The Pain Series: Part 2 - The Real Cause of Pain

PART 2: THE REAL CAUSE OF PAIN

In Part 1 of the Pain Series, titled "Pain is More Than Meets the Eye" we covered the complexity of pain, phantom pain (pain that occurs in limbs that aren't there) and watched a 5-minute video that explained what pain REALLY is, in a way that's easy to understand.

By the end of the article we had established that pain was formulated in the brain, it is NOT a normal symptom of ageing and that each one of us could be, and should be, pain-free.

In this part, we'll uncover more about pain, why medical imaging findings (e. g., osteoarthritis) are not the cause of chronic pain and I'll then explain why we get pain in certain areas of our body.

MEDICAL IMAGING FINDINGS DO NOT EQUAL PAIN

When we are in chronic pain (longer than 6-12 weeks), medical imaging (X-rays, MRI, ultrasound, etc.) is what's most commonly used by Doctors to identify what the cause is.

Medical imaging can identify many physical 'abnormalities' and the majority of the time these ''abnormalities'' are then identified as the cause of pain.

It's a common belief that a scan is going to uncover the cause of chronic pain.

Unfortunately, although this belief is common, holding this belief is where many issues towards overcoming pain start and become a detriment to any progress.

Thinking your pain comes from a physical 'abnormality' (such as degeneration/arthritis) shown on a scan, can lead people to believe that their pain cannot be overcome if this physical 'abnormality' is always going to be there.

But to begin overcoming chronic pain, medical imaging findings need to be taken with a grain of salt.

Medical imaging is great to find any ''red flags" (i.e., something serious) but imaging does very little in explaining the cause of chronic pain.

In some cases, the images can pick up all types of physical ''abnormalities'', we can be riddled with joint degeneration (osteoarthritis) and yet have NO pain.

And in other cases, images can show we have no ''abnormal'' findings or minor degeneration (osteoarthritis), and yet have excruciating pain.

There is a large amount of evidence that suggests that the “abnormalities” found with medical imaging are not causing pain.

Let's look at some of this evidence: (Click the links to see the study)

Study 1: On Spine Degeneration in Populations With No Symptoms: 

In this study, imaging findings of degeneration in the spine are present in high proportions of individuals WITHOUT any pain (or other symptoms), increasing with age.

This study concluded that many imaging-based degenerative features are likely a part of normal ageing and unassociated with pain.

Study 2: On The Discordance Between Clinical and Radiographic Knee Osteoarthritis

In this study, up to 85% of adults with no knee pain, had x-rays showing arthritis.

This study concluded that radiographic knee osteoarthritis is an imprecise guide to the likelihood that knee pain or disability will be present.

Study 3: On The Association of Hip Pain with Radiographic Evidence of Hip Osteoarthritis

This study showed that hip pain was NOT present in many hips with radiographic osteoarthritis.

This study concluded that hip pain is discordant with radiographic hip osteoarthritis

Study 4: On The Pattern and Prevalence of Lumbar Spine MRI Changes

In this study of 1043 random volunteers, forty percent of individuals under 30 years of age had lumbar spine degeneration (arthritis), with the prevalence of lumbar spine degeneration increasing progressively to over 90% by 50 to 55 years of age. 

This study demonstrates how common lumbar spine degeneration is, without pain.

Study 5: Prevalence of abnormalities in knees detected by MRI in adults without knee osteoarthritis: population based observational study

This study showed that it is just as common to have NO PAIN in the presence of these “abnormalities” seen on medical imaging.

Here is a graph that summarises the findings.

Percentages of pain versus no pain were similar for all. Including osteoarthritis (cartilage damage).

These are just five studies I picked from a large amount. There are plenty more studies out there proving this.

It's clear that medical imaging is never going to show your pain.

It can't!

So you may be thinking, “if physical 'abnormalities' seen on medical imaging are not what causes pain, then what causes it?”

THE REAL CAUSE OF PAIN (& ARTHRITIS)

Pain is..... A feeling.

A feeling that presents in areas of physical weakness in our body caused and intensified by certain stressors/factors (cultural, biological, environmental, psychological and social factors).

As we age, we have been exposed to and can take on, more stress over the years, explaining the higher incidence of pain in seniors.

Arthritis is often used to refer to any physical disorder that affects the joints. 

The most common type of arthritis is osteoarthritis (OA), where the softer cartilage in our joints can wear, leading to the bones moving closer together.

Arthritis is usually associated with pain, but can also cause stiffness and may limit your ability to move around freely.

Osteoarthritis increases in prevalence as we age. It is common in the knees, hips, spine, shoulders, elbows and fingers, and is usually the areas of weakness for most seniors.  

When pain shows up in areas of weakness, it's usually going to be the areas of arthritis. (It is not uncommon for pain to move around in people if a new, weaker area is to present).

Arthritis is not the cause of pain; it's a weak area where pain MAY show up.

By knowing this, we can begin to make progress.

YOU DO NOT NEED TO BE FREE OF ARTHRITIS TO HAVE NO PAIN.

If you could be pain-free, move the best you have in years, yet still have arthritis identified on scans, would your arthritis still be an issue?

YOU CAN BE PAIN-FREE WITH ARTHRITIS

The first step is to shift your focus away from pain and the associated 'abnormalities' and towards wellness & health.

Healthy body, healthy muscles, healthy joints and a healthy mind.

We'll cover more in PART 3, where we look at managing pain and in PART 4: overcoming pain.

Click here for Part 3 - Managing Pain

The Pain Series: Part 1 - Pain Is More Than Meets The Eye

PART 1: PAIN IS MORE THAN MEETS THE EYE

When I meet new people and they find out I'm a Physiotherapist, it's almost as if I've said: "tell me all about your different aches and pains!"

Wherever I am, when people know what I do, they'll usually start talking about their pain and ask for advice on it.

It comes with the territory of being a Physio.

I do, however, have a fascination with pain. Obviously not being in it, but studying it further in my spare time. So I don't mind hearing people's stories of pain.

I usually hear many similar stories, or pain patterns, between people. But specific stories, especially ones I heard at the beginning of my career, really intrigued me.

A story that stands out is one told by a pain researcher in my early university days. This story was about a man with excruciating hand pain.

Doctors could not find a cause of this man's pain, but it was clear to them this pain was real.

He tried everything to stop the pain in his hand, and everything he tried came to no avail.

Eventually he couldn't handle the pain any longer and desperately wanted it gone. He was so desperate that he went on the hunt to find a surgeon who would amputate his hand.

After going to many surgeons who declined, finally, he found one who agreed to the surgery.

Not long later, the surgery was complete, and his hand was now gone.

Some time post-surgery and after all healing had taken place, you'd think the pain would now be gone, right?…………. Wrong! 

The same pain, at the same intensity, still existed in this man's hand….. A hand that now wasn't there.

This is not a one-off story, this type of pain is not uncommon in people who have had limbs amputated and it is a type of pain known as Phantom Pain. 

This was one story of many that piqued my interest. I heard many more stories and saw many pain-patterns in patients, which demonstrated to me there was something more to pain than meets the eye. Pain wasn't just something physical.

This is what lead me to study pain in greater depth.

When most other Physiotherapists were studying different massage techniques or something similar, I took courses and read books on pain and the brain.

So when people now ask for advice on their pain, you could say that I'm the right person to answer this question for them.

However, giving an answer is never straightforward.

Most of the time, it's not the acute pain people are wanting advice for. Acute pain is pain after an injury or a health ailment that lasts only a short amount of time.

It's usually pain of the chronic type they are asking about. Pain that lasts longer than 6-12 weeks.

And chronic pain is complex.

I mean, everyone has their remedies that help MANAGE chronic pain, which do have their place, and I will go through them in Part 3 of this series. However, to OVERCOME pain, a different approach is needed.

This 4 part series of articles is my answer to the pain questions I get and the different approach that is needed.

I'll put everything I know about pain into these articles to not only help you manage pain but also help to overcome it.

To get started, here is a short video by the New South Wales Government.

This video explains pain a lot better than I could in 5 minutes.

Click to watch and learn below.

UNDERSTANDING PAIN

This is an excellent video educating on what pain really is and how to deal with it.

It is targeted toward younger people in chronic pain; however, do NOT be deterred by this.

Everything mentioned in this video still applies to those of all ages.

Now that’s it for Part 1 of The Pain Series. In finishing this part, I want you to remember this:

PAIN IS NOT A NORMAL SYMPTOM OF AGING.

IT IS POSSIBLE TO BE PAIN-FREE.

UP NEXT:

In PART 2, we’ll see how this new model of pain relates to seniors, with reference to a specific common pain-related condition (arthritis). 

In PART 3, we’ll cover ways to manage pain. And….

In PART 4, we'll cover ways to overcome pain, for good.

CONTINUE TO - PART 2 - THE REAL CAUSE OF PAIN.

The Guide to Stronger Legs For Seniors

(Includes: The Best Leg Strengthening Exercises and STRONGER Legs Workout Video)

With stronger legs comes many benefits; we move well and effortlessly, we can decrease or prevent pain in our knees and our hips, and we can help prevent falls.

Regardless of your current physical capabilities, keeping your legs strong and moving as well as you can is essential.

When our legs start getting weaker, life is much, much harder.

Whether you feel your legs are fine with no strength loss and are doing everything you have always done but want to keep it that way or improve your strength even further. Or, you're in the opposite situation, can feel yourself getting weaker, and even the simplest of tasks are causing you trouble. Either way, this article will be of great help to you.

In this article, we will cover why it's possible to increase leg strength regardless of age, how all of us should be moving to keep our knees healthy and how you can strengthen your legs to keep yourself moving as you should and by doing this decreasing or preventing knee pain!

CONTENTS

• WHY IT'S POSSIBLE TO IMPROVE LEG STRENGTH AT ANY AGE & DECREASE PAIN

• THE CORRECT WAYS TO MOVE TO DECREASE OR PREVENT PAIN

  • AVOID THESE MISTAKES WHEN STANDING UP

  • HOW TO STAND UP CORRECTLY (VIDEO)

  • AVOID THESE MISTAKES WHEN SQUATTING

  • SQUAT: HOW TO SQUAT CORRECTLY (VIDEO)

• STRENGTHENING THE LEGS FOR SENIORS

  • HOW TO MAKE LEG EXERCISES EASIER AND PERFORM THEM WITHOUT PAIN

  • THE BEST LEG EXERCISES FOR SENIORS

• SENIORS LEG WORKOUT VIDEO

WHY IT'S POSSIBLE TO IMPROVE LEG STRENGTH AT ANY AGE & DECREASE PAIN

Most of the changes (losing muscle bulk and/or reduced strength) are NOT caused just by our bodies undergoing the natural ageing process. The majority of change occurs due to lack of use.

We do less physical activity, and we stop using the muscles in the way we used to. The activities that keep our muscles strong. Leading to smaller and weaker muscles.

2) Pain in the knees, with or without osteoarthritis, can be helped and prevented by changing the way we move and by strengthening our legs.

If you are feeling down because you have been told you have osteoarthritis, I want you to put this diagnosis aside for a while.

Although osteoarthritis and pain usually come together. Osteoarthritis is NOT the cause of pain. You can have osteoarthritis and be pain-free, many, many people are.

So, let’s not focus on what we can’t change (the arthritis diagnosis) and focus and correct what we can change (the way we move and our leg strength).

Changing these factors has been proven to decrease strain on the knees, preventing the worsening of joint wear and tear and helping and/or reducing pain symptoms. [1]

So, what if we focused on correcting your movement patterns, allowing the body to move as it should? And, what if we also strengthened weak muscles in our legs?

We'd decrease the strain on our knees, preventing any further pain or preventing pain altogether! We would also find knee exercises much easier and less painful! We'd also strengthen our legs, decreasing the strain on our knees and making everything we do in life much easier.

There are other factors we can change to decrease knee pain symptoms, such as: losing weight, choosing softer surfaces over harder surfaces when walking (to decrease shock absorption through the knees), wearing better shoes (with shock-absorbing soles) and wearing knee supports (to provide warmth and give confidence).

But to make real, lasting changes, we must move correctly and strengthen our legs! This goes for everyone. Even if you have no pain, by learning the techniques in this article, you will learn how to improve your movement and increase your leg strength, preventing any pain that could occur.

The first step:

MOVING CORRECTLY TO DECREASE OR PREVENT PAIN

In our day-to-day lives, we perform certain movements but give little to no thought to how we perform them. This is fine. This is how movement should be. 

But when we perform the movements incorrectly, over time problems can arise. 

Bad postures, awkward, repetitive, and incorrect movements put a strain on our muscles and joints, the knee being a joint which can take on the brunt of the excess strain.

Common incorrectly performed movements that place excess strain through the knees are kneeling, squatting or even the simple task of standing up!

We can improve these movements by making a few changes. By doing this, you'll be minimising the strain placed through the knees each day which will relieve pain or prevent pain and allow you to perform exercises as they should to strengthen the legs.

AVOID THESE MISTAKES WHEN STANDING UP

We stand up and sit down many, many times during the day and therefore throughout our life. From the couch, from a chair, from the toilet, and so on.

Standing seems like such a simple task, and it should be. However, it's commonly performed in a way that puts a lot of stress through the knees.

The most common mistake seen when standing is incorrect knee alignment (knees moving in). Like this:

Incorrect Standing 1: Sitting with knees facing in.

Incorrect Standing 2 - Knees coming inward when standing, not inline with toes.

What we see above is usually the result of weak hips and glutes (buttocks).

Knees coming in is more common in women. Women have a wider pelvis and are usually told from an early age to sit with their knees together, "sit like a lady". This sitting pattern is repeated day in, and day out for life, to the point it becomes the normal way to sit and stand.  

With these factors combined, we see an imbalance in our inner and outer thigh muscles. Our inner thigh muscles become overactive with weaker outer thigh muscles (hip and buttocks).

The above way of standing puts a whole lot of strain on our knees because we are not moving our bodies in their natural alignment.

This is not only the case when standing up, because of these muscle imbalances, we are putting excess strain on our knees repetitively in different amounts when we walk upstairs, jog, kneel and even walk on the flat.

There is less force through our knees when walking on the flat over jogging or walking upstairs, but small repetitive forces over a lifetime add up!

CHECK YOUR STAND

Before we check if we stand with our knees coming in, let’s see what normal standing looks like. Knees should be in line with toes and remain like this throughout the stand. (See pictures below).

Correct Standing 1: Knees inline with toes.

Correct Standing 2: Correct knee alignment. Knees in line with toes.

STAND TEST

Let’s take the stand test and see if we have a natural tendency for our knees to come together when standing. Do not try to perform it correctly, just sit down and stand as you usually would.  Yep, it’s that simple! :)

Do you find your knees come in when you are just sitting there and/or do you find they move in when you stand up?  

If your knees are moving together, then you are not utilising your lower body muscles correctly and putting excess strain on the knees.

Now we are aware, We must correct this.

HOW TO STAND UP CORRECTLY (VIDEO)

The first step is bringing awareness to this issue when sitting. Do your best to avoid sitting with your knees together. Sit with your knees in line with your toes and your feet flat on the floor. This will be uncomfortable at first but stick to it. To continue to "sit like a lady" without your knees together, you can use a towel or blanket to cover up.

The next step is the awareness of keeping the knees in line with the toes when we stand up. When they start to come in, correct it. 

When you continue to stand correctly, you can decrease the strain you put through your knees and then work on strengthening your muscles correctly.

We must strengthen the muscles NOT ONLY surrounding the knee, which is what most people only do to improve their knees but by strengthening ALL MUSCLES in our legs, especially our hips and buttocks.

When we strengthen all muscles in our legs, we can start and keep moving as we should.

AVOID THESE SQUAT MISTAKES

Another important movement is the squat. 

It is good to be able to squat correctly so we can place less strain on our backs when we do specific tasks like lifting objects off the floor. However, squatting is also an important exercise to perform to strengthen our legs.

I love the squat for seniors because it works every muscle in the lower body and activates the core.

However, like the sit-to-stand, it is usually performed incorrectly and when performed incorrectly, can INCREASE knee strain.

The two most common mistakes I see when people squat putting added strain on the knees are: 

1) Knees coming inwards (as below) - just like what happens when we stand up.

and

2) Coming forward from the knees (as below) making our knees come forward over the toes. (This isn’t an issue when sitting from standing because people know to hinge at the hips and stick their bottom out when having to find the chair).

Incorrect Squat:
Lady in Yellow Shirt: Squatting from knees, although this would be passable for a partial squat, if this lady was to squat down further, her knees would come past the line of her toes. I would like to see this lady sitting back more into the squat.
Lady in White Shirt: Again, coming forward from the knees, knees moving inward.

HOW TO SQUAT CORRECTLY (VIDEO)

To perform the squat with correct technique, watch these videos:

By squatting correctly, you will be moving as you should and when for exercise, you will be targeting and strengthening the muscles effectively without putting strain on the knees.

STRENGTHENING THE LEGS FOR SENIORS

HOW TO MAKE LEG EXERCISES EASIER OR PERFORM THEM WITH PAIN

If having difficulty with the sit-to-stand or the squat, there are many things you can do to make it easier until you are performing these exercises with ease.

For the Sit to Stand:

1) Use Arm Rests:

Using the armrests to help assist with your standing is fine. By doing this, you are still getting the benefits of the exercise for the stage you are at, but just using your arms to provide a little assistance to help you perform the exercise correctly.

As you start to get stronger, you can decrease the amount of assistance you are using over time. (i.e. move from two hands to one hand, to no hands).

Concentrate on using your legs more than your arms for each stand.

2) Change Seat Height:

Standing from a higher seat height or taller chair will make it easier for you to stand and, again, still give the benefits of the exercise, challenging your strength for the stage you are at.

Find a chair that is taller, or place a phone book or cushion on the chair to raise the height. As you start to get stronger, you can lower the height to continue challenging yourself and improving your strength.

When you slowly decrease the chair height as you get stronger, you'll continue to improve your strength and eventually be strong enough to stand in those times when you're seated at a low height (e.g. deep, low or soft couch)

For the Squat:

1) Hold Onto A Chair, Rail or Bench:

Use your arms to assist with the squat, and use your arms to assist as required. (Make sure your bench is sturdy and your chair does not have wheels).

2) Perform a Partial Squat:

By only squatting down a partial distance (picture 2 of squat exercise below) will still challenge your strength, making you stronger for the stage you are at. As you get stronger, you can go a little deeper into the squat, but never deeper than parallel

We all have different capabilities and strength, and this is fine. With time, practice and consistency, what was once considered hard will become a whole lot easier.

Be patient, don't compare yourself to anyone else; only compare you to you.

The 10 Best leg Strengthening Exercises For Seniors

So now we’ve established the sit to stand and the squat are important movements to do each day and when performed correctly are very important to get stronger legs so we move better and decrease pain.

Here are additional exercises, which are best for seniors to improve leg strength.

CLICK HERE FOR THE 10 BEST STRENGTHENING EXERCISES FOR SENIORS

Once performed and performed consistently you'll notice big differences in your leg strength, many of your everyday activities feeling a whole lot easier with your newly strengthened legs.

SENIORS LEG STRENTHENING WORKOUT VIDEO

To make it easier here is a leg exercises workout video you can follow along to whenever you want to help get your legs stronger. It includes a warm up, all exercises above and a stretch.

Video: The Best Leg Strengthening Exercises for Seniors

CLICK HERE FOR MORE LEG STRENGTHENING EXERCISE VIDEOS

So there you have it. The best way to improve your leg strength so you can decrease and prevent pain, prevent falls,  move better,  feel better and even improve the way you look. 

With stronger legs we are more confident and we can continue to do the things we love that keep us happy.

To keep your legs strong and yourself in physical shape and healthy,  I send regular workouts and tips to mailing list subscribers and for those on my Facebook. Make sure you follow along to both!

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References

1. John Bedson and Peter R Croft (2008) The discordance between clinical and radiographic knee osteoarthritis: A systematic search and summary of the literature.

2.. Duygu Cubukcu, Ayse Sarsan, and Hakan Alkan (2012) Relationships between Pain, Function and Radiographic Findings in Osteoarthritis of the Knee: A Cross-Sectional Study