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What the NBN can teach us about injury rehab

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As I was trying to watch the Mandolorian the other night (at “peak” Netflix usage time) I was getting constantly frustrated with it pausing and buffering several times an episode (I know – first world problems). And I was again annoyed that now I finally have NBN it really isn’t significantly better than what we had before.

And the reason is this – as far as I can tell, the NBN is really only built to handle “average” usage. So I’m sure there was all this modelling and data somewhere that said “on average, the requirements for the NBN will be X, so as long as we build it to handle that, it will be all good”

The problem being we know that we don’t have regular average usage throughout the day… There are times of low demand (which the NBN can handle really well) and times of peak demand, which the NBN struggles to handle.

Now, putting aside my knowledge of telecommunications infrastructure, it got me thinking about how this applies to what we do when we rehabilitate injuries (or surgery).

A lot of the time, we see people who have had an injury, and only ever really got back to the capacity of “average” demand. Say they sprained their ankle, and now they can walk without pain, they can go up and down stairs and they can jog in a straight line. They are feeling “ok” so they are rehabilitated, yes???

The problem with that is – if they then are subject to a more “peak” demand that they haven’t returned their capacity to, there is a significant chance that this could exceed their capacity, and lead to pain or injury (How many times do we see people that return to sport after an injury and just get injured again? The answer is a lot more than we should)

The same goes for things like back pain. Yes you can touch your toes again, and sit without pain, but would you be able to move your fridge if you had to move house? Or lift the couch to vacuum underneath? Would you be able to carry your grandkids home because they are tired?

We know that there are going to be times when you have to do hard things, even if you don’t normally have to do hard things. If we ONLY rehabilitate your issue so you are just above your ability to do the average things, but we don’t build in the capacity for you to do the hard things, we are really setting you up to fail. At the same time, if you don’t continue to do some work to rebuild your capacity above just the “average” things you need to do – YOU are unfortunately setting yourself up to fail as well.

Everyone needs to have a buffer to how hard they can work. If you are working near 100% of your capacity all the time, you are going to start having some troubles (imagine you sprint everywhere you go rather than walk. Sure it’s quicker, but you can’t keep it up and eventually something will go bad).

Just like the NBN – if you are only built for average demand but you aren’t able to manage any peak demands, you will start to struggle, and potentially have issues.

We need to have more foresight than “whoever” designed the NBN in it’s current form, and ensure you have the ability to perform the peak demand activities as well, to keep you safe and healthy.

 

Julian Bowen

Julian is the Director and Principal Physiotherapist at EMC Physiotherapy.  He has spent  over a decade working exclusively in private physiotherapy practice, and estimates he would have performed over 40,000 individual treatments in that time. He has worked with everyone from Paralympians, elite athletes, WAFL Footballers, the Defence Forces and weekend warriors; to thousands of everyday people with all manner of issues.  He is passionate about injury prevention and has a special interest in the treatment of headaches, shoulder issues, hypermobility management and exercise rehabilitation for the prevention and treatment of injuries.

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How pain works part 3: Your brain can ignore pain inputs

gi joe knowledge is half the battle

Did you know you are receiving input into your brain from EVERY receptor for EVERY sense ALL THE TIME!! Millions of inputs every minute for your brain to compute and focus on.

We don’t think about it, but it’s impossible for us to be consciously aware of all these things around us all the time, so our brain has to filter most of these inputs so that we only spend our limited focus on things that actually matter. This means that our brain actually ignores most of the inputs it receives.

I’ll give you some excellent examples…

Are you wearing a watch or a ring? Or earrings? I would bet that most of the time you aren’t aware of your watch on your wrist, or your jewellery. Sure, your brain is receiving inputs from those areas that something is touching you all the time, but most of the time your brain ignores it. It’s there all the time, and your brain knows it’s not an important thing to waste precious energy and focus on, so it just writes those inputs off. (But once you focused on them after I asked, you obviously could feel them again).

It’s the same for other senses. We know that we really can’t smell ourselves most of the time. Also we get used to normal smells around us, so we can’t smell them anymore. Most smokers can’t tell that they smell like smoke. We can’t smell our own houses because we are so used to it. (Have you ever come home from a long holiday and thought your house smelled different? Often this is because your brain has gotten out of the habit of ignoring those smells because you haven’t been around for a while, so you notice it again).

Your brain has habits just like we all do. If it is used to ignoring the watch on your wrist, then one day you forget to wear it you feel ‘funny’. People say they feel naked without it. This is because your brain is used to doing one thing (ignoring the input from your watch) but without the watch there it can’t do this anymore. This creates a DIFFERENCE that causes your brain to pay attention.

The same goes for pain… our brains can ignore pain when it wants to or when it needs to (but it’s very hard to do it consciously). We also have a hierarchy of needs, so if the risk of damage from pain isn’t the most important thing then your brain will also ignore it.

Have you ever been sore, but then you had to play sport or something, and once you start the pain seems to disappear? It may warm up, etc, but sometimes you just aren’t focusing on the pain, and your brain deems the activity (playing sport) more important so it diminishes the pain experience.  IF the pain isn’t considered harmful or a risk, it can be ignored.

Sometimes, even despite injury or severe pain, you can ignore the pain. Another extreme example – if you are in a life or death example (like you are being chased by a bear) and you sprain your ankle really badly… Despite the injury, the imminent risk of death far outweighs the risk to you from the ankle sprain, so your brain will generally ignore the ankle so you can run away from the bear.

We hear about this all the time – in war zones soldiers being shot and saying it didn’t hurt at all. Or we hear stories of people breaking bones and not even realising until later on. Sometimes this is described as ‘going into shock’ but often your brain’s hierarchy of needs means it ignores the pain input as that is not the most important thing to worry about. Needing to survive trumps the risk of damaging an injury further.

Understanding that you brain can focus on pain inputs or not based on needs and perceived risk helps people to manage their pain experience. If your brain perceives the thing causing pain as a threat to survival or further damage, you will feel pain. If it decides it’s not dangerous, then you may not. Understanding whether pain is dangerous or not can in many cases even reduce the pain you are experiencing. Sometimes knowledge is half the battle.

Julian Bowen

Julian is the Director and Principal Physiotherapist at EMC Physiotherapy.  He has spent  over a decade working exclusively in private physiotherapy practice, and estimates he would have performed over 40,000 individual treatments in that time. He has worked with everyone from Paralympians, elite athletes, WAFL Footballers, the Defence Forces and weekend warriors; to thousands of everyday people with all manner of issues.  He is passionate about injury prevention and has a special interest in the treatment of headaches, shoulder issues, hypermobility management and exercise rehabilitation for the prevention and treatment of injuries.

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How Pain Works Part 2. Pain is a Warning system

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Over the last 5-10 years we have learned A LOT about pain and how it works, but a lot of this is completely foreign to most people, so we’ve decided to produce a series of articles to help people actually understand their pain and what is going on… Firstly because KNOWLEDGE IS POWER! And secondly because understanding why you feel how you feel is empowering and de-threatening (as they say – just knowing is half the battle)

This is part two of a 5-part series on learning how pain works!

PAIN IS A WARNING SYSTEM

The experience of pain is part of your body’s and brain’s warning and protective system. We’re incredibly smart when it comes to trying to stop our selves getting damaged or dying, so we have a whole host of systems built in to try and avoid us coming to grief.

Now often we think that pain = damage, but we now know that pain often occurs long before any damage actually occurs.

Did you ever get a “Chinese burn” from another kid at school? Hurt didn’t it? But any damage to your arm? Not at all.

Or a better example – have you ever touched something hot, and it HURT! So you automatically pulled away (something called a withdrawal reflex – another clever way we are designed to stop hurting ourselves).

You check your hand… but it looks ok. It hurt for a few seconds, and that settles down within 10-30 seconds. Lucky you!

This is a great example of pain without pathology, or damage. The pain you experienced (immediately and possibly severely) was a STRONG warning that you are at high risk of damage if you don’t change your behaviour (touching the hot thing). Because of the experience of pain you have managed to completely avoid any tissue damage at all (clever you). Your pain served as a perfect warning system.

Even when you have an issue, your experience of pain can still be part of your body’s protective systems. Your brain (and your body) will actually try to actively give you more pain to stop you doing things it may think are potentially more damaging.

As an evolutionary example: Say you’ve sprained your ankle, so you’re not able to run as fast as normal. This means that if you and your Neolithic buddies are out hunting woolly mammoths you could be more likely to get injured and killed (not to mention potentially do more damage to your ankle). By creating pain, which makes you unable to participate, your brain is actively trying to stop you getting killed.

This may be a bit of an extreme example, but it’s true. When you have an injury, there are chemicals released by the body (in the inflammatory fluid) that actually make your receptors more sensitive (so they will send signals to your brain that things that wouldn’t normally tell you there is pain NOW tell you there is pain.) Part of the injury process actually tries to make it MORE painful for you.

Luckily nowadays we don’t have to fight for our lives, so a lot of this is fairly redundant. But that doesn’t stop it from happening. So, more pain doesn’t necessarily equal more damage. If anything, it just indicates more warning from your brain and body.

So when it comes to our aches, pains and injuries… It’s good to know that pain is your body’s rudimentary warning system that something bad MIGHT happen, not that there is already damage. Knowing this helps us know that if sometimes our pain is worse, it doesn’t mean you are MORE damaged. It might just be your brain paying more attention for some reason.

Stay tuned for Part 3 of our ” How pain works”  series – and learn how your brain can choose to ignore sensory inputs (like pain) so you don’t feel them

 

Julian Bowen

Julian is the Director and Principal Physiotherapist at EMC Physiotherapy.  He has spent  over a decade working exclusively in private physiotherapy practice, and estimates he would have performed over 40,000 individual treatments in that time. He has worked with everyone from Paralympians, elite athletes, WAFL Footballers, the Defence Forces and weekend warriors; to thousands of everyday people with all manner of issues.  He is passionate about injury prevention and has a special interest in the treatment of headaches, shoulder issues, hypermobility management and exercise rehabilitation for the prevention and treatment of injuries.

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How Pain Works Part 1. All pain comes from your Brain

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Over the last 5-10 years we have learned A LOT about pain and how it works, but a lot of this is completely foreign to most people, so we’ve decided to produce a series of articles to help people actually understand their pain and what is going on… Firstly because KNOWLEDGE IS POWER! And secondly because understanding why you feel how you feel is empowering and dethreatening (as they say – just knowing is half the battle)

This is part one of a 5-part series on learning how pain works!

ALL PAIN COMES FROM YOUR BRAIN

Now intuitively we all understand that pain comes from receptors in our body. We have nerve endings all over our body that pick-up pain signals and signal to our brain that we are in pain, right?

Sorry but that’s actually wrong!

All pain (and all sensory experience for that matter) comes from our brain. Our body is providing millions of sensory input signal to our brain at all times, but our brain computes everything and then works out what to experience.

Then the OUTPUT from our brain is what we experience.

This makes sense when we compare what we may know about our other senses.

Our ears don’t hear sound. There are receptors in our ears that are sensitive to vibration of air particles, and when it picks up vibration of air particles those receptors then turn that into electrical information that is transmitted to our brain. Our brain then interprets that electrical signal and works out what we are hearing. What we hear is an output of our brain computing the signals.

Now we don’t hear everything the same. If you’re doing something else you might not hear at all, even though the vibrations coming into the ear are the same. So just having the receptors stimulated doesn’t mean we actually hear. It’s what the brain chooses to do with the input it receives that determines what we actually experience.

The same as our eyes don’t see – our brain sees from the information provided by our eyes. Our eyes bring in light and focus it on the parts of the back of our eyes. Light hitting those parts of the eye then stimulates electrical signals to the brain. (If you’ve read into this before you know that the brain actually receives the information upside down). Your brain has to interpret this information to then give you an experience of what you are actually seeing. If you’ve ever seen an optical illusion, noticed a blind spot or realise you can’t actually see your nose (even though it’s always in your field of view) you can understand that your brain interpreting the information it has available to it is what allows us to see.

(I bet you all just looked at your nose right now)

The same happens with pain as an input. Your brain is provided input from all over your body and it decides what you feel based on its own priorities (which we’ll cover in the coming articles).

So because of this, we know that pain isn’t just fixed or static, and more pain doesn’t necessarily mean more damage. It also means you can have a lot of pain with very little damage at all (have you ever seen someone scared of needles scream in pain before the needle even touched them??)

Knowing that pain is an output of your brain means that we can understand how we experience pain, and then help us to control our experience of pain.

Coming up in part 2, we’ll learn about pain as a warning system, rather than pain being an indicator of damage.

 

Julian Bowen

Julian is the Director and Principal Physiotherapist at EMC Physiotherapy.  He has spent  over a decade working exclusively in private physiotherapy practice, and estimates he would have performed over 40,000 individual treatments in that time. He has worked with everyone from Paralympians, elite athletes, WAFL Footballers, the Defence Forces and weekend warriors; to thousands of everyday people with all manner of issues.  He is passionate about injury prevention and has a special interest in the treatment of headaches, shoulder issues, hypermobility management and exercise rehabilitation for the prevention and treatment of injuries.

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The other top 3 mistake people make with their Physio Treatment

The other top 3 mistake people make with their Physio Treatment

I recently wrote and article about the top 3 biggest mistakes I see people make when it comes to approaching their pain and injuries. (you can check it out here)

so I thought I’d add the biggest 3 mistakes that I think people make with their physio treatment.

1. Not having a goal or a plan

Let me give you an example. A few months back I saw a lovely 78 year old lady who her GP had referred to us to help with her low back pain. Now she has had quite advanced arthritis and persistent back pain for 30 years. (not that arthritis always means pain, but in this case it was pretty severe). She said to me at the start of the session:

“I don’t know why I’m even here. You aren’t going to be able to fix my back – nothing is”

No she wasn’t exactly wrong. I can’t change her arthritis. But in many cases I believe that’s not the most important thing. I asked her

“In a perfect world – ideally what would you want to achieve out of your treatment with us? How is this impacting your life that you wish you could change?”

Her answer was “I just wish I could wish the dishes or vacuum the floors without having to stop, or sit down for an hour after because my back was hurting. If I could get to a point where I could do that I would be so happy”

This is a completely different goal, and outcome for her than “curing her back”. Realistically in this case it’s unlikely we will be able to get her completely pain free, but now we had a goal and a plan, and this was ABSOLUTELY achievable for her. We worked out a plan for some hand on treatment and a lot of exercise work to be able to build her up to a point where she could do those things. And you know what? she can vacuum the floors without stopping now. Once we had a goal and a plan we were able to work together towards impvoing her quality of life and getting her where she wanted to be.

2. Expecting Miracles

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The unfortunate truth is usually the longer you’ve had a problem, the longer it will likely take to resolve. This is because you get neurophysiological changes, more stiffness, more weakness, protective patterns, altered movement patterns, etc, etc.

(Happily the opposite is true too. A study in hamstring injury came out last year which found that if you start treatment within 48 hours of injury then, on average, you would get back to sport 2 weeks quicker than if you started treatment later).

Some problems can get better very quickly, but by and large it takes time and work.

for some reason people often have two conflicting view points. They are very concerned that their problem will never get better, but then they also expect it to be cured immediately. In most cases neither of these are true.

3. Not following through

Another unfortunate truth is that there is often a big difference between feeling “ok” and being actually 100% better. Pain is a warning system (and a very complex one at that) so it is unreliable to base our management entirely on if you have pain or not.

As a good example – we know that following an ankle sprain you are at 50% risk of re-injuring that ankle within the next 12 months. That’s 1 in 2 ankle injuries that are destined for multiple sprains! That’s a terrible outcome. (How would you feel if you got a new battery for your car but 1 in 2 of them would fail?)

BUT – if we ensure you do at least 6 weeks of neuromuscular retraining (that’s strengthening, balance and stability retraining) after the pain resolves then your chance of re-injury is more like 10%. It is actually irresponsible of us to not ensure that your are not only pain free, but back to 100% strength, movement and function AND ensuring the problem is not going to recur or become ongoing. Anything less is, I believe, poor management.

Now you (the public) don’t know these facts and statistics, so once you start to feel “ok” the motivation to continue doing the work can wear off. This unfortunately leave a large percentage of people who are out there only 70-80% better and likely to have further problems down the track. And it’s true that many health professionals don’t necessarily communicate these facts very well to help you understand WHY you need to keep doing the work (or having further treatment) once you are starting to feel ok.

If you were an athlete, and you suffered a hamstring injury – you wouldn’t stop all management once you could move around without pain and run. you need to be able to sprint from a cold start 100 times in a game, and jump, and stretch, and back that up with training every day or two, and keep that up for 6-9 months without a break. This is the difference between many elite athletes and regular people. Everyday people can end up with dodgy hamstrings (or knees, or ankles, etc) because they never get to fully rehabilitating their problem. Elite athletes do the full amount of work to give them the best chance of 100% long term recovery.

Bonus: Not doing your share of the work

The reality of life is people are busy (and a bit lazy) so we find a lot of people don’t get around to doing their homework. We may see you for something like 1/168th of the week, so that’s a very small impact we can have on your life time wise. That’s why you will often get ‘homework’ from your physio. Things you can do for the other 167/168ths of the week that are going to significantly accelerate your progress and mean optimal recovery and avoiding recurrence.

There was some research done over 15 years ago that showed that about 1 in 10 people completed there home rehab exercises! That means 90% of our clients aren’t getting the fastest or best outcomes because they aren’t holding up their end of the bargain.

Everyone who comes into the clinic just wants to lay down on the treatment couch and have someone else “fix”them. Sometimes there are issues that only require this, but usually there is some work to be done to improve capacity, endurance, mobility, strength, etc.

We help those who help themselves :)

(Actually we’ll try and help you even if you don’t help yourself at all… But it would make our job a bit easier if you do a bit too)

 

Julian Bowen

Julian is the Director and Principal Physiotherapist at EMC Physiotherapy.  He has spent  over a decade working exclusively in private physiotherapy practice, and estimates he would have performed over 40,000 individual treatments in that time. He has worked with everyone from Paralympians, elite athletes, WAFL Footballers, the Defence Forces and weekend warriors; to thousands of everyday people with all manner of issues.  He is passionate about injury prevention and has a special interest in the treatment of headaches, shoulder issues, hypermobility management and exercise rehabilitation for the prevention and treatment of injuries. 

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