Episode 70: Stop the Setbacks: PT Tools to Handle Flare-Ups & Get Moving Again

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• Joe Gambino
• Joe LaVacca

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Summary

In this episode of the Beyond Pain podcast, hosts Joe Gambino and Joe LaVacca delve into the complexities of flare-ups and the psychological barriers that can hinder recovery, such as kinesiophobia. 

They discuss the importance of managing expectations during pain and recovery, building confidence in movement, and practical strategies for navigating flare-ups. 

The conversation emphasizes the need to view pain as information that can guide recovery rather than something to fear, encouraging listeners to keep moving forward and break the cycle of pain.

Takeaways

• Flare-ups can create a fear of movement, known as kinesiophobia.
• Managing expectations is crucial for recovery from pain.
• Pain should be viewed as information, not something to fear.
• Building confidence in movement is essential for recovery.
• It's important to keep moving forward despite pain.
• Taking a break from certain activities can aid recovery.
• Using pain as a guide can help in making recovery decisions.
• Expect some pain during recovery, but don't let it stop you.
• Practical strategies can help navigate flare-ups effectively.
• Confidence in movement can improve quality of life.

Transcript

Joe Gambino (00:43)
Welcome back in to the Beyond Pain podcast. I am one of your hosts Joe Gambino and I'm here with our other host Joe LaVacca You can find us on Instagram at Joe Gambino DPT for myself and at strength in motion underscore PT for Lavaca over there. This podcast is on Instagram Beyond Pain podcast and on YouTube cups of Joe underscore PT and there we have it. Welcome back into the show. and if you have

five seconds of time this podcast could use some reviews or really help out the show. Get this podcast in front of one more person who could hopefully help. So please, if you are kind enough, drop us that review. Joe, welcome back.

Joe LaVacca (01:20)
And you could be

just the people listening. You could be that one person. The tipping point, if you will. So that's a real thing, the tipping point. Have you ever read that book? No, it's a good one. It's a good one. Easy read to all the Malcolm Gladwell series was fun and entertaining. But there's been something on my mind that I wanted to bring up right away and get it over with. Are you nervous this weekend?

Joe Gambino (01:31)
I am not.

Mm-hmm.

Joe LaVacca (01:45)
that the San Diego Chargers are playing the New York Giants.

Joe Gambino (01:45)
Hahaha

So I currently right now, I'm in a survivor pool and I have the Chargers as my pick for this week.

I don't know about it. I think this game is going to be closer than people may think. So I don't know if I'm going to keep it. I actually am a little nervous because this can be a big trap game. And then just something about the Chargers. mean, this Harbaugh era is seeming very different. it just seems almost unimaginable being a Charger fan for this long that we could start a season for now.

Joe LaVacca (02:19)
Yeah, I think that I understand your lack of wanting to be enthused and optimistic. I probably would feel the same way when the Giants start to put it back together and just ready to have my heart broken. I do think the Survivor Pool though, it's an interesting pick because you you got Dardy starting his career. The defense on the San Diego Chargers has been doing quite well.

Joe Gambino (02:20)
You

Mm-hmm.

We've been good.

We've been very good.

Joe LaVacca (02:46)
I think you have nothing to worry about. And I think that the Giants have a very realistic chance of going 1 and 16 or 2 and 15 this year.

Joe Gambino (02:57)
It would

probably be best for you guys to go that route anyway, because you guys have a lot of young talent that could be really, you guys have a bright future, think. But I don't know, man, there's something with changes that happen in the middle of the season that, I mean, it's a new, obviously a young rookie quarterback. It can go very poorly for him. I mean, we see with like Cam Ward and stuff like that, where it's just like not a good transition. It's a really good defensive start, but sometimes it's just like a spark.

And who knows, anytime, I think any football game can go in any different direction. I the odds are good that the Chargers will win, but I don't know, I think it's gonna be tighter than you may think and a lot of people think.

Joe LaVacca (03:36)
Well, I mean, I don't know what to think about obviously Dart yet. We'll start to get a sample size on him a little bit. But I also don't think it matters because the unrealistic aspect of this is that he rips off eight straight wins, saves Dable's job, saves Joe Shane, the GM's job. That's not really going to happen.

Joe Gambino (03:56)
No,

but the first game there could be a little jump kick, you know? It's like sparking the battery that's already dying and then know the battery, you just have to keep sparking it and if you don't have another spark you're not gonna get it back.

Joe LaVacca (04:00)
Maybe, maybe, but I also think...

Right, but when. But when you

go to at 15 and then you're going to have like the top one or two picks again, there's going to be a new coach. There's going to be a new GM who's going to want to pick their guy, their quarterback, and this quarterback class is much better than last year. So I really just think that Dart the best thing he could do for himself. Keep his composure, play relatively well, hope he gets traded next year or in the years coming.

Joe Gambino (04:15)
Yeah.

now.

If he plays well, that's

not gonna happen. If he shows really good signs, yeah, but if you're coming into something and he does show out and there's a lot of promise you're probably gonna try to bolster, there's other areas of that team that need a whole lot of help. yeah, yeah, yeah, yeah. So we'll see. mean, you guys look good. mean, I think there's lot of excitement around the Giants for a change.

Joe LaVacca (04:38)
I don't know, man. I just think that all these coaches and GMs always want to just...

you mean everything. All the other areas.

Yeah, maybe. I think it's anxiety, but excitement is also a word there, my friend. If the Giants were a little bit of a better team, I'd say we could put a friendly wager on this, but I'm not comfortable doing that because I think that you're absolutely going to decimate ⁓ us this weekend.

Joe Gambino (05:03)
So I'll see what happens.

No, All right. I was just

going to offer, you know, like a little small $5 bet. but, but smart better, smart better. But give me a moment today. All right. Yeah. So today we were talking about flare ups, things that, you know, just in general, think talking about flare ups is a good one, but specifically around the mindset of being fearful that a flare up is going to happen. And then having that kind of

Joe LaVacca (05:20)
I'll Venmo you. Yeah. All right. What are we talking about today, my friend?

Joe Gambino (05:43)
Rob, you may be the wrong word, but you know, maybe keep you or hold you back from doing the things you want to do because you're more worried about the flare up happening as opposed to enjoying the activities or so to speak. So thoughts on that, Joe? Anything off the top of your mind that you kind of want to lean into here?

Joe LaVacca (06:00)
Well, off the top of my head, think it, I'm just quickly reminded of our conversation with Steph Allen last week. And we sort of brought this up with her and her return to sport with her athletes and this idea of kinesiophobia or the fear of movement, apprehension going back to their sport. All of these things are going to change the way you behave in an environment or with a movement.

Joe Gambino (06:13)
Hmm.

Joe LaVacca (06:30)
And now more recency bias. had a virtual client right before we jumped on this call and she's been dealing with some sciatica like pain over the last four weeks has been doing better week to week, relatively pain free right now. So we were in a really good place with her, but yet the one thing she wanted to talk about today to start the call was her X-ray and you know, she had put it into chat, GBT to get advice and her physiatrist.

knew that the x-ray was the best attempt to get her an MRI and all of these different things. But yet, when you're starting to look at these images or any other test that a client can go through, whether it's a blood test or anything else, I think it sort of takes too much precedence over how people are just simply feeling. And time and time again, when someone has, we'll stick with x-rays or MRIs,

Joe Gambino (07:18)
Mm.

Joe LaVacca (07:24)
Their thought is, don't want to make this thing I see, whether it's arthritis or herniation or a mild tear, worse. So that fear of the pain coming back, as we're saying, the fear of reinjury changes the way they've been behaving for X amount of years. And again, I always compare a lot of the things we talk about here to the things

with life. If you have a bad day at work, you don't go to your boss's office and quit your job, right? Typically, unless it's a really bad day. I get it. But there's going to be ups and downs in your professional life. There's going to be ups and downs in our parenting life. I have a fight with Avery yesterday. It's not like I'm taking her to child services and dropping her off at the door because, I don't want to do this anymore. So I think you need to roll with these ups and downs.

Joe Gambino (08:02)
Mm.

Joe LaVacca (08:24)
make tiny pivots or adjustments, that's okay. But I feel more often, and I'd love for you to chime in here with this, is that people come back with this fear and they almost start to decondition themselves by going lighter or not getting back to squats or deadlifts or running even, right? We can name a million activities. So this protection, which I understand,

turns into almost a deconditioning. And is that something that you find too? And if so, how do you navigate it?

Joe Gambino (09:00)
Yeah, I think the D, mean, yes, there's a component of deconditioning, but I also think that when somebody has this fear, this apprehension of movement, there's, you know, the history has told them when I do X, it becomes painful, it becomes really painful. So therefore I can't do these things. It's kind of like a negative feedback loop that can keep the pain cycle elevated. So I think when you're combining all these things, that it becomes, it can become very hard to.

get out of that cycle in a sense, because when you do something, and one of my thoughts as you were talking is kind of expectations. I have somebody now that I'm working with that I'm thinking about as we're talking about this conversation where he's had pain for very, very long time. He's seen a whole lot of different people. was, you know, honestly for him to even sign on with me was like a huge like jump, you know, for him.

And he told me we had a conversation two days ago because we're navigating a flare up that he's in right now. And he said that the biggest thing for him right now has been like the support to continue to go every time it happens. So I think that's kind of, think it's something important for someone to hear when you have pain. mean, keeps happening. You need to keep moving forward, right? Because they're,

can be a way out. Maybe the expectation needs to be that there will be some pain there, that you're just never gonna be 100 % pain free, but once you give yourself permission to move, we can get you to a point where you can do more with your pain being less, and I think that improves quality of life. But the other thing is expectations. If you're expecting, like for this particular person, he was on his way out of a flare-up, like he had a flare-up, we were...

trending in the right direction, all the things were really positive. And then he played soccer for a little while with his kid. And then it kind of like set him off a little bit. And it's been like, I don't know, maybe like a week or so. And he's already coming out of that. But he was like, I only like did this for like 10 minutes. And I'm like, well, you're just coming out of a flare up. You know, we already kind of know that higher level activities are kind of like an irritant for you.

So it makes sense that this can happen. So I think part of it is expectation management. If you're expecting that, this really isn't much for me to do, and then it flares you up, I think that brings your own alarm system higher. Like, oh my God, I can't even do this, right? And then all of a sudden that sets you, you're motivating, it's harder, those things can bring up a pain response. So I think that when someone is dealing with pain and there is this deconditioning, there's this, you can't do too much.

before your pain responses come on, I think you need to set your expectations to where those things are. then how can you start to, again, I mean, we've talked about that. We were just talking about how that episode of building the bigger bucket was one of our most listened to ones. And I think we kind of go back to those concepts of, how can we start to challenge you at a point that maybe it brings up your symptoms a little bit. It may seem like really not that much work to you or that much activity, but it's enough to.

maybe drive a little bit of pain that doesn't linger around and really starts to allow us to kind of bolster up that deep conditioning and push you to that next level, allow you to do a little bit more, even if there is some pain. I think this kind of even goes back to that conversation of how do we build a bigger bucket? How do we start to bring down pain? And then how do we start to really get somebody back to activities?

Joe LaVacca (12:24)
Yeah, I love the expectation piece because with something like soccer, you can be playing for 60 or 90 minutes, right? If you go through a full match or depending on how they're organizing halfs, if it's a rec league or practice. So was the expectation going in, I'm going to be able to do this whole entire practice or was the expectation going in doubt. So I'd like to know what was his confidence level going into that activity.

Joe Gambino (12:47)
Okay.

I think for this

case, because he was like five, 10 minutes just playing with his son, like in the driveway, his confidence level was high, like, I can do this, problem. So the pain afterwards was like a shock then, you know, and we had to kind of reframe things and say, okay, well, look at, mean, the recovery is already happening. We're already almost out of this flare up by the time we've been having a conversation together, you know, on a call.

And you you're just coming out of a flare up and his symptoms are somewhat changed. It's not even like the old symptoms that are happening. It's kind of like a more centralized low back pain. And now it like he was having a lot like sciatica type pain down the back of this leg. And now he has a little bit like going to the front of his leg and like adductor sensitivity. So it's like switched a little bit. So maybe it's like a newer issue or something that wasn't reflected before that that's popping up now because maybe he is moving differently because things were feeling better.

So it's just an interesting so we had to like reefing of expectations and kind of go through things and talk about you know, hey this stuff You know, I can I can see that this being a range of outcomes based on where we were what you were doing And our journey so you know at the end of the he felt more confident into the call, which is You know what what I was hoping for at that point

Joe LaVacca (14:05)
Totally. And I think shifting that perception on even training. And I had another conversation with someone that I was training this week and I was laughing because I told him that he wrote me this email because he wasn't really connecting with some power work that I had given him and a few others this month. So we had given him some kettlebell swings and some broad jumps, right? Just to mix and match.

not going heavy all the time or just breaking up some traditional bodybuilding things. Power is a very specific quality, right, that we want to get people to be comfortable with. What we've seen now is that more and more data is telling us losing power as you and I age or our clients age is probably the number one predictor of longevity and maybe just being able to do the things you want to do as you get older. So.

Joe Gambino (14:38)
Hmm.

Yep.

Joe LaVacca (14:57)
As I'm reading more and more on that, always trying to shy these programs. But for some people who just want to like lift and grind or don't see the value in moving faster, moving weight, lighter weight a little bit heavy, a little bit quicker. He writes me this email and he's like, I just don't get this. He's like, this doesn't seem like it works for me. ⁓ But maybe I'm just not connecting with it. You know, what's the point of all this? And for him and a few others with back pain and

Joe Gambino (15:07)
Mm-hmm.

You

Joe LaVacca (15:23)
nerve-like symptoms, you sort of have to explain, hey, we're kind of always starting our rehab process in this slow, progressive manner. And that's why isometrics work. I can put you in any position that feels safe and have you push into a wall or push into a weight, and you can control that. And it's almost like we're in this lab, and every variable or as many variables as we can account are controlled. But then realistically,

Joe Gambino (15:49)
Mm.

Joe LaVacca (15:51)
you're probably going to feel better faster than I can program for you or faster than a lot of your tissues are truly adapting at getting stronger or more robust, right? Cause pain we know is very perceptual. So what does this, even though it was short five or 10 minutes of playing with your son with soccer, well, you were probably moving quicker. You probably added a couple of jumps. What your nervous system should do at that point.

Joe Gambino (16:12)
Hmm.

Joe LaVacca (16:21)
is protect you. Hey, Joe's moving too fast. We've been used to the slow mobilization stuff. We've been used to the slow tempo deadlifts. We've been used to the slow squats. We've been used to just kind of compartmentalizing efforts, maybe even for just 30 or 60 seconds. So that's what I actually tell clients is that your five or 10 minutes of continuous movement was actually about a thousand percent more

than what you were doing in the gym at any one time. So that is even a progression that one set takes you 30 or 60 seconds. You were able to run around for five, 10, 15 minutes. That's a progression. And now we maybe know where to start to streamline some things. Cause now you just reset, right, our ceiling. So maybe your next week's program isn't, you know, A1 and

Joe Gambino (17:03)
Mm-hmm.

Joe LaVacca (17:16)
A2 and A3 and taking time in between, but maybe it's an every minute on the minute or an MRAP or as many rounds as possible sort of thing for 12 minutes. We're just going to keep you moving. We're going to just get your body used to transitioning from movement to movement and then sort of go from there. And I found not always successful, of course, because like we've talked about, people always reflect backwards onto who they were.

Joe Gambino (17:26)
Mm-hmm.

Joe LaVacca (17:43)
I think during the rehab process, rather than trying to focus on the here and now or what they can be. And that's why I always never loved rehab because I think it gave people this idea that you're going to go backwards to who you were rather than forward to who you can become. And I think that's what also kind of keeps us and our profession sort of like battling, like which way to actually go. know, I know you want to be able to run again.

Joe Gambino (17:59)
Hmm.

Joe LaVacca (18:10)
But I actually really don't know anything about you and how you're going to respond. don't even know if running is realistic. mean, big data points tells me it is, or going back to soccer tells me it is, but in the event it isn't, then I probably got to do a better job coaching you on what you can control, what new identities can you bring to the table. But we'll save that for another episode. We'll just stick with the flair right now. But what do you think about that idea of, you know, sort of encapsulating you move for 10 or 15 straight minutes?

Joe Gambino (18:29)
Yeah.

Joe LaVacca (18:38)
And then we can try to like reprogram that for you next week as we start doing AMRAPs or EMOMs. You know, these are just like little things that I typically resort to, but I always value your opinion as a strength coach too.

Joe Gambino (18:50)
Yeah, I like doing one concept that I like, from like density training is the concept. you have your circuits built out. Maybe it's A1, A2, A3, then you have a B1, B2, B3, but then each one of those supersets or whatever we want to call it is done in a timed fashion. So maybe your A circuit is 10 minutes of work and your B circuit is 15 minutes of work and then your C circuit is

another 15 minutes of work and then you have a D circuit that's like 10 minutes of work and I've reached it close to an hour. And then the whole concept of that is can you do either more volume or more intensity within each session? Because then what that just tells us is that because strength is sure you can do it as like I deadlift at 200 pounds and the next week I do 205 and the next week I do 210, but strength can also be I did 210 for three sets and then four sets and then five sets, right? And that would be more of a volume.

Consideration so I think those are those are good things to start to do I will do a lot of time circuits as things start to progress Just to you know, so hey listen it kind of gives people a Hey, I give you ten reps. Well, maybe that takes somebody 30 seconds to do but if I give you 60 seconds to do maybe you still only do ten reps now the time of the tension is different or you end up doing 20 reps and

Or sometimes a lot of people will fatigue out like 40 seconds like, wow, I couldn't even do this for 60 seconds. And now we can start to build work capacity and say, okay, well let's stay with that same way to see each week if we can add five more seconds. And then by the end of the block be as close to 60 seconds as possible. So I think those are all fun ways to start to challenge things differently versus just a traditional rep model. I think there are other ways that you can kind of look at.

how we're building strength and volume and even power any sort of quality that we're looking at and start to change even power where you can just be like, okay, well, you're gonna do it for 20 seconds and then you're either gonna make it to 20 seconds or you're gonna stop when the velocity or the speed starts to slow down. Maybe you make it to 20 seconds, maybe you don't, but there's another way to start to think about it, because at that 20 second mark, you're probably gonna start to see a pretty big drop-off in power if you are actually working at like a really high intensity for it.

Joe LaVacca (21:09)
Yeah. And I think, I think what we're both sort of getting at comes back to the point you made before is when these things happen and they always will, we have to, with our clients, help them realize they're still moving forward. And that's the whole tagline at Strength in Motion. It's move yourself forward. Keep going in this direction rather than backtrack. And I know that's hard. That's a learned skill. Some people can do it.

A lot of people can't and, or a lot of people just can't do it. when they're with me, and if I'm the first person you're seeing for your persistent pain or the second person, well, you might need to see four or five other providers and get the same message before it actually rings true. And I think that's what's so valuable about, you know, us talking about this, us meeting like-minded people, us bringing on guests, because we're seeing people share a similar message and we're hoping that that message gets out more and more.

And still for so many, they do still feel stuck or they feel defeated. And that client today, who even though she was feeling better, had minimal to no pain, still had an appointment with a vasiatrist last week. And as she was telling him the story, yeah, this is what happened. You know, I was in, you know, nine out of 10 pain. couldn't move for a few days.

But now it's been about four weeks. I've been doing PT. We've been just sort of like grading things. I feel pretty good. I still have some weird numbness in my leg. Everything else became dismissed on progress. It was, well, let's get an x-ray because we're going to need an MRI just based on your symptoms. Then for me to give you an injection, I'm going to need the MRI to know like where to inject quote unquote, even though

Recently, we've seen that injections are mostly bullshit. So it's really interesting because even though you have a client sitting there basically saying, just want to know my next steps, you still have doctors trying to push you backwards. Well, hold on, let's go get an x-ray. Let's go see what was happening in there. Let's try to trace back where you were inflamed. And it was like, dude, I keep myself healthy. I work out for a reason. I eat well for a reason. I don't smoke. I don't drink for a reason. So I have the ability to heal.

Now, I just want to make sure that I'm not going to do any more damage. And then this brings me back to that point I was making before, was when we can capture people, I like to start with this idea of maybe more RPE than true reps and reserve, because I do think that there is something a little bit scary going back to your movements or to your sport.

That is a cognitive load on your body, right? No matter what, you're probably going to change the way you're deadlifting. You're probably going to change the way you're running. You're going to play the change the way you play soccer. And that's an effort that you're going to have to cope with. So even that might start you off at a five out of 10 effort, like just getting on the field. And then you start doing some light running and you're like, okay, this is a six or seven for me. Well, cool. That's all I, that's where I want you to stay. And then we can always progressively load your effort a little bit more, but.

So many times I see people stuck in that mindset of, I can't go back, I can't do this, I gotta go lighter. And then they see this pattern of occurrence happen more more frequently because they're just not even getting back to their prior level of conditioning or strength, even though that's their goal.

Joe Gambino (24:25)
there's two things that I found that should be touched based on one more time here.

Moving forward, think that's a huge one. think anyone dealing with flare-ups is trying to figure out what that step is to help you move forward. And that's one reason why in the environment that am now, I always, as long as applicable, which is like 90 % of the time, is add the fitness component right off the bat along with the rehab component. Because once we do that, there's always something that you can do that's going to be.

that's not going to really flare you up that can help start to build that confidence, help you feel like you are moving forward along with here's the stuff that we need to do to start to bring down pain, improve your movement, to improve all the qualities that's going to allow us to ramp that up more and more over the course of time. So I think finding that way, the talking about moving forward is a really strong thing. And I think that's where people in flare ups should start to be figuring out is how do I take that step to move forward versus feeling like I'm stuck.

or I'm scared to do something. The other thing you mentioned was talking about using rating of perceived exertion when you're trying to get into things. And I actually use rating of perceived symptom more so as like, you know, it's like, it's a subset of RPE to me. But I'll use, instead of saying rating of perceived exertion, like I want you to stay at seven or eight or six and just give you like a number to kind of stick at. We'll find out what...

Joe LaVacca (25:33)
Mmm.

Joe Gambino (25:47)
intensity, maybe it's an RPF-5, you're okay, you bump it up to an RPF-6 and all of your symptoms happen. So now we can use that scale. Okay, well an RPF-6 is not very hard to you, but when we look at from a pain perspective or tissue loading perspective, we've now hit a sweet spot, right? It's a two level discomfort. It fits all of our pain guidelines for acceptable pain. Well, now we know we're not going to change this program. We're going to keep it exactly as is. We're going to make sure you have some time to recover in between.

but we want to keep stimulating that RP of six so that we can recalibrate that pain scale. We can start to help you feel like build more confidence and we can help those tissues just better acclimate to these loads. And then all of a sudden now when RP of six is like, Hey, I'm not really feeling anything after these. Like I'm feeling good. Well, then we bump it up to RP of seven or maybe we add in a new movement or whatever it is to get that going. Then we find your new writing of perceived symptoms.

to work on. We can kind of keep balancing this out until we get you to a point where you're back to a higher level of performance. But I think this is one way that we can really start to figure out how to help somebody to become more confident in movement, help bring down pain. And even if pain is still there, if we did this, you started and you always had like a two level pain and an RP of five, and then two months later you're doing that at an RP of eight, well think about how that's going to change someone's quality of life. When if you can now

work out pretty hard, have one or two reps left in the tank when I'm doing an exercise and feel pretty good. Well then when they're going grocery shopping or doing stairs or up to New York when you don't have central air, the luxury that I have here of central air, have to install your own ACs, right? Like you can start doing stuff like that without feeling, or go play with your kids or go play for a round of golf, whatever that looks like for somebody.

Joe LaVacca (27:16)
Yeah.

Joe Gambino (27:35)
All of sudden now you have the confidence to that because I know I can push my body and then I know the response is just going to be a little bit of pain. And then I know based on all this stuff that the recovery time is just going to be two days or whatever it is. And now it's predictable versus before it's unpredictable. It's I do this. I think I could do this. I'm cleared up. It lasts for a week or whatever lasts for that person. And now they're in the cycle of I'm not sure. So I think, you know, this kind of route does all.

a lot of things for people, right? It's A, confidence building, it's A, teaching you how to load better, but I think it also gives you this sense of control, in a sense, because it's a predictable pattern of pain, and sometimes it's gonna go out of that, and I think expectations going back to that, that you're gonna fall outside of that as you push your body more, there's more of a chance for these flare ups to happen, but I think when all these things come together, it really helps somebody be a little bit more, helps them navigate this journey better, in my opinion.

Joe LaVacca (28:28)
Yeah. Yeah. I think my last thing that's on my mind right now, again, comes back to something you just said and that word control. And I think another thing that helps people during a flare, especially when it comes to training or programming is very simply, most programs are built the same way. It's squat, it's hinge, it's a push, it's a pull, it's a carry, right? There's elements that we would

want to program for people. And if people are used to exercising or strength training or going to CrossFit, they're used to seeing programs a certain way as well. Like, well, I need to do this. I need to do that. I need to make sure that the ratios are this way and that way and the other way. And sometimes the greatest gift you can give yourself when you're in a flare or coming back from it is just get rid of that activity.

Joe Gambino (29:09)
Mm-hmm.

Joe LaVacca (29:20)
Just take a break from it for six to eight weeks because then guess what? You just double down on squats. You double down on rowing instead of pushing or vice versa. But you're still going back to the gym and the things that you want to do and you're just focusing on the things that really bring you joy. And I had two instances of that. last, well, one this week and one client I've been working with over the last couple of months.

Joe Gambino (29:38)
Mm.

Joe LaVacca (29:46)
He's had a tough journey starting with a hernia that led to back pain and then he's back and forth and back and forth. We've crossed paths I want to say in July. And one of his like biggest things was just like, hey, I can't walk, I can't sit. You know, I haven't been back to the gym. And like we've talked about, I was like, well, you know, maybe we can just do five minute walks.

Right? You can walk on a treadmill, you can incline it, you can hold on to the handrails, like all these different things. But no matter what, for a few weeks, no matter how much advice I gave him on these micro dosing, changing your stride, walking backwards, it was like almost every single time we'd be in a flare. So I said to him, what other modes of exercise do you have available to you? Because he was going to a nice gym over here and he mentioned how the gym had a pool.

And he used to love swimming. And I was like, great. You know what? I don't even want you to touch a treadmill. I only want you to walk when you absolutely have to, right? Around your house, getting to work, coming home from work, whatever. But we're not walking for exercise anymore. We're done. You're just going to swim when you can swim. And then the last two weeks, the dramatic impact of just him not having to go and force a movement that yes is important and we'll get there, but just lifting that weight for him and saying, dude,

Don't even worry about this right now. Go swim. Dramatic improvement in the sitting. now all of a sudden you can play with this kid a little bit more. now all of a sudden he realized that he did walk more because he just, again, it took off that burden from him. And one girl this week who's a CrossFitter who started getting some shin and heel pain, sort of confusing on what she was actually diagnosed with. Was it a stress reaction? Was it a plantar fascia tear? Which one was causing more pain? But regardless, someone who I've known,

in years past, very fit, very active. And then when you ask her, hey, well, what's your lower body programming look like right now? And she was like, I'm not doing any lower body programming for like the last six months. I've just been doing upper body and core because anytime I felt like a little bit of pain in my shin or my heel, I just shut it down because I kept getting thrown back in a boot. Right. Every time I try to run more and run more and run more. And I was like, all right, well, squatting with your legs or your shin stable.

Joe Gambino (31:52)
Mm-hmm.

Joe LaVacca (32:01)
is still going to be good for you and your lower body. If we can't squat because it's just too much, then you can do leg extension and leg curl. I was like, but we gotta get low to your lower body. It's just as important as your upper body in terms of your basic overall health and function. So again, like just by removing, you know, this idea of like, need to be in no pain to be successful. I need to do an XYZ exercise to be successful. Sometimes just get rid of it.

And I think just relieving that burden sometimes of like, wow, it's okay that I don't constantly work on this. Yeah, it's okay. If you're healthy, your body should be taking care of some of these things for us in terms of healing and repair. And maybe all your body is just saying is like, yo, chill the F out, dude. I got you. Just stop messing up my work. You keep coming into my construction site and ruining shit and causing a commotion and I got to rebuild every single day.

Right? So that's how I sort of like think about it. And that was just the last point that I wanted to touch on again, based off of that word, you know, control. So for me, I think your points of remaining, moving forward and your points of trying to reestablish control in any way, or form are like my big home, my big take homes from this and even what I try to preach with patients. So I think those are like probably really big themes to highlight.

Joe Gambino (33:25)
Yeah, and I like that. just like I'm always in my philosophy is I do my best to never completely take out a movement from somebody's life unless, especially if it's important to them, unless I really have to. And in those cases where it continues to flare you up, no matter how much you're doing, then sometimes it makes sense to just, let's take a break, let's find something else, let's go down that rabbit hole. think that's, I think that's good for people to hear.

Let's wrap up this way. want to maybe both of us can just say one tangible thing for somebody in flare-ups to take home. Like what should they be doing to help navigate that situation, even if they're not in a current flare-up, but they've had many flare-ups and it's always in the back of their mind.

Joe LaVacca (34:12)
Yeah, I would just say break the pattern and know that at times like this with an acute flare, this is what your Advil is for for a few days. Please take Advil or please take some sort of ibuprofen or anti-inflammatory or know that it's okay to ice and heat yourself if that makes you feel a little bit better or know that it's okay if it's your knee that's bugging you.

wearing a knee sleeve, taping it, wearing an ankle sleeve, taping it, wearing a back brace, taping it. If those are gonna bring your symptoms down so you can start breaking the pattern of your pain and taking control of your movement to help you move forward, then do it. But right when flares happen, so many people are like, well, I didn't wanna take anything.

I didn't want to do this. was told on Instagram or whatever that you shouldn't tape it, you shouldn't do that. And the only thing I ever say is why the F not? You are in pain. We think it's related to inflammation. Why would you not take an anti-inflammatory? We know that your tissue didn't get broken or damaged. So this inflammatory cycle is sort of on this cascade of doing too much, doing too much.

You know, I don't use a fire hose to fill up my water cup when I'm thirsty. I use the sink. A fire hose would work, but it'd be very excessive for what I need to be done. So your immune system is working. It's just doing so too high for what is needed. So let's help it out. Break the pattern, control your perceptions, help move yourself forward. And I think that would be my biggest tangent.

Joe Gambino (36:00)
Yeah, I like that. I mean, we've had Stella Mike Stella on the podcast. Very good episode about, know, we talked a little bit about, did we talk about ice on that episode? No, think I know we talked a lot about manual therapy, but he's very big anti yes.

Joe LaVacca (36:10)
I don't think we touched on Mike is very big with ice in his course with end

of the ice age. There's nuance to that, I think. And maybe we should have Mike back on.

Joe Gambino (36:19)
Yeah, I don't want to get into a whole,

yeah, we can definitely do that. But I think the kind of point I was trying to make is that you can go on Instagram and wherever and you're going to hear a lot of things. Don't do manual therapy. Don't do ice. Don't do heat. Don't do this. Don't do that. And at the end of the day, especially when pain is kind of really in your face, you're looking for whatever's going to bring it down. And if you have one or two strategies, whether that be heat or ice or foam rolling or I don't know, you name it.

Do it. Let that pain come down so that this way you can go out and do all the things that you want it to do. So I know there's a big stigma about even taking like ibuprofen and Tylenol or whatever. So, you know, do those things. Use that to your advantage when you do have pain and then don't use it when you don't have as much pain and then use more movement and all these other things to drive things. But I think my take home here would be you just use pain as information and not something that is just like overly scary.

thing that happens to us, it's talked about many times, we've even had guests talk about it where pain is normal. It is there to give us information and if you have a flare up, it tells us that you probably did a little bit too much for what your body can tolerate. If you've had no flare up or nothing like that, then it's probably too low of a stimulus, right? We're gonna probably have to find like a Goldilocks effect, so to speak. But pain is information.

We can use it to modify things, to try different things, to break the pattern, to maybe remove a whole activity, to do more of an activity depending on what's going on. So try your best to, you know, process whatever happens that you're feeling when you do have pain. But remember at the end of the day, I think the pain can also be used as information for us to make decisions that will allow you to move forward as we've talked about on this podcast.

Joe LaVacca (38:09)
Absolutely, my friend.

Joe Gambino (38:11)
Any final thoughts before you take us home?

Joe LaVacca (38:15)
None other than Joe, I love you. Listeners, we love you. Thank you for making it through another episode of the Beyond Pain podcast. And don't forget to come back next week with even more exciting topics. See you then.