I would like it if people in our industry would stop saying to clients that pain is an 'output'.
‘Output’ is a recognised term for pain in academia, with clients experience is a better description of pain. Experience is better because ‘output’ is usually a description of the action that the client makes because of the stimulus that causes the feeling of pain.
The process of defining the reason for pain is complicated. When it comes to working with a client, we might need to differentiate between them having pain and them being in pain. A single pain is a feeling we have for a few seconds; being in pain is an experience we have that is a combination of repeated pain feelings.
A feeling is an interpretation of the proprioceptive information that the peripheral nervous system has allowed to get to the brain. Interpreting the information is called cognition.
Arousal is something that triggers cognitions form an awareness of something. You might hear something or see something; this activates hormones and muscles to prepare you for a readiness to respond. Our daily lives, sports, hobbies and other environment are always changing our levels of arousal and using cognition to choose the action we take.
Experience is a combination of many feelings measured over a certain amount of time. These feelings come after initial emotions; this is when we use the brain for cognition to see whether this situation is an opportunity for us or a danger.
Pain is the feeling that is associated with a client’s specific set of filtered feedback that they have perceived or they have knowledge of and experienced before.
These feelings will often lead to either an involuntary output, for example, the dilation of pupils, changes in hormones and muscles which work as a reflex. Sometimes these feelings might breach the reflex to ask the brain what to do; this may be the desire to take action by to moving, shouting, frowning or freezing.
For example - When I’m playing hockey, in midfield, I will be thinking about what runs to make. Witnessing a player showing some phenomenal skill might shock me, causing physical and chemical reactions given away by my pupils dilating, muscles tensing, heart rate increasing etc. This emotion in this context will make me want to react and make the run to the right position, and that is my reaction, action, to the stimulus.
Here is an order of this loop the body uses:
Stimulus – Seeing the player in the environment doing their skill
Emotions – Changing muscles and hormones – Initial Feelings
Cognition – Interpret it all the available information.
Feeling – If asked, you would verbally state this feeling.
Cognition – A second cognition would be around the feeling to see if it is valid, and also to stimulate an action if required
Action – the ‘output’ movement (or lack thereof) that is triggered after the stimulus has been through the process. An action can then reinforce the interpretation of the stimulus as being correct or can lead to learning it was wrong and so how to react to the stimulus differently in the future.
Opportunity - The next response will be a positive one.
Danger - Then it’s approached with a Freeze, Flight or Fight (or both) response.
- ‘Freeze’, If you feel the experience ‘pain’ then freeze might call upon more thinking from cognition to decide whether to flight or fight.
- ’Flight’ might be to never go into that situation again with that stimulus, so simply run from it, warning you to stop and stay away.
- ‘Fight’, would be to face the potential danger head-on
Most people have pain at some point in their life, they might deal with it immediately, think nothing more of it, and it doesn’t worry them. Some people might experience pain on a more long-term basis which becomes multiple feelings of pain
which most people don't fully understand, this doesn’t just go for clients who don’t fully understand.
Part of the issue is that pain is generally unpleasant, which attracts a lot of solutions and explanations which seem common sense but are not held up by the available research.
Here are some technique-based examples that focus on the pain, or creating a new stimulus, that could be interpreted as pain to solve the problem:
- Massage – Rub pain out of your muscle.
- Acupuncture - Stick a needle in to relieve tightness at the pain site.
- Myofascial release - Squash the hell out of the site of pain.
- Cupping - Suck the stagnant blood out of the pain site to increase circulation.
- Kinesio Taping - Give them some cloth tape to decrease tension in the site of pain.
These are all prime examples indicating that the tissue and the structure is the sole reason for pain with disregard to the psychology of the person or the social factors involved. Blaming the tissue for pain is a bit of a cop-out, it then gives a therapist the chance to use their magic powers to show you a short term fix for the pain, then you have to keep coming back for their magic powers when the pain comes back.
The information supplied to the person who has pain may involve multiple reasons for the pain. One of the most common reasons would be these painful sites called ‘trigger points’ or ‘knots’ (these are great for sailing). Unanimously debunked by science, trigger points do not exist. Trigger points explained to a client as a reason for pain is unethical. All that explanation adds is a layer of negative influence on the interpretation of emotion.
Go to google and try and find a photo of an actual trigger point (not a drawing), if you find one then send it to me!
As we already know from people who suffer from CIP (congenital insensitivity to pain), the consequence of not experiencing pain could be a significant injury in itself. Pain is an important feeling to have because it’s a way for our body to give us an indication that something might be wrong. That way, it’s essential for a client to see a doctor before anyone works with a person. Some disregard this and work on them anyway when there could be something more sinister going on.
Pain is a reaction to a particular set of patterns of feedback, which cause an emotional response. Emotions can have more than one identity.
Danger - Stop hitting me with the belt. I will get you my wallet.
Opportunity - Keep hitting me with the belt. I will get you my wallet.
Pain is specific to an individual and comes from their experiences, knowledge and perceptions of their situation and expectations.
An individual may guess a location or a specific area on their body when they feel that pain to help pinpoint the place to defend. With clients who have phantom limb pain, this can occur in body parts that do not exist, which shows that the pain is not from the injury, but as part of the experience.
When a person is feeling pain, they will have specific types of feelings for their pain, here are just a few. I worked with a client who had phantom limb pain, and his pain was like a chronic itching.
Types of Feelings of Pain:
· Dull Aching
· Sharp spiking
· Pins and needles
When a person is feeling these types of pain, they will look for solutions; this may lead them on a journey of seeing all kinds of people, some medical and some less so. They could end up with more problems and a list of the things that are wrong with their bodies leaving them with more reasons to feel pain, not less. Here are a few so-called solutions to pain that I have heard from clients over the years:
· Stop moving
· Move properly
· Rebalance your muscles / posture / stretch
· Get stronger
· Get more proprioceptors but stop nociceptors
· It is your movement from one part of the body, pushing more stress on another part of your body
To summarise, all the above are incomplete or irrelevant statements based on little or no understanding of the whole process of pain. The way we approach ‘pain’ is not to try and cure it or remove it but to change the sensation or the interpretation for the client. A person could have a had chronic pain for 25 years, many things may trigger that person but what can we do is to find the stimulus that can positively trigger them, the movements or tasks that change the way they interpret the situation. As trainers, we have so many tools to help people, and we must make sure we don’t get bogged down by fixing, curing and correcting but focus on the person beyond their pain.
The most important thing is to find out the individuals goal and help them to overcome the hurdles that stand in their way and for some cases, this might not just be pain that’s the problem but many of their experiences that work alongside their pain.
These are good papers to start with but for a comprehensive list then jump on the course.
Joseph Le Doux, John Quintner, and Simon van Rysewyk- 2012 Feb 23rd - Rethinking the emotional brain. Neuron. 2012 Feb 23; 73(4): 653–676.
G.L Moseley – August 2003 - A pain neuromatrix approach to patients with chronic pain. Manual Therapy. Volume 8, Issue 3 Pages 130-140
Mark A Lumley, J L. Cohen – 6th June 2011- Pain and emotion: a biopsychosocial review of recent research. Volume 67, Issue 9 Pages 942-968
Tobias Brosch, Gilles Pourtois, David Sander – April 2010 - The perception and categorisation of emotional stimuli: A review – Volume 24, - Issue 3
Deborah J.Serriena, Richard B. Ivry Stephan, P.Swinnen - The missing link between action and cognition - Volume 82, Issue 2, June 2007, Pages 95-107
John L. Quintner, Geoffrey M. Bove and Milton L. Cohen - A critical evaluation of the trigger point phenomenon: Rheumatology (Oxford). 2015 Jun;54(6):1127-8.
Johan W.S. Vlaeyen, Jeroen de Jong, Mario Geilen, Peter H.T.G. Heuts, Gerard van Breukelen - Graded exposure in vivo in the treatment of pain-related fear: a replicated single-case experimental design in four patients with chronic low back pain - Behaviour Research and Therapy 39 (2001) 151–166
Karin Roelofs, Muriel A. Hagenaars and John Stins - Facing Freeze: Social Threat Induces Bodily Freeze in Humans - Psychological Science published online 28 September 2010