Critical Decision Making and the Healing Process: Part 1

Image caption:  Crashpads and appropriate spotters are climbing critical decision making 101…double fail!

Critical decision making is one of the most important aspects, and oftentimes the key component, for the prevention and treatment of injuries.  Our bodies (and beings) have the amazing ability to heal themselves in most cases, aside from cases of severe trauma such as displaced fractures.  Its our job to create the environment to allow our bodies to do what they know how to do…heal.

There can be blockages to the healing process so we first have to figure out what those blockages are and then remove them.  This takes having a keen awareness of the things that are limiting the healing as well as those that are promoting it.   Listening to the signals that our bodies send, such as pain, depression, and anxiety, help us find the path that leads to healing.  This awareness ultimately gives us the power to make decisions that allow us to return to the life and activities that we wish for.  Pain and inflammation (discussed below) are important, albeit uncomfortable, parts of the healing process.

Understanding the healing process from a physiological perspective is a helpful start to show that healing is in fact a process, not an event.  For a more in depth description, check out the first chapter of Beyond Tape or the references below.^1-11 Simply put, there are three main phases:

1. Inflammation (roughly days 0-7):  When an injury occurs, the body sends an increased supply of blood to the area which bring in cells that remove dead or damaged tissue.   When those cells are finished, they call in a new group of cells to come in to lay down new tissue.  In addition to the cells, various chemical messengers are released, some of which signal danger (or pain) that prevent the person from continuing to touch the hot stove, for example.
2. Proliferation (roughly days 7-21):  New tissue gets laid down.  Initially, the new tissue is disorganized, like a clump of cooked spaghetti.
3. Remodeling/maturation (roughly day 21-weeks/months):  The disorganized tissue realigns in a more functional way so we can return to normal activities.  This realignment occurs from finding the balance of stressing the tissues (range of motion, stretching, strengthening, functional activities) enough to create healthy adaptation while not stressing them enough to cause more injury.

Now that we have the physiology out of the way, here are some other common themes that hold people back.  I think these topics are fascinating and shifted my personal mindset from seeing my own unhealthy decisions as “bonehead Mike decisions” to ways that I as a human being have a tendency to sabotage myself.   Having the awareness that we’re all subject to things like cognitive biases, allows us to think more critically about a decision before it takes us down a hard and unnecessary road.  Check out the lecture series “The Art of Critical Decision Making” with Michael Roberto from the Teaching Company and Daniel Kahneman’s book Thinking, Fast and Slow for a more in-depth discussion of these types of topics.

1. Sunk Cost Effect

The “sunk cost effect” is a term typically used in economics that applies to many other areas of life as well (we’ll use rock climbing as an example). It is “an irrational economic decision to invest more future resources after a prior investment has been made (costs are sunk) compared to a similar situation
without a prior investment”.¹²

For climbing, this is exemplified by making the decision to continue climbing when there is an injury present because of the desire to avoid wasting all the time, effort, and possibly money that has been spent training to reach a goal. This may involve working toward specific goals of boulder problems, red points, or summits. The climber finds herself in a situation where there are obstacles to those goals in the form of an injury, illness, or uncooperative weather. The rational decision would be to back off in order to return to climbing in a healthy
state. The irrational decision would be to ignore the obstacles and continue digging further into the hole. These irrational decisions are often easy to see in hindsight, but we are all capable of justifying unhealthy decisions when the sunk cost effect is present. Making the rational decision could mean the difference between returning
to climbing after a sprain or strain heals in a couple weeks versus doing serious damage that eventually puts the climber out for months or a year.

For mountain climbing, the difference could be aborting the mission in order to make another attempt on a later date versus continuing on and risking serious injury or death. The sunk cost effect was thought to be a major factor in the Mt. Everest tragedy in 1996 where 5 climbers died, including 2 experienced expedition leaders.¹³ Sticking to turn around times and acknowledging approaching ominous weather becomes more difficult the more prior investment has been made. Try to step back and see the bigger picture before ignoring the signs.

2. Good Pain Versus Bad Pain

Most of us were told some form of “no pain, no gain” over and over starting from a young age.  Is this a true statement?  As with most other things in life, it depends.  There is injurious pain (pain signifying injury or danger) and therapeutic pain (discomfort that leads to beneficial results).  Take a person who is training for a race and doing speed work at the track.  It’s hard and is becoming mentally painful to continue, but they know if they do a couple more sprints it will help their performance (therapeutic pain).  If that person broke their ankle, they hopefully wouldn’t continue to run because it will not help their performance (injurious pain).  That’s an extreme example, but you get the point.

This concept also comes up when talking about performing self body work at home.  I practice and teach people to perform myofascial release on themselves, which is sinking into an area that feels tight and tender and holding direct pressure on the area for 2-3 or more minutes of time to release restricted areas.  People often describe this a “good hurt”.  The idea is to work with your body rather than to beat it into submission.

This is a part of what is probably the most important message from this article…listen to the body, as well as to the environment, and to the signals they are sending. As they say, “if you listen to your body when it whispers, you won’t have to hear it scream”. Paige, Fiore, et al describe this perfectly: “Climbers should be encouraged to immediately stop climbing when they feel sharp pain. This is especially true of finger pain and if symptoms appear while “working” a move. This seems obvious, but successful climbers, like other successful athletes, have often conditioned themselves to ignore discomfort and to push through difficulties. Climbers must learn to differentiate between pushing oneself despite exhaustion and muscular fatigue and pushing oneself into a serious connective tissue injury.” ¹⁴

3. All or None Versus Modification

A crucial aspect of healing is determining aspects of our lives that either help the healing process or slow it down.  I think it helps to just start with concrete aspects without worrying about how you might modify those aspects.

For example, take a person who loves gardening, which is an activity that increases their pain.  People are often reluctant to even start this conversation, stating, “well I have to garden!” (or work or take care of my kids, etc.).  Starting from a place of either gardening or not gardening prevents us from considering the possibility of modification, or finding the balance between doing what we want but not in a way that causes further injury.  Once we have the aspect (gardening in this case), we can look at variables that might be modified. For example, length of time performing the task.  Instead of gardening for 4 hours straight, is it possible to try 1 hour blocks with a 30 minute rest break in between?  This not only might help the body heal, but it also allows a person to assess their progress over time (start with 1 hour for the first week, increase to 1.5 hours for the next if it feels ok, then 2 hours, etc.).

Some other examples of variables that can be modified might be the various activities (digging vs. watering vs. weeding vs. planting), time of day (does the pain tend to be worse first thing in the morning or in the evening?), the possibility of having someone else temporarily perform some of the more strenuous activities, body position (standing and bending over versus using a stool or bench).  The goal is to create the environment that allows your body to heal itself by making logical, rational decisions.  It helps to see these modifications as temporary, while you’re allowing your body to heal. I often suggest that if a person is having trouble deciding if they should perform a certain activity, pretend a loved one is telling them about this exact situation happening to that loved one.  What advice would you give them?

4. Real versus perceived threat 

I see lots of folks who haven’t tried a certain activity because they think it will hurt.  Oftentimes when we try the activity in the clinic, they find that its either not painful, or we’re able to modify it so they can start to ease into the activity.  Its a powerful feeling to realize that you may be capable of things you thought you were not and that there is at least the possibility you can return to your life.

There are many understandable reasons why we all avoid things that we think will hurt.  Sometimes people are told they shouldn’t do certain things (you should stop running, lifting, squatting, bending, etc.).  There can be important reasons for these suggestions (avoiding bending over or prolonged slouched positions with an acute spinal compression fracture, for example) but that’s not a long term plan.  In most cases, people should be able to return to their normal daily lives after an injury.

Problems that show up on imaging (Xrays, MRIs, etc.) can be disconcerting.  A lot of folks are under the impression that once damage is done (disc herniation, meniscus tear, arthritis, etc.) then it will be there forever.  In reality, these injuries heal the majority of the time^15-27,   or may not actually be the cause of the pain.^28-39  There are certainly times when your body may require some outside help (surgery, etc.), such as a herniated disc stopping the nerve signal to the area it controls which can cause significant and specific weakness, lack of sensation, or bowel/bladder problems.  Again though, most of the time the body can heal.

What you can do:  Gain greater and greater awareness into the meaning the signals your body sends.  See pain as a crucial tool to help you heal yourself.  Ease into activities in a controlled manner, initially avoiding forceful movements using momentum (starting a lawn mower, for example).  Consider how your body feels during the activity, immediately after, and the next day.   Assume you can heal, you may just not have figured out how yet.  People who believe they can heal make different decisions than those that don’t, which will be discussed further in Part 2.

Check out Beyond Tape: The Guide to Climbing Injury Prevention and Treatment for more information about warming up, stretching, and other climbing (and non-climbing) injury related topics.  Like my facebook page for updates and more information and rate/review Beyond Tape on my website or here.  My primary motivations for Beyond Tape and any of the posts are to:       1. Check out the most relevant and up-to-date research for each topic in order to dispel myths, sift out conflicting views, and help people to prevent or heal from injuries – letting me know about new research or opposing views is helpful and greatly appreciated       2. Contribute to the local and global communities by donating 100% of my net profits from Beyond Tape to service-based non-profit organizations, such as Rotary International, Doctor’s Without Borders, Access Fund, etc.

References:

¹Kannus P1, Parkkari J, Järvinen TL, Järvinen TA, Järvinen M. Basic science and clinical studies coincide: active treatment approach is needed after a sports injury. Scand J Med Sci Sports. 2003 Jun;13(3):150-4.
²Sharma P, Maffulli N. Tendon injury and tendinopathy: healing and repair. J. BoneJoint Surg. 2005; 87:187Y202.
³James R1, Kesturu G, et al. Tendon: biology, biomechanics, repair, growth factors, and evolving treatment options. J Hand Surg Am. 2008 Jan;33(1):102-12.
⁴Hess GP, Cappiello WL, Poole RM, et al: Prevention and treatment of overuse tendon injuries. S p o r t s M e d 8 : 371–384, 1989.
⁵Järvinen TA1, Järvinen TL, et al. Muscle injuries: biology and treatment. Am J Sports Med. 2005 May;33(5):745-64.
⁶Bondesen BA1, Mills ST, et al. The COX-2 pathway is essential during early stages of skeletal muscle regeneration. Am J Physiol Cell Physiol. 2004 Aug;287(2):C475-83.
⁷Schleip R1, Müller DG. Training principles for fascial connective tissues: scientific foundation and suggested practical applications. J Bodyw Mov Ther. 2013 Jan;17(1):103-15.
⁸Lu H1, Huang D, et al. Macrophages recruited via CCR2 produce insulin-like growth factor-1 to repair acute skeletal muscle injury. FASEB J. 2011 Jan;25(1):358-69.
⁹Arnold L1, Henry A, et al. Inflammatory monocytes recruited after skeletal muscle injury switch into antiinflammatory macrophages to support myogenesis. J Exp Med. 2007 May 14;204(5):1057-69.
¹⁰Smith C1, Kruger MJ, et al. The inflammatory response to skeletal muscle injury: illuminating complexities. Sports Med. 2008;38(11):947-69.
¹¹Wren TA, Yerby SA, et al. Mechanical properties of the human achilles tendon. Clin Biomech (Bristol, Avon). 2001 Mar;16(3):245-51.
¹²Strough J1, Karns TE, Schlosnagle L. Decision-making heuristics and biases across the life span. Ann N Y Acad Sci. 2011 Oct;1235:57-74.
¹³Roberto, M. The Art of Critical Decision Making. The Teaching Company. 2009.
¹⁴Paige TE, Fiore DC, Houston JD. Injury in traditional and sport rock climbing. Wilderness and Environmental Medicine, 9,2-7 (1998).
¹⁵Benson RT1, Tavares SP, et al.  Conservatively treated massive prolapsed discs: a 7-year follow-up.  Ann R Coll Surg Engl. 2010 Mar;92(2):147-53.
¹⁶Saal JA1, Saal JS. Nonoperative treatment of herniated lumbar intervertebral disc with radiculopathy. An outcome study. Spine (Phila Pa 1976). 1989 Apr;14(4):431-7.
¹⁷ Yukawa Y1, Kato F, et al. Serial magnetic resonance imaging follow-up study of lumbar disc herniation conservatively treated for average 30 months: relation between reduction of herniation and degeneration of disc. J Spinal Disord. 1996 Jun;9(3):251-6.
¹⁸Masui T1, Yukawa Y, et al. Natural history of patients with lumbar disc herniation observed by magnetic resonance imaging for minimum 7 years. J Spinal Disord Tech. 2005 Apr;18(2):121-6.
¹⁹Matsubara Y1, Kato F, Mimatsu K, Kajino G, Nakamura S, Nitta H. Serial changes on MRI in lumbar disc herniations treated conservatively. Neuroradiology. 1995 Jul;37(5):378-83.
²⁰Komori H, Okawa A, et al.  Contrast-enhanced magnetic resonance imaging in conservative management of lumbar disc herniation. Spine (Phila Pa 1976). 1998 Jan 1;23(1):67-73.
²¹Autio RA1, Karppinen J, et al.  Determinants of spontaneous resorption of intervertebral disc herniations.  Spine (Phila Pa 1976). 2006 May 15;31(11):1247-52.
²² Anakwenze OA1, Namdari S, et al. Athletic performance outcomes following lumbar discectomy in professional basketball players. Spine (Phila Pa 1976). 2010 Apr 1;35(7):825-8.
²³Hsu WK1. Performance-based outcomes following lumbar discectomy in professional athletes in the National Football League. Spine (Phila Pa 1976). 2010 May 20;35(12):1247-51.
²⁴Mochida K1, Komori H, Okawa A, Muneta T, Haro H, Shinomiya K. Regression of cervical disc herniation observed on magnetic resonance images. Spine (Phila Pa 1976). 1998 May 1;23(9):990-5; discussion 996-7.
²⁵Lee DY1, Park YJ2, et al. Arthroscopic meniscal surgery versus conservative management in patients aged 40 years and older: a meta-analysis. Arch Orthop Trauma Surg. 2018 Dec;138(12):1731-1739.
²⁶Sihvonen R1, Paavola M2, et al.  Arthroscopic partial meniscectomy versus placebo surgery for a degenerative meniscus tear: a 2-year follow-up of the randomised controlled trial.  Ann Rheum Dis. 2018 Feb;77(2):188-195.
²⁷Azam M1, Shenoy R2.  The Role of Arthroscopic Partial Meniscectomy in the Management of Degenerative Meniscus Tears: A Review of the Recent Literature.  Open Orthop J. 2016 Dec 30;10:797-804.
²⁸Boden SD1, Davis DO, et al. Abnormal magnetic-resonance scans of the lumbar spine in asymptomatic subjects. A prospective investigation. J Bone Joint Surg Am. 1990 Mar;72(3):403-8.
²⁹Deyo RA. Magnetic resonance imaging of the lumbar spine. Terrific test or tar baby? N Engl J Med. 1994 Jul 14;331(2):115-6.
³⁰Brinjikji W1, Luetmer PH2, et al. Systematic literature review of imaging features of spinal degeneration in asymptomatic populations. AJNR Am J Neuroradiol. 2015 Apr;36(4):811-6.
³¹Bedson J1, Croft PR.. The discordance between clinical and radiographic knee osteoarthritis: a systematic search and summary of the literature. BMC Musculoskelet Disord. 2008 Sep 2;9:116.
³²Beattie KA1, Boulos P, et al. Abnormalities identified in the knees of asymptomatic volunteers using peripheral magnetic resonance imaging. Osteoarthritis Cartilage. 2005 Mar;13(3):181-6.
³³Guermazi A1, Niu J, et al. Prevalence of abnormalities in knees detected by MRI in adults without knee osteoarthritis: population based observational study (Framingham Osteoarthritis Study). BMJ. 2012 Aug 29;345:e5339.
³⁴Schwartzberg R1, Reuss BL, et al. High Prevalence of Superior Labral Tears Diagnosed by MRI in Middle-Aged Patients With Asymptomatic Shoulders. Orthop J Sports Med. 2016 Jan 5;4(1):2325967115623212.
³⁵Kälin PS1, Crawford RJ, et al. Shoulder muscle volume and fat content in healthy adult volunteers: quantification with DIXON MRI to determine the influence of demographics and handedness. Skeletal Radiol. 2018 Oct;47(10):1393-1402.
³⁶Nakashima H1, Yukawa Y, et al. Abnormal findings on magnetic resonance images of the cervical spines in 1211 asymptomatic subjects. Spine (Phila Pa 1976). 2015 Mar 15;40(6):392-8.
³⁷Register B1, Pennock AT, et al. Prevalence of abnormal hip findings in asymptomatic participants: a prospective, blinded study. Am J Sports Med. 2012 Dec;40(12):2720-4.
³⁸Alyas F1, Turner M, Connell D. MRI findings in the lumbar spines of asymptomatic, adolescent, elite tennis players. Br J Sports Med. 2007 Nov;41(11):836-41; discussion 841.
³⁹Videman T1, Battié MC, et al.  Associations between back pain history and lumbar MRI findings.  Spine (Phila Pa 1976). 2003 Mar 15;28(6):582-8.