Seven Pathways For Getting Out of Pain
There are MANY different options for treating common musculoskeletal pains. For example, back pain is often treated with stretching, strengthening, motor control, massage, yoga, etc. Which methods are worth trying?
Of course, you should consult a medical professional for guidance. But chances are, they will prescribe one specific way to treat it, without telling you about other options that have equal support from research.
Some people will find that heavy deadlifts improve their back pain, while others will have the exact opposite experience. The same is true for yoga, chiropractic adjustment, or running. There isn't much way to tell in advance which of these activities will be helpful, so you may need to explore to find out. But you can't try all of the different options, many of which are pure quackery, and/or redundant to others you may have already tried. This post outlines seven rough categories for different ways to get out of pain. They are:
Rest
Strength training
Mobility (e.g. stretching, dynamic joint mobility drills)
Coordination/motor control (e.g. corrective exercise, pilates)
Mind-body/awareness (e.g. meditation, yoga, Feldenkrais)
General health (diet, general exercise, sleep, stress reduction)
Manual therapy (e.g. massage, mobilization, manipulation)
Each of the above methods are worth trying for many varieties of pain, even in the absence of a specific diagnosis. They are like general medicines with broad benefits and few side effects. In some cases you don't need an expert to use them, especially if you know some basic principles of exercise. Here’s a brief description of each pathway, why they might lead somewhere good, and some common pitfalls you may encounter on the way.
1. Rest
If your achilles tendon starts to hurt a few weeks into a new running program, it’s a good bet that excess mechanical stress is the primary cause. Therefore rest is the logical first choice for treatment. Most people figure this out easily, but others neglect the rest strategy, for several reasons.
One is that some people just don’t like to rest. They always err on the side of pushing themselves.
Another reason is failure to notice increased physical activity. It's obvious that 5 miles/week of running is more than none, but moving from 10 to 15 is less conspicuous. Increased physical stress is even harder to notice when it comes from a different activity. Adding in two lower body weight training sessions per week on top of your current running program might require a reduction in mileage.
The hardest additional “load” to notice is emotional stress, which has real physical effects on the body, one of which may be increased pain sensitivity. Thus, your back may easily handle 20 miles of running when you aren't under any emotional stress, but it starts to hurt when you are slammed at work, or not getting enough sleep.
To make sure you give rest a fair chance to help with pain, check the following boxes:
If it hurts don’t do it (at least for a while). Or do less of it.
Avoid overtraining and manage your training load. (This may require some expert-level knowledge if you are a competitive athlete.)
Try to reduce emotional stress.
Optimize your sleep and recovery downtime.
Caveats
More rest is not always better.
If you've rested long enough for healing, it’s probably time to get active. Consult an expert to know the difference.
2. Strength Training
Of the different strategies listed here, strength training is definitely the one that my clients are least likely to try. It’s a low hanging fruit that is rarely picked, and it’s effective for a broad range of musculoskeletal pains.
For example, the best treatment for achilles tendinopathy is relatively simple - load the calf muscles heavily through resistance exercise at an appropriate level of challenge. (1)
For several varieties of knee pain, strengthening the quads is the most evidence-based treatment. Adding in some strength training for the hips may help even more. (2)
For back pain, resistance exercise is one of many different treatments that may be effective. (3)
For neck pain, strengthening the neck muscles works as well or better than other therapies. (4)
For shoulder pain, general strengthening probably works as well as specific motor control exercise designed to correct diagnosed movement “dysfunctions.” (5)
Here’s the bottom line: for many kinds of common pains, you will not find a treatment that works better on average than simply strengthening the muscles around the painful area, in a way that doesn’t aggravate the pain. This simple approach is sometimes called “just load it” and is advocated by many well-respected physical therapists, including Adam Meakins, Erik Meira, and Greg Lehman.
Why does it work? We can’t be sure of the exact mechanisms, but they may involve one or more of the following:
Exercise-induced analgesia through activation of the endogenous endocannabinoid and/or opioid systems;
Physiological changes such as reactivation of stalled tissue healing, improvements in metabolic or vascular tissue health, or reduced inflammation;
Mechanical changes such as increased ability to use good technique, absorb force and/or stabilize joints: and
Psychological changes like placebo effects, increased optimism, and sense of self-efficacy.
For best results, you should consult an expert in resistance training, especially a physical therapist who knows how to train around pain. But the process does not need to be extremely complicated, and you can figure it out yourself if you understand basic principles of resistance training. The simple goal is to increase strength without aggravating pain. One of the best tools is isometric exercise, which means working your muscles without moving, as you would if you pushed as hard as possible against a wall. Just find the joint angle where you get the highest ratio of muscle challenge to discomfort, and continue to work until you are nearing failure.
To make sure the exercise doesn’t aggravate your pain, it is generally recommended to avoid pain levels above moderate discomfort (up to 4 on a scale of one to ten). Also, make sure your pain isn’t worse after the exercise is done or the next day. There is a good chance you will feel better almost immediately, as intense muscle exertion is a good way to create exercise-induced analgesia. Look for this as a good sign.
Even if you manage to strengthen your muscles and not reduce your pain, at least you end up with better function. This is why Adam Meakins says “you can't go wrong getting strong.”
Caveats
There aren’t any magic muscles (e.g. glutes, serratus, scapular retractors or transversus abdominus) that require special focus, and there aren’t “bad” muscles (e.g. hip flexors, pecs or upper traps) that shouldn't be strengthened.
There isn’t any ONE method of resistance training (e.g. kettlebells, barbells, machines) that is far superior to others. Focus on basic principles like progressive overload, and apply whatever method is most appropriate for the circumstance.
A common error is simply not working hard enough. Make sure you are really challenging your ability to produce force - work hard enough that you are exploring your safe limits and are close to failure.
3. Mobility work
Working to increase your comfortable and functional range of motion is a staple of treatment in many different therapeutic traditions. A simple intervention like static stretching may cause immediate feelings of relaxation, reductions in muscle tone, and reduced pain sensitivity. Further, stretching has been found to be useful in the treatment of many different kinds of musculoskeletal pains.
I think mobility work is especially likely to be helpful if: (1) you have an obviously restricted range of motion in joints near an area of pain: (2) you have an unpleasant feeling of stiffness near the area of pain; (3) the feeling of stiffness is in the muscles not the joints; and (4) you don’t currently have some exercise program which requires you to use your full range of motion.
If my clients have more than a few of these conditions, I tell them that I would be very curious to know how their pain would respond to consistent efforts to improve mobility. There are many different ways to do that such as:
Yoga
Pilates
Dance
Sport or training warm up routines
Dynamic joint mobility drills
PNF
Corrective exercise
Pick some method that appeals, make sure you don’t do get too aggressive and aggravate your pain, and see if you feel better. If mobility work isn’t helping, consider this box checked and move on to to something else.
Caveats
More flexibility is not always better.
Make sure you feel the stretch in muscles not joints.
Don’t think the goal is to lengthen tissues, break adhesions, or deform fascia. Stretching probably works to increase ROM through increasing nervous system tolerance, not altering structure.
4. Motor control/coordination
Physical therapy often seeks to correct “dysfunctional” movement patterns. As I've reviewed in other posts, there are some problems with this model. Significant research shows that efforts to change motor control can reduce pain, but often work no better than general exercise, and are effective even when motor control doesn’t change for the better. Further, most of our ideas about which movements are dysfunctional are guesswork, and fail to acknowledge the complexity and inherent variability of human movement. There are many different ways to perform physical tasks, and it's probably better to be able to do them in a wide variety of ways, as opposed to one “perfect” way that is shown in a textbook. That being said, trying to move with textbook form (e.g. while squatting or doing a dumbbell row) is for many people an engaging and interesting challenge, and working to achieve it may improve coordination and reduce pain.
For that reason, I think many different motor control methods are worth trying as a way to treat pain, especially when pain is related to movement. Here’s a short list of examples.
Feldenkrais method
Yoga
Pilates
Corrective exercise
Resistance exercise with good form
Running drills
Primal patterns (e.g. crawling, rolling, climbing, ground flow)
Martial arts
Caveats
Don’t get hung up on the idea that it is dangerous to move in the “wrong” way. Instead, think of these interventions as ways to improve your movement vocabulary.
5. Mind/body
Pain is not just about “issues in the tissues.” It depends on how the nervous system and unconscious parts of the brain perceive what is happening in the body. This is especially true in cases where pain is chronic, correlates with other perceptual disturbances, and seems driven more by psychosocial than structural issues. There are many different mind/body practices that seek to improve perception of the body through mindful awareness and focused attention, and several have been shown to mitigate pain.
If you are interested in mind/body practice, consider one of the following as a way to manage and treat chronic pain.
Meditation
Mindfulness based stress reduction
Yoga
Dance
Feldenkrais Method
Martial arts (especially tai chi and chi gong)
Caveats
Never think that pain is all in your head, that the body doesn’t matter, that pain is your fault, or that you can think pain way with the right mindset.
Mind/body methods are rarely a cure for pain. More often, they are a valuable tool in pain management.
6. Improve General Health
Anything you can do to improve your general health has a chance to help with musculoskeletal pain, especially when the pain is chronic, and comorbid with other chronic complex conditions, such as obesity, depression, anxiety, IBS, or autoimmune disease.
In this event, working to improve general health may be the best way to treat pain. That means working on your diet, optimizing body composition, aerobic exercise, getting outside, spending meaningful time with friends and family, tying to minimize emotional stress and sleeping better.
Caveats
Make sure that your interest in healthy living doesn’t morph into the unhealthy belief that toxins are everywhere, and that avoiding them is a full time job.
7. Manual Therapy
There is evidence showing that manual therapies, such as massage or chiropractic adjustment, can help with musculoskeletal pain. But I will offer the suggestion to try them with a few qualifications.
First, recognize that manual therapy probably works through modulating the nervous system’s sensitivity to pain, rather than “fixing” issues in the tissues such as misaligned vertebrae, fascial adhesions, muscle imbalances, or bad energies.
If you feel better after manual therapy, the physiological mechanisms might not be much different from what causes you to feel good after aerobic exercise, strength training, or yoga. If you can get the benefits of passive therapies with physical activity, which you can do anywhere, anytime, for free, and which have other health benefits, you should probably prefer active to passive. On the other hand, there is no doubt that for some people, skillful and empathetic human touch offers something unique. If you are high responder to what Diane Jacobs calls “human primate social grooming” then get some manual therapy. But don’t fall into the trap of thinking its required to “fix” some problem in your body, in the same way that a mechanic fixes a car. This can be disempowering.
Some concluding thoughts
I call the above strategies “pathways” to highlight the fact that, for many kinds of musculoskeletal pain, there often isn’t any one clear set of directions about what to do. You need to explore to find what works best. In complexity science, problem solving is sometimes analogized to navigating a varied landscape without a map. To get oriented and find your destination, you need to take action, and most of the information you need to solve your problem won’t appear until you get moving. A guide who knows the territory is helpful but you are in some ways on your own. Some of the pathways you pursue will be dead ends, while others will have many different forks and sub-pathways. On each one, there are some unexpected pitfalls, fun places to visit, and occasional treasure. To keep going, you need curiosity, motivation and courage. Some pathways are worth going down just for the journey and not the destination. Best of luck.
For more information, check out my book Playing With Movement: How to Explore the Many Dimensions of Health and Performance.
References
1. Malliaras P, Barton CJ, Reeves ND, Langberg H. Achilles and patellar tendinopathy loading programmes : a systematic review comparing clinical outcomes and identifying potential mechanisms for effectiveness. Sports Med. 2013;43(4):267-286. doi:10.1007/s40279-013-0019-z; Key factors to consider in Achilles tendinopathy rehab (Malliaris 2016). For information on resistance training for tendons generally, see: Cook et al. (2016). Revisiting the Continuum Model of Tendon Pathology: What Is Its Merit In Clinical Practice And Research? British Journal of Sports Medicine. 50(19), 1187–1191; Rio et al. (2014). The Pain of Tendinopathy: Physiological or Pathophysiological? Sports Medicine. 44(1), 9–23; Rio et al. (2016). Tendon Neuroplastic Training: Changing the Way We Think About Tendon Rehabilitation: A Narrative Review. British Journal of Sports Medicine. 50(4), 209–215.
2. Willy et al. (2016). Current Concepts in Biomechanical Interventions for Patellofemoral Pain. International Journal of Sports Physical Therapy. 11(6), 877; Rabelo et al. (2018). Do Hip Muscle Weakness and Dynamic Knee Valgus Matter for The Clinical Evaluation and Decision-Making Process In Patients With Patellofemoral Pain? Brazilian Journal of Physical Therapy. 22(2), 105–109.
3. Prevention and Treatment of Low Back Pain: Evidence, Challenges, and Promising Directions. The Lancet, 391 (10137), 2368–2383.
4. Gross et al. (2015) Exercises for mechanical neck disorders. Cochrane Database of Systematic Reviews 2015, Issue 1. Art. No.: CD004250.
5. See, e.g. Timmons et al. (2012). Scapular Kinematics and Subacromial-Impingement Syndrome: A Meta-Analysis. Journal of Sport Rehabilitation. 21(4), 354–70; Struyf et al. (2013). Scapular-Focused Treatment in Patients with Shoulder Impingement Syndrome: A Randomized Clinical Trial. Clinical Rheumatology. 32(1), 73–85; Camargo et al. (2015). Effects of Stretching and Strengthening Exercises, With and Without Manual Therapy, on Scapular Kinematics, Function, and Pain in Individuals with Shoulder Impingement: A Randomized Controlled Trial. The Journal of Orthopaedic and Sports Physical Therapy. 45(12), 984–97; McClure et al. (2004). Shoulder Function and 3-Dimensional Kinematics in People with Shoulder Impingement Syndrome before and after a 6-Week Exercise Program. Physical Therapy. 84(9), 832–48; McQuade et al. (2016). Critical and Theoretical Perspective on Scapular Stabilization: What Does It Really Mean, and Are We on the Right Track? Physical Therapy. 96(8), 1162–69.