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The Dose Transcript for April 25, 2024

Host: Brian Goldman

BRIAN GOLDMAN: Hi, I'm Dr. Brian Goldman. Welcome to The Dose. As an emergency physician, I treat injuries, sports and otherwise, each and every ship that I work, and I prescribe the usual rest, ice and Tylenol, elevation, etc. But that's the moment when I get stuck. And I'll tell you that recently, we heard from a listener, and I hear this from a lot of my patients. This listener does regular exercise, has a regular routine, and I gather, got injured and wanted to know, what do I do to keep myself on track, you know, given the fact that I've been injured? They want to know what they can do now so that they don't slide, and on the other hand, so that they don't make things worse. So this week, we're asking, how can I safely stay active while injured? Hi, Laura. Welcome to The Dose.

LAURA CRUZ: Hi. Thanks, Brian. Thanks for having me.

BRIAN GOLDMAN: Really looking forward to talking to you. I'm going to ask you, first of all, who would you rather give advice to on how to keep exercising despite being injured, a sedentary person or a fitness buff?

LAURA CRUZ: Oh, ah, great question. They both have different perspectives. So the sedentary person may go, oh well, that's fine, I can rest. But the active person, we need to put the brakes on a little bit usually. I guess it depends on what they perceive their next steps to be, because both can be hard or both can be easy.

BRIAN GOLDMAN: Which is why we have come to you for advice. But before we begin, can you give us a hi, my name is? Tell us what you do and where you do it. Just adlib.

LAURA CRUZ: Hi, my name is Laura Cruz, and I'm a primary care sport and exercise medicine physician in Toronto. I've been doing this exclusively for over 20 years now. My background's in family medicine, and I'm part of a multidisciplinary team, which I think for me, offers the best options for our patients.

BRIAN GOLDMAN: You know, I'm old enough. I'm an old enough physician. I've been in practice long enough to remember when it was rest above all. And obviously, that kind of advice has been kind of tossed aside in favour of something way more nuanced. So I'm going to turn it around completely. How does exercising while injured improve the body's recovery? In what ways?

LAURA CRUZ: That's a great observation, I think, where I'm probably a bit older than you, and I remember people with a disc herniation being in bed rest in hospital for six to eight weeks. So come a long way from there. Anytime you move your body, you increase your circulatory flow, so you're getting more blood to the injured area. It's going to get better faster because we know there's all kinds of healing properties in our body or immune system, new muscle, new tendons, new… everything depends on blood flow and oxygenation. It also keeps you feeling like you're moving. This is a slogan that a lot of people have heard. You know, motion is lotion, exercise is medicine. And I think that finding other ways for people to move while injured, someone has a leg injury, they may still be able to do upper body exercise if they feel that it's too difficult, or they may be able to get on a bike. So we always try and find ways to be creative, to help that person have something else that they can do that's also good for their injury, but also keeps their mind back in the routine, still having time for those exercise intervals. For folks that aren't necessarily very active, you know, we need to help them navigate their day, whatever their day looks like. So being a bit creative with that, using canes if necessary, walking boot casts, braces, tensor wraps. Lots of options now, but I think reassuring that there's still things they can do and helping them find the ways to continue to do the things they must do.

BRIAN GOLDMAN: What are some of the risks, the actual risks that people need to keep in mind if they're going to try to exercise while injured?

LAURA CRUZ: The primary risk is that they worsen the injury that they currently are experiencing effects from, and that could be an ankle sprain, you know, a mild ankle sprain, grade one, as we might call it, progressing to a grade two or potentially even grade three. More often, it's not as dramatic as that. It's more that the joint that's been injured or the muscle or tendon that's been injured starts adapting in a way that changes the movement pattern, changes its ability to function normally. And so with that, you end up with a new action and a new way of that body part working. And that's often harder to untrain. So they may be able to do some of their exercises, but now they're doing them with modifications, and then they potentially end up with secondary injuries, more likely over use in that situation. And everyone's different. So, you know, it's hard to measure these risks. I don't know that there's much literature on that. There's certainly the risk of extending an injury. It’s not an absolute by any means. So if someone's a risk taker, they may be willing to try and push the envelope, as it were, and progress more quickly. But that's probably the main concern. And, you know, someone who has one injury is more likely to sustain a second injury. And this is important for younger athletes who maybe are at university and they're trying to get professional draft opportunities. So the kid that goes back with a knee sprain and ends up really wrecking their ankle, and now they're out for the entire season and they've compromised their opportunities without meaning to. So I think extending the injury and then sustaining a second injury are the two most relevant things that we want to talk about first with them.

BRIAN GOLDMAN: I want to get as specific as I can here. What are the common mistakes that the people you see make when they're trying to stay active while they're still injured? Obviously, work, you know, doing the same activity on an injured limb seems like a no brainer. But what else?

LAURA CRUZ: One of the strategies that we used to recommend was using anti-inflammatories and ice a lot, and I think that those cautions are relevant in the first few days. I think after that, if your pain is inhibiting you from moving, I think it's probably, you know, after a week or two, it's okay to start reintroducing those. But the folks who really overload and take lots of medications, lots of ice, and then go out and try and do anything and everything without being mindful are at risk of worsening their injury. And that's actually relatively common in my experience. The other sorts of things that they forget to do is look at if it's an overuse injury, and that, you know, usually has a longer timeline and lead up to presenting in anyone's office for observation or consultation, is that they continue to do the same movement errors or the wrong exercises that they were doing before. So they're going back and trying to fix a problem using strategies that caused the problem in the first place. And that's going to be very unique to each individual and each activity. What's harder is if that activity is something that you have to do day to day to get through your life. You know, if it's cooking or food preparation or carrying your child, those are harder things to adapt and to avoid.

BRIAN GOLDMAN: You wanted to say something about that famous acronym of RICE, rest, ice, compression and elevation, and how that can play into either alleviating symptoms of an injury or actually making them worse. What do you want to say about that?

LAURA CRUZ: What we now know is that the common strategies that were suggested for decades, really the RICE acronym, rest, ice, compress and elevate, evolved appropriately to relative rest, protect, ice, compress, elevate. And then it became apparent that using anti-inflammatories like Advil or Ibuprofen, Naproxen Aleve in early days, plus lots of icing would slow down that initial healing phase. So instead of it taking three to five to seven days, it's now maybe taking seven to 10 days. And that was true for all tissue types. You know, very smart people much smarter than me said, you know, we need to change this, and I think more recently, popularized an acronym as peace and love. It’s much longer, and it takes longer to explain. So that's an obstacle for use in the emerge potentially. But it talks a little bit more about the modern approach. You know, protect the area. Yes, elevate it. Yes, avoid the anti-inflammatories. Compress if you're able. And educating patients and yourself about what to do or not to do in early days, limited activity based on pain, ability to load, ability to move. And love is gradually once you're past that acute phase, so this addresses, you know, when people ask you, well, what do I do after my first few days, doc? Gradual loading, using pain as a bit of a guide there, being optimistic that this is an injury that you can recover. That's a new phase in how we help people approach their injuries. You know, thinking about their mindset and thinking about the psychological impact. V in love is vascularization, increase circulation, do cross training, do alternate activities to increase blood flow to the injury, which will help healing, and then gradually return to exercise, starting with adapted mobilization, other kinds of activities, and then ultimately regaining strength, range of motion and the balance, the feedback, the proprioception of the joint. So that's very long. RICE was really easy. Peace and love is more current, though, in terms of where our thinking should be.

BRIAN GOLDMAN: I don't know an emergency physician who isn't into peace and love, especially with the current situation in ERs far and wide across this great land that we call Canada. Let's drill down a bit more. What are some of those lower impact exercises that people can do if they're injured?

LAURA CRUZ: I think it depends where your injury is. So if it's your shoulders, your elbows, you know, you're moving your arms regardless of your injury to get dressed, to brush your teeth, to eat. So those normal activities of life are going to help you with that mobilization. Walking is universal. So again, if it's not a lower extremity injury, you can go for a walk. That's very restorative, especially if you live near a park or a little forested area. It's really good, and it still protects your exercise time if you have a busy schedule. If it is a lower extremity injury, we use a bike for a lot of things. Now, if someone only has access to a road bike, that may or may not be ideal if they've got a bad ankle or a bad knee injury because we don't want them falling off and, you know, sustaining a concussion, for example. But if they have access to a stationary bike, but even sitting in a chair reclining on your couch, you can do bicycling moves semi reclined. Weight lifting, little weights, a jug of water, kettlebells, whatever. Do some strength training. It's a great time to work on strength training and flexibility. Again, thinking about things that they have access to, thinking about what they maybe are interested in and seeing if there's a fit. Sometimes, people can swim if they can't walk or run or don't have a bike, but they have a pool nearby that they're comfortable going to. So lots of options. We just have to dig down and see what's available to them.

BRIAN GOLDMAN: Of course, there is a physical component to injury. There is a psychological component. What advice do you have for people who perhaps injured themselves while exercising, who are now anxious about returning to the activity that caused the injury in the first place? Let's start with somebody who's apprehensive about the injury. How do you handle that psychologically?

LAURA CRUZ: We have the rare patient that comes in and they've been exercising for 25, 35 years and they've never had an injury. They have no idea. And we know that when people have knowledge, that they can digest that and consider that and then use that to their advantage, hopefully, if it's been presented well. So encouraging them to learn more if they want to know in the moment and you feel that they're open to that. Educating them about what the expected recovery time would be and reviewing the strategies, not in a lot of detail, because that's going to be overwhelming. They won't be able to remember it all. But helping them understand the natural process and the things that they can do that will help them feel that they're active participants and not just a victim of their injury. I think that's really key. The person who's had lots of injuries may still be more anxious about this particular one. Perhaps, it feels worse. So trying to help them understand why it may feel worse or feel like a greater disability on this occasion than it did in the past. Maybe it is more severe. But again, you know, when people have a sense that there's a plan and a treatment protocol to follow, that structure is very reassuring. And then exploring the alternatives. Okay, well, you can't ride your bike, but can you do this or this? You have access to this, and trying to help them navigate those options, because it's all unique. Each person has different and unique opportunities to cross train or do other activities.

BRIAN GOLDMAN: What about the opposite? How do you manage the expectations of somebody who has a race, and especially if that race is now in jeopardy? They're highly motivated, and you know that they're at high risk of either re-injuring themselves or making the injury worse. What's the approach to somebody like that?

LAURA CRUZ: I've had the tremendous fortune of working with some national team athletes, and this happens in competition or in the lead up to competition. It's not dissimilar. You know, everyone has their own physical fitness and competitive goals, so they're all legitimate. So I think we switch gears a little bit in that case and say, okay, do we need to take the approach rather than this nice, gentle, supported, nature driven natural healing augmented by the strategies that you do to help yourself become more functional when able? Or is it more risk reduction? And often, it's a blend. It's not for me to judge how important that race is for that person, because it might be. You know, who knows why that race is important? There may be very big life goals tied to that race. Again, education. The risks are this. The likelihood, as we understand it, may be X. Thinking about if you had to race today with the amount of pain you're having, would you be comfortable with that outcome? What would be the biggest impact for you? Would be a bad time, not being able to finish or making your injury worse? You kind of work with that. I mean, our job is not to encourage them to do harm, but we can help them do less harm.

BRIAN GOLDMAN: Under what circumstances would you recommend to your clients not to exercise following an injury?

LAURA CRUZ: If you have a broken bone, the bone wins, and sometimes to the detriment of the soft tissues in some cases, which is, you know, we try and be mindful of all. But a broken bone does need some time, and we can protect it. Certainly, in the old days, we put plaster and fibreglass. Now with ankle and foot injuries, more often, we're using walking boot casts, which is actually better for healing. And then probably the first few days if someone's had a head injury, because your brain does need that respect for a few days, we try and figure out what that exercise might look like. But yeah, those would be the two, I think, Brian, that I'd really want people to rest for a bit.

BRIAN GOLDMAN: I'm sure you deal with clients for whom injuries are life changing and may prevent the body from ever being able to move the way it used to. What are some of the steps to keep in mind when trying to recover and keep active after a life changing injury?

LAURA CRUZ: Great question. And it's very timely because, of course, the other day, there was the anniversary of the Humboldt hockey accident. You know, one of the survivors of that crash is now a Paralympic rower for Canada. That's a very dramatic example and a tremendously successful individual who, you know, had the right drive, the right motivation, the right personality and the right supports in place. Again, I think it's back to the basics. What do you like to do? If you can't do X, can you do Y? What else might bring you joy and keep you moving? And what does it mean by life changing? So, you know, the dramatic ones are the spinal cord injuries, the limb amputations, loss of limb. That really takes a village. And I think that's now many, many layers of advice to work through. You know, the simple things are if you like to exercise and you have a lower limb life changing injury, can you swim? Can you use an arm erg, you know, a rowing machine for arms? Are you interested in Paralympic sports? If it's an upper extremity, you have legs. What can you do with your legs that you didn't do before? It's very delicate position to be in. Perhaps this is where physical medicine and rehab has a greater team access to help support this individual in terms of all the dimensions. In the less dramatic life changing injuries, it's certainly easier with fewer layers. You know, someone who's had a significant shoulder injury and, you know, one would debate, okay, I dislocated my shoulder. Does that mean my life is over? No, but you may not have the same resilience that you used to have in your shoulder for overhead lifting, for collision sports. But good rehab will help with that. But that may be a different commitment than it took my shoulder sprain, you know, a month to improve. This may be many months and recurrent over the lifespan. You know, I think the good news is there’s always something. It’s just whether or not what you're suggesting as the educator or the health care provider is what the person's interested in. And, you know, the stakes are a bit higher here in that situation.

BRIAN GOLDMAN: And finally, how can people who are injured use the injury as a learning experience to help prevent the next one?

LAURA CRUZ: It's a chance to be better. It's a chance to move better. It's a chance to be stronger. It's a chance to have better technique. That all takes time and effort and knowledge that the patient, our client gains, that there's someone who has the knowledge to help share that with them. And in our system, it takes money. That's a bit of an obstacle, but I think you can have that sort of mindset. You can help someone who doesn't have a lot of financial resources to work with the top strength and conditioning trainer in the city, because there's a lot of resources, but it's a tremendous opportunity. And when people are open to that next phase where they're not as afraid of their injury, they're starting to have a sense that they can manage their symptoms, they can see the progressions, doing my daily activities isn't much of a burden anymore, I feel I'm moving faster, they're ready for the next. And some people don't want to get better. They just want to get back. And that's okay. You just give them the information and see what they do with it. And then there's others that are really excited about the idea of being better than they were. And certainly, from the point of view of injury prevention going forward, there's a certain amount that's important. You know, we see this with knee injuries in field athletes, the big ACL injury. Everyone has heard or know someone who's had an ACL tear and reconstruction. And there's some fundamental movement patterns that must be addressed. If you’d torn it on one side, you're at risk for tearing it on the other. And so that's fairly well known everywhere that there's a strength deficit there. That's pretty universally addressed. And I think the more we have, the more information we have about other injuries that are similar to that and convey that to our patients for those specific injuries, they're all going to get better than before they were injured. And that's going to be good for them, and they will benefit from that and enjoy that.

BRIAN GOLDMAN: Doctor Laura Cruz, this has been fantastic. I've enjoyed it. I've gotten a lot of personal benefit from it. Thanks for speaking with us on The Dose.

LAURA CRUZ: That's great, Brian. Thank you.

BRIAN GOLDMAN: Doctor Laura Cruz is a primary care sports medicine physician in Toronto. Here's your dose of smart advice. Everyone’s situation is different, but here are some general guidelines. For sprains and strains to the muscles and joint ligaments, a few days of backing off your usual routine is the way to go. Stay active moderately. Think gentle walk instead of a run so that your muscles don't get stiff. There's been a major change in how to manage acute injuries. The old acronym, RICE, rest, ice, compression and elevation is out of date. The new acronym is Peace and Love. Protect, elevate, avoid anti-inflammatory medications like ice which delay healing, compression, educate, load, optimism, vascularization and exercise. We'll post a link explaining all of this at cbc.ca/whitecoat. Get professional advice if you're unable to use the injured part of your body, have trouble walking, can't bear weight, or if the injured part is more painful than expected. Rest for a few days will not set back your conditioning. Rest is good for your overall fitness, not just the injury, because it gives your body time to recover from things like strenuous workouts and long distance runs. The downsides of resuming exercise too quickly include reinjuring the affected areas and causing new injuries through overuse. If you've been advised to rest for a longer period of time, ask about substitute exercises that can help maintain your strength, conditioning and flexibility. Remember that motion is lotion. Motion is good for your body, even if you need to do it at a lower intensity to avoid discomfort. Do not exercise immediately following a broken bone or a head injury until you've been cleared by a professional to do so. It's understandable to be discouraged about an injury that leads to losing fitness milestones. Substituting a different exercise can maintain your spirits even as it helps to maintain your fitness. Think about an injury as an opportunity to relearn how to move so that you come back even better than before. If you have topics you'd like discussed or questions answered, our email address is thedose@cbc.ca. If you liked this episode, please give us a rating and review wherever you listen. This edition of The Dose was produced by Sameer Chhabra. Our senior producer is Colleen Ross. The Dose wants you to be better informed about your health. If you're looking for medical advice, see your health care provider. I'm Dr. Brian Goldman. Until your next dose.

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How can I safely stay active while injured? - Transcript

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