#PTonICE Daily Show – Tuesday, November 7th, 2023 – But did you die?

In today’s episode of the PT on ICE Daily Show, Spine Division division leader Zac Morgan discusses the importance of challenging fear avoidance and mental barriers when dealing with back pain. Many patients with back pain tend to avoid activities or movements they perceive as potentially causing further pain or injury. Zac emphasizes the need to challenge this fear avoidance and help patients overcome their mental barriers.

Zac shares his own experience of having severe back pain multiple times while doing CrossFit. He mentions that this can create fear and apprehension about returning to physical activity. However, Zac states that when he pushes himself and his patients to confront their fear and return to physical activity, the outcome is often positive.

Zac gives an example of a patient who was scared about going back to the gym but found that the coach helped them scale their workouts and provided support. By challenging fear avoidance and providing appropriate guidance and support, individuals with back pain can overcome their mental barriers and continue to engage in physical activity.

Zac also highlights the importance of mental health in the context of back pain. It is crucial to ask patients how they are doing mentally with their back pain, as it is a significant factor to consider. Zac shares that they have personally experienced severe back pain and understand the impact it can have on mental well-being.

Zac encourages “continuing to add fitness to the region” as a primary goal of therapy. 

Take a listen or check out the episode transcription below.

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Alright, good morning PT on Ice Daily Show. For those of you who don’t know me, I’m Zac Morgan. I lead in the cervical and lumbar spine courses over in the spine division. If you haven’t checked out our orthopedic cert, we have just launched the orthopedic certification. If you’re looking to kind of combine some of the courses with ICE here and really get your head on straight for orthopedic conditions, head on over to the website and check out that page. Essentially, you’re just going to knock out four courses, cervical management, lumbar management, total spine thrust, as well as extremity management. At the end of those four courses, you’ll have an opportunity to sit for the exam with whichever lead faculty is there with you that weekend. you will find out that weekend whether you pass or fail and then that’ll be kind of a lifetime search. So we won’t ask you to continue coming back and recertifying after that. If you have any questions about that, of course, hit us up, but I’m going to dive into some content this morning. Before I do, let me just point you in the direction of the next few. cervical and lumbar spine management courses that are coming up that still have tickets available. So if you’re looking for lumbar, December 2nd and 3rd, t only a couple of seats left in Charlotte, North Carolina, so make sure you jump on that very soon if you’re looking for it. That same weekend, if you’re in Helena, Montana, We will be up in Helena, Montana, and then at the turn of the year, Rome, Georgia, January 27th and 28th weekend. So if you’re looking for lumbar, those are your next opportunities. If it’s cervical that you’re looking for, November 11th and 12th will be near Boston in Bridgewater, Massachusetts. December 2nd and 3rd right here in Hendersonville, Tennessee, where I’m coming to you live from. at Onward Tennessee here, and then February 3rd and 4th weekend over in Wichita, Kansas. So several good offerings. If you’re looking to jump into one of those fine courses, we would love to see you out on the road.

But let’s go ahead and jump into the main point of today’s talk. And this is sort of a follow-up episode, so if you missed a couple of weeks ago, I was on here. And the title was Catastrophize Rest. We talked a lot about how the actual negative side effects of someone pulling out of activity when they are hurt, and how potent those side effects are. So things like cardiovascular endurance going down. things like atrophy of muscles going down, less durable, less perfused tissues don’t heal as fast as those that are more durable and more profuse. And we had a really nice conversation about that. A lot of good questions kind of came after that and a lot of good conversations on the last couple of weekend courses because of that episode. So I just wanted to follow up here and talk to you all a little bit about did you die? And I say that a bit in jest, like the title here, is meant to be a little funny, but you all have probably seen those shirts at CrossFit competitions or at different places, different gyms, where the shirt says, but did you die? And that’s always made me laugh a little bit because I think it’s a bit of an aggressive statement. The point is, hey, you worked out so hard, but you didn’t die, and so maybe you’re just 1% better after that. But I kind of like the harshness of that. And I kind of wanted to bleed that into that, that last talking and go a little harder on that point. So I think if you all have taken any ice course, whether that’s one of the spine management courses, whether it’s pelvic health, whether it’s older adults, fitness athletes, endurance athletes, you name it. One thing that you know about us at ICE is we want our clients to continue gaining and maintaining fitness even when they’re injured. So just because someone shows up and they have pain, that doesn’t mean we’re going to take a break on getting that person fitter, getting that person stronger. We are going to push that even harder. Like I said a moment ago, you think about the surrounding tissues of the injury. If you want more profusion to that region, you want more blood in that region, If you want more durability of the surrounding tissues of that region, you’ve got to gain and maintain fitness. We’ve got to build some strength in that region. If you want to wash out a lot of those inflammatory chemicals that get really concentrated in the region of injury, you’ve got to get blood flowing to that region. Being still is not it. That’s not the answer. And so I think most of us are on board with that. Lots of good conversations, like I said, on catastrophizing rest and kind of avoiding that.

This morning I wanted to dive in a bit deeper. When I think about my expertise here, it’s definitely back and neck pain. That’s what I see the most in the clinic. It’s what I teach on the weekend. And it’s just an area that I have a lot of passion for because I think it almost gets treated occasionally like it’s special, like it’s a different part of the body, when in fact it’s very similar to other areas of the body. So let’s dive into this concept of gaining and maintaining fitness even when your back is hurt. I think this concept maybe makes more sense sometimes whenever your elbow or ankle is what’s hurt and it’s really easy to sort of scale around that problem. But when it’s your back or your neck that hurts, it’s really challenging sometimes to scale around it. Because almost everything you do as a human being requires your back. You’re gonna get your back into it. It’s really rare that we can completely spare that region. And I would argue that we really shouldn’t try to completely spare that region. We probably should work through some discomfort here in the back even though I know that that feels a little scary both for us sometimes as the clinician and also for our clients who are actually struggling with back pain. But we’ve already talked about the problems of rest. We want to avoid those problems no matter what. So one of the most common questions that comes up at weekend courses. So when we’re talking through these concepts on the weekend, a lot of times a clinician will raise their hand and they’ll ask questions like, what parameters do you use? What do you use to allow someone to push through it? Or what do you use to say, hey, this is a red light, we shouldn’t be pushing through it. Like, what do you use in back and neck pain? That answer is obvious in things like tendinopathy. We have that really nice kind of stoplight analogy, when it’s above a 6 out of 10 pain, when it’s lasted for longer than 24 hours, we know we’ve overloaded a tendon. When it’s in that kind of more sweet spot of 4 to 6, that Goldilocks zone when they’re back to baseline within 24 hours, we know we’ve done some benefit there. When it’s less than a 3 out of 10, we know that that’s not challenging the tendon enough to make it adapt, but it’s also not harming it. So those rules are really clear in the tendon. Jill Cook and a lot of other authors have brought us tons and tons of literature on that. And I often use similar parameters when it comes to back pain and working out. So those are not awful things to think about, but let’s get a little bit deeper into it. And let me start by saying, I don’t actually ask my patients when they come back after having worked out, I don’t actually ask them, hey, but did you die? When they’re worried about worsening from that workout. But I just, say that in jest. I do think we should push people who are in pain a little harder than they’re maybe comfortable with or used to. And that’s because I think we’re the ones with the level head and understanding what the blowback of actually resting that area is.

So let’s get into the conversation of what the navigational buoys look like for that person and kind of what are the follow-up questions that are the most important for you to be asking if you’re helping someone work out with pain. Really, I use this a lot as patient education, and where I ask my client to be the most mindful is in the warmup, so before they even get going in their workout, whether that’s running, whether that’s lifting weights, whether it’s CrossFit, burn boot camp, you name it. During that warmup portion, I ask them to take a little bit of extra mindfulness now that they’re hurt, and now that they have some pain on board. And so during that time, they need to pay attention to a couple of factors. And this same mindfulness carries forward once they actually enter the workout, by the way. But the first factor is, does your pain actually worsen when you get moving? So a lot of people are fearful when they have back pain that if they start moving, their pain is just going to continue this linear relationship. And if it starts out at a two, by the time they’re 15 minutes into the workout, it’s going to be at a six. By the time they’re 30 minutes into the workout, it’s going to be an eight. By the time they’re an hour into the workout, they’re going to be at a 10. That’s what most people fear is that they’re going to have that really perfectly linear relationship. But what actually happens a lot of times whenever I ask my clients on follow-up, hey, I know I asked you to do that workout through a bit of discomfort. How did that go? A lot of times what they actually feel and see is maybe a bit of an increase of discomfort as they first get moving, as those tissues first start kind of accepting load, as they first start moving around. And maybe there is a bit of a spike of discomfort. But generally, after they get going, it doesn’t continue linearly. If anything, it levels off and occasionally, or quite often, will flatten and decrease. So we’ll actually see a nice decrease in pain as the person gets moving. So what I’m commonly asking people on that third, fourth, fifth visit is, you know, I know you were very concerned about doing that workout with your back pain. Maybe it’s deadlifts and they have low back pain. I know you were really concerned about returning to deadlifts and you did that last week. How did that go? Tell me about your discomfort throughout the workout. And often they’ll say something like this, Zach, when I first got going, I was pretty uncomfortable, I was getting kind of concerned, but after I did a few sessions, after I did a few lifts, it actually started to improve, not worsen. And often, at the end of that workout, the person says something like, man, this is actually the best my back has felt since I injured it. So often, once I’ve kind of convinced that person to take that step back into the gym, they find that they’re actually better, not worse.

The second thing is a lot of education on the signs of inflammation. Like how do you know you’re worsening yourself? And some of these are immediate signs and some of them are after-effects. So let’s just talk through what that would look like. So other than just simply severe pain, which I think of as more than a six out of 10 if somebody’s in seven, eight, nine, 10 out of 10 pain, I’m probably not going to have them work through that much discomfort. But if they’re anywhere below that, I would encourage them to go ahead and try to work through it. But any other signs of increasing inflammation, any swelling, any redness, a lot of really severe tenderness to palpation in the region, anything like that, I’m always asking them, hey, did you have any blowback of those types? Because those are signs that inflammation is increasing. Maybe it’s a really big loss of range of motion throughout the workout. The first few deadlifts, they’re okay, but as they continue, it actually gets worse and they’re not moving better. In those situations, I might have that person pull back, but often what I find is the exact inverse. So once they get moving, the range of motion improves. Once they get moving, a lot of that discomfort comes down. Once they get moving, a lot of the swelling is kind of taken care of. It’s pumped out of the region. So I’m always asking them about those things during the workout, but then importantly, when you’re thinking about inflammation, you also want to ask them, but how did you feel the next morning? When you first got up the next morning after returning to that activity, Did you notice anything different about your back, about your neck? If someone’s really chemically inflamed, the morning is often going to be a really challenging portion of the day for that person. You think about it, they’ve been lying still for several hours, probably as long as they will. Hopefully eight or nine hours, but a lot of times a little less. So their heart rate is quite low. Their systolic blood pressure is probably as low as it’s going to be throughout the day, and there’s just not much fluid moving. If you’ve contributed a ton to an inflammatory experience, a lot of times that next morning will be really rough. So I’ll have them pay attention the next morning as well. If they’re no worse for the wear, even if they still hurt, but it’s not worse the next morning, I’m going to ask that person to continue pushing through that discomfort.

At that point, I think we’re continuing to add fitness to the region, not contributing to the worsening. I think what happens a lot of times with back pain is someone will strain their back in one way or the other. They’ll challenge the tissues, exceed the capacity, and they’ll have some sort of injury or pain experience. And they’ll assume that every time they challenge that region, the tissues are sort of hanging on by a thread. I think that’s the image in a lot of our patients’ minds. It’s like, if I continue to work, I’m going to exceed the capacity of this tissue and they’re just going to be hanging on by a thread. But we actually know that that work that they’re going to do builds the capacity of the tissue. It restores the load tolerance. of the tissue. It adds more tissue to the region so that that injured area has a harder time being a limiting factor for that person. So it’s kind of the opposite of what most people with back pain think is going to happen is what actually happens. So again, if they don’t wake up the next morning any worse if they don’t have those worsening signs during the workout, I’m going to encourage that person to go ahead and continue the workout.

Team, the last, the third point that I always make sure to hit hard with these patients that are having a bit of a hard time kind of returning to working out. It’s about mental health. And I think this is probably the most important one of the factors that we’re talking about. And I’ll often just ask people, how are you doing mentally with this? Because I know from experience, I’ve had pretty severe back pain a couple of times over the last 12 years or so doing CrossFit. There’s probably been three or four times that I’ve really challenged my back and ended up in a scenario with really severe pain. And mentally, that can really weigh on you. So a lot of times I’ll ask them about this. How are you doing mentally with all this? A lot of patients with back pain, they’re very fear-avoiding. challenging that fear avoidance, don’t be surprised if you bump into some mental barriers that you need to help that person overcome. But again, I think that’s what most of us assume is going to happen. What I actually find to happen as I push these people in this direction is they’ll usually come back and say something like this. You know, I was really quite scared about going back to the gym. Once I was there though, the coach helped me scale. They looked at the recommendations we went over. I was able to move through a lot of that and I was actually able to chat with a lot of my community that I’ve missed over the last several weeks. And a lot of them were super encouraging. It turns out, 3 or 4 other people in my 4 PM class have actually had the same problem, and they all seem fine now. Like they’re moving heavy weights again. So I guess now I’m starting to think, maybe I’ll be okay. Team, as soon as that switch flips in the person’s brain, as soon as they go from, you know, I’m pretty scared to do this, too, you know what, now I’m working out alongside a lot of other people who have had those similar problems, and I’m fine. and they’re fine, now we’ve got them. Now they believe that they can get better. Once someone believes they’re going to get better, our job becomes much, much, much easier. So I realize this is a little bit of a quicker episode, but I just wanted to hit those points. And I think that what I want to leave you all with here at the end, is if you’re uncomfortable with what I’m presenting to you, asking people to work out through a bit of discomfort, I would encourage you to do it yourself. The good news is, if you’re a human being on planet Earth, there is going to come a period of time when you hurt yourself. If you move forward as a human being, there will be some sort of injury in your future. And when that happens, I challenge you to go into the gym and push it and look at these factors. How are you doing with these factors? If you’re not worsening, that’s an improvement. That’s the key. It’s important to understand that if you’re not worse from that session, what that session added to you physically is helping you, whether you immediately feel better or not. So, team, that’s all I’ve got for you this morning. Again, we’d love to see you here at the end of the year or the beginning of the next. I hope you all are having a good time, sort of planning for Thanksgiving, and getting some time with family. Hit me up if you have any questions on working through discomfort. I’ll be on this thread checking to see if anybody has any follow-up questions, but I hope you all have an awesome Tuesday. Get out there and rock it in the clinic.

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