Get better results when training around chronic pain! (guest post from Megan Pomarensky)

Think back to your client roster over the past few weeks or months. 

About that client who has had pain that persists past the expected healing timeline, or where there wasn’t a biomechanical reason that makes sense to explain it.

What did you do?

Likely some combination of different exercises, movement screens, and tests, ending up with a list of faulty movement patterns, stiff joints, and muscle weakness.

Did you consider psychological and social influences though?

Did you look away from the site of pain?

Because in reality, these are likely contributing factors that are highly misunderstood.

Now. I say this misunderstood, because chronic pain is running rampant in our society, and is a leading cause of impairment and disability.

And, the World Health Organization reports that the majority of adults are not meeting the minimum requirements for weekly physical activity (both resistance and aerobic training).

Think there might be a link between these two statements?

I do.

Clients who have experienced injury and pain, especially when it lingers on past the expected healing timelines, or when there’s a disconnect between symptoms and tissue damage, are often fearful of pain or movement, they’re more sensitive to pain, or have a lower threshold. 

It can be a challenge to rehab the injured and painful area, nevermind train the rest of the body.

However, the good news is that you can improve the results you get, if you simply look through a different lens than what’s been taught in the textbooks and traditional certification programs.

So, how do you do that on the gym floor?

1) Instead of looking for all the things that are wrong, start looking for all the things that are right.

Your client needs to know what they are capable of.

What their trainable menu is. Not that their hips don’t stay level in a plank, that they shift their weight a bit on the squat, that one scap moves differently from the other, that their arch collapses when they walk, or anything like that. This type of info is going to lead to fear, guarding, and further deconditioning. Definitely don’t want that. 

Now, you could absolutely train those things if you choose to, and you can do it (with much better success) through external cueing – creating an environment that gets the adaptation you want. 

  • Put the yoga block on their back during the plank and tell them to keep it there
  • Use a band to pull them more into the weight shift on the squat so they have no choice but to correct it if they don’t want to fall, 
  • Tell them to keep their big toe pressing down into a piece of paper that you’re trying to pull out to get deep arch muscles working.

And also know this – with chronic pain, there is often no biomedical or biomechanical factor leading to the pain; it’s hypersensitivity of the nervous system, decreased thresholds, deconditioning, and/or fear. Once you confirm this through your assessment, tell the client all the good stuff! How your findings point to no structural/pathological concern, and that this can absolutely be helped with exercise. Get them fired up and ready to go. Then go there. Train them. Expose them to a stimulus that is going to challenge them and create adaptation.

Ps. If you’re unable to diagnose, get a team involved. Connect with someone who can determine the driving pain mechanism and get the big bad stuff ruled out so that the client has that reassurance prior to diving in.

2) Look outside of the rehab/gym floor, and away from the site of the injury. Are there personal or professional life factors that may be piling additional stress on their already dysregulated nervous system? This could include things from their attitude towards family/friends/healthcare providers/insurance companies, to employment status, to recreational activity participation or withdrawal.

It’s well known that stress is linked to pain intensity, so if you can help adjust the modifiable psychosocial factors (or refer to someone who can) and incorporate some activities for parasympathetic shift, you’ll see pain and sensitivity decrease, opening the window to train.

You can also check out this article that discusses 4 ways you can minimize intensity of an injury, because those tips absolutely apply here too. 

3) Non-specific pain responds to non-specific interventions. Meaning, it’s not necessary to “correct” posture, isolate muscles, or that sort of thing. Graded exposure and graded activity, and hitting all the major buckets (horizontal and vertical pushes and pulls, hinge, squat, and carry -shout out CFSC programming), can provide just as good, if not better, results as specific/”corrective” exercises. Aerobic activity can do wonders as well! This will increase overall capacity (which is always great and needed), along with vagal nerve stimulation which will lower stress responses, and subsequent pain responses. Let the low specificity empower your clients to do more, instead of limit them!

4) Be a team player. Research has shown over and over again, that clients with pain reported greater improvements when there is a better relationship with the therapist/trainer. Positive interactions are associated with increased function, increased perceived treatment effects, decreased pain, and decreased disability. If you can meet the client where they are at, create a positive experience with movement, and gradually progress them from where they are to where they want to go, you’re golden. They are bought in, and trust you, and results will come.

Simple, yes.

Easy? Maybe. 

The key is going to be that the client is bought in. That they feel seen, understood, and safe. You’ll be fighting a losing battle if the focus is always on their pain, what they can’t do, or “fixing” all the things.

So keep it simple. Next time you see that client I asked about earlier, consider these 4 tips, and watch how things shift.

If you want to dive more into these details (and more!), I created a webinar that you can access for free here, and if you want to really take things to the next level, check out how we can work together here!

Megan Pomarensky is a Certified Athletic Therapist, a Certified Functional Strength Coach and a Certified Vinyasa Yoga Instructor with a Master’s Degree in Rehabilitation Science.

Over the past 8 years, Megan has built a successful private clinical practice working with clients from professional athletes looking to improve performance to older adults with chronic pain, and everyone in between. Her mission is to empower every client to better understand their body and make informed decisions about their care.

She also helps athletic therapists, trainers and physiotherapists get out of the textbooks, protocols and checklists for better client results.

IG/Twitter @meganpomarensky