Random Thoughts February 2018 - The Relationship Between Strength & Pain, How I Recover From My Busy Life, The Importance Of Keeping Active Patients Exercising Through Rehab, And The Place Of Manual Therapy In Rehab

        I'm revamping my "Random Thoughts" series. Instead of my traditional short article series I will release a monthly article which will compile Facebook/Twitter posts and other unpublished thoughts I have on various topics on rehab & fitness that are worth mentioning but don't have enough material to make it worth dedicating a full article to.

With that here are my random thoughts from the past month....

The Relationship Between Strength & Pain

Sometimes a lack of strength can be relevant in pain – particularly when there’s a “mismatch” between a person’s demands and their physical capabilities, regardless of whether its before/after their pain started. And there is some research that does show lack of strength to be a risk factor for certain injuries/pain conditions.

That being said

1) The correlation between strength and many musculoskeletal pain conditions isn’t as strong as most people think

2) Many clinical studies have shown that changes in strength don’t always correlate with symptoms

3) Given what we know about the complexities of pain and the biopsychosocial model … to suggest all pain is due to weakness is reductionist & out of line with the evidence

How I Recover From My Busy Life Of Treating, Educating, And Lifting 

Given all my roles as a practicing physiotherapist, doing the occasional consultant, helping with 2 university curriculums, and training for powerlifting … some people ask me how I do it all and not burn out. Admittedly this took me a good year to “get right” after burning out in the past and it will be something I will continue to adjust.

My strategies have included

1) Proper nutrition

2) Proper sleep – around 7-8 hours a night. I aim to go to bed & get up at approximately the same time daily.

3) Adequate down time

I try to pencil in at least an hour of down time at the end of the day to decompress. This enables me to reset myself & sleep a lot better.

4) Time management

Last year I learned I can only run 1-2 areas of my life (ie career, lifting, family) hard at any one point in time (props to Will Kuenzel for teaching me that)… and I need some downtime. Towards that end I prioritize what I need to do, schedule it in my todoist app and my google calendar app, and also put in adequate down time.

It’s part of me realizing, as Stan Efferding said “that you can be good at anything but you can’t be good at everything” much to the chagrin of my hardheaded, Type A personality. In Brian Carroll’s 10/20/Life book he emphasizes having phases where you’re more focused on a meet vs time where you’re more focused on your external life.

5) Active recovery

I’m not a big fan of ice baths or saunas. My recovery approach consists of

-          Twice weekly foam rolling & self ART

-          Daily 10 minute walks as per the advice of Stan Efferding (I don’t do these 3x/day as he recommends due to scheduling but I do do them twice daily)

-          Daily performance of my knee rehab (knee extensions in sitting McKenzie style) and back rehab (McGill Big 3). Even though I’m painfree on a day to day basis I still believe in doing these for rehab & active recovery.

6) Stress management

Pretty much all of these count as stress managers. The only thing I would add is using a lot of positive self-talk to make sure my head is right when dealing with any situation I’m in. 

The Importance Of Keeping Active Patients Exercising Through Rehab

When athletic & physically active patients ask me "what do you think of me doing <insert exercise/activity here>" my answer, unless there are contraindications or unless they're clearly not ready for it, is "let's see how you do with it."

Quite often, more than not, many otherwise healthy & fit patients are capable of doing far more than they think but sometimes the fear of pain/injury holds them back.

Some may disagree with me - but I always believe in giving physically active patients (short of any contraindications) stuff that they can do ideally properly & painfree as it 

1) Gets them on my side - and makes me not look like the 10th person telling them to "just rest" or "never run/squat/deadlift etc again" 
2) Will likely benefit their pain, healing and mood through the benefits of well tolerated movement & general exercise and
3) Gets them to trust & believe in their bodies more
4) Gives them a means to maintain/improve fitness
5) Makes the rehab process feel less like boring rehab

The Place Of Manual Therapy In Rehab

Manual therapy has a place if a patient can't tolerate a full session of exercise/education due to
1) High irritability
2) Deconditioning - let's face it we've all had those patients that are toast after 1-2 simple exercises
3) Contraindications due to surgeries or medical conditions that prevent the patient from doing much (if any) exercise

Some would say "I'd rather only have a patient do 2 minutes of exercise than make them dependent on me." While I appreciate that idea - there's only so much education you can do in a session & expect a patient to retain effectively. If I was a patient, paid for a 30 minute session, and only got 5-10 minutes of therapy I'd be pretty POed. That's where the passive therapies have their place.

That said - the research and guidelines are really trying to push away from passive therapies & more to movement/exercise, education, and psychosocial therapies in the management of musculoskeletal pain and that's where the vast majority of our treatments should fall in.