On June 3, 2018, Dr. Spett presented a workshop to NJ-ACT on CBT for chronic pain. This is the first of two articles adapted from that workshop.
By Milton Spett, Ph.D.
I believe the best way to explain the Mindful Exercise System is to begin by discussing five of my own problems with pain. I do a lot of sports, and I have had many experiences with injuries and pain.
My Five Problems with Pain
Pain Problem #1: Shoulder pain when lifting my arms
About 10 years ago I developed pain in both shoulders when I reached up. Reaching up became so painful that I started moving things from higher shelves to lower shelves, so I could reach them without pain. My wife had to help me put on jackets and coats.
I went to two orthopedists who took x-rays and showed me what was wrong with my shoulders. The first orthopedist said I had injured my rotator cuffs and there was nothing he could do. The second orthopedist said I had lost a lot of cartilage in my shoulder joints, and there was nothing he could do. “After all,” he added, “at your age you have to expect these things.”
Both orthopedists wrote a prescription for physical therapy. I looked at one of the prescriptions. It said “shoulders.” So it appeared that physical therapists don’t treat based on diagnosis. They just have patients do a series of exercises on the painful body part, and they hope that something helps.
The physical therapists gave me many exercises to do during physical therapy and at home: strengthening, stretching, range of motion, heat, electrical stimulation. But my shoulder pain was not getting any better.
Among all the exercises I was doing, I noticed that my shoulders seemed to feel better after stretching. So I stopped all the exercises except stretching. No strengthening, no range of motion exercises, just stretching. After three days, my shoulders were dramatically better. After ten days they were normal. I put my things back on high shelves.
I believe that the stretching my physical therapist had me do helped the pain. But the strength training worsened the pain and counteracted the benefits of stretching.
My rotator cuffs may have been injured and my shoulder joints may have lost a lot of cartilage. But neither of these was causing my shoulder pain. It was only after my shoulder pain was cured that I realized what had caused it. It was a strength training class I had taken where the instructor did no stretching after the strengthening. So the strength training my physical therapist had done was almost certainly worsening my shoulder pain.
Pain Problem #2: Pain in my right knee
For no apparent reason, I developed pain in my right knee. I went to my primary care physician, who said, “At your age, you have to expect these things. When walking upstairs, lead with your good leg, when walking downstairs, lead with your bad leg.
I had scheduled a bicycle trip in the Canadian Rockies for a couple of weeks later, and I decided to go on the trip in spite of my painful right knee.
After four days cycling in the mountains, my right knee was completely pain-free. I will never know what was wrong with my right knee, but I do know that, quite by accident, strengthening my leg muscles fixed whatever was wrong. So stretching cured my shoulder pain, and strengthening cured my knee pain.
Pain Problem #3: Neck pain
Riding my bicycle one day I hit a bad pothole. When my rear tire hit the front edge of the pothole, it jammed my body up into my neck and gave me severe neck pain. This time I didn’t bother with doctors or physical therapists, I just tried the Mindful Exercise System. I tried range of motion exercises – no improvement; I tried stretching – no improvement.
After several months of systematic neck exercises, I gave up and stopped trying to cure my neck pain. I figured that at my age, I have to expect these things.
Six weeks later my neck pain had disappeared. My neck just needed rest, and all my neck exercises were probably making the problem worse. Stretching cured my shoulder pain, strengthening cured by knee pain, and rest cured my neck pain. So stretching, strengthening, or rest can sometimes cure the physical causes of pain.
Pain Problem #4: Pain in my left arm when swimming
Again, for no apparent reason, I developed pain, this time in my left arm, and only when swimming the crawl stroke. I systematically tried stretching, strengthening, and this time I tried rest as well, but nothing helped.
Then, for some reason, it occurred to me that I might be stretching too hard. So I began a new system of graduated stretching. Initially, in the shower with hot water spraying on my left arm, I did a very gentle stretch of my left arm every day for 4 or 5 days, and then I slightly increased the stretch for another 4 or 5 days.
Over the course of about three weeks, I gradually worked up to normal stretching. And guess what – I completely cured the pain in my left arm when swimming the crawl. We might call this approach Graduated Stretching.
The lesson here is you can stretch too intensely, and create or worsen pain, just as you can do strength training too intensely, and create or worsen pain.
Pain Problem #5: Lower back pain
A number of years ago I started to develop lower back pain, plus an occasional, unpredictable sharp pain in my back.
By this time I had a pretty good idea of how to overcome these kinds of pain problems. I started doing strength training for my back. I did sit ups every other night before going to bed, beginning with just a few sit ups, and gradually increasing the number. I have now built up to 40 sit ups every other night, and I have not had any back pain since I implemented this exercise routine.
This is an example of how stretching and strengthening muscles can prevent pain as well as cure pain. To function without pain, the human body needs muscle strengthening, and muscle stretching. The body also needs cardiovascular exercise, but that is not so helpful with pain.
Without exercise, body parts sometimes deteriorate and cause pain. So if a patient has developed pain without any apparent cause, lack of stretching or lack of strengthening could be the real cause of the pain.
Subsequently I wondered if doing sit- ups every night might be more effective than every other night. So, as an experiment, I tried doing sit-ups every night for three nights. This caused my back pain to return. I have now gone back to doing sit-ups every other night, and once again my back pain has disappeared.
This illustrates the importance of experimenting to determine the optimal amount of rest between exercise sessions. Exercise damages muscle fibers, and after exercise muscles regenerate, larger and stronger than before the exercise.
But this regeneration occurs only during rest. So if the rest between exercise sessions is too short, muscles will be further injured rather than regenerating.
These experiences illustrate the systematic part of the Mindful Exercise System. If patients do multiple exercises, and they get better (or they get worse) no one can be sure which of the exercises
was making them better (or making them worse). So guide patients to systematically experiment, trying one exercise at a time, including rest, to determine which exercise, at what intensity, with
what frequency, reduces their pain.
But how can patients figure out what intensity is the right intensity? This question leads us to …
The Mindful Part of the Mindful Exercise System
In order to do the right intensity of exercise, patients need to do mindful exercise: while they are exercising, they should focus their attention on their body. And they must learn to recognize the feeling of stretching or therapeutic strengthening their muscles, and distinguish that feeling from the feeling that they are injuring their muscles further.
Patients also need to note how the exercised muscles feel the next day or two. If muscles ache after exercise, but feel better or at least no worse the next day, patients should continue that exercise.
When stretching a body part, patients should feel a gentle pull on their muscles, but not pain. When doing strength training, patients should feel that their muscles are straining but not tearing. It is very important to do the right intensity of stretching and strengthening. Too intense or not intense enough can provide no benefit or can worsen the injury. If an exercise is improving the pain, the patient should gradually increase the intensity or the frequency of that exercise. Patients also need to determine how much rest is optimal between exercise sessions. Exercise breaks down muscles, and rest then enables the muscles to build up stronger than they were originally. Too little rest between exercise sessions can impede the strengthening of muscles, and too much rest can cause muscles to deteriorate between exercise sessions.
Pain medication can block mindful awareness of physical sensations, preventing patients from determining the right intensity and frequency of stretching and strengthening exercises.
After an injury or an operation, patients may need to do no exercise, but to rest the injured body part to allow healing to occur. However, resting a body part too long may cause deterioration and a new injury. So after an injury or an operation, patients should be very careful about introducing exercise very gradually, at the proper time, with the proper intensity. Introducing exercise too soon or too intensely may worsen the injury. Introducing exercise too late, may cause a new injury.
Most patients come to us after many months, or even years of operations, physical therapy, opioids, acupuncture, and other physical treatments. Usually the original injury has healed and too much rest, or too many odd movements and odd body postures have created a new injury. It is also possible that too much pain medication or too many medication withdrawals have created a new injury.
The Limits of Physical Therapists
Physical therapists do not have a theory of which exercise should be utilized for which type of pain or injury. They usually just perform the same group of exercises on the body part where the pain is experienced, and they hope that something helps. So I recommend that patients, either on their own or with a physical therapist, attempt to figure out which kind of exercise at what intensity, and with how much rest between exercise sessions, is optimal to alleviate pain.
You should help your patients experiment to determine which exercise regime works best for them. Physical therapists just don’t have the time or the information about how various exercises feel to the patient. Also, physical therapists don’t have the scientific mindset to do the systematic experimentation that will help patients discover the right exercise regimen to alleviate each specific pain.
Only the patient, through mindful, systematic observation, can really know which exercises help, which exercises have no effect, and which exercises make pain worse. So I recommend encouraging your patients to take control of their physical exercise and develop their own mindful, systematic, scientific exercise program.