3 Steps to Treat Chronic Pain Using HRV

I was 21 years old, a student-athlete playing DII basketball in the NCAA, and sleeping with my mattress directly on the floor. Not totally uncommon when in college but this was new to me.  Why was it there? Well a regular bed frame, usually a few feet off the ground, would result in crippling back pain every morning where I would be hobbling around for most of the morning justing trying to stand up straight. I never really knew why I had this problem since I thought I was doing everything that I was supposed to be doing. I was eating right, doing proper strength training, and seeing physical therapists and team doctors… so why was I in pain? Why wasn’t I getting better? What was I missing?

1 in 5 people worldwide suffer from some form of chronic pain, totaling upwards of $600 to 700 billion from health care costs and lost productivity just in the US and Canada alone.  Chronic pain is a global issue that many of us have had to deal with at some point in our lives and HRV has been a great asset to aid in the alleviation of chronic pain for me and my clients.

A recent meta analysis study showed those suffering from chronic pain have significantly low HRV values compared to those who live without chronic pain.

Those suffering from chronic pain have significantly low HRV values compared to those who live without chronic pain.

We have pain when we have an unpleasant sensory and emotional experience associated with actual or potential tissue damage. Based on this definition, we need to remove the link between pain being a stimuli even if it does have a proximate physical cause. Pain is a perception that has sensory, emotional and cognitive components; this is where HRV can be a useful tool. We’ll discuss some ways HRV can help those who are in chronic pain, especially in a physical rehabilitation setting, and cover some of the main mistakes made when treating chronic pain.

Get Away from Treating Just the Symptoms

There are many in the physical rehabilitation field that treat the site of pain and when there is a reduction or removal of pain, the patient is cleared to resume regular activity. A job well done, right? The person came in to get rid of their pain and they did, but this rarely seems to solve the problem long-term. This is why people keep coming back with the same issue over and over.  In the famous words made popular by Dr. Perry Nickelston, we need to “stop chasing pain.”

For example, a 2015 systematic literature review of MRI’s of people with no back pain found significant spinal degeneration across all age groups.  This gives a better understanding of why we should not let pain guide our treatment but instead use the presence of pain to inform us that there is an underlying problem that needs to be addressed.

Our nervous system uses pain to give awareness to a greater issue. When we get an injury or have pain for any reason, it alters our motor control, meaning it changes our normal movement patterns to work around the area’s that is causing the pain. This can then result in new problem areas as the body’s compensation puts abnormal stress on the compensating structure. This is why in many situations, chronic pain in one area can indicate damage in another area that was causing the over-compensation and structural imbalance. If we do not restore adequate movement competency, we cannot completely fix the problem.  When we look at the research, the leading causes of injury are:

1. Previous injury
2. Movement asymmetries
3. Altered motor control

This means you are already at greater risk of reinjury just by being injured in the first place. This is something we might not be able to change, but we are able to work on and improve upon the other two risk factors of movement asymmetries and altered motor control. After we remove the problem or cause of pain, we need to re-learn adequate motor control to assure we have movement competency and capacity to significantly reduce the chance of reinjury.

After we remove the problem or cause of pain, we need to re-learn adequate motor control to assure we have movement competency and capacity to significantly reduce the chance of reinjury.

HRV is an objective tool to track and monitor regression of pain symptoms and show improvement of long-term physical capacity. In the short-term, when monitored regularly, HRV can be used to indicate day-to-day readiness for exercise and stress tolerance. Since pain is a subjective feeling and we are removing the idea that pain is a stimuli to the body, monitoring HRV is a great way to safely and effectively progress physical rehabilitation and assess effectiveness.

*To be clear, you should not be doing any exercises or movements that cause you pain.  If you do, please be examined by a qualified medical doctor, physical rehabilitation specialist, or chiropractor to get an appropriate assessment and treatment plan.

Monitoring HRV is a great way to safely and effectively progress physical rehabilitation and assess effectiveness.

Find the Cause(s) of Pain

Pain is multifactorial, meaning that an increase or decrease in pain symptoms can be based on a number of factors.  Therefore, when we have an issue that causes pain, we must take a holistic approach to the recovery process.  Are there emotional triggers that occur when pain is present, such as work or family stress? Does pain occur when you are in a heavy training week? Are you supplying your body with the needed nutrients to give energy and repair damaged tissues?

When we have an issue that causes pain, we must take a holistic approach to the recovery process.

This is where you should use the HRV Optimization Checklist.  We discuss this in detail in the “Foundations of Heart Rate Variability” course, but ultimately this checklist is used to determine “red flags” that need to be discovered in order to improve your health and ability to adapt to stress.  It is broken down into 6 major topics:

1. Physical Health
2. Nutrition
3. Physical Activity
4. Lifestyle
5. Sleep
6. Emotional Health

Whether you are a medical doctor, strength coach, massage therapist, chiropractor or in any other health and performance profession, all of these areas should be addressed and discussed with every single client. If you use this checklist for yourself, you should analyze each area to determine where you may need help, what to work on to address the issues you discover, and what to track and monitor as you progress your treatment program.

As you start to address one or more issues, you can utilize HRV to determine whether the intervention you proposed is working properly, not affecting a change, or is actually causing negative adaptations to your health rather than positive.  And if you are tracking these lifestyle factors alongside HRV, you can also determine which of these categories affects you daily, weekly and monthly progress. Do you see the greatest HRV drop after a poor night’s sleep, eating food past 11:00 pm, or when you had a rough day at work? As you track your HRV and start to see a pattern, you will be able to get ahead of any issue that causes you harm, so you can counteract the stressor before it becomes a bigger issue.

As you start to address one or more issues, you can utilize HRV to determine whether the intervention you proposed is working properly, not affecting a change, or is actually causing negative adaptations to your health rather than positive.  And if you are tracking lifestyle factors alongside HRV, you can also determine which of these factors most affects you daily, weekly and monthly progress.

Use a Referral Network

I will not be able to solve every problem that comes through our door, nor should anyone claim that they can. In our clinic, it is rare that a client only sees one practitioner during their rehabilitation process. Each practitioner on our team has different expertise and limits and we make sure the client is working with the most competent caregiver for their specific situation. Not only that, we also have a network of other health practitioners outside of our clinic that we refer clients to if needed, such as naturopaths, psychologists and sport medicine doctors that compliment what we do in the clinic. We want to solve the problem that is affecting our client and it doesn’t matter who they see, as long as they get better.

To make sure we are all on the same page, we have many tests and assessments that hold us accountable to improving the client’s movement competency and becoming pain free, such as movement tests, performance measures and Heart Rate Variability testing and monitoring (see the post “HRV as an Assessment Tool” for more information on how to use HRV to assess and guide treatments).  We want the person to leave in a better mechanical (movement) and physiological (HRV) condition than when they came in and have an on-going plan in place to keep them that way.

We have many tests and assessments that hold us accountable to improving the client’s movement competency and becoming pain free, such as movement tests, performance measures and Heart Rate Variability testing and monitoring.

Takeaways

HRV has been an invaluable asset to my own physical treatment plan and to the hundreds of clients that I have overseen who suffer from acute or chronic pain. For those in chronic pain, we make great improvements in not only their “movement literacy” but also their physiological ability to adapt to stress by using the HRV Optimization Checklist and HRV guided treatment to help address issues that arise outside the clinic walls.  This allows for efficient treatment plans and less susceptibility for mechanical and physiological reinjury.

Interested in getting the HRV Optimization Checklist and learning more about the different lifestyle factors that affect HRV and system health and performance? Get access to the “Foundations of Heart Rate Variability” course!

References:

Cook, G., Burton, L., Kiesel, K., Rose, G., & Bryant, M.F. (2011) Movement: Functional movement systems – screening, assessment, corrective strategies. Aptos, CA: On Target Publications.

Goldberg, D.S., & McGee, S.J. (2011) Pain as a global public health priority. BMC Public Health. 11, 770. doi: 10.1186/1471-2458-11-770.

The Canadian Pain Society. (2014). Pain in Canada fact sheet. Toronto, ON: Author.

Tracy, L.M., Ioannou, L., Baker, K.S., Gibson, S.J., Georgiou-Karistianis, N., & Giummarra, M.J. (2016) Meta-analytic evidence for decreased heart rate variability in chronic pain implicating parasympathetic nervous system dysregulation. Pain, 157(1), 7-29. doi: 10.1097/j.pain.0000000000000360.

Treede, R.-D., Rief, W., Barke, A., Aziz, Q., Bennett, M. I., Benoliel, R., … Wang, S.-J. (2015). A classification of chronic pain for ICD-11. Pain, 156(6), 1003–1007. doi: 10.1097/j.pain.0000000000000160