What happened when I met a rock-star physiotherapist!

Regular readers of my blog will know that one of my pet topics is how do you know which Health Care Professional (HCP) to go to? How do you work with them for a good outcome? And how do you know when to run out of the appointment and never return to that person again?

My lumpy rehabilitation journey has allowed me to build up a larger-than-average sample of interactions, create a picture of myself as a ‘failed patient’ after two years of never managing to succeed on two successive weeks of physio exercises, and now I am delighted to say that my quest has led me to meet a rock star physio (and actually succeed!) So I wanted to tell you all about it…

How did I find him?

Part of spending months and years incapacitated has led me to want to really understand what is going on for me physically. So I have attended every single free seminar/webinar/TED talk etc online that I can find related to recovery. It has been fascinating and illuminating.

Paul Hobrough has written two books (‘Running Free of Injuries’ and ‘The Runner’s Expert Guide to Stretching’) and is so famous that even my Mum has heard of him. Initially I thought this is because he is based in Northumberland (where my parents live), but actually it is because he has a great common-sense column in one of the national newspapers! I heard him speak on an England Athletics webinar and when I heard that he was doing tele-medicine appointments, I had to give it a go….

Sharing the history

After years of being in and out of treatment rooms, I think that I have my history giving down to a pretty good delivery. It is definitely a learned skill that requires years of practice and improvement before graduating to professional patient level, but I hate the oral tradition of history taking. Here’s why:

  1. All HCPs are pressed for time, so when you have a complex history (as I have) I have seen the panic start to rise in their eyes and them start to look for straws to grasp at – which means that landing the holistic overview of the situation is hard. And any glancing contact with something that they have been taught is a red or amber flag leads to them jumping in with an early diagnosis and potentially the whole appointment and interaction is derailed as you either succumb to a snap-judgement that you think has already been investigated, or you try to have a respectful debate with someone who is (and wants you to know that they are) so much more of an expert than you are.
  2. In my experience the majority of HCPs are very bright, studious people with a strongly introverted approach to life. This means that they are brilliant at really thinking deeply about issues and working out great solutions – but only if they are given the time to do this. Hence the extrovert’s style of iterating through oral history-giving has to be bad for them. Additionally, they need time to consider how they are going to share their views back with you (the patient), so that you can understand them.
  3. From a patient point of view, there are times when I am in such a mess that I can barely string a sentence together let alone a complex history under time pressure. Because pain makes you live in the moment, it can be hard to step out of the moment and give a balanced overview at that point of time.

This is why I always email my history over before an appointment. Almost every time I have done this the HCP has pre-read it and come in with questions (only one did not – they proceeded to read it aloud in the appointment and then lecture me on what a pathetic specimen of a human being I was for not understanding what was needed – for a whole hour without me getting a word in edgeways – that was an appointment where I should have stood up, paid and left).

What was the difference that a rock star physio made?

Here’s the parts that blew me away:

  1. EMPATHY: Paul created instant connection between us by making a very humble joke about his presentation at the seminar that I had attended. I went from being very nervous to laughing in seconds, and I also understood that the ground rules were that it was OK for me to ask anything – which completely changed the power dynamic in the appointment.
  2. DIAGNOSIS: In the first 5 minutes he not only summarised his diagnosis of what the issues were, but also how he thought I understood them – he repeated back to me the language and things that I had said in my email.
  3. UNDERSTANDING: We then spent another 5 minutes where I was able to question him about this more – and I felt like I was having a personal medical masterclass, where he simply and clearly laid out medical theory, practice and levels of certainty in lay language that genuinely made sense to me and where it was also OK for me to say where I did not fully understand it.
  4. REFRAMING: Within this he completely reframed my expectations. I saw the medical process as me vs pain – with success as elimination of pain. He got me to talk about triathlon racing and the normal types and levels of discomfort in training and racing.  From there we agreed that it was about control, pacing and self-management of pain – which seemed so obvious (but was a new insight for me).
  5. GOAL-SETTING & OWNERSHIP: As we got to the midway point, he moved me into goal-setting. At the time I was in the split mentality of “I want to return to Ironman Triathlons but think that will be impossible – and my day-to-day is governed by so much pain that I often cannot walk to the corner shop”. He gently nudged me to explore a goal that I thought was an impossible ask, and he saw as a very viable 3-month goal. It was so exciting!
  6. DETAILED PLANNING OVER 3 MONTHS: Then he moved into explaining to me the specific movements that were going to be challenging, how to dose them in, what signs would show that it was working and what would show that I needed to regress the progress. He was completely unapologetic that it was a lot of work – that even writing the excel sheet with the programme on was a lot of work – but even that was exciting to me. I wanted to be a part of this and I was completely signed up to whatever work it took.
  7. SETTING UP SELF-MANAGEMENT: So having specified the programme in detail, he delegated me to write it and email it to him for review and any feedback/changes within the next 3 days. I did, but he had explained it so clearly within the appointment that no changes were needed.
  8. TRANSMITTING CONFIDENCE, BELIEF & HOPE: Then he wrapped up with the ‘piece de resistance’. He said “I back my opinion and experience and I really think that with this plan, you can make this goal in 12 weeks. But it won’t be easy – I think that you will have a number of setbacks – and we’ve talked about what it looks like when you need to regress, how to monitor symptoms, how long to rest it and how to move forward again each time. I also accept that no-one can truly know what is going to happen and in the event that in 12 weeks this really hasn’t worked then there is another more interventionist path that we can take, that has good scientific evidence behind it and has worked for a lot of people.” In that closing minute he had imbued me with his sense of confidence, belief in the plan, readiness for setbacks and knowledge that even this plan was not the end of the road – so there was always hope. If I was summarizing it as a mantra it would be ‘you’ve got this!’

What happened next?

I followed the plan – it happened 100% as Paul said. It was hard work, it took patience and tracking. I had set-backs and had to follow the approach that we had talked about. I doubted at times, but always thought back to his confidence to reassure myself and follow the exact detail that we had agreed. In 12 weeks I hit the goal that I had only dared to dream could be possible.

All from one 30-minute appointment – where an incredibly intelligent and kind man with a wealth of knowledge gave me the keys to the castle, to unlock so much of my misery.

I haven’t seen Paul since – and I feel bad that I only paid him for that one appointment. I can only reassure myself that by not clogging up his agenda with more he has been able to change so many more lives for the better.

Thank you Paul.

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!

How do musculoskeletal injuries heal?

Following my blog on how the body heals from invasive surgery (http://www.injuredathlete.co.uk/how-do-you-heal-after-invasive-surgery/) , I thought that it would be useful to do the same for musculoskeletal issues, since these are common injuries for athletes. This is a really huge topic, and I have struggled to get down the most relevant parts into something that I think may be useful for injured athletes and coaches to understand what questions they will ask of the medical team treating them. I have not covered musculoskeletal diseases such as osteoarthritis, carpal tunnel syndrome, tendonitis etc (many of which qualify as a disability under Social Security, if the symptoms reach a certain level of severity), as these are much more complex and long-lasting.

The challenge of most of musculoskeletal injuries is that they generally involve tendons (which connect bones to muscles), ligaments (which connect bone to bone) and/or cartilage (the soft, gel-like tissue that provides cushioning and enables movement in joints). The white colour of these tissue types give a clue to the fact that they do not have their own blood supply. This means that they heal much more slowly than damaged skin or muscles (which have their own blood supply). The surgical view is that they do not regenerate and this is why often surgery is offered – mending torn tendons and ligaments and replacing ruptured ones.

You need to play an active role in healing musculoskeletal injuries

Whilst the fundamental phases of healing are the same as a cut or muscle tear, there are a couple of key differences that you need to act on:

  1. the pain signals through the healing phases are very different and you need to actively manage your way through this – at times managing the pain to protect the healing of the correct Range of Movement for your body. It seems counter-intuitive not to listen to the pain in your body, but this is the reason.
  2. you do need to actively rehabilitate the area through each of the 3 stages, as it is unlikely to heal correctly without your active focus and support: initially using the ‘POLICE’ protocol (see below) and then with range of movement for that joint and then specific strengthening of that area. When you are in a lot of pain, the constant health professional exhortations of ‘keep moving’ may not seem to be very helpful, but this is the reason why.
  3. this is a long-term game, and you can expect to need to focus on this for a period of 12 to 24 months. But for those who stay the course and do the right things, the results do come.

Stage 1 of musculoskeletal healing – Inflammation.

The swelling and redness may be hidden inside the joint, but the symptoms will be such that no time day or night is pain-free and you may be able to detect the heat coming from the joint, as well as the tenderness, pain and loss of range of movement. If rest or a change of position gives relief, then the healing has progressed to the repair stage. The inflammation stage generally lasts 3-5 days, but can last a lot longer and if you re-injure or re-inflame the same area, then you go back into this stage.

The point of this stage for the body is protecting the area with swelling whilst it lays the foundations for the healing – clearing out the damaged cells and starting to spin webs of protective tissue that bind the wound together and stop the flow of liquids through the area.

This is the stage that you really need to apply the ‘POLICE’ protocol. This has replaced the old ‘RICE’ protocol (see the table below). So that in the past, the recommendation was Rest, get an Ice pack on the area, use Compression and Elevate the limb. All of these are designed to reduce the inflammation and allow the body to get through this first stage. Interestingly, anti-inflammatory medications do reduce the inflammation, but interfere with the body’s natural management of inflammation – so as soon as you are out of the immediate pain it is best to stop taking these in order to encourage the cellular-level healing process to begin.

The new ‘POLICE’ protocol reflects the fact that the latest medical studies suggest that some movement is good, even at these early stages. So ‘Protect ‘the joint from the bad motion that has caused the injury (eg twisting), with support, splinting or bracing as needed. Then work to get ‘Optimum Loading’ – moving the joint through the range of movement in every-day activities, but not causing additional pain. This is why we see increasing numbers of people in protective boots and slings, instead of full plaster-casts. The view on ‘Icing’ has also developed – and the guidance is that you should not apply it for longer than 10 minutes and more than 3 times per day (as too much icing can also damage the tissues).

P = Protect
OL = Optimum Loading
R = Rest
I = Ice I = Ice
C = Compression C = Compression
E = Elevation E = Elevation

Stage 2 of musculoskeletal healing – Repair or Proliferation.

During this stage the body develops the new tissue, initially haphazardly and then starting to align these cells correctly. This stage usually starts from a week after the injury and lasts 6-12 weeks or longer. Pain usually comes and goes, according to the position or movement of the body. If pain or fear of pain inhibits movement in this stage, then the pattern with which the scar tissue is laid down can inhibit movement significantly and reduce your body’s ability to function. Failure to stretch and move at this time will lead to weak, but tight muscles that are intermittently painful and vulnerable to re-injury. Therefore you really need to consistently (and gently) put the body through a normal range of movement and the unhelpful cross-fibres will be broken and the useful fibres that support the usual range of movement will be strengthened.  If this repair stage does not lead to correct healing, the danger is that the body will start to develop workarounds and compensating movements, which can lead to aches and injuries elsewhere as the body moves into the third stage of healing with the wrong fundamental structure in the injury area.

Stage 3 of musculoskeletal healing – Remodelling or Maturation.

In this stage the tissues build their flexibility and strength, and this lasts at least 6 months and can be two years or more. Even now, you may get some pain with certain movements (especially when you take the movement to the end-zones of the Range of Movement – which you do need to do), or you may be pain-free. This is why usually from around 4-12 weeks after injury (depending on the injury: follow your surgeon’s or physio’s advice), you should be adding in some strength-based training – starting very gently and slowly building up to 3 sets of 10 repetitions (working to failure), with a day or two of rest between sessions for the body to recover and rebuild (in line with the progressive overload model of development) and obviously backing off if the level of pain increases.

If you do not keep rehabbing the area, there is a very strong probability of significantly reinjuring it because it is so far below strength. This is very challenging, as it is usually just one or two exercises that you need to do over and over again, gently progressing them. And before you have done this, it may well be too premature to go back to a repetitive loading activity like running, or even cycling. Many people do not have the patience to do this progressive strengthening over the period of 12-24 months that it takes, and this is one of the reasons why re-injury is common. Even with the correct rehab, the area often stays 20% weaker than before the injury.  Hence you will need to keep looking at your form to check that there are not compensation behaviours that will cause other injuries, and look at your activities to check that you are giving it the protection that it needs.

Why pain makes this all so much harder

The challenge for many people in chronic pain* is that the correct level of managing the inflammation, mobilising the joint to get the range of movement and strength building across the 3 phases is hard to do. The pain makes them avoid exercise and stretching required for correct healing. At times the level of incorrect healing in stage 2 can need significant manipulation (even under general anaesthetic) to break up the adhesion and re-stimulate inflammation. You then effectively start back at phase 1 of healing, and need to ensure that stretching (for Range of Movement) and exercise (to stimulate the limited blood supply to the area) then begin the process of rehabilitation.

As well as medications, guided corticosteroid injections into the area are common and can bring very significant short-term relief. You need to make the decision on these with your Orthopaedic Consultant. The only anecdote that I would pass on is one where an athlete had a number of injections into the tendon over a 2-year period, and the tendon did rupture. One of the questions was whether the perforations from the multiple injections had played a role.

* The definition of chronic pain varies, but it is long-term pain and most seem to define it as having lasted for over 3 months or over 6 months. I think that the key definition is having been in pain for that length of time, you get to the stage where you adapt your physical, mental and emotional approaches to life (whether consciously or unconsciously) as a consequence of the pain. As well as these external impacts on your life, the internal impacts of your body swimming in the chemicals associated with inflammation and the nerve pain patterns can also have significant impacts on your healing.