You’ve come for a sports massage to help your runner’s knee pain. So why am I asking about your stress levels and how well you’re sleeping?
Bear with me. As well as being a sports massage therapist, I’m a registered health coach specialising in weight management. Weight loss isn’t as straightforward as eat less/move more (which anyone wanting to lose weight knows). It’s a hormonal issue, with certain foods (sugar and ultra-processed products) and even when we eat influencing the hormones which lead to fat storage. But stress and poor sleep can also affect those same hormones so are a crucial part of the weight management picture. And this is before we consider that stress, emotions and a poor night’s sleep can impact our eating decisions.
If stress and poor sleep impact our weight so profoundly, what else do they influence? For a while now, I’ve discussed stress levels and sleep with sports massage clients, especially since covid-19 came on the scene. Working from home, scrunched over a laptop at the kitchen table while juggling home schooling is bound to lead to stress and tension which can lead to pain, as we all know. But we also need to think about constant, low-level stress from families and relationships, uncertainty, traffic jams, the news, social media etc which takes its toll, even without obvious major stressors.
Why is this?
Mounting evidence shows that psychosocial factors (emotions, stress, anxiety, poor sleep, work/life balance etc) affect our perception of pain, and capacity for healing and recovery
Pain is a useful phenomenon which tells us about the world and keeps us safe. The accepted definition of pain is “an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage” (my italics). It’s an experience, not a simple nerve signal. It depends on several non-injury-related factors including context. For example, pain often seems worse at night when there are no other distractions. And while a paper cut on your finger can be acutely painful, you wouldn’t notice it if you were escaping from danger. Pain isn’t as simple as tissue damage signalling the brain. Other factors are also at work.
Pain isn’t always a sign of injury
Pain is generated in the brain and nervous system, with nerve signals and brain activity affecting the type and level of pain we feel.
The balance between nerve signals which increase pain and signals which inhibit pain (our natural painkillers) can become dysfunctional. If the nervous system ‘turns up’ the pain signals and dials down the inhibition signals, we can feel more pain even if tissue damage is negligible. If this continues long term, even after an injury has healed, we become ‘sensitised’, perceiving pain even with little or no tissue damage.
We can also perceive more pain if certain parts of our brain are overactive. For example, people with persistent pain seem to have an overactive limbic system (emotional brain). This suggests that for any given signal from the tissue, greater pain is perceived because the limbic system is active. It seems the brain can generate pain perception even without tissue damage. This doesn’t mean a person doesn’t feel pain – they do. But the pain might be amplified by factors other than injury, so it might help to address those factors.
What makes our brain and nervous system amplify pain?
Research increasingly suggests that psychosocial factors contribute to sensitisation and generation of pain in the absence of tissue damage. Anxiety, lack of sleep, stress and a negative emotional state can create the conditions for our natural painkillers to be dialled down and for the brain to generate pain. In other words, stress, lack of sleep and negative emotions can cause or increase pain.
Stress and poor sleep can reduce the body’s capacity to heal and recover
There’s another aspect to consider, too, and that’s the effect of psychosocial factors on our body’s capacity to withstand stress, heal and recover from training.
Take that runner’s knee pain. Runner’s knee or patellofemoral pain (PFP) presents in many ways and can have many causes, in the same way that a headache can be general or focussed in one spot, and could be caused by dehydration, a migraine, shoulder tension or a brain tumour. Traditionally, if someone suffers from PFP a therapist might explore quad strength, the tracking of the knee cap (patella) across the knee joint, training volume, gait mechanics, running surfaces, footwear etc. But a recent study found that although some of these factors could be relevant, they were not necessarily the whole story. The proposition was that increased load became a problem when the body did not have the capacity to tolerate it and recover from it. Increased load could come from increased distance, training frequency, speed, hill work, or different shoes for example. But what interferes with the body’s capacity to heal and recover from training load? Lack of sleep and stress.
Chronic lack of sleep has been linked injury risk in endurance athletes and teenage runners and stress has been found to reduce capacity of tissues to recover in studies with triathletes and adolescents.
This might explain why, despite no change to training load, an injury sometimes appears seemingly out of the blue without reason.
I think we all intuitively recognise that pain can be exacerbated in certain situations. And rest and recovery has always been a key element of any sports training. But now research is starting to explain why that is and provide ideas for us all – therapist and client – to consider and work on. If poor sleep and stress can lead to pain, it follows that improving sleep quality and managing stress levels will help to tackle pain.
In future blogs I’ll summarise a few ways we can do this. In the meantime, google ‘sleep’ and ‘stress management’. There’s lots of information and suggestions out there you could use straightaway.
Sources and references:
Pain science, yoga, life. Bridging neuroscience and yoga for pain care. Niamh Moloney & Marnie Hartman. (2020). Handspring Publishing.
Pain does not always indicate injury. Kathryn Thomas. Co-Kinetic Journal. (July 2021).
A contemporary approach to patellofemoral pain in runners. Esculier et al. (2020). Journal of Athletic Training.
Lou Walker is a sports massage therapist and health coach. Find out more at www.louwalkersportsmassage.co.uk and www.louwalker.com.