One of the more common questions we get from students is knowing when to push someone or back off.
As always, the answer will depend on the situation. But, there are some principles to guide you.
We discuss what we do and how to avoid the ups and downs.
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#AskMikeReinold Episode 333: How to Know When to Push or Back Off
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Show Notes
• How to Progress Loading Strategies After an Injury
Transcript
Mikaela Meyer:
All right. So we have Sarah from California, “I’ve been a PT for about five years now and still often feel unsure when to push or back off something during rehab. How do you know when you’re pushing too much or too little?”
Mike Reinold:
That is a great question. Probably one of the things we talk about the most in and around, you know what I mean? That’s such a topic of even just progressions of exercises, or range of motion post-operative, that type of thing, is how do you know when to push? How do you know when to slow down?
And it’s kind of funny. I’ve seen this commented on on social media. And people try to give you an answer on social media saying like, “Never push,” or something like that. It’s one of those things… There’s so many variables that sometimes you need to push, sometimes you need to back off. It really depends on the situation.
All right. Who wants to start this one, Dave?
Dave Tilley:
Yeah, I just had this conversation. It might have been with Mikaela or somebody else. But I think one thing that’s tough about orthopedic PT and maybe why we’re a little bit different is I think a lot of PTs are good-intentioned, but they don’t understand what a normal, hard training session is. And I think the strength coaches we have understand that very well. And I think the PTs are great.
But there are times when you’re pushing someone, and they’re a little sore, or they’re a little tired, or whatever, or the next day they get sore, but it goes away within a day. And it never really bumps up into an acute pain situation. They’re just sore and tired. It’s global, and that’s exactly what we want. People need to be pushed and challenged to get stronger and to get back to the stuff they want to do.
And I feel like that’s usually a really important baseline. You have to understand what a normal, healthy response to training is before you start to say like, “Was this too much, or was this not enough?” And I think there are proxies you can use that are a little bit more like, “Okay, this is dabbling into maybe not productive,” which is the swelling increases maybe at a knee joint. Or the range of motion goes down acutely because there’s some mild effusion and they lose five degrees of extension or five degrees of bending. Or their pain is very specific to one spot and they have trouble with their ADLs. Or it doesn’t go away in two days, it stays elevated over the weekend.
Those are rules of thumb you use to be like, “Okay, maybe this is more of a ‘we’re irritating the tissue. We’re not getting a global training response.'” So that’s pretty much always how I got it: what’s normal, is this abnormal, and why? From swelling, range of motion, ADL, stuff like that.
Mike Reinold:
I like that. And I like how Dave, in his head, because it changes for what you’re dealing with here… Sometimes one of the metrics that you look at on how well they’re tolerating the progression is the body’s response. And I like how he said it. “Did the knee puff up? Okay, so maybe you did too much.”
And by the way, you work with them for what, two to three hours a week, and they have a lot of hours on their own the rest of the week. It’s not always did you do too much, but as a whole, are they doing too much? I like that. That’s a good one.
What else? Who else? Dan, what do you think?
Dan Pope:
Yeah, I know we chat about this sometimes, but I also think it is going to depend if someone’s, let’s say, non-op or post-op. And I think a good example, maybe this is an outlier, is like a rotator cuff repair where I’m sure you guys have seen this. Every once in a while you get a massive rotator cuff repair. They come for initial evaluation, they’re two weeks out from the surgery and they’re like, “Oh, I’m feeling great.”
And you’re like, “Whoa, whoa, whoa, whoa, whoa, whoa, whoa. Stop, stop, stop.” And that’s one of those situations where it’s like, “Okay, we can’t be doing that. It’s putting a lot of strain on that repair site. Need to back off.”
And this is where protocols are actually kind of nice. You say, “Okay, at this week we can start to slowly introduce this and start to ramp up.” And hopefully the protocol is made with some sound logic, some research, maybe some EMG studies, some thought with it.
And then I also tell patients in terms of pain, if it feels tolerable, you’re allowed to do it at that point. And the next day you feel pretty good, your range of motion is still improving, your pain’s going down, your function’s getting better, your strength is improving, we’re moving in the right direction. So we’re kind of monitoring for symptoms.
I think where it gets a little bit more confusing are those non-op patients that come in with, let’s say, a tendinopathy, joint-related pain. Maybe a bone injury is a bit different because we probably shouldn’t be pushing through pain. But for folks with tendon problems, joint problems, we probably can push into some pain. And at least from an exercise prescription standpoint for athletes, and it’s probably going to change for the average person. You probably want to push them as hard as they’re supposed to be pushed at that point. So if they’re like, say an off-season soccer player and they need to work on strength three days a week and conditioning whatever it is, we want to maintain that as much as possible.
So in terms of exercise prescription, you want to continue everything as much as you possibly can within tolerance. And you can use the pain monitoring model, so less than a five out of ten, back to baseline, kind of like Dave said. And over the course of time, if you’re progressing, getting stronger, pain going down, you’re doing great. When you’re choosing exercises, you want to try to support them as close as what the sports needs are and as much as they can possibly tolerate because the higher level of exercise you give them, the more of a response you’re going to get.
So that’s my go-to. If you’re concerned you’re going to cause a flare-up, start with something easier and over the course of time, ramp up. But I think you’re trying to meet the athlete where they are.
Mike Reinold:
I like that. It’s a good way of shifting your thought process and understanding that somebody that’s a post-operative surgery that has healing constraints, there are actual constraints on tissue that needs to heal, that’s a lot different than somebody needs to be pushed. So I like it.
Dan kind of commented a little bit on how we use pain sometimes. And sometimes you want zero out of ten. Sometimes you actually want three, four out of ten. That’s actually part of the prescription.
Strength coaches, maybe Jonah, if you don’t mind jumping in, how do you instruct somebody to push their intensity appropriately then? That’s pain. But how about somebody that’s not in pain? I think in physical therapy, Dave kind of alluded to this I think, but we chronically under load, I think. I just think we under load people a little bit and don’t push them enough. How do you know that they’re doing enough loading, and how do you get somebody to pick the right intensity when they’re doing exercises?
Jonah Mondloch:
Yeah, I think there’s two main things that pop into my mind. So the first is just being aware of who the person is in front of you. Are they an older adult? A younger kid? Someone who’s new to the gym where maybe our main goal is just to get them to enjoy working out and starting with that, and then over time worrying a little bit more about the intensity? Versus are they a college athlete who’s with us for three months in the summer and is trying to get more playing time that fall? In which case, we do need to push things a little bit more? Or are they a professional baseball player? Similar thing, they need to increase velo, or exit velocity, or whatever. So one is just starting with who is that person in front of us.
And then a second is almost trying to give them opportunities to learn those things for themselves. So one of the strategies we’ll use is having sets where they’re doing as many reps as they can of a similar exercise they’ve been doing. And we’re standing there, we’re cheering them on, we’re telling them, “Get two more. Get two more.” And all of a sudden they do five, six, seven more reps than they had been doing in training previously. And then we can have a conversation based off that of, “Okay, that’s what a hard set feels like. Not every single set has to be that max effort. But now you know what hard is, let’s train a little bit closer to that.”
Or another tool is something like a gym, where you’re giving them a targeted speed and it might be something that’s really slow and they’re still lifting heavy, or it might be something that’s really fast with a lighter weight, but in either way we’re queuing them or teaching them, “Go as heavy as you can where you’re not dropping under this targeted speed.” So if the target speed is 0.5 meters per second and everything they’re doing is in the 0.6s, go heavier. And we just tell them, “Keep going heavier,” until they fail.
So giving them opportunities to learn by themselves, by approaching failure and trying to just learn what it feels like to actually train hard.
Mike Reinold:
I think that’s so important, too, Jonah, you said that so well. It’s about education. They need to understand that.
And then for the advanced stuff, you can use metrics. But it’s about education. So that’s huge.
So I’d just summarize a couple of things. One little tip that I do sometimes is I just simply ask the person, this is usually early on in that process, “Was that easy, moderate, or hard?” And they never say hard. It’s always easy or moderate. So whatever they say, you just say like, “All right. Let’s add weight to that.”
And you go up, and then eventually they’ll be like, “Okay, that’s hard.” And it might’ve took three, four times for you to add some weight to do that, and they’ll get there.
But Len, did you have anything to add? Did you want to jump in too? Sorry.
Lenny Macrina:
Yeah, I do, because I deal with this a lot. I guess we all deal with it. But I deal with it, in my head, a lot with ACLs that are seven, eight, nine months out or even that early ACL or early Tommy John. I push people, I want to say, kind of intentionally, but I do it knowing that if I do aggravate things, it’s not going to be the end of rehabs. Like I push a rotator cuff and you can tear their cuff. I could push the knee a little or Tommy John a little depending on what I’m doing and then just see how they do.
But I think another key component is seeing how the person responded to the pain, meaning, “How did that make you feel about increasing the pain and soreness?” Because some people freak out if they’re in pain, and they can call it a three out of ten, but to them a three out of ten is like a nine out of ten. So I wonder, “How’d that make you feel about the pain increasing?”
Some people are like, “That felt really good. I feel like we actually pushed it, and I feel good about it. And I know I pushed it in a safe way,” meaning I had them do a deeper squat. I had them incorporate a deadlift. I had them go up in their dumbbells after a Tommy John repair or reconstruction.
And so it’s how do they mentally feel about that new soreness, that new pain, that I want to know about too, because that’s going to tell me, “Can I push them even more, and they’re going to be okay with it? Or are they going to freak out, and they’re not going to be happy with that new sensation that they’re feeling?” So I like to know the mental component of how they’re responding to the new challenges too.
Mike Reinold:
Yeah, I think that’s great too. Again, it’s part of the education process too. It’s like they have to educate that this is an appropriate progression right now.
Dan, did you have something else?
Dan Pope:
Yeah, just real fast to add to Lenny’s. I think PTs don’t want to hear this. They want to hear what is the absolute best thing to do for your patients. But if you look at some of these studies where you push through pain or you don’t, the longer term outcome is very similar.
So I think the key is do what works for the patient. If they want to push through some pain, great. If they don’t, great. That’s fine too. Probably a large variety of what’s okay.
Mike Reinold:
Yeah, and I think more importantly is I want you to think this way. Avoid the roller coaster. There’s nothing worse than the roller coaster. You speed up so much that you panic and you have to slam the brakes on, slow down and then, “Oh gosh, we’re getting behind again. Let’s speed it back up.” You got to avoid that.
You’re never going to have a complete linear progression. But you can have little speed bumps, not roadblocks. That’s the big thing is you don’t want to have these gigantic ups and downs. So you make micro adjustments day to day based on what you’re doing. So just like you shouldn’t pull back real fast, you shouldn’t push forward real fast. You shouldn’t go from 90 degrees to 120 degrees one day, just making it up, or double the load that they’re doing one day. You have to have that nice natural progression.
So I want you to think of that too as you go through. It’s like, “No roller coasters,” just, “I want to have as smooth of a linear progression as I can.” And I think just if you approach it with that mentality, sometimes that actually tells you a little bit. “Okay, last time I pushed this much, I’m going to do a touch more today, but not more.” And I think it gives you a little bit more of a goal in your head to shoot for that hopefully ends up helping the patient.
So great question. If you have anything like that, head to mikereinold.com, click the podcast link, and ask away. And be sure to subscribe on Apple Podcasts or Spotify and rate and review us. We do read those things and appreciate everything that you guys send. Thank you so much. See you on the next episode.
