I came across an interesting ‘human’ blog: 5 Rules for Exercising People in Pain
Here’s the first line,
“A big misconception within the therapy world is that all exercises should be pain free. It is easy to assume that when an exercise is painful, you might be causing further damage or disrupting the healing process. However, that is almost never the case, especially with lower loaded interventions.”
The article goes on to note that pain and damage are not highly correlated and that pain is not a predictable indicator of any underlying mechanism for its presence. However, the article is quick to note that as clinicians we should not be promoting the “No pain, No gain” concept. Rather some rules of thumb to guide the recovery process.
1.Pain Must Be Tolerable
2.Pain Should Return to Baseline, or Diminish Upon a Determined Time
3.Avoid Increasing Symptoms More than 2 Points on a 0-10 Scale
4.Avoid Reaching Levels Where Moderate Swelling is Noticed
5.Avoid Reaching Levels Where Sleep Becomes Disrupted More than Usual
So, can these generalized rules carry over to the canine rehab field? Let’s see!
Pain must be tolerable. I agree whole heartedly. If you have an animal lying down or refusing to walk or move, then to do the exercise is clearly problematic. Here I think of my patient with lumbosacral stenosis. Heavy exercising makes her want to sit down. This frustrates the owner, so he decided to try making her exercise faster in order to get it over with sooner. This resulted in the dog being unable to do the stairs back at home for 20 minutes upon returning from their walk. My suggestion? Slow paced shorter exercise bouts in greater frequency.
Pain should return to baseline, or diminish upon a determined time. Yep! I think you’ll find scribbled in the notebooks of practitioners I trained going back 22 years, the phrasing that I still use today, “The dog should not come back from a walk (or exercise session) looking substantially worse than when it went out, and it should be back to its ‘normal’ by the following day (or day after if a hard workout session).” We know that muscles build subsequent to small microtrauma in the tissues. If we keep this in mind, then it would be permissible to have one day of soreness following a novel exercise or increase in exercise (duration, intensity, load, repetitions, speed, and so on).
Avoid increasing symptoms more than 2 points on a 0 – 10 Scale. Well, this sounds good. But what scale can we use? A visual analogue scale? We know that we can have caregiver placebo (and in some instances, nocebo) effect. So, I leave this here as a ‘that would be nice’, but there isn’t anything very concrete to go on within the canine world.
Avoid reaching levels where moderate swelling is noticed. Agreed! There is a difference in creating muscle soreness and fatigue and joint irritation. Inflammation of a joint can set back healing of intraarticular tissues (if that’s the case) AND can inhibit the very muscles you are trying to strengthen. So, yes indeed, a joint should not swell. Neither should tissues for that matter… The trick here is getting owners to be able to detect joint swelling. Alternately, YOU monitor the patient a bit more closely / frequently as you are increasing exercise until you can establish how fast you can progress and exercise regimen.
Avoid reaching levels where sleep becomes disturbed more than usual. I like this one too. It sounds fair and reasonable.
When it comes to dogs however, we can’t ask them about their pain. We need to look at the subtle clues. Lameness is our most commonly assessed indicator of pain in dogs. However, it can fool us as well. Lameness can be the result of weakness, of biomechanical impedance, of neurologic dysfunction, of instability, and so on. So, be sure to be all encompassing in your evaluation of the dog and the questions you ask. Ask about FUNCTION: stairs, getting up from lying, squatting to eliminate, getting onto the bed or couch, or willingness to play.
What if we were to say that there should never be pain with exercise (during or afterwards)? Well, that’s where the run the risk of never progressing the dog to the levels it needs to get to in order to return to off leash, return to sport, or be safe if there is an unforeseen even (i.e. SQUIRREL!)
That’s your critical thinking for the week! Have a good one!