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What is pain?

No one really wants pain. Once you have it you want to get rid of it. This is understandable because pain is unpleasant. But the unpleasantness of pain is the very thing that makes it so effective and an essential part of life. Pain protects you, it warns you about dangers, often before you actually become injured. It is your body’s alarm system. It makes you move differently, think differently and behave differently which also makes it vital for healing.

It is believed that all pain experiences are an excellent, though unpleasant response to what your brain judges to be a threatening situation. Even if problems do exist in your joints, muscles, ligaments, nerves or anywhere else, it simply won’t hurt if your brain thinks you are not in danger. The opposite is also true and concerns many chronic pain sufferers. Even if no problems whatsoever exists in your body tissues, nerves or immune system, it will still hurt if your brain thinks you are in danger. The best way to prove that statement is to look at phantom limb pain.

Phantom limb pain is the experience of pain in a body part that does not exist (mostly after severe trauma or amputation). Seventy percent of people who lose a limb experience a phantom limb which appears extremely real to them. It can itch, tingle and hurt. The phantom limb’s symptoms worsen when the person becomes stressed. Some people have reported feeling rings on phantom fingers; others reported phantom legs that “can’t stop walking”.

So if these people can feel pain without any structures causing it, chronic pain sufferers can feel their pain without any injury or damage to their tissues. So is the pain all in their head? This is probably the most frequently asked question from people learning about pain physiology. We have to be really honest here and say, “yes- all pain is produced by the brain- no brain, no pain!” This doesn’t mean for a second that it is not real- much to the contrary- all pain is real. But it’s the brain that decides whether something hurts or not, 100% of the time, with no exceptions.

This concept is hard to accept because we’ve always assumed that if there is pain, it means that something is wrong. But when someone has been in a car accident and many years later still feels intense pain, the tissues are no longer being damaged. The inflammation and the healing process are over now and the pain is felt for other reasons. I must be very clear here when I talk about chronic pain sufferers. These concepts apply mostly to people who are in pain following a specific injury: people who have hurt their back long ago, or broke a leg or had surgery years ago, and simply can’t seem to move on with their lives without being in intense pain. People with systemic conditions such as rheumatoid arthritis, fibromyalgia and crohn’s disease, to name a few, are victims of ongoing inflammation and tissue damage and these concepts are not applicable here.

Through scientific research we are now aware of some of the thought processes which are powerful enough to maintain a pain state long after tissue damage is over. (1) Some of these thought processes can have you saying things like “I’m so afraid of my pain and of injuring my back again that I’m not doing anything”. These fears will naturally cause increased stress, which releases a hormone called cortisol in your body. Persistent increased levels of cortisol has been linked to slow healing, loss of memory, depression, despair and a decline in physical performance. (2) These fears will also cause you to drastically decrease your physical activities. But inactivity has tragic consequences on our overall health and healing abilities. Joints adore movement and regular compression which keeps them lubricated and well nourished. Moving keeps our muscles strong, increases blood flow, improves our lung capacity. Our bodies were simply made to move.

At Back in Motion, our physiotherapists and the rest of our team can greatly assist chronic pain sufferers. By educating people about pain physiology, it is scientifically proven to reduce the threat value of pain. (3) Educated movement is brain nourishing. It helps restructure pathways in the brain laid low by fear and ignorance. This can help the brain understand that our body is no longer in danger, and tune down the level of pain signals you perceive. Physiotherapists can act as “coaches” and encourage patients to gradually increase their level of activity as well as understanding their fluctuating levels of pain. There are many methods used to achieve this and every treatment method will be customized to suit every patient individually. By being compassionate, enthusiastic and informed, your physiotherapist can assist you in mastering your situation.

References:
(1) Price, D.D. Psychological Mechanisms of pain and analgesia. Vol. 15. 2000,
(2) Lovallo, W.R. Stress and health. 1997
Martin, P. The sickening mind. 1997
(3) Moseley, Hodges, Nicholas; A randomized controlled trial of intensive neurophysiology education in chronic low back pain. Clin J Pain (In Press) 2003

Additional reading: Explain Pain by Butler and Moseley 2003

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Fitness After Baby: More than just shedding pounds.

Many women would agree that carrying and delivering a baby is one of the most joyous experiences in their lives… but it is also very challenging on their body. Many women assume that once they lose their pregnancy weight, they have done all they can do to be healthy and fit. After all, having a baby is a natural thing, and everything should fall back into place in time. But problems can arise years after having a baby that will never be linked to the pregnancy or delivery, but could have been avoided with awareness and exercises in the post-partum period.

1-Breathing and neck pain: During the third trimester, the baby pushes into the diaphragm, making it hard or impossible for the expectant mother to take deep abdominal breaths. She then uses a lot of neck muscles to assist her with breathing. If she doesn’t learn to breathe with her diaphragm once she is no longer pregnant, it can lead to neck pain over time, due to overused neck muscles.

2-Low back pain and pelvic pain; There are 4 muscles that are responsible for stabilizing our lumbar spine and sacro-iliac joint (D. Lee 2004). As research continues, more muscles will likely be added to this list. But let’s look at these 4 muscles that prevent our spine from shearing and enduring excessive strain.

  • A deep abdominal muscle called Transversus Abdominus
  • A low back muscle called the Multifidus
  • The diaphragm which is used mostly to breathe
  • The pelvic floor muscles; 5 muscles and a thick fascia holding the pelvic organs like a hammock.

3 out of 4 of these muscles are seriously compromised during pregnancy and delivery. The Transversus abdominus (TA) gets stretched significantly during pregnancy not to mention if a woman has a cesarean. An incision must be made right through it, compromising its strength. The diaphragm gets pushed on by the baby making it contract less efficiently. The pelvic floor can be torn by an episiotomy or tearing during a vaginal delivery. Depending on how easy or difficult a woman’s pregnancy and delivery is, the toll on these muscles will vary and so will the predisposition for low back and pelvic pain.

3-Urinary incontinence: As mentioned earlier the strain put on the pelvic floor muscles during vaginal delivery can cause low back pain. These muscles are also the reason so many women have urinary incontinence after delivery. A study conducted by Allen et al (1990) investigated 96 women both prenatally and postpartum to determine if childbirth caused damage to the pelvic floor muscles and/or its nerve supply. They showed that a vaginal delivery impairs the strength of the pelvic floor and notice that recovery had NOT occurred at 2 months postpartum. They also demonstrated via needle EMG, that vaginal delivery caused partial nerve damage to the nerves supplying the pelvic floor muscles in 80% of these women. This is significant and a weak pelvic floor has been linked to organ prolapse, which requires extensive surgery. (Ashton, Miller et al, 2001). Doing Keigel exercises is an effective way to rebuild strength in pelvic floor muscles, but it may not be enough.

I feel the women who are especially at risk of developing low back pain are those who have experienced both a vaginal and cesarean delivery. The women who only had cesareans will have virtually no issues with their pelvic floor. And the women who only had vaginal deliveries have no scar tissue hindering the efficiency of the contractions of their TA muscle.

Physiotherapists can help by assessing the impact that the childbearing experience has had on these muscles. Just like retraining is necessary after an injury or a surgery, it’s also necessary after having a baby. With the proper exercises a woman’s body can be as good as new… at least until the next baby comes along.

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