What I learned from two years of enforced social distancing & social isolation due to injury

I had an accident that led to two years of unbearable pain and repeated surgical interventions, interspersed with time in the house unable to do most things due to the pain of sitting, walking and standing. For many weeks and months I would barely leave the house, and when I did the physical cost would be having to return to lying on the floor or bed for a number of days to recover. Over time most of my social connections with the world disappeared and I became too depressed to interact with a world that I could not take part in, so I shut down all of my social media accounts. It was a very hard couple of years, but as the world enters social distancing and social isolation, I thought that I would share a few of the things that I learned.

Mental health is wrapped up with physical and emotional health

It is an obvious statement, but it takes time and effort to take care of these three interlinked aspects of health. I suddenly found myself at home with all of the time the usual rituals of meals totally disrupted. It was easy to let the nutrition and hydration slide. But actually, I found that meals can be moments of love and connection that have extra meaning. So I learned the importance of planning for them, looking forward to them and celebrating the flavour of the food and the life and energy that it was giving me.

Movement and fresh air is also really key. For me this was regulated by the physical rehabilitation exercises and targets set by the medical professionals. Many of them were complete agony, and walking to the corner of my road without overwhelming pain was beyond me for over 18 months. So I started to explore ideas like nature therapy and forest bathing. What could I do in my garden and in the local woodland to help my mental, physical and emotional health? I think that there are some deeply spiritual things that can be found, and I certainly explored much deeper parts of my mind and spirit in that time alone.

I had to really actively manage my anxiety. The pressures were overwhelming – lying on the floor unable to move and awake day and night with the pain, every worry in the world would crowd my mind – both about short-term and long-term survival. I could not resolve any of them and was totally in the power of the medical professionals and the wider universe. I developed a discipline of evaluating each one and deciding whether it was something that needed my attention today, or not today (ie later). Then I would write down the ones for today and work on how I could move those forward. All of the others I wrote on a separate page (to calm my mind by confirming that it would not be forgotten) and if there was a clear date, or a clear trigger for action, then I would write that down next to it. If others started worrying on my behalf about something that was not on today’s list, I would simply say to them, that is not today’s problem. These are today’s problems. Is there anything that you can do to help me with these?

I had to create a structure for the day, complete with little rewards and recovery moments!

In a topsy-turvy world, I came to realise the importance of ritual and routine for calming the mind. After a long period of everything being all over the place, I started to implement a timetable of when to eat (even if I had no appetite), bedtimes (even if I could not get into bed and could not sleep), getting up etc (even if I could not get up). In time the body started to respond to this routine and the Doctor helped to balance the drugs so that I did start to sleep.

I also started a timetable for each day – even if I never moved from one room. Rather than endless box-sets where the hours merged into each other and I was not sure if it was morning or afternoon, I started to make a plan for each day and break it into sections with rests and recovery in between. Given the levels of pain that I was in, days could be very different according to how my body was holding up. So I would start in the morning by getting a sense of how my body was and reviewing my list of what I had to try and solve today. Knowing that my energy would decline across the day, I would start with the hardest thing and promise myself a reward at a certain time, if I kept working at it until then.

Being a very goal-driven person, I had previously always set myself rewards based on completing the task and achieving the outcome. But I learned here that the challenges were too challenging, and so much like a running programme where the efforts are measured in time, not distance, I moved to a time-based approach. So for instance, if I could work on this until 11am, I would reward myself with a peppermint tea and a look out of the window to see what birds were in the garden.

I also kept a note of how my pain and energy levels varied with what I had done each day, and fine-tuned my timetabling to try to make days more manageable and find moments of joy, appreciation and laughter in each day. These were hard and took searching out, as life did seem very bleak.

Trying something new

With all of the things that I used to do as a triathlete beyond me due to my medical condition, I had to try new things. And some of them have been life-changing!

I always loved yoga, but now found the poses too aggressive for my body. But there are lots of free YouTube videos of Tai Chi and Qigong. These have been proven to have massive impact on all aspects of health and combine mental focus with physical and emotional wellbeing elements.

Just a short period in the morning can be a perfect way to get started, as these videos show:

Or for 20 minutes of Qigong: https://www.youtube.com/watch?v=cwlvTcWR3Gs

Taking longer-term distance learning course was fun and helped when the situation rolled on

One of the most challenging things was that I always thought that I would be better in 4-6 weeks, but the months rolled on and there could be a tendency to despair.

I was desperate to keep my mind active – both to ensure that I could get work again when I was better, and also for the joy of learning and challenging myself mentally. I loved the free distance learning via Future Learn (https://www.futurelearn.com/) where I studied for eight different courses, each of six to ten weeks long. These included online chat with other students, as well as paced weekly learning and the chance to then explore the subject more with further background reading.

The sense of something ongoing and paced in weekly does in a world where every day seemed unpredictable really helped me. Plus I learned a lot about things that really interested me!

Others helped me to be really inventive on the things that I could do!

Even when I was lying on my back on a thing memory foam mattress on the lounge floor, the ideas that others came up with to fill the time were really fun! Music playlists, adult colouring books, writing and blogging, even playing the guitar….

They say that necessity is the mother of invention, and once I started to push the anger, sadness and despair to one side then I could start to engage with creativity and invention.

Technology can be a great enabler to beat loneliness

Loneliness is deeply painful and a dangerous place to inhabit for long.

I was lucky to have a couple of key friends and my sister who would message, WhatsApp, phone and video chat on a regular basis. One used to call me every time that she was walking to the swimming pool and we would talk. These were lifelines in a world where I was sinking.

I learned the importance of keeping talking the hard way. It turned out that it is a mental and physical muscle that needs working and because it was under-used for so long, I can still find it really hard to find the right word or phrase, and am still conscious that I miscue in the usual social pacing of conversation. This adds stress and self-doubt in social interactions, which make it harder to re-engage with the world.

So how about:

  • setting up Skype or Facetime to chat for a wider family meal
  • having a book group via Zoom or Google hangouts
  • using your coffee break to message or call a friend and chat
  • have your pub night with friends virtually where you connect and chat with a drink in your hand, without leaving your own home

There are great books, podcasts, YouTube and video content

Finally, I would say that I found inspiration and insight in some amazing writing and content. This was a luxury that previously was confined to when I was on holiday, and it has been so exciting to read so many wonderful books.

In summary

Whilst this may seem like a terrible custodial sentence right now, I hope that you can and will find ways to make good things come out of it. I wanted to share my experiences of the last two years to try and help a little as we all step into a time when we need to reach out and support those around us. I know that things seem very frightening at the moment, but the human race has come through worse things than this, and with a little luck maybe it will help us to reassess some of our priorities so that we can make the world a better and kinder place.

I wish you every good wish, and if you want to chat with me – then tweet or DM me on Twitter @AthleteInjured

Why going to a Pain Clinic can be a really good step to recovery

When the physiotherapist mentioned going to a Pain Clinic, everything about it that I could find suggested to me that this was a last resort – a place that you go once you have lost every last vestige of hope that you can get better and just want to manage the pain to try to find a way to get through the minutes and hours of an agonized existence. And talking with a number of other people in pain, this perception is very common, and none of the things that I could find online change that view.

However, the reality was so very different, and this is why I wanted to write this to help others to get the help that they need faster.

They never dismiss your pain

I can imagine that one of the challenges for Health Care Professionals is when they have to admit that something is complex and they don’t really know the answer. The downside of this is that thousands of people every year are dismissed by comments and inferences that imply that the pain is ‘all in their head’. You only need to take to Twitter or patient forums to hear the things that people have been told (or at least how they have interpreted comments from Doctors and Physiotherapists).

At the pain clinic, dealing with serious pain is their ‘thing’ and they are overflowing with compassion, knowledge, support and genuine interest in your pain. This alone is a huge relief, when you have been spending months battling to get people to listen the symptoms and take them seriously. It feels like getting into a comforting, warm bath! Plus they have models and simple explanations that help you to make sense of how your life is unravelling and what you can do about it.

One model that was enlightening for me was the ‘pain triangle’ that they said was universal in serious pain – where the relentlessness and intensity of it makes you feel helpless and hopeless, and your incapacity and reliance on others then drives feeling worthless. Then each point of this ‘helpless, hopeless, worthless’ triangle reinforces the other points, dragging you lower and lower until you can find something to break out of the vicious cycle.

They really want to get to the root cause

The next bit of brilliant news at the pain clinic is that they profoundly believe that your pain has a cause and that with work, they can find it. I felt that there was almost a detective vibe – where they are searching for the cause with different clues, hypotheses and points of evidence. They listen intently to every clue that you can give them, weighing it and thinking about what it could mean in a medical sense.

The pain clinic felt different. How? Well, I sometimes joke that when you see a consultant, they only have the 3 N’s (kNife, Needle or Nothing) and physiotherapists only have the 3 P’s (Poke, Push or Pray). This is of course brutally unfair and negates all of the knowledge and complexity of what they do, but as a patient it can reflect the outcomes and the lack of transparency in the process where they have the knowledge and you are just left with the problems. But, in the pain clinic, it felt like there was a logic in the way that they assessed the total body and looked at the interactions of different body parts. This is especially important when there are different body parts involved or overlapping conditions that come under two different surgical specialties because it leads to a lack of clarity about where the leadership and ownership sits between the different specialties once you are an out-patient. Whereas in the pain clinic it is all assessed together and at the same time (almost like you are one person with all of the parts of your body connected!)  

They take a multifunctional approach

The other brilliant bit is that all of the different disciplines work together and talk to each other in the pain clinic. This is so different from life as an out-patient and even as an in-patient, when even when you try to get the physiotherapy and surgical side to align behind one treatment plan and talk with each other, one party always resists it (even if you promise to sign GDPR releases, volunteer to manage the phone call within your appointment and volunteer to step outside if there is something that they want to discuss without you present).

At the pain clinic they have a common goal to reduce and eliminate your pain, and they each bring their own specialist skills to this team goal. It feels like a sports team, with everyone rooting for each other and working hard to get a result. As a patient, you feel in good hands.

This team support is important. If there was one tip that I would give to Physiotherapists in the out-patient context it would be ‘don’t comment at all on any previous physio that the patient has had’. I have seen nine different physio’s through the path of my pain and universally in the first stage (when they ask you lots of questions about what has happened and what you have done before), every single physio has critiqued what the previous physio has done with very negative tones and criticism. This really does not help! We cannot turn time back and I have already decided to change physio to see you, so there is no need to justify why you will be better. It makes me (as the patient) feel vulnerable and scared, because it makes me wonder if I allowed the ‘wrong’ treatment to be given to me (even though there was no way that I could have had the knowledge to make this judgement). And when you have seen as many as me, you start to build a picture that there is no common view of best practice and that there may be a lot of snake-oil sales people in the physiotherapy profession who maybe have not kept up-to-date with best practice. I hope that this is not true, but is a clear impression that the criticism of others can generate.

So my advice for patients is to seek out a group who work together across functional boundaries with your wellbeing as a patient as their over-arching goal.

When should you go to a Pain Clinic?

There is not really a clear view on when to go to a pain clinic, and again you can get a lot of contradictory advice. The textbooks says that pain is considered to no longer be ‘acute’ and to have become ‘chronic’ after 3 months, although many GPs seem to operate on 6 months.

I also think that there is a lot of pressure on the resources of the pain clinic (and there is a really long waiting list for it – over 9 months in our area). My hunch is that this leads to a tendency to hold off from a referral to the pain clinic until it has been a very long and serious issue. If you have health insurance, there are also private pain clinics, although you will need to have a look at the terms of your policy to see whether this is covered and what the referral process is.

I would suggest that for the reasons above a pain clinic may be especially helpful if:

  • You have overlapping conditions that make you feel that you are falling through the gaps
  • You are not making any progress and need a different approach
  • You are reaching a point of despair

I wish you the very best of luck – you are not alone, and there is a brilliant team somewhere who can help you! Stay strong in order to find them and start to move forward.

The ‘First Law of NeuroKinetics’

Have you ever had the experience of releasing tight muscles one day, only to be right back there within a day or two with the same level of tightness in the same place? I certainly have, and have now learned the ‘First Law of NeuroKinetics’! (This is my labelling, rather than a formal academic name!) But it is very useful indeed as a framework for daily bodycare!

What’s the solution?

The challenge of releases – whether a sports massage, stretching or releases is that usually the results are transient. The muscle patterns are leading to overload on that muscle group are not changed by releasing the muscle. So for all that it feels good, it does not change the cause of the tightness and hence it comes back very quickly. So rather than recovering, it can feel like painting the Forth bridge – constantly going back over the same areas.

So I have learned ‘the first law of NeuroKinetics’, ie that releases must always be accompanied with focused activation and strengthening of the opposing muscle in the pair. And then into additional activation that recruits the synergists correctly – probably involving bigger movement patterns than the more focused agonist/antagonist activation exercises. [I have to admit that there are some parts of the body where the interactions are more complex and one muscle may be inhibiting two, three or four others! Still the same principle, but a much more complex unit.]

Looking back I can see that this was in some of the programmes that I have been given. But having it front and centre of my mind is very useful indeed.

Working through a case study

As a ‘for instance’ – if the adductors are tight it suggests that they are doing a lot more stabilising of the hip region than they should be. The simplest opposing movement is abduction, which involves the gluteus medius, gluteus minimus and tensor faciae latae (TFL). And the synergist to adduction is the inside edge of the quads, whilst the synergists to abduction are more spread across the lumbopelvic area – involving the psoas, piriformis, quadratus lumborum and rectus femoris.

Releasing

The first job is to release the adductors – and there are a lot of them. Some people talk of the ‘long’ adductors (which give you the feeling down the inside of the leg between the groin and the inside knee) and the ‘short’ adductors (which you can feel in vertical lines as you move out from the groin across more towards the hip and before you reach the rectus femoris).

There are five adductors and one of the mnemonics to remember them starting from nearest the hip and moving through the groin and into the inside leg is ‘Please Baby, Love My Groin!’ – ie Pectineus and Brevis (the ‘short’ adductors), Longus, Magnus, Gracilis (the ‘long’ adductors).

The reason that it is useful to understand this is in the stretching and releases. The long adductors are normally stretched with the legs more than shoulder width and dropping the weight vertically over a bent knee on one side. However, there are three different foot positions for the straight leg and these stretch the three different adductors. The short adductors are usually stretched with the ‘frog’ stretch, but it will take some hip movements side-to-side and the weight forward and back to stretch both of the adductors involved.

Likewise, using the edge of a foam roller or a ball to get into the areas for release will require different locations to find which ones need the most release and then getting into them to release them.

For completeness, I need to mention that good breathing methods and Proprioceptive Neuromuscular Facilitation (PNF) can really make a difference to the quality of the releases and stretches.

Activating

Then we need in the exact same session to get into the activation exercises. There is no need to fear that they will tighten up the area that you have just released. In fact, it is the exact opposite! The more the agonist contracts successfully, the better the antagonist switches off and relaxes. 

The reason that you do the exercises is two-fold:

  1. Neuromuscular repatterning. You are programming the nervous system to send the right messages and the muscles to respond to them. It is likely that the body has got out of the habit – and this is why perfect form is so important (you need to teach the body correctly) and why usually it is sets of 15, 3 times with a recovery interval of around 1 minute between the sets (to ensure that the body ‘hears’ the message).
  2. Muscular strengthening. You will also be putting the demand on a muscle that may not have been working for a little while. So the load over a period of a couple of weeks will ensure that new fibres are made and the muscle strengthens.

So back to the example, side-leg raises are a great starting point and then we can include some abduction movements (opening the hip) either on machines or via the ‘opening the gate movement’. More complex movements can include side plank (or side half-plank if it needs regressing) with moving the top leg up and down, forward and back and then in half-moon movements starting from close to the floor in front of the lower leg and finishing close to the floor behind the lower leg.

Then we can move into some more overall movements to get the synergists moving – for instance a front or back lunge, probably breaking it into stages of movement to make sure that each part of the movement is balanced and strong, whilst moving smoothly between the positions.

If it still remains tight

If after two weeks of a daily programme on both the releasing and the activating is not making any difference to the tightness, then it does not mean that the law is wrong! It just means that with the complexity of the body’s movements and interactions we did not choose the correct opposing movement and therefore probably have the wrong muscle pairing. So we need to go back to the analysis stage and look at what other interactions are going on and simply go again with another pairing. Patience and focus does pay dividends.

Best of luck!

PS – for any Urban Dictionary readers, this is all IRL!

This is THE book!

This is the book and the community that I had been looking for. And I would recommend that if you know an injured athlete, then this book is probably the best gift that you could give them.

I came across it when I was listening to one of the podcast series that I often listen to and heard it mentioned: ‘Rebound: Train your Mind to Bounce Back Stronger from Sports Injuries’ by Carrie Jackson Cheadle and Cindy Kuzma.  As well as reading it cover to cover, and going back through it over and over, I also discovered the Podcast series and the Facebook page under the title of ‘The Injured Athletes Club’.

Practical support

The book has forty-nine mental drills that map against fifteen key mental skills that you can build to aid recovery from injury. It is built from real experience helping athletes through successful rehabilitation from injury – and the core belief that one can rebound from injury.

The book includes

  • narratives describing athletes’ journeys through injury, including the key inflection points
  • Scientific explanations of the underlying psychology
  • Key points to take away and work on
  • Specific mental drills that you can incorporate into your recovery

But perhaps the community is the most important part

The book opens with talking about the fact that you are not alone, and that with that pillar in place – there is a path forward.

The community allows for the stages of grieving – accepting and defusing the negative emotions, finding the clarity and support for the steps needed for your progress and then having a genuine cheerleading group to celebrate the simple, baby-steps steps of progress towards your bigger goals.

What I really like about the book

What I really like about the book is the fact that it is flexible and multi-faceted, so you can keep coming at things from different angles and building up even as your situation evolves and changes – whether that is progress or a slip backwards.

I hope that it brings you or your friends support and strength when this is most needed.

Recognising other bloggers who have cast helpful light and perspective on my own challenges

It has been quite some months since I last wrote a blog. The back end of last year was a hard road of trying to get the pain medications to the balance that made the basics of getting through the day possible, and working out how to shrink life to the things that I could get through. Then facing up to the surgeon’s persuasion that a tenth surgical procedure was the best way forward.

Through this time I struggled to find a way to share my experience in a way that I felt could help others.

Plus, I have to say that I found various bloggers and communities who are sharing their experiences and I felt were sharing a lot of the things that I had been searching for over the last two years.

So I wanted to blog to share links to some of them – in the hope that this is helpful for people reading it.

Joletta Belton – My Cuppa Jo (www.mycuppajo.com)

Jo shares her experience of over a decade of pain stopping her ability to work as a firefighter and to run and pursue the sport and life that she loved. She has gone on to do a huge amount of study about posture, musculoskeletal issues and pain, now sharing this with others in her beautiful and inspiring blog posts and also as a patient advocate at international conferences.

Tina – Living Well Pain (www.livingwellpain.net)

Just as Jo has pioneered the path in Canada, Tina has done the same in the UK. Tina’s accident was over two decades ago and she shares her experience of how to live well with persistent neuropathic and musculoskeletal pain with lots of practical tools and advice from her own experience. These come in the form of blog posts on specific topics and most recently as a patient advocate, she has written a guide for patients called ‘Making the most of Physiotherapy’.

Pete Moore – the Pain Toolkit (www.paintoolkit.org)

Pete attended a pain management programme in 1996 and since then has dedicated himself to sharing the best information and knowledge with both patients and clinicians across the globe dealing with persistent pain, especially back pain. He has a great website and has written a number of excellent guides on pain. Most recently he has set up a monthly Pain Toolkit Online Café on Zoom, where anyone is welcome to digitally ‘pop-in’ and chat or listen to others working with similar issues to their own.

Barbara Babcock – Return to Wellness (www.returntowellness.co.uk)

Barbara’s experience of her own neurological illness and also caring for her husband meant that she saw up-close-and-personally the life-changing impact that a serious health issue can have. This led her to use her coaching experience to restore emotional wellbeing and look positively towards the future. Her blogs and self-help tools help across: managing the health issue, reclaiming emotional health, reclaiming relationships, returning to work, reclaiming meaning & purpose in life, reclaiming hobbies & interests and support for carers and supporters.

Jo Moss – A Journey through the Fog (www.ajourneythroughthefog.co.uk)

Jo is bed-bound as a consequence of the health issues that she suffers from. She writes her blog to give other people in the same position a bit of hope. She says “My life isn’t easy, but it is worth living. I may cry a lot, but I also laugh a lot. I may get depressed, but I’m also optimistic. No matter how bad things seem right now, they will get better. You can take back control and give yourself hope for your future”. Her blog is frequent, searingly honest and brutally insightful on topics that others may shy away from.

Sheryl Chan – A Chronic Voice (www.achronicvoice.com)

Sheryl lives and blogs from Singapore, living with multiple lifelong illnesses. Her blog sets out to help other sufferers with a toolbox, but more widely to raise awareness of long-term illnesses from a number of perspectives and encourage empathy amongst all facets of society, and not just healthcare. Her blogs are frequently very practical, covering both the physical and the emotional challenges with equal frequency.

The Princess in the Tower (www.princessinthetower.org)

This site has a number of useful resources for learning about chronic pain and how to manage it and reduce it. The blogs focus a lot on the emotional impact, and ways to manage this.

Then, I also discovered some really useful communities:

HealthUnlocked (www.healthunlocked.com)

This is like a medical version of Facebook and there are different groups that you can sign up to. One of the groups is Pain Concern (a charity that also have a helpline that you can call and lots of other support tools that you can access at www.painconcern.org.uk)

Anyone can post a thread and expect to get genuine responses from others. The tone is universally helpful (in my experience) and can get some good insights. Obviously, this is not professional healthcare advice, so it needs to be seen in that context.

The Injured Athletes Club on Facebook

This community was set up by Carrie Jackson Cheadle and Cindy Kuzma to go with their book ‘Rebound: Train your mind to come back stronger from sports injuries’. They moderate and facilitate the group to get to a mix of being able to vent about challenging times, ask for advice/perspective and celebrate progress, with ‘Winning Wednesdays’, Monday Motivation and Friday Feeling themes running most weeks.

I hope that you find some of these inspiring and helpful, just as I did. If you have others that you think are excellent, then do share!

Round and round in circles

My experience of rehab is lots of circles!

Whilst finally being able to move a little can feel like a release from incarceration and make you want to re-explore the world that you once knew, the reality is that it probably needs to be much closer to home!

You need to be ready to stop and rest, or stop and return home at any stage – as pushing through pain can lead to a major set-back. So, I have built loops with benches, coffee stops and quick routes back to the car (in order to return home).

I think that I now know the distance to all of the benches within a half-mile radius of home! And even bought one of those walking sticks with a pop-up seat. It was surprisingly inexpensive, and actually comfortable enough for a little rest and recovery – although you would not want to sit on it for a long period!

Having a goal, but being flexible on the way of achieving it

Initially, I struggled because the goals seemed ridiculous – for instance 4 laps of 200m in a day and then a rest day seems petty when you have run marathons and ultra-marathons.

And then I struggled even more because I could not complete them without being doubled-over with the strobing pain – the other part of the goal was without any increase in pain level.

The goals are really important – as they help you to make and monitor progress over time, without over-extending yourself. And I learned to stop deriding how petty they were and to start to think of little rewards if I managed them, like a square of dark chocolate or a cup of coffee.

I also learned how to regress it when I could not achieve it – either by reducing the distance, or by increasing the rest interval. So I would walk to the bench with my book and if my body was not ready to walk back, I would either sit for a while or read for a while and then head back. And then do the same later in the day.

The psychological benefit of a change of scenery

I would also drive to wooded areas so that even very short loops looked and felt different as I walked them. And the opportunity for a nice cup of coffee as a reward sitting at a different café and taking in a different view!

Rule number 1 – leave the watch at home!

I have to admit that the only time I would do laps was as a part of training – whether a track, road or off-road loop – the goal would always be to look at the splits of each lap! This mentality of constantly pushing yourself is not at all the mode of gently listening to your body for the early cues of progress or issues – so it is important to leave the watch at home, and avoid cheeky glances at the lap times!

The hardest parts & my coping mechanisms

The parts that I struggled with were:

  • Stopping in time – since often the worst pain would be later in the day, I struggled to find the cues of when to stop if the session needed to be curtailed. The two insights that helped a little were: (i) spotting the very early signs of fatigue and stopping whilst there was at least one more lap in me and (ii) leaving enough time for my body to settle in between each one – so I would plan to sit for at least 10 minutes and at times 30-40 mins and even an hour to let the body settle and see how it felt.
  • Keeping the discipline and only doing the plan, even on days when I felt I could do more – because I couldn’t wait to be better and make faster progress, it was hard not to over-extend by adding an extra little walk to see something when I was feeling great. Especially when I was with friends, for whom so little activity was quite boring and their natural temptation was to tacitly or explicitly encourage you to go faster or do more. My two coping mechanisms were (i) for all that it was lovely to see people, doing these was better done alone and meeting them for a coffee later (ii) keeping a log of all of the exercises and what level and type of pain I had was a useful tracker for the programme and to talk with the medical experts.
  • Sometimes these leave me very inflamed and I then struggle to sleep – so I always do the sessions in the earlier part of the day in order to give the body more time to recover.

In summary – celebrating the circles!

As you probably gather, I found the process of going round and round in small circles rather hard to get my head around. So planning for it and finding ways to celebrate is key – every single one marks progress and is an opportunity for some fresh air and seeing different things. So well worth celebrating!

Are you doing your physio exercises? If not – it is really worth working out why not!

Are you doing your physio exercises?

The actual exercises, with the frequency that you agreed?

The figures say that 80-90% of people do not do them. And I know of a physio who when injured admits that she does not do them! So what hope for the rest of us?

Injuries stop us from doing the things that we need and want to do. And the time and hassle of travelling to appointments is a further drain. So, what stops us from doing the exercises that can help us to get better?

Indeed, I was interested in a tweet from a US-based physio at the end of August where he wrote to the Twitter-sphere “I genuinely don’t understand. The activities I gave you help a lot with your symptoms, they take 12 minutes, but you “don’t have time” to do them? Can’t you get up 12 minutes earlier in the morning? Can’t you do them during all of those Netflix programs you tell me I should watch?!”  This led to some interesting points on Twitter, and made me want to write this blog post.

We tell ourselves that we do not have time. But is that really the reason? What is underpinning our procrastination and how can we find ways to overcome it?

Are we rebelling against the homework?

This is a moment to be honest with ourselves. When we know that it is doing the exercises consistently and correctly exercises, do we still want to rebel and not do them? Really?

Once we have given ourselves the pep talk to get on with it and ‘eat the frog’, how do we find the mechanisms to help us to do it each day? Some things that work include:

  • Scheduling and writing down the time in your diary to do the exercises each day
  • Setting an alarm on your phone for the time to do the exercises
  • Having a paper-tracker and star chart on the fridge or mirror as a reminder
  • Phone-based tracker of the exercises each day, with reminders
  • Giving yourself a reward for completing the exercises (eg a cup of your favourite tea)
  • Doing them early in the day, so that they do not hang over you
  • Being accountable to someone – letting them know that you have done the exercises each day
  • Letting the physio know that you really want to spend the first few minutes of each appointment reviewing how the exercises have been going, and then using these insights to progress the exercises after each appointment (you could even email an update to them before each appointment)
  • What else could work for you?….

Do we not believe in the exercises and the process?

Often we believe simple narratives and I sometimes think that for injuries, this is ‘the experts will fix me’. This is sadly not true and we need to replace it with a more realistic ‘my body needs daily help with the healing that is required, and I need to do these things every day as there are no short-cuts’.

As we think more deeply about this barrier, we may come to the conclusion that we do not believe in the current path – maybe we think that it is not yet the right diagnosis, or the right treatment plan, or the right person to work with. If these are the issues, then now is the time to talk these over with the physio, or go to see someone else for a second opinion.

I have often seen this loss of belief happen when an athlete has been seeing the same physio for over 6 weeks and is not seeing progress. I would suggest that the longer you leave making a change, the longer it will take to make a recovery – especially as I generally see the adherence to the exercises drop off with longer periods where there is no observed progress and no change in the exercises or approach. Obviously, the first stage is to talk over the concerns with the current physio, but a fresh pair of eyes generally provides a fresh perspective (and scarily frequently a completely different diagnosis and treatment approach!)

Or more simply, we may not understand why we are doing the same exercises, week after week. A good therapist will explain what the goal of the exercises is, and the test for seeing whether your body has made progress against that goal. This context is key – for instance after joint surgery doing the exercises through pain is key to stop scar tissue (which the body throws out in every direction) from forming across the movement planes of the joint and therefore limiting Range of Motion for good. Knowing that helps to push through the pain – but needs someone to explain it!

Do we fear the pain?

Many people do joke that the exercises are more painful than the injury. But really we should be in search of the ‘Goldilocks zone’ (as I blogged about in some detail last week) – enough to push and develop the under-active muscles or release the over-active muscles, but not putting ourselves so deep into the pain zone that we set the healing back, or push the body back into the ‘alert’ state that could lead to more guarding and defence.

In the event that the exercises are very painful, message your physio and when you next see them:

  • Get them to watch your form and be very specific on the exact movements and where exactly you should be feeling the benefits
  • Bring the number of reps and sets that you have managed to do (including when you have done them early in the day, when you are still relatively unfatigued) and discuss some more realistic targets.
  • Bear in mind that every single exercise can be regressed to make it easier – so get them to show you the regressions and agree what the triggers would be to move up through the various progressions.
  • Ask if there are ‘warm-up’ movements that you can do to get the releases and mobilisations before the exercise, in order to give your body the best chance of success.
  • Then stick with it and do not beat yourself up if you do not manage all of the sets and reps – every exercise that does not put you deep into the pain-zone will help!

Are we uncertain of what we are meant to be doing?

Many of the exercises are quite complex and when we are in pain we do not always listen and watch all of the form points. So if there are videos of the exercises – then watch them again and write down a note of the key points to remember in order to do the exercises correctly.

It may be embarrassing to have to admit that we are not really sure what we are meant to be doing – but it is in our benefit to clarify, so ask away! A good physio should be delighted that you are checking and clarifying. Do this at the start of the appointment, as if you only discuss the exercises in the last few minutes of the appointment, they are under time pressure and need to get you out of the door to get to their next patient.

If it is not any of these reasons, then what is it?

We owe it to our body to get to the bottom of why we are not doing the exercises, and then put in place. So keep taking a positive, inquisitive, collaborative and learning approach to your programme and your rehabilitation.

Good luck – and get those exercises done!

Finding Goldilocks!

Looking back at the time since my injury, I feel like this has been one of the areas that I have learned the most about – and so I wanted to share it with you.

In training, I think that you are always looking for that ‘Goldilocks zone’ – where you are stretched and make progress, but not to the level that it breaks you and forces you back. So that across your week’s training it is not too easy, and not too hard, but just right to get the adaptation that you are looking for.

When injured, this zone is even harder to find because there are no benchmarks. Indeed all of the normal benchmarks that you have are based on your previous, un-injured self and lead you seriously astray! It can be so hard to leave your ego behind in terms of what level is worthy of effort and exhaustion. An additional difficulty is that my sense is that the gap between stretch and stress is much narrower when you are injured, so you need to be more precise and wary of the smallest signs of over-reach, before the body stops you in your tracks. And these ‘tells’ may be completely different from those that you got when you were in full-on training and the onset may even come hours later (especially in the case of nerve-pain).

My own search for Goldilocks was a long one! In spite of constant commitment and tracking, I had a very long period where week after week I failed to get through the ‘simple’ exercises that were set – sometimes collapsing or passing out with the pain, sometimes just completely seizing up and suffering for the rest of the day and night before my next attempt. So managing to do the prescribed exercises consistently for the whole week between appointments really was a big deal.

I had no idea how much it had been torturing me. Realising this issue and actually managing to do seven days in a row of completing the prescribed exercise and actually managing to progress the reps, I now feel so much lighter in mood and belief. I start to believe that I am starting to recover and starting on my way back to life. Even though I know that these exercises are easier than a good proportion of my previous exercise sets, completing them means so much.

Why the breakthrough?

I still have a file of all of the exercise sheets that I have failed to make over the last 18 months (a few of them across 2-3 months of appointments with constantly trying and failing, and almost all of them still beyond me today). I should probably have put them in the bin, but have been keeping them for the day when I improve enough to get through and make the progress to be able to underpin the basics that could mean a return to life and sport. Looking back over them compared with what has worked for me over this last week, these are the things that stand out as differences:

  1. This exercise routine is broken down into a daily gentle mobilisation routine and the progressive part of the set is only every other day to allow for a recovery day. Many of my other programmes were up to 3-5 times per day, and always daily, which seems to have been an intensity that my body could not cope with.
  2. The first few months of the programme are all bodyweight movement exercises and only progress to include weights once I have built up to that.
  3. There is a ramp into the reps and sets, as the body adapts – with the first set very easily within my current capability.
  4. A golden rule is to always stop with at least 2 reps still in the tank. And never, ever going to the point of failure – as that can put the body into a state of alert and lead to more ‘guarding’ behaviour from the muscles (which can take weeks and months to then unlock).
  5. Every single exercise has one or more regressions to make it easier, in case the pain gets worse and I start to struggle – so I can do drop-sets, or easier sets. I have learned that every exercise has regressions, and what a difference that makes! Previously the exercises had been much more binary – it was do the exercises and if you fail early, then stop.
  6. We have gone through all of the key form points and gone to the point at which compensation sets in. For the compensations that we went through, I have a physical cue to keep the body on form (such as a roller balanced in the small of the back, a strap to keep under tension at all times, or the knees in contact at all points of the move etc)
  7. There is a clear goal to be able to breathe deeply and calmly throughout, not straining or bracing, or pushing through pain (but it is OK for the muscles to get tired or ache, as they used to when training). This is really useful, as there have been so many different views on whether you ‘push through the pain, as it is just guarding behaviour’ or ‘stop and respect the pain, as it is there for a reason’.
  8. We’ve got a clear commitment between us to keep to the recovery interval, reps and form precisely, even if that means a ‘fail’ – as this helps us to get to the root of the issues quicker and more accurately. This makes it feel like a partnership where we are both working on the problem together, rather than me feeling that as the patient I am the problem.
  9. The programme follows a clear and specific order of releasing overactive muscles and gently activating the specific muscle and then integrating it into the wider movement. This does make it a longer programme and means that there are no short-cuts, but really makes a difference. It also only works at the end-range for a short time, as this is very demanding indeed.
  10. There is a path forward with really small increments for the progression, such that there is a clear glidepath for progress, with check-steps and alternatives to take a different approach to address lack of progress. This fits into an overall ‘treatment’ plan that looks like a training plan, complete with blocks each with their own objective, quantitative progress testing every 2 weeks and a clear functional progression thread underlying all of it.  Naturally every athlete wants to know ‘how long until…’ but I have really learned now to trust the process and just to focus on the progress in each of the 2 week testing blocks and making fast interventions when something happens that is not what we expected.

Why did not managing to complete the exercises come to have such a big meaning for me?

I have to admit that I am only just starting to pick away at and release the layers of blaming myself that I feel for letting everyone down, not managing with the basics of life, and for not recovering as expected. This is all psychologically very difficult.

As an athlete I had always believed that consistent and hard work would be rewarded. And that in a recovery context this meant doing always the exercises from the physio – no ifs and no buts. Early in my recovery a friend who is a physio told me that the level of adherence to exercises from the physio is only thought to be about 20% (and actually admitted that even when she goes to see a physio herself, she rarely does the exercises!) I vowed never to be one of those 80% not doing their exercises.

So when pain overtook me over and over again such that I would collapse weeping with the pain and retire to bed or lying on the floor to recover, I felt that I was letting myself and everyone else down. That I did not deserve to recover.

But that is all in the past now! And I think that if I had known the questions to ask (based on the 10 bullet-points above), I could have got there more quickly.

So what should you do if you are currently struggling?

Even if not injured, I think that we are all in search of the Goldilocks zone and can apply these principles in our training to get to the stretch zone, but not the stress zone! In rehab we probably need to dial it even further back – to ensure that we are progressing, but not getting into the overload zone.

Having now spent a lot of time studying corrective exercise and reading a lot of books, and doing online study, I have learned that there is literally no exercise that cannot be made more basic – moving it right back into exercises lying on the floor and building from key underpinning exercises of the correct muscle recruitment in breathing. So always ask how to regress (and progress) an exercise; you also learn a lot in the process too! I realised that I did not ask this enough – I would tell the physio how I had got on and we would either just try again the next week without changing anything, or they would tell me to stop doing anything for a week.

And when doing the exercises, always focus on form and the correct rest interval – stopping as soon as the form slips. This ensures that you get the real benefit. Plus see the sense of achievement with the progression. This does mean becoming more of a Strength & Conditioning (S&C) student than ever before! Watching athletes do S&C I’ve seen that strong athletes’ bodies often (effortlessly) find another way around by using the synergist muscles rather than activating the main muscle – so knowing the cues and checks is important. Things that your body could get away with before injury can put you deep into pain post-injury and relying on dominant muscles misses a lot of the benefit of the exercises!

Finally, I would say that often the focus is on strength (which is about the muscles) but can be about the recruitment (which is the messages from the nervous system). So it is worth understanding which of these it is, as that should change the pace and type of movements in the exercise programme.

Good luck in your search for Goldilocks!

Why I asked for my money back on the FAI Fix

The FAI Fix was recommended to me by a friend of a friend. It was developed by two Personal Trainers (PTs) in the USA – Shane and Matt – who both had significant hip issues and manage to overcome pain, impingement and poor Range of Movement (RoM) without surgery – although they do admit that this has taken up to a decade of daily work! It comes with a number of success stories on the website: https://www.thefaifix.com/ and is supported by some really excellent YouTube videos and emails that made me really feel that Shane and Matt understood the issues and challenges of hip pain, and also explained the anatomy aspects of it really clearly.

However, when I was thinking about signing up for the programme I could not find any impartial reviews of how people had got on with the programme. And I saw tweets and messages of others looking for the same. So I thought that I would write about my experiences in order to support others.

The programme

There are 2 levels of the programme. The basic one is the FAI Fix Basic for $129.95 USD – a one-off payment that then gives ongoing access to the exercise library. There is then a further payment to do the more advanced programme for athletes who want more hip movement (eg powerlifters). But they are clear that this is a much smaller group, and is a progression from the first programme once you have resolved the pain in your hips in usual daily activities.

On the homepage, they explain their TSR system – Tissue Work, Stretching and Reactivation. This is a common (and well-proven) structure for many rehab programmes:

  1. releases with the foam roller, ball, knobbler etc to release the overactive muscles
  2. stretching to lengthen the tight muscles
  3. reactivation to activate and strengthen the underactive muscles

It is impressive how much more RoM you can get by doing targeted muscle releases before stretching that area.

There are a minimum number of tools that you need in order to be able to follow the programme – a foam roller, a strap (which could be a belt from a dressing gown), a lacrosse ball (or small, hard ball – there are different levels of hardness in therapy balls and the idea is that you progress) and possibly a ‘knobbler’:

The tools! The ‘stick’ was an optional extra, and the blue one is the ‘knobbler’ – but most of the programme could be done on the floor in front of a mirror with the foam roller.

When the programme link arrives there are 13 tests which are meant to narrow down which of the 5 key muscle groups is the issue. Then there is a TSR exercise set for each muscle group and a 6th workout that is a combination across muscle groups.

My experience with the programme

In advance of signing up for the programme, I was uncertain whether it was suitable for me given that I was 6 months on from hip arthroscopy surgery. However, I got a response that looked like it was a response from one of the 2 PTs reassuring me that it would be suitable – although looking back, I now think that it was probably compiled from a series of standard paragraphs.

Working through the programme is quite intense – the diagnostic exercises take quite a lot of set up and checking the form and RoM in front of the mirror. If you or someone in your family are not quite experienced in Personal Training and muscle groups it would be quite difficult to work through. And the challenge for me was that the tests were not discerning for me – all of them were painful and all of them had less-than-ideal RoM, so it was hard to diagnose where to focus.

I diligently followed the programme daily for 4 weeks. The good news is that I did see an increase in my RoM, but no reduction in the pain before, during or after the exercises. Therefore, I followed the process to get advice from Shane and Matt. I wrote a summary of how I had interpreted the 13 tests and what I had been doing, but got only a 2-line response from someone other than them telling me that I needed to choose just one muscle group and focus on that, but no further details on how to make that choice or how to better understand the diagnostic tests (given that all were painful and low RoM).

I followed the advice for another 4 weeks and then got in touch again, but did not get any response this time. In the meantime, the general emails from them changed. In the first couple of weeks, they had been bits of advice and case studies which were definitely motivational – especially on fixing the body through movement rather than surgery. But after that, the emails continued to come 3-4 times per week, but were now trying to sell more stuff (tools, personal coaching, other programmes etc). 

So, I decided to ask for my money back (which in-line with their no-quibble money-back guarantee they refunded immediately – although interestingly they did not ask for any feedback on what had worked and not worked, or why I was asking for my money back).

My summary

The exercise video library is good (there are probably 50 exercise variants covering the 5 muscle groups), but I would suggest that the money is much better spent with a Movement Trainer who specializes in Corrective Exercise and can really help you to diagnose which are the problem movements and then focus a personalised programme on just what you need. This should actually start to address where you have the pain and monitor development and progress you see with the exercises, in order to then make choices on how to progress.

That said, the overall message that you can make progress on your hip pain without surgery is profoundly supportive. Plus there is a strong sense of realism in the sense that they are clear that it will take work and time.

Good luck with getting to the bottom of your hip pain and finding the key to unlocking the pain.

My experience with hydrotherapy

I have not blogged for a while whilst I have been trying new things, doing lots of research and trying to make progress on reducing my pain and increasing my ability to cope with day-to-day tasks and activities. It has been an interesting voyage where I have become clearer that there are many paths to recovery – and no-one has the universal answer, so you have to try lots of things! With this in mind, I thought that I would share in a few blogs over the coming weeks some of my recent experiences.

Hydrotherapy was one of the things that was suggested after each of my surgeries. It is 45 mins drive to the nearest hydrotherapy pools and there are none in my local authority area. Plus you have to have a medical referral form and go through some extra checks to get access, so it all took a bit of organising. But I think that is was well worth it, as I think that it reduced pain in the short-term and had an incremental improvement in the Range of Movement (RoM) in the scar tissue and the affected muscles.

What is hydrotherapy?

The hydrotherapy pool is kept at 37 degrees Celsius, which consistently feels very pleasant and after 30 mins of doing structured exercises feels positively hot!

It is about shoulder depth and about 10m across, so it is easy to get the benefit of the water resistance as well as the immersion.  There is also easy access, including a hoist so that you can get in and out even when your body is not working well. Given that there is only space for a small number of people, it is key to reserve the slot and be there changed and ready in time.

You can work with a physio in the session, but once you have a routine it is relatively easy to work through the exercises on your own. There are ‘weights’ made from floats to create additional resistance by pushing them down in the water and inflatable ‘noodles’ for support.

How is it better than a normal pool or hot tub?

I had tried both the normal pool and hot-tub, and would say that the hydrotherapy pool is much better.

Doing my exercises in the pool was hard work (remember that 1 litre of water is 1kg – so there is lots of weight in the water resistance), and the cooler water temperature that makes it suitable for swimming means that there is not the therapeutic benefit of the muscle release that helps with RoM and probably with the pain reduction too.

I had also used the pool to try a little aqua-jogging with the float-belt (as shown in the photo). This is used a lot by elite athletes when they have injuries and it is claimed that you can keep 80% of your running fitness if you put the same hours in at the pool. This should work really well for lower limb injuries where you need to keep the muscle memory, but avoid the impact (especially in stress fractures and some soft-tissue overuse injuries). But given that for me the inflammation affects the movement pattern, I found that it was too tough at this stage.  

The aquajogging float belt clips around you to keep you upright without your feet touching the bottom of the pool (you need a pool deep enough for this!) and you can add difficulty by holding a waterbottle in each hand and changing the amount of liquid in it for more difficulty.

The hot tub is useful for me for the muscle release and for managing some of the pain. But it is not deep enough or large enough to do all of the exercises, so it is not as good as the hydrotherapy pool. I think also that the 30 mins slot, where everyone else is also working on their exercises, brings a level of focus that really helps.

Did it make any difference?

My own experience was that it was a very supportive environment – everyone there is working on getting better and is very willing to share what they have had success with.

In terms of the physical impact, the warmth definitely had a positive impact in terms of reducing pain for a few hours (just like hot water bottles etc when at home). My understanding is that this is not universal – some people find that the pain is reduced with cold, others with warmth.

Plus, I found that 30 mins of hydrotherapy definitely improved RoM for a period of 24-48 hours and if I did it 3 times per week, I saw real progress on my land-based exercises. That said, it was positively hard work – after 30 mins the combination of the temperature and the hard work was very tiring and I was keen to get out and have a nice drink of water! And the travel on top made it quite a bit harder. So, I would say that if you have a hydrotherapy pool nearby, do make use of it in your recovery and rehabilitation.