03/23/25
Pain: Better Communication, Better Outcomes Part One
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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 deal 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. 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.
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 those 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.
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. As I ventured down the rabbit holes about pain the more complicated it seemed to get, or should I be saying complex?
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.
The original thought was the nail went through the shoe and then through 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.
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 a touch receptor, Thermoreceptors are a change in temperature receptor, & Chemoreceptors [2] are gas exchange receptors. There are more but I will stop there.
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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 badly, but you look up and see a bus headed right for you, you’ll
probably forget about the ankle pretty quick to focus on the bigger threat at that moment. This is
more of an extreme case but 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 issues). These studies aren’t 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 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 do we asymptomatic abnormalities in all populations? Maybe pain isn’t as straightforward as most may think.
About eight years ago, I came across a piece of literature titled "What is a Complex System?". 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 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 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.
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: 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.
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. It’s hard to figure out. Pain just keeps proving to be a pain. (pun intended)
Before we go any further 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. [14]
*- Sham Surgery - A surgery where the doctor does everything like a real surgery with real
anesthesia, 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.
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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 or decompression of the area.
Be aware of diagnostic imaging guidelines, sometimes it leads toward unnecessary
procedures. Again, consult a medical professional.
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 they 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?
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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.”
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With that, I believe I have written enough words for today. Come back for part two for more details on implementation of words toward pain.
About The Author
Chris Larrauri
Chris is the Founder & President of 5D Training, located in Norman, Oklahoma and former Director of Performance at OU. Also an author, speaker, podcaster & researcher. He has a B.S in Kinesiology and an MBA. He has worked with thousands of athletes at every level from the youth up to the professional ranks in the MLB, NFL, & NBA. In his private facility, he currently trains youth up to the pro level in multiple sports. Chris holds certifications including: an NSCA - CSCS, Precision Nutrition Level 1, FRC Level 1, RPR Level 2, & various other credentials.
