As rehabilitation specialists, patients come to us all the time looking to get back to their activities after an injury.
Typically, our job is to help them achieve their goal. But is there ever a time that we should advise them they need to stop?
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#AskMikeReinold Episode 299: Working with Conservative Rehabilitation Protocols
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Transcript
Student:
All right. There’s questions on telling patients or if we should tell patients to avoid certain activities and it comes from Denise in Fargo, North Dakota. She asked, “How do you determine when you finally need to give a patient that limitation of no longer performing certain activities? I love lifting and obviously part of the passion of PT is getting patients the highest level of activity possible. Then you have a patient that has developing history of back pain that aggravates it at least yearly and Hank Queens queen and jerks, et cetera. When is it the final straw on limiting activities for patients? Things like explosive lifts or running or sports?”
Mike Reinold:
I think this is a great question and I can’t wait. I feel like Dan Pope should lead this one off because you essentially described your day every day right there. But I’ll start this off by sharing a quick story with my low back pain. I may have shared this on a past podcast in there before, but Kevin Kauflin, who’s not here today on our podcast, but is often one of our speakers on here, I had him look at my back. And the first thing he said is that I needed to cut back on golf to get over my low back pain. And I said it as a joke, but I essentially said that I am paying him to help me golf more.
Mike Reinold:
It’s an interesting concept when you flip it that way. I do think that oftentimes in physical therapy, we tend to go immediately to restriction and immediately to taking away when sometimes we don’t realize that the whole reason the person is here, is to help them do the things they love that they want to do. And that is our goal. And when you take that back and you start saying like, well, maybe they don’t want to get out of back pain, or maybe that’s not their primary objective. They just want get out of enough back pain to be able to continue to do the activity they love. I thought that was interesting. I think Kevin learned a little bit from that because we talked about that perspective. We got to remember that as a concept. But so Dan, I know of all the people on this, you probably deal with their most. Diwesh you’re probably number two, right? Because people are coming in with that same thing in the gym, but you want to start it off Dan?
Dan Pope:
For sure. I think for every one of my patients, it comes down with a discussion about their goals. I’ve certainly been working with, let’s say like 50 year-old-men that are super stiff that love CrossFit and they love Olympic weight lifting, but they’ve got this horrendous mobility. They can’t get in a front rack, can’t press overhead, snatching is completely out of the question, but they’re still trying to do it all the time and they want to do it and that’s why they’re coming to see me. And if that’s the case, I’m going to try to get them better. And we’re going to try to figure out ways to improve that. And if they’re having elbow pain, shoulder pain, I will present the idea that if they do less of this, it’s probably going to feel better. And if they stop doing CrossFit and they just do general weightlifting and go run a couple times a week, they’ll probably feel a lot better, but their goal is specifically to do better at Olympic weightlifting. I’m going to push that as long as that’s the primary goal.
Dan Pope:
But the other part is that we have this discussion about goals because I think that’s important. There’s a lot of folks that go to a CrossFit gym and they’re just doing all the CrossFit movements and their goals are basically to be healthy and to be able to play with their grandkids and they’re doing hang cleans and hang snatches, and they’re doing movements where they don’t really have the mobility that keeps on aggravating things in their body. And I just tell them like, “Hey, if we just modify to these movements, is that going to make you upset in the long term? If you’re going to be upset with your ability to exercise if you’re not doing heavy snatch all the time?’ They say, “No, not at all.” I’m just like, “Fine. Let’s modify right off the get go.”
Dan Pope:
I think a lot of it comes down with first asking the patient’s goals. Mike, if you come in, you say, “You know what? I want to keep golfing my back hurts and I’m going to try to keep golfing as much as possible.” I think the other piece is that you have to look out for red flags. You see this lot in runner is I just had a discussion with Chris Johnson about this. If you have, let’s say Achilles tendonopathy you can probably keep running as long as the pain is below about a five out of 10. And your pain’s probably going to get better compared to continuing or stopping all painful activities in the long term.
Dan Pope:
And if you can keep exercising, great, I’m allowing you to continue. But if you’ve got a bone stress injury, then you can’t run through that and it’s just going to get worse. I think as often as possible, you’re trying to allow people to continue doing what they love to do. Oftentimes I’m giving people the permission to, but you’re also presenting the idea like, well, if you stop doing this, I think you’re going to do a lot better long term. And if they really, really want to push specific lifts, then yeah, I’m going to keep pushing it. But if there’s the opportunity not to, and they’re going to feel way better, I’m going to let them know.
Mike Reinold:
I like that. And that’s one thing about sports medicine that I think a lot of people don’t realize. You could argue like at the pro sports level, like in baseball with us, we get MRIs right away on most of our things, even in things that we normally wouldn’t get on in the general orthopedic population and it’s for that reason. Somebody comes in with a runny nose, we’re going to get an MRI in 45 minutes from now to just make sure that there’s no crazy reason why, because they and us want to get them back as fast as possible.
Mike Reinold:
And what we’re trying to do is immediately say like, “All right, let’s just make sure there isn’t something that is sticking out that is going to cause this person a problem and put them at risk. And if not, let’s try to work through this as fast as we can.” I like that. It’s all about their goals. And I think we really have to pay attention to that here is that we have to start thinking that this is a service industry. We are not dictators. People aren’t coming to us so we can tell them what to do, they are hiring us to help them achieve their goal. Man, when you flip your mindset to that, I think things really change. Dave, what do you think?
Dave Tilley:
I think I was talking to Kevin actually about your back and this, and this conversation of it’s important to understand the difference between a recreational kind of like, I don’t know, mid-level fun competition and elite sports. I think level setting people’s expectations. I’m getting there. I’m getting there.
Mike Reinold:
This is a dig already, but continue.
Dave Tilley:
Not honestly, I have a friend who loves you. It’s honestly. I think that with certain outer limits of sports and stuff and like the volume you play, you accept the fact that if you want to do it at a very high level or really, really frequently, it’s not going to be completely pain free, you always feel amazing and you can play whenever you want. And that’s not to say you can’t play whatever you want, you can’t throw a baseball, you can’t do gymnastics lead gymnastics, it’s a ton of this. You have to realize that, like you say, throwing a baseball is bad. It’s not good your shoulder.
Dave Tilley:
And so if people accept that’s going to be some of the trade off they take, which is, yeah, I have to deal with my cranky elbow once in a while and back off, or my back’s a little cranky when I play four or five days in a row or gymnasts are like, “My ankles are going to get a little sore in the middle of the season when I’m trying to compete five weekends in a row.” That just comes with the territory of either high volume or high level sports. And I think if you level set with people, like I think, yes, we should be the ones to help them do what they want, but we should also be the ones to educate them and give them just the advice that we have, which is like, “Hey, if you want to do elite gymnastics and compete at a very, very high level, it’s going to come with some bumps and some bruises and some moments where you got to back off. And if you’re okay with that, I’ll do whatever I can to help you achieve your goals.”
Dave Tilley:
But I personally think as a therapist, I don’t like to sugarcoat with people and be like, “Oh no, it’s all going to be okay. This is totally fine. You’re never going to have any pain at all and it’s going to be okay.” I want to be realistic with people that, this is really hard on your body and the same way you guys do with the elite baseball plays like, “Hey, this is probably not going to be long term the best thing for your shoulder, but I’m here to help you with whatever you want. Let’s just make sure we level set your expectation there.”
Mike Reinold:
And that’s sports. That’s sports, physical therapy, sports medicine right there. And we have to keep that in mind, but I do agree and I think both you and Dan said it really well. We do explain these things to them. And that’s why we laugh when we say that, but everybody comes with, they’re like, “Hey, why do you think my shoulder hurts?” And they’re looking for a reason it’s like, “They’re mechanics or something like that.” I’m like, “It’s just because you throw a ball for a living.” That’s why it hurts, that’s the definitive reason. It’s about that and sometimes it’s just about workload management and understanding, if you didn’t know that a hang clean could cause your pain and you’re just doing it anyway, and you’re thinking it’s coming from your foot or something like that, then, you just need to be educated on that and then talk about workload. But from there, I think it’s all about helping them tackle those peaks and valleys like you said, Dave. What else, Dan, you want to jump back in before Diwesh-
Dan Pope:
Yeah, real quick. I know I’m talking a lot here, but-
Mike Reinold:
No, I love it.
Dan Pope:
I think it’s super important just going off of Dave is this idea of expectations because people are going to come from the gym, be like, “Well, Sally can squat seven days a week and her knees never hurt. And I can always squat once a week and my knees hurt.” Going back to this conversation that, all right, doing too much of anything is bad for you, it’s very different from person to person. And you have to understand that and super common. I think people need to know that, hey, some folks can handle snatching four days a week, some people maybe just once and that’s how it is. I wish we could give you different genetics, genes, past medical history, better sleep, stress, you can’t change everything and that’s how your body is. And that’s a little unfortunate for some folks, but I think that’s just nature of it.
Mike Reinold:
I like it. Lisa, what do you do with your athletes?
Lisa Lowe:
Especially with what Dan just said in terms of, just different bodies and frequency of people being able to continue to row and that kind of a thing, I feel like I’ve had a really interesting group of people recently and that I have a lot of rowers who are in their late 20s and early 30s and realizing that their bodies can no longer handle the same amount that they did for college and the immediate like postgrad years. And they’re very confused that their body doesn’t like them to row every day or twice a day, all week long.
Lisa Lowe:
I feel like the interesting thing that typically happens is rowers then just like, “Oh, my body can’t handle this more.” And they ditch the sport altogether rather than realizing like, “Oh, maybe I need to actually strength train to be able to tolerate these things. Maybe I need a little bit more recovery time. Maybe, this one technique thing I’ve been doing my body really just can’t handle it anymore.’ I feel like that’s typically where my conversation goes is like, what piece of your week or piece of your body can we attempt to start to change over time that will allow you to at least continue to enjoy this sport. And maybe it’s not never row again in your life, but maybe it’s row four times a week instead of nine. And that’s okay.
Lisa Lowe:
And you can still have fun and you can still race and you can still be around the community, but you can take care of your body better and not live in pain constantly. There’s plenty of rowers who come in their late 20s and are like, “Oh, I’ve literally just lived in pain for the past decade because that’s what I thought rowers had to do.” It’s like, “Well, no. There are these other things.” I have had one instance, maybe two where I’ve had to tell somebody, “Rowing is maybe not your best sport,” but it wasn’t because they couldn’t eventually do it, it was because they weren’t capable of doing the other things their body needed to maintain a healthy body in their current space. It’s like maybe when you’re later on in life, you’ll be able to come back around to this and not be painful again. But I don’t think I really ever look to tell someone that they shouldn’t be doing something. It’s just like, what do I help you figure out so that you can do this right.
Mike Reinold:
Absolutely. And then call me crazy Mike, that’s to the tea essentially the same thing with your population with golfers. They’re coming to you for a reason, but it sounds like everything Lisa said was similar for you, right?
Mike Scaduto:
Yeah. I think that’s certainly the conversation that I have. And then, I think a lot of patients, younger patients, I work with a lot of younger baseball players as well. I work with junior golfers, but also golfers who are a little bit older. They’re really looking to draw on your experience on how these type of things progress and what does the future look like for them. A lot of what I’m talking about with my patients is how they’re going to manage these symptoms in the long run. Part of our goal is to always make progress. I let them know from the get go, I say, “We can do these activities. Here’s how we’re going to be able to tell if we’re making progress.”
Mike Scaduto:
If we have a less intensity of pain, that pain goes away quicker after the onset of discomfort at a less intensity, or if a flare up is a little bit further in between. You Have more time where you’re feeling good, even though you may not be able to totally avoid a flare up of low back pain when you’re playing, you can play 20 rounds instead of three rounds before back pain comes on, that’s signs of progress. But we’re always talking about, how do we manage this going forward in the future? And also, what’s the risk assessment of this progressing into something more serious.
Mike Scaduto:
I’ll be honest, I shut people down from throwing all the time and those younger kids where they may be borderline bone stress injury, say this is what this progresses to. Here, I’ll lay it out on the table for you and we don’t want to let you get to that point. I think this is in your best interest right now. Let’s take a break from throwing. I think there’s a lot of factors that go into that, but patients really came to you for the plan and for your experience and how this plays out over the next couple of years. I think that’s what they’re really looking for.
Mike Reinold:
I think sometimes we take that for granted too, you know in your head exactly how this is going to progress and sometimes, we take that experience for granted. The person in front of you’s never felt this before and they have no idea which direction to go, so they’re really leaning on us for that. That’s a good comment there. All right. Diwesh as the strength coach, that is the person programming their hand cleans, just to go from here, how do you handle this type of person? From us in the rehab perspective, I think we get the little bit of the … We feel a little bit more comfortable shutting people down, do a little things, what are some strategies you use for somebody that you think maybe wanting to do things that is maybe causing their pain to linger?
Diwesh Poudyal:
I want to quickly go back to what Dave and Dan said earlier, just so I can put it all together. I think A, no matter if it’s rehab or performance, we got to go back to the conversation of, there is a cost of doing business. Whenever we’re trying to do stuff like hang clean or heavy squats, deadlifts, we can’t expect things to go perfect all the time, no pain, whatever. And then I think to build on that, there’s certainly a difference between being hurt and being injured. I think even in this question, I think it mentioned that this person, this particular person has hang cleans and has back pain twice a year. I think to me, that’s probably not that far from normal, you-
Mike Reinold:
Success.
Diwesh Poudyal:
… know what I mean? To me, that’s like a successful year of training. They might have gotten hurt twice and then they get back on the saddle and they get back after it. To me, that’s probably not that far off. And what I would do in that situation is, it’s always a conversation of you add some and you take away some. When you’re in a period where you’re probably, pretty healthy, that’s probably a really good time to add in some extra stuff. Maybe some mobility, some stability stuff, some dynamic control stuff to make your entire system a little bit more resilient injury for that particular lift. So we’re going back to the concept of cleaning jerk, maybe we work on some extra mobility and Ts fine mobility in the hips and ankles so that we can get into a better receiving position. Maybe we work on some overhead mobility and dynamic overhead stability to work on receiving the jerk or a snatch, whatever it may be. And we give a heavy dosage to that, and we prioritize in a certain time of year.
Diwesh Poudyal:
But now on the other side of the equation, if you hurt yourself last week doing that, maybe let’s take away clean and jerk for a week, maybe two weeks and add in some more baseline stuff and then build back up. But yeah, I think you guys all kind of said it, I don’t know that I’d necessarily jump right away into taking away that exercise, unless it was one of those, all right, you’re totally injured from this exercise, and you don’t have the goal of getting good at this exercise. It definitely does go back to the whole goal concept. If you don’t care about that exercise and you don’t have to do it, have plenty of people that don’t want to do hang cleans. My athletes don’t do hang cleans, they don’t want to do hang cleans. But if they really do, I’m literally going to try everything in my power to make sure that they can and then have the conversation with them and tell them that, if you get a little hurt, it’s fine, we’ll build you back up and we’ll keep making you better.
Mike Reinold:
I like that-
Diwesh Poudyal:
Twice a year, that’s …
Mike Reinold:
That’s right. You know what? I didn’t even pick that up from the question, but you’re right. But yeah, if you just once or twice a year, your back yard’s from a lift, I think that you’re right, that probably is success. Because most athletes are always pushing the envelope. They’re always flirting with like max capacity. Having that little flare up, I think is part of the educational process for them and then perhaps they’ll learn, all right, you know what? I wasn’t feeling good last week I was tired and I still pushed, I won’t do that next time. No need to panic, just go from there. What else? What do you think, Dan?
Dan Pope:
I was just saying, for some athletes, if you’re getting some pain, it’s like, all right, we’re pushing enough. We’re where we need to be. Oftentimes before power there’s peak for competition, they’re getting little aches and pains, things are starting to break down. And it’s like, okay, we are figuring out our limits and we’re there. We’re pushing as hard as we possibly can with our recovery. Like Diwesh said, that’s part of the game you play sometimes.
Mike Reinold:
I love it. I love it. I think, to summarize a little bit here for Denise here, I don’t think we ever seek out to say, “It’s time that you stop doing this.” We think our job is to help people to enable them to perform the activities they want to do. I think that’s the whole premise of physical therapy, but especially even sports physical therapy, when we talk about the athletic population. For us, I think that’s super important, but like Diwesh said, regress work on building blocks, work on trying to increase their capacities so they can do that.
Mike Reinold:
Like Lisa, Mike, Dan, everybody said a little bit here is educate them on the concept behind it, the workload progressions behind it. There’s so many things that I think we can do that. For us, it’s that last, little bit, but we do owe it to them to educate them on what it is they should be doing. And to say like, Hey, look, this may be stressful, but we’re going to manage it together. I think we owe it to them to say that, but great question, Denise, I think a lot of people are dealing with that. Really appreciate that. If you have a question like Denise, please head to mikereinold.com, click on that podcast link and you can fill out the form to ask your question and keep them coming, we’ll see you on a future episode. Thanks so much.
