Rehabilitation

One of the biggest change in Rehabilitation recently is that loading patients into pain with activity is no more forbidden. Not everyone can or should push into pain right away, whereas others need to stop avoiding painful activities.

Lets discuss points to consider when deciding whether to load someone into pain or whether to protect a painful area.

1: Onset of pain

In acute to sub-acute injuries, pain serves its purpose. You wouldn’t run on a swollen sprained ankle. In these situations, it makes sense to protect the painful area… at least for sometime.

By contrast if it’s 3 years after you hurt your back while gyming, and you still stand & sit as stiff as a board, it’s probably ok to bend it a little bit even if it’s a bit painful.

The only exception here are post-surgical clients where it’s normal to have some pain with activity early on and there is a narrow window of opportunity to regain proper range of motion.

2: Pain presentation

For a nociceptive, or mechanical pain presentation avoiding painful activities and protecting the painful area makes sense. If the back only hurts with end range flexion, it’s appropriate to hip hinge and use what Stu McGill would call “spine sparing motion.”

Now if working with a case that has constant pain with everything including bending, hip hinging, doing the McGill Big 3, sitting, standing, walking, lying down etc, it’s totally impractical to avoid painful activity. The only exception to this is, as above, within the inflammatory phase of an injury.

3: Presence of psychosocial factors

With patients who are more easy-going and don’t seem to have any major psychosocial factors pertaining to pain or movement (i.e. kinesiophobia, fear avoidance, hypervigilance, preference for passive treatment) it is more apt to keep them within the pain-free range while moving if possible.

For patients who are heavily guarded & fearful of doing any activity – reinforcing the idea that pain is bad & painful activity needs to be avoided just sends the wrong message to them.

For patients who have a lot of avoidance behaviours and a more general “sensitization” pain pattern, even if it’s earlier on post-injury, I will use a graded exposure approach – assuming that we’re past the early inflammatory phase and have ruled out red flags & serious tissue pathology that requires surgical or medical management.

4: Treatment goals

Some goal activities may require pushing into some pain. Most of the knee replacements I work with have goals of being able to walk normally without aid. For them, building gait endurance, improving gait pattern, and attaining the necessary range of motion to satisfy all of these will likely require working through some pain early on.

By contrast, some goals can be achieved without the need to go into pain-free activity. Consider the powerlifter with back pain that’s aggravated at end range flexion. Teach them to keep their spine as neutral as possible during their lifts and use isometric instead of dynamic core exercises, & boom – they may be able to lift pain-free no problem.