Empowered Movement for Pain
The Modality of Sunset Pain School & its signature course
for those who live with chronic pain
It is universally recognized that daily physical movement is imperative for chronic pain patients to rehabilitate from, manage and reduce pain over time. However, this population struggles to accomplish this task due to any number of obstacles, not the least of which is because they fear movement. It is quite daunting for a sufferer of chronic pain to prioritize movement because of such fear. Fear of injury, higher and inconsistent pain levels, fatigue, or time constraints, are just a few of the obstacles they may face. Typically, the path from acute to chronic pain has been costly and unsatisfying for both the patient and their providers. Unfortunately, when pain becomes chronic, patients are seldom introduced to mind/body self-management practices. Such interventions can get patients closer to their movement goals, as well as improve their quality of life. Guiding this population towards mind/body techniques is key to building the confidence necessary to succeed in accomplishing daily movement.
Customarily chronic pain patients have sought individual care from multiple practitioners through costly services rendered. Specified activities or movements may have been suggested, or perhaps the patient previously had a satisfying exercise regimen pre-injury, but are now unable to continue. In fact, exercise-based rehabilitation is the standard of care for this patient population, but only 20% of patients currently participate in this type of physical therapy in isolation. (1) When someone lives with persistent pain, oftentimes they can not complete daily routines assigned to them by the practitioner.
One gap in the knowledge of many providers is that motivating the chronic pain population to incorporate daily movement is actually more nuanced than simply assigning strengthening practices, which may work better with the pain-free population. Understanding basic pain neuroscience education, in conjunction with experiencing one’s own mind/body connection, fills this gap. Now rather than going “through the movements,” on days when it can be difficult to impossible, patients obtain a deeper understanding of the contributing factors, in conjunction with powerful techniques that can be done despite current pain levels. It is this necessarily nuanced approach that is needed to make a shift towards self-empowerment for the chronic pain patient.
Physicians may suggest that their pain patient “check out a yoga class, join a gym, or take pilates.” When the patient takes their advice they are likely to experience increased fear and/or a pain flare, and consequently not return to that activity. It should not come as a surprise that pain patients require a more specific skill set to accomplish daily movement, even after multiple individual sessions with practitioners. A qualified instructor who understands pain may be a better choice. The plight of chronic pain is extremely layered, so the introduction of new practitioners or new activities should be specialized for the pain population. More precisely the activities should take into consideration that the patient likely fears new movements. This fear has a direct effect on pain levels. (2) Therefore such new experiences could serve to deepen the fear of movement for the patient, and possibly push them even farther away from their movement goals.
Another consideration in making the inclusion of mind/body techniques imperative for the complete treatment plan for chronic pain patients is the likelihood of past trauma. This component of treatment can not be overlooked: there needs to be a somatic part of the treatment plan in order to recover from trauma.(3) Mind/body modalities are the way in which we cultivate body awareness, a crucial component of pain rehabilitation. Why not send these patients to a practitioner who specializes in the conversation of moving with pain, for those in pain? Whereas it is possible that the patient can get lucky and find an activity they enjoy, it does not compare to the “sure thing” they would receive in working with a practitioner who understands the science of pain, and can teach the role that mental and emotional states play in amplifying and easing pain.
So what is the solution? It is mindful movement, relaxation techniques, breath awareness and breath regulation offered in combination with pain education. This begins the transformation for the pain patient to better self-manage their condition.
Knowledge is power, specifically knowledge that one’s pain is multifactorial, many factors which can be altered or controlled. This reality enables a powerful shift in one’s pain experience: the patient moves closer to a locus of control. The two-prong pain rehabilitation formula of threat detection and graded exposure (4), are presented in tangible terms: now students are left feeling that change is possible. Learning one’s tissue tolerance becomes accessible in conjunction with appropriate breathing techniques. This positions the patient to design personalized graded exposure movements done repeatedly over time for real neuroplastic change (i.e.less pain.) (5)
In the case of chronic pain patients, the principles of graded exposure can be extremely daunting, igniting sympathetic nervous system activation and releasing a slew of chemicals resulting in more pain (i.e. flare-ups). When one understands the physiological changes in the body in which flare-ups create, this knowledge can have a disempowering effect on pain levels. This awareness of the body’s unconscious production of pain, coupled with breathing practices to create emotional regulation, begins to reduce the fear driving the chronic pain sufferer. (6) Equipped with scientific explanations for their flare-ups, patients are empowered to take steps towards calming the nervous system, now done through gentle mind/body practices. (7)
Patients are relatively quick to grasp the link between their pain experience, and the multiple factors contributing to pain: thus begins their understanding that they in fact have more control to reduce their pain than they had realized. Such knowledge positions the chronic pain patient to take action with their personalized practices, aware of the importance of repetition to create neuropathic change and therefore less pain.
Mind and body medicine comes in various forms, inviting the person to explore their breath-pain-connection, resulting in increased body awareness. Attaining greater body awareness leads to improved self-regulation of pain. (8) Empowered Movement for Pain (EMP) works with concepts of interoception, breath awareness (2), MBSR, among other valuable resources. (9) Furthermore, a basic understanding of the science behind how and why your pain persists can open the door for the patient to begin work towards building their body awareness. These factors enable a cultivation of curiosity (interoception), which may be the single most important goal to rehabilitate the pain response in chronic pain patients. (10)
Mind/body practices combined with a targeted education around one’s own movement limitations, highlight powerful areas from which to do mind/body work for less pain. Furthermore, the repetition of individualized movement practices reduces one’s fear of movement, therefore chipping away at the vicious cycle of persistent pain, even if the movement is very minimal and possibly just imagery without actually moving the body. (11) Creating a habit of frequent mind/body practices for pain can result in a greater locus of control for the patient, and subsequently less fear of movement.
Empowered Movement for Pain: the course
Empowered Movement for Pain uses pain education to teach how pain persists, as well as widely accepted routes to recovery. (12) This framework lends itself to specific mind/body techniques taught in 5 sessions before confirming that individuals have been able to integrate the practices in session #6. As a course requirement, participants made a commitment to spend 15-20 minutes everyday to practice the movements offered.
Body and Breath awareness is cultivated throughout the 6 weeks of EMP. Students are introduced to the ways in which pain can change breathing patterns, and breathing patterns can change pain. (13) Participants are guided to establish safe movement limits in consideration of their spectrum of pain levels. Movement limits, otherwise referred to as their “edge,” is coupled with particular breath practices. (14) This is important to do early on in the course so that if flare-ups happen students have already been empowered with doable movements, building on their sense of agency. (15)
A substantial percentage of the chronic pain population suffer from spinal pain. EMP teaches appropriate daily spinal movements through a variety of options, with a focus on empowering one to discover movements in which they can do rather than those which they can not. Each participant discovers which gentle movements to be done daily. By weeks 4 and 5 students are prepared to go deeper into the mind/body process. This is where we utilize proven mindfulness-based practices for pain. (16) The final week of the program there is a 1:1 with the instructor. This assures the establishment of individualized movement goals as well as one’s personalized daily movement practice.
EMP fills a gap in the chronic pain population. The integration of mind/body techniques allows for a wider berth for students to enter into safe and powerful movements, in ways that are more accessible than standard exercise or physical therapy. With minimal cost ($497) providers of the chronic pain population have an opportunity to direct their patients towards the EMP program. Pain education has long been debated to have direct effects on pain levels. Mind/body practices for chronic pain is accepted as a valuable resource, and the combination of these two factors is being tested for this paper.
References
Thackeray A, Hess R, Dorius J, Brodke D, Fritz J. Relationship of
opioid prescriptions to physical therapy referral and participation
for Medicaid patients with new-onset low back pain. JAmBoard Fam Med
Moseley, Lorimer, Fear of new movements
Lavine, Peter, Freedom from Pain, Discover your body’s power to overcome physical pain. Pain Numbness, Body awareness, Self-Regulation/Aliveness
Kolk, Bessel von der. The Body Keeps Score: brain, mind and body in the healing of trauma. 2015
Moseley, Lorimer, Threat detection + graded exposure
Moseley, Butler. Repeated movements with graded exposure to create less pain
Prosko, Pearson, Sullivan. Yoga and Science in Pain care: treating the person in pain
Forbes, B. Yoga for Emotional Balance, Shambhala Publications, Inc
Lavine, Peter. Freedom from Pain, Discover your body’s power to overcome physical pain. Pain, Numbness, Body Awareness Self-Regulation/Aliveness
Porges, Stephen on cultivating curiosity
Dodge, Norman, The Brain Changes Itself
Moseley, Lorimer
Vallath, N. Perspectives on Yoga inputs in the Management of Chronic Pain. National Library of Medicine. PubMed Central
Forbes/Porges
Pearson, Neil, Yoga and Chronic Pain self-efficacy & Wellcoaches Handbook
Kabit Zinn, Jon Kabit, MBSR Full Catastrophe Living