How Much Pain Can We Push Through During Rehabilitation?

I’ve written a bit about whether or not it’s ok to push into pain during rehab of chronic injuries and we’ve got some cool research to show that not only is it alright to encourage pain during rehab, but even beneficial.

Should You Push Your Patients Into Pain During Physical Therapy Exercises?

However, how much pain is OK?  Surely if we blow through too much pain we’ll end up worse then where we started?

To be honest, there are probably certain injuries you can push through and they get better and some that you push through and they’ve gotten worse.  Spend some time training at any gym and you’ll see athletes work through pain all the time.  Sometimes injuries get better and sometimes they get worse (and they end up in my office).  So how do we regulate how much pain is ok and what isn’t when rehabilitating through an injury?

It makes sense.  Tissues heals through a concept called mechanotransduction.  Basically stressing injured tissues causes a healing response (among other central / brain related responses).  If you have an injury, and an exercises creates some pain, we’re probably stressing the right tissues.  With this logic, encouraging some pain may be beneficial.

Today I wanted to share a little golden nugget I stole straight out of Adriaan Louw’s text, “Therapeutic Neuroscience Education.”  One topic Adriaan writes about in depth are the ideas of pain thresholds and how they apply to rehabilitation.  He creates some great, easy to understand graphics that immediately help patients to understand how much pain they should be pushing into.

Let’s use the example of knee pain.  Let’s say my knee is hurting because I decided to squat 10 sets of 10 reps at 70% of my max because I read an article about how cool German Volume Training was.  Not a bad choice, I’d probably do the same thing.  Anyway, now your knee feels pretty terrible when you try to go up and down the stairs the next day.  Take a look at this first image.

This image represents your body’s pain threshold before you decided to do 10 sets of 10 reps of heavy squats.  Really nothing bothered your knee and you’d have to do some really stupid stuff to have it hurt. Now check out the second image.

Now you can walk and perform stairs without pain but anything loaded in the gym or running related hurts your knees.  It makes sense.  You did too much and the knee is irritated.  Your body is trying to keep you from doing more stupid stuff so it makes your knee tender.  This grants some time for the knee to recover.

In some conditions, time away from what caused your injury and a slow ramp up back into training after the injury is enough to get full recovery.  If you avoid loaded squats for a week or 2 and then slowly increase the load over the next following weeks you might be ok.  However, in a lot of cases pain can become chronic and not go away.  This is certainly true in knee pain issues like patellofemoral pain syndrome where rest generally doesn’t provide full recovery.  So what do we do in this case?

In the image below we have a graphic that displays someone in chronic pain who never pushes enough to get to their pain threshold.

 

This represents the, “If it hurts don’t do it” individual who is avoiding anything that could potentially create more pain or injury.  Like we discussed earlier, sometimes this strategy doesn’t work and we have no improvement in pain.

The photo below depicts the opposite person.  This person blows through their pain threshold:

This is the guy who hurts his knee doing an olympic lifting program and doesn’t change anything in the program despite his knee killing him after every squat session.  This guy generally doesn’t make a ton of progress over time either and may end up getting worse.

Now look at this third depiction below:

This is the sweet spot we’re looking for.  In this case we have someone in pain who exercises near their thresholds.  As you can see, over time their pain thresholds improve and they can tolerate a bit more exercise.  Over time they continue to challenge themselves further and pain continues to improve.  Bingo.

I like to compare exercise dosage to the dosage of medicine.  If you have a headache and take a half an aspirin it might not do the trick.  If you have a headache and take the whole bottle, you’re probably going to die.  If you have a headache and take 2 aspirin, the pain generally goes away.  The aspirin is still the solution, but the dosage needs to be right.  The same thing goes for exercise.  The exercise is the medicine that makes you better, but the dosage is incredibly important.

I always say pain is like goldilocks in the story of goldilocks and the three bears.  Pain is a pain in the ass, just like Goldilocks.  We need just the right amount of exercise to progress just like Goldilocks needs the exact perfect temperature of porridge to be happy. (Who eats porridge anymore?)

Let’s say our knee pain individual has trialed rest for 3 months but his knee is still hurting and he feels like he’s made no progress.  Let’s say we start giving him some exercise that’s at his current threshold:

  • 3 sets of 8 reps back squats @50%

The load is submaximal and creates a little bit of pain, but the pain is minimal.  3 weeks later his pain is improving so we progress his program:

  • 3 sets of 5 reps back squats @80%
  • 3 sets of 10 reps dumbbell split squats

The exercise is still painful but again our patients is feeling better after another 2 weeks.  Now we progress again:

  • 3 x 3 Squat cleans @ 70%
  • 3 x 3 front squats @85%+
  • 3 x 10 reverse lunge
  • Light jog 10 minutes

Make sense?  All we’re doing is throwing exercises in a graded fashion that follows our patient’s ability to handle load and stress according to pain thresholds.

Some of my own personal guidelines are to try and exercise at an intensity level at or below a 3 out of 10 on a generic 0-10 pain scale.  I also like to see pain levels return to baseline following exercise and stay that way for the next day (Some people won’t experience much pain until the day following exercise).  Obviously there is a lot of variation from person to person but it’s my initial starting point for patients.  It’s an experimental process that we start learning about over time.

Pain during rehabilitation is not a neat and tidy process.  Some days are worse then others for what seems like no reason.  We do our best to control these variables but the up and down nature of pain during rehabilitation is more or less normal and to be expected.  We just want to make sure that over time we’re trending positive.  For example:

  • Does week 2 feel a bit better then week 1?
  • Does month 3 feel better then month 1?

If we’re progressing from this perspective then we’re doing OK.  So, this is how I tend to deal with explaining pain during rehab to my patients.  I’ll turn the question to you.

How do you help explain how much pain is appropriate for patients during rehab?

Pain is great,

Dan Pope DPT, OCS, CSCS, CF L1

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