Kirsty Mansfield talks about her experiences with chronic pain and running.
It was 1980 something, and David Schechter was injured. He was at medical school at NYU. He was prescribed exercises and anti-inflammatories, but the knee pain wouldn’t go away. He began to worry; would he run again? He was only 21.
I can relate. My knee pain started as a niggle and grew. Then it wasn’t just my knee, it was right buttock and right knee, and then my right leg. Something wasn’t right. I rested. I saw the usual array of people. I went to my GP; “It sounds like sciatica. Let’s send you for an MRI.” I went for the MRI scan (who thought sticking people in a tiny metal tube was a good idea? The kind healthcare practitioner gently suggested next time I ask for a sedative. There will be no next time). I went for my results; “It’s not sciatica.” “Okay, what is it then?” “It’s not sciatica.” “Okay, so it’s….?” “It’s not sciatica.” “Huh.”
David Schechter decided to seek out another medical opinion from one of his lecturers who was a physical medicine and rehabilitation doctor, Dr John Sarno. Dr Sarno’s response; “Ninety five percent of chronic pain is psychosomatic. What do you think about that?” (Schechter 2014)
Let’s be clear. Psychosomatic does not mean you are imagining things. That you are creating issues when there are none. That you have factitious disorder (and if you do, that’s okay, and I hope you are on a path of support). But that’s not what this is.
Acute (short term) pain vs chronic (long term) pain
As children we were accustomed to acute pain. We ran hell for leather, tripped over our shoelaces and cut and bruised our knees and hands. We never worried about it for long; a kiss, a plaster and a ‘you’ll be fine’ was usually enough of a remedy before we were off again. The older we get the less we are used to this scenario, it is more of a shock and we take longer to heal. Injury as an adult can also have significant consequences: pulling out of a race, missing a few days of work, not being able to get to the shops. How we react to acute pain in the first hours or weeks can impact on how we heal.
Pain is an extremely useful thing. It tells us something is wrong and that we should stop what we are doing (or, in running terms, ‘keep going to see if I can run it off…I’m sure it’ll be fine, just a little 5k…’). But when your pain becomes chronic it typically serves no function and it often, as Dr Sarno suggested, does not mean that your body is damaged.
Acute pain is defined as pain that has acute onset, lasting for up 6 weeks – your twisted ankle, your sprained wrist. Sub-acute pain is defined as pain lasting from 6 weeks to 3-6 months depending on who you ask – your pulled hamstring that doesn’t mend, a slow to heal fracture. Chronic pain is anything that lasts longer that this, and is a different beast. Current thinking among some doctors is that if you have chronic pain it is quite likely to be due to Tension Myoneural Syndrome [TMS], even if it had an initial identifiable structural cause.
Acute pain often resolves with RICE (Relative Rest, Ice, Compression and Elevation), unless of course there is something more sinister going on (please always check with your GP). We should add to this some Reassurance that the pain will go (the kiss, the plaster and the ‘you’ll be fine’). (Sub-)Acute pain turns into chronic pain when the mind/brain gets involved. So, if you have been given the all clear from the GP regarding underlying nasties and no structural reasons seem to be causing the problem, you may want to consider that no amount of ongoing RICE is going to work if you have been injured for more than 6 months.
Mind-body and mind/brain
Phantom Limb Pain can develop when part of a limb is amputated. The person feels pain in an area of their body that is no longer there. There are a few theories as to why this happens. One is that there is some sort of nerve damage in the area where the amputation occurred, the nerves are still connected or have scrunched up into a ‘stump neuroma’. An alternative explanation deals with how we interpret signals in our brain. When the limb is amputated the brain stops receiving information in the sensory cortex about regular sensory experiences (the feel of the ground, the material brushing against the leg – all the things we pay no attention to or we would get nothing done), the mundane and the painful, so it begins to interpret this lack of information and muddles itself into thinking it is ‘phantom pain’.
What else can convince us that pain is not always due to structural damage at the site where it is felt? How about referred pain? We’ve all been there. You have a pain in your knee and your physio tells you that it’s because you have a tight bum, then gives you exercises to do (I feel like it’s always heel raises). If you have a heart attack this is commonly felt in the left arm or neck, not your heart.
If chronic pain is in the brain can medication help? Well, yes, in some instances it can. For chronic neurological pain (if we agree that that is what most chronic pain is, and your neurological system is made up of your central nervous system (brain and spinal cord) and the peripheral nervous system) medication such as some antidepressants and anticonvulsants can be used to try to rewire your brain. Pregabalin (an anticonvulsant) works by adding GABA (gamma-aminobutyric acid) to your brain. GABA is classified as a neurotransmitter and is the surf dude that regulates anxiety and inhibits excitability in the nervous system. There are other goody neurotransmitters too: dopamine and serotonin. Let’s not forget oxytocin (a hormone) that is involved in emotions such as love and trust. Everyone feels better after a hug. On the other hand, cortisol (the ‘stress hormone’) has been linked with chronic pain. Emotions (stress, anxiety, love, happiness) are linked with hormones and neurotransmitters (brain) which impact on the body.
The drugs don’t work
Sometimes the drugs don’t work. Why? Because the brain and the mind, while linked, are not the same thing. This is where TMS comes in. Research tells us that chronic pain is linked to the area of the brain that is related to emotions (Hashmi et al., 2013). In fact, some medical professionals prefer to call TMS ‘Distraction Pain Syndrome’ to emphasise the underlying psychological causes (Schechter M.D. et al., 2007).
Mind-body and mind/brain = the brain/mind-body. Nerve pathways go up, but they also go down. This is important for long term pain. Our own life, memories and emotional responses (mind) can determine how pain (body) is perceived (brain) and whether it will be inhibited, intensified or just go completely.
If pain is linked with emotions (mind), then context must be crucial. Dr Henry K. Beecher looked into this in 1943-44. He discovered that soldiers who had been injured in combat did not feel the expected level of pain – there was no correlation between the physical injury and the level of pain, but there was with the emotional response to it. And the response to being injured for these soldiers was a positive one; ‘Sure, I’m injured, but I’m alive and I’m out of here!’ If you believe your pain will go away, or that the pain is not significant, or in this case that the positive consequences outweigh the pain, this can impact your perception of pain and how quickly you recover.
The above is an interesting, albeit an extreme, example. What does it mean for us runners? Rather than a ‘passive’ response of going back to the physio, the osteopath and the masseuse, or even maybe onto the surgeon, we can take some control to lessen or eliminate pain. Good news, right? Except, and here’s the bit you may struggle with, you have to commit to education around pain, to positive self-talk, to journaling around your emotional responses, possibly to psychotherapy, to exercising without anxiety. And now I’ve lost you all because I’ve just gone a little hippie. But trust me, this works.
My knee/leg/bum pain (not sciatica), which stopped me running, pretty much went after four gentle runs of me repeating “This is TMS, I’m in control, so just b***** off”, with a fair amount of journaling thrown in. Today I ran 10k. No pain. Now, don’t get me wrong, I still check in with my osteopath every couple of months (or ‘Elbows’ as I like to call him), and physiotherapy and massage can certainly help with relaxing your muscles and relaxing your mind. But if your pain has not gone with all the time, effort, and money you have thrown at it, maybe it’s time to consider an alternative path.
I hear what you’re saying, but my pain is because I have plantar fasciitis
Yep. I know you think you’re the exception, your chronic pain is purely structural. You have plantar fasciitis that has been there for 9 months and won’t go away, but you know that that’s what it is. No way is it linked to your emotions. No way were you stressing about the race you had coming up when you got injured. Or anxious at work around the time it happened. Or having issues in a relationship. Or having to move house in a shark-filled London property market.
I’m not a doctor. I’m not saying it’s not plantar fasciitis. Current thinking has moved on from Dr Sarno’s early thoughts and it is believed that you can, in certain instances, have TMS with a structural reason, but perhaps your TMS is amplifying the pain situation (Schechter 2014). Your immediate acute pain might have been a 9 on the pain scale, and has now been hovering chronically around a 3 or 4.
Dr Schechter reports that people with the following characteristics are more susceptible to TMS. You don’t need to have all of them. Are you; A perfectionist? A people pleaser? Hard on yourself? Highly responsible for others? Sensitive to criticism? A nice person who likes to do good? A person who likes order? (Schechter 2014) You don’t need to change yourself. These traits can make you an awesome person in so many ways, but they may make you more susceptible to pain.
We talk about mental health, emotional health and physical health as if they are separate entities. I’m not so sure that they are. Of course, things may start in one particular arena, your brain, your mind or your body, but after time I feel like they all become involved and intertwined. It is known that people with chronic pain very often also have depression and anxiety, and these need to be addressed as well as the pain. If this is you, you are not alone. Have a chat with the Serpie mental health champions if you’re not sure where to go for support.
There is limited research data on TMS. Even though the drug-free treatment plans for it have been around for a while they are still viewed as a little ‘out there’ for most of the medical community. It is not mainstream, and therefore difficult to get funding for research (the pharmaceutical industry is not interested, but Dr. Schechter has published a peer review study on the subject and is hoping to do more). But if nothing else has worked and you want to explore this idea further, here are some places to start:
- Think Away Your Pain: Your Brain is the Solution to Your Pain. David Schechter, MD.
- The Mindbody Prescription: Healing the Body, Healing the Pain. John E. Sarno, MD.
Disclaimer: The above is my interested layperson’s understanding of some of the research and literature on chronic pain. Please always get checked out by a medical professional and go straight to the sources yourself for further information.
Hashmi, J., Baliki, M., Huang, L., Baria, A., Torbey, S., Hermann, K., Schnitzer, T. and Apkarian, A. (2013). Shape shifting pain: chronification of back pain shifts brain representation from nociceptive to emotional circuits. Brain, 136(9), pp.2751-2768.
Schechter, D. (2014). Think away your pain. Culver City, Calif.: Mindbody Medicine Publications.
Schechter M.D., D., Smith, A., Beck, J., Roach, J., Karim, R. and Azen, S. (2007). Outcomes Of a Mind-Body Treatment Program for Chronic Back Pain With No Distinct Structural Pathology – A Case Series of Patients Diagnosed and Treated as Tension Myositis Syndrome. Alternative Therapies, [online] 13(5), pp.26-35. Available at: http://www.resignificaciondeldolor.com.ar/assets/miositis-smith—copia.pdf
Kirsty Mansfield Kirsty’s current training plan consists of lying on the sofa and eating pizza. When not doing this she can be found in Warrior 2, attempting to write flash fiction or learning to paradiddle.
Grace Mackintosh Sim did the illustration for this article. Go and have a look round her website (link below).