The many, many, many, many, many, MANY factors of pain

I started working with a client, who I’ll call Cathy, back in August.  She was experiencing hip pain that came on suddenly in May after going on her first hike since the beginning of Covid and the pain hadn’t dissipated—it actually got worse, and it was keeping her from doing activities she loved, such as going on regular hikes and walks with her husband.  

At the time I started working with her, Cathy was coming out of the depths of Covid life—several months of depression and isolation.  She was exhibiting mild kinesiophobia, or fear of moving, around her lower body because of her hip pain as well as catastrophization, or a tendency to magnify and ruminate about pain.  She wasn’t sleeping well and wasn’t engaged in much physical activity, all because of the pain.  She would spend at least 10 minutes of every session updating me on her pain before we began to move.

Over the course of the first three months we worked together, Cathy saw at least one physical therapist, a chiropractor, and an orthopedist.  She tried traditional physical therapy, vibration therapy, and received a steroid injection. Nothing helped, no one was able to give her information about her hip, and she was encouraged not to walk on uneven surfaces.  After finally getting an MRI, the orthopedist told her she had moderate hip arthritis in her hip (she’s in her mid 50’s) and if the pain didn’t go away, she would likely need a hip replacement.  Although this was alarming news, Cathy felt like she had the answer she’d been searching for.  She just had an old hip for some reason, even though she was young, and she would undergo surgery to fix it.

Simultaneously, over the course of those same first few months, Cathy was also slowly being indoctrinated by me.  We started by moving and strengthening her upper body.  Just because her lower body was in pain didn’t mean she couldn’t engage in physical activity elsewhere.  We also focused on her feet and how she used her feet to connect to the ground, which allowed her to connect to her lower body without triggering pain.  We didn’t elaborate on her pain in the midst of sessions—if something we did together triggered pain, we would stop the movement and move on to something else without much ado.  We directed awareness to sensations around her hip and deciphered how those sensations were not always pain sensations.  We began to train for uneven surfaces so that she could get back to going on hikes.  We talked about pain not always correlating with “damage.” We exposed her hip to triggering positions in a way that allowed the nervous system to create new positive associations with those movements.  We discussed the emotional cost of not taking walks with her husband and how this might contribute to her pain and came to the agreement that moving with some pain is ok.  

By November, her pain began to lessen, her strength began to increase, and the energy she expended worrying about her hip seemed to decrease as well.  In December, she and her husband went to spend a few weeks in their Carribbean beach home.  Her kids came to spend the holidays with her.  She took walks out on the beach in the sand, experiencing uneven surfaces for the first time since the hike in May that started it all.  Her pain kept getting less and less.

It’s now March.  There are still movements that trigger her fear, and occasionally she feels her hip at night.  But generally, the intensity of it all has calmed down and her pain is no longer a focal point of her life.  Most importantly, a hip replacement is no longer in the picture.

Each pain factor in this story deserves its own blog post.  Each factor has been heavily researched.  Pain is so unbelievably complex. Just to tease it out: here is a list of all the factors that may have contributed to her pain—they all work together in a cyclical fashion, they cannot be separated:

Too much too soon — going out on a long hike after 3 months of inactivity
A pandemic happened — ‘nuff said.
Social Isolation — ‘nuff said but in case you need it: source
Low emotional state — performing a strong bout of physical activity when feeling emotionally low/drained is a possible explanation for why the pain came on in the first place.  BUT, it’s also a factor in the pain becoming a chronic issue. (source, source).
Pathologizing — regarding random bouts of musculoskeletal pain as abnormal, and indicative of damage.
Catastrophizing — ruminating about existing pain and anticipating pain before it happens (source)
Reduced physical activity —adds to a low emotional state as well as creates stiffness and weakness which in turn reduces confidence (source)
Reduced self efficacy — feeling helpless due to lack of physical inactivity as well as after several doctors can’t figure out what’s happening and no therapies seem to help (source)
Hearing Protective Language — someone you hold in high regard (a doctor) telling you not to walk on uneven surfaces. (I’m not criticizing this—but it IS protective language and depending on how it was relayed, can heavily influence pain). (source)
Believing her hip was damaged — seeing tissue damage (in her case, mild arthritis) on an MRI can be a terrifying experience if we are subject to the since disproven but very stubborn paradigm that damage and pain have a causal relationship.  (source)

Here is a list of all the factors that may have contributed to the dissipation of her pain—again, they all work together in a cyclical fashion, they cannot be separated (sources are the same!):

Graded exposure—introducing movement back to lower body in a way that allowed her nervous system to trust her hip
Increased physical activity — three movement sessions a week, AND being encouraged to continue to walk since walking didn’t make her hip pain feel worse
Increased self efficacy — confidence that she had some control over her situation by continuing to engage in physical activity
Increased confidence in her body — she gained strength in all areas of her body, not just her legs
Moving with pain—understanding that moving while in pain is not always bad and can be helpful in improving quality of life
Understanding damage — knowing that mild arthritis in the hip at her age is normal and does not necessary correlate to pain.
Positive emotional state — a trip to Barbados and seeing her family over the holidays
Walking on the beach— experiencing her first walk on uneven surfaces and realizing that her pain did not get worse.

These factors CANNOT be separated.  There is no way of knowing which one was the strongest factor, if there is such a thing.  This process took several months and is still in effect.  There was not one stretch or one exercise that was the cure all, there was not one diagnosis that could pinpoint the pain.  There was not one doctor that understood what was happening and there was not one therapy modality that magically made her pain disappear.  

This is a hard reality.  There are very few answers when it comes to chronic musculoskeletal pain like what Cathy experienced, and that’s likely why our medical system has had a hard time adopting the multifactorial pain paradigm—it’s not easy to relay this in a 10 minute doctor visit and it’s not what people in pain want to hear.  Physical therapists who truly understand the complexity of pain will be the first to tell you, with all of their accolades and training and research, that they cannot pinpoint the exact source of one’s pain.  A lot of the time, we really don’t know what’s going on in there!!  How frustrating and exhausting, right?  

But here’s the silver lining and it’s a thick one: there are SO MANY options for how to work with our pain, AND we are, most times, not permanently damaged.  This can open the floodgates for possibility to work with our pain if we’re willing to stay open-minded and engaged in the process.

Keep moving.

xoxo