Is chronic pain something fitness professionals deny at their peril?
When Gray Cook was a high-school athlete, his coaches would comment, “That Gray Cook sure can play hurt.” He had over 20 fractures before he was 18, what with his love of football and motorcycles. He played while hurt, he says, because he had the ability to block out pain. Flash forward to 2014, and Cook—now a practicing physical therapist, certified orthopedic specialist and founder of Functional Movement Systems in Chatham, Virginia—was no longer able to block out neck pain. It was affecting his life, his work, and his ability to share his message of fitness and health.
“For about 8 years I was able to hide the pain and just suck it up,” Cook says. “At a certain point I realized that ignoring the pain in my neck could leave me permanently disabled. I balanced the thought that surgery was inconvenient against my love of being in the outdoors and being fit and active. I thought that ignoring the pain meant I was getting something accomplished—building a company and a family. There’s never a convenient, easy time [to attend to pain]. You make your decision when the fear of damaging your body exceeds your fear of having a temporary sideline. Sometimes the loads we put on our bodies can undermine our health even more.” Taking his own advice, Cook elected to have cervical spinal fusion surgery.
Surgery is just one of the many solutions to chronic pain, defined by the National Institutes of Health as persistent pain lasting for more than 12 weeks (NIH 2011). In addition to surgery as a treatment option, the NIH recommends medication, acupuncture, electrical stimulation, nerve blocks, psychotherapy, relaxation therapies, biofeedback, behavior modification, and complementary or alternative medicine (CAM) approaches such as tai chi, meditation, massage therapies and similar self-managed treatment methods. What it does not recommend is ignoring the pain or “working through it.”
This article takes a broad look at the epidemic of chronic pain and how fitness professionals manage—or mismanage—it in their own lives. Fitness veterans who have dealt with this problem, either personally or in a clinical setting, share advice on how to take care of the body so that it works optimally for years to come.
Chronic pain is persistent, with the nervous system firing signals for days, weeks, months and even years (AAPM 2015). A simplified definition for chronic pain, according to the American Chronic Pain Association, is “pain that continues when it should not” (ACPA 2014). More than 1.5 billion people worldwide suffer from chronic pain, and approximately 3%–4.5% of the world’s population suffer from neuropathic pain (Global Industry Analysts 2011). Data from the Centers for Disease Control and Prevention and the National Center for Health Statistics suggest that the main causes of pain for adults reporting it in the United States include severe headache or migraine (16.1%), lower-back pain (28.1%), neck pain (15.1%), knee pain (19.5%), shoulder pain (9.0%), finger pain (7.6%) and hip pain (7.1%) (Institute of Medicine 2011).
Not only does chronic pain have a deleterious effect on the mind and body; it also takes a toll on bank accounts. Johns Hopkins University health economists have reported that the annual cost of chronic pain is as high as $635 billion a year in the United States, which exceeds the yearly costs for cancer, heart disease and diabetes (Gaskin 2012).
Many fitness professionals not only know these facts but are able to rattle them off to clients in an effort to make a point about managing pain. However, it’s not always as simple when the tables are turned.
The Practice of Ignoring Pain
While educated fitness professionals understand how the body works, many still ignore or accommodate pain signals. At age 26, Sue Hitzmann, MS, of New York City, author of The MELT Method® (HarperOne 2013), was in so much pain that she had to crawl to the bathroom in the middle of the night because standing up was too painful. Not willing to “just work through it,” she researched the solutions that she now shares as a pain specialist. “Whether it’s an accident, injury, illness or heartbreak, pain is a good thing, as it’s a signal that something is wrong,” Hitzmann says. “Pain becomes chronic when we ignore or medicate it. We layer compensatory patterns into our nervous system until it becomes exhausted and breaks down.”
Justin Price, MA, the San Diego–based creator of The BioMechanics Method®, attributes the habit of ignoring and accommodating pain to the desire to uphold an image. “Fitness professionals must always appear fit, strong, happy, healthy and energetic,” he says. “This image must be upheld to peers and clients at any cost, similar to the way a celebrity must appear beautiful, successful and happy at all times. Celebrities will do anything to uphold this image, including undergoing plastic surgery, following radical diets, taking steroids and other drugs, and hiring public relations companies.
“Similarly, it is marketed in today’s society that fitness professionals are not allowed to have flaws or experience common human failings. Fitness pros come to believe this too, and they feel a need to create and maintain a superhuman image. This is not realistic, and eventually it leads to a physical and mental breakdown—and subsequent chronic pain.”
Anthony Carey, MA, CEO of Function First in San Diego, agrees that the pressure to look great comes from both inside and outside the fitness industry. “Whether we like it or not, there is the thought that ‘if we can’t take care of ourselves, then how can we be entrusted with someone else’s well-being?’ Many of the fitness pros I’ve worked with have endured, worked around or ignored low-grade chronic issues until they eventually became acute, and the pain interfered with work or their lifestyle. It’s an unfortunate trend.”
Describing pain as a “stigma,” Greg Roskopf, MA, of Englewood, Colorado, owner/developer of Muscle Activation Techniques®, has observed this conundrum in many fitness pros: “Chronic pain has become an epidemic,” he says, “and it is a difficult situation. We are reluctant to admit to pain, thinking it doesn’t represent health, yet if we don’t admit the problem, we can’t do what’s necessary to get rid of it. I find that a majority of health and fitness professionals confess to experiencing some chronic issue. Not only are they looking for ways to help their clients, but [they also need to] help themselves.”
“It is heartbreaking to see the looks on my patients’ faces when they realize they are made of soft tissue and bone too (just like everyone else),” says Anne Davies, MS, LAc, of Laguna Beach, California. In addition to being a licensed, certified acupuncturist and herbalist, Davies is a former fitness professional. “So many times the fittest among us believe that injury won’t happen,” she says. “This denial unfortunately tends to lead to the very situation we wanted to avoid in the first place—time off due to injury. Interestingly, this denial [is often] strongest in those concerned about aging. Mentally the process seems to be that if you modify your program to accommodate pain or injury, you’re giving in and going soft (meaning growing old). This is ironic, as we work out to maintain health and vitality, yet being in pain or injured to the point of being unable to work out defeats the point.”
Hitzmann says that chronic pain appears to be “the new norm in fitness.” “Most of the fitness pros I meet have shoulder, knee and lower-back pain, but neck pain is also [common],” she says. “Their joints are a mess. The amount of chronic inflammation, joint mis-alignment, poor posture and chronic strain is at epidemic levels. My practice has only grown as the fitness industry has gotten bigger. During my presentations, more than 80% of people in the room raise their hands when I ask who is in chronic pain.”
Carey says that when he started Function First 20 years ago, his business model centered on working exclusively with people in chronic pain. “The types of chronic pain haven’t changed all that much,” he says, adding that most of the injuries he sees are orthopedic-related challenges and are, therefore, often classified as overuse injuries. “Twenty years ago, there was a lot of focus on postural stress due to computer usage, and the concerns are now the same. We took a global approach—total function in movement—which was not commonplace in the early 1990s. Clients with chronic back pain, for example, had been doing the same generic exercises for their lower back that everyone else did.”
Pain and Perception
Chronic pain is, no doubt, a force to be reckoned with among fitness professionals and the people they serve and inspire. But is it simply a physical matter? Perhaps not. In 1985, publication of the West Haven-Yale Multidimensional Pain Inventory validated the need to fully research the cognitive and behavioral aspects of pain (Kerns, Turk & Rudy 1985). A three-part inven- tory, this pioneering assessment examined “the impact of pain on the patients’ lives, the responses of others to the patients’ communications of pain, and the extent to which patients participate in common daily activities” (Kerns, Turk & Rudy 1985).
As a result, the Joint Commission for the Accreditation of Healthcare Organizations issued pain assessment and management standards that emphasize pain’s multidimensional nature, including its psychosocial impact. Since then, overwhelming evidence has confirmed the link between chronic pain and the mind. As a matter of fact, research about chronic pain has received so much attention that Congress designated 2001–2011 as the “Decade of Pain Control and Research” (Turk & Okifuji 2002).
Nathan Briner is a strong advocate of treating chronic pain using the mind along with the body. A manual therapist who owns TrueBalance Sports Therapy Clinic in San Diego, Briner sees an issue with perception:
“For decades, fitness instructors have been led to believe that pain is a manifestation of tissue—i.e., tight hamstrings, fascial restrictions and trigger points—which has created a thought fixation that these things are defects in tissue or body. It’s putting the cart before the horse. These things are actually defense, not defect. Pain is an emergent experience created by the brain, which evaluates incoming information from myriad sources in our bodies and chooses if pain is the appropriate response. Chronic-pain sufferers need to understand this so that any physical intervention does not further provoke the system.
It’s necessary to recognize the significance of other ‘inputs,’ such as sleep cycles, adrenal fatigue (fight or flight), conscious and unconscious psychological states, and increased peripheral and central neural sensitivity.”
Price talks about the fear factor, both for personal training clients and for trainers. He sees clients being afraid that their pain will inhibit their ability to participate, which then creates anxiety and stress for the trainers as well. For fitness pros, being overwhelmed can add to that anxiety.
“We are now expected to be mini ‘fitness personalities’ within our communities, in addition to keeping up with the latest education, main-taining an engaging website, answering emails, posting social media updates, sending out newsletters and articles, and creating a high-profile marketable image,” says Price. “These mental and physical demands mean that a lot of fitness professionals are not only stressing their bodies but also having limited time for stress-reducing relaxation periods, for recovery. In my experience, fitness pros are experiencing more chronic muscle and joint pain as a result of this hectic, demanding career.”
In her book Move Your DNA: Restore Your Health Through Natural Movement (Propriometrics Press 2014), author Katy Bowman, MS, director of the Restorative Exercise Institute in Ventura, California, posits that chronic pain is a disease of behavior. As technology has allowed us to “outsource” movement, how we feel has been given less consideration than how we look. Bowman writes: “Perhaps you find yourself unable to move once or twice a year because you throw your back out. Maybe you get headaches with enough regularity that you keep aspirin in your desk. Do you have a ‘trick knee’ or a habit of spraining your ankles? Do those knees keep you from taking long walks?” She makes a suggestion that is particularly apt for fitness professionals—we may be exercising too much and moving too little.
Roskopf agrees about the possibility that fitness pros may be overexercising. “We are putting forces against the body. There is no guarantee that the body can properly absorb these forces. The idea that exercise is always a good thing is probably the main misconception that we have in the industry. If the body can’t properly tolerate the forces that come with exercise, exercise then becomes a stress that results in negative health.”
When talking about the chronic-pain epidemic among fitness professionals, Cook says it’s imperative to return to foundational principles. “Many times we ask questions about physical development without first considering the fundamental principles of movement,” he says. “If your movement competency isn’t at a fundamental, base level of movement literacy, you won’t respond to programming (or rehab) even if the program is well-designed.”
Fitness professionals are students of the body and its systems, but when it comes to addressing chronic pain, egoic blinders can prevent them from taking the necessary steps to care for themselves, which may lead to desensitization and a lack of self-trust. “Pain changes motor control in unpredictable and inconsistent ways,” says Cook. “The SAID (Specific Adaptation to Imposed Demand) principle does not work well in the presence of pain. Pain is an indicator that either safety is being challenged or there is a broken process. If you think fitness is a good solution to chronic pain, you are going in the wrong direction biologically.”
Cook urges fitness professionals to pay attention to pain signals and to the possible mental and emotional layers connected to pain. “Please don’t consider pain a diagnosis,” he says. “It’s a symptom. For instance, lower-back pain has been tied to some psychological and emotional issues, as well as physiological and mechanical issues. The first step is to do a thorough musculoskeletal exam to find out the pain’s behavior. Some fitness pros work with clients who have hip pain, for example. But the degeneration may not be where the pain is located. The pain may be in the left side of the hip, [while] the degeneration is on the right side. Unlike professional athletes, fitness pros can mask or hide pain or dysfunction and appear to be fit and physically balanced when we aren’t.”
Practical Tips & Advice
If you are a fitness pro in chronic pain, it’s time to take your own (and your colleagues’) advice. All of the experts quoted are unanimous in their belief that you need to treat the underlying cause, not the symptom.
Modify and diversify. “Think moderation and long term,” says Davies. “Pain means ‘Back off,’ not ‘Push through.’ Adjust your routine. For example, employ more coaching techniques and demos. If you are accompanying a client who runs, ride a bike instead of running alongside that client. Take the same advice you’d give a client—vary your workouts and adjust the time and intensity to encourage healing. In addition, incorporate adjunct therapies, such as regular massage, chiropractic adjustment and acupuncture. The professionals [who provide those services] can also offer advice on treatments such as infrared heat, saunas, and other natural ways to help reduce inflammation.”
Undergo screeening. Getting properly screened is paramount, according to Cook. “A movement screen is a measuring stick,” he says. “It’s a screen, not an assessment. It can tell you what the next best decision is. If you have pain on one of the fundamental movement patterns, you need a thorough musculoskeletal assessment, which should come before an X-ray or MRI. Or you can go to someone who specializes in musculoskeletal medicine. If you have pain with simple body weight movements, you are broken until somebody proves you’re not. If you don’t have pain, but are identified as being dysfunctional in one of the movement patterns, something in your environment is broken (unless you’ve had something such as surgery in the past 6 months to a year).”
Examine your technique. Cook also suggests examining technique. “When kettlebells first came to the Western world, people ran to YouTube for guidance and just started banging around, thinking they’d become proficient. Kettlebell training is about as technically difficult as martial arts, yoga or Olympic training, so that’s about as smart as thinking you can pick up a martial arts magazine and become a black belt. Don’t blame the equipment or tool if you don’t use it with the technical integrity that the masters taught. Don’t bang your body around. Don’t load a dysfunctional pattern. ‘More is better’ doesn’t float.”
Change your behavior. After years of studying the symbiotic relationship among pain, the body and the mind, Price is a proponent of behavior change if the person is ready to change. “A fitness pro with chronic pain who has an overriding goal of building and maintaining an aesthetically pleasing body will not be motivated to modify behaviors, as being pain-free isn’t the focus. However, once that pro embraces the reality that we are all human and will experience some form of chronic pain at some time, and that we all age, then it becomes easier to redirect that focus. It’s possible to look good and enjoy life with its many ups and downs, while living pain-free and happy. Modifying our own behavior is a great way to set an example for clients that is authentic and genuine.”
Improve your education. Briner encourages “diving into pain science,” and Carey concurs. “Research supports a bio-psycho-social model for chronic pain. Get educated on the process and the multitude of inputs that lead to the pain output. Be as committed to your corrective and restorative process as to your workout. Knowing the physical demands of being a fitness pro means approaching your career like a marathon, not a sprint. Your movements need to be strategic, efficient, nonprovocative and confidence-building.”
Recover fully. “Rest is the most important component of exercise,” says Roskopf. “If you do not give the muscles proper time to recover following a workout, then the muscles are continually stressed and inflamed. This puts the body into a catabolic, as opposed to an anabolic state, taking away the body’s ability to achieve growth and tissue repair.”
By following these six tips, you will position yourself to maximize healing and minimize damage. Being in denial will prolong the delay Take the Quiz www.ideafit.com/ifjquiz or mail the quiz on page 82. in that healing. Be as smart with yourself as you want your clients to be. As Davies states, “Getting older is inevitable. Getting older and having pain and mobility issues is an option. Reduce the amount of time in pain by making smarter choices.”