Guest blog by: Tom Teter, DC
I recently had a patient that was referred to me by a local personal trainer that I have a relationship with. This patient is a 60-year old female who has had intermittent ongoing left knee pain for some time. After being evaluated by her medical doctor, she was diagnosed with moderate degeneration of the cartilage on the posterior side of the patella. She was told to NEVER squat, lunge, or perform lower body exercise again as it would lead to further degeneration of the cartilage and that she would need a knee replacement. She mostly felt the pain when going up and down stairs, and stated she felt unstable as if her knee was going to give out.
As health care professionals, we need to stop setting our patients up for failure.
This person had become so fearful that she would destroy the physical structure of her knee, that she avoided all necessary lower body movement. Instead of giving her positive messages about the outcome of her condition, her doctor instilled absolute fear in her that if she even moved her knee inappropriately that she would end up on the operating table.
There are so many things wrong with this message that it is hard to know where to begin. Unfortunately, this isn’t the first time I’ve heard a story like this–I have heard these same misguided directives from chiropractors and physical therapists as well.
Here are four ways that we can instill a mindset of resilience for better patient outcomes:
Yes – pain is real and it needs to be acknowledged, but it is also not the end of the world as in most cases patients can recover with the right treatment plan in place. Years of study has taught me one thing – that the human body is designed to be resilient. Hundred of years of human evolution have shown that we have a primary drive to survive. This survival instinct gives us the ability to adapt to the ever-changing stressors of our environment, and has allowed us to continue to find ways to function even in the presence of pathology.
Simply stated – humans specifically adapt to imposed demands. The key to this statement lies in the stress of the demand, and if we treat our patients like they are fragile and will break – they will never allow themselves to be stressed in a meaningful way that allows for and elicits adaptation. Simply stated, the key to successful treatment outcomes is not treating our patients like they are fragile – but rather creating the mindset that they are resilient and designed to be able to adapt to stress.
Language matters – and how we frame the conversation around our patients’ pain will determine their willingness to comply with our treatment plan. I am not suggesting that we should not be honest about the severity of someones structural issues, but we must realize that a person is not their diagnosis and that many people have recovered from severe injury without surgical intervention.
We need to stop instilling fear in our patients about what they should NEVER do again as this sets them up for almost certain failure and gives them the idea that they are fragile and can never mover or apply load to their bodies in fearing of breaking.
In this context load is any stress that is applied to the body that can create an adaptation. While doing too much activity can be detrimental to the body, doing little or no activity can be equally as damaging. Many times when people come into my office in pain, it is because they have done too much activity, too soon, or too often. But, more often than not, it was not the activity that was the culprit in causing their pain, but rather that their bodies were not prepared for the activity and it was past their tissues tolerance threshold. Because they hadn’t done that activity before or in a long time their body could not tolerate the stress.
No one can argue that one of the many components of recovery after an injury is reintroducing the tissue to stress in a progressive and logical manner. If we do not add load to these equations the tissue may stop being painful, but will remain succeptible to re-injury in the future. The pain is gone, but the tissue has not developed a tolerance to stress.
Regardless of pathology or injury – we must load tissues to insure they can adapt accordingly and become stronger and more robust when introduced to new or different stressful environments.
Another huge problem we see in these conversations is that a provider has chosen to pick an exercise for a patient that is too advanced for their current capability. They may choose an exercise that stresses the right tissue or pattern, but will load the tissue in a way that the patient cannot adapt efficiently and will likely set them up for failure. It is imperative that we find the right landing spot for patients as we re-introduce load.
The appropriate landing spot is one that the patient can align the diaphragm over the pelvis, can cycle the breath while creating intra-abdominal pressure to stabilize the trunk and spine, and then maintain that control throughout the entire range of motion of an exercise.
Oh yeah – and most importantly it must not hurt. Discomfort is ok. Exercise is not always supposed to be comfortable – we are challenge and stressing tissue in order to force it to adapt. Working muscle can at times be uncomfortable depending on the intensity of the activity and the patients tolerance. But, it must ever be painful.
The graphic below walks through how I typically arrive at the correct exercise.
If we choose an progression exercise and the patient has pain, I will first reduce the weight. It may be the right progression with too much weight. If it is still painful then I will reduce the range of motion. It may be the right weight and you are just going too far into a range of motion that the patients body feels threatening – or that they cannot control. At that point if the exercise still hurts, then we have to move backwards with a regression of load to find the right landing spot. Sometimes that means removing weight and making a movement performed with bodyweight, and sometimes it means unloading the pattern by adding assistance or removing bodyweight.
With whatever modifications we choose, we must load patterns in order to obtain adaptation. So remember my knee patient who was told to never do lower body exercises again? She is now performing squatting, lunging, hinging, and stepping patterns with no real pain. Of course there are times when she feels some discomfort based on the position, load, or range of motion we use during an exercise but she is now executing all the movements she was told she would never do again.
When she feels discomfort we modify the exercise accordingly to ensure she can continue to load the pattern in order to continue to adapt. But, the real achievement here is that she is getting stronger and feels more confident and now reports that when she is going up and down stairs she feels less pain, more stability and no longer feels like she is going to fall.
It is amazing what happens when you can instill a mindset of resiliency and hope in your patients by using positive and affirming language, introducing them to load appropriately, and by utilizing a logical system of progression and regression in order to allow the patient to continually adapt and progress. The long term treatment outcomes are very powerful.
As always, be smart and train safe
About the author: Dr. Tom Teter is the developer of Rehab to Fitness, a hybrid 16hr live + 4hr online curriculum that teaches fitness programming post-rehab to healthcare practitioners and fitness professionals.
To learn more about all of the Rehab to Fitness course offerings and view the upcoming course dates, click here.