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Will Any Old Exercise Help Your Patient?

March 19, 2018/in Massage, Massage Clinic, Massage Therapist, Massage Therapy, Pain/by Ben Cormack

So the real question should be, how specific should we be with our exercise prescription?(Now this could have turned into an epic blog, but I have decided to keep it brief and readable!)In my opinion, WE SHOULD ALWAYS BE SPECIFIC.

Now that’s a pretty emphatic statement so I should probably add a bit of nuance to that. For some people, the term specific means that we should use a SPECIFIC exercise for a SPECIFIC problem.

The world of therapy is littered with exercises that have been held up as the ‘best’ exercise to fix a certain issue and not achieved that status, think TvA activation exercises for back pain or VMO exercise for knee pain. Being specific in this way does not appear to be warranted with the current evidence base we have.

We could also be specific to some form of physical quality like strength or range of movement.

We see that in many cases when it comes to MSK pain going after a specific physical quality also does not seem to yield better results, there ARE a couple of examples of when being specific is important and I will discuss those later.

I might be bold and stick my neck out and say that non-specific pain (meaning we cannot pinpoint the source), of which we seem to have a bunch of around the body, probably needs a non-specific approach to exercise. This means that we cannot strongly suggest a singular exercise or a type of exercise that focuses on a physical/biomotor quality.

So Why The Need For Specificity?

So, everything I have said so far may seem to point towards there being no real need to be specific.

Does that mean that we can just give someone any old exercise and expect to see a positive result from it?

I don’t think so. Any application of exercise should come with some form of reasoning and we should start with the end in mind. What SPECIFIC effect do we want from our exercise? This will be SPECIFIC to the person and their current issue or goal.

This means that the reasoning approach is always specific but the application may not always be the same. So rather than be SPECIFIC to a type of exercise or presentation we are being SPECIFIC to the PERSON standing in front of us.

What Do We Want?

Screen Shot 2017 04 10 At 17.33.20

There are many different outcomes that we may want to achieve from our application of exercise and we find we can influence lots of different elements of human function.To make things a bit simpler and more organised we could make some broad categories.

Capacity

This could be tolerance of a specific tissue such as a tendon or muscle although we still have not quite worked out the relationship between pathology and pain here. There may also be clearly defined scenarios where we see the need for specific biomotor qualities, such as strength needing to be addressed postoperatively.

Pain

Pain relief maybe another specific outcome that you want to achieve from your exercise prescription.

It seems there that lots of types of exercise may create analgesic effects. Isometrics are the flavour of the month at the moment, but both strength training and cardio training also have the potential to create analgesic responses.

I am still slightly on the fence about the usefulness of short-term responses for all but I can see a clinical need for some groups of patients.

Belief

As we start to move away from a tissue focused view of exercise and movement, the concept of beliefs around exercise becomes much more important concepts such as fear avoidance and exposure-based therapies are starting to gain traction, and rightly so, especially as their role in actually getting people moving is starting to be appreciated more and more.

We might have to be very SPECIFIC to a movement but that movement is probably very SPECIFIC to the individual as well.

Adherence

It might not matter what the exercise or its aims are if it doesn’t get done in the first place. This is a great example of when non-specific is really quite specific. We may have to be specific in:

Location
Type of equipment
Preferences & enjoyment

to get someone moving again.

Movement

It has been hard to pin down many SPECIFIC movement ‘problems’ that we reliably see as a cause for pain. Our understanding of the mechanisms behind the pain experience are broadening and we see modern concepts such as the decoupling of SPECIFIC movements from pain responses as a plausible reason for using a movement based approach, but again these seem to be quite SPECIFIC to the individual.

Variability that is either too high OR too low might be relevant to pain, maintenance of pain and injury, or not! who knows?

It might be that just MOVING is what many people need!

Being Specific – Where’s Your Data!?

This does not mean that there are NO specifics we should aim for across people but they DO need to be clearly defined.

An example here might be, return to play for ACL rehab. Better outcomes have been shown if patients achieve RTP markers of almost equal, within 10%, of quadriceps strength and also hop performance.

We also see the specific use of eccentric contractions with the prevention of hamstring injuries over concentric strength work. The key here is if you ARE being specific that you have some form of data to back it up.

Remain Vigilant To The Specific Response

All exercise gives individual responses, it’s not just fire and forget.

Lots of exercise research is based around comparing the means of two different groups to look for a statistically significant difference or variation between the two groups. While this type of analysis does point towards a trend for an effect, in reality, it gives us little idea about individual responses to exercise so it is important to monitor someone’s response rather than just expect your reasoning process to have a successful outcome.

An exercise could make someone better, worse, or simply have no difference.

It is important to know that many exercise interventions don’t achieve spectacular results. The actual effect is often around the minimal clinically important difference (MCID). The MCID is the smallest difference that a patient is likely to see as important to them. Although this number varies across studies is generally around 2 points on an 11 point 0-10 VAS scale.

We must always be prepared to adjust the exercise type or dosage based on the SPECIFIC response from the patient.

Summing Up

We always need to be SPECIFIC
Not always in the same way
Always ask “what do we want?” from the exercise
Lots of different effects across the BPS spectrum
Want to be specific? Have data!
Always remain vigilant to the effectiveness of your exercise

Articles Of The Week March 11, 2018

March 10, 2018/in Business, Massage, Massage Clinic, Massage Therapist, Massage Therapy, Pain, Sport Massage/by Jamie Johnston

Is yoga effective for managing chronic pain? Maybe, but then again maybe we just need to look at safe, non-threatening movement as a way to cure or manage chronic pain.

“Yoga, Mice, Pain and Your Brain” – Sarah Haag

There are some great points in this article about doing aggressive psoas work on patients, but there’s some things I don’t like about the article. To say that only those trained in visceral work should be doing this kind of work (because there’s not much evidence to say visceral manipulation is effective), is a bit of a stretch. However, I like the overall gist, that only trained professionals should be doing the work, and to be careful, there’s no need to do “aggressive” work.

“Serious Warning – If You Do Any Releases To Your Psoas or Abs, You Must Read This” – Antony Lo

Load management in athletes is an important factor in making athletes available for, and being in the best shape possible for competition. This post reviews three factors related to load management to help your athletes.

“Load Management Is Not About Decreasing Minutes” – Tim Gabbett

I love sleep, so I hate this part of the year where I lose an hour of it putting the clocks forward (why are we still doing this!?). A lack of sleep can lead to a host of health conditions and can affect brain health. Fortunately, massage therapy helps with sleep, so this could be a good article to share with your patients as another reason to get a massage!

“Why Are We So Sleep Deprived And Why Does It Matter?” – The Conversation

I’ve been asked many times if I would ever open up a practice at home and while it’s not for me, I know plenty of therapists who do. This post lays out several things to consider if you are wanting to open a home-based practice.

“Opening A Home Based Massage Business” – Allissa Haines

Articles Of The Week February 18, 2018

February 18, 2018/in Business, Massage Clinic, Massage Therapist, Massage Therapy, Pain/by Jamie Johnston

I may be partial, but I gotta say I love this post. It might be because I think this has happened to all of us. We have a patient come in who has been told by another practitioner that they will never get better, or they’ve been given some false information. Well, this is an open letter to everyone in our industry to do better.

“An Open Letter To My Patients Previous Therapists” – Sarah Haag

We all treat patients with low back pain. But, what are the appropriate guidelines for treatment? Well, some pretty reliable practitioners teamed up to look at the evidence, and explain the difference in guidelines, implementation, and controversies.

“Low Back Pain, A Ride Through The Guidelines” – Body In Mind

I don’t know about you, but I LOVE sleep. But how much do we really need? Well, that may vary, but it’s important to pay attention to our own individual needs, as well as looking at how to make sleep a priority.

“How Much Sleep Do We Really Need?” – National Sleep Foundation

One of the great things about massage therapy is the many ways we can focus on certain conditions or populations. If you’d like to focus on cancer treatment, this site has some good info. They present different recommendations as far as altering your treatment when someone is going through chemotherapy, and their reasoning seems pretty sound.

“Cold Caps, Frozen Feet, And Massage During Chemotherapy” – Tracy Walton & Associates

Our communication with patients is so important. So how do you present new ideas or research to them when you learn it? How about when it comes to your pain education? It doesn’t have to be complicated (in fact it’s probably a lot better if it isn’t), just explaining that certain areas of their body may be a bit more sensitive, is probably a lot better than a complicated description.

“Pain Science Education” – Lynita White

Articles Of The Week February 11, 2018

February 10, 2018/in Business, Massage, Massage Clinic, Massage Therapist, Massage Therapy, Pain/by Jamie Johnston

Like so many things in our industry, there is lots of confusion around youth strength training. Does it improve health? effect bone growth? is it even appropriate? Some great information in this article covering those questions and many others.

“Youth Strength Training” – Mario Chavez

Chronic disease is a massive expense on our healthcare system, and yet there doesn’t seem to be much done to prevent it. So how can we start to change things to start making prevention a regular part of our healthcare systems?

“An Ounce Of Prevention Is Worth A Pound Of Cure” – Jarod Hall

Quite often I have patients and colleagues ask where to get good information on pain. Well, Lissanthea Taylor is stepping up with this great resource she is developing. There will be lots of information on pain so that we can give accurate information to others.

“Where’s The Good Information About Pain?” – Lissanthea Taylor

Do you know the difference between Varus and Valgus? This post will help to give you a better understanding of the differences between the two and what can contribute to it. One of the things I like about the article is how the author points out that someone may have this kind of condition, but not experience any pain, so it may not even need treatment.

“Valgus, Varus, Vargus…What Is It?” – Whitney Lowe

Being in business for yourself is hard work! It seems there is a never-ending list of things that have to get done and we’re constantly hustling to accomplish more. But could we be more successful if we hustled less? Here are four tips on how to do just that.

“How Not To Hustle Your Way To Success: 4 Tips For Aspiring Entrepreneurs” – MeiMei Fox

Three Reasons It Matters Why A Treatment Works

February 5, 2018/in Massage, Massage Clinic, Massage Therapist, Massage Therapy, Pain/by Todd Hargrove

Why exactly does someone feel better after a massage? Or acupuncture? Or foam rolling? Or a chiropractic adjustment, or wearing K-tape, or doing mobility drills, or a hamstring stretch?

There are some good answers to these questions, and the interesting thing I’d like to point out in this post is that quite often, the therapist doesn’t know them. Or even care about them! Or maybe the therapist has heard the good answers, but prefers alternative bad answers that are far less plausible given the current state of relevant science.

Speaking of bad explanations: Foam rolling probably doesn’t work by breaking adhesions or melting fascia. Chiropractic manipulation doesn’t put joints that are “out” back “in.” Deep tissue massage doesn’t get rid of toxins or “muscle knots.” Acupuncture doesn’t access special points or meridians – putting the needles in random places works just as well. Some sham surgeries work just as well the real thing. Motor control exercises often work to reduce pain even though motor control hasn’t changed.

None of this means that the above treatments can’t work to make someone feel better. It just means they don’t work in the manner advertised. And no this doesn’t mean that everything is just placebo (that’s a confusing word without a clear meaning.)

In general, it seems that therapists have a strong bias towards the idea they are fixing “issues in the tissues.” And they tend to ignore issues in the more complex systems in the body – nervous, immune, autonomic – which are very sensitive to even minor inputs and have a great influence over how we move and feel. Maybe this is because these systems are less visible, or tangible, or just not what practitioners learned about when they were in school.

I was trained as a Rolfer and taught that Rolfing works by changing fascia. So when people got up from the table and said they felt taller, or looser, or had less pain, this was because their fascia had somehow changed for the better.

After doing some research about the deformability of fascia in response to manual pressure, I decided this was not a good explanation for our observations. A better explanation would involve the nervous system, which is constantly adjusting muscle tension, movement patterns, perception, and pain sensitivity in response to new sensory information, including the highly novel sensory information caused by bodywork.

Of course, it’s kind of a bummer to learn that a central premise of your education is incorrect. But the good news is that this doesn’t mean people can’t be helped with your treatment. That is a completely separate issue. So my attitude was – OK, it’s not about the fascia, but that doesn’t mean I can’t help people.

But for many Rolfers, it just has to be about the fascia. And for chiros, it has to be about the subluxation, and for Reiki practitioners, it has to be about energy, and for others, it needs to be about posture, or core strength, or muscle imbalances, or movement patterns.

And of course, many others will say: “I don’t care how the treatment works, I just know that it works does so who cares why?”

Here’s three reasons why it’s important to know why your treatment works.

1. If You Know How Something Works, You Can Make It Work Better

This should be obvious. If you know where the target is, it’s easier to hit the bullseye.

Let’s assume that stretching or massage works to create better range of motion by getting the muscles to relax. (Reasonable enough, right? And supported by research!)

But if you think that it works by forcefully breaking adhesions or physically lengthening tissues you might lose focus on whether your clients are staying relaxed.

When I work on someone I always ask “how does that feel?” Here’s a common response from clients who think it’s all about the fascia: “Don’t worry about me, I have a very high pain tolerance, just do what you have to do.”

And I will think to myself: “Well, I need to know how you feel because that is one of the main targets for this work.” But if my target was breaking up fascia or muscle knots then indeed I wouldn’t care how they felt. And I wouldn’t do as good of a job.

2. Unintended Consequences

Imagine someone with neck pain goes to the chiropractor, is told their neck is “out”, gets cracked to put it back “in”, and then immediately feels much better. What’s the harm if they think that pain relief came from some form of realignment?

Maybe in the short term, there is no harm, but false beliefs have a mischievous way of eventually causing problems in the long term.

Let’s say the neck pain comes back. The client thinks her neck must be “out” again so she needs another crack. So she overlooks other potential solutions like exercise, rest, or gentle movement. If the neck pain continues, she might eventually develop the pathological belief that her neck is fragile and unstable. This can have a nocebo effect – creating further pain and avoidance of healthy movement.

I have seen many clients with similar misconceptions, and this has cost them significant time, money, anxiety, and confusion.

And I’m not just talking about the clients of chiropractors.

I have seen yoga people who are always stretching; Pilates people always stabilizing; corrective exercisers looking for microscopic muscle imbalances; joint mobility fans perpetually mobilizing, as if their joints need a constant bath in synovial fluid, or will start knitting themselves together with some sort of fascial “fuzz” after just a few minutes of stasis. Rust never sleeps!

All these pathological behaviours ultimately stem from false beliefs about why certain therapies have worked for them in the past. These beliefs cluster around the idea that they have corrected “issues in the tissues” as opposed to temporarily adjusting the sensitivity of the nervous system.

The bottom line is that false beliefs, no matter how small, are like viruses – they multiply, get passed to others, mutate to form superbugs, and can eventually cause disease. Don’t spread them, people!

3. The Truth Matters

The truth has inherent value, even when its practical application is not immediately obvious. Knowledge is always powerful – for you, your clients, and the whole community.

We don’t yet know exactly why people have chronic pain and the best ways to treat it.

Even though that knowledge hasn’t been created yet, that doesn’t mean it’s useless to learn more. Every step away from misinformation and confusion is a step in the direction of the truth.

Let’s face it. The truth is good and ignorance sucks. Here’s some quotes from smart people to prove it.

“All evils are caused by lack of knowledge.”

–David Deustch

“I think it’s much more interesting to live not knowing than to have answers which might be wrong.”

— Richard Feynman

“It ain’t what you don’t know that gets you into trouble. It’s what you know for sure that just ain’t so.”

— Mark Twain

“The truth will set you free, but first it will piss you off.”

–Joe Klaas

Many thanks to my readers and members of my social media community who are thinkers, skeptics, and unafraid to follow where the evidence leads.

The Science Behind Why Assessing And Blaming Posture For Pain Is B.S.

December 11, 2017/in Massage, Massage Clinic, Massage Therapist, Massage Therapy, Pain/by Ben Cormack

If I had a £ for everybody that mentioned posture on social media or when they had a pain problem…… well lets just say I would be a pretty rich guy.

POSTURE has literally become engrained in peoples thoughts when talking about back, shoulder or neck pain even though we have a shit ton of studies that compare the postures of pain-free people with those with back, shoulder or neck pain and find no real differences, this information gets regularly IGNORED.

NEVER let science get in the way of a good story, especially if it’s on the interwebs!

In fact, I have written about posture a few times before:

The definitive guide to posture and pain 3 minutes flat

Do you really need your joints to be centred?

But just to kick off with a bit of science, this paper HERE from 2016 found NO significant difference in lumbar lordosis (spinal curve) between people with back pain and those without.

This is super important. HOW can we blame something that we see in people WITHOUT pain as a cause of pain for those that do?

I will just let that sink in…

What Are You Measuring?

In this blog, we are going to explore a few questions related to how we assess posture and if they are actually scientifically VALID, because if you don’t have a good measure, to begin with then it is pretty tough to blame something for the problem.

The first piece of ACTUAL EVIDENCE, something often missing in the posture debate, looks at the measurement of STANDING LUMBAR LORDOSIS (the curve in the back often blamed for back pain) and this assessment is something that is performed in treatment rooms and gyms the world over.

The idea is that an increase (and sometimes decrease) in lumbar curve increases back pain and is often coupled with the idea that the tilt of the pelvis has an influence on the size of the lumbar curve, even though lumbar curves do not seem to be much of a factor in lower back pain anyway (see the SCIENCE above : )

Way back in 1990 this was explored by Heino et al HERE and they found that the angle of someones pelvic tilt and their lumbar curve do not simply correlate! So looking at the position of the pelvis tells us very little about what is occurring at the lumbar spine, which is much harder to measure. A very similar study HERE from before this in 1987 also threw up the same result but this BS is still being taught today.

Anyway, back to the standing measurement paper HERE. The authors explored the variability in standing posture of 400 people, 332 without pain and 83 with low back pain, and they found that each time we stand we do it in a slightly different way.

The authors in their words state “standing is highly individual and poorly reproducible”.

So why does this matter?

Well simply put, which posture are you ACTUALLY measuring with your postural assessment. One may show an increase in lordosis, another less so.

I have some questions related to how we interpret postural assessments in light of this information.

Which of these postures is related to the problem?
How many times do you measure and do you average?
What are you comparing against to determine if the curve is too much or not enough?

The authors highlight a good point that the lack of consistency in standing posture may actually lead to the “wrong diagnosis and possibly unnecessary treatment”.

If you focus on something that is not an issue you do not focus on something else that might be or be blinded to the fact that it is not working or only works transiently (potentially why so much back pain is persistent).

What people actually use in their everyday lives might also be different to what is measured in the clinic or gym. A clinic or gym measure could be described as a ‘snapshot’ and this study HERE compared this ‘snapshot’ to what was actually used on a daily basis by the study participants.

The authors found that on average whilst standing, as most postural assessments are, there was a 33.3° lumbar lordosis but the average used over a 24hr period was only 8°, a huge difference!

So the ‘snapshot’ postural assessment would not really inform us very well about how much lordosis was REALLY being used and we could overestimate the extent of the imaginary problem.

We also have to remember these were radiological measurements and this is the clinical ‘gold standard’. Often a lordosis is measured in a much more rudimentary fashion by looking at the relationship of landmarks at the pelvis indicating a pelvic tilt and therefore change in the lumbar curve, which we have already discussed as not being well related to lumbar curve! This in itself is a problem as demonstrated by Preece in 2008 HERE as pelvic morphology is also VARIABLE leading to incorrect measures.

“These results suggest that variations in pelvic morphology may significantly influence measures of pelvic tilt and innominate rotational asymmetry”

Here is the distribution of side to side difference of the ASIS-PSIS relationship (used to assess pelvic tilt), we can see it is skewed to the right side meaning it is more anteriorly tilted at a BONY level.

So it might be that we are really bad at measuring something that doesn’t matter that much. OUCH

Are You Biased?

Another important question for those that assess posture is…are you MORE inclined to see an ‘abnormality’ in posture when you know pain is present?

This paper HERE would suggest so. Here the authors looked at scapular dyskinesis or abnormal posture and movement of the shoulder blade, which is often proposed as a CAUSE of shoulder pain.

They compared 67 people with shoulder pain and 68 without and firstly found that there was no difference in shoulder posture or motion between those with pain and those without.

Fascinatingly though when the assessors were aware that they were assessing someone IN PAIN, they reported a greater prevalence of a postural or movement problem. This shows a bias towards finding an ‘abnormality’ to blame when there is pain, even though there was NO MORE ‘abnormality’ in those with pain than without.

The authors also suggest that scapular dyskinesis actually represents normal variability between humans! Perhaps if they assessed it multiple times it would throw up different measures each time?! It is important to remember we have no scientifically defined ‘good posture’ to base deviations from in the first place.

How Do Healthy People Sit?

Another question is how do people without back pain actually behave? They must have great daily posture, right? Well actually NO.

This paper HERE shows that asymptomatic folk, 50 of them, when seating actually SLUMP. In 10-min sitting, spinal angles flexed 24 deg at lumbar and 12 deg at thoracolumbar regions relative to a standing posture. But this slumping does not seem to cause them problems.

So changes in our spinal curves seem to be fairly unrelated to pain as we can see below.

So If Posture Does Not Really Correlate With Pain, What Does It Correlate With?

Well, this paper HERE shows that cervical spine alignment changes actually correlate with age. This study split the participants into 4 groups determined by age. They found that the measures of the angles of the neck all correlated with the increasing age range of the 4 groups.

The key point to remember here is that all the participants, 120 of them, had no pain. In fact, the exclusion criteria here was pretty rigorous and the authors actually excluded 64 people, so 1/3 of the original sample, for having current or previous pain.

So simply put, as we get older our posture becomes ‘worse’ or perhaps better put our posture increases….BUT and a this a big BUT, this does not seem to cause MORE pain.

To sum up it does not seem as simple as ‘bad’ posture = pain whatever you read or are told in a bar, gym or clinic room.

Key Take Homes

People IN pain DON’T have different postures to those that don’t have pain
Posture displays variability just like movement
This means your assessment may not tell you what you think it does
Your assessment could be biased to finding a postural ‘problem’
Postures used throughout the day are probably different to those being assessed
As we get older our posture change and this happens to people NOT in pain too