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Proximal Hamstring Tendinopathy is a horrible condition affecting athletes and non-athletes alike. If you fall victim to the misguided information that is circulating the internet, symptoms can persist for months, sometimes years and start impacting your everyday life.
This podcast is for those looking for clear, evidence-based guidance to overcome Proximal Hamstring Tendinopathy. Hosted by Brodie Sharpe, an experienced physiotherapist and content creator, this podcast aims to provide you with the clarity & control you desperately need.
Each episode brings you one step closer to finally overcoming your proximal hamstring tendinopathy. With solo episodes by Brodie, success stories from past sufferers and professional interviews from physiotherapists, coaches, researchers and other health professionals so you get world class content.
Tune in from episode #1 to reap the full benefits and let's get your rehabilitation back on track!
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On today's episode, the missing link in rehab you're probably ignoring. Welcome to the podcast that gives you the most up to date, evidence-based information on PHT rehab. My name is Brodie. I am an online physio, but I've also managed to overcome my own battle with PHT in the past. And now I've made it my mission to give you all the resources you need to overcome this condition yourself. So with that, let's dive into today's episode. We're going to do something a little bit different today. I have a uh test that you can do at home as we go through this episode to learn more about if there is, if you're injured, there may be some missing pieces to your actual recovery and what interventions you might need to put in place for it to be a little bit more complete and help your odds of success for. healing, recovering, and those sorts of things. I've created a questionnaire in my own systems and processes for clients who sign up for one-on-one consulting with me. And it's been a game changer because initially when I set up my online business, I had people fill out a subjective uh form, an online form, which would be like, you know, tell me about your injury. When did it come on? what treatments have you tried in the past, what aggravates the injury, what eases the injury, just trying to gather as much information as possible. I also send people a virtual objective assessment. So based on the injury and location, I'd give them some tests to do at home that they then report if there's pain or stiffness or imbalances from right to left. And I feel like after a couple of years, it just wasn't picking up enough information. Once I started learning more and more about pain, and I started seeing more and more clients that are more chronic and more complex. And so I tried to adjust to that by putting into the subjective. How are you feeling about your injury emotionally? Or how has it impacted or affected you emotionally? Because we know that pain is multifactorial. There is this term that we call biopsychosocial meaning that there is a biological element to pain, ah healing timeframes and you know, uh physical damage, I guess you could say that does occur with some injuries. But there's this psychosocial element to pain, which is your psychological processes and your social impact around this injury can absolutely influence how painful that injury is, it, how, the odds are of healing and that sort of stuff. And we're to get really nitty gritty and dive into the, a lot of the research on this topic on today's episode. And so I then, uh, like I said, I put into my subjective form, how is this injury impacting or affecting you emotionally? And that started gathering a lot more. insight and I was starting to flag a lot of these psychosocial flags elements a lot earlier on in my intake. And it was bringing up a lot of useful stuff in terms of the interventions that were required to help people heal. um But since it was just one question, and it was being helpful, I decided to double down on that process. And now when someone signs up to work with me online one on one, they get the subjective form, they get the objective stuff tests that they do at home. But then they get this other questionnaire, which I'm going to talk about today, which is uh what I call like a pain and wellness score. And it's a completely new set of questions that helps me definitely flag how big of an impact or how much focus we need to bring to our attention when it comes to not just giving you the right exercises, not just giving you the right load management, but addressing your thoughts, addressing your emotional impact around this, the social impact of this injury. And so since implementing that, I've gained greater insights. And so I thought, what a great podcast idea that you guys can listen to this episode, do this now with me, and you can personally flag your own relevance or these flags to say, maybe there is something I'm missing in my recovery. Maybe there is something I need to concentrate on. And hopefully I do a good job of explaining the importance of this stuff. And also relay the useful research that's out there on this topic to help highlight the importance of it so that you can adjust your rehab and uh increase the odds and effectiveness, I guess, increase the effectiveness of your full recovery. And if you're not currently injured, this may help actually prevent you. If we know all the elements that impact injury, and we are cognizant of that, that address and sort of, guess, maintain healthy practices around each of these domains, that would then reduce your risk of injury. Or if you develop an injury in the future, you are now better equipped with handling it, even if it is acute, if it's not chronic. and even to subtle, I know there are a lot of psychosocial influences I do in my day to day whenever I have minor mild injuries pop up that I know increases my odds of just swiftly negotiating it. And so let's go through those questions. Now, if it does resonate with you, I have made a course I have this chronic pain reset course. I'll leave it in the show notes if you're interested in signing up. I don't really promote it too much, but I've already had 96. members of that course so far and the feedback has been amazing. It dives deep into all of these elements. I've created, partially created the questionnaire for this course as well. So all members go through this questionnaire to help them highlight their own boundaries that they might be struggling with, or at least just bring up things that they're not actually thinking about. So like I say, the aim of this questionnaire is to identify psychosocial flags. We typically call these yellow flags in my health profession. And why it is important is because pain, like I said, is multifactorial. It's not just influenced by mechanical pain. It's not just, okay, you can only tolerate 10 kilometers of running and you go out and run 20 kilometers and now you're in more pain. ah It's to do with the nervous system. Like all pain is the brain. evaluating threat levels, evaluating relevance, evaluating urgency, and then distributing the amount of pain it thinks and it deems to be safe or keeping the body in a state that it deems is relevant. But as we can see, sometimes the brain can evaluate things differently. And so um this is when we talk about nervous system regulation. Sometimes the nervous system itself can become dysregulated and that can sometimes contribute to the nervous system itself being hypersensitive and all of a sudden little flare ups or little signals of pain amplify because the brain's really overworked or really has a perceived threat level that's uh a bit, like I say, amplified or irrational. And that can all be driven by emotion and the state of the nervous system. uh I suppose it's probably important that I mentioned because a lot of these questions themselves will uh be bringing up this topic. There are three main kind of emotional states or triggers that are really, really big culprits when it comes to you not improving and you having a really poor experience, high levels of pain, uh irrational flare ups, big flare ups, and that is The three culprits are one hyper vigilance. Hyper vigilance is uh thinking or like having your brain stuck in this high alert mode all the time, even when there's no real danger. And it's like constantly thinking about pain levels, constantly thinking about the injury, constantly thinking about pain levels when doing certain tasks. Like it's one thing to say, go for a run. and afterwards be like, I wonder how my pain is. And then just having a little quick check in and be like, Oh, I feel like that was okay. And then moving on compared to every single step that you take, how's my pain, how's my pain, how's my pain. That would be a hypervigilant state. So that's one of the three big culprits. Two is catastrophization. And this is when your brain takes a small problem and turns it into a huge disaster. It's like disproportionate in terms of the impact, you may roll an ankle and think it's broken and think you'll never walk again and you'll have to be in a wheelchair. I don't know why I just came up with that. It's just a very poor example. But you can appreciate what catastrophization is. And the third one is fear, fear of movement, fear of the future fear of not getting better. So hyper vigilance, catastrophization and fear. If one of these three, or one or more of these three things are highly present in your recovery, you need to address it and we need to come up with interventions to minimise those impacts. There was a paper titled the strength of association between psychological factors and clinical outcomes in tendinopathy. It was a systematic review and they found that recovery is influenced by the psychological factors, your emotional state, hypervigilance. catastrophization, kinesophobia, which is like the fear of movement. If these are flagged high on in people with tendinopathy, their outcomes, ie how quickly you recover, can be worse can be drawn out can uh hinder your ability to recover. So it's a very real and researched phenomenon that like I say, we may be ignoring. So the test, the quest, the test that I've designed has 20 questions. They're just simple, yes, no questions and you can play along as well. And the aim is like you get a score between zero and 100. I sort of flipped it a little bit so that if you answer yes, you get zero points. If you answer no, you get five points. You actually want to be as high on the scale as we can. So zero is the poorest score you can get and 100 is I guess the healthiest score you can get because what I aimed to do, I called it like a wellness score rather than a pain score. So like a pain score would be, I guess like have a lot of negative connotations to it. And so what I aimed to do is like, okay, your score is a 35. Let's try to bump that up to say 70. There will be some questions in here that you can't control. I number one is, have you had pain for longer than six months? We can't change that. So you never really Some people can never really get to 100, but we just want to get as high as we can as we move through your rehab. And so let me go through the questions and you can play along at home. Just give yourself a, a why, a yes or a no, as you move along through these 20 questions and tally up your score at the end. And then I'll talk about like the relevance of the scores. But for now, all I want you to do is write down the yes, no's and every time when we tally them back every time you have answered no, you get five points. Every time it's yes, you get zero points. So just bear that in mind. Okay, so question one, I've just flagged, okay, how long have you had your pain for? have you, the question is, have you had your pain longer than six months? Why have I put this? um Most research classifies pain or chronic pain as having pain for longer than six months, um which is a very loosely and poor description. But the longer you've had the pain for the more that there's worry, you can start to develop a lot of unhealthy emotional patterns or day to day compensations. uh Pain just behaves differently the longer you've had it for. And so I've just quickly just put this in as a, just classify to classify people more accurately, there are some, there is some research to try to better describe chronic pain. And it's more accurately sort of pain that has persisted beyond the expected timeframes, expected healing timeframes, you could say, but that's just a lot more ill defined. I mean, what, how long does it take a tendon to heal? Like most research will say three months, some will say six months. um So I guess it depends on how severe the damage is. But nonetheless, quick, yes, no. Have you had your pain for longer than six months, I think is just a hazardous limitations but a good start. Question number two, do you think about your pain multiple times a day? This is where we start to weave in or get like a little glimpse as to how much attention you're giving this injury and how much impact it is on attention. Because more attention equals more relevance in the brain. If you are thinking about it multiple times of a run, every time you do squat or a deadlift every single rep if you're like, okay, how's my injury? How's my injury? How's my injury? Some people can think that's important because Brody always talks about these pain scores and paying attention to how long gets back to baseline. um But more attention equals more relevance and more relevance equals the likelihood of other emotional things to cascade, which I'll discuss later. um We don't want to be thinking about an injury. too much. And this is where I kind of contradict myself. If I identify a very low score on this questionnaire, I don't have people score at all. I don't have I try to distract them rather than actually thinking about pain scores because I know that paying too much attention to an injury hinders their ability to recover. If people seem fine on the pain score in total, I'm okay with them looking at their pain scores during after the next day. um Yeah, like I say, this where we need to choose the right person to discuss how much attention we should be giving to the pain. Number three, would you describe your pain as all encompassing? I see a lot of people with chronic pain, I see a lot of people in severe pain, and a lot of people who I chat with and consult with do call it all encompassing. This is flagging very, very high attention to this injury. uh And so like I said, higher tension equals high relevance, which equals, you know, the brain really prioritizing this injury and these other hypervigilance and nervous system overactivity or hypersensitivity being very likely in someone who has had it for a long period of time and thinks it's all encompassing. We know if someone, well, my assumption is if someone considers their injury all encompassing, means it's very emotionally attached to them, they may be likely to have catastrophization. It's likely to impact them socially. If someone says it's all encompassing, I can think of um it's limiting their ability to be social. Maybe they've got proximal hamstring tendinopathy and they can't sit at dinner, or they're struggling to go through their work tasks. Maybe they've had to limit their work hours or, um you know, not go out. to drinks with friends. uh I would say that's definitely impacted them socially and that's higher likelihood if they describe it as all encompassing. They may have pain with movements, day-to-day movements. uh Transport, getting on public transport, like I say, work activity or their sport and recreation, if that's really impacting them, we're definitely identifying and flagging those issues with this particular question. Number four, have you had a history of depression and or anxiety prior to this injury? There is a link to people who do have depression and anxiety and chronic pain. There is a link and has been shown that if someone does have depression and or anxiety, their ability to recover is hindered. And so how I describe this and what how I like to think about it. If someone who does have depression or anxiety, their brain has this like natural default state to catastrophize, to be vigilant or hypervigilant, to be fearful. These big culprits that I was talking about, that's where the brain naturally moves towards when someone has these emotional default modes. Also, I would say it's high that someone who has these traits and then gets injured is less likely to have the right coping strategies, the right emotional coping strategies in order to recover. And so these people unfortunately have a default state that sets them up for ah poorer likelihood of recovering. And so that's why I thought it would be important to flag it. ah And like I say, this is if you've had a history of depression and or anxiety prior to being injured. Question five is have you developed depression or anxiety as a result of this injury? I found a paper titled the relevance of depression and anxiety among adults with chronic pain, a systematic review and their meta analysis. And they found that 40 % of people with chronic pain have depression and or anxiety. So there is the link there. And those two questions can help me highlight, okay, is this person's default state? setting themselves up for poor recovery, of which, hopefully they're seeking help out elsewhere because I'm not a psychologist or trained in uh dealing with these emotional states, but ah we do want to bring it up as something that is important and a factor in your recovery. Number six, are you a self described perfectionist, a people pleaser, very hard on yourself or highly responsible for others? I'm sure there are uh other people that can describe the relevance of this better than I can, but ah we're now diving into certain personality types and I do mainly work with runners and I think a lot of runners would put themselves in this particular category. We do seem to be type A, uh highly strong data driven people that yeah, self-described perfectionists and very hard on ourselves. ah I put myself in this bucket as well. But this just opens up the conversation that there are certain vulnerabilities. Someone who describes themselves as having these traits tend to take on more stress. They tend to uh be a bit poor at managing their own stress in a positive way, like processing their stress, I guess you could say. ah This has been brought up in different books. uh There's several that I have read, I think the body keeps the score is one of the more popular ones, when the body says no. And there's a new one that's come out a few years ago, it's called mind mind your body. And ah there's just this, like I said, I think someone can better describe this. But ah if someone is like a self described perfectionist, they are taking on a lot. And sometimes the body bounces back and produces its own pain. And ah if you're in pain, holds onto it rather than processing it and moving on. This is like when emotional stress can manifest itself as physical pain. And so I think that was a very important question to put into this questionnaire. Number seven, would you say this injury has negatively impacted your social life? You could answer no, no, no, no, no for everything, but then tick yes for this one. um we know that pain is biopsychosocial and in that biopsychosocial is social. There was a paper that I found titled, Navigating the Biopsychosocial Landscape, a Systematic Review on the Association between Social Support and Chronic Pain. The purpose of this paper was to evaluate the association between social support and different aspects of chronic pain, such as pain intensity, pain interference, the quality of life, depression and anxiety. And what they found was people with a low social support were more likely to stay in pain long term. So higher perceived social support was linked with depression in 15 out of the 16 studies that they found. And so this brings up a few things. Okay, let's address and at least bring up has this negatively impacted your social life? And then if flagged, let's bring that into your recovery. How can we enhance your social life while still managing and rehabbing this injury. Number eight does thinking about your pain bring on more pain? If pain was purely mechanical, we wouldn't see this effect. However, we see time and time again, someone with chronic pain, with high levels of chronic pain, all they need to do is just bring attention to that area. And all of sudden, they notice more pain. Number nine is kind of the opposite of it does distraction. or enjoyable tasks decrease your pain. So number eight, does thinking about your pain bring on more pain? And number nine, does distraction or enjoyable tasks decrease your pain? This is where we really need to flag attention. How relevant is the attention that you're giving it? And is it effective to actually do the opposite and not think about your pain? Because I've had a lot of cases where someone says, you know, Brody, I go on the exact same 5k run. at the same pace, same amount of sleep, but it was just one day I was in a bad mood or I was a bit more fearful of my injury for whatever particular reason. And I was just giving more attention to that area. I was just thinking about it throughout the run. And then I just ended up in a lot of pain afterwards. However, a few days later, I went for that same run, same speed, but I was running with a friend or listening to a really engaging audio book. And I didn't think about my pain at all. And afterwards, I felt completely fine. And that's where we it's a tangible example where we can say, you giving yourself attention to this area is actually amplifying this attention and really ramping up the nervous system, giving it relevance that it doesn't need. And therefore the pain is uh reflecting that. And if you do say yes on question nine does distraction or enjoyable tasks decrease your pain. That's when we can layer in some interventions, we can have some insight and to be like, hey, let's go for a run, but let's think about other things. Let's do a body scan or uh guided meditation while you run or let's be more active, proactive running with a friend where you can be distracted or call someone call a friend, call your parents or call your best friend and have a chat while you run those sorts of things. Number 10. Have you experienced significant emotional distress? such as loss, hardship or trauma, either in the past or around the time the pain began. This is going back to the body keeps a score and those sort of books that really highlight the importance and link to managing stress, dealing with stress, having a history of trauma and those emotional ties embedded in your nervous system coming up and manifesting itself as physical pain. This isn't like one sub topic of this into this big conversation is around adverse childhood experiences. And there was a paper titled adverse childhood experiences in specific vulnerable developmental periods can increase the likelihood of chronic pain in adulthood results of a cross sectional study. They found that chronic pain is a highly prevalent symptom among hospital patients and is clearly associated So chronic pain is clearly associated with adverse childhood experiences. So again, we need to flag this and this questionnaire has picked up on a few things around, you know what, this injury did appear when we had a sudden loss in the family or I was dealing with something either like at work or some sort of hardship around this injury appearing. And then we can say, ah how relevant is it? We're not too sure, but let's dive deeper. and at least factor it into something that may present itself. um This is probably where a psychologist or psychiatrist would want to dig deeper. But if we keep these traumas or these emotional ties embedded within your nervous system, it's gonna be very hard to recover. But if we can bring it to the surface and address what needs to be addressed, that can significantly increase the odds of you actually healing. Okay, we're halfway there. Do my best to not drag on with these questions too much. Number 11, have you noticed a link between your pain levels and your emotional state? I'm surprised how many people answer yes for this. ah I guess now I'm not so surprised when I first created this. ah Some people just don't really realize it, but then once they answer yes and they start looking at patterns, looking at things with their chronic pain, they do say, you know what, some days I do wake up and I am a bit more anxious, a bit more fearful, a bit more pessimistic. And yes, my pain levels are definitely higher. Whereas some days I just have a better outlook on life. Um, had a good night's sleep. I moved through the day without really thinking about it. And yeah, my pain levels were fine. Then all of a sudden, uh, you know, I got dropped a whole bunch of workload on my desk and all of sudden all the pain returned something like that. As an example, um, number 12 does thinking about a task and aggravating tasks such as running fast or for people with PhD like sitting on hard surfaces does not doing the task, but just thinking about the task. Does that bring on your pain? If you answer yes, you're not alone. This is very common amongst people with chronic pain that have just these nervous system pathways that have been created. A lot of people, you know, will associate, okay, when I sit on a hard surface, pain comes on or any sitting pain comes on or running hills pain comes on and they have created that association so much in the nervous system has created its own, what fires together, wires together link between sitting and pain, pain and sitting, that even just the act of thinking about that task creates pain itself. And that's why I say just thinking about the task, bring on your pain. If you say yes, we're looking at uh a big, big link that you have these neural system networks. connected and we need to unravel those neural connections, which could be hard to do, but these interventions that we put in place can definitely help. Number 13, if you can sit or run for short periods without pain, are you still worried and searching for the pain coming on? I thought I'd throw this in here because this is a common trait with hypervigilance. Some people can think about the pain or search for the pain even when the pain's not there. It's a very, very poor have it to have but understandable why it's there. So for example, people with proximal hamstring tendinopathy, they might, they'll have various sitting tolerances. Some people five minutes, some people 50 minutes, some people, you know, multiple hours. um Let's just say your sitting tolerance is 30 minutes. You can typically sit symptom free for 30 minutes and then pain starts to increase from there. Some people like start to sit down and from five seconds in they're like, hmm, how's my pain? Is my pain there? No, my pain's not there. Is it coming on? I think I feel it there. And they're giving attention to their symptoms or searching for their symptoms, even when they're symptom free. Most people can, if you're a runner, I myself included, can think about if I've had an injury for a while, I'll go for a run and I start my run absolutely symptom free. But every step I'm like, is that pain there? Is that pain there? Is that pain there? Again, hypervigilance, paying too much attention to that area. not good for your recovery. And so that's why I flagged that with this question. Number 14 flags the same thing. Are you constantly thinking about your pain severity level when running, walking, sitting, strength training, rehab, those sorts of things. So a lot of people just like wrap themselves up into Brody says, should exercise with, it's okay to exercise if my pain is less than a four out of 10. And then when they run with pain or they sit with pain, they're like, is it a three, is it a two? Is it a four? I don't know. Maybe it's a three. Are you racking your brain and constantly thinking about the pain severity? know, exercise and rehab exercise is another one being like, okay, I'm doing my lunges. Is that a three? Is that a four? Again, not helpful if you're overthinking things. 15, do you obsess over scans like the MRI results or X-ray results? Do you obsess over a... different diagnosis, conflicting opinions from health professionals, any body imbalances or weaknesses. If you say yes, there is an increased odd that you have traits like emotional traits that aren't helpful for this recovery, hypervigilance being one of them. ah But fear, if you're constantly looking at your scans, there is a lot of fear around that, maybe uncertainty around ah the outcomes. maybe a lack of confidence from health professionals, a lack of trust from health professionals. All of these put people in a really vulnerable position that is really detrimental emotionally. We want people to be empowered. We want people to be confident. We want people to have a solid structure and path forward. This is one of the reasons why I constantly say, I'll jump on a consult with someone. I'll reassure them of their symptoms. come up with a plan for them. I'll be like, this is how we're going to start rebuilding the strength and capacity of this tendon. This is a structured systematic way we're going to go about it. And they messaged me the next day and be like, you know what, after our call, I feel so much better. Like my symptoms are feeling a lot less. We haven't done anything. We haven't even started our strengthening exercises yet. We haven't even really done anything that would reduce their pain yet. They feel so much better. And this is cause I feel like emotionally, They are feeling a bit more optimistic. They're feeling a bit more confident. They're feeling empowered. They're feeling like they have a good roadmap in place. And like I say, this is where the multifactorial elements of pain can come in. um The other thing I think about when I look at differential diagnoses and conflicting opinions, or maybe someone losing trust in the health professional, but maybe mistreated or ignored or feeling like they're not heard when it comes to the health professional setting. um doesn't directly tie in, but I did find a paper that was titled the perceived injustice and its relation to chronic pain in complex regional pain syndrome and chronic musculoskeletal pain. They found that there were like, if someone has perceived injustice, it influences, especially pain intensity through pain catastrophizing, they're more likely to catastrophize. And this interaction appears to be common in both the pain syndrome Cold Complex Regional Pain Syndrome and also in chronic musculoskeletal pain, which would be tendinopathies and all the other running related injuries out there. I do see people see a health professional and they say, oh, your glutes aren't switching on or you have one hip higher than the other. You have one leg shorter than the other. You have your core isn't activating properly. And this is causing all these imbalances and weaknesses and dysfunction in your body and clients and people go away thinking their bodies totally letting them down. And this just signals more peer and more fear, a lack of confidence, a lack of direction, and it's really not putting them in a great emotional state. uh There is research I can't exactly remember the exact numbers, but uh they looked at people with low back pain. And it was less to say I can't remember the exact numbers. But let's say you get 100 people with low back pain. And all you do is scan 50 of them and you don't give scans to the other 50. What they found is the ones who have the scan done of their lower back, they took twice as long as to recover as opposed to those who didn't have scans, despite what the scan showed. If the scan showed their back was completely healthy, they're still on average gonna take twice as long to recover. Why is that? Maybe because when you scan an area, it's creating more relevance in the brain. it creates more urgency, creates more fear, it opens up the possibility of, you know, the health professionals not really knowing what's going on. And that leads to lack of confidence. And so I wanna be really, really careful with scans, but asking this question, do you obsess over scans, differential diagnoses, conflicting opinions, um does highlight that, okay, maybe we do need to make this person more robust in terms of their decision-making, empower them to. a way through this recovery roadmap and see that this can be helped in your rehab can be successful with following the right plans and putting the right motions in place. And so that's why I found question 15 very useful. We're almost there. Number 16, do you heavily research your condition, constantly look for answers or obsess about the root cause of your injury? Again, this is flagging a lot of things, hypervigilance, fear, uncertainty, lack of confidence. uh Pretty much similar to the things we were discussing before. A lot of people just heavily, heavily researched their injury when they're in pain. It's just this link. They just go onto blogs and forums and Facebook groups and they're just constantly looking for things that's again, what is that doing to the brain? How is that rewiring your nervous system when you have that habit and that trait? 17, has pain become less localized, more widespread and or switches sides randomly? This is a classic. trait when it comes to an overactive nervous system, or just like body compensations as well. Because if you have an injury for a long time, maybe start sitting or walking differently, running differently, sitting differently, and that can trigger uh overload or just an imbalance elsewhere. But what we sometimes see is the nervous system gets so wound up as just on such like a thin edge, that now your threshold to perceive pain is quite low. And all of sudden, you do start getting these random symptoms that are more localized. Sometimes people get hamstring issues now on the other side, or they get plantar fasciitis on the other side, or um yeah, these traits of an overactive nervous system. 18, do you dread a future with this condition? This is similar to the all encompassing question, but if you answer yes, I do dread a future with this. How is that for your emotional state really flags that? I found a paper. titled reviewing psychological practices to enhance the psychological resilience processes in individuals with chronic pain. And it found people who became trapped in a cycle of catastrophizing, fear of movement and avoiding activities, they tended to experience worse pain, more disability and poorer recovery. This is just purely on an emotional standpoint. And so if someone dreads a future with this, that is fear. I will say that. they're more likely to avoid a lot of tasks, they're more likely to remove themselves from a social setting, and they're more likely to catastrophize. I would say dreading a future with this condition uh for some is catastrophizing in itself. But on the flip side, this paper found that people who developed more resilience, more acceptance, more optimism, positive emotions, and confidence in movement, they generally coped better and reported lower pain intensity over time. So the opposite is. effect and this is where we need to direct our interventions when we do identify that this is a big issue with your recovery. IE if you score poorly on this questionnaire. Two more number 19. Do you fear progressing your exercises or progressing your running? What they also found in the paper above was when people gradually expose themselves to movements that they fear. They're just like gradual exposure, the pain often didn't flare up like expected. And in many studies, pain actually decreased because they're sort of overcoming this thing emotionally as well as physically. And so if someone does say, okay, I know I need to do my dead lifts to overcome my PhD, but I have a real fear about doing a dead lift. We need to address that. We need to address the fear and making sure that we communicate ourselves in a way or have your first stepping stones into doing that exercise. where you feel safe, you feel like it's non-threatening and then we gradually expose you to trickier movements, harder movements in order to not only help stress the tissues to heal, but also overcome your fear of doing those tasks. And lastly, number 20, do minor increases in load lead to excessive flare-ups? I see this a lot in chronic. Patients, someone might increase their rehab exercises by five pounds and all of sudden they're flared up and they have a flare up for seven days. Doesn't explain, doesn't correlate, it doesn't match. The load that was increased doesn't match how excessive that flare up was. Because typically if someone, know, pokes above their load and it was a bit too excessive, you know, experience an increase in symptoms for 12 to 24 hours would be expected. But if it's excessive and it's prolonged, it's just signs of an overactive nervous system. So there's your 20 questions, count up your score. And I would say if you have scored poorly, which I would say for most would be if your symptoms or no, if your score is less than 60, I would say definitely start looking at the questions where you answered yes and start addressing the psychosocial factors. while pain is a biopsychosocial construct, recovery needs to also be a biopsychosocial construct. We can't just give you and assign you the right exercises and expect you to get better if there are these psychosocial influences that influence your pain. Like I say, I do have the chronic pain course. It dives into interventions to help you. The paper that I just mentioned above, it also highlighted that the brain itself can change, we call this neuroplasticity. And there are certain therapies to show that you can alter activity in the brain regions linked to pain, linked to fear, linked to your emotional regulation. Cognitive behavioral therapy is amongst them as one of those therapies. This is where a psychologist or a psychiatrist can start venturing into people, venturing with people who have chronic pain, mindfulness. There's also a therapy called acceptance and commitment therapy. I don't know too much about that, but that's what this paper found. What I've found helpful if someone is ranking quite low on this score, like it's not uncommon for me to have someone score 15, 10. I think 10 is probably the lowest I've seen. um And so they're answering yes to almost all of these things. ah But you know, we tailor this for you, but a lot of times my interventions are stop scoring, stop. Documenting symptoms, stop overthinking things. We just want distraction. We want to move away from hypervigilance because if someone is ranking quite low on this score, odds are they are very hypervigilant. We need to find things you enjoy, see what things are helpful that doesn't stir up this injury yet you find enjoyment with. Guided meditations can increase your parasympathetic drive because a lot of times when we're talking about fear and anxiety, we're looking at a very overactive sympathetic nervous system and the nervous system itself is really struggling to regulate and find moments in the day where you can get into the parasympathetic drive or primarily in that sympathetic parasympathetic state. So guided meditations can do that deep breathing, body scans, um they can obviously be helpful. uh Stress management, eating better, sleeping better, these kind of well-rounded um things. can definitely influence emotionally how you're feeling. A lot of times when we're in pain, we're depressed, we gravitate towards more of the junk food, the high processed foods and that just can perpetuate things. There was a paper titled Active and Passive Coping Strategies in Chronic Pain Patients. They looked at active coping strategies such as strategies where the person stays engaged, self-reliant and functional despite pain. They were found to be the most effective strategies when overcoming pain as opposed to passive coping strategies, which were more around helplessness, avoidance, avoidance of activities, reliance on others. So reliance purely on a health professional rather than the health professional relying on you or empowering you, catastrophization or just twiddling their thumbs and waiting for a QR. These are what we would call passive coping strategies. They just weren't found to be effective. Some practical examples that the paper included that were amongst the active coping strategies were continuing meaningful tasks despite the pain, staying socially engaged, distraction away from pain, positive self-talk such as like just repeating to yourself, I can manage this, I can handle this. A lot of people like hurt doesn't equal harm as a mantra that they repeat to themselves. Viewing pain as manageable rather than threatening. keeping active with the hobbies and chores. I guess that's the same as staying socially engaged and continuing meaningful activities. Mentally reframing pain sensations. A lot of people like to change the description rather than just having labeling everything as pain. could be like, hmm, this is more like a warming sensation or this is more like a pins and needles sensation. And we're just reframing those sensations and persisting with daily life instead of withdrawing. And so, those active coping strategies were found to be really effective in this paper. And so you need to identify how relevant is this for your recovery? Are these missing links? And do we need to label in some other interventions rather than just doing the right exercises? Because we want to do everything we can have this all encompassing approach to increase the odds of you healing and getting better. That might be enlisting a chronic pain specialist or a pain psychologist or someone who is more equipped at doing these things. ah But like I say, I do like to identify these. If you want to just dip your toes, the chronic pain course is there to not only do a deep dive into the pain, into the science and the research around these psychosocial influences, but then my take on all these interventions to help increase your odds of success. I'll leave that in the show notes, but hopefully this has opened your eyes. Maybe had you second guessing a lot of your thought processes, but if you are injured right now, walk away or take away after this podcast episode of just like tuning into what do I think about? When do I think about it? When does my pain increase? When does my pain decrease? How am I thinking? How am I feeling? And know this is a real element that's increasing your odds of success or hindering your ability to recover. Like I said, it's been a big game changer for me in terms of how I interact and identify things and come up with interventions with my clients. Hopefully it'll do the same for you. So hopefully you enjoy this episode and we'll catch you in the next one. If you are looking for more PhD resources, then check out my website link in the show notes. There you will find my free PhD five day course, other online content and ways you can personally connect with me. Well done for taking an active role in your rehab by listening to content. this and together we can start ticking off all of your rehab goals and finally overcome your PHT.