The International Association for the Study of Pain defines pain this way, “An unpleasant sensory and emotional experience associated with, or resembling that associated with, actual or potential tissue damage.”
Two components of this definition stand out —the acknowledgment that pain is an “emotional experience” and that pain can be experienced due to “actual or potential tissue damage”.
As a movement practitioner and physiotherapist, I’ve been drawn in the last few years to the field of pain science education, pain neuroscience education, or “explain pain”, as a tool to support my clients who suffer from persistent (chronic) pain. As I jumped into the research about pain, pain science education, and persistent pain, I found myself struggling with how to reconcile the new data with my years of training, which heavily emphasized biomechanics, pathology, posture, alignment, and correction of dysfunctional movement patterns.
Is there still a role for biomechanics, I wondered?
Pain is a normal experience and is necessary for survival. Without pain, we would not take action to remove a potential threat, such as managing a broken bone, or taking out a nail in the foot. Persistent, or chronic, pain is not considered to be typical, although it is becoming more common, affecting over 20% of the US population and adding a high financial and emotional cost to the individual, their family, friends, associates, and to society.
Our understanding of pain science is still limited, but significant research breakthroughs over the last 2-3 decades are clear on one thing—the biomechanical model that has guided treatment for many years does not explain pain in all its complexity, and is inadequate for resolving or treating pain. This outdated biomechanical model has been updated and replaced by the biopsychosocial model, first introduced by George Engel in 1977.
Psycho=thoughts, emotions, beliefs, behaviors, for example.
Social=economic, environmental, culture, family, etc.
In the Biopsychosocial model, everything matters. While the tissues play a role in creating the sensation of pain, many other factors influence the experience of pain, such as thoughts, emotions, beliefs, nutrition, culture, socio-economic reality, overall lifestyle, and much more. One way of thinking about the complexity of studying, treating, and explaining pain would be to attempt to answer questions such as, “What’s it like to be human?”, or “What is consciousness?”
What does the emerging field of pain science mean for movement practitioners? We’re certainly not psychologists, nutritionists, philosophers, or social workers. How can we incorporate the biopsychosocial model into our Pilates and movement environment if we don’t fully understand it?
Here are a few ways you can show up for your clients:
- We are partners, not teachers. This is their experience of pain, not yours. Listen and hold a space of compassion and hope as they educate you about their experience, what the pain is like for them, how it impacts their life, and what outcome they are seeking. From this space you can explore and experiment with your client, discovering a way forward together through movement. Walk the journey with them, side by side.
- We don’t have to have the answers. We don’t have to know exactly what to “do” for our clients. Let go of the expectation that you’re supposed to know how to fix them. Through movement, you can support them to improve how they live their lives, even if their pain doesn’t go away. They can develop more self-reliance, have hope that there is a path forward, and shift their experience of movement to one of confidence rather than fear.
- Movement isn’t right or wrong. As Pilates teachers and physiotherapists, many of us were taught about “faulty movement patterns”, “postural dysfunction”, “poor alignment”, and “imbalances”. There is no significant evidence to indicate that ideal posture, beautiful movement patterns, or perfect balance and alignment will result in “no pain”, and we need to let go of the idea that the way the client looks on the outside is either “right” or “wrong”. Engage them in a dialogue rather than telling them what to do—after all, it’s their experience, and aesthetics matter very little if they’re in pain. Support them to focus on what’s going well. What feels good? What creates a sense of ease? What movements, directions, and positions create a sense of well-being? How do you facilitate healthy movement rather than focusing on what’s wrong and trying to “correct” it? By pre-cueing muscle engagement, tightening and tension in clients with persistent pain, we inadvertently increase their fear response and create more movement guarding and protection. We are teaching them that movement is not safe, and they are vulnerable. In our efforts to “stabilize”, “stay safe” and “protect the back” we are increasing the likelihood that our persistent pain clients become more afraid of movement. Their protective habits increase, they move less, and the pain cycle continues.
- All pain is 100% real. Believe your clients. Listen to them. Pain is a whole body, whole mind, unified human experience, and it is not imagined, or “all in the head”. Like much of life, pain is a subjective experience and is a highly complex process. Examining your own beliefs and knowing your specific biases about pain is key because your beliefs about pain have been shown to strongly influence outcomes. What messages are you unconsciously communicating to the client about the meaning of their pain? Are you unintentionally communicating “danger messages” to the client and creating increased fear and anxiety?
Bear in mind, “Pain is modulated by any evidence that implies danger,” ~ Professor Lorimer Moseley.
- Examples of Supportive Language and Cues. Professor Lorimer Moseley, clinical pain scientist and co-author of Explain Pain, Explain Pain Supercharged and other publications, has some useful cues we can adopt to support our clients. Here are a few of them.
– Some pain during activity is acceptable, but it should stay under the point of a “flare-up.
– You just have to do it slowly enough that it doesn’t freak out your system…. We say always do more today than you did yesterday, but not much more.
– Only two things that should be really rested: major trauma or broken bones. Everything else should be worked.
– When exercising, remind yourself that hurt does not equal harm. And that it’s safe to be sore.
– We no longer think of pain as a measure of tissue damage – it doesn’t work that way even in highly controlled experiments. We now think of pain as a complex and highly sophisticated protective mechanism.
- Learn How to Create a Space for Possibility. For those of us working with persistent pain clients, our own “internal fitness” is essential. What are you doing to train your capacity to maintain compassion, acceptance, and hope while working with your persistent pain clients? Training ourselves to hold space as we take this sacred journey with our clients is just as critical as our knowledge of Pilates, PT, fitness, and exercise. My preferred personal and professional development training system to support me as I continue to grow as a practitioner is Inner Matrix Systems.
I love hearing about your challenges, experiences, and transformative journeys with your clients. If you’d like to ask questions or want to share, let’s connect!