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!

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.

Is your body cheating on you?

I have been reading a lot about some of the latest advances in understanding the brain and Alzheimer’s Disease. One of the concepts that interests me seems to explain why dementia seems to be so much faster and more brutal in the people who developed and used their minds the most. Research says that this concept is ‘cognitive compensation’ – that when the brain is used to working hard and solving difficult challenges, it finds work-arounds that disguise a lot of the early symptoms and copes for so much longer. And it struck me that the body does the same – that muscles and compensating movements and loading kick-in to get us over the line physically too.

Being an athlete can actually work against us

This issue of compensating is clearly a battle at every stage – other muscles and body systems stepping in and getting us through. It can stop us from spotting the issue early and dealing with it.

It can also be a big challenge in rehabilitation.

We have to stay so focused on the process

When the challenge from the physio is to build up to a certain number of reps and sets, this can become an all-consuming challenge.  And having been so pathetic for so long during the injury, every fibre of our mind and body wants to achieve this and start to return to the person we used to be.

But compensation can kick in so easily! And quietly…

So we really need to ensure that we totally understand the correct form and ways to check that the right muscles and movement are activating. We need to check every rep and be really honest on when the compensation is setting in. And this is why it is really useful to have regular checks from a physio, or starting to work with a Personal Trainer with a Corrective Exercise qualification and focus.

Quality not quantity

Compensated reps are empty reps. So whilst we need to ‘control the inner chimp’ (Dr Steve Peter’s book and philosophy of the Chimp Paradox) about not hitting the headline goal – we need quality reps, followed in such a way that they are pattern forming for our nervous system, muscles (helping ‘muscle memory’) and movement patterns. And if we cannot do it, this is really useful medical information that we can develop a plan to address. But only if we surface the issue and work with it.

Good luck!

Is it time to learn from a flea?

Fleas are amazing athletes – with the ability to jump 50 times their body length!

But the inspiration for injured athletes comes from the oft-quoted experiment with fleas in a jar. It is said that if you put fleas in a jar, then they jump out. But if you put a lid on the top to stop them jumping out, you can remove it a short period later and for all that they could jump out they do not. And this lasts for the life of those fleas – they have learned their new limits and do not exceed them.

The path to rehabilitation involves false starts

The really hard part of rehabilitation is that we need to keep trying things and pushing the body to learn and adapt. Sometimes this can hurt a lot, and rekindle the kind of pain that has been so hard to cope with before.

But somehow we have got to find the discipline and strength of mind to keep doing the activities recommended by the Doctors or Physios. Even if previously this led to pain or set-backs. Because this time ‘the lid to the jar’ may have been removed. And we can only find it out by trying.

This is especially hard for athletes

Every single injured athlete that I have met has pushed themselves too hard in the early stages of recovery. We love to believe that we can always be in the top 5 or 10% of people, and always beat the timings and goals through sheer willpower and determination. Sadly that cannot always be true for our bodies.

So as time goes on, the people around us get used to warning us and holding us back. And we too often start to look on the more pessimistic side, in order to avoid slipping backwards and to protect ourselves. But when is the time to move on from this important protection and guarding behaviour? How can we know?

Keeping a diary of activity and pain is very useful

Just like a good training log, a diary of activity and pain levels really helps to show the trends and ensure a gentle progression, together with the right nutrition, hydration, sleep and rest. It can also help to look at the potential reasons for times when the pain is bad, or you slip backward.

So we need to learn from the fleas as we progress down the rehabilitation path and need to spot the moments where we are being too conservative and could be holding ourselves back. Our loved ones and closest friends can also be really useful advisers, and we should ask them to look out for signs of when we need to step up and leave our injured past behind in order to get to the recovering future that we want so much.

Gaining the lift to recover after a difficult injury can be very hard, and takes work both mentally as well as physically.

How do I know that I am going to a good physiotherapist?

This was a question that I Googled over and over again, and had some pretty scary experiences. In the absence of finding any answers online, here is my view:

A physiotherapist is there to help make you better, so their first rule has to be DO NO HARM!

So – if at any stage- you feel  a sense of a lack of trust, or you feel that they are not listening to you, or if the way that they are manipulating you is not respecting your body, then I would immediately ask them to stop, sit up, step down from the table and say why you think that the appointment needs to stop there. And if they do not make you feel comfortable by talking through the treatment plan that they have for you and how it will make you better, then simpl pay, leave and never go back! I wish that I had thought through in advance of a couple of appointments how I would respond if I was unhappy with the way that I was being treated and what I would do – as in the moment you can feel frozen and under pressure to just take whatever you are being given.

When I first got referred to a physiotherapist by the consultant after reviewing my scans, I asked people who had been before what made a good one. It’s frustrating – whilst we can each get a very detailed understanding of what it might be like to eat out at a given restaurant or stay at a certain hotel based on ratings and reviews sites or specialist guides, there is no such thing for physiotherapists (or any of the medical profession)! Many have a couple of google reviews – usually all 5 stars and not more than two. My hunch is that these are done by friends, as in order to get a good google listing you need a couple of reviews. I never found a useful or insightful one on physiotherapists.

What is the difference between a physiotherapist, an osteopath and a chiropractor?

Google search shows that this is a very common question, but there are not many simple answers.   My answer is that it is all a spectrum in the ‘manual therapy’ part – ie the hands-on part (as against giving you exercises and watching you). Some physios will only give you exercises, and this would be a potential marker of a poor physio for me – a huge proportion of injuries will not get better without some manual therapy assistance and will certainly need some hands-on testing to understand areas of tightness. But within the manual therapy spectrum, physios seem to focus more on the muscular (and also sometimes fascia) connections, with osteopaths and chiropractors both focusing more on the nervous system, spinal involvement/alignment and into ligaments/tendons connections. My own experience is that the osteopathy end of the spectrum is more gentle and helpful in pain relief and relaxing issues associated with excessive tightness. Whilst the chiropractic end of the spectrum is more active and associated with actively addressing issues to get to ongoing alignment, including retraining muscles, ligaments and tendons.

The interesting part is that orthopaedic surgeons and GPs will all tend to send you to a physiotherapist and never one of the others. My understanding for the reason behind this is that physios have more years of academic training than the others, and are therefore held in higher esteem by the more traditional part of the medical establishment. But you may find that your body responds much better to the touch and skills of a different practitioner.

What are the signs that I have found a good physiotherapist?

Here is my top 10 list:

  1. They really listen to you describe the symptoms and pain sites, and ask good questions.
  2. They do a full body screening set of tests of range of movement, movement patterns and pain in all parts of your body, even if these are not the site of the injury or problem. And then as your treatment progresses, they keep going back to these tests and monitoring progress.
  3. They listen to your feedback on pain levels, and if you say that you cannot take any more, they stop. Especially if it is your first time having acupuncture or dry-needling. These should create a strong relaxation of the muscle, but some people do have a reaction to it – so if the needles continue to hurt they should take all of the needles out.
  4. They explain their thinking on the problem and their treatment plan – and answer questions if you have them. And in the case of the physio that I respected the most, I went to see him 3 times before he was ready to share his view of this, because he was building a more detailed picture and evaluating it before rushing in. One of the most useful questions I found at this point was to ask what a standard case of a XXX injury would look like a this many weeks after, and then to compare how I fitted against that.
  5. They are prepared to talk with the surgeon to build a connected treatment plan, based on all of the scans and expert judgement. This makes such a difference, as they are able to have a different conversation from the one that you can have with the surgeon. Plus, if you end up having multiple surgical interventions, it gives you as the patient the confidence that going to further surgery is the right plan, and the surgeon really does have the full picture.
  6. They welcome feedback from you (and ideally help you to structure it in a way that gives them the information that they need in a simple way) about how the pain levels and progress on the exercises has been since the last appointment
  7. They give a really clear protocol of what they want from you. Genuine misunderstandings are so rife: ‘take it easy’ can mean anything from no hard running, through to nothing more than a gentle walk! Likewise sitting might be really bad. Having a detailed protocol agreed of how you will approach general life, as well as the exercises, is really important.
  8. They layer their exercises from the simplest and least weight-bearing form of the exercise, building the complexity when your body can handle it. The most frustrating times for me have been with 2 different physios after different surgeries, when they said “oops, I chose a set of exercises that were just too advanced for you. We’ll have to try something else”. These in each case put me in a situation of being unable to move at all for days in one case and weeks/months in the other
  9. They demo exercises and then watch and correct your form on the exercises so that you can be confident of doing a perfect rep when you get home, and spot when to stop when you lose perfect form – rather than when you are crying with pain.
  10. They are prepared to say when you do not need to see them too! There are points when you continuing with the strengthening exercises and giving it time will be enough – and a good physio will say this, rather than continue to take your money!

The no pain, no gain view of physiotherapy is really unhelpful

Everyone who I spoke to before seeing a physio had the view that physiotherapy has to be painful for it to work – that the manual manipulation has to hurt to release problems and that exercises have to hurt to work. I totally refute this. I think that there is really good evidence that when a body is swimming in the chemical markers associated with pain and everything is contracting and tightening from the electrical stimulus of pain then the problems are increasing, not decreasing. This is not to say that like in sports massage sometimes pressure can help a muscle release and there may be times where a physio will warn you that there could be a little discomfort – but this should only be very short-term.

I regret having gone to see those physiotherapists whose exercises and interventions increased my pain.

As an athlete, I would steer away from hospital physiotherapists

Initially, we thought that going to the hospital physiotherapists would be the best plan straight after surgery, because we thought that they would be deep experts because they saw lots of cases of this specific surgery (given that they are at the hospital) and because we assumed that just out of surgery all patients would be in pretty much the same situation. This was a bad call. The physios that I saw seemed to always be surprised at the level of muscle strength that I had (even though after a year of problems, I had lost 15 kg of muscle mass on the body composition scales). As a consequence they regularly chose exercises that were way too difficult and caused problems. And to compound the issue, they then seemed to bounce into another set of parallel exercises with slightly different approaches that also caused more pain and problems.

So do you have to go to know?

I think that there is a certain amount that you can do before meeting a physio – you can ask specific questions to previous clients who recommend them, you can phone and ask the clinic how the physio approaches things, and you can ask to talk through your case on the phone or via email before meeting them – in order to understand whether you and they think that they can help to make you better.

But at the end of the day, some of it will unfold as the diagnosis and treatment unfolds. Keep asking yourself (and them!) the questions. If you are not improving, then you need to understand whether your time and money would be better spent somewhere else.

And finally…

As an athlete you may have built a mentality of pushing through pain to finish a race (or even a training set). Physio exercises are not like that. If they are hurting (not the good and comfy ache of activation, but jagged and unpleasant pain), then stop and do not do them again before talking with the physio. You may be rating yourself as the failure (as I was), but actually pushing over multiple days to try to complete just one set when it is the wrong exercise can cause a lot of damage. Listen to your body first, and the physiotherapist second.

Best of luck with finding a partner who can help you rehabilitate your body and get you back to the movement and activities that you love. You deserve that. There are many people out there, and many apply just the same approach to everyone who comes through the door. If that one happens to help you to improve – brilliant. But if you have to keep going, knocking on lots of different doors to find the person with the approach that fixes you – it is not a failure and it does not mean that your condition cannot be fixed.  Listening to your body, testing and monitoring progress on the key measures and finding the right person or people will move you forward, one step at a time. Keep at finding the right person, just as you would keep at finding the right coach or the right training approach. You have the resilience to do this – even when you are at your lowest ebb.

Your basic bodycare toolkit