In my years of practicing as a physical therapist, I have found a formula to explain why we get into a cycle of pain, and how to go about addressing it. This simple framework has helped many people become completely pain free, and I am going to share these rehab tips with you. This is not one magic bullet exercise or a cutting edge treatment technique, it is a systematic approach to tackling pain through smart decision making and awareness.
This approach can be applied to anyone looking to get out of pain. It’s the implementation that will look a little different for each individual person.
This systematic approach works on the assertion that pain is an experience that is influenced by a variety of factors including external stressors, mental health, diet, and mechanical stress.
Let’s go through how this framework works by using an example, “John”.
John is 30 years old, works in finance, lives with his fiancee in downtown Boston. He sits at a desk most of the day, and likes to do CrossFit to stay healthy. He developed some back pain recently as he was bending down to put his weights away at the gym. He’s tried ice, heat, and ibuprofen daily for 7 days, but he continues to have pain especially when he bends forward even 3 weeks after the injury. He’s even started to do some exercises that he found online which help a little bit, but he continues to have pain especially at the end of a long work day.
Why is John still hurting? Most tweaks and pains will resolve within 10 days if they are pretty minor, so what is keeping John from feeling better?
Zooming Out
To make John’s back pain go away for good, we need to understand all of the contributing factors to his pain, and then try to address each one. We ask questions like:
What else is going on in your life right now?
Was there a recent change within the last 3-6 months of your daily activities?
How much sleep are you getting regularly and do you track your sleep?
Do you have any previous injuries?
Tell me about the week leading up to the injury, what was your programming like?
What has your diet been like?
Here’s what we learn:
John just got engaged recently and he’s been planning his wedding with his fiancee. He also just got promoted at work and is now managing a team of 5 people which has been stressful for him to balance everything.
He was previously walking to work but he just moved further away from his office so he has been driving 30 minutes to and from work every day.
He has been burning the candle at both ends because of all of the wedding planning and new work responsibilities, so he is typically only getting 5-6 hours of sleep per night, and the quality varies.
He has a history of an ACL tear in college that feels generally fine, but when we evaluate his strength, it is less than his other side even 10 years later.
Previous to his injury, he was squatting heavy 4 days/wk to try to increase his 1 rep max
He has been trying to go vegetarian because he is concerned about keeping his cholesterol levels under control because high cholesterol runs in his family.
When we zoom out and look at the big picture, there could be a lot of things that are contributing to John’s pain, and might also help explain why he got hurt in the first place. This is the first step of the systematic approach; zooming out and looking at the big picture, then creating a pie chart to visualize all of the factors that are making John hurt.
To help John feel better, we could just give him some exercises and adjust his training routine, but that might not get him all the way there, or it might take him longer to achieve the results that he is looking for.
We need to start by picking out which of the factors on the pie chart can be adjusted:
Scheduling his days and weeks out might help him assess how busy he will be and identify the times where he might be overworked. If he isn’t scheduling down time, this might be a helpful strategy to help decrease his overall stress level
Maybe John could take a walk during his lunch break or use a standing desk to get more variability in his movements throughout the day so that he doesn’t have to sit the whole day.
John is not getting enough sleep to help with physical recovery of his body. Encouraging good sleep hygiene (avoiding screens right before bed, managing the temperature of the room, not eating too late, and avoiding drinking alcohol can help with this)
We should include some targeted strengthening for John’s weaker leg in his rehab program.
John’s training strategy was likely too high volume for gaining pure strength, and could likely achieve his goals with 2-3 times per week squatting with varying degrees of intensity.
Going plant based can certainly help manage cholesterol, but it’s important to ensure that you are taking in enough protein throughout the day to fuel your body. Especially when recovering from an injury!
Now these are just examples in a fictitious case, but the strategy is the same for any case. Look at the big picture, and start adjusting all of the factors that can be adjusted.
Achieving a Positive Trend
The second part of the systematic approach is focused more on the trend of your recovery and building capacity.
Let’s think of 0 as representing your steady state, injury free. There are some things that push you in the negative direction, and some things that push you in the positive direction.
Let’s say that John is currently at -3 with his injury (the numbers are arbitrary). When he does things like get 8 hours of sleep, go for walks during his lunch break, and corrective exercises, he moves a couple notches in the positive direction.
When he gets less than 7 hours of sleep because he stayed up late doing wedding planning, then has to wake up early to get a proposal out the door in time, sits all day at work and then has to move a bunch of heavy boxes into his basement in awkward positions, he might move a couple notches in the negative direction.
The key to John getting out of pain is for him to spend more time moving in the positive direction than in the negative direction. This is a balancing act, because there might be some days that are more negative than positive. Life can be messy! But being consistent with the activities that move him in the positive direction will help him achieve a positive trend.
Once John starts to gain some momentum, he can start to build capacity to make sure that when he has a “messy” day he doesn’t go back to square one. This is where strategic programming can be helpful.
Building and Tracking Capacity
Every day, John puts some strain on his body, some days more than others. Strain can include both purposeful exercise and things like moving boxes into the basement.
The dotted red line represents John’s capacity. If he keeps his strain below that capacity line, then he will avoid injury or exacerbation of his pain (the numbers are arbitrary). There are two main things that he can do to prevent his strain from getting up over the capacity line.
Reduce strain
Increase his capacity
Reducing strain might include things mentioned before like getting enough sleep, eating well, and reducing training errors like overtraining.
Increasing his capacity might include a solid strength training or physical therapy program to help progressively increase his tolerance to strain. This chart helps the most with determining which days John can push himself, and which days he might need to take a rest day. If he has a lot of external strain on a given day (decreased sleep, poor diet, other life strain) he might want to decrease his workout intensity for that day.
The Role of Physical Therapy
At Alterra, we always zoom out to look at the big picture. We may not always have the solution to managing stress at home, but we can recognize when it’s a limiting factor to your recovery and refer you to someone who can help.
But when it comes to this stuff...
We’re experts.
Once we’ve identified the contributing factors, we can start systematically addressing each one, which helps you achieve a positive symptom trend. As you start to feel better, we have the expertise to start adding load in a progressive way to build your capacity and reduce your risk of injury in the future. This is what we do and we love it!
At Alterra, we've helped lots of people navigate this rehab journey (even those who tried and failed before). If you're local to Boston's Back Bay and are looking for clarity in your rehab journey, we'd love to help! Book a free discovery call to chat with a therapist today.
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