Working out with pain, should that even be a thing?

If you've practiced an active lifestyle long enough you've likely had to navigate some unwanted discomfort or downright painful situations. This is one of the most challenging aspects as a rehabilitation specialist related to helping those leading such an active lifestyle. That is helping them to recover from injury or persistant pain while maintaining their active life. With this in mind the question then becomes how much can, or should you do when you're injured? If any? I mean these are very valid questions. The reality is that there are no one size fits all evidence-based recommendations that work for everyone in every situation. Not to mention pain is VERY complex and isn't just a "tissue specific issue" as so many have been lead to believe. In other words, pain doesn't necessarily relate to changes in a specific tissue, that is until it does...

            We've written about the stages of healing in previous posts. In "The Mental Road less traveled..." (You can read that post here.) we discussed some general time frames it takes for healing to occur for specific tissue types. Realistically speaking, unless you have some type of genetic disorder, a local or systemic infection or disease your body will more than likely follow a consistent, yet somewhat time dependent process of healing the injured tissue. That is if we allow the tissue to recover before placing too much stress on the involved tissue too soon.

            Therein lies the difficulty when asking, "How much can, or should I do when i'm injured?". In this post we'd like to share a few thoughts on the topic. Our goal is to provide some expert opinion on the topic and help you to make a more informed decision about how much you should or shouldn't do if you've suffered an injury or are living with pain. Please keep in mind that expert opinion is considered one of the lowest levels of evidence-based practice and this should be kept in mind while considering whether or not to apply this information. In other words, these considerations are subject to change.

When it comes to pain if you've sought medical attention for an injury then you've probably been asked to "rate your pain". One of the most utilized metrics to describe or rate pain is using an arbitrary pain scale to rate your pain on a scale from 1 to 10 with one being the lowest level of sensation and ten being the "most pain" someone has ever experienced (see the scale below). In and of itself this scale may see to provide little guidance in the way of whether or not you should perform activity.

            In fact, this scale is somewhat subjective depending on the person rating their pain. Using this same scale many believe that in the acute stage (i.e., first 5-10 days post injury) if after injury and during an activity you rate your pain greater than 3 ratings above your current level of pain (before the activity) then you should reduce, modify or stop the activity. For instance, if you start your activity experiencing a 2/10 pain then you'd try to not go above a 5/10 pain. If your symptoms moved to 6/10 pain then you should reduce your activity to the point that you return to your baseline (i.e., whatever pain level you started at, not necessarily 0/10 pain). More current work has used a rating of no more than 5 ratings above your current rating before reducing your activity, especially in the later days of the acute stage and into the subacute and chronic stages of healing.

            Another method has been described by Curwin & Stanish: Classification for Determining the Appropriate level of Discomfort Associated with Exercise or Sport Performance. According to this classification the first question to consider is when do you have pain? Is it before, after & or during the activity? If so, how long does it last? Based on this information you can determine how much to reduce the intensity of your activity of choice.

Level	Pain Presentation	Level of Activity
1	No Pain	Normal
2	Pain only with extreme exertion	Normal
3	Pain with extreme exertion & 1-2 hours afterwards	Normal or slightly decreased (~25%)
4	Pain during & after any vigorous activities	Somewhat decreased (~50%)
5	Pain during activity & forcing termination	Markedly decreased (~75%)
6	Pain during daily activities	Unable to perform (Rest)

For instance, if a person only has increased pain following an extreme activity then normal activities are ok to continue; however, if the pain lasts 1-2 hours after the extreme activity then a reduction of 25% in intensity is recommended. However, if that a person were to have pain during and after a vigorous activity then it is recommended that they reduce their activity intensity by 50%.

            Again, these are only two of the most common approaches to determine your level of participation intensity if suffering from pain, especially when recovering from injury. At this point you may be thinking, "how do I know if I've done too much too soon?" Well we've got you covered there too.

Signs and symptoms that you've performed too much too soon include:

• Exercise/activity soreness doesn't decrease after 4 hours and isn't resolved after 24 hrs

• Exercise/activity pain comes on earlier or is increased over the previous session

• Progressively increasing stiffness & decreasing ROM over several exercise sessions

• Swelling, redness, & warmth in the healing tissue

• Progressive weakness over several exercise sessions

• Decreased functional usage of the involved part

With those signs in mind, and as a general rule, exercise can cause temporary soreness for up to 4 hours following a activity performed at a high level of intensity, but if these signs and symptoms occur the exercise or activity is likely too stressful & should be modified or reduced in intensity. Notice we didn't say you should stop all activity, but rather the best course of action might be to perform the activity with less intensity and or use a different activity for the time being.

Thank you for taking the time to read this post. We hope you enjoyed it and learned something of value. If however this post sparked more questions than answers? Or you have specific questions regarding your own personal injury or pain struggles, don't hesitate to reach out to us at 4th Corner. We'd love to be in your corner!