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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The Sixth Sense You Need For Injury Prevention

In broad, obvious terms, we have five senses. Touch, taste, sight, smell, and hearing. In reality, however, the body actually has many more sensory systems than that. Thermoreceptors in the body detect temperature; chemoreceptors detect chemical changes (such as what your immune system requires); equilibrium from your inner ear handily lets you know if you happen to upside-down or not.

And then there's proprioception, which happens to be one of the most important senses that our bodies have in order to move, function, and avoid pain and injury.

Proprioception is the sense of where a body part is in space. For instance, if you close your eyes and raise your arm into the air, you will, no matter what, be aware that you arm is above your head.

Where is it? WHERE IS IT?

Those proprioceptive sensations can be much more subtle than that as well, though. Take, for example, single-leg standing on an unstable surface. It's your body's ability to sense minor changes in position and weight shift that contribute to your ability balance. That proprioception that you have for the joints in your leg provide the feedback that your brain needs to coordinate the muscles in this case.

With that in mind, it should be easy to understand how a lack of well-trained proprioception can result in a higher risk of injury. Lacking proprio in a joint certainly affects its overall stability, increasing the chance of tissue failure when the body can't properly adjust for a stimulus.

From observation and speculation in the research, there's also a link between a lack of proprioception and chronic pain in absence of true tissue damage. Lower back pain patients, for example, are demonstrated to have this sense impaired basically across the board! It may be that the body's inability to accurately reposition itself as needed could be resulting in increase muscle-guarding activity and heightened pain sensitivity as a protective response.

This being said, proprio is a vital system to retrain when rehabbing clients. It's not as easy as simply strengthening some muscles and increasing flexibility in others, as the body still won't be receptive to letting go of it's protective responses if it can't effectively sense those changes in joint position. In fact, I've had incredibly strong clients with no significant weaknesses remain plateaued in their recovery simply due to this fact! Given that proprioception can be lost as a result of injury, surgery, and even growth spurts, being mindful of this domain is one of the most crucial aspects of an effective recovery program.

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What We Know About Tendinitis (May Surprise You)

Achilles tendinitis, tennis elbow, rotator cuff tendinitis, these tendon conditions are all common causes of pain that I see in my practice with much frequency.

What many of us usually understand about tendinitis is that it's a condition involving inflammation of a tendon resulting from overuse and repetitive trauma to the structure. Responses to the diagnosis are typically to rest, apply ice for the inflammation, and then pop an Advil to further get that anti-inflammatory affect.

However, what we now know about "tendinitis" may surprise you. Rather than being an inflammatory condition (as the "-itis" suggests), we're finding the condition to be a structural one with changes to the tendon fibers occurring at the cellular level. Often, a complete absence of inflammation is observed, resulting in the research shifting to the terms, "tendinosis" or "tendinopathy", instead.

We can simplify the explanation by visualizing normal tendons as having neat, aligned fibers that are all closely packed together and running in the same direction. Normally, we think of tendinitis as this structure remaining, but inflammation and swelling simply occurring in the area due to applied stress. We know this as incorrect, though.

Instead, tendinosis involves that neat alignment of the fibers as becoming disrupted. In healthy tendons, there is regular fiber-growth activity replacing old fibers with healthy new ones in the similar fashion. In unhealthy cases, new growth of fibers is occuring in overtime (which is the reason for thickening of affected tendons) as well as growing irregularly and nonuniform, affecting the structure's functional ability and resulting in pain.

• https://doi.org/10.3810/psm.2000.05.890

It was once thought that tendinopathies occurred in stages, with the inflammation occurring first and then the structural changes of tendinosis resulting if the condition progressed. It seems like true inflammation is rare in the first place, though.

• https://doi.org/10.3810/psm.2000.05.890

The implications of this reality don't impact the prognosis of the condition; outcomes are still very positive with proper treatment. It does affect the way that we treat and the time that recovery may require. Those structural changes definitely indicate increased time for reversal than simply decreasing inflammation would. As well, they indicate how much more importantly mechanics are loading must be considered for future prevention. (Pro-tip, tendons love eccentric training.)

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Flexibility Isn't Always (Or Often) The Solution

You may have read last week's post about how flexibility is a mechanism that is driven by our nervous system, rather than being a structural issue like how we typically visualize it.

To further debunk the myths, let me also tell you about how flexibility work may not (or rather, is probably not) the end-all-be-all solution to pain or discomfort, contrary to what we often assume.

This assumption is made constantly! Back hurts? I need to stretch more. Recurring muscle strains? Stretch more. Knee pain? Stretch more!

However, I know plenty of regular yoga enthusiasts that still experience pain. If stretching was all that it took to keep joints and muscles healthy and happy, why would this happen?

Unfortunately, there isn't a lot of merit in flexibility, by itself, as a solution to pain or dysfunction. For instance, while there is a correlation between individuals who have poor flexibility and workplace back pain, the flexibility of non-symptomatic individuals can also be very low as well, suggesting that inflexibility is not the pain culprit, at least on its own.

A lack of flexibility is almost more like a symptom of a broader problem, not the problem itself!

So which direction do we go in, instead? Well, I can relate this back to a past post about the use(lessness) of static stretching. As I found when writing that one, it seemed that eccentric training of the hamstrings resulted in greater and longer-term range of motion increases than stretching did. As we know, a lot of muscular tension can be related back to a lack of joint strength or stability.This all suggests that, while a lack of flexibility may be associated with pain, that flexibility was only lost because of a need for more strength in the first place.

That all being said, when someone tells me that they're in pain and that they "just need to stretch more", I try to impart on them that it's not usually as simple as that. Inflexibility seems to, most often, be secondary to another underlying condition, and so we need to address that whole picture rather than just trying to stretch it out.

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Flexibility Is Driven By The Nervous System

Flexibility is a common concern for the health-conscious population. Right or wrong, stretching a tight muscle is often a main focus. However, what causes a lack of flexibility? How does that lengthening and shortening of muscular tissue work?

Well, you may be surprised to know that a lack of flexibility is not a structural issue. Often, we think of tissue like an elastic band. It seems like a good metaphor, as we'd like to stretch out that band enough to a point that it remains lengthened.

How we visualize muscle on stretch.

HOWEVER, the reality is that flexibility is, in fact, a neural mechanism, not a structural one. Just like the shortening of fibers occurs when you contract a muscle, the nervous system initiates similar contractions in response to stretch. (It's this response that we condition or decondition by lifestyle, rehab, or training.)

In other words, when you try to reach for your toes, your hamstrings experience a reflex that cause a contraction against the stretch.

You can't think of muscle shortening or lengthening like an elastic band. You have to think of it like a second person pulling back on a rope when you try to pull it in another direction.

What's really happening.

If you think about it, it makes a lot of sense. If you've ever pulled a muscle in your back or slept funny and have a kink in your neck, you can feel the sudden lack of flexibility in the area. Your muscle tissue didn't just magically and suddenly decrease in length (which would mean decreasing in size) in that time. Rather, the muscle is contracted and guarded.

This being said, getting muscle to lengthen and remain like that is not as easy as simple as performing prolonged stretching. If inflexibility is a nervous system reflex in response to stretch, that reflex needs to be trained out. Whether that be teaching the muscle to relax under tension, addressing a reason for excessive muscle guarding, or some other type of conditioning, it always comes back to making the nervous system happy and willing to let go.

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The Potential Rebound Effect Of Painkillers

I have a small discussion to have about some of the negative effects of pain-management drugs. Before I begin, however, let me set the record clear: Painkillers, including opioids, have a necessary and vital role in our society and healthcare heavily relies on them in numerous circumstances. I'm not allowing this to go down one of those anti-pharmaceutical, all-natural arguments made by fanatics who buy detox cleanses and don't vaccinate their children.

I banged my head against my keyboard just from Googling this image.

However, I was reading some interesting points made concerning the opioid crisis. As it turns out, chronic use of the medications may actually work to prime the nervous system and increase pain sensitivity! Obviously, this begins a problematic cycle of continued use due to heightened pain levels which are now going to be more resistant to further treatment.

This isn't necessarily a phenomenon exclusive to opioids, either. Acetaminophen has shown to have a similar rebound effect when it comes to headaches.

This creates important considerations when it comes to long-term recovery from pain, whether it's the severe pain following a spinal surgery or the headaches resulting from stress and neck tension. We need to recall the responses that the body will have to these pharmaceutical pain-management methods and be mindful when transitioning away from one management technique into the more conservative methods that I, as a therapist, employ.

In short, we can't always expect a cold-turkey cessation of pharmaceutical use. At the same time, that  use requires an off-ramp.

Disclaimer: Athletic Therapists do not provide prescriptions nor instructions regarding the use of any medication. Addressing these issues is done with the advice of medical doctors with the therapist providing the guidance for the rehab process.

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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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