ONE WIN­TER, MY HIP STARTED TO HURT WHEN IRAN. FLEETINGLY AT FIRST, BUT SOON THE PAIN UN­PACKED ITS BAGS AND SET­TLED IN. IT’ S HARD TO DE­SCRIBE EX­ACTLY WHERE IT HURT–SOME­WHERE DEEP INSIDE THAT I COULDN’ T TOUCH. SOME­TIMES IT WAS RAW AND IN­TENSE, SOME­TIMES Q

Runner's World (UK) - - Pain Science -

The physio blamed slip­ping and slid­ing on muddy trails, told me to lay off run­ning and gave me ex­er­cises to stretch and strengthen the sur­round­ing mus­cles. But noth­ing – rest, mas­sage, ex­er­cises – helped.

Days be­came weeks and I limped around mis­er­ably, pic­tur­ing the inside of my hip joint like one of those tele­phone ex­change cab­i­nets you some­times see open in the street – the tan­gled mass of wires rep­re­sent­ing the frayed mus­cle fi­bres and throb­bing nerves I imag­ined were there.

Even­tu­ally I forked out for an MRI and braced my­self for the re­sults. The dam­age? None. I was as­ton­ished. Rich­mond Stace was not. He’s a phys­io­ther­a­pist who spe­cialises in treat­ing pain (spe­cial­ist­painphysio. com). ‘ Pain is a per­cep­tion. It is not bound to any­thing phys­i­cal,’ he says.

It’s hard to get your head around the no­tion that the pain you’re feel­ing isn’t di­rectly caused by – and pro­por­tion­ate to – dam­age within the tis­sues, but ex­pe­ri­ences such as mine have been repli­cated in many stud­ies, show­ing that not only can pain ex­ist where there is no tis­sue dam­age, but that tis­sue dam­age can be present without pain.

In one study, MRI scans of the knees of 44 sub­jects suf­fer­ing no pain symp­toms re­vealed menis­cal de­gen­er­a­tion or tears (dam­age to knee car­ti­lage) in al­most ev­ery case. Other re­search, pub­lished in The­neweng­land­jour­nalofmedicine, found 38 per cent of pain-free sub­jects showed ab­nor­mal­i­ties (such as ‘bulging’ discs) in the lum­bar spine – the sort of ab­nor­mal­i­ties that would be used to ‘ex­plain’ pain, if pain were present. So if pain isn’t syn­ony­mous with in­jury, what ex­actly is it wav­ing its red flag about?

NO B RAI N , NO PAI N ‘Pain is a mes­sage or a “need state” (like hunger or thirst), which com­pels pro­tec­tive ac­tion,’ says Stace. ‘There is a need to be met and our at­ten­tion is drawn to a par­tic­u­lar part of the body. We must then de­cide whether there re­ally is a threat or danger in the area that we’re feel­ing the pain.’

So why, in my case, the hip and not an­other part of my body? ‘ The brain makes a best guess,’ ex­plains Stace. ‘If there’s enough ev­i­dence to sug­gest that there could be a prob­lem at the hip, that’s all that’s needed for pro­tec­tion to kick in.’ The threat or danger could be the re­sult of an ex­ces­sive train­ing load, al­tered biome­chan­ics or a re­duc­tion in strength, rather than what we’d typ­i­cally think of as an in­jury.

There is much re­search to sup­port the con­tention that pain is a con­struct of the brain. As Pro­fes­sor Lorimer Mose­ley, who spe­cialises in in­ves­ti­gat­ing pain in hu­mans, points out, the wide­spread phe­nom­e­non of phan­tom-limb pain in am­putees would not ex­ist if pain were truly and solely rep­re­sent­ing phys­i­cal dam­age. How can your left leg hurt if you don’t even have one? In one of Mose­ley’s ex­per­i­ments, peo­ple who had a pros­thetic limb ar­ranged in front of them as if it were their own ex­pe­ri­enced pain when that leg was at­tacked.

How­ever, it’s im­por­tant to stress that while pain is pro­duced by the brain and not the body, it doesn't mean tis­sue dam­age – or the pain aris­ing from it – isn’t real. ‘It is real, but the re­la­tion­ship is com­pli­cated,’ says Paul In­gra­ham, cre­ator of the on­line re­source Pain Science (painscience.com). Mod­ern pain science is based on what’s known as the biopsy­choso­cial model – which takes into ac­count the bi­o­log­i­cal, psy­cho­log­i­cal and so­cial fac­tors af fect­ing our ex­pe­ri­ence of pain. ‘It doesn’t im­ply that there are no phys­i­cal fac­tors, but how it dif­fers from the tra­di­tional view is that it recog­nises in­jury and pain are not in lock­step wit h each other,’ says In­gra­ham. ‘That is what nearly ev­ery­one as­sumed for a long time. And many pro­fes­sion­als, even though they know bet­ter, of­ten for­get how pow­er­fully pain is in­flu­enced by per­cep­tion.’

Stace agrees. ‘ Look­ing for a purely phys­i­cal so­lu­tion for pain tends to re­sult in poorer out­comes. We have to re­mem­ber it’s a whole per­son who ex­pe­ri­ences pain, not a body part.’ He of­fers an anal­ogy: imag­ine you are at the cinema and the screen goes blank. The at­ten­dant comes in and shakes the screen. ‘Does that re­store the film? No. The prob­lem isn’t with the screen, it’s else­where. No mat­ter how of­ten you shake the screen it’s not go­ing to help.’

Re­gard­less of whether the pain you’re feel­ing in your knee is a re­sult of dam­age there (what In­gra­ham calls a ‘ tis­sue is­sue’) or not, its in­ten­sity can be greatly inf lu­enced by your state of mind, in­clud­ing mood, stress lev­els and, says phys­io­ther­a­pist Tom Goom, thoughts about the pain it­self and what it means.

‘For most run­ners, the sport goes far be­yond be­ing a form of ex­er­cise,’ says Goom. It’s our so­cial net­work, our stress

re­lief and our arena for ex­pe­ri­enc­ing mas­tery, en­joy­ment and a sense of pur­pose. So los­ing it is a big deal, cre­at­ing stress and anx­i­ety, which, in turn, can mag­nify the pain ex­pe­ri­ence. A study of vi­o­lin players of­fers a great ex­am­ple of this. Re­searchers found that the mu­si­cians’ ‘ play­ing’ hands had greater sen­si­tiv­ity to pain than their non- play­ing hands, be­cause of the im­por­tance at­tached to the for­mer.

‘If run­ning forms a large part of your so­cial life, it’s im­por­tant to stay in­volved in other ways if you can’t run,’ says Goom. Per­haps you could still go to the club­house to do your re­hab ex­er­cises, par­tic­i­pate in the warm-up and cooldown, or vol­un­teer. Be­ing a coach was a god­send for me, en­abling me to ex­pe­ri­ence ful­fil­ment through oth­ers’ suc­cess. Many stud­ies have shown that pos­i­tive mood states (con­tent­ment, calm, joy) can re­duce pain sen­si­tiv­ity. But, says Greg Lehman, a physio who spe­cialises in ap­ply­ing pain science to biome­chan­ics ( gre­glehman. ca), the con­nec­tion be­tween pain and men­tal state works both ways. ‘ Ir­ra­tional or dis­pro­por­tional be­liefs and deep feel­ings of worry or fear can in­ten­sify pain,’ he says. A study at the Univer­sity of Malaga, Spain, found high lev­els of emo­tional dis­tress and anx­i­ety were as­so­ci­ated with greater lev­els of pain.

MIXED SIG­NALS

The heal­ing process it­self can also be af­fected by ex­ter­nal fac­tors. ‘Sen­si­tis­ing fac­tors like stress and sleep de­pri­va­tion can cause in­juries to hurt sooner, worse and longer,’ says In­gra­ham. A study at Kings Col­lege, Lon­don found el­e­vated lev­els of the stress hor­mone cor­ti­sol slowed heal­ing. It’s a cruel twist: you love run­ning, pain forces you to stop, and the dis­tress you feel by stop­ping in­ten­si­fies and pro­longs the pain.

I would prob­a­bly think it far-fetched that my men­tal state can af­fect the pain­in­ten­sity dial if I didn’t have per­sonal ex­pe­ri­ence. In that year of my hip in­jury, my dad was dy­ing of a brain tu­mour. In his fi­nal days, we gath­ered around his bed­side, shar­ing mem­o­ries through tears and laugh­ter. My hip was so stiff I limped each time I stood up to walk and at night it throbbed un­bear­ably if I lay on my side. Yet a week af­ter his suf­fer­ing ended, I ran a 10K with no pain. It wasn’t the end of the in­jury, but it of­fers a snap­shot of how pain can be af­fected by seem­ingly un­con­nected things.

‘ Re­mem­ber that the brain does not have ac­tual ac­cess to the body,’ says Stace. ‘ It only re­ceives sig­nals, from which it in­fers what’s go­ing on and

cre­ates a per­cept ion.’ I n the biopsy­choso­cial model of pain, the ac­cu­racy of this per­cep­tion is based on all the things we ‘ bring’ to our ex­pe­ri­ence of pain.

‘What do you need to have knee pain?’ Stace asks me. ‘A knee,’ I say. ‘ Yes, and what else?’ ‘A brain?’ ‘ Yes, and a ner­vous sys­tem, an ego, a his­tory… all of these will be used by the brain to as­sess how to re­spond to the sig­nals it re­ceives.’ And when it comes to run­ning in­juries, one of the most sig­nif­i­cant fac­tors in shap­ing that re­sponse is pre­vi­ous in­jury. F IND THE SOURCE ‘“Once burned, twice shy” is a very ba­sic pain prin­ci­ple,’ says In­gra­ham. ‘ The brain re­mem­bers and is para­noid, so a run­ner’s sec­ond case of IT band syn­drome or plan­tar fasci­itis kicks in at a lower thresh­old. They think they’ve over­loaded the tis­sue again, but the chances are that load is much less of a fac­tor this time round: still a fac­tor, just no longer the only one. And the more they get rein­jured, the more this is true.’

I can re­late. Since my hip in­jury, I seem to have an over-zeal­ous health and safety of­fi­cer lurk­ing in my brain. Given that the most com­mon pre­dic­tor of a run­ning in­jury is a pre­vi­ous in­jury, it’s in­trigu­ing to won­der whether this is a re­sult not of faulty biome­chan­ics or in­suf­fi­cient re­hab, but of a brain primed by past ex­pe­ri­ence to over-am­plify pain. And if that’s the case, how do we break free from this vi­cious cir­cle?

‘The first step is find­ing out what’s re­ally go­ing on,’ says Lehman. A thor­ough as­sess­ment by a physio and/or os­teopath who spe­cialises in chronic pain or pain man­age­ment will as­cer­tain if there are phys­i­cal fac­tors con­tribut­ing to your pain. ‘ You need to know if the pain is some­thing sin­is­ter re­quir­ing a spe­cific fix (such as a lig­a­ment tear), if it means you need to rest or back off, or whether con­tin­u­ing with the ac­tiv­i­ties that are mean­ing­ful to you is ul­ti­mately more help­ful,’ says Lehman. For ex­am­ple, a run­ner could have tendinopa­thy that seems re­lated to pain. ‘They will cer­tainly want to mod­ify their train­ing and per­haps add ex­er­cises to ad­dress the ten­don, but they could also keep run­ning with a lit­tle bit of dis­com­fort. Some pain and nig­gles are nor­mal when train­ing.’

From a purely phys­i­cal point of view, run­ning through pain sounds like bad ad­vice. But in­creas­ingly, pain science is steer­ing us away from the ‘rest is best’ pro­to­col, which could un­wit­tingly be re­in­forc­ing the brain’s per­cep­tion that there’s ‘some­thing bad’ go­ing on in the

‘ Pain science is steer­ing us away from the “rest is best” pro­to­col’

body that needs pro­tec­tion. ‘ Pro­vided se­ri­ous pathol­ogy has been ruled out, most peo­ple can keep run­ning or walk­ing to some de­gree with most in­juries,’ says Lehman.

Re­search has shown that iso­met­ric ex­er­cises (see Eas­ingth­e­p­ain, right) can give im­me­di­ate pain re­lief in cases of patel­lar and Achilles tendinopa­thy. ‘Ac­tu­ally, al­most any type of ex­er­cise seems to mod­u­late the tis­sue-ir­ri­ta­tion sig­nals that get sent from the body,’ says Lehman. Stace agrees: ‘ Pure rest won’t help in in­stances of chronic and

per­sis­tent pain, be­cause noth­ing has changed when you go back to ex­er­cise. Mo­tion is lo­tion.’

So where does this leave the tra­di­tional ther­a­pies we turn to when ad­dress­ing pain and in­juries, such as deep-tis­sue mas­sage and foam rolling?

‘These ap­proaches may have a small, short-term ef­fect on re­duc­ing pain,’ says Goom. ‘ They’re not great long-term strate­gies, how­ever, and can ag­gra­vate symp­toms in some. And we can be­come de­pen­dent on them rather than look­ing for long-term so­lu­tions, so they usu­ally work best as an ad­junct to more ac­tive man­age­ment of pain – ex­er­cise, ed­u­ca­tion, life­style change.’

This isn’t carte blanche to plough blindly on with your train­ing in the face of pain and pos­si­ble tis­sue dam­age. It’s about find­ing out where you stand and recog­nis­ing that you can­not as­sume that the ex­tent – or even the pres­ence – of pain is al­ways a true re­flec­tion of what is go­ing on in your body.

There are, how­ever, likely to be some clues. If you fell off the kerb and wrenched your an­kle, you prob­a­bly can make a log­i­cal con­nec­tion be­tween the pain and in­jury: ‘Sim­ple pain ex­pe­ri­ences are usu­ally ex­actly what they seem to be,’ says In­gra­ham. ‘By “sim­ple” I mean in a spe­cific anatom­i­cal location, af­fected by po­si­tion and move­ment, with a clear re­la­tion­ship with trauma or load­ing.’ This kind of ‘ acute’ pain tends to cor­re­late well with tis­sue dam­age (al­though your ex­pe­ri­ence of it can still be mod­u­lated by other fac­tors). But when pain per­sists long af­ter body struc­tures should the­o­ret­i­cally have healed, things get more com­plex. CEN­TRAL INTE LLIGENCE Chronic pain is de­fined as last­ing or re­cur­ring for three to six months. It’s on­go­ing pain that can­not – or can no longer – be ex­plained by ‘tis­sue issues.’

If, weeks af­ter an in­jury, you’re think­ing ‘But it still hurts! There must be some­thing wrong,’ even though you’ve been as­sured there is no ma­jor dam­age, the prob­lem is prob­a­bly not with your body, but with your cen­tral ner­vous sys­tem. ‘ This ‘cen­tral sen­si­ti­sa­tion’ can cause even a triv­ial tis­sue is­sue to cause dis­pro­por­tion­ately in­tense pain,’ says In­gra­ham.

Lehman likens the re­sponse to a smoke alarm. ‘A smoke alarm doesn’t tell us how much smoke there is – it can go off even when there is no smoke at all and con­tinue go­ing off af­ter the fire has been put out.’

Re­search has shown that highly sen­si­tised pain suf­fer­ers can ex­pe­ri­ence ‘an­tic­i­pa­tory’ pain even be­fore a stim­u­lus is ap­plied (such as ‘feel­ing’ the pain of an in­jec­tion be­fore the nee­dle has touched the skin) as well as a height­ened or dis­pro­por­tion­ate re­sponse to mild pain stim­uli and even be­nign ones, like touch.

Let’s say you’ve just started run­ning af­ter months bat­tling plan­tar fasci­itis. ‘ Even as you put on your shoes, your brain is won­der­ing if this is safe, says Stace. ‘If you should then step on a stone, you are likely to feel a dis­pro­por­tion­ately in­tense pain, be­cause the brain is sim­ply ful­fill­ing the re­sponse it pre­dicted.’

Once sen­si­ti­sa­tion oc­curs, the chal­lenge is to re­train the brain to un­der­stand that move­ment is safe. ‘Ath­letes and ther­a­pists tend to re­gard re­ha­bil­i­ta­tion as a process of phys­i­cal adap­ta­tion, but the longer you’ve had the prob­lem, the more likely it is to be about neu­rol­ogy,’ says In­gra­ham. ‘ If you’ve reached a stage where you sus­pect your ner­vous sys­tem is no longer giv­ing you use­ful, sen­si­ble pain sig­nals, be ex­tra cau­tious about painful man­ual ther­a­pies, and scept ical of biome­chan­i­cal ex­pla­na­tions for your pain. Such fac­tors are only part of the pic­ture, and prob­a­bly the least im­por­tant part. A bet­ter fo­cus is on de­sen­si­tis­ing and teach­ing the cen­tral ner­vous sys­tem that it's OK to use that anatomy again.’

Re­turn­ing to the plan­tar fasci­itis ex­am­ple, you might start by see­ing if you can stand on one leg without pain and if so, can you rise up onto the toes? Can you jog a few steps on the spot? Still painfree? Can you run for 20 sec­onds without pain? A minute? By find­ing out what you can do without pain, you can be­gin to move within that com­fort­able range – and as the brain di­als down the alarm sys­tem, this range will grad­u­ally in­crease. The tips on this page ( Eas­ing

the­p­ain, left) can help the process. The new pain science doesn’t sug­gest that pain isn’t real, or that it’s ‘all in your head’. But it does free us from look­ing at in­juries solely as tis­sue issues, widen­ing the scope of what we can do about them. Along­side our re­hab ex­er­cises, we may need to con­sider our be­liefs about run­ning, our life­style and our over­all men­tal and phys­i­cal health.

Know­ing there wasn’t any sign of dam­age in my hip joint helped get me on the road to re­cov­ery. Though it still hurt, it freed me from two fears: one, that I was ‘fin­ished’ and would never run painfree again; and two, that by re­turn­ing to run­ning I might cause fur­ther dam­age.

It took that change in mind­set – and find­ing a physio I be­lieved in – to get me mov­ing along that road. These days, I can even run past tele­phone ex­change cab­i­nets without a sec­ond glance.

FIND FAULT Lo­cat­ing the source of a pain is not as easy as we might think

BAD CON­NEC­TION Chronic pain could be caused by a mis­fir­ing cen­tral ner­vous sys­tem

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