No Pain, No Gain? More Like Train Without Pain

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So you woke up again this morning with nagging back pain, or knee pain, neck pain, or shoulder pain? What should you do now? Take medication to cope with the pain, go to the doctor to get some answers, or continue to just deal with it with lifestyle modifications? According to the latest population health data from the CDC, “almost 21% of the U.S population lives with chronic pain” or “pain lasting more than three months,” (U.S. Pain Foundation, 2023, p.1). This equates to 51.6 million American adults currently suffering from chronic pain. Of this group, 17.1 million grapple with high-impact chronic pain which “restricts their ability to work or participate in daily activities,” (U.S. Pain Foundation, 2023, p. 1). Where does all this pain come from and what can we do about it?

According to Dr. James Nathan, chronic pain comes from muscle imbalances which can be present from an early age (Nathan, 2022). These imbalances can occur between muscles on different sides of the body or between different muscles that surround a joint (Frothingham, 2020). Muscular imbalances can occur naturally during development, come from activities of daily life where we repeatedly complete a certain movement, inactivity, bad posture, poor exercise form and a poorly sequenced exercise programing (Frothingham, 2020). These imbalances can lead to limited mobility, pain, unbalanced appearance and instability which increases the risk for injury (Frothingham, 2020). 

During Phase 1 of the Muscle Imbalance Continuum created by Dr. James Nathan, individuals have a muscular imbalance due to one of the factors listed above (Nathan, 2022). During Phase 2, exercises and normal activities are performed with this imbalance (Nathan, 2022). In Phase 3, periodic pain occurs or little bouts of pain that can commonly be controlled with pain relievers, rest and heat/ice (Nathan, 2022). During Phase 4, this periodic pain becomes regular pain that begins to interrupt everyday activities (Nathan, 2022). Finally, in Phase 5 an individual sees a doctor and is left with the options of medication, surgery or in the best case-scenario if an individual has a quality insurance plan, physical therapy (Nathan, 2022). For example, let's consider a woman that works in an office and consistently crosses one leg on top of the other. This woman has created an imbalance due to her career and this imbalance is with her throughout her everyday life. She begins to feel periodic pain and treats this with pain relievers. The pain then begins to feel unbearable, she sees the doctor and is told that she can take medication, go through surgery to fix the imbalance in her vertebral column or go to physical therapy. This woman’s insurance plan does not cover physical therapy so she opts for surgery (Nathan, 2022). 

Figure 1. 

Muscular Imbalance Example 

This is unfortunately a very common progression when an individual has muscular imbalance. Imbalance leads to pain, the pain becomes overbearing, and surgery or medication are the only options that are often readily available. For example, between 2015 to 2016 there were 43 million visits to the orthopedic surgeons office according to the CDC (CDC, n.d.). Only 2.3% of these visits were for preventative care while 38.6% were for a new problem, 20.8% were post surgery, 32.2% were for chronic pain and 3.6% were pre surgery (CDC, n.d.).. The three principal reasons for visits included knee, hip and shoulder pain. In 59.9% of cases, medications were prescribed including hydrocodone, meloxicam and oxycodone (CDC, n.d.). 

Clearly, muscle imbalances and chronic pain are a problem. Are surgery and medication the only viable option? Luckily, no. Corrective exercise is “the systematic process of identifying movement dysfunction, developing a plan of action, and implementing an integrated corrective strategy,” (Mahaffey, n.d., p.1). In other words, the goal of corrective exercise is simply to “help people move well” by reteaching better movement patterns (Mahaffey, n.d., p.1). In the short-term, corrective exercise immediately helps change misalignment and thereby reduces stress on the joint and tissue (Nathan, 2022). In the long-term, it helps to “reprogram the brain's nero-muscular patterns to permanently maintain the more optimal alignment,” (Nathan, 2022). Benefits of corrective exercise include improved movement, reduced risk of injury and reduced pain (Mahaffey, n.d.).

Corrective exercise consists of turning-on underactive muscles and turning-off overactive muscles (Nathan, 2022). Shortened muscles which are overactive are relaxed and/or stretched and lengthened muscles that are under-active are activated with strengthening exercises (Nathan, 2022). Additionally, muscles which are lengthened and over-active (like the hamstrings) are relaxed (Nathan, 2022). The most common imbalances include inner unit dysfunction (an underactive core), knee loading, upper trap loading and arm loading/ front deltoid loading (Nathan, 2022). The major corrective activations to retrain these faulty movement patterns include core activation, glute activation, scapular activation and chest activation (Nathan, 2022). 

Figure 2. 

The “Big Four” Muscle Imbalances 

NASM has a Corrective Exercise Continuum paradigm which outlines how to move a client from a place of faulty movement patterns to a state of balanced movement (Stull, n.d.). First, an individual must inhibit tension in the overactive muscle using self-myofascial release to help reduce tension and soreness while improving circulation (Stull, n.d.). For instance, if an individual has extremely tight hip flexors, foam-rolling them before beginning exercise helps reduce the risk of injury and faulty movements patterns. Second, an individual must lengthen the muscle with static stretching techniques to reduce stiffness, improve range of motion and improve posture (Stull, n.d.). Back to the hip flexor example, this same individual can then perform a variety of static stretches (like pigeon pose) to continue to help lengthen the hip flexors. Third, an individual must activate the muscles identified as underactive or weak using appropriate strength training to increase strength and endurance (Stull, n.d.). After the individual foam rolled and stretched their hip flexors, performing a dead-bug core exercise using the muscles of the core (the appropriate prime movers) instead of the hip flexors will be much easier. Fourth, an individual must integrate using dynamic exercises to improve total-body coordination, improve movement patterns and enhance performance (Stull, n.d.). Once an individual has inhibited and lengthened their hip flexors and activated their core, they can perform an integrated strength exercise like the plank to continue to activate the under-active core. 

While every individual is unique, there are certain exercises that can be helpful for the big-four imbalances: core dysfunction aka lower back loading, knee loading instead of the appropriate hip loading, upper trap loading instead of the appropriate scapular loading and arm loading instead of chest loading (Stull, n.d.). 

Core dysfunction aka lower back loading: Core Activation: 

• Diaphragmatic breathing: Deep breath in fill your belly with air and release your pelvic floor, exhale and press out all your air while you cinch your belly like a corset and lift through your pelvic floor

• Foam roll hip flexors: lay on top of the foam roller and roll each hip flexor 

• Hip flexor stretches: runners lunge, pigeon pose 
  

Knee Loading: Glute Activation: 

• Glute bridge: lay flat on the floor with your feet planted. Inhale and squeeze your glutes to lift, slowly release your glutes as your lower. 

• Foam roll quads: lay on top of foam roller with foam roller in the middle of the quad. Roll back and forth until you find a tight spot and hold.

• Foam roll calves: sit on the floor and roll the foam roller until it is under your calves, roll until you find a tight spot and hold. 

Upper trap loading: Scapular Activation: 

• Bent arm squeeze: hold a resistance band in both bands. Pull the band in towards your chest as you squeeze your shoulder blades together and then slowly release. 

• Foam roll upper back: lay the foam roller the long way on the floor and drape your body over it and hold. 
  

Front delt loading: Chest Activation: 

• Ball chest squeeze: hold a pilates ball (or playground ball/ pillow) to your chest and squeeze it into your chest tightly for three seconds and then release. 

• Stretches: overhead tricep stretch, cross-body shoulder stretch 

References 

CDC (n.d.). Orthopedic surgery fact sheet from the national ambulatory medical care survey. CDC. https://www.cdc.gov/nchs/data/namcs/factsheets/NAMCS-2015-16-Orthopedic-Surgery-508.pdf

Frothingham, S. (2020). What causes muscle imbalances and how to fix them. Healthline. https://www.healthline.com/health/muscle-imbalance#causes

Mahaffey, K. (n.d.). Corrective exercise for better strength and performance. NASM. https://blog.nasm.org/corrective-exercises-for-better-strength-and-performance

Nathan, J. (2022). Pre and postnatal corrective specialist (PPCES). Fit for Birth. https://getfitforbirth.com/ 

Price, J. (2021). The top 10 corrective exercises. IDEA. https://www.ideafit.com/personal-training/exercise-program-design/functional-general/top-10-corrective-exercise-programming/

Stull, K. (n.d.). A guide to NASM’s corrective exercise continuum (CEx). NASM. https://blog.nasm.org/ces/a-guide-to-nasms-corrective-exercise-continuum

U.S. Pain Foundation (2023). The impact of pain in America. U.S. Pain Foundation. https://uspainfoundation.org/news/the-impact-of-pain-in-america/