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Wrestling with Your Client’s Brain; the Source of Your Frustration


Do you often feel like you care more about your clients’ health than they do?

Understanding the importance of exercise and finding the motivation to do so – what some researchers term “exercise salience” - is one of the most important topics for health and fitness professionals. For your clients, it determines their persistence and their results. For you, it often determines the quality of your day-to-day interactions and work satisfaction, as well as your income.

One of the most common frustrations voiced among caring, educated health and fitness pros is, “Why do I care more about my client’s health than they do?" Sometimes it feels like pulling teeth to get them to show up for something actually designed to make their life better!”

While the solution to this is multifaceted, modern pain neuroscience can help explain some of the unconscious (lizard brain) reasons that your clients may struggle with compliance and offer some reasonable solutions. For all of this to make sense, we need to establish some basics before we get to the meat of the article, so keep reading!

Learning Objectives:

  1. Become familiar with emerging pain science.
  2. Develop a clear understanding of the Threat Neuromatrix.
  3. Recognize how fatigue and stress have an impact on “exercise salience.”
  4. Understand the role of training stressors on inflammation and its interaction with the desire to train.
  5. Learn fundamental training guidelines that will allow you modulate your client’s training intensity and emphasize recovery.

Pain Science 101

While it may seem counterintuitive at first, modern pain science has reached one firm conclusion:

The reason you have pain is because you have a brain!

This may not sound earth shattering on first hearing but this is a revolutionary concept in many ways. Most of us were brought up with a cultural understanding of pain that originated in the mid 1600’s. Here’s a picture from 1664 that is known as Descartes Reflex. Rene Descartes developed what has become known as the Cartesian Model of Pain – and for the time it was brilliant! It basically stated that pain was a result of a stimulus created by the injured or painful tissues that was then sent to the brain. It was a pure Cause and Effect approach and it was a huge improvement over earlier theories of pain. However, it was also massively incorrect on many levels. Unfortunately, a great many health and fitness professionals and consumers still believe in this model (Louw & Puentedura, 2013).

Diagram 1

If you fast-forward 300 years you will encounter the beginning of the revolution in pain science. In 1965, Melzack and Wall published what they termed the Gate Control Theory of Pain because they knew that the Cartesian Model was incorrect. The pre-eminent message of the Gate Control Theory was that pain can increase due to actual or potential tissue damage. Think about that concept – that we can hurt because we fear injury – not because we are actually injured. This was a world-altering theory that started a long, arduous road that leads us to the present time.

While Melzack was initially satisfied with the Gate Control Theory, he also recognized that it did not provide an explanation for many types of pain. This led him to continue his research until he published in 2001 what he termed the Neuromatrix of Pain – which he further updated in 2013 in conjunction with Joel Katz. The Neuromatrix Model of Pain is as inclusive as possible of every concept found in current pain research. It basically is a model that recognizes that pain has multiple inputs and multiple outputs and that it is a far more complex sensation than either the Cartesian Model of the Gate Control Theory could adequately explain.

Below is an updated graphic, view a larger version here (Melzack & Katz, 2013).

Diagram 2

If you take a close look a the Neuromatrix Model of Pain what you will see is that your experience of pain – meaning whether you will have it or not, how intense it will be and how long it will last – is composed of a huge number of things. If you look at the left side of the graph you will see INPUTS to the brain like:

If you then switch your focus to the right side you will see PROTECTIVE OUTPUTS from the brain to the body, including:

From the Pain Neuromatrix Model to the Threat Neuromatrix

Almost 10 years ago, in attempting to find a more unified view of the Pain Neuromatrix and what we experienced working with athletes, Z-Health began teaching about what we termed the Threat Neuromatrix. The concept is extremely similar to the Pain Neuromatrix but with a slightly different focus. Based on theories of fear processing first explained by Dr. Joseph LeDoux, our concept is that there is a survival-oriented suprasystem in the brain that evaluates all incoming input and runs that input through a "threat filter." When a sufficient level of threat arises from either the external or internal environment, the brain produces a protective output of some kind – just as described in the Pain Neuromatrix.

We explain it very simply to our clients using what we call the Threat Bucket analogy:

Diagram 3

We tell them that every aspect of their life has the potential to either add or subtract some level of threat/stress to their bucket. Everything matters: sleep, nutrition, work and home relationships, movement skills, balance competency, visual skills, as well as their education and beliefs about their body. If you look at the threat bucket picture you can see that if we do enough things well it keeps the threats below an output level. But, as we accumulate more and more threats without taking an appropriate action to reduce them we get an output – either a conscious one like pain, or an unconscious one like lack of motivation for moving (Nunn et al., 2010).

If you read and really understood that last sentence you can see that the type of output created may be the key to understanding why it can be like pulling teeth to keep your clients showing up!

Watch the below video for an even more detailed explanation of how your client’s inflammation and “threat bucket” can negatively affect compliance:

Exercise, Stress and Inflammation

Generally speaking, health and fitness professionals consider exercise “healthy” because we’ve been told our whole lives that it is good for us. And, there are thousands of studies that back this up. However, as the health and fitness professions evolve, it becomes ever more important to have a slightly broader perspective.

Simply put, exercise is a stress, or to use our above model – a threat. That doesn’t make it bad, but it does mean that exercise, in concert with all of your clients’ other threats, has the potential to drive them closer to creating a protective output or give them more free space in their threat bucket.

Why?

Research has consistently shown that exercise creates an inflammatory response in the body like other forms of physical and emotional stressors (Barr, Barbe, & Clark, 2004).

Generally speaking, in an acute time frame this is a very good thing. As we stress/threaten the body through exercise and microdamage, an inflammatory response occurs that should heal the damage (aka adaptation) and prepare us for the next bout of training. However, the immune system is a delicately balanced system and exercise that is too stressful/threatening can, in conjunction with other threats, push clients into a vicious cycle of excessive inflammation.

Inflammation and Exercise Salience

In 2010, a fascinating study was published related to the impact of inflammation on the motivation and drive for physical activity. In short, the article summarized a growing body of evidence that long-term, low-grade inflammation can have significant impact on our “choices” related to physical activity. The authors state,

“The propensity to undertake voluntary exercise or indulge in spontaneous physical exercise, which might be termed "exercise salience", is drawing increased scientific attention. Despite its genetic aspects, this complex behaviour is clearly modulated by the environment and influenced by physiological states. Inflammation is often overlooked as one of these conditions even though it is known to induce a state of reduced mobility. Chronic subclinical inflammation is associated with the metabolic syndrome; a largely lifestyle-induced disease which can lead to decreased exercise salience. The result is a vicious cycle that increases oxidative stress and reduces metabolic flexibility and perpetuates the disease state.” (Nunn et al., 2010).

Simply stated, as health and fitness professionals we have to recognize that the stress we create in our clients’ bodies must be looked at the in context of their overall threat load! If we push them into more inflammation than they can manage their brain will make exercise less and less important over time – which can lead them into a vicious downward spiral (Barr, Barbe, & Clark, 2004).

If you’ve been in the health and fitness world for any length of time, you know high-intensity training practices have become more popular over the last 15 years as clients want “more results for less time” in the gym. In some cases, this works! However, in many cases it doesn’t. High intensity training can push a client’s nervous system to the point that a “threat overdose” occurs in conjunction with their other stressors. When this happens, compliance drops because training sessions become a very low priority for clients – and often this will happen unconsciously because their brain is attempting to protect them!

OK, So What Now?

Here are a few excellent strategies based on research and experience that can make a huge difference for you and your clients:

  1. Collect Subjective Data Regularly – One of the most consistent ways to progress or regress a training program is simply to have good data available. Below is a simple survey that your clients should fill out daily for you. Click here if you would like to view a printable version. This is important because it lets you track changes in their body and serves as an educational platform to better help them understand the threat bucket (Buchheit, M. et al., 2013).

    Diagram 4
    How to use the WRT:
    • Possible scores range from 10 – 50. 10 representing the worst and 50 the best score.
    • Remember that this is a subjective measurement process so there is no normative data available indicating an ideal score.
    • Use the tracker as an individualized tracking tool that you correlate with what you see in training.
    • Some athletes/exercisers will always give themselves a high score despite what you see in training, and the reverse is also true.
    • As you collect and analyze data over time (usually 2-4 weeks) you will find a “sweet spot” at which the athlete/exerciser performs well or where you see performance degrade.
    • In general, we find that most athletes do relatively well in moderate-to-intense training with minimum scores of 33-35/50.
  2. Carefully Govern Training Intensity – Generally speaking high intensity training (Over 70% of maximal effort) for longer than 20-30 minutes can initiate a significant inflammatory cascade while training under the 70% intensity level can lower stress hormones. Keep your training sessions within those parameters and emphasize a great warm-up and cool down (Tiidus, 2008).
  3. Consider Other Threats – If you look at the information presented above, working with your clients on their nutrition, sleep, visual, vestibular and respiratory mechanics are all potential lifesavers in the threat world!
  4. Consider Going High Tech – If you are interested in collecting more objective data about your clients there is an increasing number of studies that indicate heart rate variability (HRV) testing in combination with the above-mentioned concepts can help successfully modulate training intensity. Here’s a great place to start reading if you’re interested in some amazing recent results in NCAA Division 1 Football: http://uknowledge.uky.edu/khp_etds/24/

Conclusion

If you want to create a major shift in your clients' attitude toward training that allows you to see them more often, with all of the benefits that entails for both of you, closely monitoring the amount of threat you are inducing is the key. Make this switch and you will see improved results in combination with clients who stop canceling last minute and request to train more often.

Good luck!

References:

Barr, A.E., Barbe, M.F., & Clark, B.D. (2004). Systemic inflammatory mediators contribute to widespread effects in work-related musculoskeletal disorders. Exercise and Sport Sciences Reviews, 32(4), 135–42.

Buchheit, M., Racinais, S., Bilsborough, J., Bourdon, P., Voss, S., Hocking, J., Cordy, J., Mendez-Villanueva, A., Coutts, A. (2013). Monitoring fitness, fatigue and running performance during a pre-season training camp in elite football players. J Sci Med Sport, 16:550–555.

Cooper, D., Nemet, D., Galassetti, P. (2004). Exercise, stress, and inflammation in the growing child: from the bench to the playground. Current Opinion in Pediatrics. June 2004 - Volume 16 - Issue 3 - pp 286-292.

Louw, A., & Puentedura, E. (2013). Therapeutic Neuroscience Education. International Spine and Pain Institute.

Melzack, R. and Katz, J. (2013). Pain. WIREs Cogn Sci, 4: 1–15. doi: 10.1002/wcs.1201

Nunn, et al. (2010). Inflammatory modulation of exercise salience: using hormesis to return to a healthy lifestyle. Nutrition & Metabolism 2010, 7:87.

Tiidus, P.M. (2008). Skeletal Muscle Damage and Repair. Champaign, IL: Human Kinetics.

Segerstrom, S.C., & Miller, G.E. (2004). Psychological stress and the human immune system: A meta-analytic study of 30 years of inquiry. Psychological Bulletin, 130(4), 601–30.