Rehab without Pain

We chiropractors work hard to get those in our care feeling better. Therefore, it serves no one's interest to recommend rehabilitative exercise regi­mens that cause more pain. One of the best methods to avoid this is to give clear in­structions when the patient begins his or her program of rehab therapy. Two topics need to be specifically communicated: what patients can expect to feel as they are exercising, and how they can know if they have pushed the exercise too far. This is im­portant for those patients who have never exercised before, and don't know what to expect. It's also necessary for athletes and oth­ers (such as so-called "week­end warriors"), who may try to advance their rehab too quickly. Clear, specific guide­lines from the doctor or assis­tant are needed by all patients before an exercise program is initiated. Patient Preparation Most patients have little ex­perience in specific exercises. In fact, many have never exer­cised beyond the occasional recreational activity. These patients make greater improvement when they know exactly what they can expect to feel as they start exercising. They will appreci­ate your guidance and reassurance, and are more likely to follow through with your recommendations. I often prepare my patients with some verbal information, such as: "Asyou be­gin exercising this area, you may feel some soreness, stiffness, or possibly some mild irritation in the involved joints and muscles. That's normal, and it means you re working the right area. " This message provides encouragement, and it 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 Pain Issue An area of the body that is healing shouldn't be con­tinually aggravated; so, when patients undertake a rehab program, the exer­cise^) they are performing shouldn't cause pain. Some people (athletes in particu­lar) believe 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. While this seems obvious to most of us and to many pa­tients, 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. Strength Benefits of Overflow "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° beyond the exercised range. In contrast, isomet­ric exercise provides only a limited (around 5°) benefit. Eventually, the 15° overflow of stimu­lus expands the pain-free range; so when a patient exercises regularly in the pain-free range, that range gradually, but in­exorably, gets larger. This allows for a more steady response than trying to force a range expansion, which can then pro­duce a return of painful movement. The only challenge is communicating this ac­curately to the patient. Red and Green Zones If I say "exercise only in the pain-free range." most patients don't really know what I want them to do. In addition, they are not exactly sure how to implement this idea in their exercising. To ensure accurate communication, I tell my patient, "Asyou do this exercise, some stiffness and soreness is to be expected. However, if your body gives you a pain message while you 're exercising, I want you to pay attention. This pain message is a warning signal, just like a yellow traffic light or caution sign. The pain message cloesn '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 the exercise all the way through the pain-free green zone and up to the yellow light. Don 't exer­cise into the red zone. It ,'v not necessary, and it will very likely slow your progress, instead of speeding it up. " The Shoulder Example A region where this is a particular prob­lem is in shoulder rehab. It is easy for a patient to start exercising and want to push beyond the pain point, in order to make quicker progress. 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 » Continued on page 50 ...from page 46 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 initially, but then ob­serve that the green zone is slightly less than 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 the 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 could previously. It is vital that patients learn to listen to and trust the wisdom of their bodies. This is surely one of the most important lessons a patient can learn while in our care. Conclusion 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 treatment program 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 arc 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. The end result will be more consistent chiropractic results, and patients who appreciate your expertise in the field of mus-culoskeletal problems. Kim D. Chrislensen, D.C., C.C.S.R, D.A.C.R.B., founded the SportsMedicine & Rehab Clinics of Washington. He is a popu­lar speaker, and participates as a team physician and con­sultant to high school and university athletic programs. He is currently a postgraduate faculty member of numerous chiro­practic colleges and is the president of the American Chiro­practic Association (ACA) Rehab Council. Dr. Christensen is the author of numerous publications and texts on musculosk-eletal rehabilitation and nutrition. He can be reached at Chiropractic Rehabilitation Consulting, 18604 NW 64th Avenue, Ridgefield, WA 98642 or by email at