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’.
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.
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
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.
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.
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.
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!
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.
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.
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
psychological benefit of a change of scenery
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!
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!
hardest parts & my coping mechanisms
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
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!
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!
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:
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.
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.
There is a ramp into the reps and sets, as the
body adapts – with the first set very easily within my current capability.
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).
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
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)
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’.
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
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.
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
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
There have been many firsts since I got injured, but
spending over 4 hours on a late Saturday afternoon and early evening at a
‘Psoas Release Party’ is one that I thought you would all like to hear about!
The workshop was led by Jonathan FitzGordon, who started out
as a yoga teacher in the USA but now works on rehabbing people in terrible
pain. He freely admits that most people come across him at 3 in the morning,
when they are at the end of their rope and don’t know what to do to get out of
pain. This is exactly how I came across him.
What is the psoas?
Jonathan’s theory is that the illiopsoas is the most important muscle in the body. The ‘psoas is a really interesting compound muscle, as it is very difficult to reach and touch, as it starts deep in the back (up near the ribs) and loops around the inside of the hip before attaching at the front top of each of the legs in the groin area. For all its inaccessibility, it is a large muscle and is one of only 3 linking the front and back of the body, and attaches in 6 places – so pretty complex. It is often simply called a hip flexor, but it has a role in much more than this. Jonathan attributes the majority of long-term pain in the hips and back, plus the knees and feet, and even the shoulders to how the psoas is behaving.
I read Jonathan’s book ‘The Psoas Release Party’ and was struck with some of the concepts and case studies. I tried some of his stretches and releases and felt that I had started the journey. Then I saw that he was coming to the UK and was doing a workshop…
The description of the workshop said: “The psoas is the most important muscle in the body
acting as the main hip flexor and the engine of walking. A free and happy psoas
allows the body to move with peak efficiency and little strain. Issues with the
psoas can lead to any number of problems throughout your body—both physical and
emotional. Lower back pain and other joint discomfort as well as disturbances
to the nervous system can be linked to the psoas. This is not a yoga class. You
will spend the afternoon awakening, learning about and releasing the Iliopsoas
muscle group and understanding its core function within the body.”
So that is how I ended up being one of 16 people crammed into quite a small yoga studio just near to Wimbledon studio on a late Saturday afternoon. It was mainly women, with a few men and the ages spread from early 40’s into 70’s – and every single person in the room was in pain, and wanted to do something about it.
How did the party get going?
Jonathan did an amazing job
of making the anatomy really interesting and memorable, and before long we were
all evaluating our dominant muscle patterns when standing still. He looked
especially carefully at the balance between the front and back muscles, and the
angles down the body: from head to shoulders, from shoulders to the lower
thoracic spine at the bottom of the ribcage, from this point to the hips and
from the hips to the ankle and into the foot.
He had a wonderful manner
of wandering around and gently pointing out individual muscle patterns–for
instance, the level that each of the hips were in the sockets, the level of
internal/external hip rotation playing into the weight distribution in the feet,
overall muscle imbalances and the level of tension in the glutes (butt) and
And what was interesting,
was how we all had to be coached for the tell-tale cues and signs – even though
almost everyone in the room (other than me) had a yoga or dance training,
making them very body aware and elegant in their movement (but still in pain!)
What were the tell-tale cues?
Overall, the biggest message that I took from the workshop was that we all hold too much tension in the wrong places. Given that as soon as one muscle is tight, the opposite (antagonist) muscle simply cannot do anything until the first muscle releases. And this is important because some of these muscles (like the psoas) are large and connect with key processes like breathing, staying continent(!) and movements like sitting, walking and standing.
So stay loose and relaxed!
To do a body check yourself
and see whether there are any ah-ha moments across the day:
Think about your butt when you are standing and walking – are the muscles tight? (if so, the psoas cannot do anything). A friend of mine tried this for a week and was stunned at how often across the day she found that all of the muscles in her butt were tensed up!
Think about your rib cage – if you sigh out a deep breath does the tension change? (if so your latissimus dorsi may be overworking)
Are your hips forward and your thighs extended when you stand? (if so, your hamstrings are constantly short and may get persistently tight)
Was there anything
It was pretty much all practical! The four hours simply flew
by – we did not stop for any breaks, and yet there was not a moment where I was
not learning, making notes, trying different movements and learning more about
the cues and signs of my muscle patterns.
The last 90 minutes was spent on 8 gentle stretching movements – most of which were held for a very long time (we did some for 15 mins, and Jonathan can recommend an hour or more at times!) in order to allow the psoas to truly let go. Whilst I had tried almost every single one of these from the book, the specific tuition on the important points of form was incredibly useful and I understood why I may have been missing out the benefits through simply trying it on my own without perfect technique. And the good news is that they are very easy to do at home (indeed one we even talked could be done in a break at the office, if you have a role that requires sitting at a desk all day – which of course is very bad for the psoas due to spending so much time in hip flexion).
Overall verdict – worth
I have to admit that I thought about whether to attend for
weeks before I committed – the hassle of a 45-minute drive to get there, no
parking at the location and the £65 workshop fee. But my husband was kind
enough to drive me and drop me off at the door, and benchmarked against other
treatments that I have had, it was worth the money.
And like all of the best parties, with the late finish we
were locked in!
I would strongly recommend Jonathan’s book – but the workshop took it to another level for me in terms of the personal insights and advice, plus the detailed coaching on the correct technique for the exercises. If you are not able to get to a workshop, Jonathan does do Skype consultations and I cannot over-emphasise the level of knowledge that he brings to your personal situation and his commitment to getting you out of pain. I am not at all surprised that he has helped and supported so many people to incredible recovery and rehabilitation.
Self-talk is known to be one of the most important parts of
mental strength. Athletes consistently use it (often together with
visualisation) to help with performance under pressure. My suggestion is that
it is just as important when you are injured and facing the challenges of
recovery and rehabilitation.
Are you wondering what is self-talk? I define it as the
voice in your head that chatters constantly, about all kinds of things and at
times can escalate to a full-on internal debate. But there is good evidence
that the mind takes these messages and images very seriously, driving changes
in the hormonal system and the nervous system which in turn have very significant
physical impacts (as well as changing your thought patterns going forward).
Affirmations or mantras are usually short, pithy phrases to
insert positive messages into the mind. I would also be remiss not to mention
that in the Hindu faith and yoga mantras are chanted, with specific mantras to
generate powerful sound waves that promote healing, and the relaxation from the
ancient practice of gong therapy or ‘sound bathing’.
This is something that many people write about. I especially
enjoyed Carole’s blog from 2014 where she talked about Dr Coue’s mantra (or
autosuggestion as he called it) where in conjunction with their medical
treatment, they would say over and over to themselves 20 times in the morning
and 20 times in the evening ‘Every day, in every way, I am getting better and
better’. Read more on this inspiring story from over 100 years ago, plus some
great tips and book recommendations in Carole’s blog:
What kind of mantras
When I was running ultramarathons and doing Ironman
triathlons, I used mantras a lot and found:
It needs to be positive. I had a spin teacher who used ‘mine is the power and the glory’ as a mantra, and I know that many people find these universally positive exhortations very useful– hence the Ironman slogan of ‘Impossible is Nothing’.
It needs to be realistic at that moment! For instance, telling myself ‘I love to run’ is true, but in the final stages of ultra-marathons or long-distance triathlons the voice on my shoulder would scream back ‘I don’t right now – I want to stop!’ so I would use simple exhortations like ‘run for home’ or ‘nice and steady’.
It is better when it is process-based. There are times in a long race where the final finish line seems too far away to engage with, and so process-based mantras worked better for me. This seems a strong parallel with the uncertainty on outcomes in recovery and rehabilitation. So just as I would focus on technique points in races like ‘keep my rhythm’, ‘nice and light’, which brings the benefits to keeping good technique at a time when tiredness can reduce form. In the same way in the tough part of recovery focus on the exercises, release work, nutrition, hydration and sleep patterns can reinforce the positive habits that will make a difference.
It is not helpful to set specific goals that you then miss. Whilst I have spent many races setting myself a challenge for the next split time, or the person that I would overtake, these are only useful when you hit the goal and then set the next goal. Missing them really can really drag you down, as it allows the internal critic to keep saying that today is not your day and you may as well just give up.
How do I apply that
to my recovery?
It is really useful to reaffirm your strengths and the
resilience that you bring to this situation: from the factual such as ‘we have
a good plan and next steps with the medical team’ or ‘we are focused & determined
and will get to the bottom of this’, ‘I have what I need to get through this’, ‘all
of this strength and conditioning will make me a better athlete’ to the more
aspirational ‘we will beat this’, ‘I’ll be back’, ‘my body is amazing’ and ‘I’ve
come through tough times before and I will again’.
Also to recognise all of the people on your side and rooting
for you: ‘I am in great hands’, ‘I am surrounded by love and support’, ‘I stand
shoulder-to-shoulder with my team’, ‘I am enveloping my body in love and
Reaffirming the sense of progress – even when it is too
small to see: ‘every day of careful nutrition and good sleep helps my body to
rebuild’, ‘little by little my body is healing itself’ and ‘every step towards
recovery helps me’, ‘cell by cell my body is rebuilding itself’.
Some people find perspective very useful – for example: ‘whilst
this is tough, people are facing much worse than this and getting through it’.
Some inspiring quotes
This link includes some inspiring quotes for injured
athletes that could be used as mantras:
How about choosing a favourite mantra and use it every day
for a week – repeat it under your breath over and over at key points in the day,
write it on a post-it and put it on the bathroom mirror or under your pillow,
close your eyes and smile gently as you visualise it… the mind is a powerful
Your body and mind are amazing – ‘Every day, in every way, you are getting better and better’
This is the moment of truth! Sometimes there is simply no choice and the only thing to do is try to manage the process so that your recovery can be the best that it can be (do talk about scar tissue with your surgeon!). But I have talked with people who have said that it is much harder when the case for surgery is not so clear cut, and the diagnosis or outcomes are less certain.
With the informed consent rules, it can be very difficult to get any definitive advice from the surgeon on what the likely probabilities are for different outcomes, and whether in their expert opinion it is likely to help or not.
You can feel very alone, in pain and probably having been suffering for a long time and feel that you have lost out on a lot of things. What should you do?
Many athletes have
surgery and regret it
Many athletes end up saying that if they had known what it
would be like in the years after surgery, they would not have had it. Don’t let
that be you.
Some of the reasons may be that:
We are positive and believe that we can simply ‘will’ ourselves better, so when we listen to the range of outcomes and timings, we always believe that we will be in the best and fastest group – and maybe even tell ourselves that we can beat those odds too! This rarely happens. So brief the person who comes with you to listen carefully to all of the range of outcomes and probabilities.
We place high demands on our body, so even a slight level of dysfunction is noticeable and impacts our lives. We need to remind ourselves that almost everything has a workaround solution – you only need to watch the Paralympians to remind yourself of the power of this.
We may subscribe to the ‘instant-fix’ mentality of today’s modern world and forget that there is a lot of healing that takes a very long time. We are not like a bike or a machine, and will not be ready to go as soon as the mechanics are fixed – because there is too much soft tissue recovery, body trauma and system re-patterning to do.
We think that because we will be out of hospital in a few days, it will not take long. This is not at all true – whilst you will be home very quickly (and by the way you should plan ahead to ensure that you can cope in that difficult post-operative stage), the time for the body to heal is long. They will often cut through 9 different layers of tissue (even with keyhole) and each of these need to heal. Those with less blood supply heal slower, as they only get what they need more slowly. Whilst there are things that you can do that will make it go slower, there is little that you can do to make it go faster!
So what if you are
facing the decision?
You have to find your own true-north on the right path
forward… And all at a time when (for sure) your judgement is impaired as a
consequence of the pain and frustration of your injury.
Some tips that might
help could be:
someone with you to the appointment to ensure that you get a well-balanced
view of the probabilities of the range of outcomes. Having two of you helps to
ask more questions and also listen and take notes in the appointment.
the surgery itself and understand the impact of the incisions and the
consequences for the healing process. Often the scar tissue can be as much a
factor as the ‘fix’ itself. And talking this through and understanding it can
help with the decision (and indeed if you go ahead, with the choices around the
exact surgical approach – for more on this read my blog on scar tissue)
want to watch the surgery on YouTube?
Many people think that this is seriously squeamish and scary. But for
others seeing it and understanding the different aspects enables an
understanding of the level of trauma and recovery. And some watch it before
going to see the surgeon, as it prompts different questions that they had not
previously thought of. You need to think it through for yourself.
the sentiment on the internet about recovery from this surgery? Obviously every patient is different and the
internet will not tell you the answer for you. But if the prevailing sentiment
is that it is a very long recovery, and not a full recovery – what are the
common themes? And are there questions that you want to ask your Doctor about
the specifics (without referring to the internet, as that is always how to
What if you are not
It is completely normal to come out of an appointment with
the surgeon and to be really unsure of whether you want to go ahead with
If you wrote two lists on the same piece of paper – reasons, why to have the surgery and reasons why not – what would the balance of opinion suggest is the right answer? Is there any more information that would help to make it clearer? Is there anyone that you can talk over the list with to add more insight?
There are a couple of challenges to be aware of:
feel a sense of momentum that means that you feel pressure to go ahead (whether
coming from the medical process, or from family & friends, or your own need
to move forward). Resist it! This is a big decision and it is your body. So you
need to be happy with the decision.
feel that there are no other options. This is never true.
So what are the other
There are a number of other options – some of which are
below. Which one you go for probably depends on (i) how confident you are of
the initial diagnosis of the issue, (ii) the level of improvement that you have
seen (or not seen) through the current work of rehabilitating it and (iii) the
levels of risk and length of predicted rehabilitation from the surgery.
Get another opinion from another surgeon. You are absolutely entitled to this, and no-one should make you feel bad for asking this question.
Continue rehabilitation with another physiotherapist (or whatever rehabilitation specialist you are seeing). There is a huge variation in the approaches that different people in the same profession take. And I would say that if you have been seeing them for more than a couple of months and are not making progress, then a change would be a good thing.
Try a different approach. There are a lot of different therapy approaches, and when you spend a lot of time with clinicians you realise the levels of uncertainty – lots of intelligent guessing because they cannot see inside your body, and the level of variation in people. So for all that many can be very sniffy about ‘alternative’ therapies – these may be what your body will respond to.
Give it some time. This is a hard one – but can often work. So setting a time limit and truly resting and nurturing the injury by keeping away from activities that trigger it.
Only you can make this decision for your body – take your
time and make sure that you feel that
you have explored the details and the options fully. It would be really sad to
be a year or two down the line and regretting this decision.
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.
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
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.
Just recently I had two athletes each bemoaning the fact
that they were not successful in returning to training within 2 weeks of
surgery. They had both had abdominal incisions and were having issues with the
wound not sealing and a lot of pain in the surgical area.
So how soon can you
start back to training?
I thought that it would be useful to understand the hard
work that our bodies are doing in this time. The hard part of today’s
‘instant-everything’ world is that we are not giving ourselves a chance! But we
can help ourselves by looking after the wound and the healing process.
The healing process
is 4 stages – and last in total over a year and possibly two years!
The four stages of healing happen in an organised and
sequential way – but they can progress better or worse, depending on factors
associated with you (both as a patient and how you treat the wound). The second
part of this blog will look at the factors for you to promote better healing.
Stage 1 seals the
wound and is really quick!
The hemostasis phase closes the wound with a clot (usually
in a matter of minutes/hours). Various components of the blood combine to
create a mesh that forms a clot that adheres to the wound and closes it off.
You need to protect that. There used to be a school of thought that you had to
let the wound be open to air for the scab to harden properly, but the new
hospital dressings allow it to do this without removing the dressing – so you
will probably be advised by the hospital to keep the same dressing on for some
time, in order to stop infection entering the area.
Stage 2 prepares the
wound area for the growth of new tissue
The defensive/inflammatory phase focuses on destroying
bacteria in the area and removing any debris, such that the wound area is all
set for the growth of the new skin and tissue. White blood cells and
microphages in the blood do this. It normally takes around 6 days and you can
often see and/or feel swelling, redness of the skin, heat and pain. Obviously
if the area keeps getting new infections into the area, then this period is
extended. During this time it is absolutely critical to keep the scab dry – so
you will need to find some good waterproof dressings or a different way of
staying clean (wrapping cling-film over the area does not work!)
Stage 3 is the
progressive filling and covering the wound, starting from the outside edges
The proliferative phase follows three distinct stages: 1)
filling the wound, 2) contraction of the wound margins, and 3) covering the
wound with new skin. You probably remember watching this as a child, as the
new, pink skin forms from the shallowest and outside parts of the wound and
eventually closes it up. It is a very clever process that remakes the blood
vessels, tighten the open wound (often giving an uncomfortable feeling of
tightness for a time) and then the skins cells work their way up from inside
the body to form the boundary layer. This can all last anywhere from 4 to 24
days, and during this time dissolvable stitches on the surface should drop out.
In order to protect the wound, it is still really important to keep the scan
dry in order to protect it from damage, although to the latter end of the
timeframe many nurses say that you can have a quick shower, but must keep away from
baths and any kind of swimming pool/hot tubs etc until it is all completely
sealed. Also across this time, a lot of nurses suggest gently putting Vaseline
or moisturiser on the scab, in order to keep it flexible and stop it cracking
and getting damaged.
Stage 4 is where the
scar gains strength and flexibility
The maturation phase is where the tissues reorganise and
remodel as they mature. During the proliferative phase the tissue gets laid
down haphazardly, whereas the uninjured tissue is all lined up in a standard
structure. Over the usual replacement of the layers of skin, this slowly gets
addressed and as it does the way that the scar tissue moves stops being a big
block and starts to move with the body and has strength. This phase can vary
from 21 days to 2 years, and you can help it by gently massaging the wound and
encouraging the tissue to realign. Also many nurses recommend rubbing in Bio
Oil or a Vitamin E cream, which seems to visibly help the scar to fade in
colour and settle back to flat with the skin.
So it all takes time
Back to our athletes – getting the wound to seal and be
ready for the forces of movement in the area of the surgery is probably around
6 weeks, and within this time nurturing the area to maximise the healing will
Things that you can
do to encourage faster healing
There are many factors that mean that people heal
differently. Some of these are inherent to you as the patient. Age has a direct
effect on how fast we heal – as we get older, the skin is thinner and less
elastic so we need to allow it more time. There are also factors associated
with your body make-up in terms of how your body lays down the scar tissue,
which you cannot change.
However, there are a number of things that you can look
What you eat is really important – You need to ensure that you are getting some good protein at each meal, and foods that are high in zinc, copper, vitamins A, B and C can also help the healing,
Good hydration really helps too, as this has a direct effect on the blood stream.
A good overnight sleep is key. The body’s repair mechanisms work hardest during the deep sleep cycle – so do make sure that you are getting your head down and getting a good quality 8 hour overnight sleep (or more if your body needs it)
Reducing inflammation – many people swear by arnica. Obviously the cream cannot be applied to open wounds, but I found major reduction in the bruising around where the cannula was inserted by using the cream on the adjacent skin areas. And you can buy oral arnica from homeopathic providers such as https://www.helios.co.uk/ and it generally does not have any interactions with other medication that you may be taking (although check with your own Doctor and/or surgeon)
Managing your weight – skin heals better when it has the blood supply into the tissue, which muscles give but fat does not. This helps the supply of all of the agents for the different phases of healing, as well as oxygenating the wound area.
Keeping the wound area dry and clean – this is so important for the right conditions for wound healing. This can be hard to do, but is a really significant factor. Try to get the right balance between waterproof dressings to stop external moisture and getting it open to the air if it is in an area of your body that stays damp and then covering it again.
Medication can slow healing down – some medications slow healing by impairing the inflammatory response, leading to a reduction in the collagen production which is key, especially in the 3rd and 4th stages. Treatments such as chemotherapy affect the new cells, so have a strong impact on healing, Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) that you may commonly take as over-the counter drugs can also slow down the process. Obviously you are likely to need medication after major surgery, but it will help if you can keep it to the minimum that you need and bear in mind that you may need to allow longer for your body to heal.
So best of luck with your healing – do nurture your amazing
body to do its thing! And after a major surgery taking a good month or 6 weeks
off training that involves the juddering of impact, or the strain of strength
training could be well worth it. It is also worth saying that there are other
factors from surgery – for instance, anecdotally many Doctors say that it takes
around 6 months for the body to completely recover from a general anaesthetic.