, Feb. 2008; 65-68

"Does Cryotherapy Improve Outcomes With Soft Tissue Injury?"
Results: The authors reported ice to be no more effective than rehabilitation only with regard to pain, swelling, and range of motion. Ice and compression seemed to be significantly more effective than ice alone in terms of decreasing pain.
    J Athl Train. 2004 Jul-Sep; 39(3): 278–279

"The Use of Ice in the Treatment of Acute Soft-Tissue Injury A Systematic Review of Randomized Controlled Trials"
Results: There was marginal evidence that ice plus exercise is most effective, after ankle sprain and postsurgery. There was little evidence to suggest that the addition of ice to compression had any significant effect, but this was restricted to treatment of hospital inpatients. Few studies assessed the effectiveness of ice on closed soft-tissue injury, and there was no evidence of an optimal mode or duration of treatment.
    Am J Sports Med January 2004 vol. 32 no. 1 251-261.

"A Randomized Controlled Trial of Piroxicam in the Management of Acute Ankle Sprain in Australian Regular Army Recruits"
Results: 'Interestingly, subjects treated with piroxicam showed some evidence of local abnormalities such as instability and reduced range of movement.'
    Am J Sports Med July 1997 vol. 25 no. 4 544-553

Check out this New York Times article on NSAIDs. Not to mention the side effects - read your ibuprofen warning label if you want to get freaked out.

There's even more out there on this but here's the point:
We have to improve circulation and promote healing and tissue recovery through improving venous and lymphatic drainage (passive circulatory system that returns proteins too large for the veins - stuff like swelling/waste). The BEST way to do this is through compression such as active muscle contraction, compression gear/clothing, etc. to squeeze the passive tubes and get the swelling out of the system to restore homeostasis - not just stop it in its tracks. Now, don't be ridiculous and flex a broken bone or start contracting your newly-repaired rotator cuff but even gentle muscle contractions in uninjured, regional muscles will do the trick. This benefit is amplified when combined with compression. Elevate as much as possible.
*Check with your physician if this freaks you out or if you have an out-of-control immune/inflammatory system (like RA) - NSAIDs may be warranted in some, typically non-musculoskeletal conditions. Seriously though, look at this evidence with an Eagle eye.

Bottomline:
Rest: not really an option, we need to move safely when we can. And don't even get me started on the horrors of immobilization
Ice: not nice, kick it to the curb - no thanks I'd like to heal
Compression: absolutely, check this out for more ideas
Elevation: yes
Movement: yes, safely

People, we have to kick our habit of ice and ibuprofen post-injury/post-surgery. Do NOT let the drag of orthodoxy rear its swollen, ugly head! Just because have always done it doesn't mean we always should.

-Seth