Patients need two topics clearly explained to them: how they can expect to feel as they are exercising, and how to tell if they are pushing their rehab program too far. This is especially important for men and women who haven't exercised very much in the past, and are not sure what to expect. It is also necessary for athletes and athletically inclined patients who may try to advance their rehab too quickly. All patients need specific, easily understood guidelines from the doctor or assistant before any exercise program is initiated.
Initial Guidance
Unless you have a sports-oriented practice, few of your patients will have much experience in performing specific exercises. Most have probably never exercised beyond the occasional recreational activity. These patients make more satisfactory improvement when they know exactly what they can expect to feel as they start exercising. They will appreciate your reassurance and guidance, and are more likely to follow through with your recommendations.
The following is an example of how I often prepare my patients: "As you start to exercise this area, you may feel some soreness, stiffness, or possibly some mild irritation in the involved joints and muscles. Not only is that natural, it means you're working the right area." This message provides encouragement, and prepares the patients to expect some soreness as they start to exercise a problem region. I then discuss the possibility that they will feel some actual pain. It is important for patients to be able to know the difference between true "pain" and soreness or stiffness.
The "No-Pain" Program
When patients initiate a rehab program on an area of the body undergoing healing, the exercise(s) they perform shouldn't cause pain. Some patients (athletes in particular) are convinced that exercise has to be painful in order to be beneficial (the counterproductive "no pain, no gain" concept). I don't want my patients exercising through or beyond a painful point, and I tell them so. It is critical to cover the topic of pain when recommending an exercise/rehab program; otherwise, some patients won't know when they have done too much. I find that explaining the concept of "overflow training" is helpful for some patients.
Overflow and its Benefits
Overflow is a neurological concept that has been noted time and again when studying strength gains. Whenever exercise in a limited range of motion is performed, the strengthening extends beyond that limited range. In most types of exercise, this amount is about 15 degrees beyond the exercised range. In contrast, isometric exercise provides a limited benefit of up to 10 degrees only.
Eventually, the 15-degree overflow of stimulus expands the pain-free range, so when a patient exercises regularly in the pain-free range, that range gradually but inexorably increases. This allows for a more steady response than trying to force a range expansion, which can produce a return of painful movement. The only challenge is communicating this accurately to the patient.
"Stop" and "Go" Zones
When I tell patients to "exercise only in your pain-free range," most of them don't really know what I want accomplished. In addition, they are not exactly sure how to implement this idea in their rehab program.
To ensure accurate communication, I tell my patients, "As you do this exercise, you can expect to experience some stiffness and soreness. However, I want you to pay attention whenever your body gives you a pain message while you're exercising. This pain message is a warning, just like a yellow traffic light or caution sign. The pain message doesn't mean you have hurt yourself; however, if you push the exercise beyond this point - into the continually painful red zone - you risk aggravating your condition and slowing your progress. You should do your exercise all the way through the pain-free green zone and up to the yellow light. Don't exercise into the red zone. It's not necessary, and it will likely slow your progress instead of speeding it up."
A Joint Strengthening Example
Shoulder rehab is a region in which this is often a particular problem. It is easy for a patient to start exercising and want to push beyond the pain point, in order to make progress quickly. For example, strengthening the shoulder flexors is frequently necessary, both with chronic and acute conditions. As the patient pays close attention, an obviously painful point of restriction can usually be identified. As long as the patient continues to exercise repetitively to this point and not beyond, rapid progress can be expected, and the green (pain-free) zone will increase.
Green-zone increase is not always steady. Sometimes the patient will notice gradual improvement at the beginning, but then observe that the green zone is slightly less than what it was the day before. Not wanting to retreat and lose the progress made to date, some patients will force the shoulder to exercise beyond its current pain point. This "second-guessing" must be avoided. While we may not know the reason for the temporary loss of pain-free range, we do know that forcing beyond the green zone is not the answer. For whatever reason (weather changes, increased activities, or simply "unknown"), the body is letting us know that it cannot tolerate as much stress to the area as it had previously. It is vital that patients learn to listen and trust the wisdom of their bodies. This is surely one of the most important lessons a patient can learn while in our care.
Reassurance Builds Confidence
Don't be afraid to start your patients on an exercise program while they are still experiencing some pain. Waiting will just unnecessarily prolong the program of care and make recovery more difficult. Reassure your patients right away by letting them know what to expect, and then provide descriptions of the red and green zones. Patients are then able to approach their exercises with confidence. They will be comfortable with the soreness and stiffness from a new exercise program, but they will also understand that a "pain message" during exercising is something they should not ignore.
Avoidance of pain should lead to more consistent chiropractic results, and also to patients who appreciate your expertise in the field of musculoskeletal problems.
Kim Christensen, DC, DACRB, CCSP, CSCS
Director, Chiropractic Rehabilitation and Wellness Program
PeaceHealth Hospital
Longview, Washington
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