Chicken or the Egg?

The Chicken or the Egg – Pain vs. Movement in Rehab

In today’s episode, I dive into what I call the chicken or the egg problem in rehab. Do people stop moving because they’re in pain, or is their lack of movement actually driving their pain? This fundamental question shapes how we approach patient care and rehab strategies. I’ll explore the patient’s perspective, the physician’s perspective, and how we can bridge the gap to improve outcomes.

Episode Highlights & Timestamps

🔹 [00:00] – What is rehab? A quick intro to the podcast and my background
🔹 [00:30] – The chicken or the egg problem: Pain vs. movement
🔹 [01:12] – Three possible conclusions about pain and movement
🔹 [02:02] – How patient beliefs influence treatment decisions
🔹 [05:03] – The importance of understanding both patient and physician perspectives
🔹 [07:04] – Why movement is part of the rehab process, regardless of imaging results
🔹 [09:54] – The cycle of pain, imaging, and treatment decisions
🔹 [10:38] – The role of a flexible mindset in rehabilitation

I encourage you to think about your own experiences with pain and movement. Have you ever felt stuck in the “pain-first” mindset? Or have you noticed how your movement patterns affect how you feel?

Thanks for tuning in! If you enjoyed this episode, please subscribe, share, and leave a review. Let’s keep this conversation going. Wishing you a movement-filled day!

Would you like me to tweak anything or add more details? 😊

Transcript

0:00

What is rehab or rehabilitation? My name is Fred Begaris, a board-certified sports and spine medicine physician in Virginia Beach, Virginia. After 10 years of practice, I still find musculoskeletal medicine both fascinating and challenging. This podcast is about the lingering thoughts and questions I've had after residency and fellowship. My hope is to spark discussion, challenge dogma, and share my experiences in musculoskeletal medicine. Welcome to the Talking Rehab Podcast. I call this the chicken or the egg problem. Often when I see patients, they come in with two distinct problems. Number one is pain. Number two is they have difficulty moving. I'm talking about non-traumatic problems that have slowly started with a little bit of pain and has progressed. And it's fairly common, you know, with overuse injuries or sometimes these things just come out of the blue. But when it comes to pain and movement, most people will come in saying that I have pain, which is why I can't move. I started looking at the problem differently where how I'm moving is actually driving the pain. Or how I'm not moving is driving the pain. So, you know, these are kind of like three different conclusions, you know, the pain is present, therefore I can't move. There is how I'm moving is driving the pain or how I'm not moving is driving the pain. And it's kind of nuanced and I realize a lot of, you know, physicians or patients won't necessarily want to get into the nitty-gritty. But I think it's really important because we're looking at the same problem but drawing conclusions and connections differently. And it's important to understand the patient's point of view first because what we believe that is driving the issue dictates our next move or what we're open to as the next move. So, as an example, from a patient's standpoint, if someone has pain and they can't move and that's how they connect the two, the next conclusion that they usually come to is that there is something wrong, something structural. And that will often lead to maybe we need to get an x-ray, maybe we need to get an MRI, maybe we need to go to the emergency room. And I'm obviously not trying to minimize someone's pain, but, you know, little pain versus big pain, you know, I think on some level people start to wonder, is there a structural problem that's causing pain that's decreasing my overall movement? And from a physician's standpoint, we're looking for the big structural concerns as well. It's not like we're not looking at that problem, but with our experience, we have a pretty good sense of when things need imaging and when things don't. Now, of course, there's exceptions, but in my experience, I've developed a pretty good sense of when something needs more than just reassurance. But it's a it's again, another point of point of contention sometimes, because if I'm looking at it from a different perspective, where I'm saying like the reason back pain is a is a great example. You know, oftentimes people will say I'm in pain and that's why my back hurts. But a lot of times people's back pain starts because they're not moving or they stopped moving and to try and convince someone that they're who's in a lot of pain in your office and come to and try and convince them of my conclusion and not explore their conclusion. The visit doesn't usually go very far. And I think that's where a lot of patients and even physicians can get frustrated. So it is important to understand how both parties are coming at this problem. It can be challenging. I know in my earlier years, I wanted people to see things my way. You know, not necessarily because I'm a physician and, you know, I'm the authority in the situation, but I wanted people to see things my way because I was looking outside of the box. But no matter how great of an explanation or theory that I had, the theory that mattered the most was the patients. And until I started to understand their point of view, you know, the therapeutic relationship can't really start. If we're not looking at the same problems, then it's really hard to reach a solution. You know, it's even harder to try and get people to change people's minds because people want to feel heard. But at some point of the therapeutic relationship, I do think that patients have to see things the other way, where the pain isn't the driver, it's the movement. Because it is a very common scenario where even if there is a, again, using a back issue like a disc herniation or a, let's say the MRI looks fine, movement is going to be part of the rehab process and is likely the next step regardless of whether or not there's something on the imaging study. Some people embrace that, some people don't, but it does dictate how I move next. If I can tell that the patient is really more focused on the structural piece of things, sometimes we have, or the pain part of things, then sometimes you have to explore that. With insurance companies, MRIs are commonly denied, and they have policies and rules and indications for this. And again, there are reasons for an MRI from a clinical standpoint, but sometimes people can't get past the, they can't get past not knowing what their body part looks like. And rather than sit and argue with them, I've just elected to say, well, okay, you see the problem this way, I see it this way, but I have to look at things your way first before you look at things my way. So it is a give and take, and as a result, I've started imaging people sooner than later. If the denial comes, it does, again, that's not really the point of, of today's episode and knowing that a denial may come shouldn't really drive my medical decision and it shouldn't drive my willingness to look at things from the patient's perspective. And I think that's honestly a really, really big problem because sometimes you just have to scratch someone's itch. If they want an imaging study because they believe something is wrong, then you need further evidence to, to prove to them that everything isn't wrong. Now, there's really only a couple of ways to do it. X-ray, MRI, but that is part of the therapeutic relationship where I have to see their problem first and then, and then we can talk about my problem. But as a patient or someone who's just trying to care for their bodies moving forward, I encourage you to look at things from both perspectives because, in my opinion, at some, you have to look at it that way. Because there's so many people that have pain without any specific trauma, and we know that movement can be part of the problem and also be part of the solution. So you have to look at it from the other perspective, like pain doesn't always just show up and neither do fractures. They don't just show up or disc herniation. They don't just show up. You have to question your overall movement at some point in time, even at the extreme. Let's say that I have someone that's, Hey, I have this really clear disc herniation. And, you know, I'm movement is not an option. So that kind of person, they don't want to have an injection. They don't want to have physical therapy. They are only looking at the pain and that there's a structural explanation. That person will likely end up having a microdiscectomy or some sort of spine surgery, and they will likely do fine. And I think that reinforces sometimes people's beliefs, which is good, but sometimes it's not good because in the post-operative period, not everybody has smooth sailings. So, again, you're going to run into that problem where someone is going to say, I just had surgery, therefore I have some amount of pain. And they're okay with that. But if the pain is too intense or the pain lingers longer than they believe it should, what are they going to conclude? I have pain, which is why I can't move despite having surgery. Therefore, something is wrong. And it's going to drive again the cycle of getting another MRI. And is it possible? A hundred percent. Could they have a recurrent disc herniation? Absolutely. It's unlikely, but it does happen. And even if the repeat MRI showed no problem, what is the actual next step? It still ends up being movement. So, even in the most invasive pathway or the most rigid mindset of the pain is present, it's limiting my movement, and it's because of this structural problem. Even in that situation, I guess you better hope that you're going to have smooth sailings after an injection or after a surgery. Because at some point in time, there is going to be persistent symptoms that you're going to have to utilize movement to work your way through. I've just done this too long to not acknowledge that fact that it might be a solution when you're 20 or 30, but if you have the same problems over and over and over, it's not always the magic bullet that it once was. But, again, I call it the chicken or the egg. To me, it doesn't necessarily make a difference on who's right or wrong because we have to look at both perspectives. Not everybody likes to do it willingly. Not every physician likes to look at things from other people's perspectives, but that's how rehabilitation is, is you have to have a flexible mindset. A rigid mindset does not do well from a rehab standpoint and maybe even lifelong. But, again, just something for you guys to think about looking at the pain and movement problem from a couple different standpoints. I think it's really important for you guys to consider other people's experience. I hope you guys enjoyed it. Take care. Thank you for listening to the Talking Rehab Podcast. I hope that this podcast stimulates you to question your own practice and how you approach rehabilitation. I truly appreciate your time and attention. If you enjoyed listening, make sure to like and subscribe to the podcast. I wish you a movement-filled day. Take care.