Pain science 2: Chronic PHT pain

: Today we are covering Pain Science 2, Chronic Proximal Hamstring Tendonopathy Pain. Welcome to the podcast helping you overcome your proximal hamstring tendonopathy. This podcast is designed to help you understand this condition, learn the most effective evidence-based treatments, and of course, bust the widespread misconceptions. My name is Brody Sharp, I'm an online physiotherapist, recreational athlete. creator of the Run Smarter series and a chronic proximal hamstring tendinopathy battler. Whether you are an athlete or not, this podcast will educate and empower you in taking the right steps to overcome this horrible condition. So let's give you the right knowledge along with practical takeaways in today's lesson. Okay, we are diving into episode two. If you haven't listened to episode one, don't know why you jumped episode two, but if you haven't, please go back. And while you're at it, try and listen to the other episodes that we have released. If you are like me, you'd instantly just go back to episode one and follow your way through. But I know some people would just quickly go to topics that they find the most relevant for them or the ones they're most interested in. However, all of these concepts do interflow in one another and it'll enhance your understanding of proximal hamstring tendinopathy. if you do first of all listen to all of them but chronologically listen to all of them of especially the first 20 that come out I have strategically put them in sequential order so that you get the best understanding and we're going from the basics and then adding on top of those basic foundations to something a little bit more complex. So today we go from our understanding of pain and pain science and delve into if you've had pain for a long period of time, how the brain starts to reorganize itself and how the neural associations start to make these changes within the brain. And it is reversible and it is something we need to understand. In the episode I do talk about how healing times take a couple of weeks to a couple of months. Yes, a tendon can slowly form and become degenerative. And we do know that like once the tendon structure is settled down and healed, there might still be some degeneration in the tendon, but that's no reason why it shouldn't return to a pain-free fully functioning tendon. And I've explained that in earlier episodes, but just thought I'd clarify here. Same as last episode, I'll play a snippet from my pain science too, from the Run Smarter podcast. And then we will go through my key takeaways, what I've got written down. when it comes to proximal hamstring tendinopathy rehab. And yeah, we'll chime in then. So let's jump into the episode from the Run Smarter podcast. So if we wanna have a quick recap from last episode, all pain experiences are a normal process that the brain thinks is a threat. The amount of pain that you experience doesn't necessarily relate to the amount of tissue damage and the brain relies on many sensory cues including memory, reasoning, and the emotional process in order to determine the level and severity of pain. So it's working out the importance of pain when it comes to context and what the brain is interpreting to be a threat. So why have I decided to put this episode in this season? Well, chronic pain can be a bit of an issue. It goes beyond tissue repair. In the acute phase, there are some inflammatory components and some blood flow to the area that actually aids in healing. But this phase is relatively quick and most tissue repair will be completed in a couple of weeks, sometimes a couple of months, depending on the blood supply that gets to that area. If there's lower blood supply, there's certain cartilage and meniscal areas that the blood supply is limited. healing time, that recovery time is a little bit longer than usual. But once all these healing phases have been completed and the body has structurally healed, pain still remains. I also want to include this because a lot of people with persistent pain get quite defensive and insulted when medical professionals say that it's in your head. And I think saying it's all in your head is a very derogatory, perhaps insulting term for someone who doesn't fully understand how pain is processed. Yes, it's all in your head because it comes from the brain. We know that all 100% of the pain that you do experience is from the brain, but people interpret it's all in your head as you're making it up. It's not real, which is the total opposite. I wanted to read a chapter from the Explained Pain book, which illustrates this quite nicely and it addresses the, so you're saying it's all in my head. argument and this is probably the most asked question from people learning about the physiology of pain. We have to be honest and say yes, all pain is produced by the brain. No brain, no pain. This doesn't mean for a second that it isn't real. Much to the contrary, all pain is real. In fact, someone that tells you it is all in your head, implying that therefore it is not real, doesn't really understand. physiology, really understanding this is greatly empowering. So it's all about how people interpret and how effective health professionals are communicating to their patients about pain. So we discussed last episode the power of the brain and how placebos, nocebos impact the level of pain and the effectiveness of certain treatments. And to solidify the idea also helps explore the phenomenons like phantom limbs and even like people who undergo hypnosis. Like a phantom limb is someone who has an amputated limb or even people who've been born without limbs experience phantom pain. And so phantom pain is like, if you don't have a leg, let's just say someone has been amputated from the knee downwards. they can still experience itching or pain or tightness in their non-existent leg, somewhere in the foot. Imagine having an itchy foot and no foot there to scratch. These are well-documented phenomena that's been going on for years. And it clearly explains, okay, it's all coming from the brain, all this processes from the brain, because if it were from the tissues themselves, there wouldn't be any phantom pain. And the other idea is around things like hypnosis. People can have chronic pain or even people experiencing pain in surgery. That can all go away. And it's been well documented that if someone is under hypnosis, certain people won't experience any pain at all, even undergoing some major surgeries. And what hypnosis is doing is tricking the brain. So clearly illustrates the... I'm saying pain a lot and brain a lot, so I'm getting mixed up. All the pain from the brain, if you don't have a brain, you don't have any pain, sums up quite nicely. Then we go into things like persistent pain. So when pain persists and feels like it's ruining your life, it is difficult to see how the brain, how it's serving a useful purpose. But even when pain is chronic and nasty, it hurts because the brain is somehow concluded for one reason or another. often completely subconsciously that you are threatened and in danger. The trick is finding out why the brain has come to this conclusion. I thought I'd play another video. Last episode we had a listen to Lorimer and he had this entertaining funny way of explaining pain. This one's a little bit different. This is from YouTube and the title is Explain Pain, What to Do About It in Less Than 5 Minutes. It sums things up really well. It's some really nice illustrations of like a hand free drawing, all these different concepts, while the lady's talking through explaining pain, but verbally you get the message across. It's a little bit more robotic and monotone than Lorimer's entertaining video, but it really illustrates the importance of the brain pain in regards to chronic pain. So I thought I'd play that for you now. Everyone agrees that pain is a universal human experience. We now know that pain is 100% of the time produced by the brain. This includes all pain, no matter how it feels – sharp, dull, strong or mild – and no matter how long you've had it. You might have had it for a few weeks or months. This is called acute pain, and it's common with tissue damage, say from a back injury or ankle sprain. you'll be encouraged to stay active and gradually get back to doing all your normal things, including work. Or you might have had it for three months or more, and this pain is generally called persistent or chronic, because in this type of pain, tissue damage is not the main issue. What's less clear though, is when you're told you have chronic pain, is knowing what's best to do about it. Well, in Australia chronic pain is a really big problem. In fact, one in five people have it. Having a brain that keeps on producing pain, even after the body tissues are restored and out of danger, is no fun. Some people say it still feels like they must have something wrong. But that's just it. Once anything dangerous is ruled out, health professionals can explain that most things in the body are healed as well as they can be by three to six months. So ongoing pain being produced by the brain is less about structural changes in the body and more about the sensitivity of the nervous system. In other words, it's more complex. So to try and figure out what's going on, you need to retrain the brain and nervous system. To do this, it's helpful to look at all the things that affect the nervous system and maybe contributing to your individual pain experience. What can help is to look at persistent pain from a broad perspective, and by using a structured approach and a plan, it's less likely that anything important will be missed. Let's start with the medical side. Firstly, taking medication can help, but only to a limited extent. It is the more active approaches that are necessary to retrain the brain. So using medications to get going is okay. and then mostly they can be tapered and ceased. Some people also think surgery might be the answer, but when it comes to a complex problem like chronic pain, surgery may not be helpful. So if you're thinking of surgery, it's best to get a second opinion and remember to consider all the things. Next, it is helpful to consider how your thoughts and emotions are affecting your nervous system. Pain really impacts on people's lives. and this can have a big effect on your mood and stress levels. All those thoughts and beliefs are brain impulses too, but you can learn ways to reduce stress and wind down the nervous system. This helps with emotional wellbeing and can reduce pain as well. The third area to consider is the role of diet and lifestyle. Now it turns out that our modern lifestyle might not be so good for us. In fact, what we eat and how we live may really be contributing to a sensitized nervous system. Looking at all the things like smoking, nutrition, alcohol and activity levels, and seeing if there are any issues, is a good beginning. And these things can go on your plan. Then there's often enormous value in exploring the deeper meaning of pain, and the surrounding personal story. By stepping back, and looking at all the things that were happening around the time the pain developed, many people with pain can make useful links between a worrying period of life and a worsening pain picture. For many, recognising deeper emotions can be part of the healing process. Last, but by no means least, is physical activity and function. From the brain's perspective, getting moving at comfortable levels without fear and where the brain does not protect by pain is best. and you'll gradually restore your body's tissues. So to sum up pain, it comes from the brain and it can be retrained. And when looked at from a whole person or broad perspective, gives you a lot of opportunities to begin. So get a helping hand if you need it, set a goal and begin. This podcast episode is sponsored by the RANS-MARTA Physiotherapy Clinic. which is my own physio clinic, where I help treat a wide range of PHT sufferers, both locally in person and all over the world with online physiotherapy packages. In the years I've been self-employed as a physio, close to 70% of my entire caseload has been helping people with proximal hamstring tendinopathy, which is why I decided to launch this podcast. So if you're building upon your own rehab knowledge through the podcast, but still require tailored assistance, I'd love to be on your rehab team. Whether you are a runner or not, head to runsmarter.online to see your available options for working together. If you're still unsure if physiotherapy is right for you, or if you need a rehab second opinion, you can always schedule a free 20 minute injury chat with me. Find the free injury chat button on my website or in the podcast show notes to be taken to my online calendar to book in a time. So hopefully you can see how this ties into the last episode regarding context, thoughts, worries. and how that relates to chronic pain. Let's put this into an example of say a runner. If you had ITB issues or plantar fasciitis and you've had it for several years, begin to appreciate the power of the brain and the potential learned pain. And this concept learned pain has come from the book, one of my favorite books is called The Brain That Changes Itself. And I thought I would just read out a chapter just to put into context and hopefully you can relate this to maybe your ongoing persistent injuries. So this is what it says, what better way for the brain to prevent movement than to make sure that the motor command itself triggers pain. The author of this book came to believe that in these chronic pain patients, the motor command got wired into the brain system so that even though the limb has healed, when the brain sent out a motor command to move a certain limb, it still triggered pain. So this is what they established as learned pain. The brain has said, if we do these certain movements, it's going to trigger pain. Even when the tissues have healed, that connection, that brain connection to the motor movements is still there. So let's go back to our ITB or plantar fasciitis presentation. what context have you given it to start with? If you start developing ITB pain, how much worry are you giving that? How long have you had it for? And as the months and years go on, the brain starts to be like, if I run, my ITB is gonna get sore. That's happened in the past. It always has happened in the past for the last couple of years. Therefore, if I go run again, it's gonna be sore. It's gonna be irritated. And so the brain will reflect that and say, that's a warning sign. alarm bells start ringing, pain is produced even if it's not doing any damage. So in this sensitized state the brain is being fed information that no longer reflects the true health and abilities for the tissues at the end of the neurons. Put another way, the brain is being told that there is more damage to the tissues than there actually is. So if you think about it this way, it's like, it's a bit like someone has broken into your tool shed in the past and has done it a few times. So you've installed a super duper alarm system that's infrared and has motion activated sensors and it's just made sure things are just on trigger. Everything's hyper aware. Everything's hyper sensitive. This is what happens to the brain. If you've had pain episodes in the past, it just gets ramped up. I have a bit of an experience. A couple of years ago I had shoulder pain, it was a long head of biceps issue, probably about, oh looking at about 6-7 years ago now, and took a very long time for me to get over and it was initially brought on by me going on holidays for 6 months, not doing anything, getting back to everyday life once I returned from holidays and starting to get back into the gym, I was doing bicep curls, chin ups, push ups, all that sort of stuff and the tendon flared up. and it probably stayed sore here and there trying to get it under control for a couple of months. And I wasn't playing basketball regularly at that stage, but was feeling in here and there and tried to return back to basketball. And whenever I would shoot a basketball or whenever I tried to rebound a basketball, it produced pain in my shoulder and it'd be flared up a couple of days after that. And so I eventually stopped playing for a couple of weeks just to give it time to rest. doing my exercises, building up the strength. And it got to a stage where I was out of pain, but wasn't playing basketball. And I'll never forget this. I was driving home from work one day and my mate called me and I was feeling good. My shoulder had no pain. My exercise was doing really, really well. I was getting stronger. My mate called me up and asked me to fill in for basketball that night. And without doing anything, just thinking about playing basketball. I started getting pain in my shoulder again. It wouldn't make any sense if I didn't understand this explained pain book. And once I know these concepts and know why pain is produced, it makes total sense. In the past, my brain has told me playing basketball hurts your shoulder, rebounding a ball, shooting a ball hurts your shoulder. And even when I've been pain free for weeks, someone rings me up and says to play basketball, the brain says, oh no, that. is dangerous for you, that will injure your shoulder. And without moving, without doing anything, I started getting shoulder pain. Really interesting to think about and there's one example that I've experienced in the past. In this book, Explain Pain, I've got a couple of statements here that I just want to ask you if you can identify with any of these statements. And because people tell me this all the time that I hear in my clinic, and it's a bit of a flag for And so I wanna just list out a couple of these statements and see if it rings true with anything that you've experienced. So pain comes on even when I think about it, watching someone move even makes the pain hurt. It started off so simply and now it has spread. It's worse on Monday. Now there is mirror pain on the other side of my body. The pain has a mind of its own. I get lots of different diagnosis. You name it, I've had it. It gets better with gin and tonic and also a vodka. It follows a seasonal, monthly, weekly or other cycle. Treatment only gives me temporary relief. My pain gets worse when I'm anxious or depressed. It is the same pain my mother had. The pain moves around my body. And lastly, no one seems to believe me. So what is the solution? What can we do about it? Seeking a health professional who is proficient in recognizing pain, explaining pain and the brain is a good start. But there are some nice tips in the Explain Pain book to help someone who is in really severe chronic pain. I think the right education is the number one first step to doing what I'm doing now, explaining what chronic pain is so that people fully comprehend and understand it. And then it's about recognizing and empowering you to take control of your pain, instead just being victimized with your circumstances and the level of pain that you're subjected to. And then just deciding what you want to do more of. And there's a bit of an art of a graded exposure and pacing techniques to getting back to what you really wanna get back to. First of all, it's all about finding a baseline, the amount of activity that you can do and know that pain won't flare up. that's establishing your baseline and then just doing some pacing and gradual exposure after that and planning your progressions through writing down goals, not freaking out if there is a flare up, having a plan in place if there is a flare up, understanding that's normal in your circumstances and just putting these contingencies in place and just creating that slow graded exposure back to what you really want to get back to. It goes into further detail of other strategies which are outside the scope of what we want to discuss here, but a medical professional or a pain specialist would be a great starting point and would be a great help to guide you through this whole process. Similar to last episode, I want you to reflect on your past and current injuries or any pain that you're experiencing at the moment. explained before and understanding what is really happening in the body. Understanding this can actually be reassuring for people and can help build confidence and help empower you rather than going the other way and feeling victimized and feeling powerless and out of control. So hopefully this podcast episode has helped achieve that. All right. And I've got a few notes written down that I think would be worth self reflecting on. The first thing I had written down was what emotions and thoughts are brewing when you have to say bend forward, when you have to sit, when you have to increase, you have to go from a walking program to a walk jog program if your plan is to return to running. What thoughts are you creating? What are you generating yourself? I know this can be hard to understand or hard to apply to you in some of these pain concepts. I think with all of my injuries that I have, whether it's acute injuries, whether they are chronic injuries or whether they are recurrent, like I've had proximal hamstring tendinopathy recur three or four times now, I've had several injuries and no matter how acute, how chronic, how recurrent, I always self-reflect on these situations and self-reflect on what my understanding about pain and... what relevance I'm giving it and potentially positives to focus on. And I will, I think I will release my run smarter podcast episode where I talk about overcoming, it wasn't the proximal hamstring, but it was another tendon in my knee I had for six years and how I was using positive attitude and practicing gratitude every single day to help reframe my. mind where my focus, where my attitude goes, where what I'm thinking about. If I was, if I can walk pain-free, I'm blessed that I can walk pain-free. I don't think about the running miles that I can't do. I think about what I can do. Um, so have a think about that self-reflect what emotions and thoughts are brewing. It's very, very hard to put yourself in a positive mindset. If you've had constant pain, constant unremitting pain, but small steps in the right direction can help. My next point that I had written down was, what are you doing that might increase pain sensitivity? I haven't discussed this much at all, but in that video, that short snippet that we listened to the YouTube video, they talk about things like poor diet, stress, smoking, alcohol, these unhealthy habits. They actually can increase the amount of cortisol in the body and can actually be a pain amplifier. So there might not necessarily be more pain. or there might not necessarily be more damage or a flare up, but the receptors in that area are a bit more heightened, a bit more sensitive if you aren't looking after yourself in these areas. And so if someone is having a particularly stressful week or someone isn't sleeping properly, or they're putting on weight and their cholesterol is quite high and they've got a poor diet and they're really... Like listening to Michelle, she went through a small period of being quite depressed, eating the wrong types of foods, increasing weight, which then would make her more depressed, which would then spiral these unhealthy habits back in Michelle's success story. So self-reflect, are these things, are these habits maybe slowly forming that can contribute to pain sensitivity? have you, this is a touchy subject which I'm nowhere near qualified to professionally discuss about, but I have a, I can see a huge correlation between those who go on to develop chronic pain and those who have had a history of depression, anxiety, and the relevance and the impact that pain creates if someone has had that, um, in the past, either during their injury or even before their injury, does really, really hinder recovery. It's very tough to recover if we don't get professional help or address, at least address the psychological component of your rehab. And what I know about pain is, if someone is, I don't know much about depression and anxiety, I'll be the first one to say it, but if someone has a tendency to always focus on the negatives, If someone always has a tendency to, if something positive is happening to them, they'll pick out the negative and focus on that. Sometimes if someone is in a bad head space or going through a depression kind of patch, that's what will happen. And so the brain can start to spark these emotions. And if we know anything about pain of what we've learned the last two episodes, we know that can have a direct... a direct line to how you experience pain and then your recovery is hindered because of it. So something to focus on that if you do have a connection with depression, anxiety in the past, or you're starting to develop it throughout your recovery, it's important to seek the psychological help and guidance and yeah, start that conversation. The other thing I had written down are symptoms starting to correlate with emotional wellbeing. So like I've mentioned a sometimes if people can't make sense of their, or my dog's playing with her squeaky toy. I'll just take it off her just for the next couple of minutes. If you have had any connection with uh I guess poor emotional well-being on one day and you're noticing symptoms are increasing on the day where you are particularly stressed or focusing on the negatives, whereas on a positive day when you have managed to distract yourself or do something Um, spend time with your family, have a good time out, um, maybe on holidays or something and you're noticing your pain decreasing, that's a sign that there is quite a connection between this chronic pain or how much relevance this chronic pain, the brain actually has on influencing your pain experience. Uh, I have how many here? Five, five dot points. Five dot points to help treatment, like to head you in the right direction for chronic pain. And one would be to find something you enjoy. Find something that's outside of anything that produces pain, say if walking or sitting or running causes pain. Then perhaps go out walking, perhaps spend some time with friends or family out, playing in the park, just walking around, taking in some air. go to the zoo, get out in nature, do something that you find quite enjoyable that doesn't spark any symptoms. If you do notice pain during those symptoms, that's totally fine, but we don't want a huge flare up, but we want you to start doing something you enjoy, and then what we call graded exposure. Slowly do start more, start doing more and more. If it's walking, then start doing more and more walking. So that's the first stop point. The second one I have is, get answers if you feel like you are quite confused, if you feel like you're getting conflicting information about what to do with this condition, if you do feel your management plan is quite murky, you're not too sure of your next steps and you're really confused, then find the right person to develop a plan, develop a management plan that so you can see these small goals and you can see how you can progress to the goals that you have. That calms down the brain, it calms down the decision making process. I had the toy dangling down, just managed to grab it. It's going up on the table now. The third point I have is number three, establish a clear management plan and timeline. So this is similar to the point that I had before. Once you've got the answers and you have that clarity, just write it down, write down with your health professional, seek. a management plan with these a clear timeline and clear goals that you need to tick off before you progress to the next step. It could be very empowering to know that you do have that plan in place. The fourth one. Catch yourself if you're constantly paying attention to your pain. If you're really hyper vigilant about this area and every time you sit down, even if you don't notice pain just yet, if you're starting to think to yourself, is the pain going to come on? Is the pain going to come on? Is the pain going to come on? Similar to like if I was to be injured and return to running every step. Is it there? Is the pain there? Is the pain there? if you catch yourself doing that we need to try and break that habit which takes me to my next point my last point try and distract yourself and break from any negative habits or these connections this brain to movement or brain to activity connection and associating pain with that it comes with again probably some psychological some psychology techniques or yeah just ways that you can distract yourself so Along with all the other management rehab tools that we have in our toolkit now, listening to all the past episodes, we now have our understanding of pain and how we can slowly interweave these treatment tips into our current management plan that we already have. We are done for today. I can now give my squeaky toy to my dog and we'll catch you in the next episode. Thanks once again for listening and taking control of your rehab. If you are a runner and love learning through the podcast format, then go ahead and check out the Run Smarter podcast, hosted by me. I'll include the link along with all the other links mentioned today in the show notes. So open up your device, click on the show description, and all the links will be there waiting for you. Congratulations on paving your way forward towards an empowering, pain-free future, and remember, Knowledge is power.