The Journey Towards Recovery

Reading Your Chronic Pain As You Return To Activity

by Derrin Kluth, PT, DPT, RMT

 So you’ve been doing going to see your therapist and doing your home interventions and you’re feeling some improvement.  Sooner or later you will want to start returning to doing the things that you love to do!  But you may feel unsure about how to read your body’s signals as you try to get back to doing those things.  In the last instalment, we discussed how to read the body’s signals as you are performing your home interventions and how to tweak your responses in order to maximize those interventions’ efficiency and effectiveness.  In this one, I hope to expand those considerations and begin to apply them to the next step, which is to utilize the gains being made by those interventions to return to your normal activities.

            The first and most important concept to understand in this process is that in chronic pain, the progress in your healing journey isn’t only (or even majorly) measured by a lack of pain, but more significantly by a gain in function.  In the therapeutic professions, the word “function” is very important, as it denotes a gain of some sort specifically while trying to perform real world activities.  This is to distinguish it from a gain in aspects that are not necessarily gains in real world actions.  For example, if a person makes gains in strength, flexibility, or experiences a reduction in pain, these are all well and good, but are any of them making a difference if these things don’t translate into actual gains in performing the actions and activities that the person actually wants to do?  If not, then there haven’t been any real “functional” gains.

You may recall from the last instalment in this series that we discussed the difference between “acute” and “chronic” pain –that is, “acute pain is your body’s way of saying “don’t use me and let me heal,” whereas “chronic” pain is your body saying “hey there’s something here to work on or figure out so that I can heal now.”  Similarly, we have to refine how we think about gains in our recovery during our improvement from the “acute” healing journey back to normality vs the “chronic” healing journey towards the same, and describe some of those differences.  Most people think both types of recovery should look like the “acute” type – that is, give it some rest until it “heals up,” stops hurting, and then you can go about your daily life like before.  Unfortunately, for the chronic pain sufferer this is simply not how a recovery from this type of pain occurs. 

            Let’s go through some of those specific differences, shall we?  First, the chronic pain journey almost always takes longer to complete than a recovery from acute pain.  The doesn’t mean that a person can’t make significant and very promising gains quickly, of course, but it means accepting that to get back to a point with absolutely no feelings of symptoms and without having to pay attention to how one performs an action can take months or even years to fully complete.  This is because the problems underlying chronic pain usually have built up over significant amounts of time, and even in the few cases where they haven’t, they are very complex and involve many different systems working together to produce what we experience as our symptoms.  This means that recovery times can vary widely from individual to individual because each person’s symptoms are a complex layering of how they have learned from birth to move and hold their postures, tissue changes after “acute” healing from old and new injuries, potential learned compensations in how the body moves after those injuries, how that person’s nervous system is perceiving and guarding each compensation, their own perception of if and how they can heal, and their motivation and persistence to do so. 

The road to recovery is not linear.

Secondly, pain (or symptoms’ intensity in general, no matter how you experience it) can come and go, and increase and decrease, during a recovery from chronic pain, and all of it is necessary to complete the healing journey.  This is the case for a few reasons.  The immediate one is that many times, just after a person’s tissues begin to change back from the chronic pain state they’ve grown into, they may feel a relatively temporary increase in soreness that can persist for a few days.  We call this the “Healing Crisis” to denote the fact that it is a difficult but necessary part of opening up the tissues in order to give them the ability to change back from the state they are in now into something more like they used to be.  When doing so, many of the chemical and nervous system changes that were made to the tissue to get it to its current state are disturbed or “stirred up” and may require a few days for the body’s systems to clear out and reset the tissue to that something more like they used to be. 

And the longer term factor in pain during a chronic pain healing journey is that a person will have to progress in slowly re-acclimating the tissues to being used during the activity in the ways that they used to be. Inevitably this means that sometimes the person will go a little too far or use their tissues a little too much for what they were ready to do that day. Consequently, this can cause a flareup or episode of soreness that has to be calmed before the body will be ready to continue the process. By contrast, in an acute pain healing journey, pain more or less gets better at the same rate the tissue is healing so while there may be minor increases, they rarely get to the felt intensity of the original injury.

A flare or healing crisis can occur as tissues acclimate.

The final major difference between the two types is the acclimation process.  Acute pain’s healing journey usually proceeds in a way that as the pain decreases, the tissues are able to handle the return to normal functional activity at a fairly obvious relation between the two.  In other words, the less pain, the more normal activity someone can do.  The chronic pain healing journey is different in that due to the above, there will be cycles of increased pain as the person slowly restores the ability of the tissue to handle the activity.  This means that additional strategies have to be implemented to take into account the adjustment of the tissues to the stresses and strains placed upon their newly “opened up” states, and to allow the process of gradual desensitization of symptoms to happen. 

            So, taking into account these differences, there are several strategies a recovering chronic pain sufferer can do to help.  In sum we can call this these strategies and this process the “Graded Return to Functional Activity.”  The first strategy is simply to understand to not fear pain, for the reasons above.  If you do feel increased symptoms without some obvious trauma, even if very intense, it doesn’t mean that you’ve broken a bone, torn a muscle, severed a nerve, or actually damaged your tissue in any real way.  It just means that the guarding patterns are triggering an episode of tissue tightening which is compressing the pain sensitive nerve endings in the area and sending the “pain” signal much more easily than normal tissue would.  This is not the same as tissue being damaged and the first thing a chronic pain sufferer has to do is de-link in their mind the relationship between increased pain and tissue damage, and accept this in order to help calm the body’s reaction.  If the patient can keep their systems calm through the process, it usually helps keep the intensity of symptoms from progressing very far. 

De-link pain and tissue damage.

The second strategy a sufferer can do is to plan for the desensitization process and be okay with it.  Knowing that it will take time for your newly changing tissues to adapt to your chosen activity, follow the simple adage:  “Start low and go slow.”  A teacher of mine once said that the human body is amazing in that it can (within reason) adapt to almost anything – it’s just that in most situations we don’t give it that time to adapt.  This means accepting that you won’t be able to immediately go back to the same duration or intensity of activity that you were used to from before, but that you will have to start from a lower place, whether this means less time or less difficulty, and work back up slowly to where you were.  When you feel symptoms begin to come on, stop and take a 10 minute break before returning to the action.  If you feel the symptoms again at the same length of time or amount of difficulty, then that means that’s all your tissues feel like they can handle that day.  Give it a rest and try again tomorrow.  But if you can go longer or with more difficulty this time without triggering your symptoms, then feel free increase these factors until you do feel your symptoms, and then respect that “Line in the Sand” your body has drawn for today.  It’s always easier to slowly add more than come back if you’ve gone too far that day.  By doing this, over time you will slowly increase the amount of duration and/or intensity your body and tissues can handle for that activity before symptoms are provoked, and in that way you will get to a point where you can tolerate the level of activity you were performing before in a way that lasts. 

Start low and go slow.

The third strategy is somewhat related to the second one but important enough to mention on its own.  This one can be remembered with the adage: “Don’t do nothing.”  Many times the line where symptoms kick in will actually adjust lower and lower if a person doesn’t perform that activity, or lowers their amount of activity in general.  This is a problem if a person self limits from doing actions or activities due to a fear of provoking pain or injuring the tissues and making things worse.  Over time the tissues will become more guarded and chronic symptoms will kick in earlier and while doing lighter levels of difficulty.  So understanding that their tissues are indeed healed but just hypersensitized and guarded, a person recovering from chronic pain needs to be okay with not avoiding activity altogether and will require a dedication to going through the desensitization process in order to slowly recover.  It is better to do an activity and have some symptoms than it is to avoid activity and lose what tolerance for that activity the tissue does have!

            The last strategy that a person can do is treat yourself or seek treatment if required!  By now you’ve learned to do many home interventions that can counteract any side effects or flareups after going a little bit too far that day.  Getting more skilled at your interventions will make you more confident that you can control those symptoms, and consequently feel less fearful and helpless if you do feel them!  As we have discussed in prior instalments, chronic pain is the body’s signal to you to tell you that something needs to be addressed in that area.  As a person makes changes in one part of the sum connected whole of their trigger point complex, then another part will inevitably need to be addressed and this is how the body is letting you know this is the case and where to do it.  Wherever this happens is a sign that the tissue here needs to have some intervention in order to be desensitized, so not fearing your pain and “following it around” with your interventions is important and useful.  In this way you can actually make the acclimation/desensitization process more efficient and effective, and return you to your activity quicker than if you did no home intervention at all!

We’re here to help!

If you feel that you need some assistance in calming down a flareup as you increase your activity, your practitioner is always willing and able to help.  Their knowledge of how the body works allows them to pick up on small and specific but important habits that your body may have learned as a compensation for your chronic pain but now that habit is getting in the way of returning to better function.  They may be able to help you change those habits into better ones to avoid provoking your symptoms.  And they may be able to figure out specific applications of your home interventions to help you address all aspects of your recovery, and help maximize your ability to unravel the system of tight trigger points even more as you make gains in your return to activity.  Sometimes the specific interventions that were helping earlier in a recovery process are no longer as useful and a patient needs further guidance in how to apply the techniques just right for the gains and changes in their tissues and systems as they recover.

            In conclusion, I hope the reader feels more informed in their understanding that a return to more advanced activity is definitely possible even for a chronic pain sufferer of many years.  I also hope you feel empowered in knowing that, even if it takes a little longer and requires a little more care and planning up front, that you too can successfully make that journey by utilizing these strategies.  Ask your practitioner if you are at this point in your recovery and require a little help or guidance.  We’re here to help!  Future instalments of this series will focus on ways fascial therapies can be applied to different types of specific patient problems, among other topics.