Friday, 12 May 2017 10:32

The Gain of Pain

By Matthew Goodemote | Families Today

Last week I noticed I was teaching the same type of lesson to multiple patients and decided I would attempt to write about it for this week’s article. There is one patient in particular that really stands out in my memory. She came to me with left lower back pain, but at her last visit she told me it was her whole lower back that was bothering her and that it didn’t seem to her to be in any one area. 

When she first started coming to me she seemed to respond very positively, but after a few days the movements I asked her to do did not seem to be having the effect it did initially. She was frustrated and wondered if the exercises I sent her home with had made her worse. This is a common concern I hear, and my typical response is “if it is the exercise that is making you worse then you will be worse doing it or immediately after doing it.” 

It is so important to me that this point is emphasized because too often people are afraid of making their condition worse so they avoid activity. It is also common for people to be advised to avoid too much activity using the same belief that movement could make their condition worse. This has not been my experience personally or treating patients with back and neck pain for the last 20 years.

I told my patient we would figure out for certain if the exercises were the problem, and that what mattered more to me was that she learned how to discern what was making her worse and what to do to alleviate her symptoms. 

This is very important! When trying to figure out what is making your condition worse, it is VERY important to examine what you are doing at the time your pain gets/got worse or what you are/were doing immediately before it got worse. Also, instead of always thinking it must be related to an activity, consider that it may be what you are doing...when you are inactive. I have more patients that aggravate their back and neck while sitting than walking. 

The movement or activity you are doing that may be causing you more problems is typically easy to identify... I often use this example with patients: “when you sprain your ankle you know at the instant you did it or immediately after you did it. It is NOT like you roll your ankle and then four hours later your ankle starts hurting.”

So, as a starting point, focus on the exact thing you are doing when your back hurts (including sleeping, sitting or just standing there) and/or what you were doing immediately before it hurt.

Through the years, I have simplified my assessments and recommendations based on how the patient responds to specific movements and position. The movement is not what matters, the response to the movements or positions is what matters. 

One of the most challenging issues I face is teaching a patient to zero in on each moment of each day. Their issue is unique to that moment of time. Meaning just because something hurt yesterday does not mean it will today, and just because something helped yesterday does not mean it will today. Too often we are seeking to just find something that works but don’t like it when the something is different! I often say back pain is commonly “consistently inconsistent!” What matters most is trusting the body at the exact moment you are having an issue and trying to resolve it by identifying what is provoking it so you can stop...at this moment...and what specific strategies you can use to alleviate your pain...at this moment.

What works for one person may aggravate another person. No one has the “exact same issue” as another person just because they have the same diagnosis. This is important; just because one person has sciatica does not mean they will respond the same as every person with sciatica. This is also very important, if you had sciatica ten years ago is not the same sciatica you have today. In ten years, your body and life situation is different than it was the first time, and therefore the solutions may be different! What I am saying is...find what works for you NOW...then use what works for you.

This all sounds obvious, and yet this is often what I am explaining to patients each week,  partly because they are discouraged when their symptoms don’t respond how they anticipated or how they have in the past. 

My approach has evolved to a point where I am looking for immediate results and if the results are not what I expected then I am relying on the patient’s body to teach me what they need next. This requires an understanding of a few principles. The most valuable tip you can take away from this article is this:

Establish baselines: 

a. symptom baseline

b. movement baseline

Try a movement or a position (a stretch or activity)

Re-test your baselines

How did your symptoms change because of the movement / position?

 . How did your movement change because of the movement / position?

Using my patient as an example, I had her check her lower spine motion. There are four directions I check.

1. Bending forward

2. Bending backwards

3. Side glide to the right

4. Side glide to the left

My patient started with lower back pain. Her movement assessment revealed more pain on her left with both side glide motion. So, my focus now becomes finding a movement / position / stretch that will alleviate her pain and/or improve her motion. I also zero in and focus only on the movements that were limited and which one is limited the most becomes my main focus.

The movements can be any movement you have been taught, read about or watched someone do. What matters is that you pay attention to how you are feeling while doing the movement/position/stretch and how you feel after completing it. Next I have the patient re-check their motion and see what effect the movement/position/stretch had on their movement.

I recommend doing the movements that feel good during and after and/or help the patient move better afterwards. I honestly do not subscribe that when you are trying to alleviate pain you should first increase the pain. “No pain no gain” is not a smart plan here. Instead I call it the “calm down mode.” Do what calms things down and avoid what aggravates the condition. This works well and makes it easier for patients to continue because they see the results in a short amount of time. 

My patient experienced considerable relief and considerable improvements in her motion by applying this concept. Then she asked, “should I be doing all of these stretches at home?” To which I responded…”no, you should only do the one/ones that makes you feel better and move better!” Meaning...it’s NOT the stretch that matters, it is the effect of the stretch after that matters. 

I can’t tell you how often a patient comes in and tells me they did all the stretches and it doesn’t seem to be working. I typically try another way to emphasize the point that I am looking at how they feel and how they move during and/or immediately after an individual movement/position/stretch. I really emphasize focusing on and relying on baselines (symptoms and movement) to know if the movement/position/stretch is helping. 

So, if you want the bottom line...here it is. Do what helps you move better and feel better after. Stop doing what makes you move worse and helps you feel worse after. Please don’t misunderstand I am not saying to stop if it hurts...I am saying stop if it hurts more after and if you are moving worse after.

Back pain typically responds to movement but remember it can be consistently inconsistent. Don’t give up...keep trying! And remember that it is this moment that counts. Just because something helped or hurt the last time does not mean it is true this time. Ultimately the goal is to resume all activities, movements and positions without pain. The safe way to get there is by getting familiar with how you feel and how you move before and after trying something. When you move better and feel better after doing something, you are heading in the right direction!

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