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Cover Story Plant Life On Fitness Northwest Living Taste Now & Then Sunday Punch

Cover Story
WRITTEN BY MOLLY MARTIN
ILLUSTRATED BY PAUL SCHMID
· Fitness notebook
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A Moving Target
Use your body and your mind to take aim at pain

THE ACHING and swelling in the joints are gone for now, but the bottoms of my feet still burn, pretty much all the time. The tendinitis in my right forearm seems to be fading, but the back of the left knee has swollen, mysteriously, into a big, smooth lump. A nagging left wrist tenderness, from my body-surfing stupidity two years ago, did eventually calm down. But the upper arm that needed a metal rod and nine screws to repair the break that day hasn't been the same since. I have finally healed up from the Achilles, knee, back and wrist injuries I had at the end of my last go-round with basketball — nearly four years ago.

But as I write these words, deadline looming for this piece on pain and movement for our annual fitness issue, my neck has seized up.

Perhaps I've gone a little overboard on research for this story.

I'm not complaining, just taking stock. Considering the estimated 50 million Americans living with chronic pain and 25 million more each year with acute pain from injury or surgery, I'm fairly well-off.

As many of those millions well know, although the research, understanding and treatment of pain have advanced considerably in recent decades, that doesn't always translate into an ability to reduce or relieve pain, even among those who specialize in that field.

"The research data on the biochemistry of nerve function and the physiology of pain really is impressive," says J. David Sinclair, a Seattle-area M.D. and independent consultant for the management of chronic pain. "It's so impressive that if we're not careful, we can convince ourselves we know what we're treating. We know an enormous amount more than we did 30 years ago, yet we really need to keep in sight that we know very little about what we're treating, namely the extremely complicated phenomenon of the experience of pain — and most of us know very little about who we're treating."

Fortunately, one of the most powerful tools for dealing with pain — whether from exercise, injury, surgery or some more mysterious source — is also cheap and accessible, if not always easy:

Movement.

At first, it may seem counterintuitive, for when we hurt, we often feel like staying still, lying low until the pain is gone. Or we use pain as an excuse to not exercise (as I'm doing with this stiff neck). But regular, moderate movement often can help soreness dissipate more quickly and injuries heal faster, as well as help us manage ongoing pain and keep it from running our lives.

"Pain is not a valid reason for not being fit," Sinclair says. "In fact, fitness is a major contributor to the modulation of pain in a way that helps people be more comfortable."

Obviously, pain can't be counted on as the only indicator of trouble. When diagnosed with breast cancer more than 10 years ago, I had no pain whatsoever, until surgery and then chemotherapy, which were well worth living through.

Also, movement clearly isn't the solution to all pain. Certain medical conditions, such as migraine headaches, aren't necessarily helped by increased physical activity.

Often, though, there's a compromise. When I was 9, my mother knew I wasn't faking knee pain when I actually lagged behind during trick-or-treating. We learned I had a disease of the hip, and I was instructed not to put weight on that leg while the ailment ran its course, which turned out to be 2 1/2 years. But as kids tend to do, I adapted, reluctantly doing prescribed leg-lift exercises but eagerly learning crutch kickball, crutch-running (crutch, hop-hop, crutch, hop-hop) and crutch-walking (moving without touching the ground with my good foot, quite a good upper-body workout). I remember once sprinting with one crutch while preparing to launch the other, javelin-style, at some boys during recess, incurring a different sort of pain: a trip to the principal's office.

THOUGH THERE may be many kinds of pain, doctors generally distinguish between two overall categories: acute and chronic.

Acute pain is useful, biologically speaking, and crucial to protect life and health. It's the pain that tells me to take my hand away from the fire so I won't get burned.

For the most part, acute pain isn't very mysterious: Doctors understand how the signals are sent and received, and it's fairly clear which treatments help. Anti-inflammatory and narcotic medications, for example, often work well.

Acute pain also carries an expectation of resolution, that the wounded part will get better. So pain or discomfort from exercise can be considered a type of acute pain.

Chest pain, a severe injury or pain that persists during a workout should get immediate attention, of course. But when working to develop the heart, lungs and muscles, some discomfort can be expected, and is in fact needed to improve fitness.

Being able to differentiate training discomfort from acute pain can be a matter of listening to the body, knowing the risks of the sport or activity, or consulting with someone who understands one or both. Each year as the sun rises earlier and the weather warms up, I resume jogging along the downtown waterfront and climbing the stairs at Pier 66, a nice interval workout with a view of Mount Rainier. I know the burning in my lungs will lessen if I persist with these workouts, and the soreness in my thighs and calves will be worse two days after my initial outing and not too bothersome after that. But I also know, from more experience than I'd like to admit, that if I continue to run after feeling an aching in my shins, I'm likely to wind up with shin splints that can dog me for months.

One guideline says it's often OK to keep exercising with dull, temporary discomfort in the muscles but not when pain is sharp or in or near the joints. Stiffness that lasts 24 to 48 hours after exercise is normal, as muscles rebuild themselves stronger than before. Ongoing soreness, constant fatigue and a fast pulse upon waking can be signs of injury or overtraining.

Icing (see page 6) is the first line of treatment for many injuries, and immobility is used less and less. After reconstructive surgery more than 20 years ago, my knee was immobilized for eight weeks and in a hinged cast for another three. If I were to have that same surgery today, I might begin bending my knee (with some prompting) the very next day, to help reduce stiffness and retain range of motion and muscle tone, all enhancing recovery.

Even if the injured part needs rest, often the other parts of the body can keep moving: stationary bicycling while an arm mends, swimming during knee rehab.

"The quickest way to get over any injury is to use it," says Thomas Williamson-Kirkland, an M.D. in physical medicine and rehabilitation at Virginia Mason Medical Center in Seattle. "Use it to stretch it, use it to get stronger, then use it to get endurance back up. Injuries will heal themselves, mostly. You keep stretching and flexibility up, and it works best if you stress it moderately while it's healing."

Identifying and treating acute pain is also important because left unaddressed, pain itself can slow healing or, what's worse, lead to much murkier territory.

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CHRONIC PAIN, by contrast, is defined as being, well, more poorly defined. It's not biologically useful — hurt does not necessarily mean harm.

Some kinds of ongoing pain, such as arthritis of the hip, have an identifiable source and tend to respond to anti-inflammatory medications. But often, where tissue has been injured in the past, the body continues to produce a perception of pain, even though the injury is no longer active. Anti-inflammatories aren't as effective in relieving such "centralized" pain, but anti-depressants can be, even in patients who aren't depressed.

"With chronic pain, it's more difficult," says Williamson-Kirkland. "If you look at injuries, there is a gradual weeding out of people who get healed. In six weeks, 90 percent will be back functioning. Within six months, it's 95 percent. So you're left with 5 percent of the most difficult problems."

Those 5 percent are a big reason why more than 1,300 doctors in this country specialize in pain management and why pain causes up to an estimated $100 billion each year in medical costs and lost work.

Treatment of chronic pain begins with getting a reliable diagnosis and ruling out causes that might be life-threatening, such as cancer. After that, the palette of treatments can be as wide-ranging as the pain is stubborn. What helps in many cases is a combination of approaches, including medications, stress management, diet, health habits and, often, some sort of movement.

Sinclair differentiates between things that comfort, such as massage and hot tubs, and those that help. "The list of things that comfort is a mile long. The list of things that help is a line long — and most have to do with being fit."

His short list for helping with pain starts with a life of some consistency: getting up at a given time, getting washed and dressed, going to bed at a regular time. "Structure is the underpinning of an active life, and it's good for a person's mental state to be living a reasonably structured life." Also within that structure: staying active physically and mentally, using medications appropriately, and paying attention to diet.

"You wouldn't have had to tell anybody this 50 years ago," when physical activity was a natural part of daily life, Sinclair points out.

Movement stimulates the sense of where our body is in space, not only lubricating joints, improving aerobic capacity of muscle and giving psychological benefits, but also helping derail pain signals.

Pain specialists advise patients to get moving again gradually, to prevent re-injury and excessive soreness and create small successes that encourage more activity. Some start with as little as a minute at a time, repeated many times a day and adding a minute each day. Others increase activity only after three successful bouts at the previous level, or commit at first to only 20 minutes, three times a week. Another rule for patience and persistence is "one day down, two days to rehab," meaning if the period of inactivity has been a month, it could take two months to regain the previous level of function; if sedentary a year, then two years to recover it.

ALONG THE WAY, another crucial and equally cheap and accessible tool comes into play: the brain.

Bringing up the role of the brain to people in pain can be tricky. Many are extremely sensitive to hearing, "It's all in your head."

"I tell people, 'You do have real pain, even if you may not have anything to see on the X-ray. But that pain can be modified by the brain,' " says Gordon Irving, an M.D. and medical director of the Pain Management Center at Swedish Medical Center. "You have to train your brain to dampen down those pain signals."

It also helps some people to realize this: "All our conscious experiences are in our head," says David Tauben, an M.D. in internal and pain medicine at Minor & James Medical in Seattle. "That's where our biology has placed our pain perception. So pain is always in your head, just like laughter, memory, poetry, thought."

Some pain specialists describe acute pain as one part the sensation of pain and three parts anxiety. "That is as it should be," Tauben says. "We ought to be anxious that we have, say, a thorn in our leg, and be worried enough to do something about it."

With chronic pain, when there is no discernible thorn, just knowing the hurt is not doing harm can be a step toward reducing that natural anxiety and managing pain.

Years ago I pulled a groin muscle while stretching. Weeks and months went by and it never seemed to heal. Sometimes I'd start limping after just 10 minutes of jogging or playing tennis. I went to see, in succession, an orthopedic surgeon (and was given cortisone pills), physical therapist (exercises), chiropractor (multiple spinal adjustments), podiatrist (orthotics) and acupuncturist (needles). Some treatments helped for a while, but the pain always came back.

Hurting for resources?
• The American Pain Foundation is a nonprofit information resource and patient-advocacy organization: 888-615-7246, www.painfoundation.org

• Pain Connection is The National Pain Foundation's online education and support community: www.painconnection.org

• The Dannemiller Memorial Educational Foundation lists Web sites, phones and addresses as well as specialists by location: www.pain.com

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After a few years, I saw another orthopedic specialist. He concluded the pain was not a chronic groin pull but instead was related to that hip disease of my childhood. It wasn't likely to get worse, he said, but there was nothing to make it better, either, unless I wanted to go to a particular surgeon in Italy to try an operation that would remove a slice from the thigh bone, changing its angle and, perhaps, easing the strain on the malformed joint. I briefly considered the trip and the surgery, then decided against it. Knowing the pain wasn't a sign of a worsening problem, I stopped worrying about the hip. And after a month or two, the pain went away. Though the tightness is still there, it hasn't really bothered me since.

But what about pain that doesn't go away?

"Patients may expect the problem to be totally cured. That, at least at this point, is not a realistic expectation for people with chronic pain," says James Robinson, an M.D. at the University of Washington's pioneering Multidisciplinary Pain Center. "But there's a monumental difference between pain that dominates a person's attention, produces severe emotional distress, leads them to stop living, disrupts all their plans, versus pain that they'd much rather not have but they've put some boundaries down, put it in the background, and gone on with their lives."

That can require a shift in thinking.

"Much of their suffering is related to the changes the pain has drawn onto the map they were following in life," says Sinclair. "There are rivers and hills, bridges and roadblocks where none existed before. Their map of life has changed enormously, and they don't know where to go. At this point they can be 'lost' forever or they can orienteer the new territory to find old satisfactions using a new map."

It might even be possible to tone down the inevitable.

"The best thing you can do for back pain is to be happy," says Stan Herring, an M.D. with Puget Sound Sports and Spine Physicians in Seattle and team physician for the Seattle Seahawks. "Because if you're happy, whatever injury or illness comes your way, you're going to handle it better."

This seems increasingly relevant, at least for me, midway through my 45th year, or what I'm beginning to think of as my "Year of Prednisone." The steroid medication took care of that joint swelling from an apparent auto-immune problem, which has curtailed my activity though not, unfortunately, my ability to gain weight.

With all this in mind, then, I might pick the subject of next year's fitness issue a little more carefully. Perhaps "Getting in the Best Shape of One's Life" or "Making Every Day a Spa Experience."

My feet still burn. But hey — my neck is feeling a bit better.

Molly Martin is assistant editor of Pacific Northwest magazine and writes its weekly "On Fitness" column. Paul Schmid is a Seattle Times news artist.


Cover Story Plant Life On Fitness Northwest Living Taste Now & Then Sunday Punch

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