Blog Post ✍️ | Maximizing Your Potential with Rehab: When Injury Isn't an End, but a New Beginning

What is rehab?

“Rehab is training in the presence of pain or injury.”

I love this definition. I originally heard Craig Liebenson describe rehab using these words. He credits Philip Glasgow with creating the original quote.

Rehab begins with regressed and customized exercises or stretches that mimic the movements and tasks you want to be able to perform. Rehab progresses to more advanced versions of exercises that continue to move you closer to your goal. Over time, things just become more challenging. Rehab should eventually include a return to the important activities put on hold due to pain or injury. The complete lifecycle of a great rehab program should follow a “crawl ➡️ walk ➡️ run” style of progression that gets you back to your original level of performance before the pain or injury, if not better. If it is impossible to return to your original performance level, an effective rehab program should take you as far as possible relative to your goals.

Rehab provides confidence and clarity while on the journey to resolve your issue. An effective plan attempts to overwhelm your problem with an excellent solution.

Through rehab, people learn what they can do for themselves, which is another Craig Liebenson concept.

If rehab is just modified training, is rehab merely about getting stronger and fitter?

No. There is a lot more to rehab than strength and fitness gains. The benefits of rehab appear to be more closely related to desensitizing and acclimating than improving physical fitness.

We must desensitize and acclimate bodily tissues, such as muscles, tendons, and ligaments. This is a physical process of exposure therapy to different stresses, loads, ranges of motion, positions, tasks, speeds of movement, and so on.

We also need to desensitize and acclimate expectations. This is the psychological process of exposure therapy. We have all heard of the placebo effect. When someone expects a positive result, they can actually produce a positive result, even with a sham treatment or fake drug. Many do not realize that there is also a nocebo effect. When someone expects a negative result, they can produce a negative result without a harmful stimulus. When we suffer from pain or injury, we associate certain things with our pain. This is human nature and may serve as a natural warning system. For people with chronic pain, this warning system may be operating like a fire alarm that will not turn off even when the fire is put out. For example, many people with back pain avoid deadlifts because bending forward and picking things up has historically provoked their pain. While desensitizing and acclimating the body, we must also address the negative expectations associated with bending forward. We must reduce the fear of picking things up at home and the fear of performing deadlifts in the gym. We must remove and replace the fear with confidence through repetition and exposure.

In essence, rehab desensitizes and acclimates the whole person. Rehab gets you physically and mentally ready to get back to life.

Even though rehab often involves resistance training, reaching a specific numerical strength target may not matter (in many cases) because getting stronger does not necessarily result in less pain or disability.

The process of getting stronger is more valuable than the strength gains themselves. A rehab program usually involves consistent and routine movement, which increases physical activity. Increasing physical activity is valuable for pain management, goal accomplishment, and overall health. Health will be positively affected if physical activity becomes routine over decades, and pain may become more manageable.

Does rehab require special exercises?

Rehab can include special exercises; however, focusing on the basics will often get the job done.

What do I mean by “the basics?”

Squatting is important if you value the ability to use a toilet unassisted.
Pushing and pulling are valuable if you need to open and close doors.
If you want to be able to pick things up off the ground or take a knee, then deadlifts and lunges are essential.
Step-ups are worthwhile if you need the ability to walk up and down stairs.
Exercises like burpees and Turkish Get-Ups may be useful to maintain the ability to get on and off the ground.
If you value the ability to get things on and off high shelves, pressing and pulling overhead are important.
If you value heart and lung health, then cardio is nonnegotiable.
If you want to avoid falling when you slip or trip, then agility and balance training are helpful.

Focusing on the basics while gradually increasing the difficulty and intensity will take you a long way in rehab. Additionally, while you build a foundation with the basics, you need to practice the movements and tasks that are most painful and scary. You should progress toward a measurable goal that is valuable to you.

Therefore, special exercises may be necessary depending on your specific goals. It just depends on the situation.

The best rehab exercises are the ones that you will actually do. I can develop a rehab program that I believe to be perfect. But if you are unmotivated or unable to stick to the plan, my “perfect” rehab program becomes useless.

Special exercises may be good options if you need them and/or are motivated to perform them regularly.

We place a higher value on consistency than on special exercises.

What does a good rehab program look like?

Although rehab plans will vary greatly based on the individual and their goals, here is a recipe for some "Rehab Secret Sauce:”

The most important place to begin is answering this question: Why do you want to change? Rehab involves change, and things will get challenging along your journey. Understanding why you want to change is powerful. This is your motivation.
Next, you need to set measurable goals. You see a future that doesn’t exist. What is that future, and how would you define and measure success?
Then, you need to measure some baselines. In the previous step, you dropped a pin in a location for your final destination. But where are you right now? What is your starting location?
It is time to chart a path. You can begin your journey once you know where you are and where you want to go.
Answer this question: What is a doable first step in the right direction toward your goal? Focus on taking one step at a time.
Be consistent and patient. Consistency over a long period of time is the key to success.
Expect set-backs. Stuff happens. Do not let setbacks derail your journey.
Be prepared to adjust your plan. No plan is perfect. At best, you need a 70% percent solution. You can fill in the blanks as you go.
Do not expect perfection. Just look for progress. Paralysis by analysis can be a goal accomplishment killer.
Surround yourself with positive people who can help. Your environment has a strong influence on your behavior.
Be prepared to address other factors that will affect your recovery: sleep, nutrition, stress management, depression, anxiety, and other health-related issues. You are more than just an injured knee or a painful back. You are a whole person, and other factors in your life may affect your recovery journey.

You are not alone if this “secret sauce” recipe seems challenging. You may need help.

Based on your rehab plan, 1 of 3 things will happen:

You improve. Which means you’re on the right path!
No changes occur. This does not necessarily mean that you are on the wrong path. This tells us that you may need to change your plan.
You get worse. In the unlikely event that you get worse, we stop the plan and try something new.

Periodic lack of success is expected because we simply make educated guesses and test them. However, lack of success is not a waste of time because we can cross things off our list of possible solutions. Any failure gets us one step closer to success. Sometimes, we must fail a few times to see the best solution. Small failures are part of the process. They can be incredibly valuable if we do not give up prematurely or stubbornly repeat our miss-steps. Doing the same thing repeatedly and expecting a different result is a terrible waste of time.

If you are struggling, there are often numerous paths to success. Please delete the phrase “What’s the best way?” from your thought process. You have so many effective options. In contrast, there are really only two options that definitely will not produce results:

Do nothing
Keep doing the same thing, expecting a different result

People struggling with chronic pain often toggle between the only two options that will never work. They repeat behaviors that are not effective for a certain period of time. Then, they get frustrated and discouraged by failure. So, they switch to the only other option that will not work. They do nothing.

Here is an appropriate metaphor: Consider the old cartoons depicting an ostrich sticking its head in the ground to escape scary things and avoid reality. If you are struggling with chronic pain, you do not want to be the ostrich.

If this sounds like your experience, try something different. The wonderful thing about rehab is that you have options.

Consider these questions:

What is the long-term cost of wasting time?
What is the long-term cost of doing nothing?

If you are struggling and wasting time with a plan that is not working, you can make a change. Firstly, do not “work around” pain for very long. “Working around” pain may be useful in the short term. I don’t want to discount the benefit of taking a break briefly; however, avoiding specific activities usually haunts you in the long run because it is hard to completely eliminate many activities from your life. Plus, a lot of painful activities are fun or valuable. Avoiding them affects your quality of life.

Finding ways to get back to activity is helpful if you want a long-term way to manage pain. Think about “exposure therapy.” To return to valued activities quickly, reduce the intensity to moderately comfortable. In these cases, hurt does not always equal harm. Look for the “Goldilocks” zone where it is not too hot or cold (just right).

Think about this analogy: Imagine having sensitive skin from a bad sunburn. Now, imagine the shock of jumping into a scolding hot tub with your hypersensitive skin. It would be uncomfortable. Now think about how different it would feel if you had a sunburn but you gently slipped into a lukewarm bath and slowly increased the heat tolerably.

Too much, too soon, can be uncomfortable and scary when you are hypersensitive. However, exposure to any activity within the “Goldilocks” zone allows you to work through the pain without completely avoiding the valuable and fun stuff.

Rehabs Tips:

Stress the painful area regularly. By “regularly,” I’m talking about micro-dosing your exposure every 2-3 hours (if possible). If not possible, dedicate as much time as is reasonable based on your schedule. Any effort is better than no effort.
Remember that rehab may not be effective if it is too comfortable.
Pain and discomfort may be acceptable and expected, but increased pain should generally fade within 10 to 15 minutes after activity. This is your sweet spot (your “Goldilocks” zone).
Please do not get frustrated. This could be a long, uncomfortable process, depending on the issue. This is normal.
If you have questions, concerns, or fears about pain, please consult a healthcare provider. This is one reason why having a healthcare provider guide you through rehab can be valuable.
Please remember that these tips are generic and may not apply to your specific injury. Please consult a healthcare provider if you need help.

You must find ways to build strength, capacity, and tolerance within an acceptable pain threshold and begin desensitizing your body and mind to movement, positions, and valued activities.

Again, if you have questions, concerns, or fears regarding pain or injury, seek the opinion of a healthcare provider. This blog post should not replace medical advice. You do not need to do this alone.

Is rehab better than other therapies?

It is important to acknowledge that rehab is not necessarily better for short-term pain management than any other therapy. Rehab works as well as anything else for pain management, including hands-on therapies, placebos, and resting while the natural recovery process takes place.

It is important to understand that there is a difference between pain management and goal accomplishment. Pain management often comes in the form of short-term relief. Examples include but are not limited to, medication and chiropractic adjustments. Rehab is also effective for short-term pain management; however, it offers you the potential for long-term pain reduction and a path back to an active lifestyle.

When using rehab for short-term pain management, the main advantage is that movement is free, and you can self-administer your own movement therapy unlimited times throughout the week (without direct clinical supervision). As you learn more through rehab, you need less clinical care (ideally). Rehab can build confidence and autonomy. This makes rehab unique to other therapies.

Rehab is also unique when considering the long-term benefits of increasing physical activity. Remember that rehab is just customized exercises. Therefore, rehab is movement. Rehab is usually performed weekly (sometimes multiple micro-doses of movement daily). As you improve and your rehab progresses, the program can transition from the cautious realm of clinical care into more robust and realistic scenarios (like the gym or a return to sport). Rehab is a long-term movement plan to manage pain and help you return to activity. This long-term movement plan adapts as you adapt. One of the additional benefits (besides pain management, return to valued activities, and increased self-efficacy) is that rehab usually increases physical activity. Increased physical activity offers the potential for numerous health benefits that extend far beyond pain management.

Moving more:

Improves your mood and your sleep;
Slows the effects of aging;
Lowers your risk for heart problems, high blood pressure, type 2 diabetes, and many kinds of cancer;
Helps maintain your immune system, which may help lower the risk of infection, lessen symptoms, and speed the recovery from various illnesses;
Helps keep your mind sharp as you get older and lowers your risk for dementia and Alzheimer’s.

Physical activity also releases endorphins, which act like morphine. There are opioid receptors in the brain and body that act as a built-in way of killing pain. Endorphins calm the brain and relieve muscle pain during strenuous exercise by dulling pain in the body and producing euphoria in the mind. Commonly referred to as a “Runner’s High,” this is the notion that exercise fills your brain with this morphine-like substance.

Aside from elevating endorphins, exercise regulates important neurotransmitters commonly targeted by antidepressant medications.

Exercise elevates norepinephrine, which jump-starts the brain and improves self-esteem.
Exercise boosts dopamine, which improves mood, boosts feelings of wellness, and turns up the attention system. Dopamine is all about motivation and attention.
Serotonin is equally affected by exercise. It is important for mood, impulse control, and self-esteem. It also helps relieve stress by counteracting cortisol (“stress hormone”).

In addition to feeling good when you exercise, you feel good about yourself. Increasing physical activity increases your energy and simply improves your quality of life.

When struggling with musculoskeletal pain, many people are afraid to move because movement hurts, and they are worried about causing more damage. Temporarily decreasing physical activity may be beneficial in the short term, but it is a poor long-term plan. I talk to people every week who have not exercised in years because of pain. It’s sad, but it’s easy to understand. The relationship between pain and movement is paradoxical because exercise and movement can simultaneously be scary and beneficial.

The key is finding a comfortable place to begin and then progressively increasing activity to facilitate pain management while rehabilitating yourself back to everyday life. This process can be challenging; many people benefit from a guide during rehab.

Summary:

Rehab is movement.
Movement is free and can be self-administered without clinical supervision.
Rehab teaches you how to manage pain and return to your valued activities.
Rehab can be as effective for pain management as anything else.
Routine physical activity can positively affect your hormones and neurotransmitters, facilitating pain management, increased energy, and motivation. Therefore, movement-based therapies have physical and mental health benefits.
Since rehab increases physical activity, it offers health benefits beyond pain management. These benefits include a reduced risk for prevalent chronic diseases.
Rehab builds the confidence and skills for living an active lifestyle.
Rehab is a form of education. This also makes it unique when compared to other therapies. Through the rehab process, people learn what they can do for themselves.

Since movement is free, does not require supervision, is helpful for pain management, and improves health across a broad spectrum of diseases, finding a more effective form of treatment for musculoskeletal pain is challenging. From a medical/economic standpoint, you cannot get more value for money than increasing physical activity.

I cannot think of any other pain management options that offer this many benefits with such low risk. I believe rehab is a superior option to other therapies for these reasons.

The best part is that you do not need to pick one therapy. If you like chiropractic adjustments, massage, acupuncture, and/or medication, you can combine them with rehab.

However, if you prioritize hands-on therapies ahead of rehab, I think you’re stepping over hundred-dollar bills to pick up pennies.

If rehab is so fantastic, why doesn’t everyone offer it?

“When your only tool is a hammer, everything looks like a nail.”

Attending chiropractic school teaches us to perform chiropractic adjustments and bill insurance when we crack backs. They issue us a hammer and show us how to get paid for hitting stuff with that hammer. This is not a criticism of chiropractic school; it’s an observation. Over time, some chiropractors acquire different types of hammers with slightly different capabilities but still practice chiropractic as hammer technicians. In a traditional chiropractic model, if a chiropractor wants to get paid, that chiropractor must justify using a hammer on every person who books an appointment. A chiropractic clinic can bill more if a hammer is used more often. If they are savvy, they may be able to get additional reimbursement for using a slightly different hammer on a different part of the body. It becomes a billing game. The game is played by seeing how many times a chiropractor can get someone to return to the clinic so they can continue using their hammers. When someone feels better, it is common for a traditional chiropractic clinic to recommend monthly hammer sessions as “maintenance care.” You may hear words like “holistic” and “patient-centered,” but the truth is that traditional chiropractic philosophy advocates for hitting everyone with the same hammers regardless of the issue.

Do you have back pain? My chiropractic hammer will fix you.
Are you sick? My chiropractic hammer will cure you.
Do you have knee issues? Let’s use my chiropractic hammer again.

You do not need a crystal ball to predict what kind of therapy most chiropractors will recommend. The therapy is predetermined regardless of the issue. Even though you are unique, and your pain experience is distinctive, when you seek traditional chiropractic care, you get the same hammer as everyone else. The next person after you is completely different and unique as well. They experience pain differently and may have very different goals and a very different health history. Regardless, everyone will lie down on the same chiropractic table and get hit with the same hammer. The therapy never changes even though the context may drastically differ from patient to patient.

For example, three people may seek chiropractic care for low back pain. They may describe their pain similarly and have similar exam findings. The first person may be an avid CrossFitter preparing for a competition. The second person may be geriatric and sedentary. The third person may be a depressed accountant who is overwhelmed with anxiety in the middle of tax season. Even though they all use similar words to describe their lower back pain, how can the same therapy be the solution for all of them? Interestingly, if all three of these people walked into a custom shoe store complaining of low back pain, new shoes would probably be the “solution.” And if they walked into a mattress store, a new mattress would probably be the “solution.” I think you can see where I’m going with this.

This is not “patient-centered” or “holistic” care. This treatment philosophy is “therapy-centered.” Most chiropractors only have hammers, so everything must be treated like a nail.

Chiropractic clinics that subscribe to traditional chiropractic methods must recommend chiropractic adjustments to everyone because that is what they sell. Shoe stores sell shoes, and traditional chiropractic clinics sell chiropractic adjustments. The recommendations are not unique. The therapies are not unique. The treatment plans are not unique. Nothing is unique about everyone getting their backs cracked monthly for the rest of their lives.

However, it does not need to be this way; not all healthcare providers work like this. Many providers (even some chiropractors) value education in the form of rehab. The situation changes when you collaborate with a healthcare provider who values patient education and movement.

What does “patient-centered” care look like?

I have many tools in my toolbox, not just hammers; however, most patients never see any of my tools. Since I focus on education and collaboration in the form of rehab, I am 100% interested in my patients' tools. I think about how I can help my patients help themselves, not about how I can justify using my hammers.

In rehab, we acknowledge that people have tools that must be dusted off and recalibrated. Skills with these tools need to be developed and refined. Most people have tools they never knew existed; they need help locating and learning how to use them. Everyone can develop new tools along the way.

Patient-centered care means that we take the focus off the doctor and stop relying on what the doctor can do to a person with their hammers. Instead, we focus on the patient and empower the person to discover and develop their own tools. This is the beautiful thing about communication and teamwork in the form of rehab. As the patient, you get to define what success looks like. You set the goals and the timelines. We collaborate and chart a path to help you reach your goals. We walk the path together, and I help you along the way when roadblocks appear. You see a bright future that does not exist, and I help you make that future a reality. This has nothing to do with cracking your back or rubbing your muscles.

It is important to clarify that we can use my tools if you desire. Hands-on therapies can be useful. I am not saying that chiropractic adjustments and soft tissue therapies are useless; however, my hands-on skills are almost never required to help you reach your goals. My tools may help temporarily reduce your pain while you progress through your rehab program.

This entire process is the process of learning. Rehab is a method of learning. We go on a journey together and learn along the way. When your goals are reached, they are attained with enhanced knowledge through experience. Ideally, you will never need me or anyone else for this issue again. That is not to say that you will never have pain or disability again, because you probably will. I am not convinced that we can prevent or cure pain. What I am suggesting is that you will have more knowledge, skills, and confidence to manage pain and disability in the future. All of this comes from education through rehab.

That is my sales pitch for rehab and patient-centered care. I hope this helps.

References:

Spark: The Revolutionary New Science of Exercise and the Brain – by John J. Ratey MD (Author), Eric Hagerman

American College of Sports Medicine Physical Activity Guidelines

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