Tuesday, November 3, 2009

Why Not "Train Through Pain"?

Lately i've had the opportunity to listen to a lot of athletes talk about various injuries, ongoing problems, and how many of them have tried to "train through the pain." Probably we've all done it (do it). The way our nervous systems are wired, however, that's a sub-optimal response to pain that can often lead to more problems. This post is meant to be a quick look at some strategies on how to respond to a pain cue to get back in the game.

Who needs to "work through the pain"?
In a life and death situation, a person may need to work through the pain. The price of staying alive might be worth the potential long term cost of whatever damage is sustained.

A workout in a gym is not the same (is it?) Getting in a few extra reps so as not to spoil a set and "working through the pain" may have untold consequences for no benefit. Seriously.

Apparently we just don't know what the consequences of even a seemingly trivial injury can be for cascading through our systems and causing other issues. Knowing that there may be significant consequences when we break ourselves, we may need to ask ourselves: when there's pain, why not just stop and figure it out? why put our bodies at risk just to finish a set? who cares really, ultimately, if we get in 10 reps rather than 8? or 2?

I think a lot of this just-work-through-it comes from most of us not knowing what pain really is or not having tools specifically to respond to it appropriately. So i'd like to offer a little bit about what pain is, and some simple but effective pain response strategies.

Background A lot of the work i'm summarizing stems from pain research. Books like David Butler's Explain Pain, and the Blakeslee's the Body has a Mind of It's Own are super general references in this space. I was introduced to the following models/work on pain by Eric Cobb at the first Z-Health certification. When we focus on the nervous system, as Z-Heath does, and get that Pain is an action signal from the brain manifesting through the nervous sytem, we have a whole lot more tools to deal with pain as events.

Pain is in the brain, first and foremost, and it means Threat is caused by what we're doing. So CHANGE.
Pain is not what happens at the site of pain - like the ache in the wrist or the sharp pain in the back coming up from a poor lift. It's a kind of summation of a lot of information. We've all had experiences where a paper cut means nothing we ignore it and get on with our day, and other days where the same paper cut really HURTS and demands attention. This is because pain is not about the thing itself (the injury); it's about the whole system context of how our entire system is doing at that moment, including perceived threat. Yup, we can feel pain in response to the anticipation of something occurring.

Pain is not isolated; Pain takes place in the brain. It is an action signal; it's an event that is telling the body that something, somewhere is wrong (ie under threat) and to deal with it. We ignore it at our peril, and working through the pain like an ache in a rep is actually being stupid in a non life threatening situation.

Here's part of why.

In a tissue injury, nociceptors (things that detect noxious stimulus in the body, and that live particularly around joints and in muscle) get fired up and a whole chemical soup gets going around the site of trauma to deal with it. Incredibly, that response in and of itself can be pretty varied and doesn't mean there's PAIN yet. Based on whatever else is going on in the body, signals go up to the brain, and based on that context, the brain decides whether to signal or even surpress a pain event.

If the brain says this is pain, however, it means, for whatever reason, we need to attend to it.

Pain is a Threat Response - real or perceived. The nervous system is always on; it only checks a single binary condition: threat or no threat. The response to threat to the body is to respond to the area where there is threat. Often that's a kind of shut down sequence.

Consider what happens dramatically if we have an inflamed finger. The range of motion is restricted, right? Or sore quads from DOMS - range of motion and also power can often be restricted. We are being held back from injuring ourselves further in the current circumstances.

Pain becomes a clear action signal not necessarily to stop what we're doing but to change what we're doing (which sometimes does mean "stop" - temporarily)

If we decide to go ahead with that lift anyway, when the body is pulling muscular firing power away from the site and sending up pain events to say this is not a happy thing, then we're stressing our bodies out further which cranks up stressor chemicals, cortisol can get going and well, we're well far away from an ideal environment for performance, right?
It's a feedback loop for more shutdown, more pain: by working against ourselves we start setting up the body to act more to defend itself, while we're taxing it further and potentially injuring ourselves more.

I've spoken with experts about what's going on with people who say they trained through the pain and after awhile it went away. The consensus seems to be that in those cases (a) the person is actually most likely developing new movement patterns away from the site of pain (b) doing so sub-optimally at a potential cost to overly sensitizing those sites to future pain/trauma events. Similar people who "work through" pain will often also talk about the same kind of pain showing up months/years later as a now more persistent ache, or have other physical issues.

The costs of risking "breaking" ourselves in some way by working through pain are potentially complex. We really have no idea what might be the one seemingly trivial thing that can set up a cascade of events in our nervous system that will have repercussions. So even though we're very robust, and will adapt to almost anything, to ensure the robustness of the system it's really easy just to learn some strategies to respond to a pain/threat event.

Here's an analogy with stress. Stress or anxiety like we might feel before having to get up in front of a group of people and give a talk is an example of a threat response. Chemicals start to get released from the brain to get us ready for fight or flight. Often people who are stressed are encouraged to go for a walk or move and they report feeling better: we effectively start to use those chemicals for the purpose they've been stirred up - to move. The same chemicals (catecholamines) pretty much get fired up every time we work out and get our heart rate up. So they're not bad, they're just physical, and there is a physical response available. If we become aware of "getting stressed" - note the breathing responses etc and respond, we can quickly get back to normal performance.

Pain is a similar kind of response to threat - perceived or actual - and is an action signal. Again, often (not 100% of the time, but often) movement can likewise help both diagnosis that there's an issue and check if there's a good response to the action signal.

The right mobility can be an optimal response to the pain action signal
  • So first things first: never move through pain. If pain happens, stop and check. That stopping is a movement response.
  • Next, pending severity we can quickly check where the mobility around the joints where the pain occurs may be restricted. So sore elbow - how's the shoulder movement, wrist movement, elbow movement without load (it helps also to learn what the ROM of these joints is for yourself). If there's pain through everything, just frickin' stop.
  • Knowing some mobility work for the related joints, going through them where there's no pain, and rechecking range of motion - better worse no change - is again a great fast way to see how things are going. If things are improved awesome, you may want to try - gently - to see if the original move is ok, and if the load has to be reduced to move through the ROM without pain
  • Recheck regularly to see where the threat is
  • Move a bit as soon as you can without ever moving into pain.
By going through this simple protocol, we gain some fast insight into how to respond to the pain action signal, take care of ourselves, and be back to our routine way faster and stronger than bleeding out a few more reps through pain, that will set up the pain event cycle. yuck.

So, with all the athletes i work with, i recommend that at a minimum they consider making mobility practice a regular part of their daily routine. If you're interested in more of the details of why, here's an article. Likewise, if you haven't and especially if you're concerned about your performance goals, consider getting your movement in general and your specific ahtletic form checked by a movement specialist to make sure you're repping in good patterns.

Scenario of Pain Event Listening
SO let's say you're doing something that fires up a pain signal in the elbow or forearm.
You check your shoulder range of motion.
You can only get your arm up to the start of your ear - usually you're behind it. Something's wrong.
You do some opposing joint drills and recheck - your arm mobility is back to normal. awesome.
You recheck your form for whatever was hurting, remember your form: tall spine, good breathing, focus on open form, pain is gone, life is good again.

Yes it can happen that fast. The nervous system mechanoreceptors fire at 300mph. And with the SAID principle, we respond exactly and immediately to what we're doing.

Now there may be instances where the ROM does not come back; where the pain is acute when doing ANY ROM of the given move. That may be time to bag it. Rule no. 1: never move through pain because of all the above: upping threat, further shut down, more threat response chemical events etc. Related strategies are, when and as possible: reduce the range of motion of a movement that causes pain so you work outside the pain zone; reduce the load that brings on pain in any ROM.

An intriguing benefit of regular mobility practice is that, by practicing regular and better movement, better information is getting to the nervous system about where we are and what our options are, so there is a decreased incidence of injury and in no small part increased performance as well. Why? Mobility work helps us achieve the Perfect Rep - or at least efficient movement (discussed mid article here), which is the least likely to result in problems, because it also enables the best ROM from which to respond to the unexpected.

An example of mobility and connecting up nervous system communication we've talked about at b2d before is with the arthrokinetic reflex - a powerful example of what happens (1) with a threat response in the nervous system - when it senses even the slightest impingement - and how to fix that with self-mobilization and (2) how performance improves when connecting the neuro-reflexes in the body: here connecting eye movement with hip movement.

So why shouldn't we train though Pain, in brief?
We really don't know the extent to which a pain event can screw ourselves up for right now, or for some event in the future. Like a stress fracture in metal, it may be fine for some time, but it becomes a progressive site of deterioration until suddenly there's a potentially catastrophic break. By not stopping to deal with the pain, we set up a cascade effect of progressive responses in the body to get us to attend to the ever amping up signal. These further events have further costs on our performance. A way the body may deal with unattended pain is to bring on a compensation that will lead to other/new pains. Likewise, ignoring pain can also set up various sensitizations to pain that can trip the pain from a single acute incident to something that gets would up into our nervous system and goes chronic, also potentially harder to address. All in all, it's not nice.

Bottom line?
  • A pain event is non-trivial. It means something. So it's a good idea to listen to that signal.
  • At a minimum, never move into pain: reduce range of motion/load/speed as necessary (for awhile this may mean non-movement, but getting to possible movement is a good idea)
  • Mobility work like z-health rphase/iphase is a fabulous tool kit to be able to self-assess to respond to that pain event and get back to practice asap.
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