I will be presenting a free course introduction on September 2, 11 am PDT.  Learn what I will present in my online Working with the Chronic Pain Patient 3-hour class for Embodied Health Learning tv.  Link and sign up to introduction is here.

My very first You Tube is posted!!!   Watch here to see Angela Sidlo interview me about Getting Shame out of Pain.  Leave comments below and please be kind.

“It is not only possible but natural for each of us to love our bodies to find ourselves beautiful – no matter how different, disabled, old or battle scarred we may be.”  Harriet Goldhor Lerner

“Reality is always kinder than the story we tell about it.”  Byron Katie

Shame is an emotion, like fear or grief.  Shame is registered in the brain like strong physical pain. When combined with pain or stimulated by pain the hurt from each exponentially multiplies the other to create a Pain – Shame – Pain cycle.  Ironically, the positive feedback loop spirals out of control and creates negative consequences for you.

Shame is an emotion that affects all of us but physical Pain creates more situations that instigate or accelerate the Shame response.  People with Chronic Pain have more worries about job security, how to sustain a relationship, or the effects of painful procedures or drugs on the body, and they feel like these situations are their fault.  To compound the power of shame, withdrawing from what used to be fun activities in order to avoid Pain flares tips the balance further towards the negative.  The lack of positive experiences and overabundance of adverse ones leads to a poor self-image that is ripe for cultivating Shame.

Shame is also a social emotion, like shyness, guilt, or pride. You cannot have it without others being around, at least in your imagination. Shame may have once had a evolutionary purpose to keep an individual in good standing within a group by punishing brutally for the slightest imagined wrong doing. It is an ingrained habit, especially in our culture. After childhood, usually no one has to make us ashamed. We do it to ourselves.

According to Brené Brown, a University of Houston researcher and lecturer who brought the study of Shame out into public awareness, shame is an “intensely painful feeling or experience of believing that we are flawed and therefore unworthy of love and belonging.”  Brown interviewed thousands of people about difficult, sensitive experiences in their lives in order to uncover common themes around the experience of shame. She says, depending on how we deal with it, shame can either shut us down or lead to a new sense of bravery and authenticity.

Often people have a visceral reaction to the word, “shame” and shrink when they hear the word.  They try to dodge it, pretend they don’t have it or that it has nothing to do with them.  That’s one reason it is so pervasive, because it is repressed. The truth is that everybody experiences Shame and the less we can talk about it, the more cruelly it can cut.  Words help identify when shame is happening, what triggers it, and what is needed to move through it with authenticity, courage, and self-compassion.
Identifying shame can also be tricky when we cannot distinguish between shame, guilt, humiliation, and embarrassment.  We often use these words interchangeably in our culture.  People who are better able to tell the difference between shame, guilt, embarrassment and humiliation can more easily bounce back from an episode that triggered shame.
 
Shame vs. Humiliation 
The ingredient that separates shame from humiliation is whether you feel you “deserve” to feel bad. Both humiliation and shame call up the same immediate physical response - sweaty palms, racing heartbeat and the impetus to either fight back fiercely or run or shrink away.  But the next internal reaction is key. If you spill milk and a stranger starts berating for being clumsy, you could react by thinking “that is the meanest, most nasty person ever, I didn’t deserve that!”.  That is humiliation self -talk.  In contrast, Shame self-talk would be, “She’s right, I’m so clumsy, why can’t I ever hold on to a glass?”. 
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Shame vs. Embarrassment  
Embarrassment doesn’t leave you feeling utterly alone the same way shame does. If you tell me that I have some spinach in my teeth, I use my tongue to swipe it off and can laugh it off.  I can move on because I know the situation isn’t really about me.  The core of who I am and who I perceive myself to be can stay intact.  I can take the next step out of embarrassment because I know that I’m not the only person in the world who has had food stuck on their teeth. 

Shame vs. Guilt 
Guilt is also milder than Shame.  People who feel guilty feel that they have done something bad, but not that they are bad. Guilt is a focus on behavior while Shame is a focus on Self. An example would be after eating a whole pint of ice cream, thinking “I’m struggling and doing the best I can but eating that pint of ice cream was a bad decision.”(Guilt)  versus “I’m stupid” (Shame)  Guilt does not have the sense of finality that Shame carries. There is no potential for change if you are just bad or stupid or wrong or cursed.  There is no hope that you can fix the problem or hope to be forgiven.
​
Secrecy, silence, and judgment serve to propagate Shame. Unfortunately, the Pain experience fosters all three factors.  Secrecy and silence are a normal response to the message that no one really wants to hear about your troubles with ongoing Pain. Even friends and loved ones get tired of hearing about struggles with medications, side effects, painful procedures, and worries about your health or job (if you are lucky enough to still have a job).  During my toughest bouts with doctors, CAT scans and MRIs , one of the questions I was most commonly was greeted with was “Are you better?”  People don’t want to hear a “NO” answer. So the standard response becomes, “I’m fine.”  You start to feel like it’s all your fault that you’re not getting better according to plan, and that’s where self- judgment comes in.  You also may judge the lack of compassion you are finding in the outside world as well.  All of these harden your heart and leave you cloistered off all on your own.   In my darkest hours, a cluster of fears about the future arises, “that I will be alone, homeless and in Pain.”

You have encountered Shame if:

• you have ever felt Shame that you still have Pain
• you have ever felt Shame that you contracted Pain in the first place
• you have ever felt shame for not speaking up to your doctor
• you’ve ever shamed yourself for not getting enough done. 
• you’ve vented frustration about Pain on an innocent person (e.g., if you’ve ever said something overly harsh to someone, and then avoided that person rather than owning up to your mistake and moving past it in your relationship)
• Or anything else equating Pain with feeling bad about who you are at your core  – Shame serves no useful purpose and just muddies up the waters so that healing gets clogged and stopped

​Linda Hartling and Jean Baker Miller, researchers at Wellesley College, found three typical responses to shame: moving away, moving toward, and moving against it. Moving away is keeping secrets, not talking about it and just wanting to disappear into the earth. Moving toward shame is people-pleasing to the point of denying self.  Moving against means striking back against the person who sparked your Shame feelings with something equally hurtful, painful, or shaming. All three strategies keep you feeling isolated and alone.  The antidote is meeting the Shame and bringing it into the light so it’s not such a scary unknown.

Why should we engage with shame when it’s so painful? What’s the benefit to that? 
Looking at Shame is like shining a light in our darkest corners and normalizing universal experiences that make us feel very alone.  One of the byproducts of being able to move through shame constructively is that people who come out the other side feel braver, more connected and compassionate.

You need to be mindful when you look at Shame, to maintain some distance so that it doesn’t swallow you up and reinforce its Identity.  More important than that is cultivating emotional curiosity. Most of us were not raised in families where we were encouraged to get curious about our emotions, ask a lot of questions, dig in, name things. 

Wanting to name and do more about shame that comes up is a good first step. Starting small conversations with people we trust and care about, acknowledging the Shame that can be brought on by Pain, can be healing.  Expressing the Shame we feel around our Pain can be transformative. It’s all about being curious and in connection while learning.  But how can we express that curiosity when people around us just want us to shut up and get well?  

Finding a trusted counselor is one way.  They are paid to listen.  Another way is finding your tribe.  People who understand what it’s like to confront Pain on a daily basis (their pain doesn’t have to be exactly the same as yours, it doesn’t even have to be physical pain).  People who are honestly wanting to meet and get more understanding about the Shame and isolation they experience and how it both creates and is fostered by their Pain.  Sometimes you can find these like-minded people by searching online – there are for example, Facebook groups for everything under the sun.  Just googling the subject or posing a question on Quora can lead to others who are interested in reframing the Shame they feel around Pain. You don’t even need to work with other people who are focused on Pain. As long as people are honestly trying to examine any behavior or situation that stimulates Shame, you are in good company. SMART (an anachronym for Self-Management And Recovery Training) recovery groups are a low-cost alternative for processing in a group.  They are getting to be very popular, and can be found online and in most large cities and maybe even small towns.  I would say that SMART group are like AA or Al Anon groups sans the religion and identification with alcohol.  You don’t even need a group per se. The satisfaction you feel from a “tribe” who understands you can be found with just one person who is willing to listen.  And if all else fails that one person can be you.  Writing about your experiences is a way to “talk to the shame.”  You can also use the Inquiry process of questioning stressful thoughts by specifically focusing on stressful thoughts of Shame. 
 
Being willing to share is part of dissolving shame. Owning up to what I’m ashamed of not only helps me, it also helps the person I am sharing with. Speaking shame is actually a service. It helps other people feel less alone. When one person has the courage to get real about where she’s struggling, it allows everyone else to exhale an “Oh My God me too.” Owning shame also helps increase resilience to being derailed by it in the future. Which means the sharer not only gets to stop feeling the yuckyness of shame, but also it prevents engaging in the negative kinds of behaviors (e.g., hiding in the house, overeating, smoking) that Shame inspires.

Compassion overflows for the person who’s struggling – that person receives the compassion that she hasn’t been able to provide for herself. Compassion shows the person struggling that she’s not alone and that she’s not going to get kicked out of the tribe.  It allows the nervous system to calm down enough to examine the source of shame objectively.  There is space and time to get more strategic about charting a path through the difficult situation. Meanwhile, the listener gets fuel for their own next breakthrough. 

Identifying shame and making peace with it is part of how we heal shadow issues: the dark, murky, unconscious stuff from the past that undermines how we act in the present. Even if you process with others, it is also important to bring mindfulness to circumstances where shame arises.  Processing on your own involves the following steps, not necessarily in this order. 

How to Escape the Pain-Shame-Pain Spiral

• Notice when shame is at work. A practice of reflection and cultivating mindful awareness, like meditation, qigong, or journaling prepares you for catching Shame thoughts when they arise.
• Investigate what you think of as “proof” that you should feel Shame.  What story are you telling yourself? Is it valid?
• Recognize that you’re human, doing the best you can. Make your expectations of yourself kinder and forgive yourself for being imperfect, because everyone else is imperfect too.
• Treat yourself as you would treat a friend.  Extend the same compassion you would offer that friend.
• Tell someone. Speak your shame (even if it’s only to yourself) through journaling or self -inquiry (described in the last chapter). Remember, speaking about Shame diffuses its power over you.
• Inquire into what could be kinder and More True than the Shame belief that took you down. (e.g., “I am worthy of love regardless of my productivity.”)
• Do something to anchor in the deeper truth of your experience. 
  
  

To recap, Shame is another barrier that keeps you focused on what is bad about you and has no place in healing yourself.

Chronic inflammation occurs when the natural inflammatory response of an acute injury does not fully resolve.  Failure of a tissue to fully heal can happen with repeated small tears and overuse. Conditions such as an autoimmune disorder or the presence of a foreign material such as a suture or implant may also contribute to chronic inflammation. Pain in the chronic stage of inflammation may be hard to detect. It may only become evident with pressure or pull on the area. More commonly experienced symptoms are reduced range of motion and postural distortions, which if tested, invoke Pain.

It is important to note that chronic inflammation is not the same as chronic pain. Chronic Pain has been discussed in previous blogs and will be reviewed again in future posts as it is a major part of my practice and a personal concern, as I cope with medically unexplained chronic pain every day.   But back to Chronic SOI -

Chronic inflammation may not feel red, hot, swollen and painful at all.  In fact, the area typically feels cold, hard, stiff and has a pale or bluish hue, due to lack of blood flow.

The goal of Chronic inflammation is: to protect the formerly injured area.  In order to do so, scars reorient and remodel in response to pulls and tensions placed on them during daily activities.

Physiology - In order to protect the area, the following physiological processes happen:

• scar tissue continues to remodel and reorient in response to stress . This process is rapid in the first few months of chronic inflammation stage and then the remodeling slows and takes more force to change
  
• scar tissue strengthens 
  

  Therefore, Pain treatment in the Chronic SOI  focuses on softening adhesions and scar tissue that limit pain-free range of motion, increasing range of motion, and decreasing postural distortions due to habitual patterns that were once protective but are no longer serving a useful function.Persistent low grade inflammation damages connective tissue, causes necrosis and fibrosis and prolongs the healing process.  Granulation and fibrotic tissue continue to develop within the loose (superficial) CT which is highly vascular and innervated, thus further constricting blood flow and nerve impulses. Increased collagen production amidst this background leads to increased scar tissue and adhesion formation.

The Symptom Picture is :

• resolved SHARP signs (Swelling, Heat, A loss of function, Redness and Pain) except for A loss of function
• loss of full ROM (range of motion)
• decrease in functionality
• postural changes
• Pain is pinpoint and felt with overpressure or overstretch
• increased scar tissue and adhesions
  

Treatment Plan (works to decrease symptoms). Therefore LMT's and other therapists work to:

• Continue to Decrease remaining Spasms
• Increase available AROM and PROM (active and passive range of motion) 
• Increase strength
• Change proprioception / reverse somatic amnesia (forgetting what it is like to move with ease)
• address TP's that remain after fascial release
• Reduce scar tissue and adhesions

Treatment follows directly from the Plan, So in addition to successful treatments from the Acute and Subacute SOI's,

• Add in Passive Stretch to increase PROM
  
• Continue to Use PIR (post isometric relaxation) RI (reciprocal inhibition) to maintain AROM and PROM
  
• Continue to use RM (rhythmic mobilization) to reset proprioception and remind restricted tissues of how far they can move without Pain
  
• Intersperse focused work with relaxing full body Swedish, shiatsu, RM
  
• Continue scar and adhesion reduction with MFR, XFF and muscle stripping
  
• Continue to  Reduce remaining Spasms - using GTO, OI and MA
  
• Continue to massage the opposite side will decrease the stress on compensatory structures, and proximal to the injury
  
• Address remaining trigger points
  

Self Care Recommendations follow the Plan too, so good recommendations include

• Active Stretches identified in the massage as restricted
  
• PIR/RI exercises that you have identified on the table and practiced with client
  
• Other strengthening exercises - using theraband, gravity, wall as resistance
  
• Balancing movements - coordinating injured side with unaffected area
  

Hydrotherapy : Heat at rest, heat before and ice after activities or receiving bodywork,

Contraindications include:

• Do not massage with pressure or stretch that causes Pain or Spasm
  
• recognize that Pain Medications can affect the patient's perceptions of pressure that may be causing more damage, so try to get clients to space these out and take the next dose after, rather than right before a session

Pain in the sub-acute stages of inflammation is less widespread than acute pain. There are two stages of sub-acute inflammation;

1. fibroblastic repair (Early sub-acute) phase 
2. maturation-remodeling (Late sub-acute) phase
   

Late Sub-acute injuries feel even less red, hot, swollen and painful than in the Early Sub-acute phase.
During this phase, the scar begins to modify into its mature form with steady increases in tensile strength and a decrease in capillaries. Additional collagen fibers are laid down and realigned according to tensions placed on the tissues by normal pressure and movement  At this stage, massage and joint mobilization can align scars to allow for optimal range of motion and functionality. Although scar tissue gradually approximates normal appearance and function, typically the tensile strength of a scar is less than 80% of a functional tissue. Besides vascularity, it lacks elastin, and appears stiff compared to normal, noninjured tissue.  After approximately 3, weeks a firm, strong, nonvascular scar exists but the entire maturation phase can take several years to complete.

The goals of Late Sub -acute inflammation are:

• to fill the area and make the scar more durable
  
• more collagen - to anchor scars to stable tissue and to remodel the scar according to stresses and pulls
  

 
Physiology - In order to reinforce the damaged area with collagen, the following physiological processes happen:

• Scar remodelling -  collagen cross links are being laid down to further fill in the scaffolding established in the Early subacute phase
• Wound contraction - scars try to anchor to the most stable tissue (usually bone) Myofibroblasts make contractile fibers that attach to bone or other fascial planes and pull the healing tissue down and together.  Thus, less tissue is needed to fill the space, but the result is less mobility

  Therefore, Pain treatment in the Late Sub -Acute SOI  focuses on continuing to decrease any remaining edema and spasm, and working with the scar as it forms to decrease fascial adhesions, and to decrease its magnitude, so as to maintain optimal range of motion and strength of the muscles.

The Symptom Picture is :

• even more decreased SHARP signs (Swelling, Heat, A loss of function, Redness and Pain)
• There is some possible remaining edema
• If bruising occurred, it is now turning yellow or brownish.
• Pain is more pinpoint and only felt with over pressure
• There may be muscle weakness

Treatment Plan  works to decrease the symptoms. Therefore

• Continue to Decrease remaining edema and spasm
  
• Maintain available ROM (range of motion) and strength
  
• Decrease fascial adhesions and scar tissue
  

Treatment follows directly from the Plan, So in addition to treatments for Acute and Early Subacute SOI, add in:

• MFR (myofascial release) and XFF (cross fiber friction) are best to reorient scar fibers in the direction of muscles, for optimal function and strength
  
• Continue to Use PIR (post isometric relaxation) and RI (reciprocal inhibition) to maintain AROM and PROM without putting excessive stress on developing scar tissue
  
• Continue to Address trigger points that refer into the area
  
• Continue to massaging the opposite side to decrease the stress on compensatory structures, and proximal to the injury to push circulation back to the heart, speeding the removal of toxins from the injury
  

Self Care Recommendations follow the Plan too, so good recommendations include

• Continue to Educate the client on the importance of not overdoing/ re-injuring the area, as they are feeling
  
• Do encourage Pain-free movement of the area
  
• PIR/RI exercises that you have identified on the table and practiced with client to strengthen the area, progressing to gentle active stretches that do not cause pain
  
• Tell clients to warm up the area with Heat prior to exercise and to ward away any areas of acute inflammation that have been flared by exercise with cool (or ice) applications after
  

Hydrotherapy : Mild contrast, beginning and ending with Heat

Contraindications include:

• Do not overwork the area with massage or stretch (if it is painful, it is too much)
  
• If client experiences Pain or Spasm with massage or stretches or exercise, reduce or eliminate the process causing the Pain
  
• recognize that Pain Medications can affect the patient's perceptions of pressure that may be causing more damage, so try to get clients to space these out and take the next dose after, rather than right before a session

Pain in the sub-acute stages of inflammation is less widespread than acute pain. There are two stages of sub-acute inflammation;

1. fibroblastic repair (Early sub-acute) phase 
2. maturation-remodeling (Late sub-acute) phase

Early sub-acute injuries feel less red, hot, swollen and painful than in the Acute phase. This easing of symptoms continues into late Sub-Acute stage; with even less pain and signs of being less red, hot, and swollen  The hallmark of Sub-acute phases is  about forming and reforming the protective scar.

The goal of Early Sub -acute inflammation is:

• to fill the damaged area with new tissue

 
Physiology - In order to fill in the damaged area with new tissue, the following physiological processes happen:

• new capillary buds begin to form into the wound, allowing for an increase in blood flow that brings oxygen and essential nutrients for tissue regeneration
• fibroblasts synthesize collagen in a loose connective tissue matrix which replaces the clot formed in the acute stage
• the result of increased blood flow and building the connective tissue web is a very fragile granulation tissue, a scaffolding that lays down the basic framework for future collagen fibers to attach to.
• lactic acid levels rise in the area - as a result of microphage activity and the hypoxia that ensues from the cell and toxin debris.  This also gives rise to increased collagen production.

  Therefore, Pain treatment in the Early Sub -Acute SOI  focuses on continuing to decrease inflammation response, without damaging the fragile granulation tissue that has formed to fill in the area.

The Symptom Picture is :

• decreased SHARP signs (Swelling, Heat, A loss of function, Redness and Pain)
• decreased Muscle spasms (muscles contract to protect against trauma) that can now be addressed if treatment doesn't cause more pain
• Bruises are starting to heal and often turning yellow in color
• Pain is more localized and felt when tissue is stretched to resistence

Treatment Plan (works to decrease the symptoms. Therefore

• Continue to Decrease SHARP signs
  • remaining edema with diminished heat and redness
  • pain
  • can begin to address a loss of function
• Maintain available ROM (range of motion) and strength
• Begin to decrease spasms

Treatment follows directly from the Plan, So in addition to successful treatments from the Acute SOI, add in:

• Reducing Spasms - using spasm relief techniques of

                  GTO (golgi tendon organ technique) for long tendons
                  OI (origin/ insertion technique) for short tendons
                  MA (muscle approximation technique) for the muscle bellies

• Use PIR (post isometric relaxation) and RI (reciprocal inhibition) to maintain AROM and PROM without putting the stress of a stretch on fragile granulation tissue
• Address trigger points that refer into the area of trauma, avoiding pressure directly on the injured area
• Continuing to massaging the opposite side will decrease the stress on compensatory structures, and massaging proximal to the injury will also continue to push circulation back to the heart, speeding the removal of toxins from the injury

Self Care Recommendations follow the Plan too, so good recommendations include

• Educate the client on the importance of not overdoing/ re-injuring the area
• Do encourage Pain-free movement of the area
• PIR/RI exercises that you have identified on the table and practiced with client

Hydrotherapy : Mild contrast, beginning and ending with Cool

Contraindications include:

• Do not massage with pressure or stretch that puts drag on the granulation tissue(so as not to redamage the compromised area)
• Use only gentle squeezing and light strokes distal to the injury
• If client experiences Pain or Spasm with massage or exercises, reduce or eliminate the process causing the Pain
• recognize that Pain Medications can affect the patient's perceptions of pressure that may be causing more damage, so try to get clients to space these out and take the next dose after, rather than right before a session

Addressing Pain is an essential part of my medical massage and qigong practice. On September 8, 2017, I attended a lecture on the Mystery of Pain by Douglas Nelson, at the Oregon School of Massage. Mr. Nelson is the current President of the Massage Therapy Foundation, and has been in clinical practice in the Midwest for over 22 years,

Here are my takeaways from the talk.  The audience is LMT's who want to better treat Pain, but the information can also help patients seeding treatment to clarify how therapists can best help.  My emphases are in bold and in italics are my understanding of how to translate the takeaways into more effective Pain treatment.

1. Pain is a global health problem.

• 1 in 5 people suffer with pain every year
• 1 in 10 have chronic pain every year
• 100+ million people have chronic pain
• Annual costs of treating Pain are greater than the costs of treating cancer, heart disease and diabetes combined

2. Pain management has unique challenges

• Pain is complex - it affects people on biological, social, psychological and spiritual levels
• Approaches must address the "whole person", failure to do so will escalate other problems (e.g, the opioid epidemic)
• quality of life is lower for chronic pain patients than patients with GI disease

3.  Therefore, treat Pain as a mystery rather than a puzzle. 

• A mystery is something to be unravelled, There is a story and it will unfold.  The client learns to heal him/herself.
• With a puzzle, if you fit the right piece in, you have solved it, The therapist fixes the client.
• A broadbased, curious, iterative approach provides more options for the client to heal..

4. Pain is different from nocioception

• Pain is the perception of aversive or unpleasant sensation
• Pain is the brain's response to a sense of DANGER
• Nocioception is the CNS signal of tissue damage

5. The Brain wants to provide a story for the Pain

• If client didn't see what happened in an attack or accident, client does 17x worse in recovery that someone who did see what happened
• Muscles tense in anticipation when an event is foreseen (they take the injury and muscles heal relatively fast - more blood flow)
• If event is not foreseen, joints and ligaments (which don't heal as fast) take the brunt of trauma
• Psychological damage (e.g., PTSD)  is more likely when an injury is not anticipated (e.g, buddy gets blown up in war as walking down street)
• If no one can provide story for the Pain (e.g, Chronic Pain) and you believe you cannot be helped, you will be right

6. Areas of the brain that fire in chronic pain normally process

• images
• cognition
• movement
• sensations
• memory
• beliefs

7.  The brain is neuroplastic

• Massage sessions provide new stimuli for the brain in all of the above.  These are all avenues to reprogram the Pain.
• Massage can help the brain learn new responses to what was formerly noxious stimuli

8. Massage is uniquely positioned to address Pain on many levels.

• Physiologically, massage can
  • trigger the relaxation response and activate rest and repose
  • increase circulation of blood and lymph for more rapid healing of muscle and connective tissue
  • inhibit negative nerve responses and highlight positive sensations - clarifying the body map
• Touch is a social, and emotional and spiritual connection that can
  • reduce stress
  • convey acceptance and belonging ("you are not alone")
  • decrease anxiety and depression
  • increase happiness (if you make someone happier, they are in less Pain)
• Kinesthetically, massage can individuate muscles so that they work more efficiently and not stuck together as a unit working against itself.

9.  Patients in Pain want answers to questions

• What is wrong?
• How long will it take?
• What can I do? (Self-care suggestions)
• What can you do?

10. If you don't know, tell the truth, give options, and answer with authority

• In 3 months, if  see you once a week, I expect to get here
  • set short term and long term goals
• Answering too generally, ("everyone is different") is a non-answer that makes patients uneasy
• Ask what you can do to improve functionality (quality of life)  "what does the patient want to do that s/he can't?"

Addressing Pain is an essential part of my practice and I am always seeking to learn more.  If you would like to schedule a consultation, please Contact Me

Inflammation is how a body responds to injury, in the same way that your immune system fights off bacterial and viral infection in a sore throat.  Both begin with an immediate local response designed to protect the body from further injury and tissue damage. Inflammation is an aggressive process that initially causes swelling, heat, a loss of function, redness and pain  (SHARP symptoms). Unchecked, inflammation leads to additional tissue damage, which can lead to more Pain. This is why it is important to match massage treatments to your stage of inflammation: an incorrect assessment can interfere with or  prolong the natural healing process.

Describing symptoms, goals and treatment options for each stage of inflammation (SOI) is complicated.  This post presents general information about inflammation and pain. Future posts will be devoted to elaborating on each stage of inflammation (SOI) and how massage can alleviate your symptoms.  This series is designed to help those trying to rehabilitate from an injury or pain, so the goal of pursuing an active, fulfilling life is aligned with how the body is trying to heal. Here, I generally describe the process of inflammation, what purpose it serves in healing, and briefly outline the unique physiology of each stage.

Why is inflammation so aggressive?  Inflammation attacks potential invaders and walls off a hurt area so that a local injury doesn't become a systemic problem.  Acute pain also slows you down so that you don't keep re-injuring yourself.

Why slow down inflammation when it is a natural part of healing? Inflammation is a very aggressive process which can damage healthy collateral tissue as well.

When used correctly, massage and other forms of bodywork can speed healing, while minimizing pain. This why it is important to match treatments, especially massage treatments, to the stage of inflammation (SOI) you are experiencing. This requires critical thinking by both treatment providers and treatment seekers about the symptom patterns involved with each stage.  Addressing SOI is an essential part of my medical massage and qigong practice for people with medically complex conditions, located at Earthbody Wellness Center, 3810 SE Belmont St., Portland, Oregon, 97214. If you would like to schedule a consultation, click on Contact Me, 

I have been taught to recognize 5 stages of inflammation: Each stage has its own unique physiology and symptom picture.  Treatment goals aim to reduce problematic symptoms related to each stage. Once goals are identified, optimum treatment techniques, hydrotherapy and self care become clear and follow critical thinking guidelines.  A seasoned massage therapist should be able to understand your somatic pathology and stage of healing and together with your input, figure out what will be most helpful.

Briefly described, the five stages of an inflammatory response are:

1. Acute (0-3 days approximate) - Tissue has been broken down due to recent trauma. White blood cells (WBC's) migrate to the area to protect against and clean out toxic substances.  Fibrin and platelets are laid down in the area to wall off the local injury and form a net to catch white blood cells. The area is RED, HOT, SWOLLEN and PAINFUL.
2. Early Subacute (2 days - few weeks) - The damaged area is being filled in with new but very fragile blood-filled connective tissue.  Like a latticework or a scaffolding for a future building structure, this granulation tissue lays down the groundwork for new collagen to fill in.  The area is still RED, HOT, SWOLLEN, and PAINFUL but less so.
3. Late Subacute (2nd - 3rd week) - The latticework is being filled in with more collagen, a triple helix compound which is very stong.  Cross links of collagen reinforce the delicate cheesecloth-like granulation tissue: these cross links of collagen are laid down along lines of stress, and the area is remodeled to reflect those tensions. There is some possible remaining edema (swelling) and pain is less widespread.
4. Chronic Inflammation (3-4 weeks up to years after an injury) - Tissue is now continuing to remodel and reorient to accommodate pulls and tensions on the muscles that were injured.  Remodeling proceeds rapidly in the first few months and then slows. Scars harden and strengthen.  The area can feel cold, hard, and look white or blue. Muscle may be weak and range of motion is limited as the scar connective tissue is not functional like a healthy muscle would be. Pain is pinpoint and usually not felt at all, unless there is pressure or stretch directly on the area.
5. Resolution or Chronic Pain (chronic pain is defined as ongoing pain for more than 6 months)  Chronic pain is when the nervous tissue has become so protective that it is overly sensitive, even though the original injury is mostly resolved.  Resolution is when the tissue performs, for the most part, like healthy muscle.  Remnants of scar tissue do compromise the tissue so it is never fully as functional or elastic as it once was.

The time frame for each stage is approximate, depending on the severity of injury, how large the affected area is, and if the client receives appropriate bodywork and self care recommendations to recover. In my next blog, I will elaborate on appropriate care for the acute stage of inflammation, so stay tuned.

Pain in the acute stage of inflammation is widespread (not localized) and the area feels red, hot, swollen and painful.
Edema (swelling) is a hallmark of this stage, as white blood cells are streaming to the injured area and fluid follows along into interstitial (between the cells) spaces.

The goals of acute inflammation are:

• to dispose of microbes, toxins and foreign materials
• to prevent their spread
• and to prepare the site for tissue repair

Physiology

Initially, blood vessels constrict in the area of injury: this helps slow metabolism.  This Vasoconstriction is accompanied by clotting in the vessels, which seals off the wounded site.  After 5 or 10 minutes, though, vasoconstriction is replaced with vasodilation (widened blood vessels), activated by chemical messengers like histamine, leukotrines, prostaglandins and cytokines.

Vasodilation allows blood to get to the damaged area quicker and increases permeability (so white blood cells (WBC's) and clot forming chemicals move in) to the site (diapedesis), Generally, within an hour after injury, phagocytes ("eating cells" - WBC's) move into the scene. Increased permeability also means that fluid and cellular debris can seep out of blood vessels more easily, The initial discharge lasts 24 to 36 hours.  When vasodilation is complete, blood flow decreases and blood gets thicker, allowing leukocytes to slow down and adhere to vascular walls (margination). Platelets stick to this exposed collagen. Thrombin causes fibrinogen to change into very sticky fibrin which further cements the clot. Clot formation begins 12 hours after injury and is completed within about 48 hours.

Pain treatment in the Acute SOI  focuses on keeping the inflammation response from running amok and causing more damage to the area.

The Symptom Picture is :

• SHARP signs (Swelling, Heat, A loss of function, Redness and Pain)
• Elevated Sympathetic Nervous System (SNS) Response ("fight, flight or freeze")
• Muscle spasms (muscles contract to protect against trauma)
• Possible bruising
• Pain is diffuse and felt early in movement

Treatment Plan (works to decrease the symptoms. Therefore

• Decrease SHARP signs (except for A loss of function- - as the body is now guarding to protect the site of injury)

                  clear edema, and accompanying heat and redness
                  reduce pain

• Treat the compensatory structures (the other side of the body which is working hard to take the load of the injured side)
  
• Reduce the Flight or Flight response (general relaxation and calming tensed nervous system preparing for danger
  

Treatment follows directly from the Plan, So

• Use Ice to decrease SHARP signs
  
• Use MLD (manual lymph drainage) to decrease SHARP and fight or flight response
  
• Swedish (avoiding the site of injury and areas distal to it) also increases the relaxation response
  
• as does DDB (deep diaphragmatic breathing) 
  
• Massaging the opposite side will treat the compensatory structures, and massaging proximal to the injury will also help push circulation back to the heart, speeding the removal of toxins from the injury
  

Self Care Recommendations follow the Plan too, so good recommendations include

• PRICE (protect, rest, ice, compression and elevation) of hurt area
  
• DDB
  
• some gentle movement (if there is no pain and inflammation is mitigated) such as range of motion ROM in an ice bucket
  

Hydrotherapy:  Ice or if the patient cannot stand the extreme temperature, Cool - to soothe the red, hot, painful, swollen area

Contraindications include:

• Do not massage within one inch proximal to the injury (so as not to redamage the compromised area)
  
• Fever (a sign of systemic inflammation and damage)
  
• Infection  (a sign of widespread inflammation and damage)
  
• recognize that Pain Medications can affect the patient's perceptions of pressure that may be causing more damage, so try to get clients to space these out and take the next dose after, rather than right before a session
  

How can patients and practitioners treat Chronic Pain?  My approach is to first try to understand what we are dealing with.  Chronic pain, by its very nature, is a slippery phenomenon.  Without a clear cause, there is no clear protocol to fit a client who comes in with pain that doesn't go away and can even morph into pain in different areas, of different intensities, durations and onset.  Therefore, I am attempting a series of blogs to get clearer about how to deal with a problem that just won't quit.

Chronic Pain is different from acute pain.  Acute pain has an obvious cause that heals and the pain goes away, while the onset of Chronic Pain usually cannot be traced to a single cause and the pain is not going away.  These two important distinctions set chronic pain apart and can invite anxiety, depression, difficulty sleeping, and a deep sense of seperation from a world that is not allowing the pain and its cause to heal.

First of all, let us distinguish some changes that happen to the nervous system in chronic pain.

• Sensations are more intense.  Nerve receptors are activated at a lower threshold. and more nerve receptors are recruited when a person has Chronic Pain.
• A stimulus that feels like pressure to an average person, feels like pain to someone with Chronic pain.  The nerve receptors called free nerve endings have the capacity to be stimulated by both pressure and pain stimuli. Even a light touch can be noxious to someone who is having a flare of chronic pain.
• A stimulus that feels like heat or cold to an average person, feels like pain to someone with Chronic pain. Nocioceptors (pain receptors) can learn to fire in response to less intense stimuli.. Nocioceptors called free nerve endings react to pain and also respond to temperature changes. But in chronic pain free nerve endings translate both temperature and pain stimuli as Pain.
  

Now let's talk about positive feedback loops that speed up and accentuate the devastating effects of Pain.

• Pain -> Stress -> Pain.  When you are in pain, that leads to more stress. Perhaps you are stressed about the effects of the pain on your ability to perform your job, or maintain your relationships.  Increased stress and tension in the body sensitizes you to tighten up and feel more Pain.
  
• Pain -> Decreased Sleep -> Pain. When you are in pain, it is hard to get comfortable enough to sleep.  Sometimes when you finally get to sleep, the pain wakes you out of it.  Without sleep the body cannot rest and renew and pain gets worse.
  
• Pain -> Increased Depression and Anxiety -> Pain.  When I hurt and the pain won't go away, it makes me anxious and depressed about my future.  I don't see how I can have any control over making the pain go away and I dread or fear the resurgence of pain.  My increased depression and anxiety makes me susceptible to increased tension, which my body now has learned to interpret as Pain.
  

Why does Chronic pain seem to start out of the blue?
Adults rely on movement patterns that were learned long ago as toddlers.  These old ways of moving through life have gotten us where we are today. However, toddler movement patterns are probably not the most efficient ways to use an older body.  This may not surface as a problem for many years, but unfelt wear and tear accumulates. 

Inefficient movement patterns  expend energy that does not translate into movement.  The excess energy that is not being used to move turns into heat and inflammation.  This irritation slowly wears down cushiony tissue, ligaments, and spinal discs in your body.  Eventually bones are left rubbing on bones.  When the tipping point is finally reached, a simple action can cause a nerve ending to be irritated and chronic pain begins. 

So what can you do? 
The solutions I have learned to rely on involve re-learning how to move and feel more efficiently and pain-free. Sometimes entraining the body into ease needs to be demonstrated to the body passively, with bodywork, since the nervous system gets so confused that it cannot untangle what increases pain sensations and everything hurts.  At a certain point in a patient's recovery, active movement can be taught (through mindful movement such as Qigong, yoga, MELT method, Yamuna balls, Feldenkrais, Trager, and other easy movements) to reinforce retraining the nervous system. Awareness of how what I do, think and experience affects my pain can also be incredibly helpful.

The best bodywork to retrain the nervous system involves some back and forth communication with the patient so that they know what makes them feel better, even a little and what makes the pain worse.  I especially like Myofascial bodywork for this reason.  I also like Lymphatic Detox and Craniosacral techniques because they address the inflammation and heightened sensitivity that results from Chronic Pain directly.  I will talk more about bodywork, active and awareness techniques and tackle how to cope with complicating factors of chronic pain in future blogs.  Stay tuned.  Meanwhile check out my services page to learn more about my Myofascial, Lymphatic and Craniosacral bodywork and Qigong active movement classes, introduced in this post.