Don't Give Up Before Beginning

Athletes will know this feeling very well, but non-athletes will understand the feeling too.

Imagine being on a hockey team. You show up to the game and roughly half of your teammates are absent due to injury or personal matters. The remaining players are feeling sore and low-energy. The team that you play against today is top in the league. You don't really see much chance of anything going well here.

As a result, everyone who showed up does their part, fulfills their role, and goes through the motions, but no one's heart is really in it. They may not be trying all that hard. Everyone is suspecting a loss. And that's what eventually happens. The heart wasn't there.

Now imagine that you are that team of hockey players and that your opponent is your pain. You've shown up at the rehab clinic for treatment, but the pain has been so great, so persistent, and been bothering you for so long that you don't see much possibility of success. But you're there anyway.

It's very common for individuals who are seeking treatment for pain to mentally defeat themselves before the appointment even begins. It's not for a lack of conscious effort; you may be desperate and and craving pain relief, but past success has now just subconsciously instilled an expectation of failure. And unfortunately, having those low expectations will often create a similar reality.

Now, I'm not saying that everyone should just chin up, suck it up, and try harder. As I always say, "Just do it," is probably the lamest advice that any shoe company could possibly put out.

The message that I want to relay instead is that you, as the client, should try to be open and transparent with your experiences when you see the next therapist. Explain your experience with pain and with past practitioners. Help your therapist understand your goals, your expectations, and your hesitations. It's our job to not only treat with our hands, but to help create as positive of an expected outcome in your mind as possible in order to propel your recovery forward. And through careful education and goal setting, trust us, it is possible.

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Trust Your Body - The Bridge Between Recovery And Comfort

I had a client who I helped to rehab a dislocated shoulder. We got their shoulder strong again and returned its range of motion, and thereafter we went several months without seeing each other again.

Fast forward, and the client returned for a visit after reaggravating the old injury. Upon an update on the past few months, I found out that this client was still having a lot of hesitation, before that point, when it came to supporting weight through the shoulder with a hand on the floor.

To me, this highlighted the importance of making sure that rehab was carried forward beyond simply removing the pain and getting strength in each range of motion back.

Rehab is essentially relationship counselling between the brain and body.

This comes back to what I've talked about before regarding helping clients through avoidance habits. When the hesitation and lack of trust regarding certain movements is too great, it's easy to avoid anything resembling that movement to the point that we see a weakening in that joint's function again.

And with that lack of specific activity, the more likely it becomes to re-injure that joint as soon as you do anything resembling that activity again.

For this reason, as a client, we always recommend perseverance in the rehab program beyond the point where there's simply no more pain. As we return the strength and range of a joint, we then turn the exercise plan into something practical and reflecting the demands of your life and any physical activities that you do.

What's more, the sooner we can start the rehab process, the fewer avoidance habits you'll develop and the more easily we can transition to your life-specific reconditioning.

Rehab is essentially relationship counselling between the brain and body. Being strong is great, but if you can't build trust that your body can perform again, the chances are that it will struggle to ever do so.

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The Memory Of Pain

Remember that time, years ago, when you hurt your back while bending over?

Well, your back remembers it too.

You may have heard of the term "muscle memory" in the past. It's a loose term defining the body's ability to remember past motor patterns, often triggered subconsciously as soon as the right environment presents itself. For instance, someone may not have ridden  bike in 30 years, but as soon as they feel the seat, pedals, and handlebar, all the balance and coordination comes rushing back to them and off they go.

Now imagine if, instead of that feeling of the bike seat and pedals, the trigger you felt was bending forward. And instead of the ability to ride the bike, the signal that your brain digs out of storage is pain.

This is one of our BIG contributors to chronic pain. Very often, our past experiences of what caused pain in the first place, no matter how long ago, can amplify pain we feel in the future as a conditioned response. In the same way that Pavlov trained dogs to salivate at the ring of a bell, regardless of food actually being present, the nervous system can be trained to pump out pain signals, regardless of an appropriate trigger.

This concept is closely integrated with the one showing expectations of pain causing increased pain. In this example, your back is conditioned to have an exaggerated guarding response to bending forward. What's more, this bad habit is further encouraged by the fact that you've explicitly been avoiding flexion, essentially confirming your nervous system's irrational fear of the movement.

Hopefully, this helps to create an understanding of why pain can be persistent long after tissue has healed and appropriate triggers are no longer present. There are definitely subconscious and conscious factors at play here. (Along with the physical side, which, I'm not ignoring. Don't worry!)

With this being said, this is the reason why a lot of the rehab that I do with clients doesn't necessarily involve strengthening, but instead reteaching and reassuring them of movement and ranges that has been, inappropriately, acting as triggers. This goes for active and nonactive populations as well; it's incredible how many gym rats I need to teach how to round their backs again.

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Staying Involved - The Social Side Of Recovery

When pain or injury hits us, especially when it's severe, it's easy to become disconnected from the world around us.

An example might be of the elderly individual whose back pain has resulted in their inability to go out, see their friends or family, or be involved in their community anymore.

Another might be the athlete with the sprained ACL who hasn't been seen by any of the his friends on the team in months.

It could simply be the person who feels depressed in their month not getting to go to the gym while recovering from their muscle strain.

It's the reality; pain can often prevent us from remaining involved in the activity, communities, and social circles that make us part of who we are. And the tragedy is that this social isolation, as well as the often-prevailing depression and anxiety, are correlated closely to the increase of physical pain! Pain increases, depression worsens, pain increase further, and so on in an unfortunate cycle.

But it doesn't have to be this way! We tend to have an all-or-nothing approach to our activities and involvement, often writing our engagements altogether due to not being able to participate as fully as before. However, this is exactly what leads to that isolation!

Instead, it's crucial to keep individuals in pain involved in the world around them. Whether it's from pain, injury, or illness, we know that greater social support is strongly related to an increased chance of recovery.

With that being said, whether it's you, a friend, or family member, maintaining engagement in social circles is a major factor in recovery. If you're an athlete that sprained your knee, keep coming to practice and involving yourself as much as you can on the sideline. If you're missing out on hitting the trails with your running club, grab coffee with your fellow runners and stay up to date on their going-ons and lives. If your elderly mother hasn't been able to garden or walk with her neighbour, encourage her to have a friend or two to her own home for tea. There's always a way to modify the activity and environment to maintain one's place in the world outside.

Social isolation isn't fun. Add pain to the mix and it can become unbearable. Stay involved, call your friends, and engage in the world rather than let it pass by; you may find that it's what you need to propel yourself back to better health.

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If It Hurts, Don't Do It (Except Do It A Little)

Traditionally, we healthcare practitioners get used to telling clients that if something hurts, then don't do it. Seems pretty obvious.

Exhibit A

However, wait! We've talked about how avoidance of movement out of fear of pain may actually make the problem worse! Let's say that you're wishing to squat, but squatting hurts your hip. Telling you to not squat at all is likely to decondition you even further and prime the nervous system to expect pain when you do attempt the movement again. And thus, the movement does continue to hurt more and more when performed.

As we know, pain and the treatment for pain are primarily nervous system-driven. When certain movements hurt, yes, the tissue may be damaged in the case of acute injury, but the area has also become accustomed to having a lower load tolerance.

With that being said, if you've had long-term wrist pain when squeezing a fist, then retraining both strength and load tolerance will probably see you...squeezing your fist as an exercise. But maybe at 50% rather than 100%.

This is the basis of exercise rehab. The last thing that we therapists want to see is the complete cessation of any particular movements or exercises. Obviously, our job comes in when those movements need to be modified in order to reintroduce load within pain tolerance, and Athletic Therapists are the experts for recognizing when, where, and how those adjustments need to occur to get you better.

So no, when a movement hurts, it's not necessarily a call to stop that movement completely (unless it's absolutely something that the body isn't supposed to do, of course), but adjusting the method and volume of that movement is likely necessary. It's all about re-accustoming the body to the performance that we want it to do.

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Exercise And Why You Aren't Lazy

I found a great article regarding how laziness does not exist, and it applies beautifully to rehab and exercise.

"But I don't wannaaaa...."

Clients often come to their follow-up appointments with tails tucked after not doing their exercises. (And I'm speaking on doing them at all. The people who feel bad for only doing them every second day need to chin-up.)

A lot of therapists will put their hands on their hips and immediately scold their clients, citing their predicted inability to get better if they don't exercise and pushing them to just do it. But we know, but now, that this is an ineffective method, don't we?

I think I just heard Nike call their lawyers.

The psychologist who researched and wrote the above article boiled "laziness" down to two causes. One was anxiety regarding the task and a perception that the person's attempts would not be "good enough". (Fear of failure.) The other was confusion or lack of clarity on the first steps of the process.

Understanding this now, can you see why a stern "just do it" is the last thing you want to tell someone with either of these struggles? Instead, I find it to be a crucial exercise in empathy in order to help clients past their hurdles.

If a client can't foresee a positive outcome and doesn't believe that they can get better, regardless of their homeplan, then it takes a great deal of coaching in order to teach them how to perceive control over their condition. They need to know, deep down, that recovery is possible; not simply go through the motions of an appointment.

And as for the lack of clarity, any half-decent therapist should have the ability to educate and break down the pieces for their clients as needed.

Everyone has their own background. We prefer to see things as simple and black and white, but have you put yourself in someone else's shoes lately?

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When Loved Ones Are In Chronic Pain

We tend to think that pain only affects the individual feeling it, but it can be a difficult thing for the people around them to cope with as well. Educating and helping family or friends of someone with pain is incredibly important, however, as family support is shown to greatly increase the outcomes of pain patients.

If you have someone close to you in pain, this is likely going to be a very important resource for you. By managing your own energy and emotions, you can significantly help someone else manage their pain.

Understand That It's Not In Their Head

It needs to be remembered that chronic pain is neurally driven and not not necessarily require a structural cause. Some individuals may be told that their body's are not "worn down" enough or have anything wrong with them, despite being in pain, leading them to scrutiny for continuing to struggle.

Having anyone not believe that they're in pain can be a traumatizing thing, and the depression, anxiety, and stress are likely to cascade the situation and increase the discomfort they are in. Acknowledging your loved one's situation is the first step in helping them to get through it.

They Do Not Want To Be In Pain

Sometimes, a person might seemingly demonstrate a lack of desire to pursue recovery, leading to more accusations of, "You don't even want to get better!" But would you tell someone who's overweight or struggling with depression that they simply don't want to get healthy as well, though?

After living with chronic pain for an extended period of time, it's natural for individuals to begin to identify with it in order to help cope. When this happens, it becomes an inadvertent act to normalize how they feel and have trouble visualizing and looking ahead toward any type of recovery anymore. This does not mean that they have stopped caring about their health, though!

In these cases, support through motivation and reassurance that there is a positive outcome for them is vital. These individuals need to be reminded that there is still a possibility that they won't be in pain (or as much of it) again and that it is an attainable goal.

Communicate

Whether it be illness, pain, or any other crisis, frustrations are bound to go through the roof at some point. Even when understanding someone's situation, there will be times when enough just seems to be enough.

Remember the importance of communication when it comes to supporting someone in pain. Verbalize your own feelings before they boil over and encourage them to do the same. By doing so, you can help to make sure that the support be given and received does not diminish or become depreciated.

Keep Them Involved

Pain can be incredibly isolating, with removal from work and activities creating the feeling of one's life being shut down. Without finding a way to keep your loved one involved in the world around them, their ability to motivate themselves back toward recovery can quickly plummet.

I've mentioned before how I like to keep my rehab fun and applicable, not necessarily revolved around weights and reps. Even when not prescribed by a healthcare professional, if you can encourage someone to join you for walks, go to the park, spend time with the family, and more, then you're propelling both their physical and mental health recovery.

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The Rehab Schedule and Exercise Frequency

How often did your last therapist tell you to do your rehab exercises? Twice a week? Three times? Every day?

If you answered 'every day', then you're likely of the majority of individuals. There's a trend among health professionals to make this rule absolute. If you want to get better, then the more you adhere to your exercise plan, the fast the recovery will be. Makes sense!

However, how often do you see someone make a seven-day-per-week behaviour change in a snap simply because a medical professional told them to do so one time?

Sorry, what?

A lot of my clients are self-motivated fitness enthusiasts, so if I tell them to do their rehab exercises every single day, adherence is high! However, expecting perfect compliance is rare among most demographics. I'm not talking about unhealthy shlobs who are unused to taking care of their bodies at all. I'm talking about recreational athletes, weekend warriors, avid gardeners, blue-collar labourers, and more. Telling just about anyone to add a 20-minute routine to every single one of their days might not sound like a lot, but it can be quite the feat.

A lot of therapists are aware of this and will still stick to the "daily dose" model, however, figuring that clients will still do a lesser amount of exercise when prescribed the more. But is this an effective measure? Or does the higher expectation lead to a greater rate of failure? If a client feels guilty because they did less work then they were instructed to, this could lead to a quicker loss of motivation and eventual overall noncompliance.

For this reason, I find it important to get a thorough understanding of each of my clients' lifestyles, schedule, and inherent motivation. If I feel like someone is going to be perfectly happy to exercise as told every single day, then great! For most, however, setting high standards is an easy way to make clients feel disappointed. Instead, I tailor each plan to each individual, whether it's alternating exercises on each day, having them exercise every other day, or simply doing their rehab plans just as warm-ups for their activities and sports.

We're not sacrificing quality of the program by decreasing the frequency. We're ensuring overall success by helping to create gradual habits. Besides, just a couple days of exercise per week is enough to start providing beneficial effects for just a wide variety of physical ailments.

I'll say this again before Nike sues me: "Just do it" doesn't work.

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Joint Insecurity?

Disclaimer: This is purely a personal opinion post, not an accepted fact or opinion of the medical community.

"Your shoulder is unstable."

We've heard this one before. I've used it before, myself. When speaking on the "stability" of a joint, we're referring to the muscles, passive structures (ligaments) and neural systems that surround the joint to maintain its structure and integrity.

Stability can become compromised for a number of reasons, with muscular weakness, lack of proprioception, and physical tissue damage among them. In many cases, the instability is real. A previously-dislocated shoulder pops out again very easily with very little force. A post-ACL reconstruction patient experiences buckling and failure of the supporting muscles. A rolled ankle that has a much easier time of rolling again after the first injury.

But what about when this severe lack of integrity isn't present. What about the person who simply has an achey shoulder? "Multi-angular instability!" The client with low back pain? "Core instability!" Neck pain? "...Neck instability?"

It may seem like a trivial thing, but words have a lot of power, especially when used on individuals who may be in pain and coming to professionals for help. Using terminology that instills more fear about one's own condition can increase pain expectation and potentiate avoidance habits. This is why many clinicians are being more selective of their language. We're not being hopeless optimists about a problem; we're simply preventing psychology from making it worse! If the back isn't at risk of dislocating, then why are we telling people that their cores are unstable?

That being said, when a joint isn't truly at risk of injury, especially when it comes to chronic pain clients and those who might not be in situations that put their joint in danger, then should "instability" be one of the terms that's vaulted and reserved for those truly-unstable situations that I spoke about above? Lately, I've found myself naturally gravitating to the word "insecurity". Yes, just like when we were awkward teenagers in high school.

It does make sense. A lot of times, in chronic pain, muscular tone is high and pain outputs are driven due to the conditioned state of the body to think that the joint is at risk and to respond as such in order to protect the area. My metaphor for clients, often, is that the muscles are angry and on strike, not allowing the joint to function as needed. To treat, we simply provide sensations to the tissue to get it to relax and exercise it to create a better sense of security, removing the reason for the body to think that those negative responses were necessary.

I'm open to discussion from clients and colleagues. In the meantime, I'll continue to play around with this word and see what kind of feedback and success I can garner.

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Making Rehab Fun

Pain isn't fun. For many people who aren't accustomed to sport or fitness, exercise might not immediately be a fun thing either.

I find that many individuals struggle to adhere to their recovery plans due to the fact that the rehab process is perceived to be grueling and unenjoyable. Perhaps, even to the same extent as the pain itself!

Maybe the exercise is causing a different type of discomfort that the client is adverse to. Perhaps the rewards aren't immediate enough. Maybe the exercises being provided are just "lame". A lot of factors can play into the reasons why a client doesn't enjoy exercise, regardless of knowing the benefit behind it.

The difference between pain and the mental blocks of rehab is this: clients are often accustomed to the pain! That being said, it's sometimes easiest to simply deal with the pain rather than persevere through the work, as coping mechanisms for the former have already been developed.

So let's make the recovery process fun! Many therapists think that the fun factor is only applicable to making young children adhere to their pains, but why is it so absurd to think that adults might like a bit more enjoyment as well? People of all ages benefit from using fun to motivate their health behaviours.

Disclaimer: If you hate fun, don't book with me.

I'm not suggesting that every rehab exercises needs to be turned into a game. Regimented exercise has its necessary place and making fun out of everything is unrealistic. However, tedious sets and reps have a limit to holding interest and attention.

But how about using the activities that the clients are trying to get back to? Whether it's a sport, going for hikes, or gardening, there's bound to be an active activity that those individuals would like to get back to. Using a soccer ball as a piece of rehab equipment, walking or trails, or even simply incorporating light activities in the yard into the plan is going to go a long way to keep clients motivated. They'll enjoy the work, it will apply to their desired lifestyles, and it will act as a constant reminder of progress.

Many clients will thrive off of strict exercise plans and regular routines, but, like fitness, some people will need other alternatives to enjoy the process. As a therapist, it's my job to recognize which methods are going to be the most effective for each individual. At the end of the day, whatever works to get you feeling better.

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Is There Anything Else You'd Like To Tell Me?

I came across another blog post last week: When You Talk to Patients, Do You Look at Them or at a Computer?

It was a bit of a sad outlook on the state of our medical system, and it's something you've likely experienced yourself. Whether visiting a Athletic Therapist, chiropractor, or even a family doctor, have you ever felt like you were asked only very closed questions rather than being able to tell the story that you were waiting to voice?

I'm unsure if this is a growing trend or just one that's more-commonly reported on, but there seems to be a lack of empathic communication between medical practitioners and their patients. Yes, we as healthcare workers have our framework of questions that remain fairly standard from client to client. However, if a photocopied questionnaire were all that was required, then medical history would not be necessary.

What...what?!

Patients and clients will often not outright voice everything that they'd like to say immediately, often relying on cues and invitations from the professional in front of them before elaborating on how they feel. This isn't being meek; it's human nature! That being said, it seems like too many practitioners ignore and glaze past the clues that clients give them, returning to their standardized framework much too quickly rather than allowing that individual to explain their situation.

"I'm at the end of my limit and need help!"
"Mmhmm, ok. Do you wear orthotics?"

To say the least, this trend does not promote a trusting and satisfied relationship between the client and clinician.

This being said, this is why I'll continue to ask this question to all of my clients; the question that I can't feel like I have a clear understanding of their background without:

Is there anything else you'd like to tell me?

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Do Active Individuals Normalize Pain?

I've discussed, before, the barrier of individuals who identify with their pain to the point where they struggle to find the motivation to attempt recovery. Usually, however, we think about this occurrence when it comes to people who have been suffering from a specific affliction for such a long period of time that they simply come to terms with it.

What we don't talk about, though, is the rate that many other individuals seem to accept new pain as a fact of life, causing them to disregard the steps they need to take to completely heal.

We've all seen it before in athletes, gym-goers, and labourers, for instance. Highly physical people who intentionally place large demands on their bodies experience episodes of pain and injury, but for one reason or another, tend to disregard their bodies' alarm bells and simply carry on through it.

Nah, my ankle is supposed to dangle like that.

On the surface, it seems like an easy explanation. Active individuals, especially those who are mid-competition or are relying on remaining active for a paycheque, keep themselves going despite the pain as a necessity. While they may have fairly typical pain thresholds for the average population, they certainly develop higher pain tolerance. But why does this prevent these same people to continue to neglect their health once they're off of the clock or out of the arena?

I'm good, boss. Just a bruise.

Recent research on the topic was hard for me to come by, with the most current studies coming from the 90s. These studies, however, speak on the psychological effects of injury on athletes regarding depression and affected self-worth, factors that can certainly affect the perception of the injury. In fact, to cope with these effects, the acceptance of injury follows the same stages of grieving, and it stands to reason that many active individuals get easily stonewalled at the denial stage.

On the surface, this "work through the pain" attitude seems to work just fine and allows these people to finish the job and been none the worse for it. After all, ignoring your body's alarm bells can't end badly, can it...?

Juuuuuuust dropped a nickel.

Should athletes be more willing to stop in the middle of a crucial game? Should construction workers miss a day of work at the first signs of an ache? Of course not. That's not the world that we live in. What needs to happen, however, is more education from practitioners on how to guide these individuals through those stages of grief and working their recovery around the necessities of their lives. It IS possible to take care of yourself without interfering with your work and activities, and you can do it WITHOUT letting that injury define you.

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Guilt and Recovery

How many of you have been to a therapist's office in the past and felt guilty during the follow-up appointment? Maybe you didn't do your home exercises or pushed it too hard before you were ready. Maybe you're simply not feeling better and think that there was more that you could have done.

The less mindful therapists out there may look at a client who didn't quite perform up to par and simply utilize that shame as a lesson-learned to push that client into further adherence. How far does this shame help an individual's motivation, though?

Quite a ways back, I wrote about health-shaming with the assistance of a sports behavioural consultant. With the example of guilt in relation to diet, it was shown that higher levels of guilt were associated with a poor perception of control and decreased rate of success when it came to changing a behaviour.

In short, the more guilty a person feels about poor progress when trying to change, whether it's with diet, fitness, or pain-control, the lower rate of success to make that change!

From a personal standpoint, I've experienced this with clients who simply "fall off the wagon" and relapse in their pain and health. Regardless of whether it was their own doing (ie: poor exercise adherence) or not (time barriers or accidents), this sense of guilt has resulted in a lack of drive to continue forward.

As far as I'm concerned, if a client feels guilty, then the onus is on myself just as much as it is on them. It's my job, as the therapist, to create and enforce realistic expectations with a client's habits that they are happy with as well as to help them plan for any contingencies or relapses. Clients of any type of medical practitioners must not feel like they aren't "being good" and can't face the person who is working to help them. If any professional is making you feel bad about your performance, you may be developing a toxic relationship.

So to any individuals out there who are in pain, please don't feel guilty.

To the clinicians, stop making your clients feel guilty!

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How Getting Past Pain Relapses Is Like Quitting Smoking

We made it to February!

How are those New Year's resolutions coming....?

Mmmhmmm!

Stepping aside from New Year's-specific goals (as you already know my opinion on them), let's discuss the realistic situation of regression.

Across the board, regressions and relapses occur in every type of behaviour or lifestyle change, whether it's recovery from pain, smoking, or weight loss. While the ideal is that we persevere through the road block or speed bump and continue on through the recovery process, often, hitting a point where pain returns, a cigarette is lit, or a few pounds are gained back are enough to shatter motivation and derail progress altogether.

One research group categorized pain relapse responses into four possibilities, some less ideal than others.

1) An unpleasant mystery that leaves negative feelings towards oneself and the situation.
2) A fact of life that should just be ignored.
3) A reminder to keep within physical limitations in order to avoid a future relapse.
4) An indication to change your behaviour to avoid another relapse.

You can probably assume that the first option is the least constructive, likely resulting in an ever-increasing level of negativity regarding the pain and loss of motivation to pursue further recovery.

The second option, ignoring the pain, is dangerous, as it may result in the individual becoming too content with their pain to the point of identifying with it.

The third possibility is good to a point. During a more acute phase of healing, learning to stay within limitations is vital, and sometimes the reminder is necessary. However, avoiding behaviours for too long can end up in a person simply using avoidance as a long-term coping mechanism.

Lastly, the fourth option is the most ideal in the long term. Understanding triggers or becoming aware of an increased need for self-work for your health is the most productive response to have if reexperiencing pain. However, sometimes coaching (whether it be self-coaching or help from a therapist) is necessary to reevaluate a relapse in order to maintain a positive foreseen outcome on the situation.

As it turns out, you can closely relate behaviour change relapses between health behaviours fairly well across the board! For instance, these tips of quitting smoking are amazingly applicable to this very process!

1) Focus on the next 24 hours:
Manage the acute phase of the relapse. Modify the environment so that further aggravation doesn't occur. Understand that this was an acute occurrence only and that you shouldn't become down on yourself and treat all the work up until this point as a failure.

2) Talk to someone:
Seek advice or support as needed. Seek your therapist or even consult a doctor if it puts your mind at ease that this wasn't a complete reset to square-one.

3) Analyze what happened:
Did you decide to get too aggressive with the weight you were squatting? Did you take a week off of your rehab exercises in too-early of a stage? Try and ask yourself exactly what may have caused this relapse to happen so that you can use that knowledge for future recovery.

4) Build a new plan:
This one is built straight into the basic rehab process. We're always modifying and changing pain-management and prevention strategies as needed, and having this relapse happen is a bit of a blessing in disguise, as it can help you and your therapist to further progress your long-term plan.

I try my best to ensure that my clients are ready for the possibility of their pain returning at some point, whether it's simply next week or a sudden reoccurrence in five years. Yes, it may happen. No, it is not the many steps back that you may think it is. And yes, there are steps that you can take to get right back on the train and continue to always get better.

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Life Doesn't Mirror Gym Movements (And Doesn't Have To)

No, I'm not telling you that the gym is bad and that you should stop going. There are many fantastic reasons why the gym is awesome.

However, there's a certain phenomenon among many of my clients that I'm noticing. Fear of movement.

The best example is the rounded-spine position. On one hand, many individuals who experience back pain are told by doctors, therapists, and more to absolutely avoid bending down and rounding their backs; that doing so will result in more pain. Having this fear of that movement instilled, however, does little to remove their pain, as these positions are, to say the least, inevitable. As a result, the nervous system, essentially, becomes primed and ready to guard against those movements, causing pain in those ranges and positions when pain wouldn't normally be a necessary response in that case. 

We call this kinesiophobia, the fear of movement due to pain which actually works to prolong pain and disability.

Here's the surprising thing. Active and healthy individuals experience this too! I've also seen this in very disciplined gym-goers who, for all intents and purposes, have nothing mechanical going on to suggest that they should be in pain. However, due to the immense emphasis on "good form" that active and athletic individuals may be bombarded with, I've been witness to the exact same avoidance-triggered pain. These are clients who are under the impression that it's necessary to square-up and keep a neutral spine curve every time that they so much as bend down to tie their shoes. And again, this belief that any other type of position is harmful is so strong that, just the same, they experience guarding and pain. Even so-called functional training isn't devoid of instilling these messages.

The takeaway from this is that the body has very natural movement patterns that it likes to use that don't necessarily reflect the strict and controlled form of the gym. Absolutely, if you're at the squat rack, moving in a single-plane only, and are loaded up with multiple plates per side, then you should definitely be observing "proper form". However, whether you're an active or inactive individual with or without formal training, the body is built for free and fluid movement. Don't let anyone, including Instagram personalities, magazines, or even doctors to tell you that dropping form as you live your life is a dangerous thing.

Credit: Greg Lehman

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Get Out Of Pain - 3 Steps For Maintaining Motivation

I tend to harp on New Year's resolutions a lot, mostly because of how well-documented it is that they don't work.

That's not to say that it's not possible to make changes at this time of year. However, "because it's January" is a reason for change with a rather abysmal success rate. I see many clients at this time of year who have looked at the calendar, groaned, and decided that it's time to deal with their back pain, and it often becomes my challenge to make sure that they take advantage of that temporary drive and turn it into a permanent one. Here are a few things to think about when you're considering taking the first step.

1) Determine Your Reasons Why

A lot of people will walk into a therapist's office saying that they want to get out of pain, but without much more reason in mind other than "knowing they should" or "have to". Especially in chronic pain cases, this attitude is very detrimental to the recovery process, as it reflects a kind of "going through the motions" approach.

If you've had severe back pain for years, it's easy to default to this attitude, but if you want to make an earnest attempt at progress, then you need earnest reasons for it. Try to find intrinsic, rewarding factors to motivate you such as family, quality of life, return to activity, or longevity to keep you adherent to the healing process.

2) Start Small And Create Goals

Next, those reasons you've determined are important, but going all in with only that end-goal in mind often leads to failure as well. Long-term plans are tough to keep to when the going gets tough and the end barely seems any closer.

If your long-term goal is to run a marathon in two years, remember that you need something to keep your motivation during all 24 of those months. Have a one-week goal, a one-month; two, half-a-year, and so on. Those steps are vital in order to maintain a sense of realism and attainability with the entire process.

3) Expect Speed Bumps (And Prepare For Them)

Clients can often be dismayed by the fact that they've been doing incredibly well in their rehab and feeling fantastic, then hitting a hump and experiencing a relapse in pain. They can often feel like this is an indicator of the treatment not working or that their condition is, in truth, there to stay with no hope of permanent recovery.

This is wrong, however, and it's important that clients know that these are only speed humps, not complete road blocks. Even in drug addiction rehab, a relapse is not considered to be a failed recovery; rather, it's a delayed one with a lesson learned.

If a perfectly healthy person can't expect to never experience an injury, then recovering pain clients don't need to expect to never experience reirritation. Just know that it's coming, have tools to help cope with that temporary increase in pain, and then be prepared to hop right back on the train.

One step back, but always two steps forward.

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The Stressful Effect Of Stress On Pain

It's the New Year! I hope your holidays were fantastic. However, now's the time for all of us to buckle down and get back to work. Don't let the stress get to you!

Stress! GAHHHHH!

If you read even the occasional post from myself, then by this point you know that pain is not a response that's simply caused by a physical lesion alone; it's a complex phenomenon with massive psychosocial and neurochemical contributors as well.

And just like how poor sleep can (indirectly) cause an increased sensitivity to pain, perhaps mental disstress can as well.

We all know negative stress as causing potentially negative effects on the body. Many of you may also have heard of cortisol, the stress hormone. Or, to get technical, the hormone released by your body in response to stress to take part in the fight-or-flight response, regardless of how major or minor.

Well, cortisol also has this interesting effect on pain, with several demonstrations showing an decreased pain threshold and increased sensitivity while subjects were under mental strain.

This can have huge implications from a rehab perspective, especially in chronic pain cases. Even as tissue heals and rehab programs are followed, negative stress can certainly interfere in the regression of pain symptoms. This is largely why conditions such as fibromyalgia are commonly looked into, at least in part, as a stress disorder.

This could be particularly problematic with progressive pain and stress before intervention occurs. As we are finding, chronic pain clients typically have an elevated cortisol level even when looking at them in absence of stress-specific factors. This implies that the body may be pumping out even more stress hormones simply in response to pain (as seems reasonable), resulting in a potential cycle of pain and cortisol continually causing one another to spike. (Hmm, haven't we seen a cycle like this before?)

Fortunately, this opens up more avenues of treatment as well. Simply doing mental relaxation exercises and activities is showing positive effects on many chronic pain conditions. This goes to show the importance of stress management when it comes to long-term or complicated pain cases. We often overlook this mental side of physical pain, but disregarding it means overlooking a crucial avenue for recovery.

Relax man!

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