How multiple aspects of pain experience can inhibit our free flow

“Tension is who you think you should be. Relaxation is who you are”

— Chinese Proverb

“Motor responses reflect the CNS response to pain , threat, emotion,

pathology, lifestyle, environment and task demand”

— Peter O’sullivan

Normal movement is easy, and focus is away from the body (external focus). People in pain have an internal focus, and move in a less fluid sense. A perfect example of this is what is known in baseball and golf as “the yips”. The term was coined by the Scottish golfer Tommy Armour, who said it was a "brain spasm that impairs the short game."

#fail

“We act in accordance with our self-image. This self-image-which, in turn, governs our every act-is conditioned in varying degree by three factors: heritage, education, and self-education”

— Moshe Feldenkrais

The concept of psychosocial factors influencing our movement has been present in some form of therapy for a long time, as noted in this insightful Feldenkrais quote (an opening line in his "awareness through Movement" text circa 1972). How your patient thinks about their condition, about how fragile they are, about social ideas and common beliefs about pain, can all impact how a they goes about in their daily life from how they get out of a chair to if they participate in light exercise.

People with chronic low back pain move with less lumbar ROM and show proprioceptive deficits, in comparison to people without pain (as noted in Laird et al's systemic review and meta-analysis)

The fact is, when we’re in pain, we consciously think more about our body. We have constant reminders to do so. Our experiences along with our conceptions work our way into our psychology and can become a cyclical pattern, often self propagating after injury. The Physical Therapist has to help decide whether the motor responses and movement strategies are adaptive (protecting the physiological components of the body to avoid further injury or inflammation) or maladaptive (the motor responses are actually adding to the problem).

I was fortunate enough to attend a cognitive functional therapy workshop with Peter O'sullivan, and it was a fantastic course discussing how people's beliefs can change how they move and interact with their world. Can people actually adopt a pattern of moving that makes them worse? Yes… the question is WHY? And this is where we need to address psychosocial issues, and in my opinion possibly relate them to tangible biomechanical (and easily understandable) concepts when appropriate. Are restraints to movements physical, psychological or both? The fact is, teaching people to move “differently” can help them, for the sole purpose of creating an atmosphere that breaks the Load-Pain-Thoughts relationship, to place a schism in the circuitry that is currently set to manifest as a painful experience.

Tactics in changing movement and load habits can really vary, and be a common variable in positive outcomes across many different philosophies of treatment, despite the specific intention of the intervention. Examples could vary from something as simple as moving a computer monitor from the left to right side of the desk, considering if and when you exercise, or deconstructing movement during a task to inhibit some of the altered adaptations brought on by the initial injury or perceived threat.

One side-note that is important to address however is that this isn’t and eternal tactic of pain relief; meaning that we should be able to sit erect, or slouched, or whatever (really without thinking on it) and it is natural. Once we have successfully calmed down the adverse response, our goal should be to return to all movements available (in my opinion even if these are again temporarily associated with small amounts of pain, because we don’t want underlying fearful thoughts or subconscious pain neuro-tags to continue to reign dominance over a persons behaviors). People are supposed to move again. Even persons with multi level lumbar fusions play golf and return to unrestrained movement (this should be encouraging for your spine patients to hear).

Is pain itself, and the consequences of living in a current state and experiencing a past state of pain, up-driving physical adaptations (increased muscle activity) leading to a cycle of pain experience and behavior?

Subgrouping the patient with pain can help addressing loading habits: is there a loading strategy that exacerbates pain?

Is the patient holding themselves in extension and having excessive muscle activity and avoiding flexion?

Is the patient holding themselves in flexion and avoiding extension?

Communication can be difficult, even in moderately acute cases of LBP, but especially in chronic cases. Consider relating to an ankle sprain: what would happen if you did injure your ankle? Swelling, stiffness, hypersensitivity and pain right? What do you think would happen to the ankle if a year after the terrible sprain, you were still limping, guarding, and avoiding moving it? In general, what do you think would help the ankle get better?

*but what if the tissue is damaged?

Things can get damaged: cartilage can become malnourished, and chip off of its underlying structure. Surrounding muscles can undergo physical and chemical changes, and become significantly less robust. Regarding LBP, some of the most emphasized tissue-issues we hear about in life is facet cartilage (facet arthropathy) and disc degeneration. (you could explain the damage and pain relationship here, I often bring up that complaints of LBP doesn’t correlate with age, though age and radiographic degeneration have a linear relationship…it is not a fact that all grandparents must have spine pain….)

What is also important to realize however is that:

Even if there is physical damage, such as a osteochondral lesion or cyst, highlight the message that the effects of prolonged immobilization are further deleterious to the actual tissue. The best bet effort in moving forward with life is to move and strengthen in some capacity. Go back to the ankle example: knowing that joints need movement to nourish cartilage (synovial fluid production), what would happen to this environment after injury if movement ceased?
There are times when tissue morphology and tolerance to load result in constant inflammation and constant poor environment to the tissues. In these cases an attempt in adaptive changes to minimize load based on morphology of the structures (think cam-pincer of the hip) are to be implanted while maximizing movement and strength in the ranges that are not threatening. Seek to further gain use of motion above and below. Surgery can be an option, but is usually a last resort. Even when it is on the table, conservative measures still needed to be exhausted, and persons educated on what this entails and why, to deconstruct the thinking that once the “wear/tear” is present that it equates eternal pain.

Do the biomechanics matter? Yes, because these are one thing (among others) that we can modify in some Macro-capacity: I say “macro” because research notes that efforts on specific manual technique to attempt to address specific joint biomechanics is misleading. When we think of what we can truly impact, we are talking adapting positions, habits, and how our body acts in positions, to change biomechanical inputs. We may attempt address them in a specific “Micro-capacity”, but need to understand the mechanism is not well understood nor specific to the majority of the intentions of MT “techniques”. These may be acting under DNIC “diffuse noxious inhibitory control”, placebo via explanation and delivery, or novel experience guiding the patient into new movements and sensations, and the patient allowing their tissue to alter its response under the context of a therapeutic intervention. However it is much more likely that we are addressing underlying tone and the CNS response to the perceived threat, than addressing specific joint or tissue mobility as a culprit to the behavior and movement adaptations.

“A pain flare up can be a biomechanical trigger on a sensitized system”

— Peter O'sullivan

The conundrum for PT and patient alike is evident in any pain labeled “chronic”: my “healing” isn’t happening. Perhaps it is slow because the insult was to avascular tissue, the insult is recurrently agitated by underlying sensitivity to load and overactive inflammatory processes, or there is no actual insult at all albeit the tissue at a local and global level is responding as such under maladaptive CNS changes, and altering what should be a normal environment and inhibiting resolution of what was acutely considered adaptive and normal. There is not a perfect explanation, or treatment for these conditions, but finding a pathway to changing mobility and loads, strength, and patient perception are things to strive for.

Some useful examples in promoting new or more fluid motion:

“the clenched fist”: Clenching a fist isn't painful, but it might be if we were always doing it... see the white knuckles? these tissues aren't getting nice blood flow, and the tissues are under increased load and stress.

“the Yips” analogy: over-concentrating on movement can lead to decreased performance and lack of fluid effortless motion.

“Immobilization leads to tissue breakdown” analogy: NOT moving isn't a healthy option, unless the tissue is truly needing to repair its leisiion (fracture or ligament tear)

Parasympathetic diaphragm breathing in relation to sympathetic pain response: explaining how our present state can affect pain and response, and ways to calm this.

"Some form of movement and loading is almost always safe": It may be helpful to ask a patient what the first thing a person with a total hip or total knee does after surgery (they walk and load the tissues). This illustrates that even in situations where prosthetic devices are drilled into bone, doctors allow patients to walk because the loading is necessary for healing and good outcomes.

One way to break into changing movement or introducing novel movements (accessing change through movement and exercise) can be to work on dissociation of movement. This concept is fairly simple, and its mechanism of effect could be argued though likely contributions are novel movement experience, body awareness, and physiological benefits of moving through ROM (perhaps in a way that conflicts with maladaptive movement caused by muscle tension and protective behavior).

Further you can use an additional "external cues" to break cycles of internally focused movement and add engaging novel exercise while allowing the patient to see how effortful or effortless they are able to move at will, and how much motion they have in one direction compared to the other.

https://youtu.be/dnvkMLr4ImE

See a few video examples below: