A pain science workshop and its applications to personal training

Two weekends ago, I flew down to LA to a) hang out with awesome movement geeks and b) attend Greg Lehman’s workshop on reconciling biomechanics and pain science. This is a topic I find extremely interesting. Many (though not all) of my clients come to me with some sort of ache or pain. There are a number of conclusions I have drawn over the years regarding both my work with this group and the literature I have read. Recently, I found myself frustrated with the polarizing views that exist in the fitness world regarding which technique/modality/certification is most effective for reducing existing pain and preventing further pain issues. Greg’s approach to the topic was refreshing. He’s funny, a bit irreverent, and recognizes most of the time we don’t know what is actually happening. Below are a handful of the takeaways from the weekend.

Movement flaws are context dependent. This means that what a person finds painful in one setting, that same person might not find painful in a different setting. Have you ever asked a person to do a bodyweight squat only for that person to say, “I can’t. It hurts my knees.” Ten minutes later you watch as that same person gets up from a seated position on a low step for a different exercise without any trouble. This happens. We attach emotions/ideas/connections with a place, word, or cue that alters our experience of a movement. This doesn’t mean the movement is inherently flawed; the person getting off of the step might have knees that collapse in when he stands up, but it’s not painful. When he consciously tries to squat, however, it is. (I have a client like this. She had a left meniscus tear years ago. She had surgery and her scans are clean. However, she had fear and pain every time she went up or down stairs, but didn’t have any pain when I broke down the components of the step-up). As coaches/trainers/movement specialists, it is important to meet people where they are. If the idea of a certain exercise or skill incites pain, don’t do that exercise or skill, but don’t avoid the parts of it, either. The client I mentioned above gradually began to understand how her left knee worked and the connection between the left foot and the left hip. This led to trusting the left leg and not worrying every time she had to walk up and down the stairs. She had a little bit of knee valgus (worse on the right, where there was no pain), and while I gave her options other than valgus for stepping up, I am not entirely convinced the valgus was the cause of her discomfort. Changing the movement pattern was enough for her to experience the action differently and change her perception of the skill of stepping up. Give people options when there is discomfort, but don’t assume the act of (in this case) valgus is always “bad.”

Twin studies on back pain are interesting. Battie and Videman (2006) concluded twin studies suggest disc degeneration has less to do with heavy physical loading and wear and tear on the lumbar spine than it does on genetics and environment. Researchers have also found correlations between spinal flexion and genetics (Battie et.al, 2008), and no correlation between paraspinal asymmetry and LBP (Niemelainen et.al, 2011). Niemelainen and company found multifidus asymmetry ranged from 0.1% to 44.3% in adult twin males without low back pain. That is a significant range and indicates the fascination with multifidus function might not be well founded. (I am probably dating myself, but I remember when multifidus training was all of the rage. It was all about timing and sequencing of muscles firing. Like most things in fitness, it appears we were creating suppositions to explain why things work instead of saying, “lie on this blood pressure cuff. Apply pressure to the cuff with your low back. This will result in an isometric contraction in your stomach, which might be beneficial since you have low back pain,” we decided to get fancy with exact muscle sequencing of muscles we can’t even palpate). As trainers, what we can take away from the twin studies, is there are genetic influences, behavioral influences, and environmental influences that affect how we move. We can’t change genetics. Instead of trying to fit everyone into an ideal of what perfect form looks like, we would benefit from a) listening to what the person is experiencing and correcting position based on that information and b) taking what we know from a biomechanical perspective and deviating as needed to fit the individual.

There is a lot of great research being done on tendons and healing, specifically the role neuroplasticity might play in chronic musculoskeletal disorders. Basically, often in the case of chronic musculoskeletal pain while the initial injury may have been structural, there are other factors that result in pain persisting (Pelletier et.al, 2015). This involves changes in neuroplasticity that result in sensory amplification, perceptual changes in body image, changes in motor control, and persistence in pain. These are the clients that perform a biceps curl using minimal load and feel the lateral epicondylitis that’s been an issue for 5 years, or they have an old hamstring strain at the insertion point and can’t do any eccentric work because the hamstring flares. These are the same clients who, if you ask them to flex their hips, will bend at their knees, or if you ask them to bend at their elbows, will swing their arms forwards with their shoulders. Their sense of how they move lacks clarity. In a tribute to the dissolution of Gwenyth Paltrow’s marriage, Dr. Lehman called the solution to this “conscious uncoupling.” Get people to uncouple their movements to improve body image and awareness. (This, of course, is similar to Dr. Spina’s CARS approach, without the total body tension). This is within our skill set as trainers, and can be extremely beneficial for those struggling with chronic musculoskeletal pain. (Also interesting was the fact isometrics are an analgesic. He mentioned having people do isometric contractions once an hour, every hour. I tried this with my husband, who has suffered from a chronic musculoskeletal issue in his shoulder, by having him perform an isometric external rotation every hour. His shoulder is feeling better, he has more pain free ROM, and he is able to practice his martial art without any lingering discomfort, all improvements. There might be other things at play, but it will be interesting to see if the improvement continues). 

Edge work can be a useful intervention if pain is present. Edge work is a concept that involves taking people to the edge of pain to allow the body to gradually decrease the perception of threat regarding movement. This isn’t really a concept I would feel comfortable using as a trainer (in my opinion, taking people to the edge of pain is under the umbrella of physical therapy). However, what can be utilized in a training setting is the concept of finding a novel stimulus that doesn’t cause pain. If someone has pain while turning his head and you are trying to figure out a way to get the client to access his neck, try keeping the head still and turning the body. Chances are high this won’t be perceived as painful while turning the head might be. This is where it becomes extremely beneficial for trainers to explore mobility work, isometric work, and isotonic work in a variety of ways. If we only have two ways to ask someone to turn his head (“look over your right shoulder,” or “turn your head to the right”) we will find ourselves stuck when working with a client struggling with chronic neck pain. The same is true of teaching breathing, pelvic tilts, hip hinging, or any other movement. The more adaptable we can be as trainers, the more of a positive impact we will have on our clients well-being without furthering pain or discomfort. 

There can be degenerative changes involved in chronic pain. Factors resulting from central pathophysiological changes can also be involved. Again, as trainers, we don’t treat pain. Not our gig. However, it’s useful if we are working with someone struggling with a chronic pain condition for us to understand we don’t know why the client’s hamstring hurts. Maybe it has to do with his anteriorly rotated pelvis. But maybe not. We shouldn’t try and offer explanations. Fear and catastrophizing play a role in contributing to risk of developing chronic pain. If you tell someone he has a pathological pelvic asymmetry or that his transverse abdominis isn’t firing, this doesn’t bode well for his mental security in how his body moves. Everything works just fine for the person standing in front of you; otherwise he wouldn’t be standing. 

Stress equals adaptation. In the realm of fitness, exercise is a stressor. And like all stressors, exercise can (and should) fall into the category of eustress, or good stress. If, however, you continually do something that causes pain after your workout, this is akin to pissing off an angry bear. Let’s say you feel pretty good until you do the workout that consists of 100 push-ups. After you do that specific workout, your shoulder feels irritated, in a not good sore way. Instead of getting rid of push-ups entirely, perhaps you lay off the push-ups for a week, and then gradually implement 5 push-ups back in. Monitor how your shoulder does and maybe add in one more push-up the following week. Think of stress in your life. A little bit of stress is good. It encourages adaptation and increases strength. However, when someone begins to feel stress all of the time, there is a tipping point where the stress is no longer giving you strength. It’s breaking you down. You will adapt until you can’t. If you have hit your tipping point in a specific activity, it doesn’t mean you can’t do it anymore. It simply means you need to step back, re-evaluate, and start off doing less than you think you can. From a training perspective, if a client loves running and can’t run because it hurts her back/achilles/knee, incorporate short jogs into her workout of 20 or 30 seconds. Show her it’s not that she can’t run; she just might benefit from re-framing her running for a little while. Poke the bear once or twice from afar. Don’t wave food repeatedly in front of it wondering what will eventually happen. (If you ever catch Greg live, the bear analogy takes on many humorous forms).”Treat pain like a memory. Let’s not make new memories,” (Lehman, 2016). 

Calm stuff down, build stuff up. As trainers, we tend to excel at building stuff up. It’s what we do when we place a muscle under tension and load. Things become stronger. We aren’t always so good at calming things down. Clients want to go hard, we like to push them hard, and then we are surprised when aches and pains crop up. I have even noticed this trend in the yoga world. People become excited when the sequence is physically challenging because they like to feel like they got a good workout. If you see clients regularly, they will benefit from a restorative movement day once every 6-8 weeks. This doesn’t mean they rest supine and meditate; instead, it’s taking the time to focus on sensing various parts of the body, moving a little more slowly and mindfully, and maybe implementing moves that are more playful. Rocking movement, consistent breathing, spinal waves, joint mobility work, and crawling patterns are just a handful of the ways I incorporate restorative work into my clients’ routine. It’s an amazing thing to watch someone’s entire posture change during the course of 55 minutes. Not focusing on numbers and instead focusing on feeling is extremely beneficial for teaching autonomy and auto-regulation. Long exhales don’t hurt either. 

Can biomechanics and pain science be reconciled? I think so, though it might be a while before the neurology people and the biomechanics people find a middle ground. I sincerely hope researchers stop arguing long enough about which exercises produce the highest EMG readings and how to improve multifidus and transverse abdominis firing to recognize different people respond favorably to different protocols. There is no “right” or “wrong” way to program exercise for painful conditions. Don’t make things worse, teach people how to move joints independently, get people strong, and give people tools to relax. Watch magical things happen.

References:
Battle, M.C., & Videman, T., (2006). Lumbar disc degeneration: epidemiology and genetics. Journal of Bone and Joint Surgery, American, 88(2), 3-9). 
Battie, M.C., Levalahti, E., Videman, T., Burton, K., & Kaprio, J., (2008). Heritability of lumbar flexibility and the rocs of disc degeneration and body weight. Journal of Applied Physiology, 104(2), 379-385.
Niemelainer, R., Briand, M.M., & Battie, M.C., (2011). Substantial asymmetry in paraspinal muscle cross-sectional area in healthy adults questions its value as a marker of low back pain and pathology. Spine, 36(25), 2152-2157.
Pelletier, R., Higgins, J., & Bourbonnais, D., (2015). Is neuroplasticity in the central nervous system the missing link to your understanding of chronic musculoskeletal disorders? BMC Musculoskeletal Disorders, 16(25).