Episode 94: Acute vs Chronic Pain Treatment: What Actually Works and Why

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• Joe Gambino
• Joe LaVacca

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Summary:

This episode explores the different types of pain: acute, chronic, and acute on chronic, and how understanding these categories can improve rehabilitation strategies. 

Hosts Joe Gambino and Joe LaVacca share insights on managing pain, setting realistic expectations, and tailoring rehab processes to individual needs.

Takeaways

• Differences between acute, chronic, and acute on chronic pain
• Rehab expectations for tendinopathy, muscle strains, and injuries
• Importance of patience and realistic timelines in recovery
• Role of lifestyle factors and stress in pain flare-ups
• Communication and setting expectations with clinicians

Transcript

Joe Gambino (00:00)
Welcome back into the Beyond Paying podcast. I am one of your hosts, Joe Gambino. I'm here with our other lovely host, Joe Lavaca. You can find us both on Instagram at joegambino.dbt for myself and at strength in motion, underscore PT for Lavaca podcast on Instagram as well, Beyond Paying podcast. And if you do want to watch along as we chat on YouTube cups of Joe underscore PT, that's where we're living. Joe, welcome back.

Joe LaVacca (00:25)
That's where we are living. It is good to be back. ⁓ As always excited to have another conversation with you, my friend, and to reengage with our wonderful growing audience. So thank you guys for tuning in. Thank you guys for sharing the podcast. Thank you guys for liking the podcast. ⁓ It has been making a big difference and we greatly, greatly appreciate it. So I just wanted to start with that little gratitude today, little love today to get it rolling. Because I know we got it.

Joe Gambino (00:37)
Yes.

Mm-hmm. Yeah podcast

hits some PR so you know, I'll take it

Joe LaVacca (00:54)
Yeah, we got we got a nice

topic that you had handpicked. So I'm excited to dive into it. So you want to you want to frame it out for us there, Joe? What what are we talking about today?

Joe Gambino (01:04)
I do.

Yeah, so I think today and I'll let you know, we'll use the the goosebumps, choose your own direction ⁓ type of book metaphor here. So you can you can pick where you want to start. But I want to talk about the differences between because on this podcast, we talk a lot about like chronic pain and expectations and how we're trying to in essence get beyond pain and back to a life that you want to you feel.

Joe LaVacca (01:12)
Mmm, love it. Love the goosebumps. ⁓

Joe Gambino (01:33)
comfortable and confident in living in, right? But the rehab for somebody who would have just like a typical tendinopathy or a muscle strain or sprained ankle, right, is going to be very different. So I wanted to highlight some of the differences, the expectations, the thought processes, and what you should expect from rehab if you're coming through either of these pathways, because I think that will give a lot of clarity to people who are dealing with pain and where they may.

need to go or need to think about during the rehab process.

Joe LaVacca (02:05)
Yeah, so I think, ⁓ great question. And I think that there's probably for simplicity standpoint for listeners, I'm gonna break down pain into three buckets for us, or at least right now. We have acute, we have chronic, and then we have acute on chronic, which maybe we would talk about a flare of like a previous condition. So let's start with acute first, because I'm gonna say acute is new.

Um, you've never had this pain before it was in your tendon. was in your muscle. Um, the question I always want to know is if there was a trauma involved because that might lead us down this route of, Hey, do we need medicine to come on board? Do we need imaging? You know, do you need a cast, a brace, a surgery or something along those lines? Right. So that's where acute trauma.

We'll put that in a separate bucket because maybe that's you know, a tail for another day or, know, maybe even outside the scope of what we do. I'm not doing too many surgeries and embracing in the clinic these days. I don't think you are either, especially virtually, although AI is probably going to give you that ability, Joe, you know, just pop on your, headset one day and you can start mobilizing people with sensors and everything. It's going to be a really wild time. You're muted. You're muted.

Joe Gambino (03:28)
Always! said I'm gonna just do ACL surgeries right from my office here. Just headset, virtually, just pressing some buttons on my keyboard and we're done.

Joe LaVacca (03:32)
Boom! Love it.

Yeah, love it. Love it. So let's just move on from that one. And we'll just say that it's an acute, ⁓ non sort of traumatic injury. Maybe there was a training ⁓ error. Maybe there was just like an ankle roll or something like that, right? But something that's going to require higher level referrals to medicine or something along those lines. I typically want to do very little to alleviate pain in those situations.

And the reason why I say that is because inflammation or pain is part of your healing process. And I'll kind of use a client that just came in this week with ⁓ an acute calf injury. So was training, had some extra running that she was doing during the course of the week. ⁓ Then added in some jump rope towards the end of her workout, and then just felt like a little pull happened into her calf.

So as a result, she was limping. As a result, she couldn't do a lot of heel raises. As a result, she didn't necessarily feel confident with going back to squatting and to deadlifting and all these other things. So when she came in, I basically told her that, sure, we can wear a compression sleeve. She did have some swelling in and around the medial calf based on palpation and just visual assessment.

So if the muscle wasn't doing its work, hey, we can put this sleeve around you. We can cause some healthy compression or movement of fluid, right? Just give it a little boost. But at the same time, I don't want you to just think that we're gonna put this brace on or this sleeve on, and I want you to just force yourself to walk normally. You only had the strain happen about five days ago. I think that the pain will actually tell you when it's safe to add a little bit more.

But in the meantime, the pain is there to just be like, hey, hold on, don't go too fast on the steps or don't go too fast walking across the street or hey, you know, all the ⁓ sort of like deadlifts and squats you were doing. Yeah, we've had enough now. Like let's pull back of it. So with acute pain in this situation, I'll always sort of envision like a construction site. ⁓ Our cells are working over time. They're trying to repair the area, clear some waste. We can help them.

by bringing them more supplies, but we can also hinder them by constantly stopping their work or their flow or asking questions and tapping them on the shoulder. So in that sense, I would view acute pain as something we want as a part of the initial phases of healing. I want to promote protection, behavior change. I want you to limp.

I want you to hold your arm close until we start to feel a little bit safer. So I'm going to pause there. Acute, do you look at it any differently? Do you want to just smash out that pain, Joe? What are we thinking?

Joe Gambino (06:44)
Now I think I'll just leave it with my own personal experience with my body is that anytime I have a flare, anytime that something pops up and it's like very cute, I have learned from my body is that doing less is more. So I find that if I have a little inkling in my back or an ankle or my neck or whatever, and right off the bat,

Joe LaVacca (07:04)
Mm-hmm.

Joe Gambino (07:13)
even if it's just like, I just feel a little something coming on. If I do a whole bunch to try to get ahead of it, I tend to make things worse. If I just let it be for a day or two, it usually does what it needs to do. And then I can start the process of moving it and seeing where my tension is and what might be limited and then can actively start to work on some of those things. I agree. think when something, and I've actually seen this, ⁓

Joe LaVacca (07:21)
Mm-hmm.

Joe Gambino (07:40)
with a bunch of people that something pops up, it's very acute and they go for a massage and they get deep tissue and they're like, oh, my pain's worse after. I'm like, yeah, I mean, you have pain. You have someone press on it really hard. It's a force is no different than if you try to pick something up really heavy or whatever it was that could re irritate it. So it makes sense. Like you're going to have some pain after that. So I think that you need to give a acute new onset, anything, some time, and then you can.

You don't have to give it a ton of time. don't think rest needs to be this whole like, I need to rest until my pain goes away and then I need to load it. But to some degree, you need to give it a little bit of space so that you can then start the movement process, the loading process without it being too much too fast in a sense where it can become a much bigger flare up than whatever it started as.

Joe LaVacca (08:15)
Mm-hmm.

Yeah, I usually go just go by the general rule of thumb of you know, just wait three to seven days. You know, if you're starting to feel something, listen to your body. Don't rush to take medication. You don't need to rush to you know, change everything you're doing in your life. But just let your body take over. Right? And this is I think the benefit of staying quote unquote healthy. Right? This is the benefit of not smoking. This is the benefit of you know, controlling your sleep, controlling your weight. All of these processes are going to be

Joe Gambino (08:35)
Mm-hmm.

Joe LaVacca (08:58)
much more effective and efficient when you are healthier as a person. So give it three to seven days. Let's monitor it. We'll look for trends. Is it getting worse? Is it staying the same? Is it hopefully getting a little bit better? But I love what you said. We don't need to pull the alarm, integrate 27 rehab exercises, lateralize 800 different movements. Just give yourself a little bit of time. And I think that's the acute standpoint of like the tissue.

The other category for me, like acute on chronic, like a flare, you like your back pain coming back after mulching, you know, a condition you've had in the past. Well, I'm not thinking necessarily about your back tissue. I'm not thinking about your disc. I'm not thinking about your nerve. I'm thinking about you. Hey, Joe, you had a lot of extra stress this week. ⁓ Hey, ⁓ you mentioned Jen was gone. Hey, you mentioned, you know, Olivia wasn't sleeping. You mentioned Joe was giving you a hard time during naps. It was really affecting you.

Joe Gambino (09:36)
Mm-hmm.

Mm-hmm.

Joe LaVacca (09:58)
⁓ you know, sword was super busy. had, you know, 80 new clients online because you just launched your rehab for, you know, new rehab program this week. Right. What else is happening in your life that could have tipped the scales for us and how can we bring those things back under control? You know, one thing at a time. Sure. Maybe it's going partial range of motion and some of your emotions at the gym. Sure. Maybe it's taking a day off. Maybe it's programming a bike ride, but

Joe Gambino (10:14)
Mm-hmm.

Joe LaVacca (10:27)
I think a bigger part of all that stuff is, Hey man, maybe, you know, just really focused on getting some good sleep tonight or for the next couple of days. You know, Jen's back, ask her for help. ⁓ reach out to the people who support you and let's just get, you know, you back into sort of like a homeostasis again. And then we can revisit and say, all right, now knowing your life kind of went a little bit wacky.

Joe Gambino (10:45)
Mm-hmm.

Joe LaVacca (10:50)
The next time that comes up, because I'm sure Jen's gonna travel again, I'm sure Olivia or Joey's gonna have a little tough night of sleep. I'm sure ⁓ all these other things could happen in your life, but if we now look at them ahead and say, you know what, I know last time this happened, ⁓ I kinda was suffering for a little bit. Maybe I scale off the gym and just do my mulching today, or just do my gardening today. That counts as movement or my exercise. So I think that's where I would kinda shift gears into acute on chronic.

Joe Gambino (11:12)
Mm-hmm.

Mm-hmm.

Joe LaVacca (11:21)
And what are your thoughts about that?

Joe Gambino (11:23)
Yeah, I would agree. think in more chronic, this has popped up a bunch. think, you know, especially if it's non-traumatic, any non-traumatic injury, it's, know, it's looking at lifestyle, it's looking at the factors that could contribute to discomfort. But overall, I think anything that's a newer flair, think overall, I'm probably not really changing, you know, how the first initial period of time goes, right? It's going to be, can you get more sleep? Can you do the things to recover? Can you just chill out and let's see?

what the nature of this pain does for you. Does it go away in a day? Does it go away faster than it has in the past? Those are good signs that recovery is going well for the acute on chronic type of conditions. But anytime it's acute, whether it's been something that's on and off, or whether it's like an ankle sprain or whatever, ⁓ beginning, let's let it cool. Let's see what the trajectory goes. What can you currently do? How bad is it impacting your life? All those things start to weigh.

And then looking at, know, trying to figure out why something might have flared up, especially if we've been working through it for a while or, you know, you've been dealing with it for a while. Is it because you did something like, Hey, I have a mulch and I don't know how long and I decided to do a giant mound in my garage and shovel it all over my property. Um, and that's what pissed off your back. Or was it just because of a bunch of different lap style things or, know, cause sometimes, I mean, we've talked about it before, right? Sometimes paint can seem like it comes for no reason at all.

Joe LaVacca (12:51)
Mm-hmm, mm-hmm.

Joe Gambino (12:51)
Right?

So sometimes it can be hard to pinpoint. So I'm with you.

Joe LaVacca (12:56)
And

I think a lot of times it does. I do think that like, having read a lot about pain, you know, I, I believe it was a little bit more based on preclinical stuff or animal based trials. But when you look at nerve firing patterns, they're kind of spontaneous. They just happen sometimes. So for as much as we want to have an answer for why I flared or why my pain happened, sometimes the answer is just bad luck.

Joe Gambino (12:58)
Mm-hmm.

Mm-hmm.

Joe LaVacca (13:26)
And when you acknowledge that and you can reaffirm to someone, hey, you're not doing anything wrong, right? ⁓ You couldn't have done anything better. I think that's also like a big relief because so many people come in and they're healthy and they work out and they sleep and they eat a balanced diet and they have good relationships and they're like, this isn't fair. Why did this happen to me? It's like, well, you're a human being.

Joe Gambino (13:50)
Mm.

Joe LaVacca (13:53)
that senses emotion and has experiences and pain is part of those experiences, just like happiness and joy and grief and sadness and everything else. So because you are a human, you get to feel all of these things. It does not mean that there's anything wrong with you. And I think that's kind of the shift then, you know, we can close out with this idea of like, okay, well then what about chronic pain when people come in and just a chronic state? And I think we touched on this a little bit.

Joe Gambino (14:06)
Mm-hmm.

Mm-hmm.

Joe LaVacca (14:22)
in our previous episodes, but I want to just start shifting the focus on like, all right, you can't squat, but can you lunge? know, can you step up? You can't run, but can you walk? Can you swim? Can you bike? Can we find things that you are strong at and emphasize those to a quote unquote, better health and wellbeing and taking time.

I'm not talking about biking for a week and then trying to go run again. I'm talking about biking for eight, 12, 16 or more weeks and then coming back as you've had some adaptation and then see if you can tolerate running again. Changing up your workouts to lunges and things that make you feel successful for that same period of time and then coming back to those aggravating factors because if it's chronic pain,

Joe Gambino (15:06)
Mm.

Joe LaVacca (15:18)
Again, I'm going to probably move away from the idea that it's a tissue, a joint, a this, and start to just kind of think about your overall person. But the slight difference of acute on chronic is what was different about your life in the last week versus what can we make ⁓ really magnify that's already good about you and the things that are going on and just keep those rolling.

Joe Gambino (15:26)
Hmm.

Joe LaVacca (15:46)
So in this most simplistic terms, think that's where for me to break it down quickly, like acute, acute on chronic and chronic, those would sort of be the frameworks I would take with people or have them think about in their lives.

Joe Gambino (16:00)
Yeah. And I think the last thing I leave, if we're talking about like expectations for where you are and your rehab journey is like anything relatively, you know, cute, whether you trauma, you need to have surgery and then you have rehab after or pre rehab and post rehab, or if you just like, like sprained an ankle or just had it at like a regular acute injury, they're more like a mechanical pathway in a sense. Obviously it's never going to be linear and rehab is not going to be on the same timeline for each person.

but there are like timeframes and steps and things that we want to see happen as we're trying to reload that tissue and get you back to where you want to be. And chronic pain is a little bit more all over the place. You you can have lots of different things happen and focus on a lot of other qualities. And sometimes you're just like, Hey, maybe we need to just focus on sleep right now. And it's like, along with exercise and movement and the things that we feel like you need to do to build up a bigger bucket, so to speak. ⁓

Joe LaVacca (16:56)
Mm-hmm.

Joe Gambino (16:57)
Is it, do we need to just get you back into more strength training and build some confidence and do that in a way that we know is going to be not safe, but like something that you can have some success with now, right? And then say all these other things, we're not taking them off the table, but we're gonna treat them all like rehab and we're gonna slowly reintegrate them at certain points in time as certain things happen from a movement perspective, right? So we're gonna look at things a little bit differently.

And there's a lot more pathways and it's just not a very specific structure to it, I think it can be very dependent on that person, their lifestyle, the stressors, what they can do at that point in time. So it's a little more in flux. think that's also what makes it harder for people besides the fact that they've just been in pain for a long time.

Joe LaVacca (17:44)
Yeah. Yeah.

Yeah, totally. And, you know, something you've hit on, ⁓ just now and before, like those expectations are important for people and they're important for your clinician and you to be talking about, because if you guys are on different wavelengths, ⁓ it's not going to be successful no matter what you could have the best program in the world or the worst program in the world. ⁓ if you guys are not on the same path forward and at least understanding this might take two months or three months or six months.

Um, and then what realistically, you know, especially in those acute scenarios, how quickly does muscle heal? How quickly does tendon heal? How quickly does cartilage heal or, or joints take to calm down? Um, you know, for all of the wonderful things that we do as PTs and we all pride ourselves on education and, um, assessment and treatment still to this day over the last, um, how long have I been with strength and motion now? Avery was three or.

No, she was four when I got started in Strength and Motion. So for the last eight plus years, the biggest common denominator of new clients who've seen other people is they just have no idea what to expect or they have no idea how different tissues heal. And the minute you give them that gift and they're like, oh, so this is totally normal what I'm feeling. Yeah.

Do you feel more confident now about going to the gym and doing some things and working into pain and giving yourself some space and compassion? Yeah, I'll try. And that's it. That's all need you to do. I need you to just be willing. I need you to be accepting of the message, and then we can tweak it as we go.

Joe Gambino (19:26)
Yeah, I would just say the last thing as far as. How a lot of you know, we had the last episode we talked about. Now how you know, we're talking about strengths too much, we're talking about weaknesses too much and like, where is that kind of where should that middle ground be? And I feel like a lot of providers in just the medical field in general, they will talk about. They use no civic language, I'll tell you all these things that are wrong with you and then your your.

prognosis or your outlook, it's an easy process. you have this meniscus surgery, you'll be up in no time. It's going to be a relatively easy surgery. And then that person goes to rehab and it's not an easy process and is longer than they expected. And that stuff is like, again, right, like the. It makes their rehab journey harder because the correct expectations were in the beginning. And now when they're going to the process, like, well, why am I they think something's wrong with them in a sense?

Joe LaVacca (20:06)
You

Joe Gambino (20:24)
Why am I the person that's having a hard time and it's not such an easy process like this doctor said, or like my friend told me, right? And now all of a sudden when you're comparing yourself to this potentially like perfect scenario and you deviate from it, and this can be with any chronic pain, with acute pain, with surgery, right? Like all of a sudden it makes things harder for you. So I think understanding that, you you need to have your own journey and go through it.

That's probably the first step. can't compare yourself to other people. And I think that we all really need to do a better job of, hey, like you're going through the surgery. Sure. Like it might be an easy process for you, but it also might be a hard process for you. And I think we've talked about this on the podcast before. You may have even had a surgery really well on one side. You cannot even expect that surgery to go the same on the other side. All right. And I've seen it multiple times ⁓ happen. Meniscus surgery, bunion surgery.

Rehab was great, went really well on the other side, and it was a much harder, much more frustrating journey. So I think that is a big part of it. I think ⁓ us as medical providers have ⁓ a lot to do with that. And I think we can ease up a lot of problems in the future just by saying, even if we say it's going to be harder than it is, right?

If it happens easier, this person will be so happy. They're to trust us more. They're like, wow, look at this. This surgeon did such a great job. You told me it was going to take me 17 months to get better and I got better in 12. Right? Like how good is that surgeon at PT going to look in that scenario versus the opposite? You're going to be hailed in one month and then it takes them six months to get better. Now it's like, oh my goodness, what a uphill battle that's going to feel like.

Joe LaVacca (21:51)
You

There you go.

Yeah, so there you go.

Yep.

Yeah, so clinicians, hedge your bets and clients. Yes, we occasionally we occasionally lie to you.

Joe Gambino (22:13)
Yeah.

Joe LaVacca (22:20)
yeah. right, cool. Well, I think that was great. It's a good leave off point. ⁓ Joe, love you. Listeners, we love you. Thank you for making it this far. And again, if you are enjoying the podcast, please like it, share it, tag people who you think it can help. It has been helping and we appreciate you and we will see you next.