The Two Arrows: How to Minimize Pain-Related Suffering

Pain is one thing. Suffering related to the pain is another. We often do not have total control over our pain, but we can learn to have more control over what grows around our pain:

The stories we tell ourselves about our pain, and the ways that our pain impacts the rhythms of our life.

Buddhist philosophy often refers to two arrows. Imagine a person in the forest gets struck in the arm by an arrow, and pain results. That is the first arrow. Then, the person begins to think… “What’s going to happen? Am I going to get an infection? Am I going to lose my arm? How will I be able to work? What’s going to happen to my family? Who is going to support them?” That is the second arrow.

The first arrow is the pain itself- the event and the raw sensations of the pain. The second arrow is what our mind does in reaction to the event. Our mind assigns meaning to the pain, creates a narrative, compares our pain to our past pain and our expectations of future pain, emotions ensue, and suffering results.

The first arrow we generally cannot control. The second arrow we can. 

Beware of the second arrow. The second arrow often grows bigger than the first. This second arrow is what contributes to prolonged suffering, unhelpful beliefs about our pain, and perhaps withdrawal from our lives, our loved ones, and our loved activities.

Tendency towards a second arrow of suffering could be considered a habit. How do we become more aware of and break our unwanted habits? Check out our past blog post, “Befriending Unwanted Habits” for more information.

Becoming aware of the two arrows is the key to minimizing the impact of the second arrow. This can apply to physical pain, but also any other event that triggers anxiety or other negative emotions.

Try this as an example. Consider an event that brings about distressing feelings, be it physical pain, or emotional pain such as anxiety, fear, sadness, or frustration. Perhaps this is an event that happened recently. Try to identify the first arrow, and then identify the second arrow. What are you telling yourself that is creating the second arrow?

For instance: “Today, I spent a long time gardening. Now my back hurts. What did I do wrong? Is there something damaged in my spine? Perhaps I need to get imaging. What does this mean for my future? Should I stop gardening? Is there something wrong with me?”

1. Identify the arrows

Can you identify what the two arrows are?

→The first arrow: Temporary sensations of discomfort experienced in the low back.

⇉The second arrow: All of the thinking that happened afterwards. Self-blame. Catastrophization and medicalization of the pain. “Predicting” the future. Assigning meaning to the pain without evidence. Consideration of avoidant behavior.

The second arrow makes the pain worse, and can create a feedback loop that contributes to a chronic pain pattern. Once we can start identifying the first arrow and distinguishing it from the second arrow, we can question the second arrow or let go of it to minimize suffering

2. Create a new response

After identifying the two arrows, notice if there is resistance to letting go of the second arrow. Where does that resistance come from? What is the harm in letting it go? 

Now, create a new response. Letting go of the second arrow, let’s pay attention to the first arrow. The intention is to accept the first arrow, and then practice self-kindness

Acceptance: Acknowledge and accept what is happening right now. Consider the mantra “This belongs too.”

Self-compassion: Then practice saying something kind to yourself. Imagine the first arrow happened to someone that you dearly love. A partner, a child, etc. What would you say to them if the first arrow were to happen to them?

Let’s relate this to the above example-

→The first arrow: Sensations of discomfort experienced in the low back.

♥New response: “This too. These sensations belong, they are what I am experiencing right now, and they will pass. I am strong, resilient, and have the tools that I need to get through this. Perhaps next time I will try some movements to warm up my body before gardening, and take breaks when my body begins to request them. ”

The quest to become pain-free is fruitless, because pain is an inevitable part of life. The first arrow will come. The quest to minimize suffering related to pain is realistic and achievable, and starts with becoming aware of the second arrow, and practicing self-compassion and acceptance whenever it arises. 

Summary of Key Points

• Two metaphoric “arrows” can exist relative to our pain experience. The first is the initial event and raw sensations of pain. The second is our reaction- our thinking and behavioral changes relative to the first arrow.

• First arrow = pain. Second arrow = suffering

• Distinguish between the two arrows in your own life, and change your response to the first arrow to minimize the impact of the second.

• To the first arrow: Develop any mantra that communicates self-compassion and acceptance. “This belongs too.” “I am safe.”

• Feel how changing the response to the first arrow has the potential to minimize pain-related suffering

Written by Jacob Tyson, DPT - Physical Therapist, Yoga Instructor and The Wellness Station Team

References:

1. https://tend.health/wp-content/uploads/2020/07/Two-Arrows.jpg

2. https://monarchwellness.com/wp-content/uploads/2020/08/pain.jpg

3. https://images.squarespace-cdn.com/content/v1/56e8ba83b09f95153203dc05/1463450760182-MWE6SFO6NIE3XKUQPRIF/self-compassion.jpg

4. https://dbtforlife.com/portfolio/dbt-group-notes-the-two-arrows-of-pain-and-suffering/#:~:text=And%20the%20Buddha%20says%2C%20%E2%80%9Cbe,inevitable%2C%20we%20all%20experience%20that.

Overdoing: To Do or Not To Do?

We live in a culture that is “go go go”, where we prioritize doing far more than not doing. Many of us juggle excessive work hours, family and household responsibilities, hobbies, fitness and wellness practice, social lives, errands, appointments, and more. We are often left with little to no down time, and when we do have this down time, we may spend it in ways that are less than ideal for restoring balance and peace back into our lives. This constant rush can be stressful and taxing on our bodies and minds, and due to time constraints we begin to have to pick and choose what we do. Self-care and sleep may be underprioritized, setting us up for burnout.

Think about yourself as a tea kettle: a 100% full tea kettle means you are in a state of optimal health, energy, comfort, peace, happiness, and overall well-being. The less tea you have in the kettle, the less bandwidth you have, which can manifest in irritability, exhaustion, reduced performance, as well as mental and physical health challenges if this continues over time.

If our goal with the “go go go” mentality is to achieve and succeed, but this mentality actually can set us up for failure over the long term, isn’t this entirely counter productive?

Think about what sources in your life are draining your tea kettle, and what sources are helping to fill up your kettle. Consider both external and internal factors. External may be people, situations, and activities, whereas internal may be thoughts, beliefs, behaviors, emotional reactivity, and movement patterns. What changes can you make in your life to ensure you have a full kettle? After all, an empty kettle serves no one!

Written by Jacob Tyson, DPT - Physical Therapist, Yoga Instructor and The Wellness Station Team

Does How You Think About Your Pain Affect Your Pain?

Low back pain (LBP) is extremely common, and is globally ranked as the leading cause of disability in adults (1). LBP is often a source of confusion for healthcare practitioners and patients alike. Where is the pain coming from? Is there a serious issue that needs to be addressed? Fortunately, bouts of pain often resolve on their own with time and appropriate behavioral responses, and the majority of time do not represent a serious underlying pathology. However, too often back pain becomes a chronic problem that begins to impart major impacts on one’s comfort, quality of life, and mobility.

Chronic LBP should be investigated through a biopsychosocial lens, as it is a multifactorial issue that cannot be reduced to one cause. (See our previous blog, A Holistic Approach to Pain Science) There are many factors that can influence the cycle of chronic pain, and among them are cognitive factors- how we think about the pain. How we think about our pain affects how we react and respond to the pain, both on a physiological and a behavioral level. The meaning we assign to our pain can either act as fuel to the fire of chronic pain, or water to dampen its rage.

A danger alarm gone awry

Oftentimes, when it comes to chronic LBP, the bark is worse than the bite. Pain can be considered as a “danger” signal from our nervous system that is indicative of a threat to our safety. However, when pain becomes chronic, part of the problem is in the sensitivity of the danger alarm itself, rather than only issues in the tissues. In chronic pain, learning has time to occur, and this learning is not always helpful. The nervous system begins to amplify pain signals associated with certain activities, and we begin to avoid certain activities, thereby weakening or changing the physical structures that must be used during these activities, creating a negative feedback loop that is consistent with disabling chronic LBP (2).

Consider a home smoke detector.  Can you recall the last time you were cooking, and perhaps had the heat just a little too high for a little too long? Tendrils of smoke begin to float up from the pan, and the next thing you know, the smoke alarm is blaring at full blast, causing you to drop everything, turn off the stove, turn on the fan, open the windows, and apologize to your neighbors. While house fires exist and are a huge threat, there was no fire in this case, and the smoke alarm might have caused more of an inconvenience than the smoke itself. Now, imagine that each time this happened, the “sensitivity” dial of the smoke detector turned up just a little bit, the volume of the alarm got a little louder, or perhaps the detector itself somehow started getting closer and closer to the stove. These changes would be maladaptive, and would lead to more situations in which your eardrums get pierced, stress hormones flood your system, and your neighbors start to question your sanity. You might even begin to avoid cooking. Or perhaps you take a more active approach and call a mechanic to help fix some of the issues you are having with the detector. 

Cycles of chronic pain can behave in a similar way. Your brain’s pain “alarm” can change overtime, becoming hypersensitive to lower levels of pain input (known as hyperalgesia), or respond by generating pain in situations where normally there would not be pain (known as allodynia). This nervous system plasticity that occurs with chronic pain is known as central sensitization, which is a well-researched phenomenon within pain neuroscience (3). We know that the brain is plastic, and we can learn fear, amplified pain responses, and unhelpful appraisals of our pain. We can also unlearn these maladaptive changes, and begin to relearn safety, comfort, and control. 

Changing Your Response to Pain

Amplifications of this danger alarm can occur if we believe that our pain is indicative of severe threats. These beliefs can stem from previous encounters with health care providers, uninformed health messages from society (e.g. our spine is a weak, vulnerable structure), and can even root back to childhood and one’s parent’s responses to pain. If we believe that our pain is not within our control to change, it is more likely to persist.

Try to be with your pain, feeling into it at that exact moment. What is the little person in the control center (your nervous system) trying to communicate? Show your nervous system there is no danger by finding a comfortable, safe environment, slow down your breathing, and engage in some gentle movement of the tissues that are contributing to the distress. Comfort, joy, safety, and pleasure are the opposites of pain, fear, and danger. The sooner you can get yourself into this place, the more likely the smoke alarm will turn off and you will reestablish a state of tranquility. 

Asking For Help

In order to make significant, lasting changes to chronic pain, therapeutic interventions are required that we provide at the Wellness Station. A multifactorial, individualized approach is warranted in which bio, psycho, and social issues are addressed. We strive to provide informed care where we can see the intersection between mind and body, the psychological and the structural. Dysfunctional movement patterns are what we look for, and are reflective of protective tension, fear-avoidant behavior, and muscular weaknesses. These patterns may be detected in the way you walk, breathe, bend, reach, turn over in bed, and more. They can also be detected through passive movement, in which we as the therapist move you while you intend to stay relaxed and not help. Addressing these movement patterns are key to bridging the gap between issues in the mind and in the tissues, and will help you make lasting changes in your ability to change and respond to your cycles of pain. While pain is part of being human and it is not realistic to be “pain free”, we can move towards our pain being the occasional pebble thrown into a pond with quickly fading ripples, rather than constant boulders creating tidal waves.

Written by Jacob Tyson, DPT - Physical Therapist, Yoga Instructor and The Wellness Station Team

References:

1. Vos T, Flaxman AD, Naghavi M et al.. Years lived with disability (YLDs) for 1160 sequelae of 289 diseases and injuries 1990–2010: a systematic analysis for the Global Burden of Disease Study 2010. The Lancet. 2012;380:2163–2196. 

2. O'Sullivan PB, Caneiro JP, O'Keeffe M, Smith A, Dankaerts W, Fersum K, O'Sullivan K. Cognitive Functional Therapy: An Integrated Behavioral Approach for the Targeted Management of Disabling Low Back Pain. Phys Ther. 2018 May 1;98(5):408-423. doi: 10.1093/ptj/pzy022. Erratum in: Phys Ther. 2018 Oct 1;98(10):903. PMID: 29669082; PMCID: PMC6037069. 

3. Latremoliere A, Woolf CJ. Central sensitization: a generator of pain hypersensitivity by central neural plasticity. J Pain. 2009 Sep;10(9):895-926. doi: 10.1016/j.jpain.2009.06.012. PMID: 19712899; PMCID: PMC2750819.

Images:

1. https://www.google.com/url?sa=i&url=https%3A%2F%2Fonlinelibrary.wiley.com%2Fdoi%2F10.1111%2Fjabr.12125&psig=AOvVaw1JHcqoPV34D_evHNqFIGOP&ust=1676907126933000&source=images&cd=vfe&ved=0CA8QjRxqFwoTCNCv9P7zof0CFQAAAAAdAAAAABA8 

2. https://www.google.com/search?rlz=1C9BKJA_enUS933US933&hl=en-US&sxsrf=AJOqlzWV_WK2FOcZC4qGZmRvZWSM8YYdWw:1676301748365&q=danger+alarm&tbm=isch&sa=X&ved=2ahUKEwivlf3R5pL9AhUcGFkFHQDBDmIQ0pQJegQIHhAB&biw=1366&bih=905&dpr=2#imgrc=AwpaQLmgKUDIqM 

3. https://encrypted-tbn0.gstatic.com/images?q=tbn:ANd9GcQBzpLWrips6ax-khNB59gPoCtJ8A7E4qshPw&usqp=CAU 

4. https://www.google.com/search?q=a+pebble+in+the+pond+with+ripples&rlz=1C9BKJA_enUS933US933&oq=a+pebble+in+the+pond+with+ripples&aqs=chrome..69i57j0i512l3j46i512l2j0i512j46i512j0i512j46i512.3906j0j4&hl=en-US&sourceid=chrome-mobile&ie=UTF-8#imgrc=1JB3ecM7OTxY7M 

Chaos Vs. Rigidity: Finding Your Balance

All of us live our lives on a spectrum between chaos and rigidity. Some of us tend to live more in a state of chaos and constant change, while others tend to live with more rigidity and stagnation. If our life is overly chaotic, we may live in a constant state of fear, anxiety, hyperactivity, and reactivity. On the other hand, if we are too far on the rigid end of the spectrum, we may become inflexible, resistant to helpful changes, and even close-minded. We might have certain contexts within our lives that are towards one extreme or the other- chaos in our work life, rigidity in our home life, or vice versa. Perhaps we subconsciously bring structure and rigidity into one aspect of our lives, such as our fitness routine, in order to balance the chaos and unpredictability within other aspects of our life. 

Daniel Siegel, M.D., described this spectrum in his book Whole-Brain Child. Because living on either end of the spectrum can be problematic, it is important to find integration, or a harmonious place somewhere in between rigidity and chaos. This finding of balance can be described by considering floating down a river in a canoe. On one side of the river, there is no flow, only still stagnant water. This side represents rigidity- it is safe and predictable, but unfulfilling and devoid of energy. On the other side is white rapids, rocks, and dangerous currents. This side represents chaos, overwhelm, constant change and even danger. In this extreme, we can lose our footing and get lost without any sense of control. A good place to be is the center of the river. This area is a system that has flow and energy, while still allowing us to maintain a sense of control. This allows us to explore, experience new things, learn and grow. How can we find this in our lives?

It is important for anyone to practice self-study, which in yogic philosophy is known as “svadhyaya” (sva meaning “own” or “self”, adhyaya meaning “lesson” or “study”). Can you feel when you are moving more towards a state of chaos, or stagnating into rigidity and mindless repetition? Our emotional state can be an excellent barometer of where we are at. In the middle of the two extremes we find a state of flow, in which we experience the most joy, discovery, and creativity. We should all seek to build a resilient self in which we are strong and stable, but also adaptable, flexible, and open to positive change. 

Our self-care and movement practices are excellent strategies to direct ourselves towards this state of balance. The low hanging fruit is… are we taking care of ourselves? Are we sufficient in sleep, nutrition, hydration, movement, relaxation, and social connection? What are we doing a little too much of, and what are we doing not enough of? Within the context of our movement practice, we can find even greater finesse.

Consider the following: 

During many functional movements, we have to find a balance between mobility and stability, which can be likened to chaos and rigidity, respectively. Our hips are essential for providing mobility (ability to move in all directions) and also stability (ability to maintain or control joint position). If our hip has too much mobility and not enough stability, our movement would be out of control (chaos). If we have too much stability and not enough mobility, our movement would be stiff and inefficient (rigidity). The middle of the river is an excellent place to be, which allows us to move with both fluidity and strength. 

Consider the examples of unilateral movements in our previous blog. The single leg stand to reverse lunge is an example of how the weight-bearing leg must stabilize, but also allow for controlled movement to occur. A similar phenomenon happens every time we walk, go up stairs, and even kick a ball. Our weight-bearing leg must provide stability so we do not fall or strain our tissues, while also allowing our pelvis to move relative to our thigh bone, so we can move and participate in life. Consider this “movement snack”. Can you feel how the weight-bearing leg is controlling the movement with a balance between mobility and stability? When the stabilizing leg is well organized for mobility, that is referred to as skilled movement, and is a necessary component for moving with efficiency and ease. 

At the Wellness Station, we will help you become more in tune with your natural rhythms, and provide opportunities to help you find your balance between chaos and rigidity. 

Written by Jacob Tyson, DPT - Physical Therapist, Yoga Instructor and The Wellness Station Team

References:

1. https://www.mindfulwisdom.ca/blog/2021/8/26/finding-flow-between-chaos-and-rigidity 

2. https://rhettsmith.com/2013/07/brain-integration-finding-the-balance-between-chaos-and-rigidity/

3. https://www.ekhartyoga.com/articles/philosophy/the-niyamas-svadhyaya-or-self-study 

The Power of Belief: Saying No to Nocebo

As the fields of cognitive science, psychology, and new biology continue to develop, the scientific community is beginning to understand more about just how powerful our beliefs are. The way we think affects our behaviors, our mood, our perceptions, and even the way we move and experience pain. Most of us have heard of the placebo effect- this is a beneficial effect that occurs after a particular stimulus that cannot be directly attributed to the stimulus, but rather to the belief that the stimulus had a positive effect. This occurs due to both expectancy and conditioning. We expect something to happen, perhaps because it has happened for us in the past, or because someone has planted the idea into our heads that something will happen. This expectation has a neurophysiological effect, which activates particular circuits in the brain that will actually contribute to the expected effect.

The specific neurophysiological mechanisms of how thoughts can impact our physiology are not fully understood, partially because our understanding of consciousness is still extremely limited. However, it is clear that our thinking can impact our body. If you have any doubt about how thoughts can impact our physiology, consider this thought experiment. Does imagining yourself biting into a lemon trigger any kind of physical reaction? Why might that be? 

While the placebo effect can certainly be used for good, we must be wary of its dark cousin, the nocebo effect. The opposite of a placebo, nocebo is a stimulus that creates negative expectations that result in negative health outcomes.1 This might be done intentionally, but more often it is an unintentional adverse effect commonly experienced through interactions with healthcare providers. Ever have an experience in receiving imaging (an X-ray, MRI, etc.), and the provider makes a comment such as … “Wow, no wonder you have pain! Your spine is a mess!” Or another favorite, “Geez, your knee is bone-on-bone! I’m surprised you can still walk! Time for a knee replacement…”. After hearing this information, the nocebo effect can occur, and one may actually begin to experience more pain. It can also impact behavior- perhaps by believing that one’s knee is bone on bone and walking should be difficult, one might stop walking as much, or may begin to compensate while walking. This can lead to actual tissue changes such as deconditioning, excessive tension in various muscles, and more. The negative belief that resulted from imaging and the subsequent conversation with the doctor ended up resulting in a greater experience of pain as well as impaired function. 

How can we use the power of belief to support our health and function? For starters, question negative beliefs, whether these are personal beliefs or from someone else. Anyone who receives imaging should be well informed that structural abnormalities found on imaging do not correlate with pain or function. While people with low back pain may have some abnormal findings on their MRIs, so do asymptomatic people.2 If 100 random people were taken off the streets and underwent imaging, there would be plenty of people with abnormal results with no pain, as well as people with crystal clear imaging who are in severe pain. If people attach too much value to their imaging results, they give up on their belief in themselves to get better. “I have stenosis and arthritis in the spine… physical therapy certainly can’t fix that!” Someone who maintains this belief is deciding that their situation is not in their control, and they are less likely to believe that they will get better. They will be less likely to participate in therapy, more likely to experience pain and dysfunction, and may seek more aggressive treatment options. 

In addition to questioning negative beliefs, create your own positive beliefs! Evidence shows that the use of positive affirmations can lead to improved performance, well-being, and more.3 The use of positive affirmations is a prime example of using the placebo effect to trigger positive health outcomes. By changing our beliefs about ourselves, we can change our behavior and function. This can be very helpful for those of us experiencing pain. A simple exercise could be creating several positive affirmations to repeat to yourself morning, afternoon, and night. The affirmations could be phrases that you don’t currently believe, but what you wish your life was more like. For example, consider the following positive affirmation: “I am strong. I am resilient. I am at peace with my body.” For someone experiencing chronic pain, it can be very difficult to experience peace with one’s body. However, having a sense of peace with oneself can have extremely beneficial effects, including downregulating tension in the body and decreasing the affective components of pain. As we continue to repeat these positive affirmations, they will gradually shift our mindset, beliefs, and experience of life. Ever try to force a smile while upset? Similar to the use of positive affirmations, simply smiling will bring about positive changes in mood, as our brain associates the mechanical act of smiling with happiness.

1. https://journals.lww.com/painrpts/fulltext/2017/03000/nocebo_and_pain__an_overview_of_the.2.aspx

   2. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6118107/ 
   

   3. https://www.mindtools.com/pages/article/affirmations.htm

Written by Jacob Tyson, DPT - Physical Therapist, Yoga Instructor and The Wellness Station Team