PAIN AND EXERCISE: GOOD PAIN VERSUS BAD PAIN

“GOOD PAIN” VERSUS “ BAD PAIN” PAIN FROM ACTIVITY AND EXERCISE

A question that arises commonly as we tackle the rehabilitative phase of a patient’s treatment plan, is what level of discomfort is to be expected and tolerated when patients start resuming normal activities or pursue exercising when being treated for an acute or chronic condition. In other words, what is the defining line between good and bad pain?

First, we should talk about when we start introducing therapeutic activities in the first place, especially when patients are acute, as some patients are pretty eager to start exercising to get better faster. As a general rule, I may not add much beyond in office treatment and light walking, breathing, general movement and active range of motion stretching in the first week or two of treatment. You cannot inherently strengthen or stabilize something that is completely dysfunctional or structurally misaligned.

Usually by the end of the second week at the latest, we can start adding more specific activities. With the input of the patient, we look to find the right balance between pushing the patient enough to make gains, and not pushing so hard as to reinjure. It can be a bit of a balancing act, and I give the patients three guidelines to stay in the safe zone:

-          There is a difference between pain and soreness. Soreness is a normal reactivation reaction that is more of a generalized discomfort. Sharp pain is normally to be avoided as a sign that you are pushing too far too fast.

-          I like to use the 2 points on the 10 scale rule: during the therapeutic activity, it can be OK to have a little more discomfort than at baseline. For example, if youR pain at rest is a 2 on a 10 scale, it can be at a 4 on a 10 scale, but really you should not let it get much higher.

-          The discomfort associated with the activity should not significantly outlast the activity itself, ideally returning to baseline within 30-60 minutes.  If post activity related pain lasts into the rest of the day, if it interferes with sleep, if it is still present the following day, these would all be indications that you are pushing too hard, too fast, or that the exercise is not right for you.

There is not a one size fits all solution to what discomfort is OK in your situation, and you ultimately need to discuss that with your provider. Some people have underlying conditions that will carry a little more baseline pain during the rehab phase ( inflammatory arthritis, meds, fibromyalgia), that will require creative accommodations. But in the end, where there is a will, there is almost always a way to get stronger.

Photo courtesy of Freepik

Walking safely when the ground is icy

The conditions of the last few weeks often reminded me of this important seasonal resource that I never get tired of posting with great delight. Several of my patients enjoy getting some mild cardiovascular activity doing outdoor walking, and while there is nothing that will fully replace that, it's really not a safe option when we have a persistent layer of ice that may be with us until April.

The walk from home free YouTube channel allows you to get a good cardiovascular routine using a small amount of space, a huge variety of videos of different durations and complexity, and a lot of fun music and coaching. Please remember that you have alternatives, and really no excuse, to continue getting a little bit of cardiovascular endurance during the winter months.

https://www.youtube.com/@LeslieSansonesWalkatHome

3 technique pointers for a safer deadlift

3 TIPS FOR A SAFER DEADLIFT

I've found myself teaching those instructions to patients often enough that I decided to make a quick video about it so I can refer patients to view them again after the appointment. While I have not spent as much time as Dr. Steve in a traditional gym setting, I've done enough deadlifts in my own exercise time to know how quickly they can go wrong, especially if you happen to be recovering from a recent lumbar strain or any other lumbar injury. The main goal of the debt lift modification is to keep a stable flatback in maximum descent and muscular contraction. The 3 modifications, namely wide stance, slightly flexed knees, and firing up the good muscles ahead of time, facilitate maintaining a safe lumbar posture

(photo courtesy of Freepik)

https://www.youtube.com/watch?v=sFqTF5iy3WQ

Shoulder strength and stability: hug the ball

https://www.youtube.com/watch?v=YfpNnMjEsqw

When working with patients with shoulder girdle weakness and instability, whether from an acute injury or more of a chronic postural strain, there are a couple of foundational exercises that we will use as a starting point for strength and stability recovery. Those exercises can be done safely as a starting point with little to no risk of injury when performed correctly, and can be used as a progression tool to more aggressive strength building.

The "hug the ball" (or hug the pillows) exercise allows patients to recruit the scapula stabilizing muscles and prevent some of the chronic rounded shoulder and shoulder blade winging. The ball or the pillows allow for a counter resistance that can be light or intense, and allows for a slow eccentric release. The main technique to pay attention to is making sure to engage the deep interior blade muscles to squeeze the ball and not the biceps.

Shoulder strength and stability exercise: crocodile pushup

https://www.youtube.com/watch?v=frjhTszm3Cc&t=21s

On the same topic of shoulder strength and stability foundational exercises, this form of modified push-up is a great tool to be used as a stepping block when patients are extremely weak following a shoulder injury and not quite ready to do more traditional plank type exercises. Like the hug the ball exercise, it can be gradually made more challenging as the patient progresses in their recovery.

The "crocodile push-up" ensures that the elbows are facing the knees, keeping the elbows from flailing out, and the glenohumeral joint firmly centered in the socket. The patient will start doing the exercise from the knees up, and can bend as little as needed in order for the isometric hold to be tolerated for about 5 seconds before a slow release. The patient can eventually progressed to lower push up, longer hold time, and full plank starting position.

The 3 cats and three cows of the morning: how to get out of bed when your low back is really stiff and painful

We have had a lot of patients inquire about the best method to get out of bed and loosen up when they wake up with a lot of intense low back stiffness and pain. This is not an uncommon finding with patients who have underlying lumbosacral inflammation from new injuries or degenerative disc disease.

The brief video goes through 3 versions of the cat and cow, starting right on your back before getting out of bed, and gradually progressing through the seated version and into the traditional tabletop version. By the time you finally stand up, the pain is often 50% reduced. This allows patients, who normally dread getting out of bed because of the half hour of intense pain and stiffness, to work through gentle progressive active range of motion in a few minutes, and be able to be functional much quicker at sunrise.

https://www.youtube.com/watch?v=gJdsrYrLS_g&t=3s

Lumbar traction-decompression : inversion table versus prone kneeling traction

This is another one of these are long overdue blogs that finally bubbled up to the surface after 3 patients asked me the same question in less than a week.

There is a lot of interest decompression traction device. And there is a lot of confusion and chaos about which ones are safe and effective and for whom.

Inversion tables are very popular, and successfully used by a lot of patients. However I always caution people who asked me about it depending upon what I know of the underlying condition. This blog is to describe the difference between inversion tables, which are easily accessible over the counter at a lower price point, versus more sophisticated device that we recommend for our patients.

The concept of traction decompression is not new. We have records of Egyptian doctors using crude form of traction 5000 years ago, by hanging people from a rope underneath their shoulders and attaching a weight to their feet. 1st of all, let's describe what traction decompression may be used for. Lay patients will use them for just about anything that feels like a low back pain when stretching it feels good. In our practice, we will use traction decompression primarily for 2 conditions: either a chronic or acute disc prolapse that is associated with nerve root compression down the leg, and responds to flexion decompression challenge in the office. (And have no contraindication to traction, which unfortunately are quite many). The other indication is for people who have degenerative stenosis, whether central and sometimes lateral. In the 1st case, the traction will usually be used for a defined period of time, with option to repeat during relapses. For the latter, patients usually need to use that as an ongoing maintenance tool to manage their condition.

Inversion tables and prone flexion decompression units such as the NUBAX (the loaner equipment we have at the office) try to achieve the same goal but with some notorious differences:

– inversion tables will maintain a lordotic curve and in many cases accentuate the lordosis (if patients have any sort of anterior hip soft tissue or muscular tightness). The NUBAX allows for partial flexion of the lumbar spine away from lordosis in addition to axial decompression. Being able to add flexion can be extremely helpful in stenosis in particular, since extension aggravates central canal narrowing. It can be helpful with disc herniations depending on the location and shape of the prolapse as well.

– Inversion tables will have a much longer and thus less accurate traction lever since the capture the patient either at the knee or at the feet and has no 2nd point of traction. The NUBAX isolates the traction levers right at the lumbosacral spine with the hip strap, as well as the level of the shoulders with the shoulder pads.

– The inversion table requires the patient to be head down for prolonged periods of time, which can be a huge problem and contraindication with patients who have certain types of vertigo, cardiac, like circulation, brain and other neurological issues

– the inversion table with its long lever at the knee or ankle is actually contraindicated for patients with most joint replacement at the knee or hip, something that is not broadly recognized by a lot of patient who self prescribed the unit.

In the end, traction inversion can be a very powerful tool when selected for the right patient, but it's not a panacea for everyone. Once we determine that a patient may be a good candidate for trial of decompression traction, will set them up at the office to learn how to use the loaner unit which they can have for 30 days before deciding if it's something they should purchase for themselves.

https://www.youtube.com/watch?v=_yCYi2ruMN4

YOUR HEAD IS A BOWLING BALL

Maria and I had fun with her grandmother's bowling ball that was collecting dust in a closet, to record a video illustrating the impact of anterior head posture on the neck and shoulders.

https://www.youtube.com/watch?v=DN-nT3w6SFQ

https://www.youtube.com/watch?v=DN-nT3w6SFQ