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Breaking the Cycle of Fear

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The patient says to the doctor: “Doc, it hurts when I do this!” So the doctor nods her head sagely and replies, “Don’t do that.”

You’ve heard that one before? Well, funny or not, there is a flaw in that medical advice that remains counterintuitive to most. As a medical exercise specialist, the pain/fear avoidance model walks through my door just about every day in one form or another. Let me explain:

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When it comes to movement and exercise, we have three typical responses to pain.

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One: We fear the pain, so we avoid the activity that causes the pain—and we ultimately sink into disability and depression.

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Two: We mask the pain with pills, so we create unnecessary damage—and we ultimately sink into disability and depression.

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Three: We do not fear the pain, so we are able to listen to it and figure out exactly what it is telling us to do next—and we recover and get on with our active lives.

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For example, A few years ago Betty developed what she self-diagnosed as severe hip pain. It hurt when she did certain activities, so she stopped doing them. Then she tried doing other activities, but that hurt too, so she stopped doing them as well. Then she just stopped.

Fast forward—actually slow, painful forward—three years. Betty is now in constant pain and much heavier than when it started. When she comes to my fitness center we discover that her hip pain is not actually hip pain at all. Hip pain typically presents itself in one of three ways: in the butt and low back (posterior), on the side (lateral), or in the front (anterior).

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Anterior hip pain is referred to as “true” hip pain. Betty’s pain is presenting on the side; her foot is turned out (rotated externally) and her knee is caved in toward her midline (valgus collapse). What that means is that Betty is actually suffering from a wicked—and common—case of IT Band Friction Syndrome. When the iliotibial band (a stubborn strip of fascia that runs from the ilium down the side of the leg to the tibia on the outside of the knee) is overly tight or aggravated, it pulls structures out of alignment, inhibits muscle function, and hurts like hell.

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I explain all this to Betty. Then, with Betty seated on medically specialized exercise machines, I cue her to rotate her foot into a vertical position. This makes her knee cave in more, so we identify that. She then makes the conscious decision to align her knee directly over her foot. As she goes through her various exercises and activities, she is vigilant to maintain this new orientation, to reinforce this “new” pattern. After two sessions Betty calls me, slightly frantic. “I just got out of a chair without pain for the first time in three years! Is that even possible?”

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Another example is Ann, who called recently for an exercise orientation. When she arrived I recognized her: She had come in two years earlier, had one session, and never came back. She explained that the recumbent bicycle made her arthritic knees hurt, so she stopped—doing anything. In those two years, she had lost weight, specifically muscle weight from disuse and atrophy.

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She had also lost function, and what little muscular support she had for her arthritic knees had diminished. So her pain had increased. I explained this vicious cycle to her and we talked at length about the pain/fear-avoidance model. She got it. She worked through her pain on the machines and is doing just fine now. Better than fine: her strength and function are vastly improved and her pain is now gone.  By:  Andy Baxter

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