Uprooting Nagging Injuries
As a species, we are fascinated by cause and effect. When an event occurs, we are compelled to understand the mechanisms that led to the outcome. In doing so, we can make better models of our world, becoming better at predicting how our actions will affect the future.
Understanding the relationship between a cause and effect works well with simple situations such as why a car broke down (transmission went) or how someone broke their wrist (slipped on ice), but what happens when the cause isn’t as obvious? What happens for example, when someone starts developing pain but there wasn’t a clear cause?
Clinically we see this frequently. Someone comes in with pain that has been progressively worsening over months. There wasn’t really any triggering event and since it was only painful from time to time, and didn’t interfere with their work or hobbies, it was easy to dismiss. What we often fail to recognize is that pain does not directly relate to the state of our tissues nor does there need to be a specific event for pain to occur. So while in traumatic injuries, the cause (a slip) and the effect (pain) are obvious, conditions that are more progressive and/or degenerative are often initially left undetected by our nervous system. As such, when we do get some small warning signs of pain, it may warrant some further consideration before being brushed aside.
So why don’t we get more obvious signs of injury earlier on? If our conscious selves were aware of all the subtle ongoing changes in our tissues, we would be quickly overwhelmed by the stream of information coming in. So, unless the underlying changes in a given tissue are significant enough, our nervous system does not bother to raise the alarms, at least not in really obvious ways. Think about it this way, when do you want your car alarm to go off? When there is an attempted break-in right? The purpose of the alarm is to let you and everyone around you know that your car is being broken into. If a bird lands on your car, it would be pretty annoying for the alarm to go off. So we want to insure the alarm is sensitive enough to detect a break-in but not so sensitive the bird landing on it or someone touching the side mirror sets it off.
Let’s come back to our patient with progressively worsening pain. There might not have been a traumatic mechanism but that doesn’t mean the pain came from out of nowhere. It just means that the causes of the pain weren’t singular or as obvious as say a fall. It might mean the underlying issues were developing slowly at a level that was below the threshold of your alarm bell’s (nervous system) warning signal. That is until the wire was finally tripped.
The straw that breaks the camel’s back may be fairly innocuous; going to tie your shoes, reaching for a box, lifting your child. In the frame of that moment, it is easy to point the blame at these activities as being the cause, and consequentially, wanting to avoid these movements in the future. However, if we take a 30, 000-foot view of the situation, we can see that there were numerous contributing factors that led to this event.
An example.
A recent patient came in with low back that had been on and off over the past six months. The previous week he had bent over to tie his shoe and experienced such significant pain that he had to take the next couple of days off of work as he couldn’t sit for prolonged periods of time. During our initial treatment, I learned about his high levels of stress at home and work, his consequential poor sleep, and how since injuring his back the year prior, had avoided back exercises in the gym. It’s doubtful this patient caused structural damage to his back by bending to tie his shoes, he has done this movement a million times before and his back certainly is capable of much more. That said, the event was enough to trip the alarm bells and send him into a bout of back pain. It just happened to be that bending forward happened in such a way, under such circumstances, that his nervous system marked the event as threatening.
But what would have happened if…
He had had a great few nights of sleep?
Had been regularly exercising his back?
Had not been stressed thinking about his work demands?
Had addressed his back pain when it first started appearing?
If he addressed all of the above, I doubt that he would have felt his back go that morning tying his shoes. Of if it had, maybe his pain would have been at least manageable enough to continue to work, and resolved by the end of the week. Had he worked on building a healthier system, both physical and mental, in all likelihood the event of bending forward would not have triggered his back pain nor the on-and-off pain he had been experiencing for the past few months.
Recall the influences of health and pain.
What I encourage my patients to consider is that their pain is like weed. What we can see (our consciousness) lies above ground (our pain and presenting symptoms) while the rest of the weed is hidden beneath the surface (the state of our physical and mental well-being). What we see as our pain is only a part of the issue. There are underlying factors that we need to address if we truly want to get rid of our pain. If we don’t resolve these pieces, our pains are likely to reoccur.
When we come to physiotherapy or massage, we are often asking our therapist to cut down the ugly weed that has been growing (get rid of the pain). In some cases, where the weed is young or stunted, it’s easy enough for us as therapists to simply pluck the weed- weak roots and all. You’re in and out of your appointment and that recent nagging issue is completely fixed after only a couple of treatments. I’ll admit, as a therapist, it can be satisfying when I can help “fix” you with just one session.
Other times, the weed has matured. It’s no simple task for the therapist to uproot it. It is going to take some doing on the patient’s side to make the environment susceptible to change. Sometimes, patients just want the therapist to cut the weed down at the base (“just get rid of the pain”). And from the patient's perspective, it seems like everything is fixed. The weed is gone! But sure enough, without having removed the root system, in time, that weed will grow back. If we truly want to get rid of the weed, we need to remove the whole thing- roots and all. This can be a challenging thing for therapists to remind patients.
This situation not only occurs with slowly building pain and repetitive strain injuries. We also see this during rehab. As your pain improves, it's easy to be lulled into the idea that your underlying issues are healed. While certainly, you are making positive gains, we need to remember that just as the pain slowly developed after there were already some structural changes, pain relief precedes complete tissue recovery. We as humans tend to be short-sighted; we like quick fixes. So asking patients to commit to more (often strenuous exercise) is a big ask once the memory of the pain has begun to fade. But I can assure you, the efforts are worth the reward. Not only by completing the process are you helping to future-proof yourself from re-injury you will be building a healthier version of yourself both physically and mentally.
When is rehabilitation complete?
When you come to Pursuit Physiotherapy for rehab, we want to make sure you completely recover from your injury. Beyond pain relief, we want to insure you are set up with long-term habits that will set you up for better health than when you first walked in. From the physical side of rehab, this means you leave with stronger tissues and a plan to continue to build the health of your muscles, joints, and cardiovascular system. From the mental side of rehab, your goal is to move your body thoughtlessly and fearlessly. If these elements are achieved, you have set yourself up to not only move out of pain but to stay out of pain.
