What is positive versus negative interventions in pain management?

The lesson for today is to understand positive versus negative interventions. In science (and psychology), we sometimes use the terms positive and negative to denote addition of something and removal of something.

For example, in positive feedback loop, it is about the amplification of something. So there is more. Whereas negative feedback loop will lead to less of something. It has nothing to do with whether the feedback loop is actually good or bad.

In psychology, an example of positive punishment is spanking a child for misbehaving. Confiscating their mobile phone or ipad for the same behaviour would be considered negative punishment. Positive or negative interventions is really about addition of something or removal of something.

Today, I will discuss, from my perspective as a chiropractor, how this concept can be applied to recovery from chronic pain or injury.

Common positive interventions in recovery

When it comes to recovery from chronic pain or even acute injury, positive interventions refer to anything that you do that is extra. Exercise, for example, is an positive intervention in the sense that you are doing something additional.

Medications, massage, chiropractic adjustments similarly all can be considered positive interventions because they are all extra things that you are doing for your recovery.

Not all positive treatments are beneficial. A clear example is lobotomy (i.e., removing part of a brain) for the treatment of mental illnesses. It is positive in the sense that it is something extra that is being done but yet the results can be very negative!

Negative interventions in recovery

Negative interventions would refer to things that you are removing or avoiding. You can think of removing it from your lifestyle.

Let’s say you have knee pain from an ACL tear, you may decide to stop playing basketball. This would be a negative intervention because you have decided to take something out of your life.

If you have diabetes and you decide to remove sugar from your diet, this can also be considered as a negative intervention. Unlike lobotomy, cutting out sugar actually comes with a whole myriad of positive health benefits!

These interventions, regardless of positive or negative, do not need to be permanent. You may decide to stop playing basketball for perhaps just a few days for a very minor strain or maybe for months after a surgery. For some cases, such as cutting out sugar, you do want to aim to keep it permanent.

Rest can be harmful

Rest is probably the worst thing people can do for their injury as people tend to over-rest. Rest can be considered a negative intervention because it is about removing physical activity from your daily life. While it seems like it’s something you “do”, it is more accurate to consider it as an absence of activity.

When we rest too much, our body start to decondition and deteriorate. This makes coming back to good physical health and functioning extremely challenging. It is true that sometimes we need a little rest but too much rest is a no go.

Rest can also come in other forms. For example, the use of braces and sleeves. Quite often people with joint sprains tend to wear braces and sleeves. It is true that they can provide some stability for the joint in the short term, it can also lead to more issues in the future.

Some people may think there is no harm in resting or no harm in bracing as a precaution. But no, the risk is present but just perhaps a little less tangible to most of us.

By the way, even among older adults, rest is not recommended for majority of back pain cases.

Good recovery is about balancing both the positive and negatives

It is very important to understand that it is 100% possible to have too much of a good thing. Exercise is a great example. Even for perfectly healthy individuals, it is possible to exercise too much and get injured!

We see this a lot in novice runners. Beginners in endurance sports tend to overtrain at the start due to their lack of experience, which contributes to their less-than-ideal-judgement. Novices tend to overestimate how much they can do. This becomes a too much too soon situation, and can lead to repetitive stress injuries.

The other factor at play is not-me-not-now or optimism bias. With little experience, novices are less likely to accurately assess their risk of injury. Because they think they are over optimistic about their abilities, they tend to take higher risks and also subsequently end up with injuries.

So, exercise is a good thing and running definitely is good for our health. But too much of a good thing is a problem.

Positive interventions gone wrong

If there is anything I am good at, it’s attention to detail (when I want to be). In fact, my attention to detail can be so extreme that is almost a fault. Some people may even describe me as being anal.

The upside of this is that I take super detailed notes of my sessions and almost always give super detailed advice and recommendations for my clients.

Exercise is a big part of what I do for my clients. Sometimes, my clients will receive homework in the form of exercises to do at home. The exercises are prescriptive in the sense that you will be told what to do, how often to do them, and the sets and repetitions for each of time. Sometimes, when relevant, I would even denote the time of the day when the exercises should be done.

To recap, exercise is a positive intervention and it’s 100% possible for it to be too much of a good thing. The same thing that is supposed to help you, can harm you.

This is the case with one of my newer clients recently. Because of overdoing the exercises, his aggravated his ankle injury. The client attributed it to having twisted his ankle from the exercise. This may be true but it’s not the “root cause” of the problem.

The “root cause” is in over-doing.

What is harm?

Off the bat, we know that harm is something bad that happened to us. But harm can be present even before something sinister occurs.

Tangible harm is the harm we are familiar with. For example, when a person overtrains, they may end up with a repetitive stress injury. The harm is obvious and explicit.

But harm can also be less clear. For example, harm can come in the form of increasing your risk of injury. When you choose to do too much of a prescribed exercise, either consciously or unconsciously, you are increasing your risk of injury. This increased risk of injury was what ultimately led to an (unnecessary) aggravation for the client. The harm already occurred even before the twisting of the ankle.

Other harms that are less tangible but very well reported is delayed recovery. When it comes to choosing treatments that are not backed by science and evidence, delay in recovery is common. For chronic pain, less ineffective treatments like dry needling, chiropractic adjustments, etc are not the recommended first line of treatment.

By choosing these treatments, you are effectively delaying the time you take to get better. This delayed recovery in itself is considered harm.

Holistic recovery means considering factors that are non-physical as well

Everyone talks about holistic care. It is considered desirable and it is preferred. Cognitively, we understand that holistic care is better for us. However, it can be a lot to embrace!

Holistic care, as the term suggests, will involve looking at ourselves as a whole. This means addressing non-physical factors as well.

If you want good long-term results in your recovery from chronic pain, you must be able to consistently do the right thing over time. In order to consistently do the right things, you must have a sound framework in your decision-making process. Those without a working decision-making framework would inevitable end up injured again.

Because, our physical health, is the result of our choices! Knowingly or unknowingly.

Understanding behaviour change from a finance perspective

We have high financial literacy in Singapore so I will use personal finance as an example. If a person were to get to credit card debt, it doesn’t matter if you help the person to clear their debt. Because, unless they change their behaviour, they will likely end up in debt again. But behaviour doesn’t just change on its own. This is why people often engage in interventions like cognitive behavioural therapy. The understanding is that if we can change a person’s thoughts and attitudes for the better, we can improve their behaviour.

This probably also explains why people who win lotteries tend to go broke way too soon. The issue is not how rich or poor a person is, the problem is really in how we make decisions. Without the relevant knowledge and skills, what seems like a few lifetimes of savings can be gone in just a few years!

Similarly, when it comes to recovery, it’s not how strong or how fit you are. It is not how much you have but what you do with what you have. If you are able to make the right decisions over and over again, you will incrementally get better.

If you cannot, you will always get worse over time. This is when you need extra help and where I can come in to help.

Understand recovery is not just do or don’t do

It’s always good to keep in mind what you do for your recovery, and that there are positive versus negative interventions. It is a good idea to balance them appropriately so you can get a true holistic approach to recovery.

For example, if you were to take a break from basketball to focus on your recovery (i.e., negative intervention), it is a good idea to consider how you can include appropriate rehab exercises (i.e., positive intervention) to make up for the activity shortfall.

If you do too much of a positive thing (i.e., do more rehab exercises than prescribed), understand that the reverse action is to stop doing those exercises for a while. Once you have reverse the action, the body should settle at a baseline. You can then start to slowly add back the exercises again.

Recovery is kinda like a tango. There are forward and backward steps. It’s not just bulldozing your way to success. Having the agility to respond to different situations (foreseeable or otherwise) and having the mental focus to be able to stay present without rushing into anything will yield exceedingly positive outcomes.

The self-management gold standard

I totally get that people don’t want to always come back for more sessions. I am sure most chronic pain sufferers would want to be cured in a single session if they could As nice and magical that sounds, that just simply doesn’t exist. Perhaps in a few decades, when we will have a better understanding of chronic pain, that would be possible. Maybe researchers in the distant future may develop some mind blowing treatments that only one take one session to cure years of chronic pain and/or injury.

Until then you have me. It’s not perfect or ideal but it is enough to get you started on your recovery. Part of my work as a chiropractor is to help my clients find freedom from pain. After running my practice for eight years, I still believe in making myself redundant for my clients. But it takes time and effort. Most important, it takes change. Something needs to change.

I am going to emphasise that it’s not about what you have or how much you have. It is being able to consistently and repeatedly make the right decisions over time.

If what I do or advocate is not what you subscribe to, there are plenty of chiropractors and physiotherapists in Singapore to choose from as well. More personal trainers have also upskilled to include rehab as part of their personal training services. You have no lack of pain treatment options in Singapore.

Regardless who you go to, one thing remains, long term results is going to take change. So, my question to you is what are you changing today?