It’s Only Pain – 80/20 Endurance
Patellofemoral Pain Syndrome

It’s Only Pain

I’ve been learning a lot about pain lately. My sudden interest in the topic was sparked by the collaborative work I’m doing with Ryan Whited on a book about self-managing athletic pain and injury. The new science of pain is utterly fascinating and completely contrary to prevailing beliefs about the deceptively familiar phenomenon.

I credit my ongoing crash course in pain science for the lack of surprise I experienced in reading a new study on knee pain in runners that may surprise many others. Led by Shahabeddin Bagheri of the University of Nahavand in Iran and published in the Journal of Athletic Training, the study investigated the effects of mindfulness training on “pain severity, knee function, fear of movement, and pain catastrophizing” in female runners dealing with patellofemoral pain.

A few definitions: Mindfulness is an intentional mind state that involves being maximally present in the moment and accepting of one’s thoughts and feelings as they are. Fear of movement (aka kinesiophobia) is just that, but it is also a vastly underappreciated contributor to the pain experience. Fear of movement literally creates pain. Finally, pain catastrophizing is a “tendency to magnify the threat value of a pain stimulus and to feel helpless in the context of pain.” Based on past research demonstrating that the pain experience is every bit as much psychological as it is physical, and that psychological interventions including mindfulness training can be helpful in pain management, this new study sought to determine whether supplementing traditional training modifications with mindfulness training could improve outcomes in athletes dealing with one of the most common running injuries.

The subjects of the experiment were women runners with an average age of 28, all dealing with persistent PFPS. Half of them were assigned to a standard, 18-week exercise treatment program focused on symptom control. The other half completed the same exercise program as well as an eight-week mindfulness intervention that started four weeks earlier and thus overlapped with the exercise program by four weeks. At the beginning, middle, and end of the 18-week exercise program, all 30 subjects rated their pain level at rest, during stepping, and during running, provided information of functional limitations of the knee, and completed questionnaires designed to assess fear of movement, pain catastrophizing, and pain coping strategies.

In a word, the mindfulness intervention worked. At 18 weeks, the subjects who received mindfulness training showed a 15.8 percent greater reduction in pain during running, an 8.2 percent greater improvement in knee function, a 20.8 percent lower fear of movement, and a 40.9 percent lower level of pain catastrophizing compared to the subjects treated with exercise only. Members of the mindfulness-plus-exercise group also demonstrated greater reliance on the coping mechanisms of ignoring pain sensations and distancing from pain.

The funny thing about this “new” way of managing athletic pain is that it isn’t new at all. Rather, it represents how everyone used to deal with pain before it became medicalized in modern society, transformed from a normal part of everyday life, like appetite–mere somatic information that’s useful in choosing appropriate subsequent goal-seeking actions–into a cataclysm to be feared and avoided at all costs. The catastrophizing of pain and the fear of movement that mindfulness helped the subjects of this study overcome are modern creations. When an 18th century rancher developed knee pain, they worked around it and through it quite adeptly without giving it more thought than was strictly necessary and certainly without complaining about it to anyone else. But when a 21st century runner develops knee pain, they freak out and stop cold and run (sorry, walk) to the doctor.

Don’t get me wrong—it’s nice that we have doctors. What studies like Bagheri’s are showing, however, is that we need to start to undo the damage that the medicalization of pain has done to the athlete’s psyche without throwing away the evidence-based diagnostic tools and treatments that help athletes get past the few nontraumatic injuries they aren’t capable of managing outside of the clinical context. Ryan Whited and I are doing our part to push what we both perceive as a coming revolution in the management of athletic pain. While our book is still at least 18 months away from publication, I’m certain I’ll be sharing more of what I learn about the subject here in the interim, so keep an eye out.