Green Light To Move
Charlie Merrill, PT
8.24.23
You are an athlete. Now I realize that for some this could be a jarring way to start an article about pain. I’m sensitive to the fact that calling one’s self an athlete can feel intimidating. Yet so many desperately want to believe in their body and even get emotional when I label them as an “athlete” during treatment. There’s sadness about losing that part of yourself and you hope that I might be right. It’s emotional to consider and the reactions I get are honestly mostly powerfully hopeful. But naturally some of you will have doubts. After all, when you’ve been in pain for months or years, athletic is not a word you’d likely choose to describe how you “feel”. But assuming you are a human being and part of the same species as me, I’d like to start by acknowledging that you are, by nature and by definition, an athlete. In fact movement complexity is a reason we evolved as humans. Our brain development and subsequent ascent to the top of the food chain is related to our ability to move. We (the collective we) as a species ascended to our rightful place near the top of the natural hierarchy by being the best movers on the planet.
First, I’d like to define what I mean by “athlete”, because it’s different from the dictionary definition, which creates limiting beliefs about movement. An athlete is anyone who navigates and explores the world through movement. I’m not talking about “exercise”, which is goal directed and often infused with competition or pressure. I’m also not talking about people who perform or compete at high levels of sport like the olympic games athletes or those who make their living from exercise as a form of competition. I’m simply talking about movement as a way to explore and be alive in the world. Movement to play and learn and have fun. Movement that allows us to fulfill our purpose in life and to succeed as a human beings.
To ease any discomfort with this notion, let’s say that part of you went dormant at some point on your pain journey. Naturally we lose fitness and our ability to move when we’re in pain. The body can become deconditioned and experience adaptive changes that limits the ability to inhabit it’s highest physical form. Essentially the brain loses a clear and robust connection with the body so the communication between them is fuzzy or blurry. Due to the brain’s loss of a clear focus about where the body is in space, fear and thus symptoms increase. We end up moving less, further reducing a healthy mind/body connection and creating a vicious cycle of fear-avoidance-pain, etc. I want to reassure you that there’s nothing dangerous about this. When you understand neuroplasticity and the science of pain, you realize the connection can always be re-established. There is no deadline. It’s never too late. You’re never too old. No one and no thing can take away your inner “athlete”. It’s untouchable.
As a physical therapist, I spend a lot of time in my clinical practice reducing fear and giving people permission to start moving again. It’s hard to believe that movement is indicated and recommended in spite of pain. But we have a ton of evidence about the downsides of not moving and an equivalent abundance of evidence about the universal benefits of moving regularly.
Everyone needs a different bit of information to trust the process and believe it’s possible to resume moving despite pain. Especially when they’ve heard many scary messages based on outdated information and old school ideas from (mostly) well meaning providers. Some like to understand pain neuroscience. Some need permission to let go of unhelpful myths about the body. Others need thoughtful and gradual physical guidance. Still others need support removing the natural psychological and social barriers that exist. Most need to personally experience safe movement so that they believe it’s possible. But one paradox I rely on to shift the paradigm for people in pain is the idea that movement is not a goal or something for the future. It’s an important part of the process and almost universally required to unlearn pain and other symptoms. If I use fear in any direction, it’s to help people understand the upsides of movement and the downsides of NOT moving. Regardless of why you’re in pain, movement is the way out. Moving through pain creates an opportunity to unlearn it.
As a mind/body physical therapist, 4 myths that I’m often helping people jettison include
Pain does not correlate with tissue damage. Pain is not due to wear and tear, bone on bone, arthritis, failed surgery, age, body weight, or many of the other false associations we used to think were important. Most importantly, pain does not correlate with imaging, including MRI. We know most of the things we see on MRI are normative (natural changes over time). People with normal MRIs often have pain while people with significant and often severe tissue changes on MRI often have no pain. Radiologists have no ability to predict who has pain based on images alone. Early imaging increases fear, increases unnecessary and invasive treatment, delays effective treatment, and results in worse outcomes. Wrinkles and grey hair don’t hurt, at least not physically! The things we see on MRI are just like wrinkles and grey hair on the inside. Reducing fear about the things you’ve been told about your body is critical to success with movement.
You are not a car. Cars don’t heal, but you do! Regardless of whether you had an actual injury or surgery or not, the body heals itself. Healing is reliable, predictable, and linear. You can count on it. Most people don’t know the expected healing times of different tissues so I’ve included that information in the image below.
You can see that most tissues heal in weeks and months. And pain is designed to turn off before healing is done allowing you to start to move again to teach those tissues how to do their jobs again. After injury/surgery, a short period of relative rest can be helpful. But thereafter, movement actually encourages optimal healing. So if you’re still dealing with pain after healing is done, it’s no longer due to injury. Regardless of how long you’ve been in pain, it’s not too late to regain fitness.
Your tissues actually get healthier, stronger, and more robust the more you move. The SAID principle (Specific Adaptation to Imposed Demands) states that all the tissues in your body adapt to the stresses placed upon them. Reduce the stress by avoiding movement and your tissues lose health. Increase the stress via healthy movement and the tissues adapt to become stronger, more robust, more resilient, and simply better. The SAID principle applies to bones, muscles, tendons, ligaments, nerves, fascia, cartilage, and joints. It’s the science behind use it or lose it!
There is no difference between highly prescriptive, specific, and controlled physical therapy exercise (tedious & boring movements) and more interesting functional exercise that you choose. The research shows this later type of general exercise actually performs better, probably due to the fact that you might actually do the types of movement that YOU enjoy. Movement that’s fun and interesting. Movement that’s not bound by rules and perfection and fear. Movement not based in fear but rather awe, wonder, joy, fun, play, and social connection. We know the best outcomes result from making movement preferred so you have autonomy and self efficacy about what to do and how to do it. But movement is even more effective when you truly enjoy it and so you make it a habit. Dancing along with the fitness marshall might relieve your hip pain more than gym machines and pickleball might relieve your shoulder pain more than boring band or weight based gym exercises. There are many ways to engage your body with the world. While there’s little benefit from movement you have to do, should do, need to do, or are told to do, I like to say there are no bad movements.
Essentially, your brain normally LOVES information from the environment. As I said above, it needs and craves this to establish a clear picture of your surroundings; and to understand where your body is in space and how it relates to the environment. Deprive the brain of information from the world around you, by reducing movement, and even the most resilient human will suffer. In fact this “bottom up” information is one of many things the brain weighs in it’s decision to create pain or not. The homonculus is the brain’s `representation” of the body (see figure below).
You can see how the more sensitive parts of the body have more representation in the sensory input and movement output regions. The more safety information we feed the brain, the more accurate and clear the brain’s perception becomes. However, once pain starts, and the less we move, the homonculus becomes “smudged” or out of focus. The lack of clarity increases the brain’s tendency to create pain.
It’s important to reinforce, at this point, that the brain is where all pain is constructed and experienced, regardless of the cause. While all pain is real, pain does not come from or exist in the body. Instead the brain receives INFORMATION from the body that it’s left to interpret. All pain is constructed in the brain. Most of the time, the information from the body never makes it up to our conscious awareness. Think about all the parts of your body your brain isn’t even aware of most of the time. Most information from the body is filtered out as unimportant noise, until your brain has a reason to care. The brain’s interest might be triggered by an injury, a surgery, or most often some other fear that has nothing to do with your body. Like life stress tied to intimacy, change, control, or order. But we know, in the later cases, the best way to get an athlete’s attention (remember you’re an athlete) is with pain. Sadly, we don’t come with warning lights like your car.
So once the brain decides pain is helpful to protect you from danger, it won’t stop until you feel safe again. Once the filter between body and brain is open, even normal information from the body starts to get interpreted as dangerous. Now your brain really cares about that part of your body and a sort of vigilance is established. The information is now blurry, and there’s a lot of it!
At this point, all of this inaccurate bottom up information is cross-referenced with your context, predictions based on past/present/future experience, and your thoughts, feelings and behaviors. If this information is perceived as dangerous, you will have pain. If the information is perceived as safe, no pain. Regardless of whether pain is from an injury or not (usually not) your brain will consider the following factors in it’s decision to make pain:
Things you hear, see, smell, taste, and touch that create fear.
Things you do, say, think, and believe that create fear.
Places you go & people in your life that create fear.
But if movement is something that’s universally important to human life, and the absence of it is objectively unhealthy, why might the brain start to think that movement is dangerous? This is a common barrier to people trying to start moving again. Attempts to get brave and go for it tend to backfire. Sometimes the pain gets worse during movement but usually it flares up after movement; hours or days later. This is one of our favorite symptom behaviors because it reinforces that your brain, not your body, is what’s driving the symptoms. In other words, despite very real pain, these flare ups are the result of injury or damage but rather your brain’s perception of danger. This is why your belief is so important when it comes to how successful you are returning to movement. If you go into movement thinking it’s dangerous, pain will flare up consistently, even if the dose is small. However, if you see pain for what it is and use a ton of reassurance, noticing thoughts and feelings to make connections between physical and emotional sensations while doing it anyway, you will break through. Even if you’ve tried and struggled many times before. When you understand that your brain is altruistic in it’s goal to keep you safe and alive, it’s easier to view pain through a more compassionate lens and see how your brain protecting you from doing healthy movement is normal and common. Understanding why this happens is foundational to shifting belief in order to get brave and move through pain with a new mindset and intention.
One way I like to think about pain and movement is in the context of prediction and learning. Your brain relies on it’s predictions about the future, about what might happen next, in order to keep you safe. This is very helpful most of the time. Think of how you might have learned to swerve to avoid another car turning into traffic because once another driver turned into your lane. Your brain will use this prediction to avoid accidents in the future. Thanks brain! However, if your pain starts because of, or connects with (real or imagined) things like bending, squatting, running, driving, sitting, or working, it’s natural for the brain to predict those things are dangerous. While this might be helpful in the short term, it’s absolutely not helpful in the long term! Rest is almost never indicated for pain; and this is where learning adds to the challenge of pain and movement. Turns out our brains are really good at learning. Once this subconscious prediction that movement is dangerous is established, the brain will pair those two things together and the prediction will become a new unconscious habit. This is called a neural circuit. You might have heard the saying “nerves that fire together, wire together!” Now every time you try some movement, the brain interprets that information as dangerous and creates the experience of very real pain. Luckily, just like you can learn that movement is dangerous, you can also unlearn it. As I said before, it’s never too late. Remember, you are an athlete, even if your brain doesn’t believe it yet.
Now you know that pain is due to a brain changes that happen as a result of injury, surgery, and/or some psychological or social stress in your life, a few reasons it stays in a state of danger alarm after healing is done:
Your brain has become vigilant to that body part and stays concerned allowing all incoming information to reach your conscious awareness unfiltered. Even normal information is perceived as dangerous.
Your brain subconsciously starts to predict and learns that movement and exercise are dangerous and make a habit out of that pairing. These neural circuits are always being created and pruned/eliminated based on how much we practice them. How much are you “practicing” pain with your thoughts, feelings, and behaviors?
The paradoxical act of using movement to overcome pain is as simple as stopping practicing the old neural circuit (fear and avoiding movement) and instead starting to move despite pain while thinking and feeling differently about it. While it can be scary and take courage initially, practicing this new neural circuit will result in the old one getting pruned and the new one getting stronger. As you do this, your brain will start to prioritize only the most important information again based on what you’re asking it to do. It’ll filter out the noise and you’ll start to be rewarded for your efforts. This becomes self reinforcing and rewarding so it’ll become easier and easier to do in time.
The first step in returning to movement, whatever that means for you, is understanding how pain works, designing a process for how to use movement to unlearn pain, and seeing how movement is the way out of pain. This video describes how to think about the process of returning to movement as you allow some symptoms and work to reconceptualize the meaning and purpose of pain.
VR with Karuna can be extremely helpful in the process of unlearning pain. Your brain can’t tell the difference between actually doing movement compared to visualizing/ mentally rehearsing movement, or doing movement in VR. From the perspective of your brain, VR and mental rehearsal is the safest way to start exploring movement. While we needn’t be concerned about whether your body can handle movement (remember you’re an athlete) we do need to respect the brain’s opinion of whether we’re safe or in danger. So having success in your mind using VR can set you up to do the real thing in time. You can do this!
A few other strategies to consider as you make a plan to return to movement include:
Set your intention in the morning toward what could go right, not wrong.
Creating a context that gears more toward safety.
Pick a movement/movements that are fun.
Choose something novel that the brain doesn’t interpret as dangerous.
Close your eyes and visualize/mentally rehearse based on your memory of that movement feeling easy, pain free, joyful, and fun.
Make movement playful, immersive, and distracting.
Pick something social to increase the feeling of safety.
Do it in nature to create a more present and divergent focus.
Attend to what feels good and distract from more aversive sensations using your breath.
Allow yourself to experience/track thoughts, emotions, and sensations that emerge for short periods. Reassure yourself often and with confidence.
If you get scared, remind yourself of the evidence you have for safety and remember what you learned from reading this article.
Reassurance, reassurance, reassurance. Unless your pain feels like a bully, then let’s talk about how to stand up to it.
Ultimately, I like to encourage people to develop what I call a “movement vocabulary”. When you understand that there are no “bad” movements, you learn to truly enjoy all the ways in which you, the most talented mover on the planet, can be in your body. The idea is that by exposing the brain and body to many movement patterns, positions, contexts, situations, feelings, and variations, those things become familiar and non-threatening. You’re actually desensitizing yourself in the opposite direction so that your brain doesn’t feel threatened when your body encounters those movements in the future. This phenomenon is what allows athletes to do incredible things with their bodies. While you don’t need to be an elite performer to move in your life, I hope you’ll dream a bit about how movement might fit into your life. What lights you up? What feels like self care? What would bring you joy, a sense of awe or wonder, or be social and playful. Then start practicing those things to create new neural circuits in your brain and body.
