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Hi, it's Tom here from Running Physio. Today I want to talk to you about how to settle symptoms and make progress with people when pain is a significant barrier. Like you, I see lots of people in clinic who pain is really having a big impact on their life and it's making it difficult for them to get back into the things they want to do.

It may be making it difficult for them to actually engage in the rehab process itself. So often we have to try and overcome this barrier of pain initially in order to make progress. I've also included a link today for our free video series. We've got lots of good stuff available for you there, including a great series on shin pain and one on iliotibial band syndrome. So do check those out.

I want to start by saying, honestly, none of us have all the answers for this. If you are struggling with some patients to settle their pain, you will not be alone.

There are no magic fixes that any of us have. So I'm not sitting here in a position with all the answers, but I've given it a good deal of thought, the things that should help that we can try with people.

This isn't just about runners. I think this should be useful for a lot of patients you see in clinic.

First step, you've got a patient coming in with severe symptoms that you're struggling to settle, the first sensible step is to screen for serious pathology.

Make sure there's nothing driving this pain that needs to be assessed in more detail.

Recently I worked with a gentleman who presented with constant unremitting pain. He had very significant past medical history. He wasn't very well in himself. He'd had a lot of weight loss, and he actually had previous history of cancer.

So in that situation, this should be waving a flag for us to think, okay, there could be a serious pathology driving this constant pain that needs to get checked out. And urgent investigations were arranged, which did unfortunately show cancer, but that was able to then be treated. So first step screen for serious pathology here.

In our athletic populations, consider some of those things that can lead to quite severe symptoms like bone stress injuries and stress fractures can lead to quite severe symptoms. Screen for serious pathology in athletic populations. Think about those ones if they're struggling to weight-bear in particular, if they've got weightbearing pain, night pain, that should make us wonder, perhaps there's a stress fracture underlying it.

Step two. If you've got someone whose symptoms are really severe, they're irritable, they're not settling, I would consider an analgesic review. Now, I'm not a prescriber of medication, so I can't recommend medications to patients, but I can suggest they speak to their GP or pharmacist to review the medications that they're on to try and reduce the severity, and irritability of their symptoms if it's just not settling. There are three “S's” here that I sometimes use to guide me to think that pain relief might be a good option to consider. And those would be if pain is Severe, if it's Sustained and if it's disturbing Sleep, because that's gonna have a really big impact on quality of life.

So in a patient in that situation, I'll often say, go to your GP, let's explore some pain relieving options that we can use here to settle symptoms down and allow us to start this rehab process. Often surprises me how many patients will try and tolerate and manage even very severe pain before considering pain relief.

So it's something for us to discuss with them.

The next point, severe pain is often really frightening for patients, and it often has a big impact on their quality of life. So it is really important to discuss the pain with them, to help them understand it, to help recognise that severe pain doesn't of course mean severe damage.

And to give them some idea of the prognosis, how quickly you're expecting it to settle how likely they are to get back into their normal activities. We see this sometimes with severe tendon pain where actually in a flare up it can be very severe. But it does tend to settle once we reduce load to a manageable level.

But that can take a little bit of time. So I'll often, discuss that with patients. We'll put the right things in place, but it may actually be a week, two weeks, maybe even more before you start to notice this really settle. So there needs to be a bit of patience and time with it in that case.

So hopefully we've discussed it with them. We've helped them understand the condition, what things will or help it settle. The next step is gonna be identifying and modifying aggravating factors. It's very hard to settle irritable pain. if we keep doing the things that irritate it. So we had a runner recently, for example, who was finding that after running they were getting ITB pain for two or three days, including night symptoms.

But they were continuing to train and this was just really stirring up the ITB and not allowing it to settle. So when we are going through our aggravating factors, It's worth really trying to explore, what seems to irritate your symptoms, what leads to lasting increases in your pain in particular, and can we look to modify and adapt them?

And sometimes it's worth going a bit deeper and thinking the other way around what would I expect to aggravate this condition? And can I ask them if they're doing a lot of that activity? For example? So we had a patient with irritable proximal hamstring tendinopathy and she was struggling to identify what was aggravating it.

So we started to go through some of the things that will, it's often gonna be prolonged sitting, driving, and something that often stirs it up as if people sit in bed, sits up in bed with her legs straight in front of them. So I asked her if she was tending to do that, and it turns out every night she was doing that for two or three hours reading a book in bed and then being very sore afterwards.

So sometimes it's worth exploring those things and then modifying it. We asked her to cut down that time in the evening and put a couple of pillows under her knees so she's not in a position where that muscle and tendon stretch for such a long period. It's worth really delving into and exploring those aggravating factors to find the ones that keep irritating tissues.

Naturally most cases when we take away the irritation, the tissue will tend to settle. Not all cases, but most if there's a clear aggravating factor, when we reduce it or modify it, things get better.

Next on our list, then, if we've screened for serious pathology, we've looked at pain relief, we've discussed the pain, and we've maybe tried to modify aggravating factors would be looking for self-soothers.

I like to start with what the patient can use themselves to settle pain. because it places them in control. It empowers them to manage rather than, first of all, looking what we can do with our hands-on techniques potentially. And a lot of this stuff is really simple and it's a question of a little bit of trial and error.

Now there is a bit of evidence supporting use of ice or heat so why not use that as a starting point. See if that helps to reduce their symptoms. Can gentle self-massage help as well? Generally, if something's very irritable, we would avoid self-massage over the particularly tender spot.

Let's say you've got someone with very irritable lateral hip pain, don't get them pummeling with a tennis ball over that greater trochanter where we know it's gonna be very sensitive, but work into those muscle muscular points around that area just gently, even just short periods initially to see if it helps to soothe symptom.

Then look to see if there are any particular exercises that will help.

This is where exploring the easing factors can help.

So a gentleman I'm working at the moment with at the moment has quite irritable proximal hamstring tendon pain, but he can walk for five to 10 minutes completely pain free. And that seems to help. So he's going out and doing that two or three times a day.

And that's just based entirely on what he's saying. We might think certain types of exercises like isometrics can have a pain-relieving effect. However, this is very individual specific, so it's a little bit of trial and error to see what people find settles their symptoms.

Also part of this valued activity is very important to show people that they can do the things that they want to do. So try and engage them in valuable activity, which is particularly useful if it's distracting, if it gives them what we call experience of flow, which is they're in involved in that activity and time whizzes by without them realising it, because that can often take them away from their pain if it's strongly distracting, and give them a bit of a break.

For some patients, if they're very irritable with things like low back pain maybe sciatic symptoms, I'll look for rescue positions. And these are just positions they know they can get into that are comfortable and that they can tolerate for a while, even if it's just five, 10 minutes sometimes like crook lying in bed.

So lying on your back with a knee flexed and supported on pillows can be very well tolerated for some patients with lower back pain. So we might say, okay, we don't want you doing this all day, but if you're struggling with your symptoms, take some time out in that position. Listen to some music or an audiobook or a podcast.

Just give yourself a bit of a break from symptoms, and then we'll look at other exercises to keep things moving and ticking along. Now, it might be with some patients, certain footwear, for example, might be useful if they've got foot and ankle pathology orthoses might be an option too. Strategies that can reduce the stress on this very sensitive, irritable tissue.

A runner that I've seen very recently this week, for example, with quite irritable insertion, Achilles pain has found that seeing a podiatrist and getting some insoles with a heel raise in them, combined with a rocker style shoe, has significantly reduced symptoms. So we're looking for these strategies the patient can adopt that aren't really reliant on us too much to help settle their symptoms.

In many cases, we can find things a patient can do to settle their symptoms, but if we can't, I do feel there can be a role for hands-on stuff and it's not very fashionable at the moment, and people on social media may react to this suggestion, but I think if pain is a real barrier to progress for people, It's certainly reasonable to consider if some hands on treatment is going to be safe and effective, but I'd want to test it on an individual basis.

Does it reduce their pain during a known aggravating activity? Let's say someone's got, for example, some lateral hip pain during a squat. If we do some hands-on techniques, does it then reduce their pain during that squat motion or during going from sitting to stand or walking? So we're actually testing to see if it's working for them.

So I think it's reasonable to, to consider things here like some soft tissue work. Especially if the patient's telling you it's helpful for them. Some taping if that seems to reduce their symptoms during aggravating tasks. Possibly acupuncture is another one that divides people. But if a patient is telling you it really helps their symptoms, it may be something to consider as a short-term strategy where pain is a barrier.

There may be a role here for mobilisations, manipulations, those types of things. Again, where safe and appropriate for the patient, particularly where pain is a barrier. I think we all know that of course the research in this area is not particularly strong. But we work with individuals and it's often difficult to capture individual response with research, and I'm sure many of you can think of examples where a patient's really struggled, you put all the right things in place, and then some form of hands-on techniques seems to have made the difference.

So I think it's worth considering if you've got the other things in place.

We often want people to have exercises to go away with. But realistically, if they're, they have pain as a barrier, it's likely that those exercises initially are not gonna achieve rehab goals around developing strength or flexibility or maybe control, because the pain will prevent that from happening.

So when we are looking at exercise prescription for patients in this situation, the first question I have is this tolerable for them. I don't mind if we are looking at very low reps, if it's very unlikely to challenge them in terms of strength. I just want to find what's tolerable. Ideally, I'd like it to reduce pain if possible, but the start point with exercise selection here is what is manageable for the patient.

So this might be two or three exercises done little and often, like two or three times a day. A patient I'm working with at the moment, I've asked them to do just four reps of some exercises they're doing. They're doing some balance work, some shallow range squats and some double leg bridges.

Just four reps. Two or three times a day. Now that's not gonna get them stronger, but we've tested it in the session and we've found that doesn't provoke their symptoms. So we can then see if that's helping them at home. And then if it's tolerable, start to gradually increase those reps.

Once they're up to 10 reps, two or three times a day, then we might take that into a more traditional like Strength session, where we're doing three sets of, 8 to 12 reps .

Then we can start to think about adding loads so we can gradually progress that from what's tolerable towards what will actually have some therapeutic benefit in terms of improving strength or any of your other rehab targets.

Find what's tolerable first and then gradually progress.

That's also true of function. In particular, severe or irritable cases when you know patients unfortunately are likely to flare up with changes in load.

What we want then is to try and create a gradual and consistent return to valued activities. So important.

Sometimes this can mean starting at a really low level, which may be just minutes.

I think that's a reasonable start point if it allows them to do it without a significant flare in symptoms, and then we can just gradually build and build from there.

And it takes time. But you can over time have significant life-changing events.

A particular patient I'm working with at the moment who struggled with sitting and couldn't tolerate any sitting e even for a few minutes initially. But we were able to find that manageable point with her, which was just one minute of sitting initially, and just by gradually and consistently increasing over a period of time, she's been able to build up to sitting for up to seven hours a day.

But there's no magic in it. It's just finding what is manageable and just consistently and continually adding little by little, and then you can actually restore these things to people's lives, and it's so important to do that.

So a few different thoughts there on what may help to settle symptoms when pain is a barrier.

Quite often I think if we can help someone understand their pain, if we can rule out more serious pathology and we can then start to bring in some strategies for them to use to help it settle we can then often bring it down to a manageable level that allows us to progress in terms of function.

But occasionally you can do all these things. You can get everything right in place. You can be confident of the diagnosis and still find that their pain isn't settling. Now, in that situation, I think it can be appropriate if you've got all the right things in place to shift the focus from pain onto function to say that it might just be time that we need for this to settle because we've got everything in place. We would look at something like gradually increasing their activity over time. As you can see on the blue line in this graph. People often think if their pain hasn't changed, they're not getting better, but if they're able to do more without an increase in their pain, as you're seeing in this graph, that is still a significant improvement and often I would expect this kind of red pain line to gradually tail off over time if we've got the right things in place and then we shift the focus onto function and quality of life.

If we come back to that sitting example, we haven't completely removed her pain, but we've given her the chance to get back into an activity that's so fundamental to what we do. It's difficult to eat, to socialise, to travel if you can't sit. So we've brought that back into her life and improved her quality of life.

And it took time before the pain has actually gradually started to subside for that.

Okay, so a few points I hope are gonna be useful for you working with patients where pain is a barrier. As I said, none of us have magic answers here, but I think if you get some of these things in place, the majority of people will find their symptoms settled and that allows them to progress and get back to the things that they want to do.

If you'd like to find out more about injury, particularly running injury, do check out the link that I've posted in the headline. Two are free resources. Lots of great things in there and I look forward to your comments and replies. Thanks for listening. Bye for now.