Normalising Pain

You have lived your entire life in the middle of a pain pandemic, that almost no one talks about. We suffer terribly with pain and disability, even (some say especially) in the world’s wealthiest countries. Large population based studies indicate that somewhere between 30-50% of people in developed countries suffer with chronic pain. The researchers behind these studies predict a steady increase in these rates of pain due to our  increasingly sedentary lifestyle  and an aging population.

I wasn’t alive in the 1600’s, so it’s hard for me to know for sure, but I would imagine that people just accepted the fact that rotten teeth were a completely normal part of the aging process. If everyone you know had rotten teeth by the time they were 30 it’s highly likely that in the absence of any deeper scientific insight you would simply assume that dental decay was a normal part of the aging process.

If this was the case, it most certainly reflects our current cultural attitude towards back pain, hip pain, knee pain, ankle pain and foot pain. We by and large accept them as part of the aging process. It is only natural to assume that the health issues we face en masse are a normal part of reality.

Imagine you are visiting in your time machine, chatting with your dentally challenged foreparents in the 1600’s. The conversation turns to dentistry, and they tell you their black teeth are ‘just old age’. What would you want to explain to them??

In our luxurious ‘first world’ life is good, better than it’s ever been before maybe, at least  in terms of the broader conditions most conducive to a long healthy life. We don’t have to hunt large aggressive wild animals for food anymore, yet we are still sitting on top of the food chain. We live in warm dry homes. Very few of us perform gruelling manual jobs. We breath clean air for the most part. We are well fed, well healed and well vaccinated. We have ample time to move our bodies in whatever way we choose. We don’t have to fight to maintain our territory. We have comfortable furniture and nice squishy mattresses.

Desk work is far from ideal, but realistically it isn’t coal mining and it isn’t hunting. In the latter cases we are talking about careers where death and dismemberment are ever present risks.

Seemingly life is not that hard on our bodies, yet we suffer with an unfathomably widespread pandemic of lower body pain. A pandemic that we have normalised so wholeheartedly that it is quite normal for people to hold some expectation and acceptance of stubborn pain beyond the age of 40. Possibly much like the presumable acceptance of universally black teeth in people over 30 in the 1600’s.

How Much Pain? Heaps!

It is hard for anything to compete with the likes of refined sugar, smoking and alcohol in terms of impact on societal wellness. The impact these highly lethal yet culturally sanctioned products have our health makes for disturbing reading.  But you might be surprised how competitive chronic pain can be. Pain is a legitimate major public health issue, especially when you take into account …

– All the pain, in and of itself.

-All the physical disabilities associated with chronic pain.

– The financial cost to society through loss the of productivity, impact on   individual careers and healthcare spending created by chronic pain.

– The well documented (and completely awful) impact chronic pain has on mental health.

– The incredibly serious mental and physical impact of pain medications have on pain sufferers. Including the shocking death toll of opioid based pain medications in certain developed nations

– The well documented interaction of chronic pain and poverty.

– The common and tragic illicit drug addiction that can arise from chronic pain (this is a huge topic in the US).

– The death toll on operating tables, the failed surgeries and post surgical infections.

-The fact that chronic pain can wreak havoc on close relationships.

-The serious long term harm done to people’s cardiovascular system through forced inactivity (this is an extremely common and and largely untold epidemiological story that impacts a very significant number of people)

It is very difficult to put total numbers on the amount of heel pain, ankle pain, ankle sprains, iliotibial band pain, knee pain, hip pain, plantar fasciitis and back pain that we suffer with in our society. Such is the enormity of this situation we don’t stand much of a chance in effectively unifying the statistics. In reality though, the data on individual complaints easily speaks to the bigger grimmer picture. The data on back pain alone is indicative of a profoundly serious global healthcare issue.

We have no longer term need to dwell on pain statistics, thankfully! It is a little dull even from my perspective. The journey with our own pain is a rehab journey – that’s where the rubber hits the road. Bearing in mind that to fix something we must first accept that it is malfunctioning: let’s take a few moments to stand back for a moment and survey the cultural-wide carnage. This may help reduce your sense of suffering alone, and hopefully reinforce the idea that something is genuinely not right with ‘us’

Lower Back Pain

The World Health Organisation have officially christened lower back pain ‘a major cause of disability’ across all Industrialized nations. The WHO have also stated clearly that back pain is the leading cause of work absence throughout the developed world.

The 2010 ‘Global Burden Of Disease Study’ placed back pain among the ‘10 most impactful conditions to people’s overall wellbeing in developed countries’.

In industrialised societies the lifetime frequency of back pain is estimated at 60-70%.

Studies in the United Kingdom have revealed back pain as being the leading cause of disability in young adults and attributes 100 million lost work days per year in the UK alone.

A survey carried out in Sweden during the 1980’s identified back pain as the cause in 21 of their 28 million total lost work days in Sweden per year.

The US estimate for the financial cost of back pain to society through people missing work alone – is between 100-200 billion dollars per year. *Even allowing for a few mental health days and hangovers being blamed on

back pain, these numbers should have the power to shock.

Hip Pain & Knee Pain

In the UK research indicates the percentage of 65+ year olds reporting hip pain is 19.2%. While the percentage of 65+ year olds reporting knee pain is 32.6%. The percentage suffering both hip or knee pain was 40.7%.

General health status scores of elderly people are similar to those of people aged under 65 yr in those who aren’t living with chronic pain.. This shows a correlation between pain and wellness in older adults.

A study carried out in the US indicated that a total of 14.3% of participants aged 60+ reported significant hip pain on ‘most days’ in the 6 weeks leading up to the survey.

Knee pain is estimated to affect approximately 25% of all adults, at levels that limit function, mobility and quality of life

From 1991 to 2006, the numbers of total knee replacement in the United Kingdom more than tripled.

In the US, the rate of knee replacements among individuals over 65 years increased about eight-fold from 1979 to 2002.

Ankle Pain & Ankle Sprains

Sprained ankles have been estimated to constitute up to 30% of injuries seen in sports medicine clinics and are the most common musculoskeletal injury by far.

25,000 Americans a day sprain their ankle, and more than 1 million visit emergency rooms each year because of ankle injuries.

Lateral ankle sprain accounts for up to 20% of all sports-related injuries. Indoor and court sports have been shown to carry the highest risk of ankle sprains.

UK study estimates 302,000 new ankle sprains and 42,000 new severe ankle sprain patients bad enough to attend emergency departments in the UK every year.

A US Army study found that ankle sprains are the most common foot and ankle injury in active-duty Army personnel with a rate of 103 sprains per 1000 persons per year.

Approximately 40 percent of those who suffer an ankle sprain are estimated to experience chronic ankle pain, even after being treated for their initial injury.

Studies indicate that ankle sprains are not simply a matter of bad luck, certain people suffer re-occurring sprains and many others live their whole life without ant ankle sprains.

Heel Pain & Plantar Fasciitis

Approximately one million doctors visits per year in US are due to plantar fasciitis.

Some literature on plantar fasciitis shows the prevalence rates among a population of runners to be as high as 22%.

Heel pain has long been recognized as highly prevalent in the senior population, which impacts approximately one third seniors older than 65 years.

There is data that indicates the type of functional issues seen in the feet of plantar fasciitis and heel pain sufferers is associated with poor balance and increased risk of falls.

Heel pain is the most common in active people over the age of 40.

Osteoarthritis

According to the CDC in the US today there are estimated 54 million people with osteoarthritis.

Osteoarthritis is the most common cause of disability in adults globally .

The lifetime risk is of developing symptomatic knee osteoarthritis in Western Society is 45%.The lifetime risk is of developing hip osteoarthritis with noticeable symptoms is 25%.

There are 14 million individuals in the U.S. who have symptomatic knee osteoarthritis at any given time. Nearly 2 million of these are people under the age of 45.

The overall rate of osteoarthritis in military service members is 26 percent higher than the general population, at age 20 to 24 it is twice as high as the general population aged 40 and older. 

A study in 2012 demonstrated that osteoarthritis was the highest cause of work loss and affected more than 20 million individuals in the U.S. The estimated cost to the economy is more than $100 billion annually.

What I hope that you can sense here is that for there to be this much pain afflicting people who essentially every advantage in life there is surely something up?????

Opiate Prescription

For a better  acknowledgement of how severely we struggle with pain: there is some value in being at aware of the opioid crisis that has plagued the US over the past 20 years. Prescription opioids are a justifiable tool for about 0.0001% of pain sufferers. The class of poor unfortunate souls who have suffered the likes of extensive burns or nerve damage. Significant trauma and significant disease, are sound justifications for the use of this class of drugs.

At the height of the American opioid epidemic in 2012; the number of annual prescriptions peaked at 255 million. OxyContin is to heroin what treacle is to table sugar; the distinctions are more micro-molecular than they are meaningful. So realistically this was a case of 255 million ‘heroin’ doses being dispensed to chronic pain sufferers by American doctors in 2012. A huge number of these patients would have been back pain, hip pain, knee pain, foot pain sufferers and the like.

Statistics published in the American Journal of Public Health: estimate that there were between 17,000 and 32,000 deaths from prescription opioids during 2016. Each of whom was someone’s mum, dad or at least someone’s child, lest we forget what stats represent.

On top of the thousands of deaths you can safely assume that for each death there are perhaps 5-10 or even 20 other patients living an utterly miserable addicted existence.

The American CDC estimates the total economic burden of prescription opioid misuse in the US is $78.5 billion a year.

Realistically, all the stats are glorified guesses, no one really knows how bad it all is. Death certificates for the 42’000 total opioid overdoses in 2016 do not make a distinction between deaths caused by illegal opioids like heroin, and deaths caused by prescription opioids.

These opioid deaths are not like the inevitable toll we associate with extreme medicine, like emergency open heart procedures where it was touch and go for the patient pre-admission. These are deaths caused by pain relief medications!!!!

If chiropractors dismembered 30,000 Americans during 2016, that would be shocking would it not? It should be even more shocking that a single class of prescription pain medications (with very few sane applications) does. For some reason we tend to leave these kind of stats under the rug, while others not so much. If chiropractors killed 300 Americans a year you would hear ALL about it… lest they should kill 30 thousand.

The human story behind the medically endorsed and executed opioid death toll includes the ‘surface symptom’ that is chronic pain. It also includes the profound physical unwellness, emotional trauma, physical trauma, cycles of abuse, poverty, stress, poor diet, a lack of proper rehabilitation and a severe lack of education.

The type of patients who become opioid statistics are nearly always either the hardest of the hard, or the fragilest of fragile… or both. As a collective they cost society more than all the other pain sufferers put together. They require more help and support than all the other pain sufferers put together… literally! The reality is that an inconveniently massive amount of love, care, rehabilitation, support and education is needed for many of these patients to stand any chance of a normal pain free life.

To respond to all this, not with acknowledgement, not with support, not with rehabilitation, but instead ‘systemically sponsored’ drug dependency and societal ‘addict stigmatisation’ is heart breaking stuff. And the fact this happens in our supposedly modern world speaks deeply to our struggle with chronic pain.

The Rest

For the sake of brevity I have carefully left out all the IT Band issues, bursitis, piriformis syndromes, achilles pain, calf pain, groin strains, hamstring issues, sciatic pain, disc injuries, shin splints, stress fractures, bunions, ingrowing toe nails, Morton’s neuroma and others. But rest assured they add up in a big way.

I know this is a bit dry, but at least now you are fully aware of the vast and very human mess you are a part of when you live with pain.

Okay, So Why Does A Global Culture That Has Been To The Moon Struggle So Much With Something As Basic As Musculoskeletal Pain? Is Pain Management Harder Than Rocket Science?

So to my mind there are really only 2 worthwhile questions to ask next once we have become enlightened as to how severe our pain epidemic is.

Very important question no. 1 – Is there an actual reason or reasons for all this pain, or is it just an inevitable part of being human?

Answer – Yes there are some really obvious reasons if you know what to look for! And no, on the scale that it exists now it most definitely isn’t an inevitable part of being human. 

Very important question no. 2 – If it isn’t just an inevitability is there actually anything we can do about all this pain

Answer – Yes there is a great deal that can be done to heal, halt and reverse the pandemic of lower body pain we suffer with. We can heal this, both as individuals and as a society. We are going to move past this the same way we moved past smallpox, polio, endemic dental disease and a host of other crappy chapters in our collective medical history.

Pain management isn’t rocket science, you can trust me when I say that many of the most effective solutions are almost shockingly simplistic. As one small example of this – I personally know several hundred people who would be very happy to tell you that I helped them to resolve their severely debilitating heel pain using a porcelain soup spoon. And while many chronic pain sufferers do have complex webs of physical weakness, physical scar tissue and even emotional trauma that hold their back pain and knee pain together – in most of those cases it is really just about layering simple solutions on top of simple solutions. It really isn’t rocket science I promise you.

For most patients being stuck with chronic hip, ankle or knee  pain is a bit like having a nasty splinter in your finger; but also being part of a tribe in which almost no one understands how to get splinters out. That splinter could cause you a lot of problems – but not for the want of a complex brain surgery-like procedure – just for the want of some pretty simple wisdom. If you know how to get a splinter out splinters aren’t a big problem. If you don’t know how to get splinters out, over time they can cause carnage.

If you peel back the real reasons we struggle so much with pain they are complex, cultural, quasi-scientific and somewhat philosophical. If you want to understand that better have a read of this LINK TO ORTHOPEDIC BLOG.

But we aren’t here to unpack how we got here dear reader. We are here to unpack what is actually causing all this chronic lower body (back – hip – knee – ankle – foot). And we are also here to unpack what we are actually going to do about managing all this pain.

So Hit Me With It Then – What Causes All This Lower Body Pain?

I am going to make this really really simple for you, and that’s going to be easy because on the level that we need to understand it here it is simple. The following principles are more than likely all you will ever need to know in terms of what causes your lower body pain. Bearing in mind – if we know roughly what is causing our pain we can make far more educated choices around which type of solutions we roll out. Because in the end all this talk is only for the purpose of bringing us closer to effective tools so that we can get ourselves free.

The following causes of our lower body pain pandemic are inevitably not the whole story. But they are enough to guide 99% of us to get rid of 99% of our pain if we are willing to make them , and it could be the basis of a our holistic roadmap for full rehabilitation.

Cause 1 – Hard Flat Surfaces

Our ancestors lived in the big outdoors with their feet in the mud. A million generations of your direct ancestors didn’t walk on hard flat ground like concrete and tarmac, they walked on variably soft undulating ground. Natural surfaces hug the sole of the foot as you walk on them which means that the arch receives support – and the entire foot benefits from shock absorption.

It would be very hard to overstate the impact (literally) our sudden shift from soft undulating ground to hard flat ground. After millions of generations spent evolving on and adapting to soft surfaces, 5 human lifetimes ago we invented cobble stones and flag stones and rest is hard homogenous history.

Imagine in your minds eye jumping down from a high seawall onto soft sand, and choosing to land heels first with straight legs. Most of us can clearly imagine doing this for fun, not only on sand but on a range of other natural surfaces. Now visualise the same experiment, jumping down from a high seawall –  but this time landing on concrete, again with heels first and straight legs. It shouldn’t  take much imagination to get a sense of how dangerous this could be. The difference between the impact of hard industrailiased ground on the tissues in our lower body and the impact natural surfaces have on the lower body is vast. This visualisation gives you a window into the increased stress that our joints an soft tissues are subjected to over the course of an entire lifetime.

With no arch support and no shock absorption our tissues are subjected to massively increased rates of microtrauma and general wear and tear. In addition to this the lack of muscle activity and balance control required to get from a-b on completely flat surfaces engenders muscle wasting in the muscles of the core and lower limb. If you go for a long walk in the forest away from any tracks you will get a chance to marinate in this truth. It is actually pretty hard work getting around in the big outdoors. But it certainly isn’t hard work strolling along the conveniently flat and homogenised surface in an urban street. The lack of challenge presented by industrially fabricated surfaces causes insidious patterns of muscle wasting in our body’s and a gradual loss of effective balance (aka proprioception). Needless to say, muscle wasting is an excellent ingredient that one might include when cooking up a recipe for chronic pains like back pain, hip pain, knee pain and ankle pain.

The combination of microtrauma induced through lack of support and shock absorption, and muscle wasting induced by the lack of work involved in moving around the planets surface make for a potent mix of pain inducing cellular changes in our body’s. As is the case with any form of stress we do of course have greatly varied levels of susceptibility to the creeping ravages of  hard ground. Those of us with high arches, flat feet and wide hip angles are all examples of those who tend to suffer more than their fair share of the pain inflicted upon us by this incredibly convenient but ‘biomechanically toxic’ aspect of our modern world.

Cause 2 – Sedentary Lifestyle

Unlike the hard surfaces, the impact of excessive and prolonged periods of activity is a far more well known causative agent in pandemic of pain we are amongst. Admittedly we are far more aware of the impact that prolonged sitting has on the neck and shoulders, than we are of the impact sitting can have on the lower body. This is probably simple because we are far more attuned to the more obvious changes that happen to peoples spinal posture over time. But excessive sitting has just as much impact on alignment in the lower body as it does the upper body, just in a less visible way.

The obvious impact sitting has is that it leads to gradual loss of muscle mass. In the shoulders and spine this means loss of the upper back and core muscles. In the lower body this means a loss of tone in the stabilisers of the hip and thigh. All of which happens far more quietly and insidiously deep in behind the hip, and under the desk.

In addition to the loss of muscle mass in the lower body, excessive sitting creates loss of joint mobility and a loss of elasticity in the soft tissues of the lower body. Shortened hamstrings and shortened hip flexors are the most well known of these chronic adaptations that contribute greatly to the pool of chronic pain and disability in our world.

The legacy of all the sitting we do often bears its bitter tasting fruits during times of increased activity as opposed to during the sitting itself. What this means is that when we injure our hamstring in the masters soccer match it isn’t a true injury, but a chronically shortened hamstring that has failed to rise to the occasion. Due to 26 thousand hours of ‘chair time’ in the preceding year. When we ask our chronically shortened tissues to move, often they can’t, especially as we get older. But it isn’t age that is the cause, it is what we spend our years doing that determines what pain we have. The longer we smoke the more we cough, the longer we keep sitting the more we ache. Neither are age related they are both just bad habits.

Cause 3 – Physical Injuries & Scar Tissue

Injuries are probably the most over-estimated and over-rated cause of pain in our cultural pain paradigm. And scar tissue may be the most under-rated and under-estimated cause of pain in our world. This can seem like somewhat of a contradiction in terms unless you understand that scar tissue can often come about as the result of repetitive strain and persistent lifestyle factors like poor posture.

A true injury is when we are are 100% healthy one minute and then broken the next. Many of the back injuries, ankle injuries and knee injuries we experience are however a little more complex than that. It is often our weaknesses that come to the surface during relatively minor incidents, which masquerade as true injuries. This being said there are obviously many other occasions when we sustain true injuries.

Regardless of whether they come from weakness or genuine bad luck, many of our injuries leave us with lasting challenges. This is obviously true of the majors like back pain and whiplash injuries after major car crashes, but it is in many ways just as true of the common garden variety ankle sprains.

Physical injuries cause chronic pain through the legacy of scar tissue and muscle wasting. Ineffective rehabilitation is injury management that doesn’t deal effectively with the scar tissue and muscle wasting left by classic ankle sprains. And FYI effective injury rehab is the exception not the rule in our society. These principles where chronic pain is the long term result of an injury applies to neck pain, shoulder pain, back pain, hip pain, knee pain, ankle pain and foot pain.

By virtue of the sheer quantity of weight bearing the lower body does it frequently cops the worst of what scar tissue and muscle wasting have to offer. In addition, we depend so heavily on the tissues of the lower body for movement they by and large have greater scope for manifesting chronic disability.

Cause 4 – Lack Of Education

Consider for a moment how well you look after your teeth. Five minutes in the morning and 5 minutes in the evening, erry damn day!! Regular check ups, semi-regular visits to a hygienist. If hey you have pain in a tooth you seek help immediately. And at least if you are one of the few slackers who don’t stick with the dental program, you most likely know that you should.

In contrast consider how the average person looks after their spine.. It’s fair to say that since the rise of yoga (borrowed from another culture) there a few westerners who take some time out to care for their spine. But mostly we don’t have anything like the same kind of routine ‘spinal hygiene’ built int9 our lifestyle. We don’t generally don’t work on the mobility and strength of our spine tissues in religious way. And those of us who do aren’t anything like as regular with that process as we are with our teeth.

The reason we care for our teeth so well is that we are carefully educated and indoctrinated from an early age. By the time we are 7 year old we have an excellent grasp of what it is that impacts the wellbeing of our teeth, and we know exactly what we need to do about it.

If you go onto a busy street in any city in the developed world 100 people what you should do about your tooth lain you will get near enough 100 really consistent responses. In fact 100 out of 100 will even know how you could have prevented it from hurting in the first place. On The other hand, if you head onto the same street and ask 100 people what you should do about your back pain you will scarcely the same answer twice, and take my world for the fact that very few of them will be high quality responses. We have absolutely no consensus and very little understanding of what really causes problems like back pain, hip pain and knee pain. And even fewer of us know what the real processes are for resolving these complaints once they become chronic. This is due to a lack of education… systematically and even amongst healthcare professionals.

Cause 5 –  Stress & Emotional Trauma 

The research has shown conclusively that there is is a profound connection between psychosocial stress, trauma and chronic pain. Broadly speaking there are 2 primary ways in which chronic emotional disturbances create and influence chronic pains like back pain and hip pain. The first is habituation of muscle tension and stress related postures which cause the type of physical changes we associate with chronic pain. The second is chronic activation of pain pathways deep in the central nervous system.

Much of our ancestry is made up of animals that were prey times for much bigger toothier critters. And all prey animals are equipped with a freeze reflex that compliments the fight or fight system.

There is a big advantage to having a freeze reflex. if you get grabbed by a big cat and you freeze instantly there is a reasonable chance it will assume you are already dead and not go in for the full neck bite. Being frozen up, only partially chomped and seemingly dead gives you a small but real evolutionary advantage. If the predator is distracted by another predator or goes off to fetch its Cubs for dinner you have a chance to escape.

Being on the inside of the freeze reflex is not a fun place to be, just ask anyone who has been there. In the moment when you feel like you need to be your strongest your body completely shuts off all motor control. As far as the nervous system goes, the freeze responds is like driving a car at 100km per hour and suddenly applying the handbrake without coming off the gas. It can be terrifying to feel weak and defenseless in a moment where we naturally want to feel strong.

Animals are far better than us at literally ‘shaking off’ traumatic events. The tremble and shake to release the freeze response and then run like the clappers. Humans have developed a tendency to react very badly to freezing moments. Having large  frontal lobes as we do means in moments like that we make snap judgements like ‘I am totally powerless to defend myself’. These impressions carry with them the tendency to ball up the freeze response moments rather than express it effectively.

‘Unprocessed freezing up’ is how we carry trauma in our bodies. And the double shitty news is that it doesn’t only happen with the big stuff. Even small events can  create this kind of reaction in our bodies, and it’s basically how we convert lots of small stressful moments into a build up of anxiety, fear, stress and the other emotions that we use to cover them up like anger.

Carrying these layers of unprocessed trauma in our nervous system is how many of us ultimately covert our stress and trauma into chronic pain. Chronic muscle tension and irritable nerve pathways are unsurprising knock-on effects of trauma responses stuck in the body over the longer term.

In Conclusion 

So now you know (assuming you are willing to take my word for all this) that our lower body pain pandemic is not the big achy mystery it might have been – given how much there is out there.

The point of this article was firstly to acknowledge what a pain pickle we are in as a society, and perhaps reassure you that you aren’t alone if you are struggling with chronic pain. And secondly to demystify all this pain, as a start point on the journey towards full rehabilitation and recovery. Because good news I have to share is each and every one the lower body pain causes I have touched on here comes with a wide range of reciprocal and effective solutions.

The scar tissue that causes so much of our knee pain and ankle pain can be broken down. The muscle wasting causing our back pain can be resorted with the right exercises. The impact of hard surfaces can be mitigated with exercises and custom orthotics to provide support and shock absorption to our joints. We can learn about how to take better care of our muscles, joints and soft tissues.  And our trauma can be healed and released, often with surprisingly simple tools and exercises.

And when we put all this together for ourselves in a way that works for us – we will have taken a small but hugely meaningful bite out of the largely silent pain pandemic we are living in the midst of.

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Part 2 of Pain Pandemic

Part 3 of Pain Pandemic

Part 4 of Pain Pandemic

Part 5 of Pain Pandemic

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