REHAB

S C I E N C E
HOW TO OVERCOME PAIN AND HEAL FROM INJURY

DR. TOM WALTERS

WITH GLEN CORDOZA
First published in 2023 by Victory Belt Publishing Inc.

Copyright © 2023 Tom Walters and Glen Cordoza

All rights reserved

No part of this publication may be reproduced or distributed in any form or by any means,
electronic or mechanical, or stored in a database or retrieval system, without prior written
permission from the publisher.

ISBN-13: 978-1-628601-39-8

The information included in this book is for educational purposes only. It is not intended or
implied to be a substitute for professional medical advice. The reader should always consult
their healthcare provider to determine the appropriateness of the information for their own
situation or if they have any questions regarding a medical condition or treatment plan.
Reading the information in this book does not constitute a physician-patient relationship.
The statements in this book have not been evaluated by the Food and Drug Administration,
nor are they intended to diagnose, treat, cure, or prevent any disease. The author and
publisher expressly disclaim responsibility for any adverse effects that may result from the
use or application of the information contained in this book.

Cover design by Elita San Juan

Interior design by Yordan Terziev and Boryana Yordanova

Illustrations by Allan Santos, Elita San Juan, Crizalie Olimpo, Charisse Reyes, and Eugen and
Arsim Loki of @Pheasyque

TC 0123
 contents

5 / INTRODUCTION

146 / chapter 15:

PART I: PART III: HEAD & NECK

PAIN REHAB PROTOCOLS

186 / chapter 16:

SHOULDER
PROTOCOLS
10 / chapter 1:
WHAT IS PAIN? 108 / chapter 11: 234 / chapter 17:
PROTOCOLS ELBOW
16 / chapter 2: PART II: OVERVIEW PROTOCOLS
HOW PAIN
WORKS INJURY 118 / chapter 12:
TRAINING &
260 / chapter 18:
WRIST & HAND
26 / chapter 3: PROGRAMMING PROTOCOLS
THE DIFFERENT GUIDELINES
TYPES OF PAIN 280 / chapter 19:
60 / chapter 6: 126 / chapter 13: BACK & SPINE
34 / chapter 4: WHAT IS TOOLS & PROTOCOLS
THE FACTORS AN INJURY? EQUIPMENT
THAT INFLUENCE 328 / chapter 20:
FOR THE REHAB
PAIN 64 / chapter 7: HIP PROTOCOLS
EXERCISES
THE TYPES OF
46 / chapter 5: 382 / chapter 21:
INJURIES 132 / chapter 14:
HOW TO KNEE PROTOCOLS
COMPLEMENTARY
OVERCOME PAIN 78 / chapter 8:
& ALTERNATIVE 426 / chapter 22:
HOW LONG
MEDICINE (CAM) ANKLE & FOOT
INJURIES TAKE
INTERVENTIONS PROTOCOLS
TO HEAL

86 / chapter 9:
FACTORS THAT 472 / REFERENCES
INFLUENCE
486 / INDEX
INJURIES

98 / chapter 10:
HOW TO HEAL
FROM INJURY
INTRODUCTION
In many ways, the rehab model is broken.

It’s not that the interventions practitioners provide aren’t helpful or that rehab doesn’t
work—it’s that the system is fundamentally flawed, and that has created a disconnect
between the role of the practitioner, the goals of rehab, and the needs of the patient.

I became a physical therapist (PT) to help people. But when I started my first job in an
orthopedic clinic nearly two decades ago, I was instantly hamstrung by the insurance-
based model. I was expected to see a dozen patients a day, the sessions were kept too
short, and return visits were spaced much too far apart. Before patients could make
a full recovery, their insurance coverage would run out and treatments would end.
Like many of my fellow PTs, I was overworked and frustrated knowing that I wasn’t
providing adequate care for those who were suffering.

I’m sorry to say that the same problems persist today. A patient might have insurance,
but they have trouble finding a clinic that prioritizes their health. And when they
finally manage to locate such a clinic, they have to wait months for an appointment.
Worse still, there are many patients who don’t have insurance, which can take even
less-than-optimal treatment options off the table because they can’t afford the out-of-
pocket expenses.

These factors tend to leave people with just a few options:

• They can do nothing and hope that their pain goes away or their injury heals.

• They can seek alternative forms of treatment and pay out-of-pocket for in-person care.

• They can attempt to self-manage their condition.

Let’s examine each option. Through that examination, I’ll outline the solutions Rehab
Science provides—and tell you what this book is about, who it’s for, and how you can
get the most out of it.

With most injuries, you need to implement

OPTION 1: techniques that reduce swelling, promote
DO NOTHING blood flow, and alleviate pain within a few days
of getting hurt and then start rebuilding the
Some injuries and pain symptoms simply go tissue with movement and exercise. But most
away with time—you rest, avoid the behaviors people do the opposite. The natural response
and activities that led to problems, and get is to protect the area, which is fine in the early
better. In this way, doing nothing can work, but phases of healing but can turn into a passive
only immediately following an injury that causes coping strategy that perpetuates a cycle of
sudden or acute pain. pain avoidance. When you move less, the area
becomes deconditioned, and the likelihood of
reinjury and developing chronic pain increases.

5
OPTION 2: OPTION 3:
SEEK ALTERNATIVE SELF-MANAGE
IN-PERSON TREATMENTS Self-guided pain and injury management is
the heart of Rehab Science. The goal is to
It’s hard to beat in-person treatment from a
confront the problem intelligently with active
skilled PT using science-based methods in a
coping strategies—education, movement, and
facility that prioritizes quality care. These PTs
exercise. Through education, you can learn
make assessments, design programs, select
how to identify and address potential factors
exercises, and use manual therapy techniques
that influence the pain experience. Movement
that are specific to the individual and the
and exercise will break the pain cycle, improve
condition. If you have a catastrophic injury or
tissue capacity, and boost confidence in the
need reconstructive surgery, it’s the best option.
system, which ultimately encourages self-
But let’s assume you have pain or an injury
efficacy.
that is less severe and not life-threatening—
When you learn how to do something
such as an overuse injury like a tendinopathy,
yourself and avoid becoming dependent on
muscle strain, joint sprain, sudden acute pain,
medication, surgery, or passive manipulations,
or lingering pain. When in-person physical
you gain physical and psychological strength
therapy is not optimal because the clinics in
and resiliency. The problem is that most people
your area follow the broken model, you are left
have an incomplete picture of how their mind
with complementary and alternative practices
and body are connected to their symptoms and
such as acupuncture, massage therapy, and
what steps they need to take to get better. It’s
chiropractic (to mention a few). Practitioners
difficult to know who to trust and how to filter
in these fields offer services that are typically
through information to find the right treatment
not covered by insurance. You often pay out-
plan. People get stuck, or they jump from one
of-pocket for treatment and, as a result, you
program to another, never making progress.
may get more attention or receive a type of
I wrote this book to change that.
specialized care that can be helpful. But these
modalities are not without flaws.
For starters, these services are out of
reach for most people because they are too BECOMING
expensive or are not available locally. Even when
complementary and alternative practices are an
YOUR OWN PT
option, it can be difficult to find a practice that’s
My intention with this book is to simplify the
geared toward mobility and resistance training,
science so that it is accessible to everyone, and
which have the best long-term evidence for
to provide stepwise strategies for dealing with
resolving pain and rehabilitating injuries.
the most common musculoskeletal conditions.
Even more concerning, many of these
I’ve done so with two groups in mind:
practices base their entire business model
around the narrative that what they do is • People who want to better understand how
necessary for the patient to remain healthy. to treat orthopedic pain and injuries on their
They stress the importance of return visits for own
tune-up treatments that might not really be • Medical and non-medical practitioners
needed. The role of a healthcare practitioner is (doctors, physical therapists, personal
to help patients find relief and heal—not to lock trainers, and so on) who want to expand
them into an endless cycle of follow-up. With their knowledge, pass along evidence-based
this model, people can become dependent strategies to their patients or clients, and find
on the treatment and lose confidence in their concise methods and programs that they can
ability to self-manage their condition. reference and implement

6 REHAB SCIENCE
 To help you navigate this book, I’ve broken it I’d also like to point out that you do not need
into three parts. to be in pain or injured to benefit from the
Part I: Pain and Part II: Injury focus on programs. Whether your goal is to address a
education. Knowing what pain is, how it weak link in your body, improve mobility with
works, and what the different types are will certain movements or ranges of motion, or
give meaning and purpose to the strategies strengthen a specific body region, the three-
for alleviating and preventing both acute and phase exercise programs will serve you well.
chronic conditions. The same is true for injuries. Simply go to the body region that you want to
There are many types, each of which has a improve or maintain and follow a program, or
different healing time frame and plays into cherry-pick from the exercises to design your
how you should approach rehab. When you own program.
understand pain, you get better faster. When Remember, the exercises you do in rehab are
you understand what is injured and how long the same exercises you use to maintain and
it should take to heal, you’re less likely to make improve the health of your body.
the injury worse, and you will recover more If you decide to go to Part III as your first stop,
quickly. Understanding improves adherence, that is fine. You don’t need to understand the
and adherence promotes consistency—both of science behind pain and injury to benefit from
which are necessary for getting better. the programs. Although I believe the science is
Parts I and II also explain how pain and injury important to understand—the knowledge can
are different, which is why I discuss them expedite healing, prevent future occurrences,
separately. They are often related because and help you approach rehab in a more
injuries can create acute pain, but you can have efficient way—the protocols are the highlight
pain even when no tissue is damaged—as is of this book. When followed diligently, they are
the case with chronic pain. That’s important the quickest route to recovery. However, I’ve
to know because if you have pain that is not found that as patients go through them and
tied to an injury, you might need to address experience the benefits, they often become
other aspects of your lifestyle that could be more interested in the science, which is waiting
contributing factors, which I cover in Chapter 4. for you in Parts I and II.
Part III: Rehab provides comprehensive With a healthcare system designed
rehab protocols for the most common pains to treat symptoms with medication and
and injuries for all the main regions and joints surgical interventions and a rehab model
of the body (see page 117 for the full body area that doesn’t always provide the best care, it’s
map). Each protocol includes a movement and more important than ever to take control of
exercise program broken into three phases your health—and that is exactly what Rehab
based on your pain symptoms, stage of healing, Science will help you do. Through education
and functional abilities—similar to a program and stepwise programs, it will empower you to
that a licensed PT would develop for you. self-manage common musculoskeletal issues
To address your particular pain or injury and start resolving your pain and healing your
immediately, go to Part III, find the protocol injuries on your own terms.
that matches your symptoms or diagnosis, and
then follow the rehab exercise program. Just be
sure to review the introductory chapters in that
part so you understand how the protocols are
structured and how to get the most from the
exercises.

INTRODUCTION 7
8 PART I: PAIN
P A R T I

PAIN

chapter 1: WHAT IS PAIN? 9

CHAPTER 1

WHAT IS PAIN?
“What is pain?” is probably not the first question you would ask when you are
experiencing pain, but it’s an important one to answer.

First, it’s crucial to realize that pain is not only normal but also important to your
overall health. Pain is an unpleasant experience that helps keep you alive by
alerting you to actual or potential bodily damage.1 It warns you that something
might be wrong, and it gives you an opportunity to change or stop what you’re doing
to prevent further harm. But pain is a complex phenomenon, and many factors
influence it.

In the coming chapters, I’ll outline what’s going on inside your body when you
experience pain and equip you with the tools and knowledge to prevent and alleviate
it. Because there are strategies that can help, even if you’ve been in pain for years
and nothing has worked. By educating yourself, you can reshape how you think
about pain and take the first steps toward healing.

But before you delve into the solutions and prescriptive protocols, it’s helpful to
understand why we approach pain the way we do. How did pain science get to
where it is today? How do we know what pain is and how it works?

10 PART I: PAIN
THE CARTESIAN MODEL OF PAIN
Much of what we used to believe about pain It would be wonderful if pain always worked
was based on the Cartesian model established that way. You could just stop doing the thing
by philosopher, mathematician, and scientist that was hurting you, and the pain would go
René Descartes in his book L’Homme, published away. Unfortunately, it’s not that cut-and-dried.
in 1644. He proposed that pain messages were The problem with the Cartesian model is
detected by receptors in the body and sent that it separates the mind and body (a concept
along pathways to the brain. Those messages known as mind-body dualism) and doesn’t
made us aware of a problem so that we could explain the vast array of pain experiences
act in a way to reduce further harm. 2 that people report. As a result, researchers
Back then, pain was thought to be a started to broaden their focus when studying
fairly simple sensory experience, as if the mismatches between the physical stimulus and
nervous system was merely detecting an the person’s pain experience. Ultimately, the
external sensation—something that existed research began to reflect a changing view of
independent of the brain. the brain’s role in pain.

According to Descartes, In the Cartesian model,

when the finger feels the the mind and body are
heat from the fire, a pain separate and distinct.
message travels to the The body produces
brain, setting off an alarm pain and tells the mind
that says, “Ouch. It hurt.” about it.

chapter 1: WHAT IS PAIN? 11

MODERN
PAIN SCIENCE
Pain is not always as simple as
tissues being in danger. Activities
that should create pain—like a
contortionist bending their body in
unnatural ways—sometimes don’t.
And pain can exist when nothing
dangerous is happening to the
body, such as when sitting at a
computer.
This new understanding of pain stems from danger. In these studies, subjects were made
several types of studies, starting with phantom to believe through visual cues that harm was
limb pain—a phenomenon in which up to going to be done to their bodies, and their
85 percent of people who have lost a limb brains produced pain to protect them from
complain about pain in the absent body part. 3-6 potential tissue damage. In one study, subjects
These studies show how complex pain can be were shown a red or blue light just prior to
and explain why pain is sometimes referred being touched on the back of the hand with a
to as an illusion created by the brain. The fact metal rod. Even though the rod was always the
that there are no messages traveling from the same temperature, the subjects who saw a red
limb to the brain because the limb is gone light reported more pain because red signifies
demonstrates the role that the mind plays in hot while blue means cold. Additionally,
the physical experience of pain. subjects who were allowed to watch the rod
Other studies have shown that people can touch their hand reported more pain than those
feel pain even if their tissue isn’t damaged or in whose vision was blocked.7

PHANTOM LIMB PAIN VISUAL CUES AND PAIN PERCEPTION

Ouch!

It's OK!

12 PART I: PAIN
 There are also cases in which an MRI or X-ray Touching a hot stove, for example, activates
shows evidence of injury, but the person feels nociceptors—danger receptors that detect
no pain. Various studies on asymptomatic noxious stimuli. These stimuli can be thermal
(pain-free) subjects found that 30 to 80 percent (such as something hot), chemical (such as a
of them had a bulging disc,8 34 percent had a corrosive substance), or mechanical (such as a
rotator cuff tear,9-11 30 percent had meniscus smashed finger).
degeneration,12,13 and the list goes on. When you touch something, a sensation
One such case study relayed the story of a called an afferent message travels from the
soldier who had an X-ray for an unrelated reason tissue up through your spinal cord to a certain
and, despite experiencing no pain, was found part of your brain, depending on the type
to have a bullet lodged in his neck.14 It’s as if his of message it is. If the message is sensory,
brain decided, “This isn’t dangerous. There’s no it usually goes to your sensory cortex. If it’s
need to create pain.” dangerous, it’s translated via a process called
nociception. At that point, your brain makes
decisions in the form of outputs, which fall into
No pain,
three categories:
Sir! • Pain (you hurt)
• Movement (you decide to move)
• A stress report (you feel anxiety)
The first type of output, pain, directly
contradicts the Cartesian model, which
presumes that pain comes from the body.
Instead, sensations are constantly coming into
the brain. The brain looks at all those inputs,
weighs the situation, and chooses how best
to protect you, possibly by outputting pain.
BULLET Basically, it decides whether the circumstances
you’re in are dangerous and whether you need
to alter your actions to avoid injury.

What these studies—and many more—

illustrate is that pain comes exclusively from
the brain, not from pain receptors or pathways
INPUT OUTPUT
in the body. With this new understanding, NEUROMATRIX
researchers started to consider a two-way
model in which the brain receives stimuli and
decides whether those stimuli warrant a pain
response.
This model views the brain as a neuromatrix
(network of neurons) with multiple inputs
and outputs.15 Inputs refers to sensations, but
not only those things you touch, see, hear,
or smell. You also have joint receptors called
proprioceptors that tell you where you are in
space, as well as emotional inputs that bring
thoughts and feelings into the neuromatrix.
Your brain constantly evaluates all these inputs
(along with others) to determine whether your
environment seems safe.

chapter 1: WHAT IS PAIN? 13

PAIN COMES
FROM THE BRAIN THE BIOPSYCHOSOCIAL
(BPS) MODEL:
A COMPREHENSIVE
With this new understanding of the brain’s role,
APPROACH TO
pain becomes a complex experience shaped
TREATING PAIN
by our thoughts, our emotions, our beliefs, our It’s natural to want to hunt for a direct cause
memories, our stress levels, the sensations we of pain symptoms—a single variable that
feel, the visual information we take in, and so could be easily fixed. In most programs,
on rather than simply being a message sent practitioners and trainers are taught to think
from the physical body. about pain as a tissue-driven biomechanical
Lots of people have pain that is largely due to problem. We call it the postural-structural-
high stress, poor mental health, lack of sleep, biomechanical, or PSB, model. But over time,
and other similar factors. But simply listing that model has been shown to be incomplete,
factors isn’t helpful; you need to understand especially in terms of fundamental takeaways
how these factors influence pain and, more from pain science research.17 Certain people
importantly, how to treat it. In subsequent simply don’t get better with that old-
fashioned approach.
chapters, I’ll dig deeper into the experiences
Yet this is the model that most physical
and types of pain so that you can confidently
therapists learn in school and most trainers
evaluate your situation and choose the right
and doctors base their treatments on—this
rehab protocol to follow.
idea that all pain and injuries stem from your
To sum up, your brain produces 100 percent structure, your posture, or your biomechanics
of the pain you feel.15,16 The brain is complex, (the way you move). Thinking about it from
thus so is pain. That said, the statement “pain that limited perspective leaves out other
comes from the brain” is often misinterpreted factors that are often more closely tied to
as “the pain is all in your head.” That is not what pain than anatomy is.
I’m saying. While pain is created by the brain, it With the old PSB model, every problem
is not made up. Each person’s pain experience has a mechanical answer. However, the
is real and unique. To understand why, we must mechanical treatment doesn’t make every
delve deeper into how pain works, which is the patient better. That’s where modern pain
focus of the next chapter. science and neuroscience come in, analyzing
the problem using the biopsychosocial, or
BPS, model.18

14 PART I: PAIN
To explain the word biopsychosocial, let’s break it down into its three components:
• BIO: This component encompasses the traditional PSB model, which includes looking at
structure, posture, biomechanics, and anatomy. These things are important because many
people have pain issues that are driven by their tissues. We look at how force and load affect
the body and whether certain postures or movements trigger a person’s pain. “Bio” is necessary
because we don’t want to ignore the tissues of the body; in most cases, the problem really
is mostly physical. It is what rehab explores first, trying to figure out if the pain is linked to a
mechanical problem with a biological tissue. This is the acute pain phase—pain experienced
immediately or soon after injury. Most people who have acute pain remain in “bio” territory,
especially if they can point to some kind of physical trauma.
• PSYCHO: Thoughts, emotions, and beliefs are hugely important in how you evaluate the world and
your own body. At the end of the day, pain is a protective mechanism—it helps you survive. This
means your brain can create pain based on a perceived threat, even if there’s no damage to your
tissue. Pain can also be tied to stressful life events, making “psycho” an essential variable to consider
when addressing chronic pain conditions that persist beyond the normal healing time frame.
• SOCIAL: The people you interact with are another huge element in pain. We are becoming more
and more aware of how important social interaction is to overall health. Loneliness, for example,
can be a significant factor for people with pain—lacking social engagement may predispose
someone to depression, and that can lead to chronic pain disorders.
All these components are interrelated. And it’s important to understand this, because once you
realize how your mind, body, and environment (relationships) are connected to your symptoms, you
can start to address all the potential factors that might be contributing to your pain.

PSYCHOLOGICAL BIOLOGICAL
FACTORS FACTORS
mental health, age, gender,
emotional health, genetics, and
and beliefs and tissue health
expectations

PAIN

SOCIAL FACTORS
relationships,
social support, and
socioeconomics

chapter 1: WHAT IS PAIN? 15