No Pain No Gain

“No Pain No Gain” – Why I hate this phrase and you should too

“No pain no gain” the smiling gym trainer says patronisingly as I groan under the strain of another rep and obviously want to give up. ‘Do you really expect to see ANY improvement if you wimp out so easily??’is underneath this motivational remark.

No pain no gain is so well dug into our health and exercise culture that it’s hard to see a clear alternative. We’re encouraged to push hard if we are going to get any improvement at all from our exercise or other efforts. How can you get the results you want if you won’t put in the work? If you let a bit of pain put you off you ain’t gonna get nowhere man!

Injury

One problem with no pain no gain is that it takes you much closer to the point of injury and so increases the risks of exercise or activity. It’s normal to push a bit when you’re exercising, to get a bit more out of yourself But pushing strongly can make it more likely you’ll get a muscle tear, tendon injury or an joint or ligament strain.

You can get good results from your training without pushing yourself that hard. Top athletes train hard but for them the possibility of injury is too great to risk it. It would ruin their preparations for an important event so they never push too strongly. Just hard enough to get the gains they’re looking for.

Rehabilitation

No pain no gain is even less useful and more risky when you’re recovering from an injury or operation. You are unfit and your muscle strength is reduced as well as its capacity to cope with training stresses. You can put out relatively little effort and get good increases in training strength and endurance.

This is where a good physiotherapist or other therapist can guide you. How much force to put through your tissues at each point of your recovery is the crucial decision. That way you can improve at the fastest speed with the least chance of setbacks.

Remodelling

If you push while you are still healing you are much more likely to reinjure as your tissues aren’t ready yet for normal exercise stresses. Soft tissue healing is complete sometime between six and twelve weeks but the tissues don’t return to normality for longer.

Once scarring is complete the tissue goes through a period of remodelling. The scarring that occurs after injury means the damaged tissue cannot be exactly as it was. However the stresses we put on our healing tissues mean they remodel to a similar type and strength of tissue.

Putting the right level of stresses on the tissues as they heal is the key skill. Mostly we just do this naturally unless we’re encouraged too much by someone who doesn’t understand the tissue healing process.

Tissue Tolerance before Soft Tissue Injury

Tissue Tolerance before Soft Tissue Injury

 

  • What do our tissues do?
  • How much work they are designed for?
  • How much work is too much?
  • How do we overdo the limits of our tissues?
  • What consequences can overdoing have?

Those are the questions I want to at least partially answer.

Understanding the idea behind tissue tolerances is key to the whole process of getting things done without suffering pain or disability. And key to injury recovery and pain management.

We’re all superbly designed for our daily activities so we can achieve the things we want or need to do. Our bodily tissues cope with the demands of moving our heavy bodies about and with any jobs we perform. We don’t usually think about it at all, we just get on with the stuff we are doing.

Until, that is, suddenly we have to do something different, something heavier or for a much longer period of time. Then we notice. Even then, it may not be much. Just a feeling of muscle soreness or an ache in a joint which settles in hours or days.

But sometimes it’s much worse than that, we get severe stiffness or pain after doing something, or even a soft tissue injury.

Body Building

I love the documentary programmes showing how the world’s biggest ship or the world’s most advanced aircraft engines are made. The complexity and attention to detail are staggering.

The engineers choose the designs and the materials to suit the stresses and strains the various parts of the machines must cope with to do their job best without failing.

Our bodies’ tissues are exactly the same. Each part of our body is “designed” to do a particular job and cope with a range of stresses and strains. Bone supports us and takes compressions strains, ligaments hold our joints together, muscles move us about, tendons transfer forces from our muscles to our bones, cartilage makes our joints easy to move under load.

Each tissue has its job. And each tissue has its “breaking point” in terms of the amount of force that we can apply and not suffer any effects. Luckily we don’t test our tissues to their actual breaking points all that often. Soft tissue injuries are common however.

This idea of our tissues having a tolerance for physical stresses is logical but quite difficult to grasp as it mostly just doesn’t occur to us.

Do and Overdo

As we do things our tissues change and react to the forces involved in a way that machines don’t.

  • Imagine cleaning a window. That was ok wasn’t it? No after effects, no aches and pains.
  • Imagine cleaning five windows. How are things now? Perhaps next day you have a bit of muscle soreness, a bit of shoulder or neck pain.
  • Imagine cleaning fifty windows. How’s that? I’m betting you’re in a lot of pain and having difficulty moving your neck and arm properly for several days after.

Those muscles that contract and relax hundreds of times, those joints which bend and stretch, those tendons which slide back and forth and those lubrication sacs which reduce friction are all under stress with this kind of activity. Too much stress and they become inflamed and painful. This doesn’t happen to the window cleaner as he’s had years of training and his tissues are used to it.

Overdoing means any activity done often enough or long enough to cause an inflammatory reaction in the tissues, indicated by pain and stiffness. This is a soft tissue injury.

Exercise

Exercise is a very common way that we overdo activities in daily life.

When we exercise, we cause what we call micro-trauma to the muscles concerned. This is good as it forces our muscles to repair, which they do and then respond by getting bigger and stronger.

Our tendons move back and forwards rapidly which can lead to the inflammation of acute tendonitis. Lubricating sacs help reduce the friction of our body parts against one another and can become inflamed with too much repetition. Anyone who has developed housemaid’s knee after kneeling too much will know what I mean.

So it’s fine if you don’t overdo it. I did once in particular. I caused so much micro-trauma that it wasn’t micro any more! The normal process of inflammation occurred at a much greater degree than I’d anticipated. This gave me widespread soft tissue injury and a high level of pain for a few days.

I had overstepped the tolerance of my tissues to physical stress. So I paid for it.

We all have tissue tolerances and it’s ok if we mostly don’t push our luck. But when we do push our luck it can have unpleasant consequences such as soft tissue injury or more and I’ll get onto that in another post.

The Human Body – Body Tissues

The Tissues Of The Human Body

I’ve been thinking about tissue tolerances. This is the tolerance of the human body’s tissues to cope with this or that amount of physical stress and how we tend to overdo it so often.

Sport is probably the worst offender. Mostly it doesn’t matter a whole heap but sometimes pushing ourselves can lead to injury or worsening of pain conditions. And then it can get important.

So before I get going on tissue tolerances, overdoing, activity cycling and pacing, I thought I’d review the different tissues of the human body as a starting point, a baseline from which we can go on to more complex ideas.

Bone

Bone is the structural tissue, it holds us up, our muscles attach to it and it takes the weight of our bodies as we move about. Our bones are an active tissue and constantly changing in response to the stresses we put on our bodies. Runners have denser bones than non-runners in their legs, indicating that bone changes like any other tissue but it’s just not as obvious or as quick.

Muscle

Muscle is the movement tissue. Its second and  very important function is to hold us up posturally in all the positions we take up. If we are standing still there’s no movement but many of our muscles are working hard to maintain us upright. Muscles also react to activity or inactivity by changing and this can be fast.

If we work out muscles hard, beyond their easy capacity, we damage them to a small degree. This is why the muscle can feel stiff or sore the next day or so. This minor damage is the stimulus the muscle needs to repair and as it repairs it gets stronger and larger. Bodybuilders do this to an extreme degree! However, this response occurs in all of us when we work our muscles a bit harder than normal.

Tendon

Tendons are the force tranmission tissue. Muscles have connective tissue through their structure, but at each end of the muscles this connective tissue thickens into a band or a rope-like shape. Tendons connect muscles to the bone. To be able to move anything, a muscle needs to be attached to a bone and it’s the tendons which do this job.

Tendons are also often neat and small so that they’re strong enough but don’t get in the way. There’s no room for big forearm muscles down near the wrist and hand and if you look at your hand when you’re moving your fingers you’ll see the long, slim tendons doing their jobs.

Nerve

Nerves are the irritable tissue. Their job is to be irritated in some way or other and communicate that input up to the brain where it can be processed. Nerves report back to the brain on a whole list of things going on around or in us – to pressure, heat, cold, touch, joint position and pain. And that’s not counting vision and hearing.

Nerves have a surprising degree of “plasticity”, meaning that they can react very differently to a stimulus depending on what’s been happening to them recently. They are not just on/off switches but change the volume of their responses.

Ligament

Ligaments are the binding tissue. Ligaments bind all our joints together and prevent them from going beyond their limits. Bend your finger back with your other hand and you’ll see it’ll only go so far. Push any further and you will feel pain. That’s your ligaments objecting to being stretched too far.

Joint

Joints are the hinge tissues. They allow movement in one direction or a number of directions so we can do what we want. An example is the shoulder joint – its job is to put our hands in front of our faces so we can see them and do things with them. Joints vary from large weight bearing ones such as the hip and spine, to small ones such as the fingers and toes.

Cartilage

Cartilage is the anti-friction tissue. Joint cartilage covers both surfaces of many of our joints and is very slippery and low friction. This allows us to move around easily even when there’s a big load on a joint such as going upstairs. It doesn’t really feel any different to going down apart from being a bit more work. This is important as we are large animals in the scheme of things and so weigh a lot.

Activity or inactivity has effects on each of these tissues of the human body although we are often not aware of the changes at the time.

Manipulation Techniques for Acute Lower Back Pain – Waste Of Money?

Manipulation Techniques for Acute Lower Back Pain

Manipulation techniques are commonly used by physiotherapists, chiropractors and osteopaths in the treatment of many types of musculoskeletal condition, including acute lower back pain. But do they give good value for the time and money and do they change the course of low back pain?

Acute low back pain is defined as back pain of less than six weeks duration in the Cochrane Collaboration study and they found 20 randomised controlled trials to assess. The scientific quality of the trials gave the assessors reasonable confidence that their findings reflected the truth about this treatment in acute lower back pain.

The results showed that there is little or no good evidence that spinal manipulative techniques (SMT) are any more effective than pretend SMT, non-active treatments or when it is added to normal medical management. So it doesn’t seem to be any more effective (or is just as ineffective?) as many other back pain therapies.

SMT is a relatively safe intervention for low back pain (although high neck manipulation may be less so) but the time and costs of attending a qualified professional should be questioned when the evidence for usefulness is not forthcoming.

Pain Relief in the Iraq War

Anaesthetist Drags US Military into the 21st Century

Recently I caught this article from Wired.com from 2005. With the war in Iraq, US military medical services have had to cope with large number of acute trauma in their soldiers. Morphine was the standard treatment for them but this still left them in acute and severe pain much of the time, hampering their recovery and causing great suffering.

Dr Chester “Trip” Buckenmaier, a pain specialist at the Walter Reed Army Medical Center in Washington, DC, has worked hard to make pain relief for injured soldiers much more effective. Pain specialists often use peripheral nerve blocks where they inject an anaesthetic drug directly around a nerve which has been identified as on the pain pathway, but this was not being used in the US military.

This article in Wired – The Painful Truth – is worth reading even though it’s quite long and spread over 6 pages so you have to click to continue each time. It shows what a determined person can do to change a big, slow organisation for the better.

My Standing Desk

Standing Desks Are Great

standing deskI write quite a lot for my work. This means, as I’m sure you realise, that I spend a heap of time sitting down. This is bad. Not only do I get backache after sitting too long but it’s not good for fitness, circulation and who knows what else.

Varying your working position, pacing yourself to avoid static postures for too long is a really good idea but I’d been lazy about this. I just got up when I became too achy and cramped which is not a good plan.

So I thought I’d look at a standing desk, because a physio should really think of these things. But they are expensive! Cheapest look around £220 / $355 and the most expensive at way over £1000/$1500 if you add bells and whistles for this and that.

Then I had a brainwave! Well, what counts as one for me anyhow. I could use my Ikea chest of drawers in my bedroom as a standing desk. The second drawer was almost the right height for typing, perhaps a little low, so I needed a plan. Here is my standing desk.

5 Ways A War Can Hurt You

The Syrian Civil War and Pain

We hear reports of wars around the world, the engagement with the enemy, the soldiers killed or injured, the civilians killed or injured, and the distance makes them seem like dry numbers. Of course we know they are not but the reality of what’s going on is not obvious if we live in a peaceful country.

And we hear very little about pain. There must be a huge amount, much more than we realise. For every dead person in the Syrian civil war there are a larger number of injured people who survive the conflict and live on. But how do they live on?

So what can hurt someone in a war? Well my list is really quite long, perhaps you might have some more:

  • First the direct military assaults, the bombs, shrapnel and bullets and even chemical weapons. This is what we hear about most clearly.
  • Second there are the causes of death and injury which are directly related to military action such as building collapses, malnutrition and starvation, absent or dangerous water supplies and less obvious things such as dust from damaged buildings.
  • Thirdly a war is a fertile ground for all sorts of indirect accidents such as falls with broken limbs or head injury, cuts on metal fragments or burns from makeshift cooking fires. Gas and electricity supplies, when not cut off, may present risks to the local populations.
  • Fourthly musculoskeletal complaints such as back and neck pain, joint pains and arthritis and overuse pains must be caused or worsened by cramped conditions, the inability to move about and the need to do everything manually because labour saving devices are no longer available.
  • Psychological trauma is very great but I am not addressing this here. This goes on long after the war is forgotten.

 

Casualties of War

So what do bomb fragments, shrapnel and bullets doing to people in the Syrian civil war? As a California mayor said recently, I paraphrase, “It’s not like the movies, most people who get shot die”.

However, many of those who survive have not just had a tissue injury which is now healed. The aftermath can be much nastier. If the bullet broke a bone, damaged some muscle tissue or an internal organ then once recovered the person might be ok.

Joint Arthritis

But there are tissues in the body that are far less forgiving of traumatic insults than these. A bullet which damages a joint changes the architecture of the joint which can then function abnormally. As the stresses of life are put through the joint, it wears at a higher rate and becomes arthritic and a source of lifelong pain.

Neuropathic Pain

But even that is not the baddest of bad news. If you are unlucky enough for a bullet to hit one of the areas rich in nerve junctions then you could have an even worse time. Cutting a major nerve, with its thousands of smaller nerves like a telephone cable, causes paralysis of the muscles supplied by the nerve and loss of feeling in the skin and other areas where that nerve goes. While the paralysis can be a huge loss even this is still not the really bad news.

The central nervous system hates being cut off from part of its domain, so when a nerve is damaged or cut and the input from the nerve alters or stops, it throws a tantrum.

Since all our pain is in our mind (reminder – subject for another post!) the central nervous system is capable of generating pain without any incoming stimulation. And without those incoming signals from the damaged nerve, that’s just what it does.

This is neuropathic pain. The nervous system is normally a conductor of what’s going on, telling us if it’s hot or cold, sharp or blunt, painful or not. However in this case it becomes a generator of pain and causes a type of pain both particularly unpleasant and particularly hard to treat.

The basic numbers of casualties, the dead and injured, must be the bare minimum of the suffering of a local population in a conflict such as the Syrian civil war. Without even giving any thought to the huge and longlasting psychological effects of a war, the incidence and persistence of pain must be a huge problem.

When the Syrian civil war is over and the headlines have moved on to another conflict, all will seem resolved. Underneath however there will still be large numbers of people who suffer intractable pain with little or no help from medical sources.

Pain – Why A Blog About This?

Personally I’m not enthusiastic about pain! Like you I try hard to avoid it. But for me pain is also a fascinating subject when I’m not suffering from much, which fortunately is much of the time.

The Problem with Pain

Great strides have been made in the last 50 years in the understanding and treatment of pain conditions. However it is often poorly recognised and under treated, even in medical units such as hospitals. Outside these units there is very little understanding of how common and how limiting pain conditions are.

In countries without developed medical services the situation is even worse, but it is war zones which may show the greatest number of hidden pain casualties. We hear of how many people have died and been injured, but how they are or how they suffer for the years following the war is not reported.

My aims are to help bring pain further up the agenda of people’s attention and to help individuals who are suffering to change their lives in ways they wish to.

A Bit About Me

I was a physiotherapist working in pain management for over ten years. I was very fortunate to work with a great team which included clinical psychologists, nurses, occupational therapists and consultants. I learned so much about how pain works, the underlying reasons for many conditions, the treatments and management approaches, helping people to change their behaviour and the psychological impact.

I enjoy teaching people who have pain problems what they want to know. They usually want to understand what’s going on and then to form a logical management plan they can stick to with too much difficulty.

Over the years I developed a way of imparting this knowledge and hope to share this with you if you have a similar problem. I’ll be posting on many subjects related to the topic and am developing a series of presentations on explaining pain as a starter.

Let me know if you have any comments or would like me to help you in any way. I’m starting this blog off and hope it will be useful in time but for the moment I’m not clear how it is going to develop. Any suggestions are always welcome.