Finding the "Sweet Spot": Reflections on Chronic Pain

Thursday, June 1, 2017 - 16:30
Chronic Pain - reflections
Years and years before I happened upon the field of pain science, I found that using a strategy with chronic pain clients whereby I very gradually (re)introduced their bodies to movement and exercise was very effective.  This reduced the exercise science principle of “progressive resistance” to its most elemental form, as I progressed many of these clients much more slowly than the standard.  Most of these individuals had seen multiple, well-meaning rehabilitation professionals in the quest to heal their bodies, and, to this end, most had been given sheets of exercises to do at home.  The problem, I found, was that despite most of the exercises being good ones, the number of repetitions and sets prescribed was far beyond what the typical nervous system of someone suffering from chronic pain could handle.  Everyone knows that exercise taxes our muscles – but most are unaware that exercise is far more taxing on the central nervous system (termed “neural fatigue”), which takes up to three times longer to recover than the musculoskeletal system (Poloquin, 2017).  The fantastic exercises my clients had been given were not “graded” to what their nervous systems were able to handle, after an extended period of time of restricted movement, and therefore caused more harm than good.  The field of pain science, I learned, had a term for this very concept which I had been using for years: graded exposure.
In the health field, we often speak of the dose-benefit ratio, a term traditionally applied to pharmacology but equally relevant to exercise science: at what dose a given exercise is beneficial, and at what dose that same exercise is harmful.  The dose-benefit ratio looks very different for everyone.  Finding what I call the “sweet spot” takes time, effort, and trial and error.  An evidence-based exercise to address low back pain may, at low reps, be helpful in the beginning stages of rehabilitation.  The same exercise at high reps and multiple sets may, at the same stage of the healing process, be crippling.  
The field of pain science is especially relevant because it brings together the two worlds of physical health and psychological health.  Did you know that one of the biggest predictors of back pain is job dissatisfaction? Emotional states such as anger, depression, and anxiety reduce tolerance to pain (Hargrove, 2010).  Emotional and mental health have a profound impact on our pain regulatory system – a compromised mental state makes our central nervous system much more sensitive and reactive. To be clear, this is not to say that pain is not real, or “all in your head”.  In the words of Dr. Jan Dommerholt, a renowned expert in the physical therapy diagnosis and treatment of people with chronic pain “the pain is what the patient says it is, where they say it is, to the magnitude they say it is” (Wendel, 2017).  However, to neglect mental health in the treatment of chronic pain is foolhardy.  A toxic work environment, bad marriage, or ongoing family stress is going to make that sore back feel much, much worse.  Psychological resilience portends physical resilience.
So, because chronic pain is multi-factorial, create a comprehensive treatment plan for yourself.  Take control of your situation.  Assemble a team of helping professionals who make you feel better, not worse.  Adopt effective strategies to manage your mental health.  Get enough sleep – crucial for fostering a calm, composed nervous system. Exercise daily if possible, as physical activity causes our brains to produce pain-relieving endorphins - analgesics which are in most cases more powerful than opiate drugs like morphine.  Exercise also normalizes movement patterns, improves function, and increases stamina.  Most importantly, be optimistic about your ability to recover – this will usually compel us to take action to improve chronic pain and adopt many of the strategies that are known to help.