Excerpt from Chapter 1, The Gift of Pain, Pain & Performance: The Revolutionary New Way to Use Training As Treatment for Pain and Injury
A few years ago, a leading over-the-counter pain medicine ran an advertising campaign targeting athletes and exercisers. In a series of 30-second television spots, everyday men and women were shown grimacing through group fitness classes as the voice-over intoned the brand’s market-tested tagline: “When pain says you can’t, Advil says you can.”
Millions of athletes and fitness enthusiasts saw these ads and thought nothing of them. But for me, a trainer dedicated to helping athletes self-manage pain, the new slogan encapsulated what’s wrong with how pain is taught and treated today. And what’s wrong with it is, well, everything.
Pain Is Normal
For starters, contrary to what you’ve always been told, pain is normal. It has existed for as long as organisms with nervous systems have existed and is an inescapable part of being alive. Only in modern times, when everything that can possibly be medicalized has been medicalized, has pain come to be regarded as pathological—something you need a pill for.
Yes, pain is unpleasant, but unpleasant is not synonymous with bad. In feeling bad, pain serves the crucial purpose of signaling threats (like when a painfully loud noise warns you of potential harm to your eardrums) and motivates self-protective actions (like covering your ears to block out that loud noise). It’s natural to avoid pain, but you sure as heck wouldn’t want to take a pill that made you incapable of feeling it. People who suffer from congenital insensitivity to pain can’t feel it, and they often die prematurely because they’re unable to take self-protective measures when threats to their well-being arise.
For athletes, pain serves the additional purpose of marking physical limits. Similar to fatigue, pain lets an athlete know when they are approaching the edge of their body’s current capacity. Developing as an athlete requires a delicate balance between respecting and challenging limits, and pain is an essential tool in maintaining this balance. I tell athletes to think of pain as their employee, not their employer. If you employ pain appropriately, you will find more success and greater fulfillment as an athlete than you would if you let it boss you around. In my gym, pain doesn’t say, “You can’t”—it says, “Proceed with caution,” or, “Let’s try something slightly different.”
Pain Is Not Synonymous with Injury
Most athletes associate pain with tissue damage. That’s because they’ve been taught to do so by doctors, physical therapists, and other clinicians educated in the so-called structural model of pain, where pain is thought to be directly caused by underlying tissue damage, which is in turn caused by incorrect movement patterns, which are in turn caused by imbalances in the musculoskeletal system. In reality, the link between pain and injury is a lot looser than we’ve been led to believe. People often experience pain in a part of the body that has no significant underlying tissue damage, and just as often, we experience little or no pain in parts that do have significant damage. That’s why the International Association for the Study of Pain now defines pain as an “unpleasant sensory and emotional experience associated with, or resembling that associated with, actual or potential tissue damage.” Yet the medical establishment continues to conflate pain and injury, a stubborn error that results in overdiagnosis, overtreatment, and iatrogenic pain, or pain caused by unnecessary medical intervention.
To be clear, tissue damage frequently does contribute to pain experiences, but it is never the singular cause of pain. In 1977, physician and psychiatrist George Engel introduced a new biopsychosocial model of pain in which pain was understood to be fluid, personal, and multidimensional and influenced by biology, psychology, and the social context. Initially dismissed by the medical establishment, this model has gained traction in recent years, although the structural model remains dominant.
One example of a psychological factor that affects pain experience is expectancy. Simply put, people tend to feel pain when they expect pain. This has been shown in a variety of studies, including one by Norwegian researchers involving subjects who believed (as many people do) that the radio waves emitted by cell phones gave them headaches. Sure enough, when these individuals were exposed to radio waves in a laboratory setting, a majority reported experiencing headaches. However, they reported the same symptoms when they were merely told they were being exposed to radio waves and in fact were not!
Unfortunately for athletes and exercisers, today’s standard process for treating workout-related pain remains based on outdated ideas about pain that originated with René Descartes in the 17th century rather than on the biopsychosocial model. Among the many problems with the current treatment process is that it creates poor expectancies. Consider the typical sequence of events that unfolds when an athlete experiences pain that’s significant and persistent enough to interfere with training.
First, the athlete is likely to assume that the pain is being caused by an injury because, again, athletes have been conditioned to do just that. As I’ve suggested, though, pain often occurs in the absence of an underlying injury, and to assume that something must be wrong whenever pain reaches a certain level of intensity and persistence can lead to negative consequences. Evidence of these consequences comes from research involving Aboriginal cultures where the medicalization of pain is less prevalent. A study conducted by Israeli researchers and published in the journal Spine in 1996, for example, found that nearly half the adults in a semitraditional Australian Aboriginal community experienced chronic low-back pain, yet none of them thought of it as a “condition” or as something to complain about it. Instead, they simply lived with it, treating their low-back pain as a normal part of life, like going to the bathroom, and functioning quite well despite it in most cases.
When a different team of researchers did a follow-up study in the same community nearly 20 years later, they found that things had changed—and not for the better. By that time, Western medicine had achieved far greater penetration into the culture, and a majority of those with chronic low-back pain, having received diagnoses and treatment from medical professionals, now explained their pain in the same language of “structural/anatomical vulnerability” that their doctors used. What’s more, the individuals in whom these beliefs about pain were most ingrained showed the highest level of dysfunction.
Pain Does Not Require a Diagnosis
The next step in the standard medicalized regime for treating athletic pain is naturally to seek help from a medical professional—either a general practitioner, an orthopedist, a sports medicine specialist, a physical therapist, or a chiropractor, all of whom receive little or no pain science education in their training. The decision to take this step assumes that the athlete is not capable of dealing with the pain on their own, which is a perfectly fair assumption to make when it is already assumed that strong and persistent pain is always an indicator of underlying injury. After all, few athletes own an X-ray machine or an MRI scanner or any of the other fancy technologies that are used to diagnose sports injuries, and just as few possess the credentials or authority to prescribe or administer common treatments, including medication and physical therapy.
The problem with all of this is that it places the athlete in a position of dependency when dealing with pain. It is a proven fact that people in pain feel better and regain function more quickly when they possess a high level of pain self-efficacy, which is defined as a belief in one’s ability to cope effectively with pain. The medicalization of pain systematically (albeit unintentionally) robs individuals of pain self-efficacy and thereby worsens outcomes. A study led by Kim Bennell of the University of Melbourne and published in Arthritis Care & Research in 2015 compared the effects of two different treatment regimens on men and women suffering from knee osteoarthritis. One treatment consisted of a 10-session exercise program, while the second coupled the same exercise program with training in pain-coping skills. Bennell’s team saw significantly greater functional improvement in subjects who’d learned pain-coping skills, and one year later, they were still doing better than those who hadn’t. The sad irony is that this training in pain-coping skills really did nothing more than counteract the negative impact on pain self-efficacy that is wrought by our current system of treating pain, which seldom includes such training.
So the athlete sees a doctor or physical therapist with little or no education in pain science who endeavors to diagnose the injury and identify its cause. Although the athlete may not be consciously aware of it, a variety of elements of this experience will influence how quickly their pain resolves and they are able to return to full training. Certain contextual factors are known to improve pain outcomes by positively influencing expectations, while others have the opposite effect. If the doctor actively involves the athlete in understanding their pain and in making treatment decisions, for example, the athlete is more likely to be satisfied with the results. Again, however, this is not the norm. In the typical clinical appointment, the athlete takes a very passive role that further diminishes self-efficacy.
The specific language clinicians employ is another important contextual factor. Have you ever been evaluated by a clinician who used the words imbalanced, weak, or tight to describe parts of your body? Not only are such words usually inaccurate when presented as causes of an athletic injury, but they also stoke a sense of fragility in athletes that is not helpful to long-term prospects for successful pain management.
Pain Does Not Require Treatment
The final step in the standard regime for treating athletic pain is, of course, treatment. There’s an old joke that encapsulates what happens all too often at this stage: Doctor: What seems to be the problem? Patient: It hurts when I raise my arm. Doctor: Then don’t raise your arm. It’s not a terribly funny joke, and it’s even worse advice, yet it’s pretty darn close to the advice someone would get from a clinician if they went in complaining of pain around specific movements.
Most athletes are familiar with RICE, a mnemonic that encodes basic guidelines for self-treating musculoskeletal pain. Any guesses on what the first letter stands for? That’s right: rest. If it hurts when you run, don’t run. If it hurts when you lift weights, don’t lift weights. You get the idea.
Now, to be fair to the doctors, it seems like common sense to not do something that hurts. But it turns out that rest is generally not an effective response to musculoskeletal pain, at least not if you intend to use the painful part of your body athletically again. The other letters of the acronym aren’t much better. The I, for example, stands for ice, and even Gabe Mirkin, the physician who came up with RICE, later admitted that although icing does tend to reduce inflammation, it can also slow the healing process. As for C, compression, a 2005 review conducted by Anita Pollard and Gerard Cronin concluded that “little evidence is available to support this kind of treatment.” And nine years later, Dutch researchers made a similar judgment on E, elevation, reporting that “no evidence based on studies with high levels of evidence is available for the effectiveness of elevation.”
The same goes for most other treatments commonly prescribed for athletic pain, including NSAIDs such as ibuprofen. There is no scientific evidence that these medications accelerate the return to full training in athletes whose ability to work out is currently limited by pain, and there’s plenty of reason to believe that overreliance on such drugs may delay the return to full training. NSAIDs, in particular, impair soft tissue healing and blunt certain beneficial muscle adaptations to exercise.
Okay, if none of the classic pain treatments actually work (and you can toss in fancier treatments, including cupping, lasers, ultrasounds, and dry needling), what does work to manage pain, stimulate adaptive tissue remodeling (i.e., healing), and counteract pain’s limiting effects on training? Only one treatment can be considered truly essential based on scientific and real-world evidence, and it’s pretty much the opposite of what common sense and medical tradition suggest: exercise.
That’s right. As strange as it may sound, the closest thing to a panacea for pain associated with movement is movement. Support for this idea comes from an ever-expanding body of research, including a study that was published in the New England Journal of Medicine in 2017. Scientists at the University of Copenhagen recruited 50 amateur athletes who were recovering from severe muscle strains and separated them into two groups. Both groups went through a rehabilitation program involving gradually intensifying the use of the injured muscle, but while one group started the program just two days after being injured, the other rested for nine days and then started exercising. All the athletes were tracked until they returned to full participation in their sport. This took an average of 83 days for members of the “rest” group compared to just 62 days for the “exercise” group—a 25 percent difference.
Movement helps athletes who are experiencing pain in a number of ways. On a physiological level, exercise improves function in more or less the same manner it improves fitness, pushing back the limits on what and how much the affected part of the body can do without an unacceptable level of discomfort. At the same time, movement operates on other levels, mitigating pain expectation (hence pain itself), enhancing pain self-efficacy, and more. Add it all up and you’re left with one conclusion: The most comprehensive treatment for pain associated with athletic training is training.
If this sounds like a radical concept, well, it is—at least from the perspective of the standard, medicalized process of dealing with athletic pain. As far as most doctors are concerned, training ceases the moment an “injury” (signaled by pain) occurs. But the athletes I work with are always training, whether healthy or hurt. Only the mode of training changes when a problem occurs. An athlete who is able to train the way they want to and is not limited by pain is in training-for- performance mode. If something goes wrong and pain begins to limit an athlete’s training to some degree, the athlete switches to what I call Training as Treatment mode. But they’re still training.
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