Rehab reasoning! The 6th R.

One of the most powerful skills that anyone can posses is the ability to use reasoning to find the most applicable course of action for the person standing in front of them.

The 5’s of rehab is a conceptual framework incorporating some of the different types of interaction that someone may need during the rehab process. These range from the more cognitively based such as pain education to basic motor skills, that we at Cor-Kinetic term ‘movement vocabulary’, increased proprioception and finally loaded and dynamic movement.

*Click Here* for the 5Rs of rehab.

The 5 R’s could also be used as a (very) simple reasoning tool to decide which of the different types of interaction maybe most relevant for both the longer term and also single sessions within a longer-term plan.

Rather than attempting to sub group people into categories or focus solely on biomechanical or cognitive factors we may need to use all the categories but with different percentages of each being used dependent on the person, injury/pain and the stage of their rehabilitation.

This percentages based approach allows us to be inclusive of many elements that may impact on the current state of the individual whilst also allowing an appreciation of the individual weighing of each element that needs to be applied at differing times during the rehabilitation process.

Studies have shown benefits from combining both cognitive and movement based interventions.

*Click Here*

*Click Here*

This is also a theoretical framework *Click Here* for combining neuroscience education and movement/exercise.

Essentially we would like to incoperate elements of:

• Therapeutic neuroscience
• Basic movement vocabulary/skill
• Relevant/meaningful movement & activity with progressive loading

We can place the different elements in order of importance to the individual’s current state. If the major focus is from one of the points in a specific box then we would address that element first.

E.G. A clear 'Fear of pain and reinjury' would mean that I would put reassurance at #1 in the order of importance and address it accordingly.

Here is an example of how we could organise this process to use as a guide for percentages of interaction.

We can broadly split the different elements into two categories. One being more cognitively focused, reassure & reconceptualise, and more movement/action focused, recalibrate & robust.

Below we explore the different types of interactions and how we might start to get indicators of the type of interaction to use.

The type of questions asked or tools used such as questionnaires will influence the information received. This process still needs much more exploration.

Red Flags

Rather than incorporating this into the interaction process this would be addressed in full by a qualified professional before initiation of any rehabilitation process.

Information acquired such as a specific diagnosis or lack of clear diagnosis would guide the subsequent program.

Reassurance - Cognitive

All pain will have some element of psychological impact but for some it maybe much more influential than for others. Worry can create stress that may exacerbate the pain experienced.

It needs to be highlighted that there is a plethora of expert literature and practitioners out there that specialize in this field this is merely a simple tool that may be used to emphasis a need to delve deeper into the relevant area or seek help from a more qualified or applicable person.

Two tools that can be used, designed originally for back pain, are the Oswestry disability index (ODI) that can used to gain a better understanding of someone’s sense of disability and the Orebro (OMPPQ) musculoskeletal pain questionnaire that is used to predict long-term disability after an acute injury.

Indicators that may be used to highlight a need for intervention in this area could be.

• Fear of pain and re-injury
• Kinesiophobia & Fear avoidance
• Hypervigilance
• Impact on future health and ability

 Fear of pain and re-injury

 Does the person avoid even what may be described as low demand tasks in case they reinjure or trigger pain.

“it might set off the pain and then it doesn’t settle down for days”

 If there are specific tasks or activities these may form a basis for relevant and meaningful movement recalibration.

 Kinesiophobia & fear avoidance

Kinesiophobia:

Excessive and irrational fear of movement stemming from vulnerability and fear of re-injury. This may happen in varied situations such as chronic back pain sufferers or post operative ACLR patients. The movement may pose little or no threat and the structure may have sufficiently healed to easily tolerate the movement demand required.

Tools such as the Tampa scale for kinesiophobia can be used to better gauge this

Fear avoidance:

Pain experienced leads to managing situations by avoiding certain movement behaviors or positions. The lack of pain reinforces these behaviors over time. This avoidant behavior may increase disability by decreasing tolerance to certain movements (that inevitably occur) or a general decrease in movement.

We may see this in someone who avoids flexion of the lumbar spine to avoid pain or fear of pain. They avoid any movement involving flexion and increase their vulnerability of the area to the inevitable moment flexion is required or is unavoidable.

Waddell’s ‘Fear-avoidance beliefs questionnaire’ (FABQ) can be used.

Hyper vigilance

Although more confrontational of movement hyper vigilant individuals may be very ‘in tune’ with what they are feeling.

This could be described as an enhanced state of sensitivity and a high responsiveness to stimuli.

Impact on future health & ability

Does someone show an increased anxiety related to what they will be able to do in the future? This could be a footballer and their career or sport they love or simple activities such as picking up their kids or someone with a physical job who needs to support their family.

These anxieties may affect rehabilitation outcome and may need to be addressed through cognitive means.

Someone with an acute ankle sprain may still benefit from a discussion of the inflammatory process.

“The swelling contains the blood and chemicals required to heal the injured tissue and is a real positive! So is the pain, it naturally stops you from putting more load through it and exacerbating the problem. It is the best protective mechanism we have.

 Early mobilization of the tissue mostly pain free is also a positive, it may make it a little sorer in the short term but has huge benefits”

Reassurance maybe the part that highlights that inflammation is normal, positive and can stick around for a while.

Reconceptualization may come in when we actually discuss the processes involved, what this does to the tissue and essentially how it is a positive thing.

Reconceptualisation – Cognitive

The factors below may allow us to get a sense of how much reconceptualising of the pain experience could be applicable for the individual.

• Beliefs about pain
• What they have been told
• Beliefs about body
• Duration of pain beyond normal healing times and frequency of reoccurrence

Beliefs about pain

The concept of what pain represents to that person. Do they believe that every time it hurts during certain activities they are causing more damage or the pain is a reflection of the damage that has already occurred?

Helping people understand the nature of pain and specifically their pain can be key. People can have very strong belief systems and if we can alter this it can be a powerful tool in recovery.

What they have been told

When a trusted health care professional tells you something you tend to believe it, after all they are educated people and know more than you about these complex matters.

Reporting of imaging can result in someone being informed that they “have the spine of an 80 year old” and being told not to bend over anymore in case they damage their spines without an appreciation of the negative efects of these comments.

The transition from acute to chronic pain can be predicted by high levels of fear and anxiety, this fear can stem from beliefs that have been driven by what they have been previously told.

There is also the difference between what is meant and how it is interpreted. We now understand more the power words have to influence and even damage.Terms that are misunderstood are often misinterpreted. Terms such as instability could be interpreted as ‘liable to pop out’. *Click Here*

Taking the time to find out how your information has been interpreted at the end of a session maybe extremely insightful and beneficial.

Beliefs about their bodies

People form solid beliefs about their bodies and these can often stem from what they have been told by professionals, what they read on the internet or friends, family and work colleagues.

This may lead to avoiding certain movements or activities and influence their levels of movement possibly exacerbating any issues. This may lead to fear and avoidance as discussed above.

Using metaphors is a great way to help people understand the way that pain works especially for more ongoing/persistent pain states. Seeing pain as an over sensitised alarm system rather than simply reflective of damage is often helpful.

Recalibrate – Movement & some cognitive

Movement should be fluid, free and ultimately performed without any negative awareness. We often don’t even become aware of this natural fluidity until we cannot move without being consciously aware of pain or the impending fear of pain.

The aim of movement recalibration is to regain this freedom calibrating the level of threat posed from basic and previously pain free movements to the pre injured/pain state.

We can also combine recalibrating movement with cognitively based elements. Discussing the movement before and the expected outcomes and then discussing the actual outcome may help to create a cognitive change in perception of that movement and therefore the future perceived level of threat.

A clear modulation of pain or fear would have to be experienced to create this cognitive change and start the process of fear extinction. *Click Here*

Here are some of the major factors that may influence a decision to place an emphasis on movement recalibration.

This is when pain or fear is experienced by (non exhaustive list):

• Relevant & meaningful activities
• Specific areas of the body
• Specific position e.g. flexion
• Restoration of maladaptive movement
• Fear and expectation behaviors present

Relevant and meaningful activities

This could be doing up your shoelaces or gardening or playing a sport such as golf or tennis. Rather than a structure being a problem it could be the specific mechanics or the pain becoming associated with the movement itself *Click Here* for a previous work on pain and movement associations at a neural level.

Specific area of the body

It maybe a specific area of the body is problematic in many different positions such as a hip or shoulder. We may want to increase movement options and load toleration in the specific joint through graded exposure.

Specific positions

A flexion intolerant back may need to be recalibrated to be able to comfortably flex forward again, a completely natural part of the human movement repertoire. A graded exposure to a flexed position would form a major part of this strategy. This would be designed to desensitize both anatomical and neural elements to the significant position.

Maladaptive movement behavior

Often accompanying specific positions we may have movement behaviors that maintain the problem, an example maybe stiffening the trunk of someone with forward flexion issues. We may also see antalgic postures that originally were adaptive but could maintain pain states and behaviors. That pain changes movement is well documented but this change may be implicated in maintaining chronic pain behaviors.

Changes to movement after pain such as increased stiffness and decreased variability may also be regarded as maladaptive and impact on future injury. Previous injury is a big factor in the development of future analogous injury.

Fear and expectation behaviors

Regularly experiencing pain can lead to associative learning between a movement and pain which may even alter movement behavior before it has even begun.

Stiffening and bracing before a movement is initiated and slowing movement down before hitting the ‘painful arc’ are telltale signs. Grimacing before movement and changes in breathing such as breath holding or increased breathing rate may also be present. We may also see an obvious delay in willingness to move. Addressing these behaviors BEFORE moving may create a change in mechanics and pain experienced.

This may also be accompanied by a general lack of awareness of body position, regulated internally by the proprioceptive system, lack of coordination and inability to replicate simple exercises.

Recalibration may involve simply increasing basic motor skills and proprioception. This could be achieved by using simple concentrated motor tasks designed to expand the body’s ‘movement vocabulary’ and increase the movement options available.

The best form of ‘novel’ movement may be expanding the movement repertoire around stiff joint or a meaningful problematic movement. This way we can still be relevant but also novel.

Robust - Movement

Creating a protective buffer in both tissue tolerance and the CNS tolerance (pain, sensitivity & motor responses) should be an eventual aim of any rehabilitation program.

Tissue that is deconditioned and has a lower work capacity may become overloaded far more easily than more conditioned tissue.

Altered movement strategies after previous injury that increase joint stiffness and decrease variability could be hypothesized to lead to tissue deconditioning and a quicker onset of overload with increased activity as well as increased sensitivity of the CNS through the sensory and motor systems as a protective mechanism.

For running injuries, exercise aimed at increasing robustness may form the majority of the interaction rather than more cognitive elements. Tissue that has become overloaded may need a more progressive load to increase tolerance.

• Added load to relevant and meaningful movement
• General exercise
• Sport

Added load to relevant and meaningful movement

Certain movements may be implicated in pain responses as previously discussed. These movements may also need to be loaded to increase their buffer zone of tolerance to increased loads or durations.

Someone who regularly ‘tweaks’ their back in response to picking up heavier loads or activities of increased duration such as gardening would need an increased robustness at some point during rehabilitation.

General exercise

A decrease in previous activity levels or historical lack of activity may decrease robustness. An increase in activity levels within tolerable boundaries is often beneficial on both local and systemic levels.

Sport

A large increase in specific sporting activity is often implicated in overuse injuries. A more gradual approach to overload and subsequent adaptation maybe required to create a more robust system. This could be general capacity building or sports specific capacity or a mixture of both. This could also be regarded as a meaningful or relevant activity.

Case studies

Achilles Tendonosis

A simple example would be a first time overuse injury such as a Achilles tendonosis affecting a novice runner. The major focus would more than likely be towards the robust end of the scale, looking at heavy slow resistance programs and modifying training volume. This could also be augmented by analysis of running gait and the movement/motor behaviors of the foot and hip.

It could be argued they would still need an element of reassurance regarding their injury and why it may have occurred. A discussion of normal tissue healing times for this type of injury and what types of activity, such as the stretch shorten cycle, may aggravate would also be applicable for a healthy rationalization of their injury.

When dealing with more chronic tendon injuries the focus may shift to address the cognitive factors that are often involved with chronic pain. Central processing of nociceptive signals in a chronic pain state may result in an increased pain output or pain responses that has less to do with the state of the tissue especially with longer durations of pain.

A better understanding of the changes that may occur away from the painful tissue during persistent pain states may help the individual to rationalize the transient nature of pain that may be confusing and puzzling *Click Here*. Educational strategies addressing neurophysiology and neurobiology of pain have also been shown to have positive effects in chronic musculoskeletal problems *Click Here*

We could start to arrange it a little like this for the first time running injury (The % attached a merely representative and certainly not an exact science):

1. Robustness – Increasing tissue tolerance through progressive loading and moderating exercise programming to avoid training error – 70%
2. Reassurance – Simple understanding of tissue healing and aggravating activities – 15%
3. Recalibrate 15 % – Effects of pain on proprioception and subsequent motor and sensory behavior.

More persistent situations may look like this:

1. Reconceptualise – A better understanding of the adaptive and maladaptive nature of pain. 25%
2. Reassurance – That this will not stop them from ever running again and the implications that might have on their quality of life. 25%
3. Recalibrate – Effects of pain on proprioception and subsequent motor and sensory behavior. 25%
4. Robustness – Either a slower even more progressive load or a more comprehensive approach involving an additional focus on more functional rehab elements such as SSC and rate of force development. 25%

Lower back pain

An approach to chronic lower back pain could be very different. Reconceptualization and recalibration may take a much greater role in the interaction, especially in the early stages, rather than the need for robustness.

Many people have been told things about their bodies that have affected their perception of what they feel able to do and therefore reconceptualization would form a large part of any interaction for this person.

We also see specific movements or positions, such as lumbar flexion, that are associated with the ongoing pain experience and beliefs about those movements and what harmful affects they may have on the body.

This could come in the form of an MRI report highlighting what could be considered normal age related degeneration or a diagnosis of ‘instability’ of the lumbar area. This may lead to decreased movement in the back and activity in general that may impact on the ongoing sensitivity of the area.

So cognitive change maybe required with reconceptualization of the pain state and a physical change with movement behaviors. We may see a crossover of the two with specific movements and the cognitive perception versus actually physical reality of a movement during the fear extinction process.

1. Reconceptualisation – Hurt of the back vs the actual harm to the structure. Pain as an oversensitive alarm. Fear of a movement. 40%
2. Recalibration – Graded exposure to fearful movements or activities 30%
3. Robustness – Increases in level of general activity or exercise 15%
4. Reassurance – Hope for the future and return to cherished activities 15%

This may transition at later stages to:

1. Robustness – Increasing demand such as load and speed of specific movements. Increased general activity & graded return to sport. 50%
2. Recalibration – More relevant and meaningful activities explored. 20%
3. Reconceptualisation – Through experiential learning and fear extinction. 20%
4. Reassurance – Ongoing that a progressive approach will achieve desired level of functionality. 10%