Pain: Better Communication, Better Outcomes - Part One

Imagine waking up everyday with a pain that no one can see, a pain that dictates your every move and thought. Now, imagine if understanding and communicating this pain could transform your life. Whether you're a fitness professional, athlete, or weekend warrior, this blog aims to illuminate the path through pain, transforming struggles into resilience through communication.

Pain is an inevitable part of the human experience. Yet, it remains one of the most misunderstood aspects of life. It’s reported that 1 in 5 adults deals with pain [1]. The world is plagued with it.

Pain can cause a person to have subtle changes in their gait pattern or complete avoidance of a movement. One of the most common sources of pain is low back pain.

We must pay respect to the law of repetitive motion for repeated bouts of flexion from sitting all day at your computer, consistently looking down at one’s phone scrolling through social media, or in the athletic population being in a severe amount of extension can all lead to what Dr. Stuart Mcgill would refer to as non-homogenous (not alike) conditions like low back pain.

Dr. Mcgill has a wide array of resources regarding this subject and quite a few other subjects. Look him up at www.Backfitpro.com to learn more. Now back on topic.

As I ventured down the rabbit holes about pain the more complicated it seemed to get, or should I be saying complex?

Before I get too far into this topic, I want to make a disclaimer. I am not a doctor, physical therapist etc. and do not have a background in these areas besides working alongside some great ones over the years. If you are in severe pain contact your nearest specialists for advice on how to navigate it. This blog is from a strength and conditioning coaching perspective.

The International Association for the Study of Pain would define pain as “an unpleasant sensory and emotional experience associated with actual OR POTENTIAL tissue damage or described in terms of such damage.” If you notice, I highlighted potential there. This is because a pain response can occur without actual damage to tissue. Look at the picture to the right for example.

Initially, it was thought that the nail went through the shoe and the foot. This person was in massive amounts of pain and rushed off to the hospital. Come to find out the nail slid between the toes not causing any tissue damage, but this person was in agonizing pain. Why? Let’s start with Nociception.

Nociception and Pain Perception:

I won't go to far into detail because I don't want to lose anyone. Essentially, Nociception is a neural process of how our body registers sensory input. In the case above, the guy stepped on a nail, nociceptors signaled that message to the brain, the brain decided to perceive the situation as pain and gave real sensations of pain even though there was no tissue damage.

Different receptors process different stimuli. To name a few: Nociceptors are a pain receptor, Mechanoreceptors are touch receptors, Thermoreceptors are a change in temperature receptors, & Chemoreceptors [2] are gas exchange receptors. There are more but I will stop there.

Pain is weird. Just like how their can be pain with no tissue damage the reverse is also true. There can be tissue damage with no pain. How is this?

Example: You’re walking down the street you twist your ankle, but you look up and see someone riding a bike headed right for you, you’ll probably forget about the ankle pretty quickly to focus on the bigger threat at that moment. This is more of an extreme case but you get what I'm saying.

There are also times where tissue damage can be done and our body doesn't register it because it happened over a long period of time. It wasn't an acute (immediate) thing, it was more like a river cutting through rock. A slow and steady stream of micro traumas that the body didn't register. Look at this infographic from Adam Meakins:

As you can see, various studies show people with orthopedic abnormalities (something not normal) experience no pain. Over 3,000 subjects participated in one study, while 700 were involved in another, demonstrating issues on an MRI but the patients remained asymptomatic (not having a sensation of pain, dysfunction etc.).

These studies may not be the most applicable to athletes since they were conducted on various non-athletic populations aged 15 to 80 years [3] [4] [5] [6] [7]. However, studies conducted on athletic populations tell the same story.

In a study by Pennock et al. (2018), it was shown that there is an 8.5x greater likelihood of finding an abnormality in the dominant arm of little league baseball players compared to the non-dominant arm. This study had a relatively small sample size of 23 players but still revealed various asymptomatic abnormalities within the throwing shoulders of 10- to 12-year-old kids. These changes are occurring in the athletic population at a young age across multiple sports.

Shifting to another population, a study of collegiate and professional hockey players Hacken et al. (2019) found that out of 25 athletes, 25% had labral abnormalities in the shoulder and 8% had AC joint abnormalities, most often found in the non-dominant stick hand (top hand).

This makes sense, considering that this is usually the side of the body male hockey players will use to contact another player. The SAID (Specific Adaptation to Imposed Demand) principle must be coming into play here. While we know that overuse injuries are on the rise and can cause further abnormalities, let’s focus on the asymptomatic group.

Why is their asymptomatic abnormalities in all populations? Maybe pain isn’t as straightforward as most may think.

Complicated vs Complex Systems:

About eight years ago, I came across a piece of literature titled "What is a Complex System?". It's a great read that I recommend often. While much of it was above my level of understanding, I did grasp some key points regarding Complicated vs. Complex Systems.

Complicated System - Something that can be evaluated in a linear progression to diagnose the issue and fix it. For example, you take a car to the mechanic, who connects it to a computer, finds out you need a new water pump, and fixes it. Everything works perfectly. They diagnosed the issue, found a solution, and resolved it in a linear fashion, with few outside influences affecting the resolution.

In contrast, many doctors and fitness professionals view the body as a complicated system. For instance, if you biceps tendonitis, practitioners often go directly to the bicep and start interventions there. This may sometimes be appropriate, often it isn’t, as controllable (posture, sleep, nutrition, etc.) and uncontrollable factors (genetics, previous injury, body adaptations) affect the outcome.

The human body is much more of a complex system than a complicated one. This raises the question: what is a complex system?

Complex System - “In a general sense, the adjective ‘complex’ describes a system or component that by design or function or both is difficult to understand and verify ... complexity is determined by such factors as the number of components and the intricacy of the interfaces between them.” ([10], P.3) Athletes may wish to simplify their conditions, but they are complex systems.

For example, if their knee hurts, they may immediately want an MRI, thinking surgery will eliminate the pain. This isn’t always the case; factors like posture, breathing, stress, nutrition, genetics, previous health history, and others play a part in the issue and how to “fix” it. They need to view themselves as complex systems rather than a complictated.

Although we want to keep things simple, the issue often stems from areas such as the hip or ankle and interventions like positional breathing, spring ankle, FRCs, and strength training may be necessary after proper evaluation.

Placebo Effect:

Now that we have explored the differences between complicated and complex systems, we can agree that the body and pain are indeed complex. This leads to another point that adds to the complexity: the placebo effect.

What is a placebo?

It is a substance or procedure without specific activity for the condition being treated. While most have a basic understanding of what a placebo is, I’ll provide examples that illustrate the complexities of pain.

One of the leading authorities on the placebo effect is Ted Kaptchuk, a professor of medicine at Harvard Medical. Kaptchuk et al. conducted a study in 2014 that revealed subjects with periodic headaches experienced the same relief effects from a placebo as they did from actual treatment, even when they knew it was a placebo.

Let's delve further into this with some slides [12] [13].

It’s interesting to see studies that show the placebo effect being a powerful tool. One study showed when taking two pills in comparison to one, participants received better results. The other one compared sham surgeries* to real surgeries. It showed the participants that did the sham surgery had the same effect as the regular surgery at reducing pain and improving disability.

(*- Sham Surgery - A surgery where the doctor does everything like a real surgery with realanesthesia, real incisions, and real stitches but does not do anything to the inside of the body. Just seems like they did when the patient sees the marking on the outside of the body. It is a placebo effect.)

It’s hard to figure out. Pain just keeps proving to be a pain. (pun intended)

I want to repeat, I am not a doctor, physio etc.. You need to consult with your doctor if you are having pain but be cognizant that they aren’t just trying to get you under a scalpel to make money. Why do I say that? Look at this infographic that adds to the placebo affect. [14]

For certain conditions such as subacromial shoulder pain (frontside shoulder pain) we can see that no treatment had close to the same effect as arthroscopy (removal of fragments of bone, cartilage etc.) of the area. Be aware of diagnostic imaging guidelines, sometimes it leads toward unnecessary procedures. Again, consult a medical professional. 

This doesn't just go for the shoulder, this shows in imaging of other areas also. Lets take a look at this infographic regarding imaging of the lumbar spine:

We can visualize from the above infographic that disc abnormality may be more normal than we think. [15] [16] Maybe you as an office worker or an athlete don't not need to have surgery even though you may have something going on but are asymptomatic. Again, I am not a doctor. I am not trying to talk anyone out of surgery, but I am trying show how complex pain is.

Now that we have a better understanding of that notion, we can move into how we can better communicate it, so the wrong perception doesn't keep us stuck. This includes the communication to ourselves (self-talk). Why does it matter if the wrong perception is thought of?

The words we choose can seriously affect all of us, for better or worse. “Words are the most powerful tool we possess, but words, like a double-edged sword, can main as well as heal” - Bernard Lown, MD. This isn’t just for doctors may I add. We can insert any person in a leadership position, coach, physio, teacher, manager, CEO etc. Like world renown strength coach Joe Kenn says: “Words Win.”

With that, I believe I have written enough words for today. Overall, we see that pain can be a complex subject. Sometimes we have tissue damage with no pain, other times we have pain with no damage. This is why our communication strategies and tactics are so important. Come back for part two to see how we can implement words toward pain for better outcomes.

Sources

1. Pain as a global public health priority 

2. Physiology, Respiratory Drive 

3. Systematic Literature Review of Imaging Features of Spine Degeneration in Asymptomatic Population

4. Ultrasound of the shoulder: asymptomatic findings in men

5. High Prevalence of Superior Labral Tears Diagnosed by MRI in Middle-Aged Patients With Asymptomatic Shoulders 

6. Prevalence of abnormalities in knees detected by MRI

7. Prevalence of abnormal hip findings in asymptomatic participants: a prospective, blinded study 

8. Shoulder MRI Abnormalities in Little League Baseball Players

9. Prevalence of MRI Shoulder Abnormalities in Asymptomatic Professional and Hockey Players

10. What is a complex system?

11. Demonstration to Medical Students of Placebo Responses and Non-Drug Factors

12. Altered Placebo and Drug Labeling Changes the Outcome of Episodic Migraine Attacks | Science Translational Medicine

13. Sham Surgery in Orthopedics: A Systematic Review of the Literature

14. Arthroscopic subacromial decompression for subacromial shoulder pain (CSAW): a multicenter, pragmatic, parallel group, placebo-controlled, three-group, randomized surgical trial 

15. Systematic Literature Review of Imaging Features of Spinal Degeneration in Asymptomatic Populations

16. Incidental Findings on Magnetic Resonance Imaging of the Spine in Asymptomatic Pediaric Population: A Systematic Review