Thursday, November 26, 2015

The Dialogue of a Recovery Log

A patient walks into my office with a problem.  To them it is a medical condition that needs figuring out or solving and it is my job to solve their problem.  It is eerily similar to a criminal investigation.  So I rain the questions down...

What happened?
When did it happen?
Is it getting better, worse, staying the same?
What makes it better or worse?
Once symptoms are aggravated how long do they take to calm down?
Does time of day affect your symptoms?
How do your symptoms change when you ______ ?
At what distance/intensity/weight/repetitions/etc do your symptoms flare up?

It's almost like this brainy crew is waiting to help you.

Now imagine that the "victim" in this scenario could tell me nothing, or next to nothing, about the crime.  In rehabilitation I hear things like, "I'm not sure when or how it started, I just noticed it one day."  This may or may not be true.  Frankly, there is no real way of going back in time and figuring it out.  Some people are great historians and others can't remember what they had for lunch yesterday.

But how much can any of us really remember about a crime scene when we don't realize a crime is occurring?  It's hard to remember tiny details when we don't know that we should be paying attention.  I can't say much for actual crimes but I do have a simple answer for anyone struggling with an injury and it goes a little like this...

Log everything that happens after the incident.

Think of it this way- if you were to watch the behavior of everyone after a crime, you would probably get a reasonable idea of who was guilty. If you aren't paying attention, or if you don't know you are supposed to be paying attention, then you may never notice how the bad characters are giving themselves away.

Einstein said that if he had an hour to solve a problem he would "spend 55 minutes thinking about the problem and 5 minutes thinking about solutions."  What does he mean by this?  You need to understand the problem before coming up with solutions.  It sounds too obvious and yet this is not the way things always work in the world of medicine (or rehabilitation, fitness, health/wellness).  For this reason, one of the first things I ask my patients with a chronic injury to do is start a symptom log.  I want to understand their problem and a symptom log does exactly that.  When completed daily it gives a clear picture of what seems to be helping and/or hurting the patient's healing.  I could come up with a solution on day one, but that does not mean I am dealing with your problem.  I may get lucky and guess correctly.  I may be able to perform enough tests in the clinic that give me a strong suspicion of what your problem might be.  Based on this research, based on the history you provide, based on my experience, based on how your symptoms act in front of me in this given moment, your problem is probably THIS and therefore the solution is THIS.

Understanding the method for problem solving is a key part of Einstein's genius. 

Making educated guesses makes me look smart when I'm right.
But who is right ALL the time?
A symptom log confirms or denies both my and your perceptions about the problem.

When we watch how the characters involved in the crime behave we may find some surprising things.  Many of my perceptions about my injury were crushed by my symptom log.  I thought I needed supportive shoes but it turns out they were making my plantar fasciitis and hip pain worse.  I thought I should do more glute muscle activation/strength exercises, turns out they were making my hip stiffer and hurt more at the time.  I thought I shouldn't run until I was completely pain-free but it turned out barefoot running helped ease my symptoms and heal my body.  I kept a symptom log for about 5 months until I felt I understood my problem well.  I had seen steady progress in the right direction and each time I had a flare up I was able to understand why and quickly manage it.  Over time I had less flare ups while being able to achieve more physically.  At some point I decided I didn't have to log every day; I knew what was good for me and what was not.


Each tab was a week.
For each page I listed the days of the week along the top row.
Each row represented a different component (or character) that I wanted to keep track of...some examples are:

Workout: write down everything you did for exercise, be as specific as possible
Pain/Swelling: write down ALL areas of the body that you have pain, not just your primary injury or area of concern, log intensity 0-10/10 for each location of pain, note any changes to pain before or after activity or based on time of day.
Stiffness/soreness: log the same way you do for pain, location, intensity, and if it changes
Rehab/Therapy/Treatments: any treatment you had (massage, dry needling, manual therapy, etc), any program you are testing (stretching program, specific exercises targeted to your problem).
Shoes worn: if applicable
Medication: if applicable
Other: you can have whatever rows you want.  I kept an "other" section where I sometimes wrote my "perceptions."  For example, one day I wrote that, "minimalist running seems to be the best thing for my foot and hip."  Other days I dug deeper into how my hip was acting, "the clunking is still there when I swing my leg."  You can't be too specific, only too vague.

This is about 4 months into my recovery log.  On Sunday I made a note that I lost good running technique if I "wore too much shoe."  I'd been doing mostly barefoot running prior to the month of April.

I knew by this time that barefoot running felt good to my foot and hip but I was trying to gauge if I could get back in shoes.  Over time I learned I could wear more shoe but I would have to maintain correct technique.  Be careful about judging yourself or your progress, just write the facts down and see what you can change/modify to make things better.  You are basically your own science experiment so keep your emotions in check here.

This was 3 days before when I attempted to run in my shoes and I couldn't do it without pain, so I went back to barefoot.  On 3/6/2015 I was able to run okay with the shoes if I really watched my form.  Remember your progress will not be stagnant and symptoms will change, some days you can get by and some days you can't.

Going back further in time to February 2015 when my mileage was still very low.  Note that I described the trails/terrain.  This could be helpful later because I may run the same distance but feel different on a different trail / elevation change / road / etc.  It may be valuable information later about how terrain affects my symptoms.

Stepping back further in time, by keeping the log for about a month (since late December 2014), I began to realize that just spending time in minimal shoes and not being too stationary were going to be important components in my recovery.

This is an amazing post a few days later (by the way, I had a concussion that month if you're wondering).  I'm basically saying that "based on my recovery log" I feel that I will be able to heal and make progress.  In other words, I'm not better yet, but I'm learning what works and I have more power over my symptoms.  This was a major paradigm shift from a month earlier when I'd had foot pain for a year and hip pain for 6 months and hadn't made progress in all that time.  ONE month of logging changed my mindset completely.

It is a daily commitment to yourself to keep a recovery log.  I am not selling you instant gratification because the body does not heal itself instantaneously.  I am selling you common sense and a way to listen to your body.  This will make you smarter over time which is way better than relying on someone who doesn't live in your body every day and who doesn't have the same level of investment in your health as you do.  Even if you cannot fix yourself and you need a doctor or a therapist, you will make it much easier and more efficient for your doctor or provider to help you.

This is seriously the opposite of success.

With my recovery log I was able to go to my military doctor and ask for a "soft shoe" profile with 100% confidence and 100% evidence of what I needed to heal.  How amazing is that?  He reviewed the evidence and agreed with my unconventional treatment to plantar fasciitis..."well I guess if the boots are clearly hurting and going minimalist has improved your symptoms, we will go with it."  Without the symptom log, I may not have figured out how to heal myself, I would have continued to make the assumption that I needed supportive shoes.  The symptom log also demonstrated to my doctor that I was fully committed to healing, he took me seriously right away and demonstrated he was on my side by offering his help, time out of those darn boots!

These boots are heavy, clunky, and totally mess up my proprioception!

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