Understanding Chronic Pain: What You Can Do About It, and How Structural Integration Can Help
Approximately 3000 words (16-18 minutes reading time).
Understanding Chronic Pain: 3 Key Points
What You Can Do About Your Pain
How Structural Integration Can Help
You may be hoping that better posture will help reduce your pain, and are considering Structural Integration (SI) as a way to help with this. SI isn't intended as a treatment for pain - it's more accurately described as an approach to mind-body (somatic) education - but many have found pain relief through SI, myself included.
In considering SI as a treatment for pain, it's important to understand: any relief you may experience is not because of improved alignment, per se. Decreased stress on the joints can play a significant role in pain reduction, but it also has much to do with the feelings of ease, stability, and heightened sense of body awareness that SI clients often report.
This is an important distinction! There are 168 hours in a week, and you might spend one of them on a therapist's table. While that hour can mean a lot, what you're doing in those other 167 hours has far more to do with how you ended up where you are. I want to empower you with information, skills, and awareness that will help you maintain any changes you may experience through our work together, and help you take better care of yourself during those hours when you aren't on my table.
In my practice, I approach your pain with the understanding that pain is complex, and aim to address as many factors as possible to help you feel better in the short and long-term. It all starts with understanding current ideas about what pain is, and how it works.
Part I - Understanding chronic pain: 3 key points
1. Pain is not an indication that your body is damaged.
This may seem counterintuitive, but it is perhaps the most important point to realize. Science has clearly established that, while external factors may contribute, pain is ultimately a conscious experience generated by the brain - not a damaged condition of the body.
Example: A few summers ago, I was in the forest near Mount Hood one afternoon for a camping trip. While setting up my tent, a pole that was under great tension suddenly snapped out of place, striking the middle of my thumbnail with extreme force. I immediately withdrew my hand, letting loose a cathartic stream of profanity. The pain was throbbing and intense. I was certain that my thumbnail had been damaged, and would probably turn black-and-blue before falling off. I protected my thumb from further damage or irritation by wrapping it with a bright red bandana, taped securely. Later that evening, the pain had diminished, so I decided to remove the bandana to assess the damage. While undoing the tape, I cringed with anticipation. Lo and behold, there was no damage to my thumbnail, and hardly any bruising at all... just a tiny, slightly blue dot right in the middle. I shook out my hand, then pressed on my thumb with my other hand - the only time I experienced any pain at all was when I pressed directly on the tiny blue dot with some force. All that, and nothing! I didn't bother to wrap it again.
This story is just one illustration of how the amount of pain you experience is not necessarily proportionate to the degree of injury. In fact, it is possible for you to experience extreme pain, without having any tissue damage at all.
2. Pain motivates you to protect your body from perceived threat.
Pain makes more sense when we consider it as a sort of alarm system for the body. When your brain perceives threat, the alarm goes off, creating a pain experience that motivates protective behaviors. Such behaviors might include shifting your weight off of a painful leg (limping), holding a painful shoulder close to your body (bracing), or avoiding exacerbating activities altogether.
Example: Returning to the story above, when the tent pole snapped into the center of my thumbnail, the protective behaviors motivated by the pain included the immediate withdrawal of my hand upon being struck, wrapping it with a bandana to protect it from further damage or irritation, and avoiding use of that thumb for the rest of the day.
3. Pain is an output of the brain - not an input to the brain from the body.
Your brain is constantly gathering information from your body, interpreting it, and then sending "outputs" (nerve signals, hormonal responses, etc.) to your body to accomplish goals. As we've already discussed, pain is one such output that accomplishes the goal of protection from perceived threat.
What are some of the sensory "inputs" that contribute to pain?
Excess pressure, temperature, and chemical signals
"Nociception" is a form of sensory signaling that indicates danger to the tissues of your body. The nerve receptors responsible for this, called "nociceptors," monitor excesses in temperature, pressure, and chemical signals (like inflammation). The nociceptors then send that information to your brain, which decides whether or not the perceived threat is valid. Nociception is usually the most important input in determining pain, but it is not the only one, as you will see below.
How you perceive your body in space
"Proprioception" describes how you perceive the various parts of your body in relation to each other. Your brain recognizes certain body positions as being more dangerous, and others as being more safe. For example, if you previously hurt your back while in a certain position, then it is more likely that your brain will later interpret that same position as threatening and generate pain, even in the absence of any tissue injury.
What you see and hear
The things you see and hear also offer a source of information about possible threat to your body, which can influence pain. If you watch an injury as it happens to you, you will probably cringe and brace, making it all the more painful. Conversely, I often point out scrapes and bruises on my clients' bodies that they had no idea were there, or how they got there.
Your thoughts and expectations
If you expect a given stimulus to cause pain, then it's more likely that it will. This is how well-meaning practitioners, by giving inaccurate information that a certain posture or imaging result is the cause of your pain, can actually increase your pain experience - a phenomenon known as "nocebo" (the opposite of placebo).
Depression, anxiety, hopelessness, fear, and lack of control are all associated with chronic pain. Lack of sleep, lack of movement, difficult relationships, job stress, and other factors can contribute to your emotional state, making you more irritable, increasing the likelihood of your brain perceiving threat and generating a pain experience.
With sufficient social and financial support, you are more likely to feel safe, and are therefore more resilient to physical injury. A compassionate parent, spouse, friend, or therapist can help relieve pain in a very real way, by their presence and support increasing your sense of security. Financial resources, or a lack thereof, can similarly influence your sense of security, perception of threat, and therefore your pain experience.
Example: Revisiting the tent pole story, it becomes clear that several of these inputs contributed in that situation, some more than others. The input of the tent pole whipping into the center of my thumbnail was overwhelming (nociception), and it certainly didn't help that I watched and heard the "thwack!" as it happened (visual and auditory input). I visualized my thumbnail turning black-and-blue and eventually falling off (thoughts and expectations). The drive to the campsite had been stressful and I was lacking sleep, both of which made me more irritable, sensitizing my nervous system (emotions). All of these inputs likely contributed to my initial experience of intense pain.
Later on, the inputs shifted from perceived threat, to safety. With my thumb protected by the bandana taped securely in place (decreased nociception, visual input, emotions, expectations), I eventually settled in to the campsite and turned my attention to enjoying the company of friends (social context, emotions), eventually forgetting about my throbbing thumb completely. Upon realizing that I had forgotten about my thumb, I felt safe enough to unwrap my thumb and assess the damage only to find very little, almost no damage at all (visual input, expectations). At that point the pain almost completely disappeared, except for when I pressed directly on the tiny bruise (nociception).
As this example illustrates, while nociception is a major factor contributing to pain, it is certainly not the only factor. It is possible to have pain without tissue damage, or tissue damage without pain. While it is important to listen to your body when you feel pain and respect the feedback it's giving you, it's also important not to jump to conclusions about what that pain means, which might exacerbate your pain experience.
This does not mean that pain is "all in your head!"
Let's be clear: none of this means that pain is not real, or that it's "all in your head."
Pain is real. It's a real feeling, but that feeling does not necessarily indicate that your body has been damaged.
It's also important to understand that, even though pain depends on your brain for its existence, most of the processes that contribute to it are beyond your conscious control. Your pain is not your fault, and you cannot simply think it away. Your thoughts can influence your pain experience, but they play a relatively small part compared to other factors.
Part II - So, what can you do about your pain?
Below are some common ways you can find relief from pain. Please understand that these methods are no substitute for the attention of a qualified medical professional. Make sure to seek medical help for the treatment of any pain.
The most obvious way to reduce pain is to eliminate sources of nociception (biomechanical strain, muscular tension, nerve compression, "trigger points," etc.) near the troubled area. This is what we're doing when we shift our weight to one leg to avoid putting weight on a painful leg. It is also the aim of many manual therapy approaches and surgeries.
Unfortunately, 1) this is too often the only strategy employed in pain relief efforts, 2) it is too often assumed that just because a given treatment was effective, that is was due solely to reduced nociception, and 3) it is extremely difficult to determine the exact source of nociception - given the complexity of factors contributing to pain, it is often wise not to jump to conclusions about specific causes.
While finding and reducing sources of nociception is an important part of pain treatment that often requires individualized assessment and treatment from a skilled professional, the strategies described below can also help significantly, and are relatively easy to apply.
Avoid painful movements
This isn't about protecting your tissues from normal load - tissue is much more resilient than we often think. Rather, avoiding painful movements is a temporary strategy to help desensitize your nervous system, allowing it to calm down before you start gradually reintroducing threatening movements (see next strategy).
While it can be tempting to bite your lip and power through painful movements, especially if the pain is relatively mild, this can actually be a bad idea. When you do this, the sustained nociceptive input can sensitize your nervous system so that the pain effectively becomes a habit. Even if those movements aren't causing more tissue damage, they can make the pain more intense and longer-lasting, creating a vicious cycle. Avoiding painful movements for some time can serve to "starve" the pain, breaking this cycle. However, over time, this strategy can have negative effects of excessive fear of movement, sustained functional impairment, or deconditioning.
Gradually re-introduce threatening movements
If a threatening movement or stimulus is re-introduced slowly, carefully, and with appropriate timing, allowing you to successfully and painlessly perform a movement that used to hurt, your nervous system will tend to find that movement less threatening in the future. This method is known as "graded exposure," and can require some creativity that is best guided by a skilled professional. However, any form of vigorous movement that does not cause pain can also be a form of graded exposure, as it feeds your brain good news that your body is healthy and resilient. As such, general exercise can often help keep chronic pain at bay.
Understand the basic physiology of pain
Misunderstandings about pain are rampant. These include "my back is out," "I'm just getting old," "it's because of this thing I saw on an x-ray/MRI," and "there is nothing I can do about it, I better get used to it." Popular myths such as these can increase feelings of threat unnecessarily, causing you to avoid movement and exercise that might actually help your pain. Research has demonstrated that proper pain education can help improve chronic pain, freeing you from the fear and anxiety perpetuated by these myths.
Become more aware of your body
Your brain maintains an image of your body, sometimes referred to as a "body map," that it uses to guide sensorimotor functions, like movement and posture. As with any map, more clarity, accuracy, and detail yields better function. A more refined body map may also help reduce chronic pain. It's possible that an unclear, inaccurate body map may result in your brain creating pain somewhere it doesn't belong, mistaking normal sensory input for nociception, or just feeling threatened because it doesn't know where your body is or how to move it well.
Put your attention elsewhere
The processing and perception of sensory information can be "drowned out" by competing sensory information, a phenomenon known as "sensory gating." Pain relief through sensory gating may be more effective when the competing stimulus is closer to the painful area, is more interesting/novel, and comes from active movement (rather than passive movement or touching). This is probably a large part of why massage is often effective for pain relief. While these effects tend to be temporary, they may open a window of opportunity to re-introduce movements that were previously threatening, to more lasting benefit.
Beat the heck out of it
Also known as "counterirritation," this occurs when the competing stimulus is also a painful one. This is probably what is happening when "deep tissue" massage, instrument-assisted soft tissue modalities such as Graston, and foam rolling are performed aggressively, yet ultimately result in pain relief.
The risk of this strategy is that it can sometimes make your pain worse, or even result in injury. If you want to go this route, a good guideline to use is whether or not the pain you experience feels enjoyable. If you're cringing or bracing, your nervous system is interpreting the stimulus as threat - try backing off a bit and reintroducing the stimulus more slowly.
Improve your emotional state
Feelings of stress, anxiety, depression, pessimism, and powerlessness can all make your pain worse. Anything you can do that improves your emotional state, like fulfilling hobbies or quality time with loved ones, may help reduce your pain. Improving your general health (see below) can help improve your emotional state, thereby reducing pain.
Improve your general health
Anything that improves your general health can also help with pain. These include all the things we know we "should" be doing: good nutrition, sleep, exercise, stress reduction, healthy relationships, and engaging in meaningful activities all help put you in the best possible position for healing.
In particular, sleep and stress reduction are two areas where we can make more immediate changes that can have a significant impact. It might be worth talking to a qualified professional for guidance, and a health coach for help sticking with your plan until it becomes part of your lifestyle.
Part III - How can Structural Integration help?
Since I practice Structural Integration, and you're reading my blog, I assume that you are already at least somewhat familiar with the work I do. If not, you can learn more about SI here.
While there hasn't been much clinical research on SI, I assume based on my own experience as a client, as a practitioner, and the experience of many others over time, that one of its primary benefits is long-term pain reduction. I also assume that the changes in movement/posture commonly experienced through the SI process are primarily a result of improvements in spatial orientation and sensorimotor coordination. With these assumptions in mind, it seems to me like SI can help to reduce pain by several of the means described above:
Reduced physical stress
This one is obvious. As you learn to move and carry yourself with more ease, you place less stress on your joints, reducing nociceptive input. That means less stimulus for your brain to potentially interpret as threat.
Improved body awareness
I sometimes describe the initial series of SI sessions as a sort of guided tour of your body; how its parts relate to each other, how you relate to the whole, and how you relate with your spatial environment. Being more body-aware can help you feel more stable, comfortable, and safe, which can reduce pain.
Novel stimulation with active movement
The manual therapy techniques I apply offer novel stimulation which distracts your nervous system, providing relief from pain (sensory gating, described above). I will often have you perform active movements while I apply the techniques, further helping with this process.
Gradual re-introduction of threatening movements
During the window of opportunity that is opened while the nervous system is distracted, I'll often have clients stand up off the table to feel their bodies, move, and walk around. I encourage them to do this slowly, with mindfulness. This allows for the reintroduction of once-threatening movement in a new context of safety.
Feelings of optimism and support
Clients often begin to feel hopeful through our work together, and supported through our therapeutic relationship. Emotional factors such as these can help reduce pain.
Spending less energy on effortful, inefficient movement/posture may free up more energy overall, contributing toward general health and improved emotional state, which can mean less pain.
While working together, I try to illuminate these points whenever relevant, and offer resources such as this article to help provide you with empowering information.
Part IV - Learn more
This is post is intended only as an introduction to understanding pain. If you want to dive deeper, I suggest the following resources:
I highly recommend Todd Hargrove's "A Guide to Better Movement," which this post is largely based on. Todd is a fellow structural integrator who eloquently offers science-based information and practical suggestions.
While you're waiting for Todd's book to arrive, check out this article that delves a bit deeper into specific research studies, "Pain is Weird" by Paul Ingraham of PainScience.com. There are many other gems to be found on his site as well.
For something more simple and fun, the Retrain Pain Foundation offers 1-minute lessons and other helpful resources.
Daniel Akins has been a Board Certified Structural Integrator since 2013, and a massage therapist since 1999. He lives and practices in Portland, Oregon.