The Beyond Pain Podcast

Episode 44: All Gas No Brakes? Knowing When to Push and Pull Back with Pain in Rehab

• Par Four Performance • Episode 44

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Summary
In this episode of the Beyond Pain podcast, hosts Joe Gambino and Dr. Joseph LaVacca discuss the complexities of client motivation and pain management in rehabilitation. They explore the importance of education, setting realistic expectations, and the role of emotional management in recovery. The conversation emphasizes the need for clients to explore their limits and measure their progress objectively, while also addressing the fluctuating nature of pain and its impact on rehabilitation outcomes.

Takeaways
Understanding client motivation is key to effective rehabilitation.

Education on pain management can prevent flare-ups.

Clients should be encouraged to explore their limits safely.

Emotional management is crucial for client success.

Pain is not always a reliable indicator of progress.

Setting realistic expectations helps clients navigate their journey.

Tracking specific movements can provide objective measures of progress.

Encouraging clients to push through discomfort can be empowering.

Exploration in rehab can lead to better outcomes.

Communication about pain experiences is essential for recovery.

Joe Gambino (00:00.958)
Welcome back to the Beyond Pain podcast. I am one of your hosts, Joe Gambino, and I am here with Dr. Joseph Illuminati-LaVacca over there. I can see him much more crystal clear with that little backlight over there. Love it.

Joe LaVacca (00:13.67)
I'm telling you, it really made a big difference. for the next couple of weeks, I will definitely use it. And then we'll see how goes in the new place. Like I said, lot more natural light, think, in the new place, a lot brighter, a little bit more updated. I think I've referred to my apartment the way my landlord had referred to my apartment, which is Grandma Chic. And...

Joe Gambino (00:40.456)
I like that.

Joe LaVacca (00:42.006)
It turns out that Avery and I have grown out of Grandma Chic. And even being of the Italian heritage, being surrounded by the baby angel faces, the ornate God above my oven. I don't know if I ever sent you a picture of that before. This beautiful picture of Venice that I have for some reason in the kitchen. I think we've just realized not our style.

Joe Gambino (00:46.111)
Mm-hmm.

Joe Gambino (00:58.336)
No.

Joe Gambino (01:10.57)
Mm-hmm. Fair.

Joe LaVacca (01:11.234)
And it's just time to move on. yeah, we're excited. We're excited. New apartment. Let's say I know I got to come up with a good word for it. I to get in there and feel the vibes. right, modern, modern something modern something but maybe more like modern stepdad or something like that. Or you know, maybe like we'll stick with the family theme or like modern uncle or

Joe Gambino (01:15.219)
How are you gonna be describing the new apartment?

Joe Gambino (01:26.813)
I see. Okay, fair enough.

Modern grandma, got a modern grandma feel.

Okay, all right, all right. We'll have to pull this back up once you're in there for a couple weeks. Well, anyway, you can find Joe and I very easily on Instagram. That's where we're most active at, joegambino.dpt for myself. At Trent in motion underscore PT for Lavock over there. You can find this podcast on Instagram, Beyond Paying Podcast.

Joe LaVacca (01:40.654)
I don't know.

Joe LaVacca (01:44.844)
Yeah, yeah, yeah, we'll figure it out.

Joe Gambino (02:02.746)
And you can find this on YouTube as well, cupsofjoe underscore PT. I think I got it all. And there is a link in the show notes for all this stuff. But if you do feel like you want some of our help, there is an application form as well. Please feel free to reach out and one of us will get back to you. Joe, welcome back. I think we have a question from you today.

Joe LaVacca (02:26.23)
Yes, I do. I think oftentimes when we talk about our clients, a lot of it stems from how do we get people motivated? How do we get people consistent, especially when they're in pain? I think the most common thing we see is people holding back, maybe over protecting.

dropping weight, dropping reps, dropping sets, dropping frequency or days at the gym. But then every once in a while, I do think we probably get people who come along who are very eager to get out of pain, who hear our message and boom, go full throttle with it, right? Where tolerable pain during a workout is merely a thought process, because you can tolerate.

any amount of pain really when you think about it. So I have a client right now, one of my hardest working clients. And one of the theme that keeps coming up in our weekly check-ins and conversations is this frustration. And when we look at his program, he's pushing as hard as he can with all these isometrics. He's pushing the shoulder.

Joe Gambino (03:23.936)
Sure.

Joe LaVacca (03:51.092)
into painful positions. He's really trying to open up that space for himself. And then when he has very sharp pain, it sort of leads to this discouragement again. So we've been trying to navigate expectations while not holding him back. And I wanted to bring that up to you because I'm sure you've had clients like this and I'm sure there are clients like that listening right now. How can we help them?

Joe Gambino (03:53.908)
Mm-hmm.

Joe Gambino (04:20.288)
Hmm

Joe LaVacca (04:21.396)
in this process of knowing when they're maybe pushing too hard and hitting the throttle too much too soon.

Joe Gambino (04:29.632)
Yeah, I think there's two ways in this particular example that I would go about. One would be education on why you shouldn't be ramping hard into pain because that's a recipe for flare ups. And especially if it's closing angle discomfort, like we have some sort of impingement stuff going on. We know it's a joint issue underlying there. There's no amount of isometrics or pushing through it that's going to make it better and just

kind of potentially end up making it worse. And especially with this person where it's like a frustration and this like yo-yoing of feeling better pushing and then moving back, how do you get them out of that cycle? So I think just some education on like what's going on there and why you shouldn't be pushing super hard. And then I'd probably give them like very specific guidelines on like how hard I want them to push, you know, like I'd give them the percentages of effort and then see how things go.

The other thing I would probably do in a situation like this is find other places where they can push hard that are safer is not the right word, but like where I know that they can do it with no problem. So if intensity is something that they enjoy and makes them feel good, what can we start to like almost like shift their focus on? Like, okay, well, I don't want you to like isometric your shoulder to death, but.

You know, you like to work hard, like maybe there's some stuff from a lower extremity standpoint, or maybe there's a pull version if a push is painful, that we can say, why don't we just go heavy here, let's go harder here, you know, take it to failure or whatever it is that you want to do. But this should allow us to actually move forward versus moving forward and then taking a step back and constantly playing this game of back and forth. I'm curious, you know, A, what do you think about that? And B, what have you been doing with this particular person?

Joe LaVacca (06:18.114)
Yeah, no, I think that obviously the education piece always comes first and foremost, the idea of trying to determine when or what structures or tissues are capable of handling more. think that for the most part, I've started falling out of the notion

Joe Gambino (06:20.064)
.

Joe LaVacca (06:43.764)
all the time thinking that a closing angle pain is always a joint. And I think we might've mentioned that on the podcast before, because I do think that inflammation can lead to that. do think that tendons can sort of share that sort of like similar property. So I'll combine that with like range of motion loss. But anyway, when it comes back to this particular client or maybe clients that we've worked with in the past, I think that my normal inclination

is to keep bringing them back to this idea that, okay, you're pushing really, really hard. What's happening after the fact? Because I can see this going two ways. One, you're pushing really, really hard. You're showing yourself, hey, I can work through almost anything, which is good, but then does it have an impact on your function, you know, six, 12 or 24 hours later? So you push all you want. I mean, I can't...

objectively measure your pain for you. I can't feel it, I can't see it, but I can talk to you about it can hear your experience. So in the beginning, when we were sort of first navigating this and I saw how committed he was, my natural intention was, look, we still don't know enough about the shoulder. I'm basically treating you like chronic rotator cuff tear. Yeah, there is some data out there that, you know, surgery could be helpful.

you seem to have passed the window where we would get the most benefit. Not that it can't be beneficial still, but I don't know if we've given ourselves enough time or space to really know for certain if we could be successful. So I did purposely pull him back a little bit earlier. Then as his range became pretty symmetrical compared to the other side, there are still some glaring weaknesses between right and left, but now I'm sort of giving him the keys a little bit more because he is pain-free during the day.

He's not seemingly having much sleep disturbance. But the thing that I think is kind of important is that he'll be riding high like, hey, okay, cool. Like I'm, good. I'm good. I'm good. And then it's like a deck of cards, right? And I think that that for him, that emotional sway up and down can be discouraging. And I don't want that to sort of take away from the progress that he's made or make him feel like

Joe LaVacca (09:08.504)
he's not being or that the consistency isn't paying off in some way, or form. Because I think we've had these conversation around moments of pain. So I can go through a whole workout and I'm looking at some of his things he's doing right now. Maybe there's five or six things that he's doing when you count in finishers and stuff. And for the most part, it's going good, good fatigue, going good, good fatigue, and then bam, super pain. And then we kind of get caught up in that one.

particular motion or exercise. So most of the time, at least lately, you know, things within the workouts have been going well, but it seems like these higher effort thresholds, give him a little bit of trouble. So that's what we're kind of working on now. So I guess it's come down to this idea of like where he was in his rehab, where people have been in his rehab. And for the most part,

I'll be honest, if you think you can tolerate it, then go ahead and tolerate it. However, I do think that we need to be a little bit more objective to set you up for success long-term. And in that case, if we did see a loss of function, then we have to hit the timeout button, right? Because then it's not just like this little editor flow thing. So I think for him, it's gonna become a lot more managing emotion, maybe even managing the tissue.

because it doesn't seem like the tissue is necessarily suffering except in that moment in time. So I don't know if you've ever thought about letting people, like when do you just let people bite down, push through it and just say like, hey, I'm here.

Joe Gambino (10:36.096)
you

Mm-hmm.

Joe Gambino (10:48.638)
Yeah, it's a, you know, I let the response to how they feel be the determining factor, right? If you're, we're having these flare ups, but you know, everything is, everything is great and we're just kind of managing the high. mean, like with, with that, I'm probably going to have them just back off and I'd probably give him like, okay, this is the position that we're going to be working on. Like this particular range of motion within that pattern.

And I want you to go and figure out like when does it start to be pain? I want you to measure that like what is that internally to you? 50 % with your head and like, you know your arm and almost full flexion. Sure. Okay. That's what we're to do. But now what I want to see is over the next four weeks that I go from 50 % to 70 % and 80 % because sometimes people when they have something to measure now it's helpful for them. It's not just like this, like random. have to push this and I have to go hard. It's like, okay, well this is what's tolerable. Now I can like

Joe LaVacca (11:35.938)
Yeah, it's a good idea.

Joe Gambino (11:43.92)
see progress in the sense because now it's the same position, it's repeatable. And then when you see you go from 50 % before pain to 70%, you realize there's actual change happening. That's probably what I would do there. But otherwise, you know, if it's, if someone was just pushing and like, was a little bit uncomfortable, you know, I'm going to fall to those pain guidelines that we've talked about a thousand times in this podcast. You know, it's like, is it go over a four? Does it last for two, three, four, five days?

You know in a case like this even if it wasn't within those those ranges and the person was like always on super edge about it and like it was like Frustrating and we have to like talk them off the cliff every single time those are the times where I'm probably gonna say okay like we need to Re-evaluate here if someone's pushing, know, I have a client very similar He's like always like his isometrics are probably like harder than him trying to do like a 1rm bench press like he's like always as hard as possible

Joe LaVacca (12:36.62)
Yeah.

Joe Gambino (12:38.72)
But if there's no pain nothing really kind of going on I'm not gonna stop them from doing that is when it starts to become like all of a sudden like, you know, we've talked about this on the podcast like if someone's Navigating that line of pain we should still see that they're tolerating more stress that things are starting to feel better things are you know, long as they're giving enough rest and recovery in between that there's like We can see some sort of benefit happening from an objective motion standpoint from a pain standpoint from a function standpoint but if they're

toying that line and there's not any progress or their pain is like building up or it's like not what we'd expect from rehab, then you have to make the adjustment. And I think really it comes down to less so about what you're pushing into or how hard you're working. There's always the response afterwards that should really guide what's going on. And once people really learn how to listen to their body, I that's a game changer for most people. So, yeah, I think that's kind of really what I got there for you.

Joe LaVacca (13:36.598)
Yeah, no, think what's I like that idea of like, just going back to like measuring effort. Hey, like we know the couple of like, isometric positions or movements that are really causing some pain. So having them hone in on that, I think will be part of our conversation. I'm going to see him over the weekend. The other thing I thought though, that was sort of like tricking me because he does really well with all this like pulling exercises. I mean, we're, we're having crushed lower body. So

Joe Gambino (13:38.272)
Hmm

Joe Gambino (14:02.037)
Mm-hmm.

Joe LaVacca (14:05.206)
I think in that case, one of my also go-to's, and we've talked about this, hey, what can you do really well? Let's push that as hard as possible. Go as heavy as you can on squats, as deadlifts, because you'll get that systemic effect of strength by doing a lot of these bigger compound movements. So guess what's lingering in my mind is without the, I guess let's say, repercussion and function six, 12, 24 hours later, is there any detriment to just letting him

Joe Gambino (14:18.56)
Hmm

Joe LaVacca (14:34.36)
push as hard as he can, sharp pain in the moment, because I do that. And I think I mentioned that in like the first couple of episodes we were talking about how we deal with injury. I poke it, I prod it. I kind of like start laughing like, my God, this could not be more painful when I've had injury. And I just keep doing it. So I don't know if I'm doing myself a disservice. Am I lingering that pain around? I mean, I've been able to recover luckily. know, again, knock on wood. think this is what the second episode we've been knocking on wood for me.

Joe Gambino (14:46.366)
Hmm.

Joe Gambino (15:02.043)
Mm. Back to back to.

Joe LaVacca (15:05.133)
You know, but like of all the things I've read about pain, there's very few, if any studies that I can recall that are just like comparing one group or it's like, Hey, we're to let this group be tolerable. We're going to let this group just go to eights, nines and tens because you know, who's really going to push themselves that hard anyway. And then let's see where they're at six, 12, 24 weeks later.

Joe Gambino (15:25.984)
You know, I need to see if I could refine that article that I could pull the pain guidelines from in the past and see and try to remember exactly why those numbers popped up because I pulled my pain guidelines like many years ago when I was at Perfect Short. I found an article that kind of talked about it and I don't really remember the nuances of it. I just remember at this point the scale and it's worked really well for me. Helping people kind of understand pain a little bit better and what to expect and things like that.

But it's not a hard, fast rule. mean, some people could be within the pain guidelines and struggle and some people can go over it and be fine. Right. So again, going back to how people feel and tolerate, mean, there's been plenty of times where I've had some pain or I've kind of like, ah, don't go into, you know, the rule, don't go into closing angle pain or don't really do this. And I've done it before. And afterwards, I feel really good. Right. So like, sure. You can. I think everyone should have the ability to play. I want to try it, especially when you're feeling better. I don't want to like push it a little bit more.

I think people, and I actually always bring it back to one patient, I had a perfect stride, I was always in ACL. But people who push themselves a little bit more, especially in times when they start to feel better, tend to do better in rehab overall than the person who's afraid to push it. And I had somebody who was in ACL, she was a gymnast, very, very active, had ACL surgery, she was young, and she just like almost always just just overdoing it with her knees. She'd always come back with these like little flare ups and things like that.

But as we're going through the journey, she like progressed very quickly. Range of motion came back fast, strength came back fast. Like everything went really well. And I was just like, you know, people just need to kind of explore it. And if it's too much, it's too much. It's not going to break you, right? You just need to process, you know, again, like your, patient can feel the frustration and process it. But at some point, you know, you have to kind of come back down and re.

visit things and then figure out is this something I need to continue going down this path or do I need to adjust the pathway? And I mean, he's lucky enough to have you where you can you can help him make those decisions. But the people who are fearful of things, it takes longer for recovery and the people who just go out and explore tend to do better in my experience with myself, with the people that I've worked with. So I think exploration is an important part of.

Joe LaVacca (17:33.326)
Mm-hmm.

Joe Gambino (17:45.918)
Rehab and getting over pain because you may push it and realize this was good. This was safe. I feel better and all of a sudden mentally now Your nervous system everything the guards down. Okay, I can push through this I can do this it's it's empowering in a sense and then sure if it flares up, know, it can be Detrimental it can feel like you've hit a wall. It can feel like a setback. It can be frustrating and sad But once the one, know, and then also say hey, let's see what the recovery time line looks like

for that person. There's been plenty of times where someone's afraid of these flare ups because it can take them months to recover and they have a flare up down the line and it's like, in like three days I felt better. Well, look at that. You had this major flare up, but in three days time, you're back to normal. We can go and push again. It's not two months. Look at how far you've come. So I think regardless of pain, no pain, you can learn a lot about pushing your body. And I think when people get over the hump of being scared of pain and just taking it as information.

Joe LaVacca (18:25.294)
Mm-hmm.

Joe Gambino (18:43.946)
that they can learn from and adjust from, that's a game changer for somebody. That's been a game changer for me with my pain journey and history. And I mean, I've known all this stuff and it can still be frustrating for me to have pain. So, you know, if you don't know any of this stuff, I can see how it can be very, very frustrating for you. But yeah, mean, exploration I think is a key component of all of this process.

Joe LaVacca (19:07.852)
Yeah, I think play exploration. love those words and it kind of brought me back to the peak end rule with any experience. And I don't know why I didn't think about that with him or really anyone training recently, but we tend to judge our experiences on like high highs or low lows or just how that experience ends. And, you know, I think we mentioned this with vacations before when we talking about Mexico, actually. Yeah. You know, I could be having a great family vacation.

Joe Gambino (19:24.223)
Mm-hmm.

Joe Gambino (19:34.612)
Mm-hmm.

Joe LaVacca (19:36.824)
but my flight gets delayed on the way home. now I talk about that vacation like, what a terrible experience. So the way that it ended kind of negated what I felt like during the course of those days. So maybe what I'll start to play with is more of this like positioning too, now that I'm talking to you. If we know that these one or two movements are going to be particularly painful, maybe we put them at the beginning. So they're not at the end. He's not like doing them with a finisher. He's not kind of going through his whole workout, but put them in the beginning.

Joe Gambino (19:45.941)
Mm-hmm.

Joe LaVacca (20:06.636)
Hey, all right, you know, that was a little bit frustrating, but then look what you were able to do after it. You were able to do push press, you were able to do this, you were able to do really heavy bent over rows, you were able to do a push up. And then maybe that will be a little way to help him with his frustration. So I'm gonna try that.

Joe Gambino (20:22.164)
Yeah, that's a big, and I think just having like a lot of times what I have with people after an assessment is like, here's two or three things that we want to see change and we're going to track them and measure them. And they're almost like a test for you also. So if you do something in the gym or you do these things and all of sudden you feel like those movements are more painful or way worse than, know, you're probably pushing too hard and whatever you're doing. So I think having like a couple of objective things, because we know pain is a terrible measure of progress. cause pain can fluctuate up and down for.

almost sometimes no reason at all. So I like always giving someone like, is the homework. These are the movements that we're tracking. We want to see these things have progress. So when flare ups do happen or whatever, we can always fall back on those movements. Look at how much these have changed. This is exactly what we wanted. This flare up is just a little blip in the journey. Now we can kind of get back on track. I know we've gotten really far off of our original topic, but I think this is exactly what.

Joe LaVacca (21:13.742)
No, but that's good. think there were, yeah, no, there were a lot of...

Exactly what I was hoping for. Well, Joe, thank you for all your insight. Thank you for your time. I love you. Listeners, we love you. Thank you for making it through another episode of the podcast. Let's go with our heart. dang, I feel like I keep messing it up though. Is that right? Yeah, I feel like I gotta turn it up, turn it up this way. Okay, yeah, all right. Yeah, you're right. Now I got it. All right.

Joe Gambino (21:20.712)
Yeah, there we go. Perfect.

You as well.

Joe Gambino (21:39.056)
You just gotta, yeah, yeah, just gotta supinate that a little bit more.

Joe LaVacca (21:47.202)
Thank you again and please make sure you come back next week for another exciting episode of the Beyond Pain podcast.