How To Manage Pain Flare Ups

Nature Helps Calm Stress

Pain flare ups are a common occurrence with both acute injury or chronic pain. Knowing how to manage them well can be the difference between being able to maintain a high quality of life or not.

Pain flare ups, simply put, are a normal part of being a human in pain. Sometimes, they are related to something you have or haven’t done, but many times, there is no discernable cause for a pain flare up.

Most pain flare ups are short term – be it a few days or weeks – which can, at the time, seem like they will never end, leading you to pursue options for relief that are ineffective, costly and possibly even dangerous.

Instead, with this article, I hope to show you some strategies you can use immediately, or store away for reference in the (unfortunate) event of a pain flare up.

Why do pain flare ups occur?

Biological systems are non-linear, complex systems. Whilst it is easy to think of recovery as a straight line from injury to repair, in reality, things are a lot more up and down. (2)

In fact, I wrote about this in the last newsletter (you can subscribe at the end of this post, so you won’t miss any future issues).

This fact alone means pain flare ups are an expected, yet unpredictable phenomenon, but beyond saying that flare ups are inevitable, there are more issues at play.

Sensitisation

Sensitisation is the increased sensitivity of the nervous system to stimuli, whether it is at a peripheral level (nerve endings throughout the body), a spinal level or in the brain itself (3).

Because of this process, what was once a pain free task can become painful over time.

Biologically this is designed to protect us from further harming an injured area, which works well in acute injuries, but with chronic conditions, where pain and tissue damage become poorly correlated, it’s not so useful.

Lowered tissue tolerance

Whilst similar to sensitisation, lowered tissue tolerance occurs when you do not use/load body tissues appropriately over time and they decondition.

Whereas sensitisation is purely neurological, tissue tolerance is related to structural changes as well as a heightened sensitivity. The two often go hand in hand.

An easy way to understand this is with the example of muscle wasting caused by immobilisation. There is a reduced tolerance for load, and exceeding this can cause pain.

With both acute injuries and chronic pain, often the loading on the affected area is decreased, either consciously or unconciously, which leads to decreased tolerance of the tissues to loading.

Expectation

Often people with pain, whether acute or chronic, expect certain things to hurt them.

I was wearing heels all day yesterday because I had a wedding, so I knew I’d be sore today.

What’s interesting about expectation, is that is a self-fulfilling prophecy.

If you think something will hurt, it probably will, thus confirming your thoughts.

That’s not to downplay the involvement of the activity in question, but there are studies that show simply priming  (3) someone with “old” words and thoughts causes them to walk more slowly, without even realising it.

With this in mind, if you are expecting the worst, then chances are you’ll get it. (4, 5, 6)

What to do about pain flare ups

Every strategy to manage pain needs to be individualised to the individual – no one thing works for everyone, nor does anything work the same from person to person.

Acceptance

Acceptance and Commitment Therapy (ACT) is becoming more and more popular in treating/managing pain, because it is so effective (7).

What is so powerful about ACT, is that accepting flare ups will happen, and that you will be in pain, takes away their biggest weapon – frustration and disappointment.

In ACT, thoughts and feelings are not considered to be “helpful” or “unhelpful”. This is important during pain flare ups, because pain can cause us to think negatively, painting situations into worse than they are within our minds.

In essence, ACT is a form of mindfulness.

This is probably the most challenging thing to master, but when you do, the results are profound, both in the context of pain, but also in the greater context of your life.

Modify your activities

Whilst in the long term, avoidance strategies aren’t very successful, because they simply reduce what you are capable of, in the short term, as a management strategy, modifying or even ceasing activities that hurt is a viable option.

Ideally, you will continue as best you can, with what you want/have to do, but it is completely reasonable to put things off.

This makes intuitive sense: if you have low back pain and it hurts to bend, then you will likely avoid bending when it hurts.

However, as mentioned, simply avoiding bending forever is not a solution, and actually makes things worse.

A better approach is to see if you can modify how you bend, and how much you are bending in the short term, whilst working to restore the ability to bend freely in the long term, using a graded approach.

Use pain relieving techniques that work for you

When in pain, it’s natural to want to get rid of it as soon as possible, no matter the cost.

Unfortunately, there is no one medication/therapy/product that can effectively eliminate pain in everybody, all the time.

So, instead of chasing a magic bullet that drains all your time, money and energy, it makes sense to stick with proven strategies.

Once you have found your “recipe” for relieving pain, you can seek to optimise it, with less conventional methods, if they are safe.

Things you can try, which do have effectiveness to varying degrees are:

Focus on what you can do

It’s really hard to stay positive during pain, the whole point of pain, from a biological perspective, is to over-ride our consciousness to take alternative/evasive action from our current situation.

This means a stress response, and a stress response, physiologically, is designed for action, black/white thinking.

What this can do, is cause you to focus on negative thoughts and emotions, setting of a vicious cycle making things worse over time.

If you focus on what you can do – with both a macro and micro perspective – then you completely shift the way you are living.

After all, if you can’t control whether you experience a pain flare up, wouldn’t you at least want to control your thoughts and activities?

BONUS TIP: Spend time in nature to calm stress

Just as I was editing this, I realised it was hard to find pictures of “pain flare ups”, so instead I went for a calming picture of nature, because spending time in nature is quite beneficial for a multitude of reasons, but simply put, time in nature calms our bodies and our minds, which is a massive key for anyone in pain.

Conclusions

Pain flare ups are a massive challenge for patients and practitioners alike, for many reasons.

As with most things, there is no quick fix, but you can definitely improve your experience of pain flare ups in the short term, whilst in the long term, a tailored pain management strategy can help reduce or even eliminate them.

 

This blog post is meant as an educational tool only. It is not a replacement for medical advice from a qualified and registered health professional.

 



 

References

(1) Complex systems theory

(2) Neurobiology of pain

(3) Priming

(4) How expectations shape pain

(5) The subjective experience of pain

(6) Expectation of pain enhances response to non-painful stimuli

(7) ACT

Why Mobility Exercises Don’t Work, And What To Do Instead

Man with great mobility doing yoga with laptop

You don’t wake up one day suddenly stiff, it only feels like that.

Mobility, like most skills, exists on a “use it or lose” basis.

Unfortunately, for most of us adults, our daily lives don’t incorporate much “using it”, so we end up “losing it”.

The best way to maintain mobility if your life doesn’t have you climbing trees and crawling around on a daily basis is through exercise, but, if you have already lost a large amount of mobility, then you’ll have to work specifically to regain it, exercise alone is often not enough.

If you ask google “how to increase mobility”, the top 5 results say roughly the same thing: stretch, foam roll, perform dynamic “joint mobility” and “activation” exercises.

These are valid, but incomplete strategies.

The reason being, lack of mobility is usually not a true range of motion issue – I could lie you down on a treatment table and passively move your joints through a much greater range of motion than you can demonstrate – but rather, a stability issue.

Instability is perceived as a threat by the central nervous system, so protectively, it shuts down range of motion so you can’t cause yourself any harm.

Thus, the underlying cause of limited mobility is neurological.

So, in order to improve mobility in the real world, you must go deeper than foam rolling and targeted stretching/joint exercises and “release the brakes”.

If you don’t, you will just end up spinning your wheels, because when improperly applied, mobility exercises don’t work.

This is because you can’t force the body to do anything, it will resist in an effort to maintain equilibrium.

Now, there are definitely cases where there are physical changes to soft tissues and joint structures that limit mobility, but, outside of diseases and trauma, these physical changes usually occur as a result of the limited mobility caused by the nervous system (use or lose it principle).

So, if you have lost mobility over time, how do you get it back? There are many ways, this is the process I’ve found effective and use with my patients:

Osteopathic Manual Therapy

Being an osteopath, I like to start with manual therapy, but not for the reasons you might think.

Manual therapy doesn’t change tissue length, nor does it “put you back into place” or “re-align” you.

What manual can do, and in the hands of a skilled practitioner, does very well, is provide the body with a chance to change.

Movement, or motor output, is the result of complex co-ordination that takes place in the brain, based in part, on sensory information provided by the peripheral nervous system.

Nociception, the transmission of “danger” signals to the brain and spinal cord from nerves located throughout the body can inhibit motor output.

Nociception is related to, but not the same as, pain. You probably know that if something hurts, it usually doesn’t work well. This can also happen when that something doesn’t necessarily hurt, but the nerves are hyper-active anyway.

Because the body functions as a whole, when one area isn’t moving properly as a result of this increased nociception, then there is a chain reaction throughout the rest of the body.

By using manual therapy, we can inhibit nociception, change motor output and affect a change throughout the rest of the body – often decreasing pain and increasing mobility.

Often manual therapy alone is enough, especially if the issue is relatively new or minor, and new, dysfunctional patterns have not had time to become ingrained. If the problem has been around longer, or is not responding to manual therapy alone, we can move to the next step.

Restore Reflexive Stability

Reflexive stability is the term physiologists give to the near instantaneous adjustments that take place when we move.

This allows us to move safely and effectively, and usually efficiently.

With disuse and pain, this response is dulled, and one of the results is an increase in stiffness, which is designed to protect us in the absence of true stability.

To restore this, you have to go back to fundamental movement patterns, progressing to the next only when you have reached mastery each position/stage.

As mentioned earlier, most stiffness is the result of instability, rather than a true range of motion issue. With this in mind, regaining lost reflexive stability is an effective way to improve mobility by addressing the underlying cause.

Reflexive stability exercises are by nature, whole body movements, performed in progressively more challenging positions/postures.

For the vast majority of people, a combination of manual therapy and reflexive stability exercises will improve most mobility deficits.

For an example of reflexive stability in action, try this simple test:

Perform a squat, noting your depth and the amount of tension involved in achieving it.

Now, get down on your hands and knees and perform 60 seconds of quadruped rocking (below):

After 60 seconds, get up and retest your squat.

If you notice an improvement, then you just witnessed the benefits of reflexive stability. If it was the same for you, then either you don’t have a deficit, or your deficit is elsewhere.

Maintaining Reflexive Stability

After you have gone through the progressions, moving from ground based to upright, the easiest way to maintain your reflexive stability and build your health is by walking properly and walking regularly.

Walking is largely reflexive – a lot of the control occurs at a spinal, not brain level – which means that once you have restored your reflexes, maintaining them simply requires using them.

Now, any old shuffle won’t do, what you want in order to reap the benefits, is to walk with a contra-lateral arm swing, looking up. Ambling down the street with your phone in your hand and your eyes on your phone isn’t going to help you, it’s only going to re-inforce the issues the caused you stiffness in the first place.

For most people, especially those of you who don’t exercise, these two steps alone are enough to restore the mobility you need to go about your daily living.

If you are exercising and/or you want to take things even further, then we can add a few more steps.

Active Stretching and Functional Movement

If you have addressed potential issues with manual therapy and general (reflexive) stability work, but you’re still not getting the specific mobility improvements you want, it is time to begin more targeted work.

One form of targeted mobility work I like to use is “active stretching”.

Active stretching is probably just another name for PNF (Proprioceptive Neuromuscular Facilitation) stretching, but it’s simpler for my patients to understand, so I prefer that.

Active stretching is where you are stretching a muscle group whilst simultaneously activating opposing or synergistic muscle groups – essentially adding stability to the newly explored range of motion.

I’ve found this to be far more effective than passive static stretching, and it really helps people “get” what a joint position is supposed to feel like.

If you then use this increased joint range of motion in more demanding, functional tasks, then you “teach” the body that this range is okay to use, because you are adding strength/stability to a previously weak/unstable position.

This results in an increase in mobility.

In the following example I shared on Instagram, I’m using an active hip flexor stretch, followed by an isolated glute activation exercise before reinforcing the new pattern under load with a barbell squat:

If the problem was at the ankle instead/as well as at the hips, another sequence might involve an active calf stretch (demonstrated below), followed by a dynamic mobilisation of the ankle joint before squatting.

Again, these exercises are not only addressing range/length of a joint/tissue, but improving stability, which, as we discussed, is often the real driver of joint mobility.

The functional exercise then reinforces the pattern, and once repeated enough times, in correct fashion, it is usually enough on its own to maintain the improvements in mobility.

Whilst I demonstrated the example with a barbell squat, this isn’t necessary, you might simply perform a full squat position, as millions of people around the world do on a daily basis, in order to maintain mobility.

As always, the execution will depend on your needs and wants, but the underlying principles remain the same.

An Aside On Exercise Technique

In the examples above, the active stretching is then reinforced by the high demands imposed by the squat.

However, if you are squatting with poor form, then you are undoing the effects of the active stretching.

Good form is easy to spot – it is controlled, stable and smooth. Whilst everyone has different body shapes and sizes, thus the execution of movements will look different, the ability to perform controlled movement should be universal.

It’s also important to understand that if you skip straight to exercise, without addressing the stability issues first, then your body will simply “survive” the exercise by using whatever movement pattern is strongest, optimal or not.

Once you have addressed these issues, using optimal exercise technique reduces the need for continuing mobility work – once you’ve got it, maintaining it is easy – this is why in countries where people continue to squat throughout their life, mobility deficits are less common.

Maintaining Mobility

Maintaining mobility is relatively simple: use what you have got.

If you are coming to this article with restrictions, then it is still simple: regain what you’ve lost, then use it to keep it.

If you go to all the effort and expense of getting treatment and performing the work to regain mobility, only to continue with the lifestyle that got you needing treatment in the first place, then chances are, you’ll end up back where you started, given a long enough time frame.

Because we don’t have many (any) physical demands to survive anymore, we have to deliberately perform tasks that challenge us physically, including our range of motion.

This goes against human nature, which is to conserve as much of our energy as possible – it’s wired into our brains to do this – so, what I recommend is to build mobility maintaining activities into your day.

Examples of mobility maintaining activities are:

  • Walking properly (as discussed earlier) instead of driving short distances
  • Sitting on the floor to watch TV instead of on a couch
  • Squatting instead of bending to pick things up from the ground

Whilst these activities are not going to prepare you for a Cirque de Soleil audition, they will help with your activities of daily living (ADL) and your quality of life.

Beyond this, exercise, particularly full range of motion strength training, in all its forms, is the best way to maintain, and even improve mobility.

Conclusions

Mobility exercises need to be used in context. If you use them when you have an underlying stability issue, either at the stiff segment or elsewhere in the body, they will not be effective.

Used in a sensible, principle based approach, like the one I outlined above, they can play a valuable role in regaining mobility.

Once you have restored lost mobility, it’s much easier to maintain. This can be done by incorporating activities into your day that require you to use extra mobility.

Walking is one of the best general exercises, if you do it well, and can help maintain good health, including mobility.

For more focused efforts, full range of motion strength training is probably the best way to maintain and even improve joint mobility, once you are moving correctly.
This blog post was written by Dr Nick Efthimiou (Osteopath), founder of Integrative Osteopathy.

This blog post is meant as an educational tool only. It is not a replacement for medical advice from a qualified and registered health professional.

 



 

References

Nociception and motor function

Cutaneous afferent regulation of motor control

Feed forward control and movement stability

Physiological basis of functional joint stability

Training the Core

Lower motor function, Lederman, E., The Science and Practice of Manual Therapy, pp 99-100

Osteopathy for Headaches and Migraines

Woman with headache

Chronic headache is the most common neurological complaint presenting to GPs in Australia. (1)

This means it’s likely to be even more widespread than statistics suggest, as many people simply don’t seek medical treatment for chronic pain conditions.

So it’s safe to say, headaches and migraines are kind of a big deal.

Most people experience headache at some point in their life. If it is simply a one off, or infrequent, then most of the time, the best management involves either putting up with it, taking simple over the counter analgaesics or getting treatment from an osteopath (or similar).

However, when headaches are persistent, more targeted management is needed, and the first step is identifying the type of headache you have, which will influence the type of treatment accordingly.

Types of Headache

When it comes to headaches and migraines, there are two broad categories:

  1. Primary headaches, which the headache is the problem itself. These include migraine, tension type headache, cluster headache and other (less common) primary headaches.
  2. Secondary headaches, where the headache is a symptom of an underlying condition, including meningitis, brain tumours, aneurysms and brain bleeds. (2)

Because of the serious nature of the underlying conditions that cause secondary headaches, new headaches, particularly very intense or persistent ones, and those with other neurological symptoms like nausea, dizziness, visual changes and loss of balance should be examined by a medical professional.

This post will look at primary headaches and migraines, to give an understanding of the physiology involved as well as treatment options and self-management strategies.

The Headache Continuum

Primary headaches account for 90% of headaches, and are a common cause of visits to health professionals, including osteopaths.

The two most common form of primary headache are migraines and the tension type headache.

Understanding the difference between the two will help identify appropriate management strategies, so an accurate diagnosis is imperative (this means seeking out someone who went to university and studied medicine, not someone who watched an episode of House and wrote in an online forum).

A helpful way to understand the differences between tension type headaches and migraines is by the use of a continuum (3).

Health professionals love a good continuum, and I’m no exception. In the case of headaches, we have migraines on the far left and tension type headaches on the far right.

Headache-Migraine Continuum

In terms of the continuum, we have neuro-vascular involvement (migraines) at one end, and psycho-neuro-muscular involvement at the other (tension type headaches).

Though not officially recognised by the International Headache Society (IHS), there tends to be an agreeance amongst many clinicians and academics of the existence of mixed type headaches as well, which would exist about halfway along the continuum.

Finally, for this post, we will consider cervicogenic headaches, as commonly diagnosed by osteopaths and physical therapists, as well as GPs, to be similar to tension type headaches, in that the clinical features and physiology underpinning them is quite similar.

Migraines

Migraines are typically intense headaches that can last up to 3 days, often accompanied by other neurological symptoms such as photophobia (sensitivity to light) and dizziness. There are two main types of migraine – those with an aura and those without.

Migraines involve the activation of, or the perception of, the activation of the pain-producing innvervation (nerve supply) of the cranial blood vessels. (4)

Diagnosing migraines comes down to a careful history.

As migraines involve a heightened sensitivity to change in stimulus, with a careful history, often triggers can be identified and managed.

Although this is a tedius process, for those sufferers who can identify specific triggers through a process of elimination, managing migraines with lifestyle changes becomes a whole lot more viable.

In addition to lifestyle changes, there are medications which are effective in both the management of acute migraine and in the prevention/reduction of chronic migraine.

For acute migraines, one of the most effective interventions is to take 900 mg of aspirin along with 1000 mg paracetamol. (5)

In some people, NSAIDs (Naproxen, Ibuprofen etc) will have a better effect.

In many cases, there are more specific medications that will work better than those listed, though the list is long-ish, so it might take some trial and error to find out the specific medication and dosage that works for you. Again, work with your doctor, not a blog, to figure out the best approach for you.

Please understand, all medications (in fact, all interventions) have potential side effects, so before you go taking any medications, get medical advice.

Tension Type Headaches

Tension type headaches are mostly diagnosed on an exclusion basis – that is, they don’t have particular features that would classify them as another type of headache. They are the most prevalent form of headache, but often go untreated, as people don’t seek out assistance for them.

The specific patho-physiology of tension-type headaches isn’t clearly understood, but the name implies some form of mental or physical tension involvement, which is agreed upon by headache researchers.

The reason they exist at the opposite end of the continuum to migraines is the absence of vascular involvement. (6)

It is most important to get an accurate diagnosis, as these headaches, are quite a clinical challenge to treat. So if you actually suffer from migraines, but get diagnosed as suffering from tension type headaches, you are potentially missing out on efficacious treatments.

Many people with tension type headaches experience exacerbation in times of psychological or physical stress.

If this is you, pro-actively managing your stress is one of the best preventative treatments available.

Additionally, tension type headaches often have a muscular component – that is, physical tension produced by overactive muscles, usually across the face, head and neck.

Osteopathy For Headaches and Migraines

What is interesting about headaches, is that, in terms of nerve supply, facial and cranial areas are all supplied by the trigeminal nucleus.

So although the cause may differ between a migraine and a tension type headache, the origin, may be the same.

This is clinically significant, because the trigeminal nucleus blends with the nerves from C1, C2 and C3 (the upper part of the neck).

This means that treatment to influence these nerves, can, theoretically, influence all kinds of headache.

Unfortunately, theory doesn’t always translate to practice, but many osteopathic techniques to treat this area relatively safe and risk free, with the big exception being techniques that involve end range rotation of the neck, thus it may be worth exploring.

Additionally, for most people, osteopathic treatment can help relieve some of the systemic effects of headache, including an increased stress response and muscular tension.

Some of these systemic effects include:

            • Sympathetic inhibition via rib raising. The sympathetic nervous system is involved in the stress response, including blood vessel dilation/constriction, which can potentially affect migraines. (7)
            • Parasympathetic stimulation via manual therapy and breathing exercises (see the image below). The parasympathetic nervous system counteracts the sympathetic nervous system, and stimulation is involved relaxation and recovery from many stress mediated conditions. (8,9)

Take a deep breath.Chances are you’re not aware how breathing can improve your health and wellbeing (beyond keeping…

Posted by Integrative Osteopathy on Monday, 8 February 2016

These manual techniques can be quite effective, however, as previously mentioned, it is important to “treat the person, not the headache” and consider psycho-social variables as well.

An osteopath can help you recognise and deal with particular triggers of migraines or your response to stressors that might be contributing to your tension type headache and if there is further management required, an osteopath will work alongside your “health team” which may include your GP, neurologist and possibly a psychologist to optimise your management.

What Can You Do For A Headache?

Best practice for the treatment of painful conditions involves what is term an “active approach“, that is, an approach where you are engaged in you care and actively participating to achieve a result.

i.e. “doing something”, as opposed to merely showing up and receiving treatment passively, or having something “done to you”.

This means, if you are suffering from headaches you can definitely do a few things that may help relieve or reduce the incidence:

                          • Educate yourself. Understanding a problem can help you deal with it better. Understanding alone doesn’t seem to improve pain outcomes, but when combined with other active therapies (as listed below) and incorporated into your medical management, it makes a big difference.
                          • Increase your physical activity. If you don’t meet the guidelines (>30 mins daily of moderate activity), then increasing your activity by walking more will have general health benefits that may improve your headaches.
                          • Practice mindfulness. Mindfulness helps you deal with stressful situations better. It also “strengthens” your brain, building neural links that are often negatively impacted with pain.
                          • Sleep better. Improve your sleep hygiene – take electronic devices out of your room, use black out curtains and keep the room slightly cooler than the rest of the house. Additionally, build a bed time routine so that you fall asleep more easily. Fatigue can increase neural sensitivity, and the only way to combat fatigue is with adequate high quality sleep.
                          • Talk to people. Chronic pain, including headaches, can be quite debilitating, as well as isolating. Talking to others who suffer from headaches/migraines in support groups, or a professional counsellor can help with some of the negative thoughts and feelings that develop around pain and often times make it worse.

The best thing about all of these things, are that they are either free, easy to do or both.

Conclusions

Headaches are debilitating, yet with a proper diagnosis, treatment and management is possible.

This treatment must incorporate biological (physical) as well as psycho-social factors.

Looking at the research on osteopathy/manual therapy and headaches, it can seem that often times “nothing much can be done about them”.

However, when you look at physiological plausible mechanisms of treatment, and apply these to both the causes and origins of headaches, the picture seems more promising.

As always, there is no holy grail, and getting on top of things takes a team effort between yourself and your practitioner(s).

Additionally, there is much you can do for yourself, which, while it may not be “headache specific” can greatly improve your health, wellbeing and potentially your headaches.

 

This blog post was written by Dr Nick Efthimiou (Osteopath), founder of Integrative Osteopathy.

This blog post is meant as an educational tool only. It is not a replacement for medical advice from a qualified and registered health professional.

 



 

References

(1,2, 3) RACGP – Management of Chronic Headache

(4,5,6) Wall and Melzack’s Textbook of Pain

(7) Rib raising and autonomic activity – http://www.ncbi.nlm.nih.gov/pubmed/20606239

(8) Osteopathic Manipulative Therapy and HRV – unpublished research from London School of Osteopathy

(9) Deep breathing, pain and autonomic activity – http://www.ncbi.nlm.nih.gov/pubmed/21939499

(10) Relationship between rcpm and dura – http://www.ncbi.nlm.nih.gov/pubmed/8610241

 

7 Effective Ways To Avoid Injury Exercising

Group Exercise @ Healthy Fit, Fitzroy North

Supervised group training at Healthy Fit – professional supervision is a great way to reduce injury risk whilst exercising.

There are numerous benefits to exercise, but what’s often not mentioned in all the pro-exercise publicity, is that there are also risks involved, chiefly the risk of injury.

Many people, despite their best intentions to get healthier and feel better, actually end up unhealthier and feeling worse after injuring themselves pursuing their fitness goals.

Recently, I polled my personal Facebook account for stories of injury whilst exercising.

It didn’t take too long for my notifications to start pinging like crazy. Here are some of the responses I got:

went for a 7-8km run then stupidly tried to do a back session whilst fatigued. deadlifting with no energy then gave me a slipped disc and a very shitty year ahead.

it still niggles. its probably at about 85%. back in the gym but i never lift at more than about 60%. also trying footy again this year but am a little worried about getting a big bump. long car trips are also a horrible experience if i dont have a rolled uo towel to place on my lower back.

I was doing weight training and now my knees are stuffed!

Sore left glute early on in hockey season. Hockey is a right handed game (seriously) and a lot of players tend to develop niggles on the left side.

Buggered knee from years of over exertion bad form and bad knees

Yes many times mainly due to my strength being far superior than my mobility and flexibility at the particular time.

High volume squats. Poor form with my wrist. – sprain which eventually led to avascular necrosis of the lunate.
Heavy tb deadlift pb. Not enough food tat day and lifted too heavy given a lack of conditioning (hadn’t lifted heavy in 3 months) back injury – 6 months.

Back is fully recovered, wrist is permanently injured.

 

Not all injuries are created equally, however, and there were many stories involving accidents and trauma which I haven’t shared. Whilst little can be done to eliminate accidents, setting yourself up to exercise as safely as possible can greatly reduce your risk of injuries like the ones described above.

In my years of practice, and especially now being an osteopath based in a gym, along with almost a decade of personal training experience , I’ve learnt a few things about why people get injured exercising. A lot of the time, there is the perfect storm of preventable factors that combine to result in injury.

With that in mind, I’ve listed 7 ways to prevent injuries whilst exercising:

 

1. Make sure you want to exercise in the first place

Most people don’t think things through properly before they start.

When it comes to exercise, before you start, you have to know why.

Without a good reason to exercise, you won’t put in the effort to do things properly, which is a sure-fire route to getting injured, or you will, but the effort will be such a stress that it negatively impacts other aspects of your life.

Deciding to exercise will either have a positive or negative motivation behind it.

Positive: I want to be healthy and feel strong so that I can live a full life.

Negative: I don’t want to end up weak and frail and isolated in a nursing home.

Neither is right or wrong, but from experience, negative motivation only lasts so long. If it gets you going, great, but be aware that those that stick to exercise for life tend to have positive motivations for doing so. Don’t worry though, chances are you’re reasons for starting will be different to your reasons for sicking to it.

Exercise is fantastic, most people should be engaging in some form, but it is not essential to exercise to be healthy.

So if you chose to do so, know your reasons.

 

2. Learn to move well

This was almost going to be number 1, because, even if you don’t “exercise”, chances are you move.

Learning to move well is both simple and complex at the same time.

The knowledge behind the process is actually quite complex, but what you have to do is relatively simple. The key is to seek out an expert who has the complex knowledge but can provide you with simple, actionable steps to get you to move well.

Whether it’s an osteopath, a personal trainer or both, the initial investment in learning to move well will pay you dividends for life.

 

3. Know your weaknesses (and address them)

We all have strengths and weaknesses. Naturally, we gravitate towards our strengths.

Big strong people tend to like to lift heavy things. Tall and lean people tend to like to run, row or ride.

Of course, these are just generalisations, but the point is, if we only ever focus on our strengths, chances are we will limit our potential achievements and increase our risk of injury, as our bodies become ever more efficient at compensating until they can no longer.

Identifying your weaknesses is a tough thing to do. Most of us a terrible at looking at ourselves objectively. This is where it pays to hire a professional to tell you what you need to work on.

Not only will address your weaknesses make you more resilient, but your biggest fitness gains will come from improving your limiting factors.

 

4. Progress intelligently

One of the biggest predictors of injury is the ratio of acute to chronic training volume.

What the heck does that mean?

It means when you see a big increase in the amount of work done in the short term, relative to the amount of work done in the long term, then injury is more likely.

Put another way, you have to build up your tolerance to large training loads.

That means starting well within your capabilities and progressing gradually.

The 10% rule – not increasing total training volume by more than 10% per week – is a good general guideline to go by.

Start with an assessment to work out your current abilities, and then progress gradually, using different means of progression. Intensity, volume, frequency, rest, density and even activity/exercise selection are all variables that can be manipulated to provide progressions.

You should have certain indicators that help you identify when you are ready to progress – whether they are qualitative (rating of perceived exertion (RPE) scales) or quantitative (biofeedback like heart rate or power output). (1)

This will prevent your ego getting in the way and causing you to make to big of a jump too soon, which is a massive cause of injury.

 

5. Prioritise recovery

Everyone loves to train hard, not many people like to put in the effort to recover well. However, your ability to exercise is determined by your ability to recover.

Recovering means more than time off training. It means actively taking steps to relax and regenerate both your body and mind.

That means your nutrition and sleep must be on point, but also, your workload and personal life must be taken into consideration of your exercise load.

There are a few ways you can monitor you recovery.

Old school: keep a journal, track your mood and a RPE for each session. If your RPE is going up and your mood is going down, it’s a good sign you’re not recovering enough.

New school: Heart rate variability (HRV) apps. HRV is a way to measure your autonomic nervous system activity, which is a good marker of how stressed you are. You can download various free apps which will sync up with a chest heart rate monitor, whilst at least one can use your smart phone’s camera to measure your heart rate via your finger tip.

Recommended HRV apps*: EliteHRV,  ithlete, HRV4training (iPhone only) (2)

The best approach, which is also the most effort, is to combine a journal, RPE scale and HRV data. Initially, it won’t tell you much, but over a longer period of time, you’ll gain valuable insight to your physical and mental state, which will allow you to know when to push hard and when to back off.

Even if you don’t monitor your recovery status, simply allocating time for active recovery techniques is doing better than 95% of people.

 

6. Balance your training over time

Depending on your individual goals and personal characteristics, you will train in a way which builds particular physical qualities.

However, it is important for health and longevity to build all physical qualities to some degree – flexibility, mobility, power, strength and endurance.

Even if you are a highly specialised athlete, outside of your sport, all training is general in nature, and thus you should aim to improve a range of general physical qualities to minimise injury and maximise performance. If your sport is “the game of life”, then this only adds to the need to exercise a broad range of attributes.

Balance is more than being well rounded; you want balance between periods of hard training and periods of consolidation, which goes back to prioritising recovery.

 

7. Don’t chase fatigue

Anyone can make you TIRED. It takes a skilled professional to make you BETTER.

One of the biggest mistakes people make when exercising, whatever their motivation for doing so, is “chasing fatigue”.

This is a problem, because whilst how we feel on any given day is important, it gives us no insight into whether we are actually improving.

Additionally, chasing fatigue often results in compromising your movement in order to complete a given task, which is risky business to say the least.

This occurs because people associate with certain feelings, and a common association, often perpetuated by the mainstream media is that a workout has to be hard to be effective.

Now, of course, some exercise sessions will be tiring, that’s completely okay, but fatigue should be a by product of exercise, not a goal in and of itself.

You don’t always have to improve from session to session, or even in a straight line (pro tip: neither happen in the real world anyway), but, over a long enough period of time, you should improve at what you are doing.

The best way to know this is to keep a training journal, but if that’s too tedious, having “milestones” throughout the year where you test yourself are a good way to keep track on a macro scale.

8. (BONUS) Fit the exercise to your body, not your body to the exercise

Not everyone is built to run long distances or squat heavy weights with a barbell.

This goes back to knowing your weaknesses (and strengths), but you should choose activities and techniques that suit your body type and abilities.

If you like to run, that’s fine, but maybe marathons on roads don’t agree with your body, so instead, you try shorter distances or trail running.

Likewise, if the gym is your thing, build your program around exercises that suit your body, not what some article online says is the best “butt builder”.

Final Thoughts

Injuries can still happen, despite your best intentions, but there are lots of things you can do to minimise your risk, the above list covers 7 very important elements to consider.

A lot of them have overlap – doing too much too soon and not getting enough rest – and are generally brought about by not knowing any better (forgiveable) or getting emotional/letting your ego guide your decisions (not-so forgiveable).

Exercising should be enjoyable, not a chore, and this list isn’t meant to take the fun out of exercise, but rather, help keep you injury free so that you can continue to exercise in a way that you enjoy.

This blog post was written by Dr Nick Efthimiou (Osteopath), founder of Integrative Osteopathy.

This blog post is meant as an educational tool only. It is not a replacement for medical advice from a qualified and registered health professional.

 



Notes

(1) To read about a simple, easy to use RPE scale, as used by the Australian Institute of Sport, read this.

(2) I’ve only used EliteHRV, but the other two come highly recommended from other professionals I trust.

Effective Nutrition for Injury and Rehabilitation

Fresh Food

An often overlooked aspect of recovering from an injury is nutritional intake.

This post will look at nutritional needs for injury from a broad perspective including:

  • Energy needs during reocvery from injury
  • Macronutrient needs during recovery
  • Micronutrient needs during recovery

A future post will explore effective supplementation for pain and injury, but as always, it’s important to start with the “big rocks” first.

Before we go into further details, you need to understand the difference between pain and injury.

Injury occurs when tissues are stressed beyond their tolerance, resulting in damage as either a partial or full rupture of the tissue. Injuries usually fall into one of two categories: acute/traumatic, chronic/overuse. Whether soft or hard tissue is involved, each injury undergoes an acute inflammatory phase followed by a rebuilding phase. Both the inflammatory and rebuilding phases can benefit from targeted nutritional approaches.

Pain is the unpleasant feeling we experience, often, but not always, in response to an injury. We can also experience pain without injury, so just having pain is not an indicator you need to modify your nutrition.

To know whether you are suffering from pain resulting from and injury, or simply “non-specific” pain, you can ask yourself a couple of simple questions:

  1. Was there a traumatic incident that could have caused the injury, and did the pain start after this?
  2. Is this a new pain? (recurring pain is typically non-specific, or less associated with injury)
  3. Are there obvious signs of inflammation – redness, swelling, heat?

Answering yes to one or more of these questions could indicate an injury. If you are unsure, it’s best to seek out a medical professional for a diagnosis.

Energy Needs During Injury

As you can imagine, an injury results in an increase to our energy needs, as the body increases metabolic activity to repair the damaged tissues.

Most textbooks calculate an increase of approximately 20% on top of your energy needs, if you are sedentary and eating at maintenance (not gaining or losing weight).

If you are already highly active, you will actually end up eating less than normal, as being highly active would require eating greater than 20% above maintenance intake.

You don’t have to track your intake exactly, but rather be mindful that if sedentary, you will need to increase your energy intake during an injury, whereas if you are highly active, you will need to decrease it, but not all the way to your baseline maintenance intake.

Macronutrient Needs During Injury

Macronutrients are the three different constituents of food: protein, fat and carbohydrate (alcohol is also considered a macronutrient, but it should be obvious that it isn’t good for injuries or recovery).

Depending on your current diet, you may benefit from changing the macronutrient ratio of your diet.

Protein

For someone eating a fairly average diet, when injured, an increase in protein intake is beneficial. The recommended protein intake is 0.8 g/kg of body weight, whilst the recommended intake for an injury is 1.5-2.0 g/kg, double the baseline. If you are already consuming a high protein diet (as is common among athletes), you don’t have to change anything.

Fat

The amount of fat you consume in response to an injury isn’t as important as the types of fat you consume.

Recall that after injury there is an inflammatory phase. This is when the body increases blood flow to the effected area, breaking down the damaged tissue to prepare it for rebuilding.

If the inflammatory phase is prolonged and/or too extreme, healing can be delayed. This is the reasoning behind applying ice and compression to acute injuries.

Different kinds of fats can be either pro or anti-inflammatory. Thus it makes sense to limit your intake of pro-inflammatory fats during an injury.

There are 3 kinds of fats: saturated , monounsaturated and polyunsaturated. Dieticians generally recommend your total fat intake is evenly divided amongst the 3.

Certain types of polyunsatured fats, omega-6 fats, are pro-inflammatory. Typical western diets are already high in omega-6 fats, so they should generally be reduced, even more so during an injury. Common sources of omega=6 fats are flax seeds, hemp, canola, safflower (and their oils), commercial dressings and many nuts.

At the other end of the scale, omega-3 fats have an anti-inflammatory effect, and can be increased during injury. The best sources of omega-3 fats are marine oils (fish oils) and algae. Many people do not eat adequate amounts of  fish to get enough omega-3 fats, so it is commonplace to supplement. However, the quality of fish oil supplements varies highly, with many brands using low quality sources, along with poor transport and storage methods, which mean that it is unlikely that you are getting what you pay for. In fact, if the oils have already oxidised, then you are actually taking something that is likely causing your health harm*.

It is important to understand that whilst reducing inflammation slightly can accelerate healing, reducing inflammation too much (or eliminating it) can impair healing, thus, you want to eat adequate, not surplus amounts of omega-3, especially if you are also taking non steroidal anti inflammatory drugs (NSAIDs) like aspirin, ibuprofen (Nurofen) or diclofenac (Voltaren).

Carbohydrates

There are no specific dietary guidelines for carbohydrate intake and injury.

Understanding the injury process leads us to two conclusions regarding carbohydrate intake:

  1. We need some form of carbohydrate in our diet, as glucose is required for repair.
  2. Ideally, these carbohydrates come primarily from fruits and vegetables and whole grain sources, as excessive processed carbohydrate intake can be inflammatory.

So while very low carbohydrate diets are currently popular for weight loss/management, during a time of injury it is advisable to consume adequate amounts of carbohydrate.

Micronutrient Needs During Injury

Micronutrients are vitamins and minerals found in foods. As to be expected, the needs for certain micronutrients increases with injury.

One important thing to understand, at this stage, it is not clear whether simply having adequate amounts in your diet is optimal, or whether there is benefit to be had from “megadosing” certain micronutrients during time of injury.

Here is a list of micronutrients that play important roles in recovery from injury:

  • Vitamin A: supports early inflammation, reverse post injury immune suppression and assists in collagen formation. A dosage of 10,000 IU daily for 1-2 weeks post injury is likely safe, but be aware that Vitamin A accumulates in the body and can become toxic if taken in excess. Remember to consider all dietary sources.
  • Vitamin C: enhances white blood cells the help fight infection as well as improving collagen formation during repair. It also is a powerful anti-oxidant and immune booster. Recommended dosage: 1-2 g/day during injury repair.
  • Copper: helps the formation of red blood cells and acts with Vitamin C to form elastin – part of our connective tissue. Recommended dosage: 2-4 mg/day for the first few weeks after injury.
  • Zinc: is required for over 300 different chemical reactions in the body. It also helps with DNA synthesis, cell division and protein synthesis – all necessary for tissue regeneration/repair. Recommended dosage: 15-30 mg/day during initial stages of healing.
  • Calcium and Iron: more in the preventative category, as deficiency in either or both minerals are quite common, leading to increased risk of stress fractures.

It is important to remember that these recommendations are guidelines only. For specifics, it is best to speak to a qualified practitioner well versed in nutrition (or a dietician) to tailor a diet and supplement plan specific to your injury needs. Some of the above if taken continuously can lead to toxicity, whilst others can cause interactions with other nutrients if taken in excess.

Conclusions

The main key to managing your recovery from injury with nutrition is to ensure you are getting adequate amounts of everything you need.

If you already eat a healthy diet and your weight is in the healthy range, it is likely you don’t have any excesses or deficiencies (it is still possible), so continuing to do what you already are is probably your best course of action, with perhaps a modification of total intake up or down as needed.

There are certain supplements that can help with injury and pain resulting from certain conditions, and we will explore those in a future post, however, in terms of this article, the majority of your nutrient needs should be met with food. If you feel you might require specific supplementation, it is best to speak to a qualified health professional (in Australia, go with an AHPRA registered professional as your starting point).

 

This blog post was written by Dr Nick Efthimiou (Osteopath), founder of Integrative Osteopathy.

This blog post is meant as an educational tool only. It is not a replacement for medical advice from a qualified and registered health professional.

 

References

(1) Berardi, J., Andrews, R., The Essentials of Sport and Exercise Nutrition, 2nd Edition, Precision Nutrition, ON

(2) Foods high in omega-6: http://nutritiondata.self.com/foods-000141000000000000000-1w.html?

*The two brands of fish oil we recommend in Australia are BioCeuticals and Metagenics. These are “practitioner only” ranges (we can order them), though you can often source them from health shops with a naturopath on staff.