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Issue 8

Table of Contents

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Discomfort, pain and stiffness: what do these terms mean to patients? A cross sectional survey with lexical and qualitative analyses

Dr. Joe Camoratto PT, DPT

Key takeaways:
  • There are distinct differences between the constructs of pain, discomfort and stiffness
  • There is overlap between these three constructs as well
  • Qualitative studies help us to move the needle forward regarding understanding and communicating with patients

 

There is a question I like to ask myself pretty frequently. Not only in the clinic or while working with athletes, but just in life in general. That question is:

What are we even doing here?

Not here as in like, the universe (although, something to ponder), but more so the specific context that we find ourselves in on a regular basis. The opening of the article I’m reviewing today addresses that head on, at least in the chiropractic world.

“Health care professionals, including chiropractors, provide clinical care to patients, aiming to improve pain or other relevant clinical outcomes in order to enable patients’ achievement of functional activities.”

If I were to paraphrase in my own words, it would look something like “to reduce fear or hesitation, return people to meaningful activity and facilitate improved perception of symptoms”. What does improved perception of symptoms usually look like? Historically it seems to be how we think about and measure pain. I mean, pain is the fifth vital sign after all, if you didn’t know. Everyone loves to ask how people’s pain is.

I bet the first thing you or your support staff were taught to ask was “how would you rate your pain?” as they walk through the front door of your clinic. I know that’s how it has been at about every clinic I’ve worked at least. I have been against this practice for quite some time as I don’t appreciate bringing something so, so, so… fuzzy and hard to describe and difficult to manage as pain to the forefront of people’s brain when they come to see us. It’s classical conditioning at its best. Pavlovian if you will.

It’s not lost on me that we are in the business of managing pain and symptoms, but we are moving into a world where pain is an afterthought to function and ability. Not totally forgotten, but there is a much needed movement towards focusing less on pain and how little influence we have over it, and more on getting people feeling confident, robust and back into things that mean something to them. Does this mean that we need to do away with asking about pain altogether? Well, no.

That’s how you convince a patient that you don’t give a shit about what they are feeling. It just doesn’t need to come second to a greeting. So now that I’m off my soapbox, let’s do a 180 and take a look at stepping down into the muck that is the attempt to put definitions on subjective experiences.

“Discomfort, pain and stiffness: what do these terms mean to patients? A cross sectional survey with lexical and qualitative analyses”

This paper was published 6 months ago and it is what we call qualitative research. Less numbers and statistics and more feelings and words. Good for people like me who don’t know who this ANOVA dude is or why he is mentioned in so many papers.

“The purpose of this study was to explore patient’s perception of discomfort, pain and stiffness concepts and if/how patients differentiate between them.”

I’m not quite sure how they decided to look into discomfort and stiffness as comparators to pain, but it begs the question of what subjective descriptions of symptoms are worth looking into? All of them? None? There are many clinicians that are thought leaders in our space that subscribe to the idea of let’s leave well enough alone and just take our patients word for it when the only descriptor they can give us is “it hurts.”

Honestly I’m in that camp, sometimes. But other times it does seem to be just fine and even appropriate to dig a little deeper into that subjective experience. The overarching theme that lingers over this whole study is this: We are only able to understand the experience of another person as well as they can describe that experience.

“Different understandings can lead to miscommunication and misunderstandings in the clinical encounter, where clinicians and patients interpret different experiences based on their own definitions.”

So let’s look at some definitions imposed by the authors:

  • Discomfort: a negative physical and/or emotional state causing unpleasant feelings of sensations
  • Pain: an unpleasant sensory and emotional experience associated with or resembling that associated with actual or potential tissue damage
  • Stiffness defined as:
    • a subjective experience (“feeling” stiffness)
    • a physical state that can be objectively measured (“having” stiffness)

 

The participants in this study were sent a survey asking 3 things:

  • Are you experiencing any of the following (discomfort, pain and stiffness) and if so, where and at what intensity.
  • In your own words, describe what discomfort, pain and stiffness mean to you (a bold question to ask anyone)
  • What are your demographics? (age, sex, condition there were receiving care for and its duration)

 

They then took the words that the participants used to describe the three constructs and plugged them into a program that churned out this nifty figure that shows words that were repeatedly used by participants and any overlap between the three constructs that existed.

 

 

Discomfort required only partial attention and that they were consciously aware of it.

“When you are consciously aware of your body and know it’s not functioning optimally.”

Some participants described the difference between pain and the other two constructs as its ability to be ignored or not. Participants also described both discomfort and stiffness as allowing the participants to remain functional, “can function during activities of daily life but it doesn’t feel ‘normal’”. Pain was described as stopping or limiting activities. Character was simply the adjectives used to describe the construct. Discomfort was described as dull and tingling. Pain was described as being sharp and shooting. Stiffness was described as tight and restricted.

“Discomfort to me is almost a dull ache. Not something that is debilitating but something that is noticeable and is not usual. Pain to me is when there are sharp shooting sensations or feelings of discomfort that become unbearable. Stiffness to me is when something is a bit tight or hasn’t been stretched properly. When I move a certain way and there is resistance but no pain.”

Feeling spanned the emotional experience of how each construct made them feel

  • Discomfort – not at ease
  • Discomfort and stiffness – unpleasant and annoying
  • Pain – hurt and in danger

Intensity could be described as the severity of the construct, although this is my word and not the author’s or the participants. Discomfort and stiffness were said to be less intense than pain. Finally, temporality describes the time component of the constructs. All were described as being potentially constant, but discomfort was described by some participants as being short in duration, and others described stiffness as being both constant and intermittent.

Here we see some of the inherent issues with qualitative research, but those issues are also the point. It’s a step away from the objective reality that gets us stuck in the mechanical way of thinking in the clinic, and into the constantly moving world of the unique lived experience. In an attempt to see if there was a differentiation between these three (possibly arbitrary) constructs, we see that the answer is yes, but also no.

It DePeNdS. Of course.

 

 

The authors were kind enough to give us another figure to visualize any differences and overlaps between the 5 major themes. So where does this all leave us? Despite the constructs defined here being seemingly arbitrarily chosen, there being overlap in the way that the participants describe them, and there being obvious differences in the way that they are perceived by unique people, I would say that this helps us understand that subjective experiences are confusingly unique.

As I’ve been writing this and as I was reading the paper, I tried to better square this circle, but it’s hard. One of the voices inside of me wants to take this paper and almost disregard it as trying to describe what noise the flavor blue makes. The other voice inside feels that this is important work that can help to better understand what it is this subjective experience of not feeling amazing really means.

While we do leave from this paper with a better understanding of how patient conceptualize these constructs, we need only close our eyes and randomly point to another construct to study (eg. sore) or ask another person what they experience to open the floodgates of questions. It reminds me of the expression “its turtles all the way down”.

I do feel that asking questions like “is it pain or is it discomfort” can be both helpful and troublesome during patient interaction. Helpful in that discomfort is likely to be a more tolerable experience, depending on who you ask, and that can be a step forward from pain. But I fear it can be troublesome when the patient feels that you may be attempting to put them into a box that they may not feel is where they belong.

I unfortunately have no crisp way of ending this. I’ve tried and my fingers hurt from hitting the backspace so many times. Maybe ask yourself what your definitions of pain vs discomfort vs stiffness are and if they have a clear enough delineation to help you describe or characterize what you’re experiencing to someone else. Then ask yourself if they would agree with your definitions. Then just do that with every other human on the planet. Let me know what you come up with.

 

References:
  1. Funabashi M, Wang S, Lee AD, C K Duarte F, Budgell B, Stilwell P, Hogg-Johnson S. Discomfort, pain and stiffness: what do these terms mean to patients? A cross-sectional survey with lexical and qualitative analyses. BMC Musculoskelet Disord. 2022 Mar 24;23(1):283. doi: 10.1186/s12891-022-05214-y. PMID: 35331201; PMCID: PMC8944041.

 

Volume for Muscle Hypertrophy and Health Outcomes: The Most Effective Variable in Resistance Training

Dr. Jacob Templar PT, DPT

Key takeaways:
  • Ten sets per week per muscle group appears to have a more robust effect than less sets
  • There is a dose dependent relationship with strength, hypertrophy, and health outcomes. The ceiling of this dose is variable
  • Many trainers and healthcare professionals are always trying to strive towards a minimum dose, which may actually result in undertraining or suboptimal health, strength, and hypertrophic outcomes

 

We all know that exercise is good for us, but many forget some of the health benefits of resistance training. We can see substantial effects on insulin sensitivity, bone density, inflammatory responses, muscle quality, cardiovascular function and many others with resistance exercise. Several major medical and fitness societies recommend regular exercise for its numerous health benefits, from those who have cancer, people who are pregnant, the young, the old, and everyone in between.

There are many variables that affect how we design an exercise program, rest intervals, exercise order, exercise selection, total weight used (intensity), speed, weekly frequency, but the most important factor appears to be volume. Volume is typically defined by the number of reputations x sets performed x intensity. There are minimums that appear to induce adaptations, but in the case of most healthcare professionals, less is not always more.

Many fitness and health professionals neglect volume for the sake of a minimum amount of exercise (the time commitment), or are afraid to have individuals perform higher volume programs due to implicit and explicit beliefs about the human body. However, this may be shortchanging the benefits individuals they are working with are receiving from exercise.

When all factors are equal in resistance training programs literature consistently reports that those who perform more volume see improved muscle mass. While there are benefits to ensuring that the total intensity is adequate, volume is still the king. Thus far, most adjustments to training variables to achieve the maximal effect revolves around maximizing the amount of volume an individual performs. This is the main drive of most adaptations. As well as mechanical tension, which is a topic for another time.

One example of this would be adjustment of rest periods, which often when someone is making adjustments due to time is the first thing to be shortened. However, the trend in the literature is that shortening rest periods influences performance and the total volume someone can perform within a session. This might yield aerobic benefits, but in most cases why wouldn’t you just do cardio instead?

Also typically when we see that someone is not having an adequate response to training it is because they are not performing enough volume. X et al (50 on the article) for example did a study with individuals who appeared to be non-responders to training over a 6-week period. After the initial 6-week period, they added additional volume, which then resulted in improvements in the studies key outcomes.

Again, to further hit you over the head with the idea that volume is important, many meta-analyses on hypertrophy have demonstrated you can see improvements with 5 sets per week but almost double the response is seen when someone performs 10 sets per week. There is a ceiling effect for this within a session, for example James Kreiger’s analysis of this literature suggests a ceiling at 6-10 sets per session for a given muscle group. Nevertheless, this area is not well understood scientifically.

To further clarify, in most cases the number of sets are tracked on a weekly basis, with 10-20 sets being thought to be more beneficial for most goals. Currently, our understanding of what particular mechanisms are responsible for this improvement remains elusive, but most experts believe it has something to do with mechanical tension. Also, greater responses to volume as mentioned before had been researched in untrained individuals. Moreover, even the ACSM and WHO activity guidelines typically recommend 9 sets per week.

Resistance training has substantial influence on many health conditions and markers for health, in a dose dependent fashion. A study of overweight women performing resistance exercises for 11 weeks and performing 9 sets per week of 8 exercises each showed substantial improvements in their triglyceride levels. Resistance training shows a substantial reduction in both systolic and diastolic blood pressure via many mechanical and cardiovascular mechanisms, all of which are dose dependent.

Further, A1c levels show substantial improvements with resistance training. When individuals performed resistance exercises, for each 60 minutes of exercise per week there was a 13% reduction in risk for type 2 diabetes. Even in sarcopenia interventions for individuals in this population range from 7-39 sets of exercises per week. Our reluctance to add load in most populations can lead to suboptimal volume. As there may be limits to how many reps someone can perform per set without losing focus, and adding sets is significantly more taxing.

So by not adjusting load we are shying away from the easiest variable to adjust. Additionally, as mentioned previously the absolute load is what drives mechanical tension and many positive adaptations associated with resistance exercise. And without adjusting volume we could be missing out on benefits, especially for elderly patients/clients, as as we age we also become more metabolically resistant, where processes involving protein synthesis are slower/blunted, and may require more volume. In addition, this is safe.

As seen in the LIFTMOR trials where individuals performed 80-85% of their 1RM on squat, deadlift, and overhead press. Some articles also have individuals do 90% of their 1RM. To date, there is a lack of consensus on the high-end threshold for resistance exercise volume. A minimum of 10 sets per week is required to see substantial improvements in most untrained individuals. We also need to ensure adequate program design focusing on maximizing volume with loads of at least 65%+ of 1RM. The benefits of exercise are numerous but we need to remember to not underdose the medication.

And remember:

“Frailty is not a contra-indication to physical activity, rather it may be one of the most important indications to prescribe physical exercise.”

References:
  1. Aguirre LE, Villareal DT. Physical Exercise as Therapy for Frailty. Nestle Nutr Inst Workshop Ser. 2015;83:83-92. doi:10.1159/000382065
  2. Brad J. Schoenfeld, Dan Ogborn & James W. Krieger (2017) Dose-response relationship between weekly resistance training volume and increases in muscle mass: A systematic review and meta-analysis, Journal of Sports Sciences, 35:11, 1073-1082, DOI: 10.1080/02640414.2016.1210197
  3. Borde R, Hortobágyi T, Granacher U. Dose-Response Relationships of Resistance Training in Healthy Old Adults: A Systematic Review and Meta-Analysis. Sports Med. 2015;45(12):1693-1720. doi:10.1007/s40279-015-0385-9
  4. Androulakis-Korakakis P, Fisher JP, Steele J. The Minimum Effective Training Dose Required to Increase 1RM Strength in Resistance-Trained Men: A Systematic Review and Meta-Analysis. Sports Med. 2020;50(4):751-765. doi:10.1007/s40279-019-01236-0
  5. Schoenfeld, B.J., et al., Effects of Low- Versus High-Load Resistance Training on Muscle Strength and Hypertrophy in Well-Trained Men. J Strength Cond Res, 2015. 29(10): p. 2954-63.
  6. Watson, S. L., Weeks, B. K., Weis, L. J., Horan, S. A., & Beck, B. R. (2015). Heavy resistance training is safe and improves bone, function, and stature in postmenopausal women with low to very low bone mass: novel early findings from the LIFTMOR trial. Osteoporosis International, 26(12), 2889-2894.
  7. Harding AT, Weeks BK, Lambert C, Watson SL, Weis LJ, Beck BR. A Comparison of Bone-Targeted Exercise Strategies to Reduce Fracture Risk in Middle-Aged and Older Men with Osteopenia and Osteoporosis: LIFTMOR-M Semi-Randomized Controlled Trial. J Bone Miner Res. 2020;35(8):1404-1414. doi:10.1002/jbmr.4008
  8. Fiatarone MA, Marks EC, Ryan ND, Meredith CN, Lipsitz LA, Evans WJ. High-intensity strength training in nonagenarians. Effects on skeletal muscle. JAMA. 1990 Jun 13;263(22):3029-34. PMID: 2342214.