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

Whether or not you should push your patients into pain during physical therapy is a pretty common question.  I've seen people on both ends of the spectrum.  Shoulder experts like Jeremy Lewis recommend a procedure to eliminate pain during shoulder exercise while pain science experts like Adriaan Louw recommend their patients push into a bit of pain during therapy.

Patients are often confused.  Is pain bad?  If I push through pain will that make me worse?  Is having some pain during exercise good?

Here's what happened:

So basically encouraging these patients to push into some pain during rehabilitation improved their short term pain levels (But not functional outcome measures).  The effect size was fairly small but ultimately this does seem to show that pushing into some pain is not bad and potentially leads to faster improvements in pain levels.  For me this is a powerful study because it gives us even more ammo to eliminate fear in our patients with pain.   A typical conversation will go like this:

Not only is pushing into a little bit of pain alright and safe for your injury, it may actually help you improve faster then if you didn't!

I think this really helps with those patients with a lot of fear avoidant behavior or are just paralyzed by their pain.  It may help them start believing in their ability to heal and stop fearing movement.  Sometimes it's like granting permission for our patient's to start exercising and moving again (which is most likely a good thing).  

My thoughts are that there are probably some types of injuries and people where pushing through more pain will potentially delay rehab and then there are probably certain diagnoses and people where you can push harder and make better progress.  

My general rule of thumb for pain during exercise is to keep pain levels below about a 2-3 out of 10 on a pain scale while exercising and then  making sure your pain returns back down to baseline the following night and day after exercise.  This can help patients self regulate and ensure they don't go too wild with rehab exercises.

What rules do you guys follow when your patients are exercising with pain?

Dan Pope DPT, OCS, CSCS

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