What should I do when a certain movement triggers my pain?
When a movement hurts, we avoid it. That’s totally normal and is part of the protective element of pain. You sprain your ankle, your body makes it hurt to stop you from walking on it, potentially injuring it further.
It is natural to think that continuing to rest and avoid these movements and painful situations can help the body to heal when in fact it’s quite the opposite. Avoiding certain movements whilst may help in the short term, in the long term only serves to makes your body more sensitive to that movement, it becomes more painful to that movement and we then avoid it more. It becomes a vicious cycle.
This is common in low back pain, especially with a flexion (bending forwards) movement. Often this can be a trigger for pain, so it’s avoided. When this is compounded with a long history of “bending being bad for your back” it’s avoided even more. We then end up in a situation where patients have been avoiding bending or flexing for 30 years… So much so that not only the movement can trigger pain, the brain can even be conditioned to create pain based on our thoughts, fears and beliefs.
If you want to be really bad at something, the best way would be to never do it. Imagine never bending your elbow, ever… Then being forced to bend it to lift a shopping bag, you can imagine it wouldn’t be very comfortable. Spines are the same, in these patients who never bend, it’s understandable that bending will be sore or painful.
Breaking this cycle is important, as long term fear-avoidance is associated with decreased quality of life, social anxiety, depression and persistent pain.
So how can we do this? Graded exposure therapy is one way aiming to reduce this fear avoidance behaviour.
This involves gradually and repeatedly exposing the body and brain to painful stimuli, aiming to retrain the brain and sever the link between certain movements and pain, and there are many different approaches to do this.
The first step, and an important one, is educating your patient about pain science. Making sure they understand what pain is, and the fact that pain is linked to a threat, not tissue damage.
Then identifying patients fears and beliefs, what are they afraid is going to happen if they do the trigger task? What’s happened in the past? What happens now?
Then gradually introduce the trigger movement, which can take many forms. If we take the fear of flexion for example. Getting the patient to flex the spine in different positions can be helpful. For example, a supine (laying on your back) double knees to chest, seated slumps or child’s pose are all movements that flex the lumbar spine but often don’t trigger pain or trigger less pain than a forward bend. This can often be due to patient beliefs, ie “they aren’t bending over” and bending = bad.
I like to highlight this to patients, make them realise that isn’t flexion that is the daemon, it’s often their fear of it that’s worse. This gives the brain a chance to adapt and become desensitised to these painful or threatening movements. Exercises are then incorporated into a home rehab programme, with patients continuing these repeated movements at home, little and often, ultimately decreasing the threat of these movements over time.
This can be gradually built up, moving to wall roll downs, seated deadlifts, kettlebell swings and ultimately more challenging movements like Jefferson curls if appropriate.
This can be done in many forms for all movements, if bending backwards hurts then I like to encourage my patients to do this regularly too, or side bending. This doesn’t mean forcing it or pushing it through pain, I like to say “approach the area of pain then back off”, the more you do this, your body will all you to push it a little further, ultimately cementing this new movement as normal. You may find after a few hours it goes back to where it was, that’s fine but now you know what to do again.
Eventually, it will start to stick, especially as you use that new movement in your daily life, backed up with rehab!
For more information, check out episode #069 of the podcast!