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Introduction

Setbacks are an inevitable part of the long-term training process. Progress is driven by applying more training stimulus over time to induce adaptation — and this stimulus always carries an inherent risk of injury. Although there are effective strategies we can use to mitigate the risk of injury, preventing injuries entirely is impossible. Furthermore, preventing the experience of pain is not only impossible, but undesirable, given the importance of pain as a protective mechanism for survival.

Pain and adversity are therefore a part of life, a normal human experience. Learning how to respond to and overcome these situations is what matters most. Setting the expectation that such setbacks are part of the process and cultivating acceptance of the situation allows us to respond skillfully and, with time, return to our normal life and desired activities. This article aims to discuss some of the nuances of returning to “baseline” fitness levels following an injury and the mindset required to execute an effective rehabilitation plan.

What is an injury?

We’ve all heard the age old question, “are you hurt or are you injured?” Although this question may sound intuitive for some, defining an injury is actually quite difficult. One of the commonly used definitions for injury comes from Timpka et al.,

a physical complaint or observable damage to body tissue produced by the transfer of energy experienced or sustained by an athlete during participation in Athletics training or competition, regardless of whether it received medical attention or its consequences with respect to impairments in connection with competition or training.

For the purposes of this article, we’ll focus on acute injury that results in a sudden onset of symptoms that can be attributed to an identifiable mechanism of injury, ultimately producing a decrease in performance. An example would be dropping a heavy single on the deadlift (mechanism of injury) after feeling a sudden ‘pull’ in your low back (sudden onset of symptoms), which resulted in an inability to complete your prescribed back-off sets for the day (decrease in performance).

First Steps

The first step in managing an acute injury is to attempt to stay calm — which is often much easier said than done. Experiencing an unexpected sensation during training often leads to ‘worst case scenario’ thinking known as catastrophizing, which perpetuates fear and anxiety. Catastrophizing, defined as ‘the tendency to focus on pain and negatively evaluate one’s ability to deal with pain’, has been shown to increase pain intensity, decrease activity levels, and is associated with the development of persistent pain [2]. With this in mind, it is important to understand that the experience of pain is complex, always resulting from multiple factors (never just one single “problem”). It also has a variable (often poor) correlation with tissue damage [3, 4]. So even in the setting of an acute injury, there are always multiple inputs driving the experience of pain, as depicted below:

(Infographic created by Michael Ray, MS, DC)

Readers who are unfamiliar with some of these ideas may be skeptical right now, thinking things like “I’m pretty sure that if I broke my leg, it’s going to hurt!”. And indeed, while the experience of pain with a sudden, acute injury tends to correlate more strongly with tissue damage, psychological and social factors always play a role to some degree. These other factors might include things like fear, attentional focus, prior beliefs and experiences, self-efficacy, the responses of others, and many others [5].

Furthermore, an acute pain experience can also occur in the absence of objective tissue damage, and discerning a single structural cause with imaging like X-rays or MRIs can actually be quite difficult. This is because we find lots of pain-free individuals with evidence of rotator cuff tears, intervertebral disc degeneration, labral tears, cartilage changes, and many other ‘abnormal’ findings on imaging [3, 4]. So when individuals experience pain it can be tempting to immediately blame the “objective” abnormalities on imaging, but it can be hard (if not impossible) to know whether those findings were present all along without symptoms, and the new pain has developed for another reason entirely.

Since physical training requires a certain degree of stimulus in order to create a desired physiological adaptation such as strength or hypertrophy, fatigue is a part of the process. This perception of fatigue can often be misinterpreted as pain and tissue injury. When we recognize that several factors contribute to pain (as described above), we can appreciate how things like psychological stress, poor sleep, and fatigue can contribute to an exacerbation of pain symptoms. This recognition can help decrease the perception of “danger” associated with pain, and should provide us reassurance.  

In fact, laying the blame on a specific tissue can create fear about the ability to train safely. Deconditioning (loss of fitness, detraining) occurs when this fear leads to the avoidance of loading. Similarly, ignoring these sensations completely and continuing to load aggressively can also lead to exacerbation of symptoms, which often delays the return to normal training [6]. The goal is to find the appropriate dose of training stimulus to maintain as much fitness as possible while creating a positive environment for healing.

O’Sullivan et al. Br J Sports Med 2018;52:555–556.

Why is this information important?

Fear of re-injury, doing further harm, “wasting time”, and not being able to return to previous levels of performance are thoughts that are likely to arise after an injury [7]. With an understanding that symptoms are not typically  indicative of further or ongoing damage, we can cultivate an acceptance of tolerable levels of symptoms during the rehab process. It is important to note that the level of “tolerable” symptoms will be subjective and specific to each individual. In other words, an increase in symptoms doesn’t necessarily mean you are doing more harm or experiencing a new setback.

Outside life stress, fear, catastrophizing, fatigue, and ineffective coping strategies are several factors that have a huge impact on the experience of symptoms day-to-day. Setting the expectation that the issue will get better with time promotes acceptance over the injury. Also, having a plan in place promotes a sense that the symptoms and process are within the individual’s control (rather than feeling helpless or dependent on others to “fix”). This internal sense of control is known as self-efficacy, and is a major contributing factor for the resolution of symptoms [8]. The sooner we can cultivate acceptance over the injury, the sooner we can get to work on the solution in an active manner.

Load Management

Most non-contact musculoskeletal injuries are related to poor management of training load. Training load is defined as the cumulative amount of stress (physiological, psychological, or mechanical) placed on an individual from a single training session, or from multiple training sessions over a period of time [9]. Training load can be further subdivided into external load (e.g., absolute weight on the barbell, sets, and reps) and internal load (the individual’s perceptual and physiological response to an external load; ‘how difficult was that session/set?’) [10]. In a recent systematic review of 57 studies by Eckard et al., the authors concluded that the relationship between training load and musculoskeletal injury risk is now well established. Of those studies, internal training load using session Rating of Perceived Exertion and relative loads using the Acute:Chronic Workload Ratio had the strongest evidence. [11]

With this in mind, tracking session RPE (sRPE) is likely a good idea and is very easy to implement. At the end of each training session, simply ask yourself, “How difficult was that session?” with 1 representing complete rest, and 10 representing the hardest session of your life. The most common error when applying this in practice is an over-emphasis on perfect accuracy or searching for some “objective correlate”. The rating is supposed to be subjective — this subjectivity is where the benefit lies, since it captures the all the “intangible” factors contributing to an individual’s total internal load at any given time. The idea is that if we are having multiple sessions in a row where the workload leaves us feeling like we’re on the brink of death, it may be wise to change course. For example, we can use the Baraki Exertion Scale or other similar chart as a guide:

Figure 1: The Baraki Exertion Scale is visually represented by the degree of grimace, rubor, and proptosis exhibited by the lifter during the set being evaluated. [Note: this is a joke.]

 

Essentially, this tool gives us insight into how prepared we are to handle the training load we are about to undertake. Research by Tim Gabbett and others on team-based sports have noted there appears to be a ‘sweet spot’ of relative loading to maximize positive training adaptations while reducing risk of injury [12].

As an injured area starts feeling better, the temptation to jump back into normal training becomes almost irresistible. However, at this point the concepts of load management are as critical as ever, because there is likely a period of deconditioning that occurs following an injury due to a decrease in performance levels. Returning to normal training without doing the necessary work to build back up to that level of training is associated with increased risk of injury due to a relative ‘spike’ in workload and can potentially be detrimental. Conversely, if we avoid loading completely (i.e., rest) for an extended period of time following an injury, then we risk unnecessary deconditioning, developing fear of movement, and becoming less resilient [6,11,12]. Here are some practical strategies for finding ways to train with pain and injury presented by Dr. Baraki:

The last step in management is a critical piece that often gets overlooked: embrace the process.

Embrace the process

Although the timeline for recovery will vary depending on the injury, the process will require setting appropriate expectations. Based on the work of Thompson and Sunol [13], there are four different types of expectations:

(1) Predicted expectations: what the individual believes will occur

(2) Ideal expectations: what the individual wants to occur

(3) Normative expectations: what the individual believes should occur

(4) Unformed expectations: the lack of a preconceived idea regarding a situation or intervention

Predicted expectations are the most important to consider based on their association with outcomes related to the management of musculoskeletal pain conditions including work-related injury, total joint arthroplasty, chronic pain, neck pain, shoulder pain, whiplash-associated disorder, and low back pain [14]. In other words, your predicted expectations (such as believing an injury will get better, versus believing the area is permanently damaged) can influence outcomes of pain, function, and likelihood of returning to work following an injury.

In the context of sustaining an injury during training, the ideal expectation is to achieve full recovery as soon as possible. However, going into a training session expecting to perform at the same level as before the injury with no symptoms can quickly lead to frustration and discouragement.

Controlling predicted expectations and operating from the premise of training to get back to baseline, rather than training for a performance based goal (strength, hypertrophy, endurance, etc.) can help with embracing the process and acceptance of symptoms.

All of this is to say, our approach to adversity makes a substantial difference in outcomes. Recovering from an injury requires patience and an understanding that progress — both in rehab and in regular training — is made through an accumulation of small “wins” over time.

The process will not be easy, there will be setbacks, and there will be days where you feel defeated. Don’t let that discourage you. As long as you keep showing up and putting in the necessary work, you will get back to baseline and far beyond.

Thanks to Derek Miles, DPT, Michael Ray, MS, DC, and Austin Baraki, MD for their contributions to this article.


About the author

Charlie Dickson is an intern for the Pain and Rehab Division of Barbell Medicine. He graduated Summa Cum Laude with his B.S. in Human Nutrition, Foods, and Exercise from Virginia Tech and is currently a 2nd year Doctor of Physical Therapy Student at Radford University.

Charlie started powerlifting in 2014 and went on to win the Junior 83kg International Powerlifting Federation (IPF) World Championship in the summer of 2018. He has achieved personal best lifts of a 675lbs squat, 440lbs bench press, and a 715lbs deadlift.

When Charlie isn’t studying or lifting heavy things, you can find him playing with his 3 poodles, hiking, or contemplating the meaning of life.

Instagram: Charlie_barbellmedicine

Email: Charlie@barbellmedicine.com


References:

[1] Timpka T, Alonso J, Jacobsson J, et al. Injury and illness definitions and data collection procedures for use in epidemiological studies in Athletics (track and field): Consensus statement. Br J Sports Med 2014;48:483-490.

[2] Martorella, G. , Côté, J. and Choinière, M. (2008), Pain catastrophizing: a dimensional concept analysis. Journal of Advanced Nursing, 63: 417-426. doi:10.1111/j.1365-2648.2008.04699

[3] Moseley GL, Butler DS. Fifteen years of explaining pain: The Past, present, and future. J Pain 2015;16:807–13.doi:10.1016/j.jpain.2015.05.005

[4] Lewis J, O’Sullivan P. Is it time to reframe how we care for people with non-traumatic musculoskeletal pain? Br J Sports Med 2018;52:1543-1544.

[5] Hainline B, Derman W, Vernec A, et al. International Olympic Committee consensus statement on pain management in elite athletes. Br J Sports Med 2017;51:1245-1258.

[6] O’Sullivan K, O’Sullivan PB, Gabbett TJ. Pain and fatigue in sport: are they so different? Br J Sports Med 2018;52:555–556.

[7] Forsdyke D, Smith A, Jones M , et al. Psychosocial factors associated with outcomes of sports injury rehabilitation in competitive athletes: a mixed studies systematic review. Br J Sports Med 2016;50:537–44.doi:10.1136/bjsports-2015-094850 

[8] Menendez ME, Ring D. Factors Associated with Greater Pain Intensity. Hand Clin. 2016 Feb;32(1):27-31. doi: 10.1016/j.hcl.2015.08.004.

[9] Soligard T, Schwellnus M, Alonso JM, Bahr R, Clarsen B, Dijkstra HP, et al. How much is too much? (part 1) International Olympic Committee consensus statement on load in sport and risk of injury. Br J Sports Med. 2016;50(17):1030–41.

[10] Impellizzeri FM, Marcora SM, Coutts AJ. Internal and External Training Load: 15 Years On. International Journal of Sports Physiology & Performance. 2019;14(2):270-273.

[11] Eckard, T.G., Padua, D.A., Hearn, D.W. et al. Sports Med (2018) 48: 1929. https://doi.org/10.1007/s40279-018-0951-z

[12] Gabbett TJ. The training-injury prevention paradox: should athletes be training smarter and harder? Br J Sports Med2016;50:273–80.doi:10.1136/bjsports-2015-095788 

[13] Thompson AG, Sunol R. Expectations as determinants of patient satisfaction: concepts, theory and evidence. Int J Qual Health Care.1995;7:127–141.

[14] Bialosky JE, Bishop MD, Cleland JA. Individual expectation: an overlooked, but pertinent, factor in the treatment of individuals experiencing musculoskeletal pain. Phys Ther. 2010;90(9):1345-55.

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