The art of rehab is about finding the fine line between doing too much and doing too little. Like Goldilocks, you want to find “just right.” The purpose of this blog is to help you find your “just right.”
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Most people know the story of Goldilocks and the Three Bears. Goldilocks, a young girl, goes into the home of the Three Bears and eats their porridge that they’ve left out. The first bowl of porridge is too hot, the second bowl is too cold, but the third is just right.
Out of all the famous fairy tales that exist, this is one most applicable to rehab. Instead of discussing things as being too hot or too cold though, I’m going to talk about things as being too much or too little.
Goldilocks Story Applied To Training
Let’s start with a training example of wanting to build muscle by going to the gym a few days per week. It can be helpful to consider the extremes.
If you do absolutely nothing but lay in bed during most of your waking hours, it’s reasonable to assume that you’re going to lose muscle. You’re doing too little.
On the other hand, if you suddenly start maxing out 5 hours per day with minimal rest, you’re probably going to develop a muscle injury, such as a strain or rhabdomyolysis. You’re doing too much.
If you happen to do the perfect amount of volume and intensity day after day, week after week, and month after month, you’re going to accomplish your goal of building muscle. What you’re doing is just right.
But understand that just right isn’t a fixed set point. It exists on a spectrum within an individual and between individuals, and can fluctuate over time.
Depending on your training history, your just right volume and intensity may differ from someone else reading this blog.
And that just right volume and intensity will change for you over time as you continue to train or if you take a break from training.
Consider the porridge again. In the Goldilocks story, the third bowl of porridge was at a temperature that was just right. But just like the training example, just right isn’t a fixed set point.
If the porridge was 1 degree hotter or 1 degree colder, it likely would have still been just right.
For someone else, it might have needed to be 5 degrees hotter or colder to be just right.
What about the other factors that go into making the just right bowl of porridge? How’s the flavor and texture? What’s the serving size? Are there any toppings or ingredients mixed in?
With regards to building muscle, how’s your diet, sleep, and stress? Are you considering all of the variables that help create an environment that’s just right for building muscle?
Before moving on to the next section, I want to mention that searching for just right is actually better than aiming for perfection. When you’re trying to build muscle, you start with an educated guess based on what is known about these variables and their influence on the process, and consider what’s reasonable for your lifestyle. For example, we know that more sleep is better than less sleep and some protein is better than no protein. Simple enough.
But what about the volume or intensity of your training? This is where it’s useful to start with averages. On average, people tend to build muscle with 10-20 sets of training per muscle group per week. If you’re new to training, you’ll likely begin on the lower end of that range. Over time, you can do less or more depending on how you’re responding to your program.
You’re making a reasonable, educated guess and slowly making small adjustments to determine what just right is for you, while also understanding that just right is going to fluctuate over time.
Goldilocks Story Applied To Injuries
So how does the Goldilocks story apply to injuries? Well, many injuries occur from doing too much, too soon.
You might be thinking to yourself right now – “This guy went through 7 years of college to tell me that?”
This is information that everyone kind of intuitively knows and understands, but then often completely ignores in practice. I’ve met people who do the 100 push-ups per day challenge for a month, experience shoulder pain, and then blame their injury on a lack of stretching. I’ve also met people who start a couch to 5K running plan, develop knee pain, and then blame that pain on their running shoes.
In either case, it’d likely be easier for these people to accept that they probably just did a little too much, too soon. No big deal.
A simplified framework for why injuries occur is that the volume, frequency, and intensity of loading during a single exposure, or across multiple exposures, exceeds your current capacity or ability to recover and adapt appropriately. This will look different for different individuals, so it can be helpful to consider the extremes again.
If you’re an active individual, such as a regular runner, it does often come down to doing too much, too soon. For instance, if you normally run half marathons but suddenly increase your total running mileage in preparation for a marathon that you want to do next month, that spike in training load may exceed your current capacity.
On the flip side, if you’re a sedentary individual who’s been doing too little for too long, your capacity may be decreased and more easily exceeded.
And just like the example for building muscle, your overall health and well-being as they relate to stress, sleep, nutrition, general physical activity, alcohol intake, smoking status, etc. play a role here. Moving the needle in the right direction for any of these factors should increase your capacity to handle more load.
Goldilocks Principle of Rehab
How does the Goldilocks story apply to rehab after an injury?
Well, if you think about capacity as your ability to handle and adapt to various stressors on a day-to-day and week-to-week basis, you may consider it decreased during times of injury or pain.
Therefore, your goal is to increase your capacity to the point that it matches or exceeds the stressors you’re exposed to on a regular basis.
How you do that is the challenge. You don’t want to do too much where you’re constantly exacerbating symptoms and limiting progress, but you also don’t want to do too little where you’re deconditioning and not working toward your goals. Instead, you want to find the just right level of activity that complements your goals while minimizing flare-ups.
Before showing you how to find your just right level of exercise for your goals, let me explain two common mistakes, which are adapted from Lorimer Moseley and David Butler.
The first scenario relates to individuals who chronically do too little because they’re fearful of their symptoms or what their symptoms might mean. Without a structured plan, and as a way of avoiding pain, they do less and less activity over time to the point that their capacity becomes severely diminished.
The other scenario involves people who persist, or push, through their pain, which leads to an incapacitating flare-up. They do too much and require a period of rest to allow that spike in symptoms to subside. Then, when they’re feeling a bit better, they try to repeat that same level of activity, but come to realize that the flare-up happens even sooner. This cycle repeats until their capacity is also severely diminished.
The art of rehab is about finding that fine line between doing too much and doing too little. You rarely need to completely rest and avoid all symptoms, but you also shouldn’t approach rehab with a “no pain, no gain” mentality.
Throughout the rest of this blog, I’m going to show you what the rehab process realistically looks like and provide you with the knowledge to find your just right level of activity.
Since I’m describing the rehab process as finding the appropriate balance between load and capacity, it’s important for me to further define how I’m using them in this context. Load is referring to external load, or the physical work being done by the body, such as weight lifted or miles run. Capacity represents your ability to tolerate, recover, and adapt from these loads based on your conditioning, strength, general health status, etc.
Capacity is also augmented by the other factors I mentioned earlier. If you’ve only had 3 hours of sleep and you’re stressed about a work deadline or final exam, your ability to tolerate loads is likely going to be reduced. This can be an acute response (as described) or more chronic in nature.
Based on this information, there’s 3 steps you want to take to create the just right environment for rehab:
- Ask yourself if there’s any low hanging fruit as it relates to your sleep habits, physical activity levels, nutrition, etc. that you can reach for to positively influence your general health and well-being. What’s the smallest, practical change you can make that will have the largest impact?
- Temporarily reduce or modify aggravating loads, so that you’re not exceeding your current capacity. This is the focus of this section.
- Gradually reintroduce those loads, so that you induce positive adaptations to drive your capacity higher. We’ll come back to this later.
When it comes to load management, you want to think big picture.
If you’re a runner, what about your runs is problematic? Is it the speed? Is it the mileage in a single session or the total mileage for the week? Did anything change in the days, weeks, or months leading up to your symptoms?
And I know it sounded like I completely dismissed shoe wear earlier, but it probably wasn’t the primary contributing factor for the new runner who went from doing nothing to running a 5k in a short period of time. However, if you’re a seasoned runner who hasn’t changed anything about your program, but you switched from a very supportive shoe to a minimalist shoe overnight, then sure, that’s a consideration because it’s affecting how certain tissues are being loaded.
If you’re a regular gym-goer, what exercises are bothersome? Is it a specific exercise that’s the issue or is it the weight being used? Or the range of motion? Or the total number of sets that you’re doing in a given week? Can you change any of those variables to make your time in the gym more tolerable?
The same is true for walking, gardening, cooking, or any other activity. What is it about what you’re doing that’s an issue, and is there anything you can do to modify it?
Activity modifications are intimately tied in with load management. They can be used to reduce the frequency, duration, and/or intensity of symptoms.
For example, if your low back pain starts after 30 minutes of sitting and intensifies with every minute that you continue to sit, then that is an activity you would consider modifying. An easy modification in this scenario, if it’s available to you, is to stand at the 29 minute mark or earlier before sitting back down and continuing your work. You would incorporate these standing breaks as needed throughout the day. Other options include going for a walk or integrating short exercise breaks into your daily routine.
Most activity modifications are not meant to be permanent. In the previous example, I wouldn’t expect you to only be able to sit for 29 minutes at a time for the rest of your life. Over the course of days, weeks, and months, you’d re-integrate and progress those aggravating activities as your symptoms and/or function improve.
So, activity modifications are about identifying if certain positions, movements, or activities exacerbate your symptoms, and determining if there are ways that you can modify them.
Graded loading is the third step I mentioned earlier – gradually reintroducing and progressing loads, so that you induce positive adaptations to drive your capacity higher. Or, to put it more simply, you’re just trying to do a little more over time.
Once again, it’s one of those concepts that everyone knows and understands, but ignores in favor of searching for a quick fix. If you hurt your shoulder doing 100 push-ups per day for a month, a massage gun or some other fancy treatment shouldn’t be the immediate focus of your management for that injury.
Graded loading is similar to hiking a mountain and investing in the stock market.
Many people assume that rehab is going to be a smooth, linear process. Sometimes it is, but oftentimes it’s messy.
If you want to climb to the top of a steep mountain, you’re not going to get there by staying on flat ground. You’re just circling the base of the mountain. You’re doing too little.
Similarly, in most cases, the best path isn’t the steepest or most dangerous. You might hit a dead-end or wind up hurt. You’re doing too much.
The best way to get to the top of a mountain is to use the trail that gradually takes you higher in a reliable manner. Some parts of that pathway are going to be steeper. Some parts are going to be flat. Some parts might even be downhill a bit. And, most importantly, everyone is going to be climbing a different sized mountain.
Graded loading is like the stock market because most sound investments aren’t made with the intention of making money today or tomorrow. The purpose is to make money in the long run. You’re trusting the process and accepting that you’re going to have highs, lows, and everything in-between, but your patience and commitment will eventually pay off.
So, unlike the 2 previous graphs that demonstrated a gradual decline in capacity from doing too much or too little, you want to recreate a graph that has a gradual incline, while understanding that there will be ups and downs along the way.
How do you know you’re moving in the right direction, though?
Well, if you’re trying to gradually increase your capacity by exposing yourself to greater and greater loads, it’s helpful to keep track of those loads. Are you writing down your running mileage, weight lifted, or time spent walking? Are you also taking note of how you are responding to those activities? It’s much easier to recognize progress when you have it written in a logbook or journal.
And remember, when you are dealing with pain or an injury, you’re generally starting from a new baseline. Wherever you’re at right now, that’s completely fine.
Start there without comparing yourself to others or even comparing yourself to what you used to be able to do. You might want to strive to get back to your previous level of function, but it can be helpful to recognize and accept your current situation, so you don’t end up doing too much, too soon.
How much pain is acceptable during exercise or activities?
Honestly, this is unique to you. One person watching this video might only be comfortable exercising with slight pain while someone else might be comfortable exercising with moderate pain. There’s not necessarily a right or wrong way to go about it, but there are some strategies that you can do to help find what works best for you.
Ask yourself 3 questions:
1. “Is my pain tolerable during exercise?”
If it’s helpful for you, you can rate your pain on a scale from 0-10 and determine the highest acceptable number for you. Some physical therapists might recommend staying at a 3/10 pain or less while others might suggest 5/10 pain or less. You get to decide.
2. “Is my pain better, worse, or the same after exercise?”
If pain after exercise negatively impacts your sleep, daily activities, concentration with work, etc. (more so than usual), it might be an indication that you did a little too much.
3. “Is my pain better, worse, or the same the day after exercise?”
If your symptoms were tolerable during and immediately after exercise, but you had a flare-up the next day, that’s also an indication that you might have done a little too much.
Pain during exercise doesn’t necessarily mean that you’re damaging structures or worsening your condition. However, if it’s at a level that’s negatively affecting your day-to-day activities or hindering the progress of your short and long-term goals, then it’s probably appropriate to scale back. You’re constantly looking for that Goldilocks level of loading that promotes improvements in function without causing intolerable levels of pain and flare-ups.
Goldilocks Story Applied To Pain
Does an increase in capacity lead to a decrease in pain? Not necessarily.
Up to this point, I’ve described an increase in capacity as the ability to handle more load. It could be represented by the ability to lift more weight because your strength has increased or run a faster mile because your conditioning has improved.
But it can also mean that your tolerance to handle loads has improved. For example, maybe you’re able to lift the same amount of weight now that you did 2 weeks ago, but you’re able to do so with less pain.
Or maybe you have the same amount of pain, but you’re able to lift more weight.
Although it would be ideal, improvements in pain and function aren’t always linear. Sometimes function improves while pain remains the same.
Think back to the earlier scenario in which some individuals chronically do too little because they’re fearful of their symptoms or what their symptoms might mean. They do less and less activity over time because they’re avoiding pain or waiting until they’re completely pain-free. However, as demonstrated, this is a strategy that can lead to a gradual decrease in capacity.
An increase in capacity can mean that you’re physically capable of doing more, but it can also mean that you’re willing to do more. Sometimes all it takes is the confidence to get started.
I understand that the elimination of pain is the goal for many individuals, but it’s not something we can always control or guarantee. That’s why I think it’s important to consider other markers of progress as well. You can ask yourself if the severity or frequency of your symptoms have decreased, but you can ask yourself other questions:
- Do you have more control over your symptoms?
- Has your function improved?
- Are you doing more of the things you enjoy?
And the Goldilocks Principle still applies – you’re trying to find the just right level of activity that you’re comfortable performing and gradually doing more over time. And just like Goldilocks who had to try a bowl of porridge that was too hot and too cold to find what was just right for her, you’re going to have times when you do too much or too little.
That’s completely okay. It’s all part of the rehab process.