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Free

Tobias Hall — Tue, 22 Aug 2023 23:48:28 +0000

Free

We long to be ‘pain-free’. Because physical pain is somehow the exact opposite of physical freedom, it places terrible limitations on the variety, quality, and vibrancy of the life we are able to lead.

Living with chronic pain can feel like being ‘trapped‘. Not by bars or restraints but by invisible, internal knots and blockages. Knots and blockages that can seldom be seen, felt, or fully understood by others.

Chronic pain sufferers tend to look like everyone else from the other side of the room. But when you really take the time to hear their stories and listen to what their lives are like, a very different picture emerges.

On the day of writing this, I spent two nearly identical hours with two different ladies, who are both less than 35 years of age. Both appear perfectly healthy and cheerful when you first shake their hands and engage them in some small talk. Yet in both cases, the description of their day-to-day quality of life is very distressing to hear.

Severed and strained relationships, clinical depression, faltering career paths, loss of confidence, inability to exercise, weight gain, broken sleep, severely constricted social lives, and substantial fear and uncertainty about pain. Factors that all too often lead to very real and very understandable mental health struggles.

All of which is just normal for people with chronic pain, and depressingly normal for both of these ladies (both of whom have been like this for years, despite strenuous attempts to find a solution), And they are far, far, far from alone in their struggles. There are millions of people like them. Mostly suffering in virtual silence.

For the worst sufferers, chronic pain becomes something like a biological prison. It constrains the full expression of our life force.

‘Limitation‘, ‘restriction’, ‘imprisonment’, ‘constraint’ ‘entrapment’ are all symbolic feelings we have about pain. And as feelings, they speak to the type of suffering pain triggers at the deepest levels of our psyche. Pain triggers some of our deepest, rawest, most ancient forms of suffering, like loss of freedom and loss of connection.

All of our physical connections and physical freedoms are underpinned by the ability to move without inhibition.

All pain hurts physically, but persistent pains hurt us even more because of their impact on our basic physical freedoms, many of which spill over into another pillar of happiness—the ability to connect with others. Therefore, chronic pain is limiting, but it can also be isolating.

Choose any topic that’s ever held your attention in any way, shape or form. It will almost certainly boil down to connection or freedom, or both! Connection & freedom are 2 of our most fundamental human instincts. Probably because for social hunter-gatherers, freedom to move and connection tend to equate to survival. Being physically trapped and/or separated from the tribe is not good.

All our instincts for accomplishment, achievement, qualifications, career, excellence, financial success, creativity, travel, sport, health, fitness, well-being, conflict and survival represent freedom in one form or another.

The exhilaration of reaching the goal, making the sale, passing the test, building the masterpiece, winning the race, overcoming the challenge, getting the promotion and receiving the bonus: owe their feel-good factor to a glorious inner sense of freedom. Freedom drives so much of what we do.

And then there is a connection with others.

Many of life’s deepest cravings are, at their core, cravings for connection. All the love, acceptance, approval, appreciation, praise, support, sharing, rewarding, caring, cooperation, charity, service, giving, community, pets, family, friends, and kids all represent connection in one form or another.

When we give and receive, when we care, when we share time and socialise, when we serve, when we collaborate, and when we love, it all boils down to expressing our instinct to connect. It’s an impulse that’s deeply encoded into our social DNA.

Like our desires, our deepest fears often lay bare our most powerful instincts. Hence, isolation and physical restraint are among our most fundamental human fears. And combining the two is, for most of us, a totally horrifying prospect.

Being isolated and alone means no connection. Being trapped, enclosed or restrained means no freedom. Thus combining them makes for one of the worst experiences imaginable. This is why human societies have concluded that prison is such a logical punishment. And it is also why solitary confinement is widely considered the very worst form of human torture.

In a study published by the American Public Health Association, they concluded that acts of self-harm were strongly associated with the assignment of inmates to solitary confinement. Inmates punished by solitary confinement were approximately 6.9 times as likely to commit acts of self-harm, even after controlling the length of jail stay, mental illness, and ethnicity.

No matter how bad prison community life gets (which is often indescribably bad), solitary is almost always far worse. Most humans will beg to be allowed back to the threat of rape and violence in the general prison population, even after very short periods of solitary. And countless humans have chosen to take their own life rather than face extended solitary because they were deprived of their instincts to express freedom and connection.

It would be a mistake to think this is straying off the pain topic. We are deep in the truth about stubborn pain. Because chronic pain touches exactly the same human rawness that solitary confinement does, it just goes about it in a very different way.

Imprisonment creates external constraint and disconnection, while pain creates internal constraint and disconnection.

Deep within the human psyche, persistent pain is like imprisonment; it limits our physical freedom – but instead of bars, there is a loss of mobility and deep shards of pain. And instead of physical isolation, pain is an invisible veil that disconnects and alienates us from those around us. Others can’t see it or feel it, and many cannot understand it. It also prevents us from full participation in life – which, for many, makes life feel lonely.

Imprisonment creates external constraint and disconnection, while pain creates internal constraint and disconnection.

If your pain isn’t severe, these truths may only apply to you in a small way, like being unable to play golf with your friends (Sunday morning limitation & isolation). But for people with the worst pain, the loss of freedom and disconnection can be very severe and extremely isolating. And the worse our pain gets, the more like imprisonment or even solitary confinement it becomes.

The sweetest freedoms are the simplest ones, and they are also the ones pain threatens most.

Being able to cuddle someone without it feeling like there are pieces of sharp metal between you. Being able to rise from a chair easily. Being able to fall into a deep comfortable sleep when we’re tired. Feeling physically good enough to enjoy the company of others. Standing and walking comfortably. Being able to exercise comfortably. Being able to pick up a child. Playing with a child. Being able to concentrate at work without pain. Making love to someone we have chosen to spend our life with. These are the sweetest freedoms that make 99% of a happy life if we let them. And they reveal themselves so clearly to those with the most pain.

At its most fundamental level, pain is a loss of these freedoms. Therefore, we wish to be set free from our pain. In the same way, an inmate is set free at the end of their sentence.

Being pain-free is being free from constraint-free from disconnection and isolation – free from frustration-free from stiffness – free from physical limitations – free from uncertainty – free from sleeplessness – free from embarrassment – free from feeling trapped by a body that isn’t comfortably expressing the most normal and basic functions.

And the flip side of all this rawness is how good it feels to be free of our pain. How much happier we are when we are able to re-comment and re-mobilise.There is no sweeter feeling than the ‘release’ and ‘relief’ of getting better. No matter what kind of health challenges we face.

I’ve never told anyone this in person for some reason, but I can clearly remember the exact moment I knew I was cancer free.

It was 2010, and I was living in an idyllic but very small blue boat shed that I was renting from a friend in Pauahatanui, NZ. It was early morning, and I was stirring from a very deep sleep. It was one of those mornings when half woke, I was not sure where I was.

My eyes were adjusting to the room, trying to figure out where I had woken up. Then I suddenly realised what was different, and it wasn’t the location. I’d slept through a whole night without waking drenched in pain or sweat. I’d had a deep, full, restful sleep for the first time in 3 years. And I knew exactly what that meant. I could feel with absolute certainty there was no cancer in my body.

We talk about ‘floods’ of emotion for a reason. The healing we have craved over the years can feel like a dam bursting when it finally comes, and that’s exactly what that moment was like for me. I’m re-feeling some of the emotional relief as I type this more than ten years on. I am still relieved. I still feel set free from that sickness and the physical suffering that came with it.

Finally, feeling better after sickness or pain is one of the best feelings in the world. It’s a release that stands in absolute contrast to the feelings of limitation and disconnection. Most of us feel a piece of that euphoria even after a short bout of food poisoning, let alone when we have struggled with pain or sickness for years at a time.

A month later, my doctors told me officially that after three years of biopsies, every alternative therapy under the sun, chemotherapy, radiotherapy, more chemotherapy and bone marrow transplants, my cancer had finally relented. It felt like a formality because I already knew I was better.

If you are genuinely 100% done with your pain, and you put a ¼ of the energy into it that I put into healing my cancer – you’ll probably love where you end up. The freedom and reconnection of a pain-free life are almost certainly a possibility for you.

You’ll get to take a breath. Life will feel so sweet, and you’ll feel so happy and grateful just to be alive. The effort was all so worth it. Calm seas and a gentle breeze. Freedom.

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Better Injury Care

Tobias Hall — Tue, 15 Aug 2023 01:16:14 +0000

Better Injury Care

John (that’s not his real name) is one of those rare gentlemen who has continued to play competitive soccer well into his late 50s. He is in really good shape, which you need to be to play football at that age—good shape except for his left leg. His left leg is not in good condition at all. In fact, once you get to know his left leg a bit better, it becomes apparent that it’s miraculous that he’s able to run at all, Let alone the type of running required to play competitive soccer against younger men. John’s left leg is riddled with arthritis.

John’s arthritic left leg is an anomaly because the whole rest of his body is extremely strong, mobile and healthy for its age.

To understand a left leg like Johns, you have to view it in its context. John’s whole body is exceptionally mobile and healthy for his age, he has the look of a lifelong athlete and all-around strongman because that’s what he is. No part of him is 30 years old any more. But he has no signs of stiffness or weakness anywhere in his arms, spine, or right leg. His overall mobility is excellent for his age, hence in part, the long soccer career.

John’s left leg is another story. It has advanced osteoarthritis in every major joint. His knee, hip and ankle are all severely arthritic. They stand in complete contrast to the rest of his body which is not even mildly arthritic, let alone suffering from advanced cartilage loss. He has had four separate arthroscopic surgeries at different times. All on joints in his left leg.

It’s all a bit surprising until you look closer – firstly, at John’s gait pattern and, secondly, his health history. Once you have understood those, the left leg makes perfect sense.

Computerised gait analysis measures the distribution of weight in each foot during walking and running in great detail. It then compares the left with the right to establish whether there is a gait insufficiency or asymmetry compared with the normal population. Essentially, it’s a dynamic postural analysis of the lower limb.

Gait analysis of John’s left leg reveals a catastrophic degree of pronation (arch collapse) with every step. While John’s healthy leg only exhibits the slightest amount of pronation (the amount he was born with). The pronation reveals that his gluteal muscles have wasted away to nothing on his arthritic side. His knee, ankle and hip all collapse inwards with every step – Millions of times yearly on the same side as all the arthritis.

Based on all this, John’s case starts to look like the healthcare equivalent of a murder mystery with no suspects until you go back far enough.

It’s all a bit surprising until you look closer – firstly, at John’s gait pattern and, secondly, his health history. Once you have understood those, the left leg makes perfect sense.

Based on all this, John’s case starts to look like the healthcare equivalent of a murder mystery with no suspects until you go back far enough.

When John was 16 years old, the full weight of an adolescent rugby scrum collapsed onto his left ankle. The resulting sprain was so bad that he was on crutches for five months. He confesses that his ankle never felt the same again. He also recalls that he sustained two further bad sprains during his late teens and early 20s. Mystery solved.

The joint trauma, scar tissue and muscle wasting left in the wake of the ankle sprain left John with a severely unstable foot and ankle. And if you have an unstable ankle, you have an unstable leg, foundations being what they are. The chronic instability caused chronic wear and tear, not only in the ankle but also in the knee and hip. Yet it was more than three decades before John started to really feel the longer-term impact his ankle injury would have on the hip and knee.

As for John playing masters football on such a severely compromised leg, that was easily attributable to a combination of innate athleticism and sheer belligerence. Despite this, once he had seen the results of his gait analysis and finally understood why his left leg was so compromised, he played the last two matches of the season. Finally, he retired—instead, choosing to pursue general exercises and rehab to prevent further unnecessary joint degeneration. He had never connected the ankle sprains with the arthritis he had in that leg, nor had any of his previous healthcare providers.

Despite the common and somewhat irrefutable nature of case studies like John’s ankle, there is still some scholarly debate over the true prevalence of joint degeneration after injury; because the current data is far from conclusive. Yet there is so much data, clinically, statistically and anecdotally, there is a consensus about there at least being some level of correlation. And arthritis aside, there is certainly no doubt about the high prevalence of further pain and injuries after ankle sprains and the like.

A study published in the Journal of Athletic Training in 2019 highlighted what countless clinicians have known for a long time. Up to 70% of people who sustain an acute ankle sprain develop some level of residual physical disability in that leg. This study highlights the devastating potential of ankle sprains; and also the fact that we struggle to effectively rehab even the most straightforward musculoskeletal injuries.

We need to do a better job of injury care if we are going to conquer the pandemic of chronic pain we live in at this point in history. Unrehabilitated injuries and complex injuries contribute significantly to the pain burden. Walking must always come before running, individually and collectively. So, if we can’t get to grips with the humble ankle sprain, what chance do we have of conquering back pain, complex PTSD-associated pains and an opioid epidemic?

Improved injury management is as much a mindset as it is a set of rehab approaches.

If we adopt a mindset where we assume that all but the most extreme injury events have something to reveal about the integrity of our musculoskeletal chains, we have made a giant step towards better care of injuries, complex injuries and complex pain.

If we adopt a mindset where we assume that the injuries seen on scans and x-rays are just the tip of the injury iceberg; and that other more subtle but significant soft tissue injuries play out ‘under the medical radar’. A world of injury and pain healing approaches opens up to us.

If we adopt a mindset where we are willing to give our painful and ‘injury-prone’ body parts the kind of long-term attention we give our teeth, we will have made another quantum leap towards preventing long-term pain and disability.

Once we have made this small handful of shifts in our belief structure around injuries and rehabilitation, we become open to proper use of the full injury and pain rehabilitation toolkit, in which the techniques and approaches are often surprisingly straightforward. Just like flossing your teeth daily and seeing a hygienist twice a year is straightforward.

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Own Your Pain

Tobias Hall — Mon, 14 Aug 2023 23:35:30 +0000

Own Your Pain

Steve (that’s not his real name) was a fixer, the kind of person you really trust to get the job done. He was a resourceful and intelligent business coach with 20 years of experience pulling small business owners out of deep stressful-filled holes they mostly dug for themselves. He had the appearance of someone who had failed to take the necessary time to care for themselves over a long period of time. Despite having a naturally healthy and athletic disposition, the combination of occupational stress, minimal sleep, and a poor diet was making his 43 years look like an unhealthy 53. At the centre of all this was Steve’s bad back pain, which had contributed to his loss of physical well-being. And Steve mostly blamed his back for his poor physical state.

Taking a deeper dive into Steve’s pain and his attempts to resolve it revealed two common themes. The first was that he had consulted unsuccessfully with around 20 different clinicians from all disciplines, including multiple doctors, multiple surgeons, multiple physiotherapists, multiple chiropractors, and a list of many others. The second common theme was that Steve had done absolutely nothing to try and fix himself, no stretching, no pilates, no yoga, no stress management, no core exercises, no research, no cardio, and no weight loss.

Steve had taken almost no responsibility for working on his own pain. This observation is offered without judgement; Steve’s choices weren’t based on laziness. His choices were, in fact, more rooted in a lack of education. He genuinely didn’t realize that his pain was caused to a large extent by his lifestyle, stress, and his general physical condition; if he had, he may have acted very differently.

Steve believed his pain was among the types of medical conditions that require ‘a medical procedure’ to be performed. He genuinely thought that his back pain was like a tooth cavity that just needed the right dentist to do the right filling, and it would be permanently fixed. He didn’t realize that the bulk of the issue he was facing was far more like being unfit or having a poor diet. Thus being a life challenge that requires an unavoidable and sizable dollop of personal responsibility.

Happily, once Steve realized this truth, he was able to gradually merge better self-care with treatments that helped reduce his pain meaningfully. After a few months, he was able to gain some real momentum. This ultimately led to the resolution of his pain. After many many years of suffering.

Steve’s case is a slightly unusual one because most pain sufferers these days do take a certain amount of responsibility for their pain, in the form of exercises and tools intended to reduce their pain over time. In truth, though, most pain sufferers sit somewhere on a ‘responsibility spectrum’, inhabited at one end by those who take no responsibility and at the other by those who take too much responsibility and won’t ask for help.

I have met literally thousands of pain sufferers and had the opportunity to have substantial conversations with them about their pain. As you might expect, there are many repeating patterns, especially among those who have suffered the most and for the longest. One such pattern is the Steve pattern, where the patient sees it as the job of healthcare providers to fix the pain. In particularly bad cases, this logic extends to those patients who start to blame their ‘doctors’ for their pain. It is no coincidence that this type of ‘blame psychology’ and the feelings of powerlessness that go with it are well-documented as significant contributing factors in many of the worst poor pain and disability outcomes.

From an early age, we are somewhat conditioned to think of our physical complaints as the job of a doctor to fix, and of course, there are times when this is true. Personally, I believe we are responsible for our own well-being. But of course, I don’t, for example, extend that to a small child who needs treatment for leukaemia, which is definitely a job for an oncologist, not a toddler. It also isn’t our job to put pins and plates in our own broken bones. you need an orthopedic surgeon for that.

Not all health issues are the same in nature, and not all of the chapters within the history of each health issue are the same. If we use tooth decay as an example, it is quite clear that it is the dentist’s job to perform the filling. But whose job is it to prevent tooth decay from happening in the first place? If you have a tumour in your lung, it is your medical team’s job to see if they can resolve it for you, but is it the consultant’s job to stop you from smoking? No, that’s your job!

So understanding that we probably have a certain amount of work to do ourselves if we want permanent resolution of our pain is a big step. But there are two other ingredients that must be added before we are able to graduate to taking full responsibility. The right tools and understandings.

The completely opposite type of pain sufferer (from Steve) are those who work relentlessly at fixing themselves and refuse to seek any professional help. This type of approach tends to be driven partly by fundamentally positive personality traits (like confidence, independence and tenacity) but also by disillusionment with past treatments that have not worked. Consulting with multiple practitioners and not getting anywhere can easily create the impression that help will never come, leaving the patient entirely self-managing and self-Googling their own chronic pain.

Sadly taking too much responsibility can be as fruitless as taking no responsibility, no matter how admirable it is. Dealing with chronic pain is, on many levels, the responsibility of the individual suffering from the pain. Yet without the correct guidance, much of the effort can be wasted on ineffective or inappropriate tools that won’t get the job done.

To be able to take the right amount of responsibility for our pain, we need to be armed with the right tools. To get the right amount of help with our pain, we need practitioners who are also armed with the right tools and insights. It is our responsibility to care for our own pain and our own body. But taking personal responsibility doesn’t mean you have to figure it ALL out for yourself.

The best health outcomes tend to come when there is a healthy shared responsibility for resolving the complaint and its causes between ourselves and practitioners whom we trust. Part of their job is to perform the ‘pain-relieving procedures‘ that help us return to normal function, but it is also their job to help guide us towards which aspects of our physical well-being WE need to work on and then we fully commit to running that gauntlet on our own 2 feet.

Chronic pain needs more than ‘a procedure’ in almost every instance. Even after full joint replacement surgery, a significant percentage of patients continue to suffer from pain in the same area, and countless more continue to suffer from stubborn pain elsewhere in their bodies. This clearly demonstrates that even our most radical pain solutions seldom land like magic bullets.

Stubborn pain is a highly complex issue, and the genuinely mature approach to it acknowledges this by not oversimplifying it. But instead, taking a broad and flexible approach. By tackling pain in a collaborative, holistic, and self-responsible way.

Perhaps the best way to achieve this mindset is to stop asking, ‘Who can help me’ or ‘How do I fix myself’ and instead ask… ‘Who can help me fix myself’.

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The Family Doctor Myth

Tobias Hall — Mon, 24 Jul 2023 23:36:25 +0000

The Family Doctor Myth

There is nothing wrong whatsoever with seeking pharmaceutical pain relief to tide you over until real healing of your chronic pain starts to take effect. But in most instances, seeking real answers to chronic pain from your family doctor is a highly questionable endeavour. Doctors are trained and equipped to treat medical issues. And there can be grat value in drawing a distinction between medical issues and fundamentally non-medical issues. Value for us individually but also value for an overloaded healthcare system.

Is a tight hamstring a medical issue or something that you just need to stretch out?

Is the common cold really something medical, or is it between you and your immune system?

Is a weak pectoral muscle something medical? Or is it between you, your willpower, and the humble press-up?

At what point do sickness, weakness, tightness, and soreness become medical issues?

These are not easy questions to answer necessarily in some cases, and yet in other cases, they are extremely easy to answer. Like those above.

There is no question that if the struggles faced by our musculoskeletal system become severe enough that they can become medical issues. Major injuries and auto-immune disorders qualify. Yet, perhaps surprisingly, chronic pain seldom qualifies. Despite the severe impact it can have on our lives.

I meet people on a daily basis who have been back and forth to their family doctor for years, asking for help with their pain. They are often quite frustrated with the way their issues have been handled.

The list of solutions explored tends to follow the same basic patterns. Pain killers, non-steroidal anti-inflammatories, blood tests, x-rays, surgical specialist referrals, steroid injections and, sadly, on occasion, opioid medications, which have been conclusively shown to be far more lethal than chronic pain itself. All of which approach pain as if it was a disease rather than a fundamentally healthy form of biofeedback.

There was a study carried out in the U.S. which highlights the absurdity of having a family doctor manage ongoing pain.

In an attempt to loosely measure how well we manage pain in the elderly, a group of researchers measured the duration of pain consults in doctors’ offices.

Many elderly patients consult their doctor about multiple issues at the same time, so it was a little tricky to design the study. Getting specific about the duration of pain

consults meant it was necessary to start a timer the moment a patient mentioned pain and stop the timer again once that part of the conversation concluded. They did this across hundreds of doctor visits.

The average duration of a pain consult for an elderly patient at their doctor’s was less than 3 minutes, which is close to constituting a complete dismissal of a very serious health issue.

To put that in context. In my clinic, we often spill over the 60-minute mark in initial pain consults with older patients. And trust me, I am every bit as time-poor as any of those doctors.

The time spent on specific issues reveals a great deal about practitioners. It’s a direct flow from the amount of honest training, thought and focus we have placed on that topic. If you asked me or your dentist for some advice about diabetes, this would be apparent. That would be a very short conversation, mostly about who you should actually be talking to.

Now, I’m not claiming any insight into what your doctor has or has not done for you. Nor am I seeking to diminish the good work family physicians do.

I am merely seeking to highlight the undeniable truth of this matter; the average family doctor’s education does not encompass the rehabilitation of chronic pain: any more than it does the management of tooth decay. It’s just not their field of expertise.

The fact that so many of us still rattle on year after year, Endlessly consulting doctors who know next to nothing about rehabilitation, biomechanics or pain management, is just another symptom of a society that struggles with pain.

Cut your family doctor some slack; they do a hard job. If you are peeing blood one day, they might save your life. But if you have knee pain, consider leaving them in peace.

Our problems become medical once they are so bad that the body cannot heal itself any more, like a badly broken bone or an infection that exceeds the immune system’s capacity. Less than .001% of chronic pains qualify. The body has the ability to resolve chronic pains in the same way that it has the ability to resolve obesity or a general lack of fitness.

Work with professionals who are actually trained to diagnose, treat, and rehabilitate pain. Just make sure they are primary healthcare providers. You might have something serious going on, so they need to be fully qualified! If you do it this way, with the right people, everyone wins, but mostly you.

But of course, there is nothing wrong whatsoever with seeking pharmaceutical pain relief to tide you over until some real healing takes effect.

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Shockwaves, Pain Treatment & Hormetic Stress

Tobias Hall — Tue, 11 Jul 2023 23:39:53 +0000

Shockwaves, Pain Treatment & Hormetic Stress

Using hormetic (healthy) stress to heal painful tissues is a crucial element of pain management.. Even for pains that are predominantly nervous system based (like PTSD-associated pain), there is great value in healing and strengthening painful tissues.

‘Hormetic stress‘ is a term few have heard of. Yet it’s a cornerstone of health, of our lives, and the entire natural world. Hormetic stress is also a significant key to getting out of chronic pain.

Hormetic stress is an invisible by-product of healthy life processes, and it’s everywhere. If life were a chocolate cake, Hormetic stress might be the baking powder. An invisible flavourless ingredient that nonetheless holds everything together. Without this, the entire recipe becomes an unappealing stodgy mass.

In nature, the benefits of hormetic stress show up under a wildly diverse and broad set of circumstances. Its benefits support individual cells, organs and muscles but extend to shaping entire species and even the environments they live in.

Excessive stress of almost any kind can destroy life very quickly. Zero stress tends to cause a slow death and failure to thrive. But, with the right amount of stress, life is fortified and can truly thrive. This healthy stress is hormetic stress.

If you set up a warm, damp environment in a petri dish, bacteria love it. Then, if you add a sugar solution, they can continue to survive. But there’s another ingredient that you can add that will cause them to truly thrive—a microdose of arsenic.

Bacteria left with the perfect conditions for life are consistently outperformed by bacteria with the perfect conditions for life – plus a little bit of poison. Knowledge of this fact reveals a great deal about life, health and successful pain management.

Bacteria with too much arsenic die. Bacteria with no arsenic just survive. Bacteria with a microdose of arsenic become a roaring success. The right amount of poison in their environment acts as a hormetic stressor. A manageable dose of stress forces adaptation and makes them stronger. In this way, infinite versions of hormetic stress benefit all of nature, from single-cell organisms to entire ecosystems.

Giant Sequoia trees bear the largest scars on any life form on earth- Scars left by fire. Sequoias are utterly besieged by seasonal fires in a way that is almost impossible to believe could be helpful to them in any way – Until you look closer.

Sequoia once occupied the entire Northern Hemisphere. Yet only three species have survived ‘recent’ ice ages. The Giant Sequoia is one of the three. And their home range is now limited to 77 small tree communities in a 260-mile strip of the Western Sierra Nevada mountains.

Compared to Giant Sequoia, human biology is ant-like. They are living, breathing apartment blocks with three-foot thick skin. The largest being 100 ft in circumference at the base and 26 stories tall. Body masses that exceed that of 15 blue whales (or 300 elephants) are common. Single trees can live 3-4 times longer than the most successful human cultures, over 3000 years. But these are not the big numbers.

The Giant Sequoia’s direct bloodline is around 150 million years old. That’s about as long as the entire mammalian family tree. And they may achieve a longer stay on the planet than all of the dynasties of dinosaurs combined. They are a single, seemingly immortal species that have outlived numerous biological epochs. And the secret to their success is mastery of hormetic stress.

The Sierra Mountains are prone to biblical forest fires. A bad forest fire can burn for up to 6 months at a time. And fire, being fire, has the capacity to decimate vast tracts of forest. The Castle Fire in 2020 destroyed 4 million acres of forest. Smaller tree species tend to get the worst of it. Yet when fires are bad enough, Sequoia groves can suffer catastrophic losses too. But giant sequoias are uniquely fire-tolerant.

In the same way that antelope are highly adapted to the specific goal of not being eaten. Sequoias are highly adapted to the specific goal of not being burned alive. What a lioness is to an antelope, too much fire is to a Giant Sequoia. So a substantial portion of their biology is dedicated entirely to fire resistance.

Naturally, large enough fires can wipe out sequoia groves. Like too much arsenic poured on a bacterial culture. And even the most massive trees can succumb to fire. Larger trees need to burn for months for it to happen, but once several feet of bark armour is breached, the delicate heartwood can burn, and the tree will die.

But even when the protective bark is breached by fire, sequoia usually doesn’t die. Instead, they end up with giant scars that can be up to five stories in height. These giant black V-shaped scars serve as a stark reminder of how fragile all life is. And that even the immortal sequoia, who lives through the rise and fall of empires, has its own vulnerability and impermanence. It is also the scars that create the false visual impression that fire is the Giant Sequoia’s enemy.

Seeing the damage fire inflicts on these magnificent beings; it appears certain that fire is a destructive presence in their lives. But nothing could be further from the truth. Fire deeply nourishes, supports and even births sequoia trees.

Sequoia requires vast resources to support its growth. Fire clears out smaller trees that might otherwise compete for the nutrients they desperately need to support their enormous mass.

Sequoia needs granite-hard pine cones. So their seeds are safe from pests during the 20 long years their cones take to grow. Only fire can crack open the cones and birth the sequoia’s baby seeds. Flames fulfilling the role of midwife to the trees.

Giant Sequoia is a pioneer species. Once their seeds are free, rising hot air from fires gently lifts Sequoia seeds. It carries them to their own part of the forest, where they have a chance to establish themselves at a healthy distance from their giant parent.

Despite their parent’s size, sequoia seeds are the size of an oat flake and very fragile. If the seeds do not land on bare earth, they dry out and die. So fire lovingly clears debris from the forest floor, creating the perfect bare soil conditions for the seedling to sprout.

Young sequoia grow very slowly compared to smaller tree species. So when fire pre-clears the forest of smaller trees for the seed, it also removes competition that might otherwise choke the slow-growing baby tree and compete with it for light.

When Giant Sequoia seedlings sprout from the ground, their ‘first meal’ is the fertilising ash left behind by fire. Like a first drink of mother’s milk, fed directly to it by the process of fire.

Once adults, sequoias are strengthened and supported by the presence of fire also. Fire adaptations make sequoia taller, thicker, and more resistant to pests, rock falls and droughts. These attributes enabled them to ‘outrun’ all other tree species in their environment. Thus winning the race for light, water and nutrients.

In the right amounts, fire acts as a classic hormetic stressor to the biology of Sequoia trees. By harnessing and adapting to it, they have become some of the largest, longest-lived and broadly indestructible organisms on earth. The fire that appears as such an alarmingly destructive force to the sequoia is its very lifeblood.

Sequoia requires vast resources to support its growth. Fire clears out smaller trees that might otherwise compete for the nutrients they desperately need to support their enormous mass.

It is deeply telling that such potent and successful life forms have an intense relationship with hormetic stress. It points to how essential hormetic stress is in enabling all life to thrive. It also points to how important it is that we understand hormetic stress’s role in maintaining our general health. And how vital it is to harness this wisdom when seeking to heal tissues that are stuck in the cycle of chronic pain.

Hormetic stress supports life on every conceivable scale. From micro-organisms all the way up to entire mountain ranges. And everything in between, including the human body. There are countless ways that hormetic stress benefits the human body.

Exercise is a hormetic stressor to humans. The most obvious hormetic stress mechanism in our human world is physical exercise. We all know the body needs the constant stress of movement to support healthy muscle and cardiovascular function.

Gravity is a hormetic stressor to humans. Without the stress of gravity, bone demineralises and wastes away. One year in space can leave a cosmonaut with over 20% of their bone mass wasted away to nothing. Without constant mechanical strain, bone stops regenerating itself effectively.

Heat is a hormetic stressor to humans. Sauna research has shown that when we are exposed to heat, our body’s cells generate heat shock proteins. Heat shock proteins assist with cell repair, muscle repair, inflammation control, improved immunity, cardiovascular function and elimination of free radicals.

Cold is a hormetic stressor for humans. The stress of regular cold exposure has been shown to increase dopamine levels, promote greater well-being, reduce auto-immune inflammation, boost immunity to viruses and boost metabolism.

Fasting is hormetic stress for humans. Calorie restriction imposes healthy stress on the human machine. Intermittent fasting can trigger a healthy switch from glucose metabolism to ketone metabolism, increase stress resistance, increase longevity, and decrease the incidence of diseases, including cancer and obesity.

Toxins are hormetic stressors for humans. Tannins found in tea are poisons. Yet, in controlled doses like a cup of tea, they are known to protect against cell damage, heart disease, cancer, invading microbes and toxic free radicals. In larger doses, though, tannins are very toxic to the body, like all forms of hormetic stress.

But the question is, how does this all apply in more specific terms to successful chronic pain management?

Hormetic stress can be harnessed and directed to resolve pain, to significant effect, in the overwhelming majority of cases. And the hormetic stressor most vital in healing chronic pains is not heat or cold of chemical stress; it is ‘mechanical stress’.

Mechanical stress can be used almost universally to stimulate the healing and strengthening processes required to resolve chronic pain. To some extent, this is common knowledge, as hopefully, we all understand the central role exercises play in resolving chronic pain. Yet another integral phase of hormetic healing is required (usually before exercise prescription). Where treatments that harness mechanical stress are necessary to trigger healing in painful tissues. If you have found that exercises increase your pain, this should be of some comfort.

There are many pain treatments that leverage hormetic stress to heal tissues and reduce pain. In fact, the overwhelming majority of effective pain relief tools involve the application of mechanical stress to tissues. One example, in particular, serves as an excellent window into how these treatments work.

Quite unexpectedly, it turns out that intense soundwaves can support tissue healing, the same way fire supports giant trees, by delivering a controlled dose of healthy stress that supercharges biological processes.

Extracorporeal Shockwave Therapy (ESWT) was originally developed in the late 20th Century for the treatment of kidney stones. Some brainiacs realised that intense soundwaves travelling through fluid created a shockwave. And that these shockwaves were strong enough to crack a piece of porcelain; but did not harm living tissue. Because tissue is mostly fluid and offers less resistance to the energy. These observations teased the potential for safe, non-invasive breaking up of kidney stones using shockwaves.

After many years of research and development, ESWT was cleared for use on humans with kidney stones. Which is when something very curious started happening among the test subjects -In the form of unexpected side effects.

After the successful dissipation of their kidney stones, numerous patients felt to compelled to inform the researchers that stubborn pains they had suffered for years had spontaneously resolved. At first, this was understandably dismissed as either placebo or a coincidence. But then something far harder to ignore happened.

A patient with chronic hip pain found that it spontaneously resolved shortly after the treatment of her kidney stones. Which in itself was not unusual, except that the known cause of her hip pain was osteonecrosis (bone tissue death) of her femoral head (upper thigh bone). Then, when x-rays were taken, the bone had spontaneously healed itself. The tissue had mysteriously come back to life. An unheard-of and ‘medically impossible’ event had taken place in her tissues.

Osteonecrosis of the femur happens when the head of the bone loses connection to its blood supply. This can happen as a knock-on effect of other health issues, including radiation treatment, various diseases, and trauma. And often also occurs for no apparent reason. Starved of its blood supply, the bone tissue literally rots away inside the body, causing inevitable pain and disability.

So the only reasonable explanation was that shockwave treatment had triggered the dying bone to re-establish its own blood supply. Naturally, this warranted significant further investigation.

Fast forward 40 or so years, and ESWT is a gold standard treatment for an incredibly wide range of musculoskeletal pains. Plantar fasciitis, heel spurs, tendinopathies, calcific tendinopathy, stress fractures, Achilles pain, tennis elbow, knee pain, and frozen shoulder are all firmly on the list. And many others, like back pain and neck pain, have yet to be studied in depth but, nonetheless, often respond well in real life.

Shockwaves’ ability to heal bone and soft tissue means that it has potential application for treating pain almost anywhere in the body. In addition, it has become a standard treatment for erectile dysfunction. And its ability to trigger nerve regeneration has even led to it being studied for its potential use in treating spinal cord injuries, brain damage and Alzheimer’s.

Underlying all this lies a bewildering number of well-documented cell and tissue healing responses. Exactly the type seen when stem cells go to work. New blood vessel growth, new cartilage growth, protein synthesis and the release of various ‘growth factors’ are all well documented.

All of which come directly from the application of mechanical stress to the cells and the spaces between the cells. The soundwaves create intense pressure, which creates mechanical stress in the tissue, which creates a hormetic response.

So ESWT is a classic hormetic stressor. It imposes healthy stress on tissues and stimulates a wide range of healing responses, which lead to a reduction in pain. Fundamentally acting just like controlled doses of fire do on groves of sequoia trees.

ESWT is very typical of the treatments that most reliably lift people out of chronic pain. Because most of them also apply mechanical stress to the tissue and elicit a hormetic stress response.

Rehab exercises, deep tissue release, spinal manipulation, yoga, pilates, cupping, fascial release and acupuncture and trauma release exercises are other excellent examples of how home mechanical stress can be exerted in order to heal tissue.

For most pain sufferers, the secret to harnessing these hormetic stressors is to use multiple stressors in conjunction with each other. Combining ESWT with cupping, for example, dramatically improves its already excellent hit rate. In addition, it’s usually necessary to do things in the right order.

The more passive treatments (i.e. the ones you just lie down on a treatment table and receive) should be used first to heal the tissues and reduce pain. Then, when the pain has reduced, less passive treatments like strength exercises should be used. This helps avoid bad reactions to exercise by ensuring the tissues are sufficiently healthy before strengthening starts.

The best way to explore all the options is to find a clinic where they systematically mix and match treatments. Failing that, you can curate your own investigation into various hormetic stressors. By hiring a deep tissue therapist, a shockwave therapy practitioner, a chiropractor and an acupuncturist (just for example). In addition, always prescribing your own dose of hormetic stress by keeping your body moving regularly and in healthy ways (as much as you can without causing more pain).

A strategy of this nature ensures that your painful tissues receive diverse forms of mechanical hormetic stress. The benefits of which should become apparent within weeks, or at least months. Once the treatment combination is right for your body, that is.

Beyond these pain specifics, it’s also well worth considering a more holistic embrace of hormetic stress. Sauna, cold plunges, cardiovascular exercise and fasting have all been of immeasurable benefit to people on healing journeys of all kinds.

Annoyingly, both in and out of pain management, hormetic stressors tend to be uncomfortable. Shockwave therapy isn’t always fun, running up hills isn’t fun, and cold plunges are generally even less popular. So it takes willpower to repeatedly throw one’s self into these fires. But ultimately, a life hollowed out by chronic pain is infinitely worse. So once they fully understand the value of hormetic stress, most pain sufferers find the choice between the two quite an easy one to make.

It’s a mystery why the body needs agitation to be fit .. to heal pain. But it so often does.

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The Old Age Myth

Tobias Hall — Tue, 11 Jul 2023 00:28:54 +0000

The Old Age Myth

Over time, a toxic belief can be as harmful to the body as a toxic chemical.

One of the most toxic and inaccurate beliefs nurtured by many pain sufferers is that their pain is caused by getting older. This old age myth may stem directly from the global family doctor’s office, where it is often advertised, but it’s hard to know for sure where it started.

For some, dispelling the age myth is the most important learning on their road to recovery. Developing clarity around this myth has the capacity to profoundly impact people’s quality of life: if not immediately, at some point in their future. Many people can achieve clarity in a matter of minutes and find it serves them for years.

Words hold great power over our health and well-being. Especially the ones we repeat often. Imagine the long-term health impact of sitting a small child down every day and telling them in a serious tone, ‘All exercise is very, very bad for you’ or ‘Only stupid people eat vegetables’. Words and phrases, when repeated often enough, can have a life and death hold over us.

‘It’s just old age’ is a phrase that I have seen wreak direct havoc on the health of countless people, for decades.

‘It’s just old age’ are words that contain many subtle threads of meaning, but ultimately it boils down to ‘nothing can be done because my machinery has broken down irreversibly’.

You may have noticed that friends, neighbours, healthcare providers (and even yourself?) frequently attribute pain in the over 40’s to ageing. In contrast, after 20 years in the front lines, managing the pain of people from 90 days old to 90 years old, I have come to believe ‘It’s just old age’ is one of the most overused, inaccurate and seriously harmful phrases in the English language.

Did you know that research has shown, beyond any doubt, that people in their 50s get far more back pain and neck pain than people in their 80s?

Did you know that the majority of age-related disc bulges never cause any pain?

Did you know that only a very small percentage of arthritic joints actually cause pain?

Most of the people I talk to about pain and their ageing process are surprised by these facts.

Des was 93, and he felt it. He was the kind of older gentleman who everyone finds adorable. No doubt, he had always been a sweet-natured man. But over 93 years, life had softened him to the point of being baby-like in his ability to light up a room. I had known Des for six years and liked him a lot, but I never saw much of him.

Long before I met Des, he had started attending the clinic where I worked to get his lumbar spine checked every six months. These legacy treatments had been agreed upon by Des and my predecessor after he had serious back pain in his ten years earlier. And I continued that care with Des. This meant that Des and I had brief interactions twice a year. And in time, I became aware that they were highly repetitive in nature. Word for word, our conversation always followed the same pattern.

Me. ‘Hey Des, how are you feeling at the moment?’.

Des. ‘Oh you know, I feel old; I’ve had a good life though; I’ll be quite happy to go soon, I don’t mind’.

Me. ‘What parts of you feel like that, Des?’ (fishing for specifics)

Des. ‘Well, you know I am so stiff all the time. It’s hard to get up in the morning, and I can’t even go for a walk. Going upstairs is a struggle; I am just very, very old, you know. But you know I’ve had a good life, I’m not complaining.

Me. ‘Well, let’s take a look and see if we loosen things up a little bit for you, Des; let me help you onto the table’.

Des. (very slowly clambering onto the table) ‘It’s okay, I’m just getting old’.

The treatments themselves were also highly generic. Some gentle dry needling and mobilisation. Which Des always felt helped loosen him up slightly. Enough to make it feel mildly beneficial was my impression.

Des was living with a lot of stiffness and pain, mostly in his lower back region. He felt extremely stiff, stooped and uncomfortable all day, every day. And naturally, he attributed it to the ageing process. The treatments took the edge off this feeling.

In the unspoken background to these conversations, I sensed Des was suffering a great deal. Despite being superficially philosophical, his eyes told a different and far more emotional story.

A percentage of older men who’ve led a full life appear to soften as they age. And thus, find their emotions far more raw and visible than they were in their youth. They cry more easily than most younger men. Des was one of those gentlemen, and it made him incredibly easy to read. In these talks, his eyes watered visibly, and it was painfully apparent from his demeanour that he felt a great deal of anguish about his loss of mobility.

Older people who battle just to get up and dress themselves in the morning suffer. Dementia notwithstanding, they all remember vividly what it was like to leap up without a second thought. Just because they have different numbers attached to their birthdays, it doesn’t mean they like being crippled any more than the rest of us would. Des was suffering.

There was another unspoken narrative in the background of these predictable chats with Des. The physical things I was seeing and feeling as a clinician. And they were causing me to become highly sceptical of the ‘I’m just old’ narrative, unbeknown to Des.

From the way he moved, I could see there were certain legitimate age-related changes that accounted for parts of what Des was feeling; he was 93, after all. Yet there was also something very suspicious going on. Something easy to miss—unless you treat biomechanical pain for a living.

If you treat enough chronic pain patients, you eventually attune to how different types of patients move. Gout sufferers, hip pain sufferers, frozen shoulder sufferers, disc pain sufferers, back pain sufferers, knee pain sufferers etc. They all tend to move in their own specific and predictable ways, especially when they rise from chairs and then climb onto treatment tables, as luck would have it.

This was the suspicious thing about Des’s ‘I’m just old’ diagnosis. He didn’t move from chair to table like a struggling 90-year-old. Des moved like someone who had back pain. And for as long as I had known him, he always had done.

Another ill-fitting jigsaw piece was Des’s left sacroiliac joint. Motion palpation of the dear old boy indicated this joint was perpetually locked and very inflamed. It gradually became impossible not to suspect chronic mechanical pain, as opposed to old age pain.

Despite my suspicions, I never wanted to rock the boat. I admired Des’s commitment to maintenance care and didn’t speak up about my suspicions for a long time. It’s often harder than you might think to have those conversations. Des really truly believed his immobility was old age, and so did his family doctor of 50 years. Pushing back on these narratives can create discord. But eventually, I spoke up. The opportunity presented itself after Des’s pain and stiffness went through a flare-up.

Long story short. I could tell Des thought my ‘back pain, not old age’ theory was at least 90% youthful overconfidence, but he trusted me. So he gave me the green light to treat him the way I’d been wanting to, instead of the legacy treatments we had always done. This involved manipulating his sacroiliac joints far more firmly than most people would imagine being appropriate for a 93 yrs old—deep tissue release for his lumbar fascia, then rinse and repeat twice weekly for two months.

After the first sacroiliac adjustment, Des stood up straighter than he had in over a decade. He was completely astonished. From week 3 of the new plan, Des’s entire demeanour changed, and he never mentioned feeling old and ready to die again. He resumed his daily short walks after a 5-year hiatus. Found getting up in the morning comfortable. He dressed himself easily. And his general energy and mood were completely transformed.

Once things had settled, Des decided he would resume his maintenance care at a fortnightly interval rather than the original six-month intervals. This kept him mobile for his remaining years.

Des’s experience played out exactly as it does when you unlock chronically inflamed sacroiliac joints in 50-year-olds. Admittedly he remained frail. But Des didn’t perceive any suffering in his normal age-related limitations. It was the chronic back pain that caused him to suffer. And once that was gone, Des had a new lease on life at 93.

Des’s actual diagnosis was ‘sacroiliac joint pain syndrome’ or, if you like ‘, simple mechanical lower back pain’.

The original misdiagnosis was severe ‘It’s just old age-itis’. That small cluster of seemingly reasonable but deeply malignant and deeply inaccurate words, ‘it’s just old age’, had been ruining a precious and meaningful part of Des’s life.

Some 80-year-olds play golf three times a week, go to the gym twice a week, and manage multiple cruises a year. Other 80-year-olds can barely dress themselves because of crippling disability that hollows out their quality of life. The slowing down of humans is not a straightforward and linear process; it’s a complex topic.

If I could convince you that even arthritic pain isn’t ‘just old age,’ it might be easier to believe your pain isn’t ‘just old age’.

*This is a conversation about ‘wear & tear’ arthritis. As opposed to the likes of rheumatoid arthritis is an autoimmune condition.

At a glance, arthritis certainly appears to be a very simple case of ‘just old ageness’. Old people’s joints just wear out and get sore. But in truth, this is an oversimplification that borders on the utterly absurd.

Even the most basic facts of arthritic pain reveal an infinitely more complex situation.

Over 90% of joint surgeries for arthritic pain are performed on patients who don’t require the same procedure in their other knee, hip, ankle etc. So neighbouring joints that are the same age have not worn out.

Over 90% of joint surgeries are in the lower limbs. Not the joints in the upper half of the body. This is because arthritis almost never develops symmetrically or evenly throughout the body.

The majority of arthritic joints never hurt and go completely undiagnosed.

Wear and tear arthritis frequently shows up in people who are far younger, usually in highly specific and isolated parts of their bodies.

If I could convince you that even arthritic pain isn’t ‘just old age,’ it might be easier to believe your pain isn’t ‘just old age’.

*This is a conversation about ‘wear & tear’ arthritis. As opposed to the likes of rheumatoid arthritis is an autoimmune condition.

Even the most basic facts of arthritic pain reveal an infinitely more complex situation.

Over 90% of joint surgeries are in the lower limbs. Not the joints in the upper half of the body. This is because arthritis almost never develops symmetrically or evenly throughout the body.

The majority of arthritic joints never hurt and go completely undiagnosed.

Wear and tear arthritis frequently shows up in people who are far younger, usually in highly specific and isolated parts of their bodies.

These cursory facts alone reveal ‘arthritis is just old age’ to be little more than a contemporary superstition. Just like ‘pain is just old age’.

To make this more tangible, let’s take a closer look at a very typical pair of 75-year-old knees.

Gary is tough, way harder than your average customer and for good reason. His childhood was very impoverished by modern Western standards. Then his early adult life was difficult too.

Gary’s unique selling point is that he once raised three children alone with essentially no money. His wife died suddenly, leaving him unable to reconcile the logistics of paid work with the full-time care of 3 small children. He had no extended family or childcare to lean on. And was too proud to receive government support.

He survived by growing his own food and hunting constantly to feed his family, subsidised only by a very small amount of paid employment. Very few people alive today have lived as a borderline hunter-gatherer, so it makes him a rare and interesting case history. His is an impressive story of love, grief, hard work and ultra-resilience. And what makes Gary even more extra-appealing to me personally is that despite the hardships, he has no rough edges to his character. He’s like a teddy bear made of thick indestructible canvas.

If there was a flaw in Gary, it would be that he is far too willing to put up with pain and hardship. He goes through all sorts of difficulties without asking for help. And it’s not hard to guess why.

Self-sufficiency is clearly a virtue, but excessive self-sufficiency can become dangerous, especially when it comes to health-related matters that need treatment. It’s a well-documented source of problems in male patients.

Gary’s right knee had hurt for decades, so much that it had genuinely tested Gary’s toughness to its limits. All said and done, it had severely reduced his ability to live the life he wanted. He’d been on a fraction of ‘the walks’ (hunts) and had a fraction of the decent sleep that he deserved to have had; over many years. And his day-to-day life was blighted with chronic disability. All because of his knee. His right knee had progressively worsened over 30 years and eventually reached its 75th birthday. So no surprise it had extensive arthritis as well as pain.

Meanwhile, Gary’s left knee had never hurt a day in its life. ‘My left knee is perfect’, he would often say. Although if you squint hard enough at the left knee x-ray, it has a tiny bit of painless arthritis.

Asymmetric problems like Gary’s are very typical for older patients with knee and hip pain/arthritis. A closer look at this fact reveals the absurdity of casually dismissing knees like Gary’s and the suffering they cause as ‘just old age’.

Both Gary’s knees have done the exact same mileage – both had the same job – both played all the same sports – both raised the same children – both had been on all the same hunts – both worn all the same boots – both lived and worked on the same surfaces – both been on all the same runs – both slept in all the same beds – both had the exact same nutritional support – both have the exact same genetics – and above all else.. both knees are the same age.

Yet Gary’s two knees had in some way led to such different lives. Going back 30 years, his right knee already had intermittent niggles that stopped him from road running. Then 15 years previously, the right knee even made walking on gentle hills and sleeping afterwards a challenge. By the time Gary was 65, he felt 85 half the time, just because of the right knee. His left knee had never hurt even once.

This is routinely how life impacts pairs of identical neighbouring joints in the same person. So looking with open eyes, how can we keep a straight face and say the right knee has pain and arthritis because of old age?

If arthritis was ‘just old age’, it would develop symmetrically in pairs of joints that had done the same work. Which it almost never does. The same is true for all musculoskeletal pains.

In the real world, pain and osteoarthritis are not simple; they are complex. They relate to the intermingling of genetics + lifestyle + psychosocial stress + biomechanics + injuries + mileage. And these complex truths definitely applied to Gary’s case.

The arch of Gary’s right foot collapsed when he walked millions of times a year. He also had very weak muscles in his right leg from an early age. This situation developed after a very bad sprain to his right ankle, sustained on a hunting trip when he was 28.

After the injury, the disastrous decision was made to put him in plaster for five weeks and then in a moon boot for six months. When he finally escaped the damn boot, it took him another year to be able to walk properly. There was never any actual rehab. Compounding this, Gary has also led a very physically and emotionally stressful existence. Also, tellingly, both Gary’s parents had arthritic joints.

It may not have rolled effortlessly off the tongue like ‘it’s just old age’. But the above paragraph is the authentic explanation for why Gary’s right knee had mysteriously disintegrated. And after addressing these factors, Gary was able to enjoy more hunts in his late 70s than he had in his early 60s.

So even arthritis in 75-year-olds is not simply ageing. Let alone lower back pain in 45-year-olds. For many, this knowledge opens the door to a far happier, healthier, more connected and more comfortable life.

Next time you are at a large international airport walking (hopefully) to your gate, pay close attention to your fellow passengers. When it’s time to walk the half mile to your gate, you get a chance to see how age does not determine pain and immobility.

There are those 70-plus’s who walk the half mile quite normally, keeping up with the younger passengers. There are those who walk okay but much slower than the herd. There are those 70-plus’s who walk with some degree of assistance, like a stick; most of these need to take breaks too. Then finally, there are those 70-plus’s who are in such a poor state that they require the nice man driving ‘the golf cart of shame’ in order to get to their next gate. Yet all these elder folks are in the same age group.

Obviously, our bodies naturally stiffen up as we get older. The average age of those riding the golf cart is far higher than those who walk to their gate; that’s pretty obvious. Wear and tear is a real part of life, after all. This is not in doubt. The thing is, though, ‘correlation’ and ‘causation’ often look like the same thing. But they are not the same thing.

Wear and tear happens over time, but it’s not the time itself that inflicts it.

I challenge you to name one chronic physical problem that doesn’t tend to show up more in older people.

Older smokers cough more and get cancer more; are their coughs and tumours ‘just old age?

Older couch potatoes are more obese and have higher BP, is their physical deterioration ‘JUST old age’?

Older type 2 diabetics suffer from terrible skin sores and neuropathy as they get older; is that ‘just old age‘? Or is it the long-term ravages of a disease?

Older sugar addicts have worse teeth than young sugar addicts, are their black teeth ‘just old age’?

Tissues that are exposed to long-term stress suffer more and more with the passage of time. But it’s the stress and not the time itself that’s the primary problem.

‘JUST old age’ means that time and mileage are the only factors that led me to where I am at. This is literally never the case with pain or with arthritis.

People can get pain at every stage of life. Some knees wear out by their 70th birthday; some don’t. Some humans wake up on their 80th birthday and throw themselves at 18 holes of golf; other 80 yr olds can barely get to the toilet unassisted. Some people have a hip joint replaced at 45. Some people have terrible back pain in their teens and then none later in life. Pain and mobility are complex issues. If we can learn to respect these facts, it opens us up to a world of pain solutions that are otherwise ruled out.

The person who has flat feet and a strong tendency towards ankle sprains in their teens and 20s. Then later develops chronic knee pain in their 40’s & 50’S; will tend to suffer a lot when they are older.

The person who is vigorously healthy but suffers a dramatic motor vehicle accident followed by a sloppy rehab process in their 50s has a far higher probability of chronic pain when they are older.

The person who lives with long-term neck pain throughout their whole life and never seeks treatment will tend to suffer more when they are older.

People who go through substantial emotional adversity in their childhoods tend to have far more chronic pain throughout their lives. Then when they are older, their arthritic joints hurt far more than people who haven’t held stress and trauma in their body’s for a lifetime.People with untreated trauma and PTSD suffer from a lot of pain and disability later in life.

People who don’t exercise and carry extra weight for long periods tend to suffer with pain and mobility when they are older.

These are the type of poor souls who rely on sticks and golf carts in their latter life chapters. And when they are younger, for that matter.

The milder patterns of pain we live within the first half of life often herald the onset of premature disability later in life. There is nothing random, mysterious or inevitable about any of it.

Many much younger patients show early signs of arthritis on x rays. Some studies have even shown that up to 15% of school leavers have the tiny but demonstrable beginnings of spinal arthritis. Arthritic changes often start slowly, very early in life.

Our beliefs hold great power over what happens to our bodies. Even a physical challenge as simple as the removal of a splinter becomes impossible if we say that it is. Simply because we seldom put any real effort or energy into tasks we believe are impossible. The chances of us truly applying ourselves to treatment and rehabilitation for a body part we believe is fundamentally ‘worn out’ are slim to none. This is the power beliefs have to determine our health.

Yes, older people suffer more joint pain in their lower limbs, but conversely, they get far less back pain and headaches. So we must be careful not to conflate all pain into a single ‘old age basket’.

The ‘Just old age myth’ is ensnared into the fabric of how we approach pain as a global culture. It isn’t just a superstition held by those without the advantage of a medical degree. Elders with pain are systemically under-served.

A 2011 study published in The European Journal Of Pain found that the median duration of a doctor consultation for elderly patients requesting help with pain is 2.3 minutes. It’s fair to surmise that this is most likely a clear non-verbal cue that these doctors subscribe to the old age myth. For comparison, at a clinic like mine, it is 45-60 minutes, and that is just the first step.

Over the course of my career, I’ve met literally thousands of older patients who had been told in no uncertain terms that their pain was untreatable when in actual fact, it was eminently treatable. This systemic neglect is driven in no small part by that malignant little phrase that just rolls off the tongue so effortlessly ‘It’s just old age’.

My advice is to reject our culture’s catastrophically oversimplified ‘just old age’ narrative. Instead, open your mind and your body to the far more complex and fruitful truth about pain. If you can do that, you’ll naturally open up to the countless solutions for pain that actually work at every stage of life.

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Injury Myths

Tobias Hall — Wed, 05 Jul 2023 01:15:04 +0000

Injury Myths

– A true injury is what occurs when physical forces conspire to damage a previously 100% healthy tissue. –

The nature of a classic injury doesn’t require much explanation. Life has an all too obvious capacity to break bones, rupture tendons, tear muscle, dislocate joint tissues and rip ligaments. Less serious ‘true injuries’ cause the microscopic equivalents of these major injuries. Microtears to muscle fibre and ligament tissues and the like.

Healthy, strong tissues are highly resilient to damage; if they weren’t, there would be no such thing as contact sports. So true injuries are, without exception, memorable physical events. If you experience a ‘sudden pain’ in your spine picking up a box of tissues, it is worth questioning how healthy your spine is; and whether it really qualifies as a true injury at all.

The most obvious feature of true injuries when they occur is how much they hurt. The purpose of this pain is protective. It is nature’s way of protecting you from the unthinkable horrors of running on a broken ankle bone or ACL tear. When you are injured, the body fires pain signals and releases a cascade of essential inflammatory chemistry. Under normal circumstances, you feel all that as temporary pain and swelling. This pain of injury is absolutely vital for the preservation of life.

Yet, if an injury site hurts for too long or resolves temporarily, then comes back later, it stands to reason that there is something more complex going on. A persistent or recurrent pain after an injury is something that you should pay great care and attention to in the long term. The body is a very sophisticated system. One that seldom (if ever) generates persistent symptoms without a good reason to do so.

The progression in how we manage significant injuries in the past 100 years is a match for the improvements we have made in telecommunications and transport in the same time period.

At the beginning of World War I, as many as 90% of leg fractures were fatal. Most ultimately bled out after being thrown carelessly onto stretchers with no splints or casts. These days, however, almost no one dies of a broken leg, even in war zones. We have truly wondrous high-tech surgical means to preserve life and limbs after major injuries. Yet the longer-term rehabilitation of injury (which is supported by a mountain of scientific literature) still frequently remains an afterthought in today’s frontline healthcare setting.

There is still a dark side to the way we tend to manage injuries in the 21st Century.

Louise was an apparently healthy 32-year-old American lady with lots of curly hair and the look of a world traveller. On first impressions, she seemed pretty normal, if a little stressed.

Once you get talking to Louise, you gradually realise she isn’t living a normal life at all. You also notice after a few minutes that she isn’t able to sit in one position very long, and she constantly moves her body weight in the chair. The other thing you fail to notice right away is that she has some very dark blackish stripes across her face that she partially covers with makeup. These stripes are very distracting once you have noticed them because they are not the colour of any scar or birthmark you have ever seen. They are really, really black, like rubber.

When she was 23, Louise was driving home late one night in the small car her parents had purchased for her 21st birthday. For reasons she can’t explain, at an intersection, she accidentally ran a red light. As she crossed the intersection, her tiny little car was directly hit side-on at 90 mph by a very large commercial vehicle.

The impact was so significant that it crushed her little car like an empty beer can. And in a bizarre, miraculous, incredible, one-in-a-million turn of fate, she seemingly wasn’t injured. She had no broken bones. She had no joint dislocations. She had no damage to her internal organs and no internal bleeding. And there was no brain damage or damage to her spine and central nervous system. She didn’t even have any concussion symptoms.

The only visible injury that Louise presented with at the hospital was two deep indented black marks which extended from her cheekbone across her eye into her forehead. These were caused when the frame of the car window drove itself into her face on impact. When I met her ten years later, she still had two long black stripes so deeply impregnated with rubber that they looked like strange black facial tattoos.

The night she was in the hospital, all her tests were done within less than 2 hours. Then the ED doctors report back to her on the miracle they had discovered. None of her scans or x-rays showed any major trauma whatsoever. The ED doctors confirmed that based on similar crashes, they would have expected her to have sustained multiple life-ending injuries. Yet she didn’t even so much as get a broken wrist for her troubles. All she had was the two black facial lesions.

All in all, after the most extreme car crash imaginable. Louise was congratulated and sent home with a few days worth of codeine and told she wouldn’t even need any follow-up physiotherapy. She was in the hospital for less than 3 hours.

It all seems like a pretty happy story until you hear the rest of it.

Louise went home the night of the crash with a pounding headache. Then when she woke up the next morning, every muscle in her body felt like it had been torn apart. She also felt such an intense pain throughout her spine that she felt like it was literally on fire. The day after the crash, she also had a violently intense migraine that lasted about 3 hours.

Fast forward six months, and Louise was still in just as much pain as she had been the day after the crash. Her whole body ached and throbbed constantly. She also still had debilitating spinal pain and crippling daily headaches. She was unable to work, exercise or socialise. Her family doctor had diligently ordered a second set of scans several weeks after the crash, all of which also came back clear. He had prescribed her some strong painkillers and told her to wait it out in the hope that her body slowly recovered, which it was showing no sign of doing.

A year or so after the injury, she got desperate and took matters into her own hands. She started seeing a chiropractor and a soft tissue therapist. Two years of weekly soft tissue sessions gradually got her muscle pain to a level where she found it manageable. While frequent gentle chiropractic sessions got her migraines down from 7 days a week to 3-4 days a week. Nothing touched the spinal pain, however.

Fast forward ten years, and Louise is sitting in my office on the other side of the world in New Zealand. Shifting around in her chair to take pressure off her back and telling me about the level of chronic pain she lives with.

When she met with me ten years on, Louise literally couldn’t remember a single waking moment without pain since the crash. She had never got rid of the headaches, and the spinal pain had simply never gone away, even for a moment. She estimated that her day-to-day quality of life was about a 4/10 due to the pain. She had long since given up on the career she had planned because she could only work about 20 hours per week, choosing to go on a long-term working holiday instead. She had not played sports or exercised with any intensity since the day of the crash. Her pain had not reduced in any appreciable way in the previous seven years.

It took two more years of intense weekly treatment and spinal rehabilitation to finally get Louise’s pain under control. At this point, she was able to resume a fairly normal life, aside from the ongoing work she requires to prevent the periodic relapses she is still prone to.

All of Louise’s scans and x-rays were clear. Yet the reason for her headaches and spinal pain was clear as day if you know what you are looking for. Her functional spine tests and motion palpation tests (performed by me ten years later) revealed that she had sprained virtually every joint in her spine. These joints remained locked and inflamed a decade later, having never been mobilised. The fascia (connective tissue) around her spine had lost all its elasticity due to widespread scar-like adhesions. And ten years on, the muscles surrounding her spine were so tight it was as if the crash had occurred the previous day.

In other words, Louise’s entire spine had sustained an incredibly severe whiplash injury. And subsequently, they did not even make a partial recovery. Instead, it had transitioned into a chronic unhealed state which included the addition of extensive chronic inflammation and scar tissue. Perhaps none of which is that surprising given the nature and severity of her accident.

Louise’s story contains many grim lessons about how badly our culture can still fail people with pain and injuries.

The obvious healthcare fumble presented by Louise was the complete lack of a diagnosis. It is still common practice to assume that the only injuries worthy of note are those that are identifiable with the limited medical scans and imaging we have. This is a corruption of the ‘disease model’ of healthcare which makes great use of ‘ lab tests’ to identify organic diseases in the body. And also works well for identifying fractures and the like.

The ‘if it isn’t visible on the scan, it didn’t happen’ approach overlooks the elephantine fact that only a micro-fraction of our mechanical pain and injuries can actually be seen using medical scans and tests. The inflammation, joint stiffness and even scar tissue of a severe whiplash cannot be seen on MRI scans, x-rays, CAT Scans or ultrasounds. But that doesn’t mean they don’t exist.

Louis’s case also highlights the fact that we have yet to become a rehab culture in the sense that we are already a surgical and pharmacological culture. The notion that a human body could go through an impact of that magnitude and not need any follow-up physical therapy is outlandish. Admittedly Louise’s case is a particularly extreme example of ‘rehab oversight’. Yet it is a fair reflection of a widespread problem. We still routinely perform major surgeries and discharge major injuries (and pains) without meaningful rehab.

Another grim observation posed by Louis’s terrible suffering is the fact that many injuries simply don’t heal unless they receive substantial encouragement. Many of them seemingly need a great deal of stimulation before the body is able to express its potential for healing.

It is not known why so many of our injuries don’t ‘just heal’ fully.

It’s worth noting that our bodies have a great capacity for strength and fitness, yet without the proper stimulation, they turn to jelly. The same is true of healing. Our bodies don’t need to move much these days, compared with the outdoor life they are evolved for. This ‘sedentary factor’ may at least partially explain why so many injuries fail to heal on their own terms. It would also explain why all injury rehabilitation involves ‘supplementary movement’. To replace the natural movement we are starved of, perhaps?

There is one further thing that is fair to say about Louis’s catastrophic spinal whiplash. It was definitely a true injury – Unlike many of the ‘sudden pains triggered by movement‘ that we call injuries, but are, in fact, something far more complex and insidious.

There is a massive amount more to the topic we call injuries than meets the eye. The life cycle of a true injury is relatively simple. Yet, many of the musculoskeletal injuries we sustain unfold in a manner that is far more complex and concerning, often having far-reaching consequences for our health in the form of slow recovery, relapses, reinjury, chronic pain and chronic disability.

Complex Injuries

“When back pain suddenly shows up, we are tempted to blame it on the last minor stressor that affected it, such as a soft bed in a hotel. This is like blaming your bankruptcy on the last latte you bought before your account finally went into the red.”

– Todd Hargrove

Complex injuries look and feel like true injuries. They are triggered by movement and involve a sudden onset of pain. In reality, however, they are caused by a buildup of repetitive strain that weakens the ‘injured’ tissue long before any symptoms appear.

Miles was 6ft 4 inches tall and routinely squatted 130 kg for reps at the gym. He was one of those men who were born destined to be big. He had heavily supplemented his genetic fate with a lot of weight-lifting over many years. Then one day, he had occasion to pick up a small dog kennel.

Despite the kennel weighing in at a mere 30kg, the lift completely detached Miles’s right bicep tendon at its insertion point on his elbow. When this happens, the visual impact is remarkable. The whole bicep muscle bunches into a tennis ball-like appearance at the top of the arm. And it hurts every bit as much as you would imagine. Surgery was needed to reattach the bicep tendon at the elbow.

Even to the casual observer, Miles’s bicep tear was clearly something more complex than an injury. When a man that strong tears a tendon during such an insignificant lift, it’s pretty clear that something was not right with that tendon. And then there was the fact that Miles had always been one to over-train his well-developed biceps.

Many of the events we call injuries are just like Miles’s bicep. Although admittedly, it often isn’t as obvious that the tissue must have been compromised.

A prospective study of 583 habitual runners (carried out all the way back in 1989) examined factors that predicted the likelihood of running injuries. The researchers identified three factors that accurately predict which runners are most likely to get injured: Running over 64 km per week – previous injury – inexperience. Data like this reflects a universal truth, most ‘injuries’ are not random. An unknown but very high percentage of injuries are caused by factors that lead to repetitive tissue strain and tissue weakening long before the ‘injury event’.

It is common knowledge in rehab circles that there is seldom anything random about ACL sprains, ankle sprains and ‘back injuries’. They all have well-known and predictable precipitating factors. They also don’t spread themselves evenly throughout the active population like random events do, instead tending to happen to certain individuals. This knowledge sits in contrast to the more common cultural belief that injuries are all driven by a combination of luck and the sheer forces at play in the ‘injury moment’.

Many of the sudden pains we name as injuries are not true injuries. They are, in fact, ‘complex injuries’ or even just sudden pains that occur in body parts that already have big problems.

A complex injury is when physical forces cause sudden pain or rupture in tissue that had been previously undermined. Usually by repetitive strain, weakness and/or by a previous ‘true injury’. These forces are often far less extreme than the forces that cause true injuries

The confusing thing about complex injuries is that they often look and feel exactly like true injuries. One minute you don’t have a care in the world; the next, you are in agonising pain, watching your knee swell up. So, to grasp complex injuries, it is necessary to check in with what you most likely already know about the principle of latency—remembering that in life, things aren’t always as they seem.

‘Latency’ is when you are feeling great moments before you die of a massive heart attack. Latency is when you have asthma and IBS, but today you feel great and have no symptoms whatsoever. Latency is the years you spend smoking prior to the cough and emphysema. And latency is also what you are experiencing the moment before you ‘put your back out’ doing some minor DIY task.

The body absolutely does not report all tissue malfunctions at all times; in fact, not even close. If it did, our hunter-gatherer ancestors would have had so many pains and physical symptoms they wouldn’t have been able to hunt, gather and collect water consistently enough to survive.

Your body is deeply invested in the suppression of symptoms associated with everything and anything deemed less biologically important than your immediate survival activities. It has evolved this policy of suppression over millions of years. And if it hadn’t, we wouldn’t be here, let alone be the evolutionary success story we are.

Meanwhile, we have a suspiciously broad spectrum of happenings that we think of as injuries. In fact, we have a strong tendency to identify all sudden pains as injuries.

Let’s split up the type of events we refer to as injuries into five groups so you can reflect on them.

It’s important to be clear these levels are not ‘levels of injury’ – these levels reflect how extreme or un-extreme the circumstances of the supposed ‘injury’ were.

Level 5 - Major Events

These are the self-explanatory car wrecks and grizzly attacks we rightly refer to as injuries. Most of these involve full-scale rips, tears, joint dislocations or fractures, often within multiple body parts. We can safely call these true injuries. They all involve immense physical forces that would badly injure 100/100 people who experience them.

Level 5 - Major Events

Level 4 -Serious Events

These are the likes of significant sports injuries. The ‘big falls’ that tend to lead to a bone breaking, a ligament tear, or some dislocation or other. All of these lead to an extended period of recovery. The overwhelming majority of these events are serious enough to damage the vast majority of bodies.

Level 4 -Serious Events

Level 3 - Significant Events

These are the somewhat milder and more random sports injuries. The change of direction while running at a speed that leads to an unexpected but significant sprain or a cruciate ligament tear. A heavy lift at the gym that leads to a ‘back injury’. Some of these lead to extended periods of recovery, and others don’t. These are events that seldom cause problems for healthy people. The % of deadlifts reps that lead to pain is very low.

Level 3 - Significant Events

Level 2 - Minor Events

These are often ‘somewhat random’ type movements that rarely lead to ‘injury’ but do for some. Picking up a heavy-ish box leads to 2 weeks of back pain. The minor stumbles that lead to sprains. A percentage of these still lead to a lot of pain over an extended period. The incidence of these types of movements causing pain or injury relative to how humans undertake them is infinitesimally small.

Level 2 - Minor Events

Level 1 - Non Events

The twinges and tweaks that happen during inconceivably minor events but still lead to sudden pain. The sneezes that lead to back or rib pain, minor twisting movements that lead to sudden pain. These can, nonetheless, still leave people incapacitated. Again, what percentage of human sneezes lead to significant episodes of back pain? Is ‘micro-fraction’ a word?

Level 1 - Non Events

As you can see, we have had to weave ourselves a very large basket to fit all these supposed ‘injuries’ into. When you see this many differing scenarios getting thrown into one conceptual basket, it pays to be suspicious. Health and life are rarely so simple.

Let’s re-insert a definition of ‘true injury’ that, hopefully, you can agree to.

‘A true injury is a physically traumatic event – where a normal healthy tissue is suddenly overwhelmed – leaving the tissue physically damaged or compromised by the event’.

There’s no question this description applies to many real-life events. The healthiest and strongest bodies have their limits. Virtually all Level 4 & 5 events easily qualify for this injury classification.

Here’s the thing, though, the further down the levels we go, the harder it becomes to make a plausible case that we really showed up to the incident with a truly ‘normal & healthy tissue’.

Here are some practical questions to mull over; answer each of them for yourself based on your own life experience.

If you end up with a ‘knee injury’ just because you marginally increased the amount of gardening or jogging you did for a week… do you genuinely believe that was a strong, healthy knee?

You trip on a curb after two glasses of wine, your ankle is badly sprained, and you still have ankle pain six months later. Do you truly believe that was likely to have been a healthy ankle? Bearing in mind the fact that millions of people have had near identical experiences and recovered quickly/instantly.

Your brother-in-law ends up lying flat on his back for 10 days (unable to even get to the toilet unassisted) after trying to hitch a boat trailer. Do you believe it’s likely he has a healthy, strong back?

Some of us can play season after season of test rugby without a significant shoulder injury. Others can’t get through 6 months of low-key gym exercises without multiple ‘shoulder injuries’. Do you believe the difference is likely to be luck?

Countless millions of people go a whole lifetime without a sprained ankle; others suffer multiple sprains per year for their entire adult lifespan. Knowing this, do you suspect that the people with persistent ‘injuries’ may really be suffering from some form of weakness?

It takes a lot to damage healthy tissue. Healthy tissues can play professional sports, trip, fall, lift and do endless physical work without pain or ‘injury’. Healthy tissues are highly resistant to sudden pains and injuries.

Many sudden pains that look like injuries are ‘tip of the iceberg’ moments – with deep underlying biomechanical issues being their true root cause. Many of these problems have been sitting latently in the body for months or years at a time. It is a well-documented fact, for example, that the natural angle of the knee and the strength of the deep gluteal muscles can predict the likelihood of ACL tears in young athletes. In other words, knees that don’t bear weight efficiently are known to be far more prone to major ligament tears.

Once a tissue is weakened by persistent strain over an extended period of time (e.g. standing on concrete every day with flat feet, running on the tarmac with bad form for long periods, or even just sitting behind a desk for 20 years), it may become undermined. Then almost any small event can trigger pain.

The difference between a trigger and a cause can be a very big difference indeed. Imagine if you believed that tennis truly caused heart attacks, as opposed to being a trigger for heart attacks.

Without understanding the true mechanics of heart disease, you could easily assume tennis was what caused your cardiac arrest. Without understanding heart disease, it seems perfectly logical ‘I played tennis, then I had chest pain; therefore, tennis damaged my heart’.

Understanding that tennis is a trigger for heart attacks, as opposed to a cause of heart attacks, is very important knowledge. Without this knowledge, you wouldn’t respond to the heart attack by giving up smoking, stress and soft drinks – you’d just give up tennis and think your work was done.

For many pain sufferers, the realisation that they suffer from chronic weakness and tissue strain rather than recurrent injuries: is a majorly transformative step towards better health. It opens the door to finding the real causes of pain.

Once you understand the true nature of a physical disorder, it becomes far easier to differentiate causation from coincidence. Just because the heart stopped during tennis, it doesn’t mean the tennis did it.

If you understand that many ‘injuries’ are, in reality, just pain triggers, it frees you up to shift your investigation onto more plausible suspects.

Meanwhile, the damage of complex injury pain is often mistaken for true injuries by patients, doctors and insurance providers alike. If you have had an ‘injury’ or ‘injuries’ in your past, it is entirely possible that the cause was wear and tear to the tissue that finally gave way. Many of us have had this happen and been misdiagnosed with a true injury.

Culturally, we believe very strongly that sudden pains are caused by injury. Patients with new pain often say, ‘I can’t think what I have done?’. This means, ‘I have a new pain, so I must have injured myself, but I can’t remember doing anything significant’. When in reality, if we injure a healthy tissue, it is always a memorable Level 4 or Level 5 event.

Overlooking the vital nuances that separate true injuries from complex injuries being brushed over is a big issue. It’s problematic because the misappropriation largely robs us of the ability to work on prevention and full rehabilitation. Identifying the patterns that led to the injury is the key to preventing further pain and further tissue damage.

True injuries and complex injuries both contribute significantly to the pandemic we live in the midst of.

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Getting To Grips With Pain Triggers

Tobias Hall — Tue, 20 Jun 2023 21:38:42 +0000

Getting To Grips With Pain Triggers

Triggers Vs Causes

Many pain sufferers struggle to discern between what really causes their pain and what simply triggers their underlying pain issues.

Triggers are always external forces and events, like bad sleep and awkward lifts. Whereas causes can be environmental, but are often internal challenges, like having a weak core, for example.

The true causes of pain are always a very big and important deal. Pain triggers, on the other hand, are very helpful to know but often trivial in the grand scheme.

To truly understand the difference between a trigger and a cause, it is worth looking at heart disease.

Tennis can trigger cardiac arrest, yet it most definitely isn’t the ’cause’ of cardiac arrest. The actual causes of cardiac arrest are lifestyle, stress and genetics, which leads to artery blockage. Tennis just triggers a heart attack after a long slow decline in blood flow to the heart muscle. This is why cardiologists clearly don’t lose much sleep over tennis.

The heart attack example highlights the huge distinction that can exist between triggers and true causes. Similar distinctions exist between many pain triggers and the true underlying causes of pain.

Performing an awkward lift or sleeping in a bad position can trigger pain. But triggering is not always the same as causing. The cause of the pain after an awkward lift is more probably something like a weak core or a gradual overuse mechanism.

If your office workstation causes you endless problems and needs endless fine-tuning, look around at your colleagues. If they seem more at ease with the imperfections of their workstations, it could be that your workstation is a pain trigger rather than a pain cause.

Knowing your pain triggers is a vital part of the process in gaining some momentum towards the goal of a pain-free existence. The long-term goal should be to have a body that is healthy enough to withstand simple triggers.

Knowing The Difference

It is important to work at discerning between triggers and causes whilst holding the whole topic lightly. Because there are many grey areas. And in many ways, the trigger vs cause question is a complex spectrum where firm distinctions often don’t exist. And where curiosity and open-mindedness are both wise and helpful.

Differentiating pain triggers from pain causes is a vital step that potentially informs and eases the entire journey. But it isn’t easy, and there are so many pain triggers that can seem causal.

Chocolate does not ’cause’ migraine headaches. It triggers them. Migraines are caused by deeply entrenched mental, biomechanical and emotional patterns that usually stem from childhood trauma or chronic stress. Millions of people enjoy chocolate without headaches.

Bad sleep does not ’cause’ neck and shoulder pain. It aggravates the underlying mechanical issues that neck and shoulder pain sufferers are afflicted with. Hundreds of tummy sleep can eventually ’cause’ neck pain. But a single bad sleep that leads to pain is just a trigger.

Moderate dehydration does not cause tension headaches. But it does trigger headaches in headache sufferers. Only chronic headache sufferers suffer from headaches that are easily triggered by dehydration. Dehydration makes many health conditions worse.

Workouts that lead to back pain are often (but not always) perfectly good workouts. Most often, there is a significant weakness in the person’s spinal tissues. The weakness is the ’cause’ of the pain; the workout is just the pain trigger. A useful step to start teasing out your triggers from your causes is to reflect on how your pain-activating variables affect other people.

First, bear in mind the fact that healthy tissues are pretty resilient. Even in older people

If a specific activity or event brings on your pain, reflect on how the same action impacts others. If you’re sure it would have brought on pain for almost everyone, it probably caused pain. If virtually all the healthy people you know would have been unaffected by it, it may just have triggered a deeper, more complex pain issue.

Snake venom is a great example of how life’s causes work. If you give a big dose of brown snake venom to 100 people, it results in a minimum of 99 dead bodies. That’s what causation looks like.

Compare this to chocolates’ role in headaches for instance. If you give chocolate to 100 people, you may only get one migraine; you might get none. That’s what a true trigger looks like.

Admittedly there are factors that tread the line between causality and triggering. A bad deadlift can trigger episodes of back pain. But done often enough, it can ’cause’ back pain too. Stress can trigger headache episodes, but over time, it can also act as a causal factor.

The wisest way to proceed with factors that clearly lead to pain is to keep an open mind about whether they are truly causal. Many of them will be, but others will just be triggers.

Avoiding Triggers

Trigger avoidance is a double-edged sword. It can be beneficial for improving the quality of life while we are in an unrehabilitated state. It can also be good if our triggers are genuinely not good for us. Yet, trigger avoidance can present grave dangers in the long term, especially if our triggers are healthy life activities.

Megan was 30, and she had figured out exactly how to ‘fix’ her knee pain.

She just completely stopped running and limited her walks to no more than 40 minutes on flat terrain. It doesn’t take much imagination to foresee where this type of strategy tends to lead in the long term.

Once Megan had the scar tissue that was trapping her IT Band broken down, strengthened her gluteus medius and made some better footwear choices, she was able to resume running. Because she had worked on the causes of her pain.

Working on our pain solely at the level of triggers can be extremely treacherous. Not only does it tend to ignore deeper truths about our pain and deeper healing that the body requires; for as long as we are focused on triggers, the source of our pain is always outside of us. Which is not healthy, nor is it very often true.

Avoiding triggers is important, but it’s not a comprehensive strategy for managing chronic pain. For many, it leads to significant constriction of fitness, health, socialisation and general quality of life in the long term. The real key to opening up the reconnection and freedom of a pain-free life is in eliminating and/or healing its true causes.

Megan was 30, and she had figured out exactly how to ‘fix’ her knee pain.

Identifying & Addressing Causes

There are many grey areas, but the following list is of factors that tend towards being the causes of pain. If a factor that activates your pain is either not on the list or doesn’t resemble anything on the list, it may simply be a trigger.

Scar tissue (which can be caused by both injuries & repetitive strain).

Excessively sedentary lifestyle.

Prolonged exposure to hard surfaces.

Weakened ‘frayed; tendons (tendinopathy).

Unhealed injuries ‘that never came right’

Cartilage tears/osteoarthritis.

Years of tummy sleeping.

Gait pattern asymmetry.

Extreme over-training for long periods.

Extreme overthinking for long periods.

Rotator cuff muscle wasting, usually due to postural habits.

Core muscle wasting, usually caused by old injuries or bad movement habits.

Gluteal muscle wasting , usually caused by movement patterns, environment, and inactivity.

Flat feet and high arches combined with exposure to concrete and tarmac

Bad lifting technique over long time periods leading to repetitive strain.

Weak ankles (or a tendency to sprain ankles) cause instability in the lower limb.

Extremely poor general health / self-care/obesity.

Depression which leads to inactivity, poor posture and changes in the brain.

Chronic anxiety which causes excessive muscle tension and changes in the brain.

Unaddressed bereavement and grief have a powerful effect on the

PTSD which is known to predispose people to pain in a host of different ways.

Unaddressed childhood trauma acts a lot like PTSD.

Toxic relationships cause a huge amount of tension in the body and changes in the brain.

Toxic work stress/environment, which acts a lot like toxic relationships

If you avoid the awkward lift or position, all you have done is remove a trigger. But if you strengthen the spine or heal a tendon, you have addressed the underlying cause of the problem.

Countless people have found that reducing stress and strengthening their spinal muscles has led to a normal relationship with their workstations because the stress and the weakness were the causes of their pain. The workstation was just a persistent trigger.

Treatment, healing, rehabilitation, therapy and self-care are more often the real answers to chronic pain, along with the elimination of any true underlying causal factors.

With the right healing tools and rehab in place, most pain sufferers find that their superficial triggers fall away very quickly. Leaving only deeper causal factors to work on in the longer term.

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When Lower Back Pain is More Than Just Lower Back Pain: 7 Ways Back Pain Can Be Caused By Something Serious

Tobias Hall — Sun, 29 Jan 2023 05:37:41 +0000

When Lower Back Pain is More Than Just Lower Back Pain: 7 Ways Back Pain Can Be Caused By Something Serious

Acute lower back pain is defined as a rapid onset of pain, stiffness, tension and discomfort. It is localised below the upper back/chest and above the glutes and can present with or without lower leg pain. Lower back pain is surprisingly common, affecting one-third of adults, with another third of them seeking advice from a health practitioner in any given year. Furthermore, the prevalence of individuals presenting with lower back pain has substantially increased globally, affecting 377 million in 1990 to 557 million in 2017. Most episodes of acute lower back pain self-resolve within two weeks, with a following 80-90% recovering fully within a 3-month timespan. We should not trivialise these cases, however due to the fact that many of them re-occur over time.

For most individuals with low back pain, a thorough history taking and clinical examination are sufficient, with most episodes described as non-specific back pain. However, a small percentage will fall into the category of serious pathology, meaning the origin of the lower back pain is much more sinister than something simple like a muscle sprain/strain.

Here are seven red flags to look out for when experiencing an episode of acute lower back pain:

1.) History of Cancer

For people with severe back pain, it is natural to wonder whether or not the pain might be a sign of spinal cancer. In most circumstances, acute lower back pain is rarely a sign of tumours or cancer. Certain predispositions (>50 years of age, history of cancer, genetics, obesity, smoking) can increase the probability that your lower back pain is caused by cancer growth. There are a few cancers that can present with lower back pain, such as prostate and lung cancer; There are a couple that is specifically relevant to the lower back, such as a spinal tumour (a growth that develops within your spinal canal or within the bones of your spine) and a vertebral tumour (a growth affecting the bones or vertebrae of the spine).

The signs and symptoms of spinal/vertebral tumours can vary depending on the type and the stage of development however, some tell-tale symptoms include:

Pain at the site of the tumour due to tumour growth. Back pain, often radiating to other parts of your body. Feeling less sensitive to pain, heat and cold. Loss of bowel or bladder function. Difficulty walking, sometimes leading to falls. Back pain that’s worse at night. Loss of sensation or muscle weakness, especially in your arms or legs. Muscle weakness may be mild or severe in different parts of your body.

There are many causes of acute lower back pain, with the significant majority unrelated to spinal/vertebral tumour growth. However, keep an eye out for symptoms, including:

– It’s persistent and progressive

– It’s not activity related.

– It gets worse at night.

– You have a history of cancer and develop new back pain.

– You have other cancer symptoms, such as nausea, vomiting or dizziness.

Seek immediate medical attention if you experience:

Progressive muscle weakness or numbness in your legs or arms or changes in bowel or bladder function.

2.) Age <20 Years, or New Back Pain Age >50 years

One particular red flag when treating an individual within these age brackets is the risk of a client having lumbar spondylosis, a general term to describe an array of conditions affecting the discs, vertebral bodies, and/or associated joints of the lumbar spine. The lumbar region is the most affected because of the exposure to mechanical stress. Spondylosis is common and worsens with age, mainly due to daily use. However, degenerative changes may appear in young individuals without trauma history.

What to do:

Lumbar Spondylosis is a complicated diagnosis. In many cases, individuals are symptom-free, and no specific treatment is required. However, keeping track of other symptoms that may have started at the same time as the lower back pain can help ensure best practices in your treatment.

Physical Trauma

Physical trauma is defined as a serious injury to the body. Two main types of physical trauma include:

Blunt force trauma—when an object or force strikes the body, often causing concussions, deep cuts, or broken bones. Penetrating trauma—when an object pierces the skin or body, usually creating an open wound.

Coming from a Paramedic background, I can relay that in the event of trauma, our concerns (as paramedics) can range from Traumatic Brain Injuries (TBI’s), limb Injuries, dislocations, concussions, spinal cord injuries and a whole lot more. However, in the therapeutic pain Management world, when considering trauma in lower back pain, our biggest cause for concern is the possibility of a fracture, specifically within the spine. Minor traumatic events (such as a simple fall) with the elderly can increase this risk substantially due to the bony changes associated with aging, predominantly osteoporosis.

What to do:

In such circumstances, mentioning to your practitioner any kind of traumatic event that may have led to your lower back pain can help give a clear snapshot of its origin, allowing for further radiological evaluation such as a CT/MRI Scan when needed.

3.) Physical Trauma

Physical trauma is defined as a serious injury to the body. Two main types of physical trauma include:

What to do:

4.) Unrelenting Back Pain or Pain that Worsens While Supine (lying on your back).

With the development of acute lower back pain, one can obviously expect discomfort/soreness and a reduction in mobility. If the pain is severe and remains constant even in positional changes such as lying supine (on your back), it can signify a medical emergency that may become life-threatening or result in disability without prompt attention. One cause for concern that separates unrelenting back pain from other red flags is the possibility of Nephrolithiasis (Kidney Stones). There can often be a crossover of symptoms because kidney stones frequently cause lower back pain.

What to do:

If you’re having symptoms of acute lower back pain that is relentless and non-alleviating, consider consulting Healthline to ensure that your symptoms aren’t mimicking a more serious condition that may require immediate hospital intervention.

5.) Widespread or Progressive Neurological Deficit

When hearing the phrase neurological deficit, one may assume a significant decline in an individual’s psychiatric state. The truth is a lot broader. A neurologic deficit refers to abnormal function of a body area. This altered function is due to injury to the brain, spinal cord, muscles, or nerves. Common symptoms of a Neurological Deficit include:

Urinary retention, Urinary and/or faecal incontinence. “Saddle anaesthesia” sensory disturbance can involve the anus, genitals and buttock region. Weakness or paralysis of usually more than one nerve root. The weakness can affect the lower extremities. Pain in the back and/or legs (also known as sciatica) or Sexual dysfunction.

While many diseases, syndromes, conditions and disorders can cause neurological deficit, one commonly appearing with acute lower back pain is Cauda Equina Syndrome. This rare disorder results in compression of the spinal nerve roots. Cauda Equina Syndrome (CES) is no joke; left untreated, CES can result in permanent paralysis and incontinence. After confirmed diagnosis with Magnetic Resonance Imaging (MRI) which creates a computer-generated image of bony structures and soft tissues such as muscles, ligaments, tendons, and blood vessels, urgent/emergent surgery is usually the treatment of choice with the goal is to free up the compressed nerve roots and give them the best chance of recovery.

What to do:

Similar to that other red flag recommendations, keeping track of other symptoms that may have manifested within the same time frame of your acute lower back pain can be paramount to correct diagnosis, therefore allowing early medical intervention. Cauda Equina Syndrome is something we are incredibly conscious of while treating our clients at Featherston Pain Clinic. When seeing us, don’t be afraid to state any of the aforementioned symptoms you may be experiencing.

6.) Systemic Involvement

In health terminology, systemic means affecting the entire body rather than a single organ or body part. One such circumstance of systemic involvement would be rheumatologic disorders such as Osteoporosis. A condition in which bone mass decreases, causing abnormality in the structure and strength of bone tissue, resulting in an increased risk of fracture. From a practitioner’s perspective, systemic involvement in acute lower back pain can be a symptom of a deeper problem rather than the main cause.

What to do:

When considering your acute low back pain, be conscious of informing your practitioner of any genetic background, medical interventions, and health history that you may feel are pertinent.

7.) IV drug Use/ Immunocompromised/Steroid Use

You’re most likely thinking of illicit IV drug use. However, this goes into any circumstance where any medication/drug is given to an individual in an intravenous route. Furthermore, a recent study on the red flags for the early detection of spinal infection in back pain found that patients with immunocompromised conditions/diseases (diabetes, rheumatoid arthritis, lupus) were substantially at higher risk of developing a spinal infection. One common infection that can result in acute lower back pain is vertebral osteomyelitis, essentially causing inflammation or swelling of bone tissue that is usually the result of an infection. The veins in the lower spine (Batson’s plexus) drain into the pelvis and provide a direct route of entry for the bacteria to enter the spine.

What to do:

Like other red flags of acute lower back pain, osteomyelitis can present with a rapid onset of lower back pain. However, most often, the condition presents other associated symptoms, including:

Fever, chills, or shakes, Unexplained weight loss. Nighttime pain is worse than daytime pain. Swelling and possible warmth and redness around the injection site. Recent colds/infections (including Covid-19)

When consulting with your practitioner about your lower back pain, ensure that you mention any recent IV medication/drug/steroid use (especially in chemotherapy). This allows us to make an informed decision on the best treatment.

Summary

Acute lower back pain affects people of all ages and contributes to disease burden worldwide. Managing your back pain should focus on ruling out any serious underlying causes and referring to a diagnostic workup or specialist referral when appropriate. In circumstances with no serious pathology, management through effective non-pharmacological therapies, education, analgesic medicines, and regular review create an effective treatment plan.

If you have any questions regarding your low back pain, don’t hesitate to call us on 04-385 6446

Acute Mechanical Low Back Pain: What to Expect?

Tobias Hall — Sun, 04 Dec 2022 01:51:27 +0000

Acute Mechanical Low Back Pain: What to Expect?

Acute mechanical low back pain is one of the most common complaints for GP visits in the United States and across the Western World. The prevalence of mechanical low back pain is estimated to be up to 84% of the population, with a further 12% experiencing severe disability within their lifetime. In New Zealand, it is the leading contributor to disability, incurring significant medical costs, workers’ compensation and ACC claims. Most occurrences of low back pain are mechanical, meaning the pain intrinsically comes from the spine, surrounding soft tissues, spinal joints and/or intervertebral disks. For low back pain to be considered acute, it has to be present for less than four to six weeks. Acute mechanical low back pain is also commonly referred to as lumbar syndrome, lumbosacral sprain/strain, or idiopathic low back pain.

What Causes Acute Mechanical Low Back Pain?

The causes of acute low back pain are usually mechanical, meaning the source of the pain is triggered by movement within the spinal column. This can lead to irritation or damage to the moving parts of the spine, impacting the ligaments, tendons, facet joints, vertebral bodies, intervertebral discs, or surrounding soft tissue that can lead to a reactive spasm. In the majority of instances of mechanical low back pain, the exact cause is identified in only 20% of cases, with the rest remaining unknown. Fortunately, most cases resolve quickly with time and low back pain treatment. While less common, other factors that can lead to acute low back pain include spinal stenosis, herniated discs, zygapophysial joint pain, discogenic pain, vertebral fractures, sacroiliac joint pain, and myofascial pain.

What Are The Symptoms of Acute Mechanical Low Back Pain?

The most common symptoms of acute mechanical low back pain are discomfort, stiffness and muscle tension localised around the lumbar spine. The pain may radiate to other body areas, such as the groin, glutes or legs. While less frequent, radicular symptoms (tingling, numbness, muscle weakness) can be present but usually indicate another back pain pathology such as sciatica. These symptoms can increase in severity with flexion of the lower back or lifting heavy objects.

How is Acute Mechanical Low Back Pain Diagnosed?

Here at Featherston Street Pain Clinic, we do a careful examination of your medical history, followed by a detailed physical examination that will allow us to determine if you have acute mechanical low back pain while ruling out if your back pain isn’t being caused by something more nefarious. We then create a personalised treatment plan appropriate to your low back pain. If we have determined that your low back pain is mechanical, further testing is rarely required. However, if our assessment indicates the possibility of a pinched nerve, infection, or malignancy (cancer), additional tests, such as blood work, CT scan, MRI and/or nerve conduction studies, may be required. In these circumstances, we would immediately let you know.

What Are The Symptoms of Acute Mechanical Low Back Pain?

How is Acute Mechanical Low Back Pain Diagnosed?

How is Acute Mechanical Low Back Pain Treated?

Following your consultation with one of our practitioners, there are multiple treatment modalities that can increase recovery time from acute lower mechanical back pain. Treatment examples include:

Spinal Manipulation: Manipulation of the spine frees restricted movement and helps restore vertebral bodies to their proper position within the spinal column. This can help with reducing nerve irritability, muscle spasms, pain, and other symptoms commonly seen with acute lower mechanical pain.

Shockwave Therapy: Extracorporeal shockwave therapy (ESWT) softens the tissue around nerves, increases blood flow, and reduces pressure from the soft tissue that may contribute to your acute mechanical low back pain.

Physical Therapy: The goal of physical therapy is to find exercise movements that decrease symptoms of lower back pain. A tailored exercise program would be made to increase muscle flexibility along with exercises that strengthen the lower back.

These are just a small number of the many clinician tools we use to treat mechanical lower back pain!

If you have any questions regarding Acute Mechanical Low Back Pain and its treatment, don’t hesitate to give Featherston Street Pain Clinic a call at 04 385 6446

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– A true injury is what occurs when physical forces conspire to damage a previously 100% healthy tissue. –

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“When back pain suddenly shows up, we are tempted to blame it on the last minor stressor that affected it, such as a soft bed in a hotel. This is like blaming your bankruptcy on the last latte you bought before your account finally went into the red.”

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