Pain Behaviors

Rituals are sequences of intentional behavior designed to curate a feeling. Habits are sequences of automated behavior designed to conserve energy, as they allow us to move through the world without having to think about every single thing (how exhausting). In the context of persistent pain, we create conscious rituals and subconscious habits to protect ourselves from the pain. While both patterns of behavior have their place, I’ve found that intentional rituals often stay useful even when the pain is gone, while automated habits are, at best, no longer needed, and at worst, actually harmful.

Rituals are intentional

A ritual is “an act or series of acts regularly repeated in a set precise manner.” A ritual, different than a habit, connotes intention.

For example, those with children understand the importance of creating a very systematic bedtime ritual to create an easy domino effect that, if successful, ends with a soundly sleeping child. Tennis players often have pre-serve rituals involving a variety of intentional movements and fidgets designed to prepare their minds for the pressure of the moment.

People also form rituals around persistent pain.

Eileen has low back pain that’s particularly tight in the mornings.  She wakes up and hugs one knee at a time into her chest while still in bed.  As she makes her way to the side of the bed, a 20-minute routine of twists, forward bends, and cat/cows ensues.  She does it the exact same way, every single morning.   This is a ritual for Eileen because it’s intentional. She’s created this routine and chosen these exercises on purpose in order to ease her back stiffness and make the rest of the morning a little easier.  Sherry has a mid-night ritual when she can’t sleep due to her knee arthritis. She gets up, takes a walk around her bedroom, spreads Voltarin on both her knees, takes two Tylenol, self-massages the muscles around her knees, and gets back into bed.

These are productive routines that were created intentionally and are performed intentionally. They help alleviate the pain and curate a feeling of psychological groundedness in the midst of discomfort.

Habits are automated

William James defined a habit as “a routine, behavior, or even cognitive process that starts spontaneously but is repeated automatically as a result of prior experience.” We’re creatures of habit. We form habits around almost everything we do that occurs on a regular basis. Habits form subconsciously and become so automated that we don’t even realize we’re doing them. For example, most of us have habits around getting up in the morning, meal times (like lunch breaks at work or dinner prep), workouts, or packing for trips. Some people have a series of facial movements or body fidgets when expressing particular feelings. Have you ever thought about the way you put on your clothes?  I guarantee you put on your shirt, pants, socks, and shoes the exact same way every day without realizing you’re doing it.

And, we all form habits around persistent pain.

Frank has wrist and arm pain from stressful hours at a computer. Every time he hangs on the rings or bears weight into his hands on the floor, he shakes out his wrist and elbow a few times, both before and after the exercise. He’s subconsciously trying to alleviate the pain. Here’s a personal example. I have pain in my left shoulder that’s triggered by hanging exercises, like pull-ups.  Every time I finish an exercise set, I slowly descend from the bar, swing my left arm backwards two times, grab the top of my shoulder with my right hand, and then half-swing it forward two times.  It’s a total habit.  I do the exact same thing every time, but I don’t do it intentionally.  It’s an automated reaction to quickly alleviate the discomfort I feel after hanging.

When pain has subsided . . .

But what happens when the pain is gone, or less than it has been? Are the behaviors still useful? Does it even matter?

Sometimes, nothing needs to change.

Eileen’s morning stretch ritual is a great thing for her to keep doing, even on mornings when she’s not experiencing back pain.  She’s alleviating other stiffness in her joints and spending a few moments in touch with her body before she starts her day.  (I also happen to know that she really enjoys her morning stretches — all the more reason to keep them). Another example: my cousin shared a story about his shoulder bothering him for several months last winter.  He would have to put on his jackets with his “good” arm first which was difficult.  After a while, he got used to it — so used to it that even after the pain went away, he still put on his jacket the same way.  I might say this is a positive extension of a ritual.  Why not be ambidextrous with jacket donning? He now has a larger mobility repertoire in his non-dominant shoulder.

But oftentimes, particularly with habits, the behavior is no longer useful and may even be harmful.

Derek, has persistent low back pain that changes in severity.  He recently experienced a stretch of feeling good and was able to do weighted squats.  I watched him do his first set, and this is how it went:  at the beginning of each rep, he held his breath.  He gripped the weight intensely as if he wanted to squeeze it between his hands. He made his way down into the squat as if he was fighting gravity (on the way down).  He then pushed himself up to standing as if he was squatting 3 times the weight he was holding. 

When he finished, I asked, “Are you in pain while doing those?”
He said, “No, that felt good!” 
“Well, for the next set, could you make it look like it feels good?”
He was confused. 
I told him how he was squatting, and he hadn’t even noticed.  After his next set, with flowing breath, a loose grip, and an easeful looking squat, he said, “That felt so much easier.”  

Daniel also has low back pain that is mostly well managed, although it’s been a long road for him.  He can now deadlift two-thirds of his bodyweight, 100 pounds.  Yet, when he picked up a 15-pound dumbbell off the floor to put it away, he held his breath, braced one arm on his thigh, and awkwardly squatted down with his chest upright. 

I asked him, “Were you in pain while picking up the dumbbell?”
He said, “Well, I always feel a little something in the same spot when I bend forward.”
I pointed out his strategy for picking the weight off the floor.
“Oh, I don’t even realize I’m doing that,” he said surprised. 
“Do those strategies actually lessen the pain?”
He tried again without the habitual routine to test it out.
“No! It feels exactly the same.”

Both Derek and Daniel’s habits were completely automatic, conditioned after years of pain, and were absolutely useful at one point. But now, since their pain experiences have changed, the amount of tension being held during their movements is entirely counterproductive. Not only does it make the movement harder, but it creates patterns of compensatory tension that are no longer necessary and will eventually have other downstream effects on how they use their bodies. 

Then there are the seemingly innocuous pain habits. Like my left shoulder thing.  A couple of weeks ago, I did some pull-ups, had almost no shoulder pain, and I still did my entire shoulder ritual.  I only noticed it after the second set, and I thought, “I don’t need to shake it out anymore.”  While the habit has no negative compensatory effects, it does have a psychological effect.  My habit reinforces the idea that I have left shoulder pain that occurs during hanging exercises.  It’s reiterating a belief in my brain that’s no longer true, or at least not true today. 

Examine the habit

Like any habit, when examined, we have the opportunity to decide if it’s helpful or not. The new awareness gives us agency to make some changes. Breaking these habits when they’re not needed, even if it’s temporary, reminds us that pain is almost never constant. There are always moments of relief — if not complete, then at least of reduced intensity.  When we disrupt the automation, we create resistance to pain stories becoming part of how we define ourselves. 

What routine behaviors do you perform around your body?  Are some of them created to alleviate pain?  Are they rituals or habits? What stories do they tell about yourself?  Are they still useful, or could some be changed to better serve how you’re feeling now?