At Tame Pain, this is a question we often hear from clients in some fashion. Most of society typically views pain as a warning sign or signal that they’ve been hurt or injured, that some area of their body internally or externally has been damaged. Pain experiences typically lead folks to asking a few related questions:
What does this pain mean?
How should I respond?
Do I need to go see a doctor?
In this blog, we will seek to provide clarity to the pain discussion while attempting to answer the above questions to the best of our ability based on current research evidence (don’t worry, we will keep this part practical).
So what exactly is pain?
At the most basic level, pain is a word we attach to experiences we have in day to day living (Bourke 2013). At the individual level, what one person views as painful another may not agree (Baliki 2015). An example will help with understanding. A person who has not been physically active recently may decide it is time to take up resistance training. On the first day in the gym, they get a bit zealous and decide to do 3 sets on all of the weight machines until they hit failure. The next day they wake and describe feeling overall body aches and pains, moving throughout the day is difficult to say the least. The person becomes apprehensive of returning to the gym again and worries they may have injured themselves. Alternatively, someone who has been regularly engaging in resistance training may have a similar experience but describes it as delayed onset muscle soreness. They aren’t concerned about an injury and return to the gym the next day but decide to modify their training based on how they are feeling. The stimulus (resistance training) was similar but the individual response was quite different.
This is what we see in the research evidence today, where experiments are conducted by applying the same stimulus to a group of individuals, and asking them to state when they experience pain (Madden 2019). Folks experience the same stimulus in a wide variety of ways, some neutral, some painful, and others perhaps even pleasurable. Even in scenarios of severe trauma, example war, where we’d expect soldiers to report pain, we have similar findings. Some returning from battle with major traumas such as fractures and penetration wounds of the head, chest, and abdomen, reported not being in pain and not wanting medication (Beecher 1946). More recent studies had similar findings with individuals reporting to the emergency department (Melzack 1982). What does this data tell us about pain? Most importantly, pain is an experience at the individual level. When someone reports pain, we (society and healthcare professionals) should believe the person. Next, we discuss how our definition of pain influences our understanding and experiences.
Meaning of pain
The meaning assigned to pain is intertwined with how we define the experience. Many define pain as a sign of body damage, harm, or disease. As a society, we only recently began attempting to define the word pain universally (Bonica 1972). In 2020, the International Association for the Study of Pain (IASP) released a new definition,
“An unpleasant sensory and emotional experience associated with, or resembling that associated with, actual or potential tissue damage” (Sinivasa 2020).
We do not need to delve too deep into the waters on this definition but one point is worth highlighting, potential tissue damage, this means an individual may report pain, but as healthcare professionals we are unable to find or locate any signs of a problem necessitating specific interventions. Often this leads someone to think, “Is it [pain] all in my head?” Our response is no, pain is a multifactorial experience that has innumerable variables influencing someone’s experience. Not being able to put a finger on a specific issue necessitating a particular investigation and intervention is a good situation to be in and means we can instead focus on how to move forward from here.
The IASP did provide a few notable key points:
Pain is always a personal experience that is influenced to varying degrees by biological, psychological, and social factors.
Through their life experiences, individuals learn the concept of pain.
A person’s report of an experience as pain should be respected.
Although pain usually serves an adaptive role, it may have adverse effects on function and social and psychological well-being.
How should I respond?
When experiencing pain, often the question centers on a person’s response. With an updated understanding of pain, hopefully the accompanying fear and apprehension experienced in these scenarios is minimized. Re-framing our understanding of pain and learned responses is a process. We often tell remote clients that we do not expect a single conversation to change one’s beliefs and behaviors. However, over time folks report feeling comforted by a new understanding of pain while fostering more self-efficacy with gaining control over their experiences (Martinez-Calder 2017, Luque-Suarez 2019). We do not set the expectation for someone to be “pain-free”, given these human experiences are a part of our existence. Rather, we seek to empower folks to feel more in control over their experiences.
The tangible variables that may affect someone’s pain experience and how they respond include their thoughts and emotions (Caniero 2021). Pain certainly can be a distressing experience, but often the inciting event resulting in pain has ceased, and yet folks may still report pain. If we take a biomedical approach to the discussion, then it’s easy to fall into the trap of thinking the pain is indicative of a “tissue issue” and perpetuating avoidance of valued life activities. However, if we have a more nuanced understanding of pain then we are typically willing to engage those activities to tolerance. Research does show some short term benefit with being active to tolerance when experiencing pain (Smith 2017). These findings aren’t likely due to activity being a silver bullet for chronic pain, but rather the individual becomes empowered in the process of engaging activities they value (Polaski 2019).
Pain has a way of robbing individuals of their social identity, which makes sense given we humans are made up of our beliefs about the world and our consistent behaviors (Karos 2018). Suddenly being unable to engage in daily and extracurricular activities can make anyone feel not like themselves, which is why at Tame Pain we advocate for continued activity to tolerance. While symptoms tend to be a part of the process, this does not mean that we ignore them and simply keep going, disregarding the pain experience. Rather, we want symptoms to be tolerable, which means not debilitating. We qualify debilitating as not crossing an individual upper tolerance limit and thus feeling unable to go do other life activities or distracting attention away from other tasks (see figure 1). Symptoms will likely ebb and flow throughout the process and that’s ok and normal. Because it’s often tough to pinpoint a singular “cause” to symptoms, we shouldn’t unnecessarily worry ourselves when we experience pain. Over time, as we regulate activity, symptoms tend to regress while being able to still pursue valued life goals to tolerance.
How do I regulate activity?
There are a few relevant variables that can be regulated for activity (see Figure 2), these include: type/mode, frequency, volume, intensity, and duration (Lorenz 2015).
Type/mode - specific activity being engaged (e.g., resistance training or cardiorespiratory activity)
Frequency - number of days of activity per week
Volume - amount of activity within a session, week, month, or year.
Resistance training - sets x reps x load
Cardiorespiratory - distance, time, amount of work completed
Intensity - two types: external and internal
External intensity:
resistance training = amount of load lifted (aka absolute intensity)
cardiorespiratory activity - terrain/environment of activity and/or time (how quickly an activity is completed)
Internal intensity: ultimately, how difficult/fatiguing/symptomatic someone finds an activity (see Figure 3). This can be tracked with rate of perceived exertion (RPE), reps in reserve (RIR), and heart rate (HR) (Eckard 2020)
Duration - time frame activity was implemented (weeks, months, years).
It’s important to remember the process towards a goal is typically non-linear. There will be peaks and valleys (more symptomatic, less symptomatic, without symptoms) throughout the process but having variables to manipulate to help accommodate current abilities is key to managing through and coping with this process.
Let’s work through two scenarios for altering dosage of activity.
Scenario 1 - Avid 44 year old powerlifter needing assistance with chronic low back pain during deadlift. The individual reported previously powerlifting 3 times per week with a specific focus on squat, bench press, and deadlift. She’s noticed right sacroiliac (S/I) joint pain as well as tingling into the top of her right thigh. She recalls performing a sumo deadlift during the summer of 2021 which resulted in a concerning low back pop and subsequent symptoms. She’s avoided deadlifting since onset for fear of making her situation worse. She’s also experienced other life events that resulted in her not training during 2022. She’d like to start back to training but is concerned about her back. We discuss her situation and settle on the following game-plan:
Day 1 (Tuesday) -
Tempo Squat (3.1.0 = 3 seconds lowering to tolerable bottom position, one second pause in bottom, and normal pace standing-up) for 3 sets x 8 -10 reps, building to two top sets at RPE 7 / RIR 3
Feet up bench press for 3 sets x 8 - 10 reps, building to two top sets at RPE 7 / RIR 3
Single Arm Dumbbell Row for 3 sets x 10 - 12 reps, building to two top sets at RPE 7 / RIR 3.
Day 2 (Friday) -
Tempo Sumo Deadlift with Kettlebell (Tempo 3.1.0 = 3 seconds lowering to ground, no pause, and normal pace standing-up) for 3 sets x 8 - 10 reps, building to two top sets at RPE 7 / RIR 3
Seated Strict Press for 3 sets x 8 - 10 reps, building to two top sets at RPE 7 / RIR 3
Split Squats (Tempo 3.0.0 = 3 seconds lowering to bottom position, no pause, and normal pace standing-up) for 3 sets x 10 - 12 reps on each leg, building to two top sets at RPE 7 / RIR 3
We now have an entry point into desired activities with which to build from. Note, we did not avoid programming any of the movements which she is fearful of, rather we specifically programmed these movements while adding some constraints to allow her to build confidence and reacclimate to training stimulus. Using RPE / RIR allows her to auto-regulate load selection for each movement based on difficulty, fatigue, AND symptoms. We set the expectation that in the beginning stages, symptoms may be the limiting factor and that’s ok, it won’t always be that way. The tempo adds constraints on her, minimizing ability to chase numbers. In subsequent weeks, we can focus on increasing loading to tolerance by increasing a top set at RPE 8 and/or lowering volume by decreasing repetitions for each set, and eventually, removing tempo
Scenario 2 - Avid 58 year old marathon runner who has been dealing with chronic left knee pain for the past 5 years. He previously was running 5 days per week, averaging 40 miles per week. He doesn’t recall a specific incident resulting in knee pain. He decided to stop running altogether late fall of 2021 and noticed complete resolution of knee symptoms. He decided to try to run again at the beginning of this year, but immediately noticed right knee pain again. He’s gone through a cycle of starting and stopping running since the beginning of this year. Finally, after much frustration, he sought consultation with a local physician who ordered x-rays and reported moderate - severe knee osteoarthritis. The physician recommended minimizing the loading of the knee joint and instead taking up swimming. We discussed his thoughts about the prior narratives and imaging report. He agreed it was time to start activity again but wants guidance. We decided to implement one day per week of resistance training and two days per week of cardiorespiratory activity as an entry point into training again.
Day 1 (Monday) - Cardiorespiratory
Walk/Run intervals - walk at RPE 3 or less for 2 minutes, run at RPE 5 - 6 for :30 seconds x 8 sets (20 minutes of total work). He has freedom to adjust running interval duration based on tolerance as well as reduce total sets as needed. We also decided to couple his RPE with heart rate reserve and calculated the running intervals as a target heart rate zone of 125 - 135 beats per minute.
Day 2 (Wednesday) - Resistance Training
Box Step-Ups - 3 sets x 8 - 10 reps to tolerable height, building to two top sets at RPE 7
Bench Press - 3 sets x 6 reps, building to two top sets at RPE 7
Dumbbell Romanian Deadlifts - 3 sets x 8 reps, building to two top sets at RPE 7
Day 3 (Friday) - Cardiorespiratory
Steady state run - run at RPE 5 (same HR as above) for 15 minutes. He has freedom to reduce time based on tolerance. Note total distance at end.
With the above game-plan we can use the resistance training day to load the symptomatic knee to tolerance while building confidence and resilience over time. The two cardiorespiratory days are geared towards titrating up running tolerance with one method of shorter bursts of running and another with sustained running. In subsequent weeks we can increase the intensity of the running intervals and on the second running day increase volume (distance/time).
Hopefully these two brief scenarios give an idea into our rehab approach at Tame Pain.
It is also worth noting that while we have supportive data demonstrating that activity helps decrease the risk of developing chronic pain, the dosage of activity is a major unknown (Landmark 2011, Law 2017, Naugle 2019, & Belavy 2021). However, this shouldn’t be viewed as a negative. Rather, this should be encouraging, specifically to clinicians who can feel empowered to find an individual activity prescription specific to clients’ goals and tolerance based on their recent activity history. If unsure where to begin, we often advocate for making moves towards meeting the World Health Organization’s (WHO) activity recommendations (Bull 2020). These include:
150 – 300 minutes of moderate intensity cardiorespiratory activity / week or
75 – 150 minutes of vigorous intensity cardiorespiratory activity / week or
Some combination of A and B and
2 days per week of resistance training for all major muscle groups
Don’t feel pressured to go from complete inactivity to immediately meeting these guidelines. While meeting these activity guidelines over time is ideal for the broader holistic health and well-being of individuals (e.g., reducing disease states and risk of early death), we have data that even just 10 minutes per day of walking decreases risk for early death (Saint-Maurice 2022). For many, meeting physical activity guidelines may be a long-term goal, but it can absolutely guide our initial activity prescription, especially for those who are sedentary and/or only meeting part of the guidelines.
When to seek healthcare consultation?
First, if worried about a pain experience or struggling to self-manage through the process, it is completely ok to seek out a trusted clinician locally or remotely. We recognize that even if someone is familiar with this information, having pain and injury can be stressful; it is normal to feel overwhelmed on where to start and can be immensely beneficial to talk through the nuances of the situation with a provider. Through a consultation, a clinician can provide evidence based information regarding the situation, determine whether further investigation (like imaging) is needed, or recommend a specific referral or intervention. Additionally, a clinician can collaborate on a game plan to help manage through pain while returning to desired activities and restoring quality of life. We’d be happy to consult remotely at Tame Pain, please complete our intake paperwork HERE and someone will be in touch soon.
When to seek local in-person medical care?
While we are able to consult with most cases romately, here is a quick list of scenarios in which a person should seek an in-person, local medical consultation for pain:
Recent trauma (e.g., motor vehicle accident or fall)
Progressive neurological symptoms (e.g., new onset paralysis or loss of bowel/bladder control)
Other associated symptoms in addition to pain (e.g., unintentional weight loss/gain, fever, rash, or bowel/bladder alterations inconsistency or color)
Closing Remarks:
In closing, pain is a multifactorial individual experience. Our prior biomedical model to understand such experiences has fallen short, leading to negative effects on those seeking aid for pain. We require a more expansive and inclusive model, such as the BioPsychoSocial model, to allow for new understanding of pain and afford more options for management beyond simply searching for “tissue issues” (Engel 1977). Recognizing how our thoughts, beliefs, and emotions influence pain can be empowering by providing more options for self-management. With an updated understanding of pain, we can take confidence in re-engaging value life activities to tolerance. We hope this article has been helpful.
Please like, comment, and share to spread evidence based information about pain.
Author’s Note: Thanks to Dr. Mora for her comments, suggestions, and edits to this article.
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