published 12/20/06

Progressive Training

How to take “baby steps” to recovery from an injury or pain problem

by Paul Ingraham, Vancouver, Canada MORE

Credentials and qualifications

I am a writer and retired Registered Massage Therapist (unusually well-trained for a massage therapist, a 3000-hour program). I’m almost done with a Bachelor of Health Sciences degree. I am a peer reviewer for The Natural Standard, and a copyeditor for Science-Based Medicine. My most important qualification is more than a decade of workaholic post-graduate study, clinical experience, and constant conversations with readers from around the world, including many experts who have provided countless suggestions and criticisms.

For more information, see: Who Am I to Say? More information about my qualifications, credentials and professional experiences for my readers and customers.

Every injury or pain problem is a challenge — and challenges are met by breaking them up into smaller, more manageable steps. This is sometimes called “progressive training” by coaches, trainers, physiotherapists and sports medicine doctors.

All serious athletes train progressively because it’s just the only way to get the job done. The principle is the same whether you are fit and working towards an athletic goal, or injured or sick and simply trying to get back to normal. It’s as powerful an idea as it is a simple one.

All serious athletes train progressively because it’s just the only way to get the job done.

This article discusses a variety of examples of how to apply the principal of progressive training in rehabilitation. This article is not just for people dealing with sports injuries — the concepts are equally applicable to trying to recover from low back pain or fibromyalgia. All healing requires you to take “baby steps.”

Progression of exercise intensity

Casual athletes often fail to heal because they try to get back into the game too quickly. They rest only when forced to, and return to their sport at nearly full intensity without any transitional, compromise activity. They have two settings: “reluctantly taking it easy” and “full on.” I am always a little amused when a soccer player who’s torn a hamstring take two weeks off and then goes and tries to play another game to “test it out.” That usually doesn’t go very well …

Casual athletes have just two intensities: “reluctantly taking it easy” and “full on.”

People who are not athletic in the first place often fail to get the exercise they need because the first step seems like a doozy. But it is not necessary — or wise — to try to create an exercise habit by starting with the kinds of things that athletic people are doing. If you’re not fit yet, why would you do an activity that requires fitness? Start with something easier! One of my clients offered me a really great suggestion:

I found it impossible to go to the gym at first. It was just too much. It was bad enough getting motivated to leave the house, and the idea of actually suffering and sweating when I got to the gym was unbearable. So I decided to start just with the challenge of showing up, just to get in the habit of being there, and I would worry about actually challenging myself with exercise later. So I started going to the gym just to get to do something really, really easy, like walking on the treadmill for twenty minutes. Before long, going the the gym every Saturday morning was routine, and once that was established it was a lot easier to actually start exercising while I was there!
anonymous client

I really like the mental picture of going to the gym … and not really doing much. Just showing up, mostly! I could do that …

Divide your exercise intensity into several stages. First of all, be sure to rest adequately. The concept of “relative” rest is often useful: take a break from activities that are a problem, but continue with activities that are not a problem. See The Art of Rest for more about how to rest.

Total rest is rarely wise. Even in the earliest stages of healing, it is important to do whatever you can: use it or lose it! PF-ROM Exercises are a perfect, often neglected, early rehabilitation exercise. Mobilizing! are the next step: just slightly more intense, but still extremely easy. These are often the “missing pieces” that people try to skip past. Many people struggling with chronic pain need to do PF-ROM or mobilization exercises for a while before moving on.

Pain free range of motion exercises and mobilizations are often the “missing pieces” that people try to skip past.

Divide muscular training into endurance training and strength training (see Endurance Training for Injury Rehabilitation and Strength Training and Injury Rehabilitation). It’s amazing how often people (especially guys) try to go straight to the intensity of strength training. One step at a time! Gentler, more repetitive endurance training is a perfectly respectable way to prepare for the “high load, low reps” of strength training.

For athletes who play competitive sports, please remember that it’s usually a pretty big step up to competition. Test yourself hard with drills or light competition with friendly players, before testing yourself against “enemy” players — it’s amazing how an injury that was fine in practice can flare up handily twenty minutes into a game!

A helping hand

One of the simplest ways of making recovery easier is to make a painful movement easier by assisting it with another body part, or with some physical contrivance.

Consider the example of a common shoulder problem, supraspinatus tendinitis. In this irritating condition, which often becomes chronic and is routinely complicated by long-lasting trigger points (muscle knots), it can become extremely painful to abduct the shoulder (lifting the arm out to the side).

So help it!

By simply reaching across and lifting the bad arm with the good one, the movement can be made possible again. Even just a 10% boost can make it possible to start practicing the movement with much less pain.

Even just a 10% boost can make all the difference.

Another classic therapeutic exercise for this condition simply uses a nearby wall — by “crawling” up the wall with the fingers, the shoulder is slowly abducted without much strain.

There are many creative ways to assist movements. You can use walls, door frames, furniture, pillows, clothing, yoga blocks and straps, and on and on. Here are three more examples:

If you have a crick in the neck, it can be extremely painful to turn your head from side to side when upright and activating all of your postural musculature. Yet if you lie down, rolling your head side to side is relatively easy and painless!
In a painful low back, the muscles tend to cramp when the spine is in extension (hollow low back), which can make it almost impossible to lie face down. So make it easier: lie face down with a thin pillow under your belly, to achieve a supported, intermediate position.
Got an injury that is aggravated by bearing weight? Get into a pool! Water training makes all kinds of painful activities easier.

First things first

Life is messy. People often struggle with rehabilitation not because rehabilitation itself is so very difficult, but because life is too chaotic. In fact, this is probably the case for the majority of people who have chronic pain.

Life is messy!

For instance, perhaps you know that you need to get some exercise, but you can’t do it because you are severely fatigued from a lack of sleep. You can’t sleep because your partner snores and you don’t have a spare bedroom, and because you have this problem at work that has you waking up at 4am every night worrying anyway. And yet there is no solving either the snoring or the work thing without still more basic problem solving.

Unravelling knots like this is an important part of progression in rehabilitation. Just as with the process of rehabilitation itself, you have to break the challenge down into small, achievable steps.

Pacing

Many a thing that can’t be done quickly can be done slowly.

If you can’t stoop over quickly without pain, then don’t stoop over quickly — stoop over slowly, for now. Too many patients feel defeated when they can only perform an action or activity slowly. It’s not defeat — it’s an intermediate step!

Being forced by pain to do something slowly is not defeat — it’s an intermediate step!

Micro goals

Sometimes it pays to break a challenge up into really small steps: so small you don’t even notice them.

Consider the case of someone who is in severe chronic pain, and finds everything exhausting, and yet badly needs to start getting some light exercise as a first step towards healing. This person may feel so fatigued that even twenty minutes of walking wipes her out and ruins the rest of the day. People in this position often feel helpless, as though there is no exercise easy enough that they can start it.

People sometimes feel as though there is no exercise easy enough.

I would advise this person to get a timer, and start doing three extremely short “walks” a day, each exactly five minutes long. Every day, she should add thirty seconds to each walk. Just thirty seconds!

For contrast, consider a much healthier person: a marathoner with a double-whammy of iliotibial band syndrome and shin splints, two common and frustrating injuries. This person is extremely fit in general, but faces a difficult challenge nevertheless. Having gone through the early stages of rehab, it is absolutely crucial to get back into running slowly, or both injuries will probably come roaring back.

I would advise this runner to get a timer, and start doing three extremely short “runs” a day, each exactly five minutes long. Every day, he should add thirty seconds to each run. Just thirty seconds!

Baby steps …

Be creative, and good luck!