I’ve been trying to write a post on how I got back to running for a number of weeks now. A sort of checklist of the things that fell into place to get me back to an activity I had avoided for over 5 years. An activity that I once loved, sorely missed, and erroneously believed I could never do again. The problem with the post is is that it’s not a post. It’s my book. It’s everything. There was no step 1, step 2, step 3. How do you capture that in a “how-to”?
So that post is on hold until I can wrap my head around what it needs to be.
Questioning the story we tell ourselves
What I do know, though, is that one of the necessary steps that got me back on the trail, one of the most important steps in successfully changing pain, was challenging my beliefs and confronting my fears and worries surrounding my hip and my pain. It was coming to a new understanding and putting that new understanding to the test.
And I’ve done a pretty bang up job. My understanding of pain has changed immensely, I’ve overcome fears of movements I had avoided for years because I was worried about the pain getting worse or reinjuring my hip, I’ve been able to get back to being active, playing, and doing things I enjoy. I snowboard, I hike, I practice yoga, I even run now.
But I don’t lift weights. *sigh*
So the job isn’t completed yet. Just when I was riding high and thought I had changed my beliefs and overcome my fears, I’ve had to question my way of thinking about my hip and my pain and confront some unfounded fears and worries once again. Fears and worries that I kind of swept under the carpet.
A meaningful conversation
Challenging our beliefs, questioning the story we’re telling ourselves, isn’t easy to do. As such, I didn’t come to this current challenge on my own, it was the result of an amazing chat I had with Simon Roost Kirkegaard – a physiotherapist from Denmark who also attended the San Diego Pain Summit – on Facebook (oh, the power of social media!).
Our exchange started out about a guest post I had written on Take Hold of Pain’s blog and Simon noting that my improvements have come as I’ve become empowered and more self-efficacious in dealing with my pain experience. He was very kind, complimentary about my successes, and gently probed my pain experience with just a couple questions.
A couple questions that quite honestly changed things a great deal for me.
He asked if I still had pain.
Little did Simon know he was opening up a gigantic can of worms (or should I say words? As you know by now, I’m never short of words). I replied that I still have pain, but that I’m no longer IN pain. Though it may seem like it’s just semantics, the differentiation is quite meaningful to me. Pain is no longer the world that I’m at the center of. It’s still there, but it’s not a focal point, it’s just sort of running in the background now.
Pain can very definitely come to the foreground, though, like when I start paying undue attention to it because my stress levels have gone up, and so my anxiety goes up, or I flare-up because I’ve been sitting in a traffic jam or I pushed too hard through an activity. At those times I might be IN pain for a bit but, nowadays, I don’t worry so much about it, I know I’m not in danger, and I get on with it and get over it. It goes back into the background, just a part of life, not the whole of life.
But pain is definitely still a part of my life. And though I say all the time that it no longer defines me, I do still identify by it. And I do still have worries, concerns, fears, and anxieties concerning it, even when I think I’ve overcome them. I’m not beating myself up over this, just acknowledging it.
He asked what factors I thought played a role in my system becoming so sensitized.
This answer is really a whole ‘nother post but the gist of it was that I was in all-consuming pain for a couple years that kept getting worse, despite interventions including physical therapy and surgery. I was incredibly stressed out. I had financial stress because my income was more than halved and my husband had been laid off to boot.
Being in the work comp system was a particularly awful experience. Care was always delayed. I always felt doubted and like I was always fighting for treatment and then waiting for approvals and then waiting for appointments. My doctor’s recommendations often got denied, including for seemingly simple things like more physical therapy. The biggest issue, perhaps, was that I had so many restriction, thoughs: NO lifting, NO squatting, NO climbing, NO prolonged sitting, NO awkward positions. NO NO NO.
Those NOs insidiously became a part of my beliefs about what I could and couldn’t do.
I thought pain meant damage, therefore ongoing pain meant ongoing damage. Further, I thought that the pain (and perceived damage) was a result of my poor postures and wrong movements, that I wasn’t doing this pain thing right. Naturally I feared movement to some degree. I was incredibly anxious and worried.
I eventually medically retired, losing my identity and becoming withdrawn from friends and family.
Talk about emotional maelstrom and ramped up threat. No wonder my systems were on edge.
But I had worked through much of that. Simon noted that I’ve already been facing some of my fears and that I’ve been walking a successful path through this changing pain stuff. But that maybe there was more I could do. One more thing that might help me make huge leaps forward in confidence, strength, and pain.
He mentioned lifting weights
Alert, alert! I’m under threat!
That’s what happened to me when I thought about lifting weights again. Even though I used to be a heavy lifter, as I had to be in order to perform my job duties as a firefighter. Even though I used to train at pretty high intensities. But that all changed after my injury and my surgery. I had all the NOs I had to abide by for one thing, but I was also scared. Not just scared, terrified. There was no way my hip could handle such a thing again.
Or could it?
I wholly believe that pain science education, which helps remove some of the fear and uncertainty surrounding the pain experience, combined with an empathetic ear, reassurance, and validation that the pain is real can go a long way toward someone successfully changing their pain. It’s these things that unlock the door to movement and movement unlocks the door to everything else that successfully changes the pain experience.
I had thought my door was unlocked and open. I was snowboarding, hiking, practicing yoga, and now I was even running. Success! And it is success. But it wasn’t the pinnacle. I’m not done yet. (Thank monkeys! How boring would life be if I was done? If this was as good as it gets?) My door wasn’t quite open all the way.
I was still afraid of lifting weights. Not a voiced fear, mind you, it was more that I just ignored it altogether. It made me uneasy so I avoided it.
He talked about low confidence and smudged maps
Simon mentioned that for many of his persistent pain patients there is a low level of confidence in the injured or painful body part in addition to (combined with? as a result of?) the body maps in the cortex being smudged.
I’m going to talk more about body maps and smudging in the next post where I actually outline what I did and what changed after this exchange. But suffice it to say for now that every part of our body has a neural representation in the brain with a bit of brain space devoted to it.
The space devoted to each body part isn’t proportional to our actual bodies, though, some parts, such as the hands or the lips, have much larger brain representations than larger body parts, like the legs or the trunk.
What we think happens with pain
Those neural representations, those maps, can get distorted or smudged when we’ve been in pain for a long time (for a great explanation on smudging, check out this video). That smudging is thought to contribute to pain persistence, so it stands to reason that if we can unsmudge the maps, we can change the pain.
In order to regain confidence in the body part of interest we have to have a clear representation of that body part in our body maps. To reestablish accurate maps, we have to face our fears and challenge our beliefs about the painful area. And if we find that our beliefs were not accurate, that our fear was unfounded, we have to test out a new belief system and set the maps right.
One very effective way of doing so is through strength training and lifting weights.
So here I was again, having to face another fear. Having to challenge my beliefs. And having to own up to those fears and beliefs.
He asked “what’s the worst that could happen if you lifted weights?”
As I mentioned, I’d been avoiding really thinking about this, but through some gentle prodding, I really had to think about and give voice to my fears and worries. Which I knew were unrealistic but which I held on to anyway.
My greatest fear was of reinjury. Of the pain returning full force. Of the damage recurring. My worry was that my femur wasn’t stable in the hip joint, there are times I feel it knocking around in there. I was also worried that my hip joint itself wasn’t stable. It was operated on, after all! Tissues were altered; bone, cartilage, muscle, connective tissue. It’s different in there. I was worried that loading it would cause some sort of catastrophic failure.
Simon reframed my (much longer than presented here) answer to ensure he and I both understood what I was trying to say and summed it up, correctly, as fearing that my hip may not be able to carry my weight and that it wasn’t stable or strong. I indicated he was correct.
I still didn’t have full confidence in my hip. Despite all the activities that I know it’s held up just fine under. So, naturally:
He asked: “If your hip was weak and unstable, would you be able to snowboard? Or run?”
I’ve been snowboarding for two years, running again for two months. The answers were no and no.
In 2014 I snowboarded again for the first time in 5 years. I had to challenge, then change, my beliefs and fears about my pain and my hip.
I knew where this was going…
He asked: “So you can run, but you can’t lift heavy weights?”
I knew the answer was no but I was still hesitant. So he asked me to just look at hip strength from an objective point of view, through what I’d learned in biomechanics about running and mechanical forces through the hip joint.
This forced me to admit that, even at my slow speeds, my hip is withstanding forces many times my body weight with each stride every time I go out for a run.
It forced me to recognize that, in fact, my hip is quite stable and strong.
Simon’s gentle reply was, “there is no way around this fact really is there?”
Nope. Nope there isn’t.
It may not seem like it in this little bit of text, but this had a HUGE impact on me. By challenging my beliefs in a non-confrontational/non-threatening manner and asking me to really explore why I thought my hip was weak and unstable, and asking me to provide my own evidence that was contrary to those thoughts, he was able to guide me to a much different understanding of my hip, of my pain, and of my capabilities.
My hip is much stronger than I believed it to be. It’s much more stable than I believed it to be.
This shift made me dive back into Todd Hargrove’s book, Better Movement (sidebar: he’ll be a speaker at the 2016 San Diego Pain Summit – go sign up! – the 2015 Summit changed my life as a patient but it’s geared toward practitioners). I’d read his book before, and thought I understood it, but now my understanding has been taken to a whole ‘nother level.
I’ve made a shift from going through the motions to being the motion.
And I had another major breakthrough. For the first time in over 5 years, my hip feels like it’s my hip. This may not make sense to some of you folks, but for a long, long, time my hip has felt ‘other’. Like it’s not quite mine. (I know it’s mine, it just doesn’t feel like it belongs. This is a thing, it’s not just me, I swear).
This is huge.
I cannot thank Simon enough for taking the time to walk me through all of this. This is a game changer (a pain changer!).
And if you’re interested in the follow-up – check out how I didn’t really follow up but still succeeded :)