There’s always something you can work on, even when you’re hurting.
Progressive Training
How to take “baby steps” to recovery from an injury or pain problem
Every significant injury or pain problem is a bit of a logistical nightmare — a difficult puzzle to solve, while life keeps rolling on. Most challenges are met by breaking them up into smaller, more manageable steps. This is sometimes called “progressive training” by coaches, trainers, physical therapists and sports medicine doctors.
All serious athletes train progressively because it’s just the only way to get the job done properly and safely. The principle is the same whether you are fit and working towards an athletic goal, or injured or sick and simply trying to get back to normal. It’s as powerful an idea as it is a simple one.
This article covers a bunch of miscellaneous ideas about how to apply the principal of progressive training in rehabilitation. Scan for the ones that might apply to you. It’s not just for people dealing with sports injuries — the concepts are equally applicable to trying to recover from low back pain or fibromyalgia. Taking “baby steps” is a useful idea in any kind of recovery and healing.
You can recover from practically anything with baby steps… but not everything
If it’s possible to restore function after an injury, it can usually be done just by gradually increasing usage — even if the progression must be very gradual indeed, especially at first, taking it easier than you want for longer than you thought you’d have to.
But can it be rehabilitated? Not every injury can be. When you’ve lost a limb, this is clear, but the impact of many other injuries is more subtle: failures to heal that defy explanation. Fracture nonunion is one of the most dramatic and tragic examples in medicine. Many overuse injuries also persist — less critical, but just as mysterious. Some musculoskeletal conditions have deep, strange roots — like frozen shoulder — and baby steps may get you nowhere.
Pain itself often persists beyond any other sign of injury, and this is often the mechanism of stubborness in injuries that don’t seem to heal. Chronic pain can often also be dealth with one tiny step at a time, but not necessarily. Sometimes chronic pain is a really difficult puzzle to solve (obviously).
Regardless, with most injuries, you have to at least try “gradually increasing usage”… and it will probably work. But, if you can’t resolve a functional limitation with a slow enough progression back to normal activity, that’s important information. You’re either going to succeed … or learn something vital in the effort.
Baby steps, baby!
The key to most injury rehabilitation & training is baby steps, consistently over annoyingly long periods. Almost no matter what’s wrong with you, you can always safely & productively push yourself to do just slightly more than you are comfortable with.
Yes, that is me.
First things first: rest
This article is mostly about how to get back into the action in small steps, but resting properly is the other side of the rehab coin, particularly the crucial concept of “relative” rest: taking a break from activities that are a problem, but emphasizing and continuing with activities that are not. In nearly every kind of healing process, there’s always something you can work on.
See The Art of Rest for more much more about how to rest — it’s actually harder than you think. And probably more important, too. Rest is generally given short shrift as an option. But rest is really just the first of the baby steps. The progressive rehab begins with taking it so easy that it looks more like rest than exercise… but rest is the beginning and basically just consists of extremely easy steps. Crawling before walking.
Patience! Especially for athletes
Everyone is eager to heal, of course. Avid walkers cannot wait to get back to walking. But casual athletes are the worst: they routinely fail to heal because they try to get back into the game too quickly. They rest only when forced to, and return to their sport at nearly full intensity without any transitional, compromise activity. They have two settings: “reluctantly taking it easy” and “full on.” I am always a little amused when a soccer player who’s torn a hamstring take two weeks off and then goes and tries to play another game to “test it out.” That usually doesn’t go very well …
Competitive intensity is the opposite of a baby step: it is a huge jump in intensity. Huge! Break that step up into smaller ones: test yourself as hard as possible with drills or light competition with friendly players, before testing yourself against “enemy” players. It’s amazing how an injury that was fine in practice can flare up handily twenty minutes into a game!
For the avoiders and procrastinators: try just showing up … and that’s all
Many people who are not athletic in the first place often fail to get the exercise they need because they don’t like athletics and don’t want to do what athletes do. That first step seems like a doozy. But it is not necessary — or wise — to try to create an exercise habit by starting with the kinds of things that athletic people are doing! If you’re not fit yet, why would you do an activity that requires fitness? You need to get fit first! So start with something easier — a lot easier. One of my massage therapy clients, back in the 2000s, offered me one of the best “baby steps” ideas I’ve ever come across:
I found it impossible to go to the gym at first. It was just too much. It was bad enough getting motivated to leave the house, and the idea of actually suffering and sweating when I got to the gym was unbearable. So I decided to start just with the challenge of showing up, just to get in the habit of being there, and I would worry about actually challenging myself with exercise later. So I started going to the gym just to get to do something really, really easy, like walking on the treadmill for twenty minutes. Before long, going the gym every Saturday morning was routine, and once that was established it was a lot easier to actually start exercising while I was there!
I really like the mental picture of going to the gym … and not really doing much. Just showing up, mostly! The principle could be applied to many kinds of activities: start by just showing up.
The easiest of all possible exercises
As important as rest may be, total rest is rarely a good idea. Even in the very earliest stages of healing, it is important to do whatever you can: use it or lose it! PF-ROM Exercises are a perfect, often neglected, early rehabilitation exercise.
Mobilize! are the next baby step: just slightly more intense, but still extremely easy. These are often the “missing pieces” that people try to skip past. Many people struggling with chronic pain need to do PF-ROM or mobilization exercises for a while before moving on to anything else — possibly quite a long while.
Muscle training: endurance before strength (and it’s easier than you think)
If you’ve done a lot of resting, and pain-free range of motion exercises, and mobilizations, what’s next? Resistance. Weights. You are your muscles. If your muscles are fit, you are fit.
The gym is not for everyone, but a lot of muscle work can be done without a gym. And it is generally easier and more efficient than most people realize. If the average person knew how surprisingly efficient strength training can be, they’d be a lot more willing to tackle it.
Also, divide muscular training into endurance training and strength training. It’s amazing how often people (especially guys) try to go straight to the intensity of strength training. One step at a time! Gentler, more repetitive endurance training is a good way to prepare for the “high load, low reps” of strength training.
A helping hand: restoring movement by finding ways to make it easier
One of the simplest ways of making recovery easier is to make a painful movement easier by assisting it — either with another body part, or with some physical contrivance.
Consider the example of a common shoulder problem, supraspinatus tendinitis. In this irritating condition, which often becomes chronic and is routinely complicated by long-lasting trigger points (muscle knots), it can become extremely painful to abduct the shoulder (lifting the arm out to the side).
So help it!
By simply reaching across and lifting the bad arm with the good one, the movement can be made possible again. Even just a 10% boost can make it possible to start practicing the movement with much less pain. For instance, a classic therapeutic exercise for this condition simply uses a nearby wall — by “crawling” up the wall with the fingers, the shoulder is slowly abducted with minimal stress.
There are many creative ways to assist movements. You can use walls, door frames, furniture, pillows, clothing, yoga blocks and straps, and on and on. Here are three more examples:
- If you have a crick in the neck, it can be extremely painful to turn your head from side to side when upright and activating all of your postural musculature. Yet if you lie down, rolling your head side to side is relatively easy and painless!
- In a painful low back, the muscles tend to cramp when the spine is in extension (hollow low back), which can make it almost impossible to lie face down. So make it easier: lie face down with a thin pillow under your belly, to achieve a supported, intermediate position.
- Got an injury that is aggravated by bearing weight? Get into a pool! Water training makes all kinds of painful activities easier.
Support rehabilitation by solving life problems
“Solving life problems” doesn’t exactly sound like a baby step, and it is a step that often gets neglected.
Life is messy. People often struggle with rehabilitation not because rehabilitation itself is so very difficult, but because life is too chaotic. In fact, this is probably the case for the majority of people who have chronic pain. Unravelling logistics knots like this is an important part of progression in rehabilitation. Just as with the process of rehabilitation itself, you have to break the challenge down into smaller, achievable steps.
For instance, perhaps you know that you “need to get some more exercise,” but you perpetually put it off because you are severely fatigued from a lack of sleep. You can’t sleep because your partner snores and you don’t have a spare bedroom, and because you have this problem at work that has you waking up at 4am every night worrying anyway. And yet there is no solving either the snoring or the work thing without still more basic problem solving!
And yet insomnia increases pain and retards healing and recovery in many ways. By making you avoid exercise, for instance. So one of the “baby” steps in a lot of rehabilitation is fixing insomnia. Easier said than done, right? Of course. All the more reason to focus on that one, basic problem first.
Solving training dilemmas: damned if you do, damned if you don’t
One of the most common problems in progressive rehab is conflicting goals. The most common stand-off between goals is the need to build strength versus the need to rest: how can you do both? For instance, what if you had significant muscle wasting in your quadriceps from a nerve injury, but you also had knee pain that is severely aggravated by training? People are often stumped by a dilemma like this and end up doing nothing, or (probably worse) some therapist convinces them that only strengthening matters.
In this example, and many others, neither strengthening or rest can be dismissed as important components of rehab. Usually you somehow you have to do both. And yet each one threatens the other. Dang!
When you have too mutually exclusive goals in rehab, all you can do is advance towards each of them cautiously:
- a phase of cautious strengthening
- a phase of cautious resting
- a phase of cautious strengthening
- a phase of cautious resting
- a phase of cautious strengthening
- a phase of cautious resting
Few goals are truly mutually exclusive. There’s almost always some wiggle room: one of them is a bit easier than the other, and you can make a little headway on one front without doing to much harm to the other goal. In the case of strength versus rest, it is possible to build strength quite efficiently (more than most people realize) … and then give your knee a good rest from that effort, without sacrificing much strength, because strength gains are also not lost as quickly as people fear.
Solving a training dilemma just involves even smaller and more carefully considered “baby steps.”
Pacing
Many a thing that can’t be done quickly can be done slowly.
If you can’t stoop over quickly without pain, then don’t stoop over quickly — try stooping slowly, for now, maybe for quite a while. Too many patients feel defeated when they can only perform an action or activity slowly. It’s not defeat — it’s an intermediate step.
Micro goals
Sometimes it pays to break a challenge up into really small steps: so small you don’t even notice them.
Consider the case of someone who is in severe chronic pain, and finds everything exhausting, and yet badly needs to start getting some light exercise as a first step towards healing. This person may feel so fatigued that even twenty minutes of walking wipes her out and ruins the rest of the day. People in this position often feel helpless, as though there is no exercise easy enough that they can start it.
I would advise this person to get a timer, and start doing three extremely short “walks” a day, each exactly five minutes long. Every day, she should add thirty seconds to each walk. Just thirty seconds!
For contrast, consider a much healthier person: a marathoner with a double-whammy of iliotibial band syndrome and shin splints, two common and frustrating injuries. This person is extremely fit in general, but faces a difficult challenge nevertheless. Having gone through the early stages of rehab, it is absolutely crucial to get back into running slowly, or both injuries will probably come roaring back.
I would advise this runner to get a timer, and start doing three extremely short “runs” a day, each exactly five minutes long. Every day, he should add thirty seconds to each run. Just thirty seconds!
Baby steps …
Be creative, and good luck!
About Paul Ingraham
I am a science writer in Vancouver, Canada. I was a Registered Massage Therapist for a decade and the assistant editor of ScienceBasedMedicine.org for several years. I’ve had many injuries as a runner and ultimate player, and I’ve been a chronic pain patient myself since 2015. Full bio. See you on Facebook or Twitter., or subscribe:
What’s new in this article?
2019 — New section (first update here in ages): “You can recover from practically anything with baby steps… but not everything.”
2006 — Publication.
Related Reading
Notes
- Amann M, Blain GM, Proctor LT, et al. Group III and IV muscle afferents contribute to ventilatory and cardiovascular response to rhythmic exercise in humans. J Appl Physiol (1985). 2010 Oct;109(4):966–76. PubMed 20634355 ❐ PainSci Bibliography 51618 ❐
- Hutchinson A. Endure: Mind, body, and the curiously elastic limits of human performance. First edition ed. William Morrow; 2018.
Sports science writer Alex Hutchinson has been cited all over the place on PainScience.com, since the earliest days. His fantastic 2018 book explores the “curiously elastic” limits on athletic performance, with one fascinating example after example of how performance is a function of surprising variables.
Although inherently interesting, this book is of particular interest to me because it is tangentially relevant to pain. Performance is not pain, but they are related: they are both are complex human experiences, both strongly affected by sensation, perception, psychology, and context. And pain is also one of the things that limits performance! Or not, depending on the context.
Alex's first book is a more general exploration of exercise science, and also well worth a read: Which Comes First, Cardio or Weights? Fitness myths, training truths, and other surprising discoveries from the science of exercise.
