I’ve had a bit of a revelation. I actually started this post a year ago but after my recent experience as a patient demo for Peter O’Sullivan at the San Diego Pain Summit, I started to actually understand it all a bit better and see postural and movement habits a bit differently.
This will be one in a series where I try to unpack my experience in Pete’s Cognitive Functional Therapy (CFT) session. I’ll tackle my anxiety and worries in a future post and relaxing and breathing in another.
I could sum up this post by saying movement and posture variability, breathing, relaxing, and letting go are important. Without context, though, none of that means anything. Yet that’s so often how we package it up to people.
Each of those things I’ve listed are along their own spectrums and will vary in meaning and in action from person to person. That matters.
It’s not about dysfunction or correction, it’s about variability
This post is a long one. I talk through my thought processes in order to offer insights to people in pain, who may have similar experiences, as well as to people who treat them, who may wonder what it is about posture, movement and breathing that might matter.
There is no bad movement or bad posture in my book. However, identifying a person’s current positional and movement habits is valuable. Are we tense or relaxed? Breathing deeply or shallowly? Bracing and tensing or moving with ease?
Being aware of our habits, our current state of being and moving, is useful when it allows us to find different ways of being and moving that may help change our experience. No pathologizing movement, posture or breathing necessary (please don’t do that). No universal ideal to be met. Just doing things differently to see if things change.
Trying oh-so-hard to change my movement habits
On to my revelation. I move the way I do because I’m always anticipating pain. I’m cautious, just waiting for it to come. Looking for it if it’s not there.
It hit me while I was going through the movements that Pete and I had worked on during my patient demo. The movements are absolutely counter to what I think I should be doing and what I’ve habitually done for years.
So they are HARD. Not just physically but cognitively.
What are they? Squats, lunges, single leg squats and hops – all with a flexed spine, a rounded back, a tucked tail. I relaxed into each movement rather than bracing. I let go rather than controlled. I was loosey goosey, not tense. I thought about my breathing more than my form. And I didn’t look for pain.
It was not my typical way of existing in the world ;)
It’s not just physical
I have to really think about what I’m doing because I’ll reflexively go back into active back extension. Upright, shoulders back, hips rolled slightly forward, maintaining those s curves, core engaged, breathing shallowly (it’s hard to breathe deeply whilst maintaining such rigidity and tension).
I habitually sit, lie and move in an active extension position. When I squatted and lunged, I worked at keeping my spine neutral to prevent my tail tucking or butt winking or whatever you’d like to call it. Chest up, chin up. Core engaged. Hoo rah!
I’ve done this for YEARS.
So moving through squats and lunges while flexed, relaxed, nearly hunched over my legs as I lower and arms dangling, is hard. Not only hard – purposefully doing these things in flexion feels just plain wrong, awkward, weird.
Wrong yet so right
But it only feels wrong in my head, you see. In my hips, it feels pretty damn all right. There’s no pain aggravation. Oftentimes there’s no pain at all. My hips feel better going through those movements in flexion. Sitting in flexion feels good. Lying on the floor in flexion feels comfortable.
Paradoxically, my hip feels pretty damn angry when I do all these things in extension, which is my habitual way of sitting, lying, moving and being.
So why, then, do I put myself in extension all the time? Why do I squat in extension when it feels like there’s a knife slicing through my ass when I do so? Why do I provoke my pain with *checks* that put me into hyperextension? Why am as I always looking for it?
I don’t know. I don’t know why, for years now, I continue to do the very things that provoke my pain. But I’m not alone in this. That’s comforting at least. It’s a thing that some of us humans do.
Directional pain responses
I learned during Pete’s CFT workshop that there are common directional pain responses: active extension (me!), flexion, lateral, and multi-directional. I’m going to focus on active extension here because that’s my deal and it’s my blog ;)
During the demo, Pete noted that I was always in an active extension position and that I breathed apically. While we were chatting I sat all the way back in my chair, wholly upright, shoulders back, hips rolled forward. You know, ‘good posture’. (Hint, it’s not ‘good’ when you never vary from it.)
When he had me stand from sitting I maintained an active extension position. When he had me squat, I squatted from the same extended position and actively tried to maintain it throughout. Same went for the lunging, single leg squats, hopping and bending over.
Where does my active extension pattern come from?
That ‘good form’ is ingrained in me. (Hint: it’s not good if it never varies.) I started lifting weights as a freshman in high school, proper form was always emphasized. I was a firefighter, where posture and form are literally drilled into you during the academy. I was a Crossfitter and heavy lifter. I was a fitness trainer and a bit of a form freak. I was someone who prided myself in my strength and physique
Not to mention that as a society we’re taught that keeping our backs straight and cores engaged. We’re told we need to protect our backs. Heck, there are even ergonomic lifting programs for office workers (despite there being no evidence such programs work). As women, we’re also we’re taught to sit and stand up tall and suck in our tummies (perhaps men are, too, but I’ve only ever been a female).
All this sits in our subconscious and when we’re in pain we revert back to what *we know*. To what we think is right and good for us.
Movement and postures change with pain
Prior to my pain, though, I moved with ease. I only had movement rules when I was lifting heavy or doing manipulative training at work.
After my pain everything changed. I planned my movement. I thought (worried) about it before, during and after. How was my posture? My lumbopelvic rhythm? My symmetry? We’re my glutes firing? Was my core engaged? Did I mess something up by moving the way I did? Did I fuck up my surgery?
Even though I’ve moved past a lot of that, I still exist in anticipation of pain, always waiting for it to happen. I hold myself up and out of my hips and hold my breath a little. I’m a bit tense and guarded, all in anticipation of the pain that has been there for so long.
This definitely affects my movement.
Thoughts, beliefs and emotions change, too
In the early years of my pain I feared that pain meant damage. That with every painful movement I was tearing up my hip joint more and more. Eventually I had surgery to repair the mess – to reshape my femur, excise the labral tear, take out all the damaged cartilage.
After surgery I feared that every painful movement meant I was fucking up all the good work my surgeon had done. I was terrified that I was going back to square one.
(As much as I dug seeing the pictures from my surgery of the inside of my hip, those images would haunt me later as I’d envision it reverting back to that red, ragged, damaged state.)
No one had told me that having worsening pain for 13 months prior to surgery might mean that I’d still have some pain afterward, even if the surgery was anatomically successful. No one mentioned nervous or immune system changes, increased sensitivities, danger and threat or the role of psychosocial factors in pain.
>So I wholly believed once my anatomy was fixed, so to I would be fixed.
Rigidity, invariability, tension
I wasn’t fixed, though. And it freaked me out and scared me and being freaked out and scared changed my movement, too.
I became more rigid and guarded. Everything around my hip constantly tensed up in protection. It wasn’t that things weren’t firing, it was that EVERYTHING was firing. I actively prevented my hips from moving as much as possible out of fear of damage and worry about pain. I walked like a penguin. I lost my butt as a result I went straight from back to thigh. (I’ve had it back a few years now, if anyone was worried.).
My movement became increasingly invariable. I developed all sorts of rules, largely falling back on all those things I mentioned before. Not explicitly so, mind you. I never wrote them out on whiteboard or anything. But I followed them religiously, all the time. No longer just while lifting heavy shit or throwing ladders.
It’s hard to breathe when you’re always on guard
I held my breath all the time. Taking shallow, apical sips of air to do the keep living thing. I still do this, it’s something I am paying more attention to and that I’m also working on changing.
It’s not dysfunctional breathing, mind you, so please don’t go there. My breathing isn’t the problem. Pain, worry and anxiety are the problem. Constantly anticipating pain is the problem. But working on relaxing and breathing deeper sure can help those things – the anxiety, the worry, the pain.
I tried to hold myself up and out of my hip, up and out of my pain. I’d offload it while sitting or standing, inadvertently loading it more. Constantly trying to physically get away from the pain even though the pain was inside my hip, inside my body, inside me.
I used to do really weird things, too. I’d do this wonky straddle leg stretch thing with my left arm around my back, clasped with my right, leveraging it against my SI joint to ‘put it back in’ (now I know this isn’t a thing, back then I thought that’s what I was doing).
All the while my pain kept going up, so to the anxiety and worry. I lost function. I lost 26 pounds of muscle. I didn’t have any fat on my body, I was the size I’d been in 4th grade. Skeletal, frail, weak.
My mood was low, low, low. I was a master catastrophizer. I was afraid. I had very little self-efficacy. I no longer had confidence in my hip, my body, myself. I was no longer a firefighter. No longer active. No longer strong. No longer me.
To go from firefighting badassery to frail and weak is hard for me to think and write about even now, all these years, a wonderful life and a healthy 35 pounds later.
All that affected my movement and body positions
And still do, for that matter. I’m infinitely better than I used to be. I am active and snowboard and work and write and play. But when my pain goes up, this is what I go back to. Those memories aren’t forgotten, those experiences aren’t just filed away in some dusty, unvisited corner of my mind. These are well traveled paths.
I say all this because I think it infinitely important to stress that postures and movement do matter, just not in the ways that we often think or say they do. Do my movement and posture habits contribute to my pain? Absolutely. Are they the cause of my pain? Absolutely not. They happened as a RESULT of my pain. They continue because of years of practice, years of anticipating pain.
Before pain I never pre-planned my movement. I never paid attention to how I was sitting or my lumbopelvic rhythm while walking. I never tried to control my day-to-day movements, I just moved, and moved well. That all changed AFTER pain.
Belaboring some points…
After pain I was labeled with all sorts of postural and movement dysfunctions that were ‘causing’ my pain and given corrections. I see now how silly that is when there’s all this other shit going on. I could work on those corrections all day long but they were never going to correct what was wrong. Sure, I might feel better for a time, but it misses too much of the story.
I’m also stressing all this because there are some who’ll say biomechanics are everything and some who’ll say biomechanics don’t matter and the truth is somewhere in between. How we move does matter, just not in the ways we might think and not in the ways we’re often told.
Damage vs Sensitivity
I stress it all, too, because even now, all these years later and with all that *I know* having studied pain now for 4+ years (and lived it for 7+), I went straight to structural worries about the new pain in my left hip because it hurts INSIDE MY LEFT HIP and across my left buttock. That’s where it is. It’s not anywhere else. So I thought *damage*, even though *I knew* it probably wasn’t.
But knowing what it wasn’t didn’t tell me what it was, and so I worried. I was afraid of going back to square one. Again.
I knew (but didn’t wholly believe, obviously) that damage wasn’t causing my pain during my session with Pete. I know that pain is an output of the brain, but that sure doesn’t jibe with the very real sensation pain IN a very specific location. It’s hard to be like, yea, that makes sense, when your hip is screaming at you with pain, like ‘no, HERE, dummy!’
Disconfirmation and reconceptualization
Pete helped to conceptualize what was going on differently, and it was huge for me. I am immensely grateful. He talked about how structures can be sensitized. How both the periphery and the central nervous system can by sensitized, and it’s not an either or, it can be an AND. He also talked about how structures can be more sensitive in certain positions and movements.
Directional provocation. Not damage. That jibes with my experience and makes sense to me. My pain is felt IN my hip, so it’s natural, even knowing a lot about pain, to think that means there’s something going on IN the hip. And there is. It’s just that it’s sensitivity, not injury, not damage.
Helping people to make sense of pain doesn’t mean just helping them understand the biology of pain. It means helping them make sense of THEIR pain. (If you missed how Pete helped me connect the dots, check out the original CFT post.)
Explanations need to fit in with our narrative. Our understanding. Our sensations, thoughts, and feelings. Our lives. Our story. Otherwise they don’t explain a thing.
What I think worked about CFT in regards to MY movement habits
It reassured me a great deal to hear that my hip is a bit sensitive and that there are certain movements and postures that provoke my pain. It made sense, jibed with my experience and opened the door to doing some stuff to change my experience.
It was also reassuring to hear I wasn’t an idiot for thinking it was damage (which I hadn’t even owned up to until that demo but which had been lurking in my mind for months).
I felt more confident after sitting, being and moving in ways that didn’t provoke my pain. It was vitally important to actually practice them, though, that’s where confidence is built. (For a previous post I wrote about confidence in pain, go here)
Pete worked me to fatigue doing forward bends, squats, lunges and hops in this new, cognitively challenging, flexed and relaxed position that is the complete opposite of how I normally exist. But it was PROOF that this can be done.
It helped disconfirm beliefs I had about damage. It helped me restore confidence in my hip. It challenged me and made me feel capable and strong. (I don’t know that everyone would appreciate the hammering I got, but Pete had listened to my story before all of this and so he knew I would ;))
Moving fluidly, relaxed, with ease
That’s the key for me. Moving with ease, fluidly, without thinking and planning. Naturally. Not being so rigid. (Rigidness and inflexibility do not equal strength!)
Elite athletes do not move rigidly, they move fluidly. Novice athletes move more rigidly, with less degrees of freedom, because they’re trying to figure it out, they’re thinking about the task rather than just doing it. Elite athletes just do it. And they can adjust as the task, situation, or environment changes.
Experienced dancers don’t move rigidly, they move fluidly. The nervous, awkward, stiff dancers who are painful to watch move rigidly. I don’t want to be them. I want to flow. Like when I’m on the mountain, a dance of sorts on snow. When I snowboard I’m not rigid and stiff, I’m relaxed and fluid. I’m trying to channel that in my daily existence.
Maybe it’s the scenery that helps me relax?
So moving with ease, letting go, breathing deeply, relaxing into the movements were important during the session and are important for me to carry forth. And oh-what-a-challenge for me to do those things while relaxed! To not brace. To not engage my core. To not hold my breath.
How can being relaxed be so freakin’ hard?
I also needed permission and guidance
I don’t know if I could do this without a permission of sorts. These have been my habits for a while. I’ve practiced them for so long and they’ve been reinforced by so many physical therapists and movement professionals along the way, it’s hard to move in a way that is counter to them.
It’s hard to do something totally outside your norm, something totally against the grain of what you’ve been taught and what you think you *know*. It feels weird, wrong even, moving in flexion. Even though it feels better.
There is something to be said for having a trusted guide.
The part that kills me is that I’ve written something like 6 blog posts on movement variability, yet I still NEVER VARIED my active extension pattern, even as I varied the movements and exercises I did. I can do all kinds of movements from that same posture. This is nuanced shit, folks!
You can’t just tell people to move in different ways, apparently some of us don’t know how we’re moving in the first place! Help us become aware of how we are moving and to discover other ways of doing so.
I thought I was switching up my postures throughout the day by going from sitting to lying on the floor to standing at the counter – but I was really in active extension that WHOLE time. I thought I was varying my movement because I do all sorts of things, all sorts of ‘exercise, but I do them all with my hips and back in essentially the same position! Never varying them.
Different strokes for different folks
I want to be clear that extension isn’t bad. Not at all. And not everyone is going to have an active extension pattern (but I think there are a whole hell of a lot of us who do).
The problem is that I seem to live my whole life in extension, rarely flexing my back and certainly not flexing it when I’m doing something – that’d be ‘bad form’, after all! So it’s good for me to practice being in flexion. I also tend to move tensed, braced and rigid in this post-pain existence, so I need to practice moving relaxed, with ease.
It’s hard to breath while tensed, braced and rigid, so by relaxing and letting go, I can breathe a bit easier, too.
Not anyone thing for everyone
It’s not that these things are better in some general sense or that it will work for everyone. Everyone’s deal is going to be different, though similarities wouldn’t surprise me. That’s why generic movement assessments and movement programs aren’t going to work and you don’t need them. This whole process started with me telling my story, after all. Not an assessment.
Listen to people’s stories. Use that time to see how they sit and breathe. Note how they stand from sitting. Have them do a couple movement patterns, like squat, bend, lunge and reach. Have folks simulate their valued activities. And ask yourselves, together, some questions.
Can they do it differently? Can they do it in a way that doesn’t provoke their pain? What do they avoid doing in their daily lives? What do they want to do? How can you figure out, together, how to get them to do it?
Build their repertoire from there in a way that’s meaningful for them. Help guide them in changing habits that might not be serving them. And reflect it back to them through their story.
I’m going to keep working on changing my own movement habits and adding to my movement repertoire. I hope to give my sensitive hip a chance to calm down and recalibrate by not provoking my pain so much.
Eventually I’ll be able to go back into extension without provoking my pain, too, because it’s not an inherently bad position. I just won’t be in in 24/7 when I do. The only ‘bad’ postures and movement patterns in my book are invariable ones that we rigidly adhere to.
And I look forward to the day I don’t have to think about this damn stuff so much. The day I will just move naturally and with ease again.
I’m getting closer. Just being aware of these things brings me closer. Breathing, letting go of tension, relaxing into movement, moving and sitting in different ways. Recognizing how my thoughts and worries affect my ability to breathe, relax and move in different ways.
It’s not just about movement habits
That’s the kicker, folks. It’s not just about changing the movement and postures. It’s about tying those things back into our stories, too. About connecting the dots on how we got there in the first place, and discovering the things that keep us there. Without that piece it doesn’t make sense.
Our stories matter when it comes to our ability to move, because our stories are what we’re living. As Pete said at the summit:
“Exercise is not the intervention – living is the intervention.”
Our thoughts and our emotions drive our behavior and influence our biology and our biology influences all of it in turn. It all matters, not just the movement. It’s all inextricably interrelated. We cannot separate mind and body.
It’s everything, the whole enchilada
All the aspects of our lives – our thoughts, emotions, fears, beliefs, expectations, relationships, environments, financial concerns, movement, daily stressors, health issues, fitness levels, sleep quality, immune and endocrine function, diet, occupation/work, ability to engage in meaningful activities, function, values, opportunities lost and gained, goals, values – are important.
It is all relevant.
If all is going well in most of those areas, we may not have directional provocations that make our pain go up. If some of those things go awry or there are just a lot of things going on in general, we may.
None of this is all or nothing, it’s endless shades of gray.
My trusted guide :)