What is Normal?
I posted this question last week to social media, and asked several patients. I got some great responses, so thank you to everyone who replied. These are some of the responses I recieved:
“Normal for me is being like I was before tearing the cartilage in my shoulder. Not having to think about every movement before I do it.”
“Normal feels like I have strength.”
“It feels effortless.”
“Normal is the ability to comfortably do the things one enjoys.”
“I would feel happy because I play and cuddle with my grandkids.”
“Normal feels like my back is stable.”
I think that all of these are great responses. Normal is complicated. It isn’t just physical, but also mental and emotional. Below is a list of the things that I think normal is. This list certainly isn’t all inclusive, but is everything I could think of.
Don’t have to think and plan movement
Can do multiple things at once
I can picture something, and then just do it
Prepared for anything
Fast and Agile
Supported and Loved
For many people who suffer from chronic pain, it is easy to forget what normal feels like. As a result, “normal” becomes painful, anxious, stiff, weak, sad, and unable to move. When this is the case, pain becomes a virus, breeding more pain, from pain.
Joe has had low back pain for 3 years. He has had various tests, surgery, months of physical therapy, but his pain remains unchanged. When Joe tries to stand up from a chair he knows that it will hurt, so he often feels anxious or worried about having to move. As a result, he tries to use his muscles to protect his back, and moves slowly and apprehensively. When Joe stands his back hurts severely, and he looks stiff and immobile. It takes him about 30 seconds to stand from a sitting position, and then he has to wait at least a minute before he is ready to try and walk.
With the above example, I think it would be beneficial to talk to Joe about what is normal as related to his back and standing from a chair. What normal should be is:
Joe is going to stand up from a chair. Because everything is normal and he does not have pain he is able to do this without much forethought or planning. Joe quickly slides forward in the chair, bends his knees and begins to stand. He feels a slight forward lean of his trunk and the muscles of his abdomen and back contracting for balance and stability. He also feels the muscles of his butt and thighs working to push him upward. He completes the motion in less than a second, and is balanced and ready to move. Throughout the movement he feels balanced, strong and the movement is smooth and fast.
I think it is important for Joe to mentally work through the second scenario in his head for several reasons.
- It will help him remember what normal is.
- It will give him a better idea of what he should be feeling and how he should be performing the movement.
- Movement planning is important. So if Joe knows that standing from a chair is painful, his muscles may brace and be tight (not in a good way), he will do the movement stiff and slow (instead of smooth and fast), he will expend large amounts energy doing this one movement, and he will likely lose balance and have difficulty getting out of the chair due to apprehension.
- If Joe starts planning for the normal pain free experience, then he should be less stiff, apprehensive and slow. Ultimately, this movement will be more efficient, less painful, and probably less painful than the movement in which he plans for the pain.
- Because of special circuitry in the brain, when we see or imagine movement, the same parts of the brain are working as if we are actually doing the movement. As a result the circuitry which may be sensitized in Joe’s system will be desensitized with mental practice of the movement.
Joe may still have some pain with movement after normal planning, but I find that patients improve quickly once they start planning to move normally, rather than moving to anticipate pain. Those who anticipate pain will tend move stiffly and with abnormal movement patterns, while those who anticipate normal will be more fluid, smooth and flexible with movement.
We will soon post a video to our YouTube Channel that follows up on this a bit. Thank you to everyone for your responses, and remember to think normal and keep moving.