Sunday, September 7, 2014

A Brief Intro to Pain Science and a Change in Coaching Style


In the last couple of months I have been studying, and plan to study further, the science of pain. It's a fascinating topic and one I admittedly have only just scratched the surface of. But the things I have learned so far are very intriguing.

Pain is a complex beast; trying to explain all of its intricacies is not something I'm prepared to do but there are a couple of interesting points that I want to note

- This first point is not so much science as it is a disclaimer. As a fitness professional you should not be responsible for treating pain. There is an entire field of professionals trained in how to do that. Trainers/coaches should be responsible for body composition and improved performance. However, a series of circumstances can put non therapists in a position where they need some knowledge of pain. Even when working with a client who is pain free, we want to keep it that way, which requires some rudimentary knowledge of how pain works. Some clients will refuse to go to Physical Therapy based on previous experience (or financial circumstances) leaving their trainer as the only line of defense [1]. Often times clients will be finished with PT and need someone to “bridge the gap” between therapy and high level fitness. Additionally many injuries do not have to prevent fitness gains. No one wants to get fat and weak while undergoing rehab. I have had many clients who simultaneously worked with a Physical Therapist and me. By understanding pain on a basic level and having a good working relationship with the therapist, trainers can improve fitness qualities while therapists decrease pain. Both parties are actually helping each other be more effective. 

- Pain is not synonymous with injury. Sometimes people get injured and feel no pain. I don't know the statistics off the top of my head but there is a large number of people walking around with herniated disks who are completely unaware of it, because they are pain free. Herniated disks are so commonplace and unrelated to pain that the American College of Physicians has actually said "Clinicians should not routinely obtain imaging or other diagnostic tests in patients with nonspecific low back pain". In fact, 95% of back pain is idiopathic- meaning that there is no diagnosable cause for it [2]. Which brings me to my next point: Many people have pain despite no structural damage. This is evident in many cases of chronic pain in which the tissues are completely healed but patients still have pain with certain movements. My dad still has ankle pain during certain movements despite not rolling an ankle in over a year. Ankle sprains, even for people in their 50’s don't take years to heal. The tissue and joint should be fine, so why is there still pain?

- The body alone does not sense pain. Pain is primarily a function of the brain [3]. The body, specifically nociceptors, senses threat or danger. The nociceptors relay that message to the brain. The brain then processes it along with a lot of other information (beliefs, past experiences, stress, etc) and decides if it is dangerous enough to warrant causing a pain response.

There are two primary models of what causes pain:

- The PSB model (postural structural biomechanics) - The PSB is what most people are familiar with. My hip is weak so my knee caves in when I run and now it hurts. You can tell the same story for the back or the shoulders. This model treats stimuli from the body as the primary means of pain and treats them accordingly with traditional biomechanical fixes (stretching, strengthening, manual therapy etc.). This is the basis for how I have treated every client that I have ever worked with, although the specifics of the training have obviously evolved. Posture, structure and biomechanics are still the foundation of all of my program design. But a different viewpoint has come to my attention that has changed some of how I implement my programs. 

- The BPS model (biopsychosocial) - The BPS model is more relating to how the brain perceives threatening stimuli and how psychology influences pain. Seems like soft science at first but there are mountains of evidence supporting the role of psychology in pain, and it has been around since the 1980’s. It relates to how perceptions and past experiences can affect the processing of stimuli from the body.

Both models are relevant, and these are not necessarily competing systems. The "B" in BPS stands for biological, which is the foundation for all of our traditional pain management methods. The two models are probably best used in conjunction with one another, but most trainers only take into account the structural model when dealing with clients. Even without being a psychologist or PT educated on the psychological model you can still take from that research and positively affect training any client. I want to discuss how I've used this philosophy to improve my own coaching and how you can do the same.

A huge part of being a coach is recognizing poor movement patterns and being able to correct them to put clients in the best position to succeed. How a coach goes about making these corrections and the language they use goes a long way in determining how effective that coach will be in both the short term and the long term. Let's take a look at two examples of correcting a valgus knee position in the squat exercise (let's assume this is a post-set correction. Mid-set cues should be extremely brief, preferably 2 words or less, and yelled over loud music in the gym)

Coach A - Drive your knees out, letting them fall in like that is going to tear up your meniscus

Coach B - Drive your knees out, it's a stronger position and it will transfer better to your golf swing/jumpshot/whatever

Coach A and Coach B are both correct. A valgus knee position under load is related to a host of knee injuries. Being able to resist that position is also related to increased gluteal strength, which allows for a greater expression of power in just about every activity. Both coaches probably got their clients to do what they wanted, assuming that exercise selection and progressions were appropriate. 

However there is a big difference between what they said. Coach A created a threatening situation to fix his clients position. Now when Coach A's athlete finds himself in a valgus knee position he or she will sense a threat or a danger. As we discussed previously, feeling threatened or in danger is a great way to trigger a pain response. These feelings are part of the thoughts, beliefs and past experiences that contribute to the pain message from the brain. Essentially, if an athlete feels as though she going to get hurt and perceives a position as dangerous, the brain will cause pain in order to get the athlete out of that position. This can trigger fear avoidance behaviors and chronic pain issues.

For this reason, I have eliminated all pain based coaching cues from my vocabulary. Telling an athlete she is going to get hurt is one of the easiest ways to put them in position to actually do it. I don't have any hard data proving if this has decreased rates of injury or pain in my clients but the current pain science all supports avoiding fear-based coaching cues. Telling someone to stop something before they get hurt is well-intentioned and likely gets the desired short term response, but as trainers and coaches, we need to have an eye toward the future. Not only do we need to increase strength in foundational patterns and follow sound biomechanical principles, but we also have to decrease the perception of threat to allow for pain free training and living. 

You can do this by avoiding the fear mongering coaching style and cueing or by any method that increases clients’ confidence in movement. Find a style that works for you but make the goal improved performance, not catastrophe avoidance through fear.


[1] Based on the crap I've seen in some PT offices, I don't blame a lot of these clients. There are good PTs out there, but you have to look hard for them. 
[2] This fact was provided by my lovely girlfriend Jocelyn. She’s in medical school, is way smarter than me and likes when I put her name in my blog.

[3] So if someone says that pain is "all in your head" they are correct, but that doesn't mean your pain isn't real or that you are conjuring it up for some ulterior motive. Pain is in your head because that's where your brain is and your brain controls everything.