Chronic Pain Is Rooted In Fear

fear painChronic pain is rooted in fear.

Chronic pain is defined as pain persisting more than 3-6 months, this is the time it typically takes for injured tissue to heal.

However, both acute and chronic pain have a tenuous association with injury (tissue damage).

People can exhibit the signs and symptoms of chronic pain earlier than 3 months.

This is influenced by factors associated with developing chronic pain, including, but not limited to, a history of anxiety and/or depression, low education level, lower income and age.

In general, most treatment of chronic pain is unsuccessful.

This is related to poor expectations of patients (after many failures, who can blame them) (1), and treatments that are overly focused on the biomedical (tissue) factors of pain, that often don’t match up with patients’ goals (2).

There have been promising results achieved by combining physical therapies with cognitive based therapies to treat chronic pain. (3)

Why Do We Experience Pain?

Professor of neuroscience and world leading expert on pain, Lorimer Moseley, has previously described pain as:

…a conscious correlate of the implicit perception that tissue is in danger

For most, the perception of danger evokes feelings of fear, heightened sensory awareness and decreased cognition.

When we assess danger, there are two main forms:

  1. Actual danger – situations where our life or safety is at risk.
  2. Perceived danger – situations where we perceive our life or safety to be at risk, but it really isn’t.

Both actual and perceived danger activate the same neuro-networks in the brain and the same physiological responses in the body. (4)

Our perceptions of danger are shaped by numerous factors, including:

  • Our age
  • Our gender
  • Our social
  • Our cultural upbringing
  • Our experiences
  • Our current capabilities.

If pain is related to a perception of danger, and our perception is shaped by all those factors, it is fair to say that pain is shaped by those factors too.

Pain science has moved forward, and beyond simply being a perception of danger, pain is beginning to be defined as a “need to protect”. (5)

The perception of danger, or threat, is in part based on predictive processing. (6)

Predictive processing is what our brains do to make sense of the world we experience and take shortcuts to achieving a conclusion.

An optical illusion based on predictive processing.

An optical illusion based on predictive processing.

Because of predictive processing, and other neural processes, we tend to not see an objective reality, but rather a subjective reality.

This is especially true when it comes to pain.

When we are experiencing pain, our brain makes predictions about whether something is going to be “dangerous”, and produces pain preemptively, in order to protect us.

Pain is not the only time that our brains use predictive processing.

Take a look at the brick wall, and see if you can spot what is not quite right.

The Neurobiology of Pain

The big problem with pain, is that pain is perception that we perceive as a sensation.

It tricks us into thinking that it is coming from our body, when in actual fact, pain is always produced by the brain and localised to the body. (7)

It is complex, and emergent, not linear.

So just because you feel a certain way after doing something, or not doing something, does not mean that your actions, or lack thereof, caused that feeling.

In the diagram below, I’ve simplified the neurobiology of pain with injury (remember, pain can occur without injury, and injury without pain as well).

neurobiology-of-pain-injury

Injury here is used loosely to describe the inciting physical event that damages the body tissue – it could be physical trauma, it could be an immune response from an infection or an auto-immune condition, like rheumatoid arthritis.

This leads to nociception – “danger” signals that convey a change to the status of the cellular environment.

That could mean a change to the mechanical load, a change to the chemical environment or a change to the temperature (the three primary types of nociceptors).

Inflammation is an immune response, and we know the brain and nervous system has a large role to play in the immune response (these days, doctors are calling it the neuro-endocrine-immune system). (8, 9)

Inflammation can lead to increased nociception, and if nociception increases, then this is a mechanism for increased inflammation. (10)

This can lead to peripheral sensitisation – where the sensory nerves in the affected body region become more sensitive due to physiological changes that take place.

All of this takes place locally, but we do not experience pain as a result of this just yet.

The Brain Modulates Everything

Modulation is a process whereby signals (nociception) reaching either the brain or spinal cord are amplified or inhibited. (11, 12)

Modulation can be affected by our thoughts – conscious or unconscious.

Here is where it gets interesting: we often think that our thoughts are ours, but there is compelling evidence that this may not be the case, and that our culture and environment shapes our thoughts, feelings and actions more than many of us would care to admit. (13, 14)

“You can do what you decide to do — but you cannot decide what you will decide to do.”
― Sam HarrisFree Will

Using this line of thought – when it comes to pain, our ideas and understanding, especially at an unconscious level are already implanted by the culture we live in.

Currently our culture around pain is:

  • Pain is bad.
  • Pain is caused by damage, or degeneration (the dreaded “wear and tear”) or misalignment.
  • “I’m just getting old.”
  • Pain needs to be “fixed” – and can be done so by the right practitioner.
  • We need to find the cause of pain, and this can be done by physical assessment and diagnostic tests (MRIs, X-rays etc).
  • The weather causes pain to flare up.

If you live in Australia, or any other Western nation with a similar culture, all of these memes, plus many others, have been implanted into your thoughts.

You don’t even question them most of the time, because you don’t know you have them, until you experience pain.

Our thoughts shape our emotions, our emotions shape our actions and our actions reinforce both.

This is especially evident when we experience pain.

Changing The Unchangeable?

We discussed earlier that pain is a protective response, which is based on the perception of threat.

There is a greater evidence of danger to ourselves, than there is of safety for ourselves. (15)

Going back to the premise of this post: chronic pain is rooted in fear.

Fear changes our perceptions.

Fear makes us think or feel that we are in danger moreso than we actually are.

Fear makes us want to find safety.

But if fear is influenced by a host of factors, many that we don’t know, and most that are unconscious, can we change it, and as a result, change pain?

I say yes.

Cognitive Based Therapy

CBT

When we can identify our fears around pain, then we take away some, if not all of its power.

Yes, pain will still hurt, that’s the nature of pain, but our suffering is different.

We stop catostrophising.

We stop worrying.

We start focusing on what we can do.

We start focusing on who we are.

The challenge of identifying and treating unconscious fears is obvious.

Fortunately, over the years, psychologists have developed many ways to explore our unconscious.

One of which, is cognitive behavioural therapy.

Cognitive based therapy is based on the premise that each thought is related to a certain emotion and behaviour, and vice versa.

By exploring each aspect around our beliefs and understanding of pain, we can change what we think, feel and do, to decrease our pain and suffering and eventually, change our unconscious thoughts.

Cognitive behavioural therapy is not only effective for treating pain, but also something that can be performed by suitably trained manual and physical therapists*.

A Way Into The Neuromatrix

The most up to date, and most widely accepted model of pain, is the neuromatrix model, proposed by Melzack and Wall (pictured).neuromatrix

What you can see in this diagram, is that there are multiple inputs (on the left) to the “body-self neuromatrix” (the representation of ourselves, within our brain) from both the body and brain, which influence what our body does, how it feels and how it functions (outputs, on the right)

These include:

  • Cognitive related brain areas
  • Sensory signalling systems
  • Emotion related brain areas.

But, that’s not all, each of these inputs can affect each other, as can each output.

Everything affects everything when it comes to pain.

What any good clinician is trying to do when treating someone in pain, is provide enough context for the outputs of the neuromatrix to change.

We do this by influencing the inputs in a way that promotes increased descending inhibition (as discussed earlier).

In addition to CBT, we can use other interventions like touch (manual therapy from intelligent, responsive hands) and movement.

Basically, we are trying to tell your brain that it’s okay, things are safe and you don’t have to be on edge.

When your brain is no longer in “fear mode”, it can resume normal modulation duties and you start to feel better.

Conclusions

Most chronic pain occurs in post surgical patients. (16)

There is an obvious physical trauma that takes place.

Many others develop chronic pain conditions after intense and/or prolonged psychological and/or emotional distress.

Something occurs to shift the brain into “fear mode”, in which it wants to do nothing more than protect itself (and you), which it does by producing pain.

We know that pain is complex and multi-factorial, but too often we think we are the exception.

It can feel like we just need to “release” that tight muscle or “crack” that stiff joint.

It can feel like there is “wear and tear” or “damage”.

But at least 40% of people with widespread arthritis don’t experience pain.

Amputees with no limbs do experience pain, in the absent limb!

You have to be fully engaged in the process, and willing to confront a lot of home truths about what you think, feel and believe if you want to treat your chronic pain successfully.

Even when you do that, sometimes you’ll still be in pain.

But, if you don’t, you’ll definitely still be in pain.

 

 

Nick Efthimiou Osteopath

 

This blog post was written by Dr Nick Efthimiou (Osteopath), founder of Integrative Osteopathy.

This blog post is meant as an educational tool only. It is not a replacement for medical advice from a qualified and registered health professional.

 

 



 

 

 

*If your condition was too complex for the therapist alone, we would refer you to a psychologist. In Australia, there is a mental health plan, under which your GP can refer you for up to 10 consultations with a psychologist, partly subsidised by medicare.

References

(1) Expectations and chronic pain outcomes

(2) Patient goals and measuring treatment outcomes

(3) Cognitive functional therapy for low back pain 

(4) Activation of threat-reward neural networks

(5) What is pain?

(6) Predictive processing simplified

(7) Pain

(8) Nervous and immune system interactions

(9) Structure and function of nervous system lymphatic vessels

(10) Mechanisms of inflammatory pain

(11) Descending control of pain

(12) Continuous descending modulation revealed by FRMI

(13) Free Will

(14) Myth of free will

(15) DIM-SIMS

(16) Chronic pain and surgery

3 Ways To Improve Your Movement Quality

Human Movement

Whatever you do, from high end computer programming to gardening and everything else, quality matters.

Movement is no exception.

As Dutch sports performance and motor learning expert Joep Joosten says:

Movement quality is hard to measure objectively, due to inherent differences between human anatomy, physiology and psychology, that the best we can do is quantify, and compare to norms.

However, if you ask any lay person watching anything involving human movement, from artistic dance to fast running, they will be able to tell you what looks “better”, or more easily, what’s not good.

My colleague, top sports physiotherapist Greg Dea, has this to say on movement quality:

There are certain things that leaders in the area of human movement agree on, and one of which, is that certain movements are fundamental to humans. These include:

  • Squatting
  • Bending
  • Rolling/twisting
  • Pushing
  • Pulling

We also intuitively understand that our movement quality can be compromised over time (1), be it due to factors out of our control like ageing, disease or injury.

But we also need to realise that our movement quality is very much affected by factors that are within our control, such as our environment, occupation, hobbies and our physical activity, to name a few.

Whatever you do, it is always a good option to try and move with more quality. Why? Movement is both an action and a stimulus. Each time you move, you are stimulating your brain. The better your movement, the better the stimulus, and thus the better the learning experience for your brain. (2)

So how do you move with more quality?

Make It Easier

This stems out of a training quote “sometimes you have to regress to progress”, but it applies across all forms of movement in life.

Sometimes, what you are doing, or attempting to do, is simply beyond your current capabilities.

If this is the case, you are performing at, or near, your “threshold”. Around this threshold we see survival strategies kick in, which impair movement quality.

To borrow from Greg again:

Survival strategies are great in times when survival is threatened.

They produce extra stability and rigidity, which in turn allows the expression of more power, strength and endurance than you normally would be able to produce otherwise.

In the short term, this is perfect. If a bear is chasing you down, you want to be able to run or climb to safety, it’s not so great if you are in the gym or on the tennis court, trying to enjoy yourself and be the best you can be, because then you can potentially do more than your body can safely adapt to, which is termed an injury.

If that is the case, making the movement easier by “regressing” it can allow your brain turn off the survival mechanisms, and you can execute movement more effectively.

Regressing can be done in few different ways:

  • Making the task easier
  • Doing less of the task
  • Breaking the task up into smaller chunks, and taking longer breaks between chunks

The cool thing about our bodies, is that they adapt to stimuli, so over time, you will get better and be able to do more anyway,

This is universally applicable, from sports to housework.

Stimulate Your Senses

Movement is an output of the brain. Once again, Greg puts it simply (maybe this should be an ode to Greg):

Outputs = inputs + processing. – Greg Dea

Most of the time, when someone wants to improve their movement quality, they focus on executing the output more, and perhaps changing the processing by thinking about certain cues (think stand tall, arch your back, lift your knees etc).

Very few people focus on the inputs aspect intuitively, but this is one of the biggest areas where you can have success in improving your movement quality.

Pictured above, osteopath Phillip Beach is discussing the sensory homonculus, which is the representation of the physical body within the brain. You can see how certain areas are quite big – these areas have the richest sensory nerve supply and are ripe for stimulation.

Now, obviously, when it comes to movement, we are probably not going to worry about stimulating our face or genitals, but how many times have you paid attention to how your hands and feet interact with your environment?

By stimulating your senses to a higher level, you drive increased brain activation, which facilitates better movement.

An obvious place to start, is with the feet. Encased in shoes for most of the day, by performing movements without shoes, you automatically get a richer sensory stimulus. This isn’t always practical, so a good rule of thumb is to spend as much time at home, both indoors and out, barefoot, and when you are exercising, try and perform your warm ups, or at least part of them, barefoot as well.

When it comes to your hands, whether your in the gym, gardening or riding a bike, you need to weigh up the benefits of protection to the costs of decreased sensory stimulation when wearing gloves.

The other aspect of increasing sensory stimulation is in relation to sensory input from within the body. If function at a joint is compromised, then the sensory input of that joint to the CNS is also compromised. However, compromised sensory input also impacts function. It’s a negative vicious cycle.

We can use osteopathic techniques, stretching and other self-mobilisation techniques to change the function at a joint, in order to improve it’s sensory input. Remember the equation Input + Processing = Output?

Change Your Environment

By modifying your environment, you can almost immediately change your movement.

What do I mean by your environment?

Almost everything. From the physical environment, all the way through to the social environment.

Let’s say you are a recreational runner, and your best 5 km time is 30 minutes. If you started running with 23-25 minute 5 km runners regularly (a change to your social environment), do you think you would get faster over time?

If you are a district level cricket player, and you get the chance to play a match at the MCG, do you think you would be more focused or less? Would you perform to a higher level or lower?

There’s not a clear answer to either question.

Some people rise to the occasion and others are crushed by the pressure. Either way, there is a change in their performance.

To improve your movement quality, you need to experiment with your environment to find the conditions that let you be at your best.

Conclusions

Improving your movement quality isn’t all about performing specific exercises or using a certain technique.

By understanding that movement is a complex brain output, that is based on many contextual factors, you can aim to change your movement by changing the contextual factors.

 

Nick Efthimiou Osteopath

 

This blog post was written by Dr Nick Efthimiou (Osteopath), founder of Integrative Osteopathy.

This blog post is meant as an educational tool only. It is not a replacement for medical advice from a qualified and registered health professional.

 

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(1) Performance on the Functional Movement Screen in older active adults

(2) Neural Correlates of Motor Learning, Transfer of Learning, and Learning to Learn

 

Osteopathy For Carpal Tunnel Syndrome

Image credit: By DoPhotoShop - http://dophotoshop.com/carpal-tunnel-exercises.php, CC BY-SA 3.0, https://commons.wikimedia.org/w/index.php?curid=14614865

Image credit: By DoPhotoShop – http://dophotoshop.com/carpal-tunnel-exercises.php, CC BY-SA 3.0, https://commons.wikimedia.org/w/index.php?curid=14614865

Carpal tunnel syndrome is a common presentation, but is often poorly managed. Osteopathy can provide a conservative option to treat carpal tunnel syndrome.

Carpal tunnel syndrome is a fairly common condition that affects women slightly more than men, with numbers ranging from 1-7% of the population affected. (1)

It is described as “a painful disorder of the hand caused by pressure on nerves that run through the wrist. Symptoms include numbness, pins and needles, and pain (particularly at night).” (2)

It usually presents with the following symptoms (3):

  • paresthesia, dull, aching pain, or discomfort in the hand associated with weakness or clumsiness;
  • fluctuating level of symptoms with exacerbation at night (nocturnal numbness), worsened by strenuous hand use or activities with maintained posture (driving);
  • and partial relief of symptoms by changing hand posture or shaking the hand.

Diagnosis or description?

Generally speaking, any condition that has the word “syndrome” in its name is not a diagnosis, but rather a collection of clinical findings.

In the case of carpal tunnel syndrome, it is considered a clinical diagnosis, but, whilst the symptoms can be similar from person to person, the clinical findings (and thus underlying causes) can be quite different, based on a variety of different factors.

Some of these factors include:

  • Individual anatomical differences (wrist space, nerve length, a cervical rib etc)
  • Lifestyle and occupational activities (assembly line workers tend to have a higher incidence of carpal tunnel syndrome than other occupations – NINDS)
  • Pregnancy – pregnant women have a higher incidence
  • Health status – diabetes, hypothyroidism and obesity are known risk factors (Frontiers)

To diagnose carpal tunnel syndrome a clinical examination is sufficient, though in more severe cases, nerve conduction tests are recommended.

When you consider that any combination of factors can be present, an individualised approach to management becomes critical.

General Recommendations

The general medical recommendations (1, 4, 5) to treat carpal tunnel are (in order):

  • Rest. Rest is important, but it is often futile if there are other issues involved, because as soon as you stop resting, symptoms flare up again.
  • Splinting, particularly at night. Splinting can be useful, but again, it isn’t because of a “lack of splinting” that you develop the condition in the first place. This means, that without addressing the other factors, splinting is just another form of rest, and symptoms will likely return once splinting has stopped.
  • Physiotherapy. Hand, wrist and arm exercises can be useful in helping reduce symptoms and address causative factors. Exercises targeted at mobilising the nervous tissue, can be particularly helpful here. Whilst different professions, osteopaths can do most of what physiotherapists can do and vice versa, and what matters most is that the professional in question is up to date in their knowledge and provides an individualised treatment approach.
  • Diuretics to reduce fluid. Diuretics can provide a short term reduction in fluid, but again, we need to work out why the fluid was accumulating in the first place. If, for example, there is lymphatic congestion, the diuretics will only have a short term effect, often with the risk of side effects. Another common cause of congestion is hypothyroidism, which needs to be medicated properly, so identifying the cause of the congestion is as important as reducing the fluid with diuretics.
  • Cortisone. Cortisone can reduce inflammation locally, with the potential risk of nerve injury resulting in worse pain. The benefits do not outweigh the risks, in my opinion, considering the alternatives available. If you do decide to have a cortisone injection, it’s best to have it performed by a surgeon who performs it often, as their skills will be higher, reducing the risk of adverse effects.
  • Surgery. Surgery is indicated in severe cases, but is not always successful (like any treatment). It has the risk of nerve and/or artery damage, with the benefit of increasing the space under the transverse carpal ligament, which is often a cause of symptoms. The success rate of surgery for carpal tunnel is generally higher at 12 months than conservative approaches, when considering nerve conduction studies, but due to the risks involved, the recommendation is to initially treat conservatively, and only explore surgery if there is not the desired improvement.

(My) Osteopathic Approach

To understand my osteopathic approach to treating carpal tunnel syndrome (and any condition really), you have to have a grasp of complex systems and emergent properties.

Put as simply as possible:

This means that something like pain, or symptoms arising from the nervous system are not predictable based on statistical or experiential averages, and any linear causality we deduce, is false logic.

So, when it comes to treatment, we have to have an understanding of normal physiology, then use our clinical skills to find the “abnormal” or “dysfunctional” or “disturbances to normal”.

We can then apply an intervention that results in a change (remember, this change is unpredictable), monitor the change (see if the abnormal has become normal) and then reevaluate the approach.

In essence, it is a trial and error approach, but an educated one.

Measure Twice, Don’t Cut

It’s important to measure the effects of treatments somehow, but, this can be hard, because clinical findings vary for the same condition, and the same clinical findings will not always result in symptoms, even in the same patient.

Because of this difficulty in measuring clinical findings and symptoms, I try to use objective outcome measures. These are simple, validated (by research) questionnaires, like the Boston Carpal Tunnel Syndrome Questionnaire, which provide a measure of the disability associated with a certain condition; and they can be very helpful to use at the beginning, mid-point and end of treatment process to gauge efficacy.

As mentioned earlier, nerve conduction tests are valuable in certain cases, but are invasive and costly from an economic point of view, so they are not always practical.

Treat The Whole, Not The Cause

As I described in Osteopathy For Low Back Pain, there are general, or systemic effects from osteopathic treatment, as well as local.

When treating a person with carpal tunnel syndrome, as opposed to treating carpal tunnel syndrome as a condition, these general effects can be important in improving overall sense of wellbeing as well as positively affecting the body’s physiological functioning.

Sense of wellbeing is often overlooked in outcomes based medicine, but, with outcomes being equal, the process that produces a more pleasant/less unpleasant experience for the patient is superior.

nerves_of_the_left_upper_extremityIn addition to the general aspects of an osteopathic manual treatment, with carpal tunnel syndrome, a focus on the structures related to the median nerve starting from it’s origin in the brachial plexus as it arises from the C5-T1 nerve roots, all the way to it’s end point in the hand.

It is surprising how many people I see who have consulted with their GP and perhaps a rehabilitation professional (occupational therapist, physiotherapist, hand therapist) who have only had interventions directed at the wrist and hand.

Simple anatomy suggests that this will not be adequate.

Given the nature of nerves, symptoms will appear distal to (below) any site of adverse tension/compression. Considering the hand is the site of carpal tunnel syndrome symptoms, my preference is to work up from the hand and wrist towards the neck and thorax.

Common areas of dysfunction include:

  • Transverse carpal ligament (this is what surgeons cut)
  • Carpal (wrist) bones
  • Radius and ulna (forearm bones and their joints)
  • Interosseus membrane of forearm (connection between radius and ulna)
  • Elbow flexor muscles and associated connective tissues
  • Pectoralis minor
  • Upper ribs (especially the 1st rib) and clavicle
  • Scalenes (and other neck muscles)
  • Cervical spine (neck) and thoracic spine and rib cage

Unless all these areas are considered and any dysfunction addressed, I wouldn’t consider the examination process thorough enough.

Neurodynamics must be considered

One of the issues with traditional approach to carpal tunnel syndrome, is that the median nerve itself is not considered as a primary cause of the symptoms, but rather a secondary “victim” to other changes.

Neurodynamics considers 3 aspects (Shacklock):

  1. The mechanical interface of the nerve and body tissue (joint, ligament, muscle etc)
  2. The neural tissue itself
  3. The innervated tissues

Abnormal changes at any of these aspects can alter neurodynamics (the function of nerves), leading to symptoms.

Techniques Are Secondary

Lot’s of people want to know what technique will work best, whether it is a manual technique delivered by an osteopath, or an exercise to self manage. The technique doesn’t matter as much as the reasoning behind the technique and how the technique is executed.

So if someone reasons that muscular tension in the neck muscles is affecting the median nerve, a range of techniques to reduce said tension will be helpful. These can be active or passive and are guided by patient and practitioner experience and preference, as well as a risk to benefit analysis (when known).

This technique needs to be delivered or performed in a mindful manner, with attention being paid to the experience of the technique, as well as the response, by all parties involved (patient and practitioner).

By engaging patients in the process, the treatment automatically becomes more “active”, which we know produces superior results to passive treatments in the long term (BMP).

Conclusions: Putting It Altogether

 

Carpal tunnel syndrome has two components – the symptoms experienced (pain, numbness and tingling etc) and the reduced nerve conduction, which is not always perceptible.

Osteopaths have a role to play in reducing the symptoms (6), and research performed on other manual therapies supports this (7).

However, it must be considered that there is no set formula for a condition like carpal tunnel syndrome, and that each person will have their own “physical story” explaining their condition, and it is this story that a practitioner must somehow read, understand and interact with.

So when you are seeking treatment for carpal tunnel syndrome, you want to find a practitioner who considers everything, not just what is happening at the wrist, not just what is happening “in your body”, but everything.

It sounds cliche, but that is what a truly holistic approach entails.

 

Nick Efthimiou Osteopath

 

This blog post was written by Dr Nick Efthimiou (Osteopath), founder of Integrative Osteopathy.

This blog post is meant as an educational tool only. It is not a replacement for medical advice from a qualified and registered health professional.

 

 



 

 

References

(1) Primary Care Management of Carpal Tunnel Syndrome

(2) Better Health Channel – Carpal Tunnel Syndrome

(3) Carpal Tunnel Syndrome – Primary Care and Occupational Factors

(4) Conservative Interventions for Carpal Tunnel Syndrome

(5) Is surgical intervention more effective than non-surgical treatment for carpal tunnel syndrome: a systematic review

(6) Effectiveness of Osteopathic Manipulative Treatment for Carpal Tunnel Syndrome: A Pilot Project

(7) A Pilot Study Comparing Two Manual Therapy Interventions for Carpal Tunnel Syndrome

(8) Median Nerve Image

Common Gym Mistakes: Squats

The back squat is rightly called the “king of exercises”, in fact, it’s said that if you don’t have squats in a training program, then you don’t have a program.

Now, I’d never be so absolute, but the squat is a fundamental movement pattern and forms the foundation for lower body performance training and rehabilitation.

Despite squats being such a fundamental movement, because of the amount of muscles and joints involved, there are a lot of chances for compensation.

Compensation is an interesting topic.

Some claim it leads to injury, yet the research is unclear on this.

Additionally, real world examples abound, one only has to look to the recent Paralympics to see examples of high level compensation, so it’s not necessarily a bad thing to compensate.

What Makes A Good Squat?

With the back squat, we can split lifters into two groups:

  1. Competitive powerlifters, whose goal is to lift the most weight in competition
  2. Everybody else

If you are a competitive powerlifter, you can probably ignore this advice, because your goals are so unique.

If you are like most people and you are squatting to improve your leg and core strength to assist with physique goals, health goals or performance goals, then read on.

Executing a squat optimally requires the following:

  • Adequate ankle dorsiflexion range of motion and motor control
  • Adequate hip and knee flexion range of motion and motor control
  • Adequate isometric strength of the erector spinae muscles to maintain the spinal alignment
  • Adequate abdominal strength to maintain pelvic and rib cage position
  • Adequate thoracic extension and shoulder external rotation range of motion and motor control

Unfortunately, most people are deficient in one or more of these areas, which can negatively affect their ability to squat efficiently with a barbell.

That’s not to say they can’t squat heavy loads.

It’s common to see people who are strong squatters with well developed quads, perhaps adductors and low back muscles, but with relatively underdeveloped glutes and sometimes hamstrings.

Others have extremely well developed calf muscles as well.

What is happening?

Their bodies are using a different recruitment strategy to the “optimal” one, which relies on the glutes as primary hip extensors.

Why does this happen?

Safety. Survival.

Our brains are not concerned with long term well-being when it comes to movement, but rather, completing the task at hand, at that moment in time.

When it comes to standing up with a loaded bar on your back, this can mean using whatever muscle is most readily recruited or in the most mechanically advantaged position.

When people have biomechanical limitations elsewhere in the body, this can affect the movement.

As a result, a hip extension becomes a back extension.

Analysis of My Squat

This was a set of 10 repetitions in the back squat, which I have taken still shots from at various points (they aren’t all the same rep, as you can see by the time).

To the untrained eye, my set looks pretty good, but as you’ll see, upon closer look, there are a lot of compensations occurring that are costing me efficiency.

I’m using myself as an example, as my issues are some of the most common issues I see, just in differing degrees.

Set Up:

back-squat-1

My elbows should be further forward, under the bar or as close to as possible, facilitating thoracic spine extension and activation of the erector spinae muscles to stabilise the spine. Additionally, I have a forward head posture, again related to not getting enough extension through my thoracic spine.

Bottom Position:

back-squat-2

This is where it gets tricky, as this bottom position looks really good at first glance. My torso and shins are greater than parallel (blue lines), my hip is below my knee, what’s not to like?

Well, for a start, my weight is too far forward – thus the centre of the barbell is in front of my toes, instead of through my midfoot (yellow line). This sets me up to use a knee extension dominant strategy to stand up.

The most likely culprit for this is a lack of hip flexion range of motion or control.

My ankles don’t have the best dorsiflexion range of motion either, which wouldn’t help.

What we cannot see in this picture is whether my low back is flexing to compensate or what is happening at my feet – they could be pronating to give me extra range of motion at the ankle.

The problem with this strategy, is that by shifting my weight forward by using spinal or pelvic flexion, I will have to extend again at some point, which takes the spinal erectors from stabilisers in the movement to prime movers.

Ascension:

back-squat-3

Here you can see that my torso and shins are no longer parallel (blue lines).

My knees have extended faster than my hips, which have to remain flexed somewhat to keep the weight balanced – this is most likely due to my limited ankle range of motion, which meant my bottom position wasn’t as good as it should have been.

Another factor is the isometric strength of my spinal erectors and abdominals and their ability to maintain my trunk position.

This sets me up to have to use my lower back spinal erectors to straighten me up quickly, as in the image below.

back-squat-4

Here you can see what has happened – my knees have extended only slightly, whilst my back has extended quite a lot in a short time.

What should have been a powerful drive from the hips ends up as a two part movement – the initial extension of my knees with minimal hip extension, followed by the compensatory back extension to get my torso more upright again.

Lockout:

back-squat-5

Finally, once my knees are at almost full extension, my hips are still flexed – I’ve stood up by extending my spine more than my hips.

A Squat Is Not A Squat

This example demonstrates the effect that mobility and motor control limitations have on the execution of movement – I can get the squat done, but sub-optimally.

Now that you are aware, if you watch the video (it’s easier in slow motion) you can see that I compensate by using my back extensors (erector spinae) as prime movers, something their not optimally designed for (we have massive glutes for a reason).

Luckily, our bodies are adaptable, and even “sub-optimal” biomechanics aren’t a recipe for injury – it all depends on adaptability.

Up to a certain point, my low back muscles, joints and ligaments will get stronger to withstand the loading of squatting.

Once that point is reached, I will no longer be able to progress, or I’ll get injured.*

*I’ll get injured not because I’m moving incorrectly, but rather, our bodies are only capable of adapting so much, and inefficient movement patterns put increased demands on an area that are not as well designed to withstand them. The same is true even if I had “perfect” squat mechanics – after a certain point I will fail to progress or get injured.

Does It Even Matter?

I always ask myself, if a patient is paying me money to obtain the best result possible, does this information add value to their experience and outcomes.

In the case of what I’ve just discussed, does it even matter if you squat with optimal motor patterns or not?

As always, it depends.

If I’m not going to the gym, and I only squat occasionally to pick something up at home, then it probably doesn’t matter. As long as I’ve got the physical capacity to withstand the demands of that task, I’ll be okay.

However, if you are squatting to improve your aesthetics, performance or leg and core strength, then executing the movement optimally matters.

Sure you can get away with “just squatting” and moving weight however you can.

But is it ideal? Not to me.

The reason being, that despite our bodies being adaptable, we only have a finite amount of energy. For every inefficient movement pattern, energy cost of execution and recovery increases, thus gains (performance, health, aesthetic) decrease.

Aim High

How you do anything is how you do everything.

To me, the argument of whether you should aim to improve your movement quality and efficiency is a moot one.

Even if the benefits were neglible, I am a person who takes pride in striving for improvement.

In the case of exercise, improving the movement for the sake of improving the movement is enough of a reason to do so.

Be better. – Greg Dea, Sports Physiotherapist

I understand that this mentality doesn’t apply to everyone, so all I can say is this:

  • If you are training for aesthetic goals, and you are squatting to improve your leg and hip muscle development, an optimal movement pattern will best recruit the muscles of the glutes, quads and hamstrings.
  • If you are training for a performance goal, then an optimal movement pattern will improve sequencing of hip extension, as well as power and strength, in turn improving running speed and jumping height.
  • If you are training for a health related goal, then striving for optimal movement patterns can be an end unto itself.
  • Anecdotally, the people I see who strain their backs squatting typically demonstrate this type of movement pattern.

So How Do You Improve Your Squat?

To improve your squat, you have to identify what is limiting your performance. It could be any of the following:

  • A technical issue
  • A flexibility issue
  • A mobility issue
  • A motor control/stability issue
  • A strength issue
  • A structural/anatomical issue

To identify what your particular issue(s) is/are requires an individual assessment.

Once you know your issues, the interventions are relatively straightforward.

 

 

Nick Efthimiou Osteopath

 

This blog post was written by Dr Nick Efthimiou (Osteopath), founder of Integrative Osteopathy.

This blog post is meant as an educational tool only. It is not a replacement for medical advice from a qualified and registered health professional.

 

 



 

 

Rethink Pain: Posture

Xray bronze Vitruvian man isolated on white

I’d say that almost every practitioner who deals with people in pain would have heard a variation on the following a million and one times:

I have terrible posture.

The implication is that this “terrible” posture is:

  1. A problem, in and of itself.
  2. The cause of their pain.

Previously in this series I discussed moving towards a model of pain that focuses on the nervous system, rather than muscles and bones (and other tissues) and osteoarthritis.

This post is going to look at posture and it’s link, or lack thereof, to pain as well as strategies to improve your posture, including the role of osteopathy.

What is posture?

The position of the body with respect to the surrounding space. A posture is determined and maintained by coordination of the various muscles that move the limbs, by proprioception, and by the sense of balance. (1)

What influences posture?

A commonly held view is that posture is purely structural.

Unfortunately, while this would be great, as it would make things simple, it’s not accurate.

Posture, like pain, is an output of the nervous system, which is influenced by (in no particular order):

  • Skeletal structure
  • Psychological factors – mood, emotions etc
  • Physical activities
  • Postural reflexes

Does posture cause pain?

No.

There are people with all kinds of posture who have pain, and there are people with all kinds of posture who don’t have pain.

If posture caused pain, then all people with the same posture would experience pain, or all people with the same pain would exhibit the same posture.

When you understand pain is a protective output of the brain, you can extrapolate that when you have pain, and your posture is altered, these postural changes are protective.

By the same token, changes in posture that occur after treatment for pain, be it hands on or movement based (or anything else really), occur because your brain is no longer needing to protect the affected region, because the perception of threat or danger has decreased.

Do You Need To Improve Your Posture?

Whilst there is a very low correlation between posture and pain, there are at least a couple of reasons why you may want to improve your posture:

  • Improved movement efficiency
  • Improved aesthetics
  • To improve some musculoskeletal conditions (this is a separate issue, because it is specific to the individual and condition)

So unless these are a priority, then you have to ask yourself if you really want to (or need to) improve (or change) your posture.

If you do want to improve your posture, then there are things you can address:

  1. Your mood, emotions and mindset.
  2. You habitual activities and positions.
  3. Improving postural reflexes.

Sorry, but you can’t change your skeletal structure.

So now you know what to change, but how exactly do you do it?

Let me show you.

Change Your Mood, Change Your Posture, Change Your Mood

You can pretty much tell how someone is feeling by observing how they are holding themselves.

What is interesting, is that whilst mood affects posture, posture also affects mood. So if you are in a bad mood, simply changing your posture can change your mood.

Your mood is simply an emotion, a feeling, and according to the theories surround Rational Emotive Behaviour Therapy (REBT) “humans do not get emotionally disturbed by unfortunate circumstances, but by how they construct their views of these circumstances through their language, evaluative beliefs, meanings and philosophies about the world, themselves and others”. (2)

So really, to change your mood, you have to change your emotions by changing the language you use (to yourself and others), examine your beliefs and philosophies about the world. This will then have a flow on effect to your posture.

This is way beyond my scope of expertise, but if you find you are constantly experiencing negative mood and emotions, you could benefit from speaking with a psychologist trained in REBT or Cognitive Behavioural Therapy (CBT).

What You Do, You Become

Most of our day is made up of habitual tasks and activities. From the way you brush your teeth, to the way you pour yourself a glass of water, all the way through to your regular sitting positions and favourite activities (or lack thereof).

As our bodies crave efficiency, they will adapt to accommodate our habitual postures and positions. Some of this adaptation is structural (bone, muscle and ligament remodelling) and some is functional (loss of stability, range of motion, neural tension).

The way to change this is to increase your awareness of what you are doing throughout the day, and pay attention to how things feel while you are doing them. Then modify.

For example, if you always lean up against the left arm of the couch when watching TV, you are habitually shortening one side of your body and lengthening the other. If this was causing you problems, you could practice alternating sides of the couch, which might feel weird at first, demonstrating both the mental and physical adaptations that have taken place.

What You Really Came For – Reflexive Exercises

When we are babies, we have primitive reflexes. Part of our development sees these reflexes “going away”, however, in a way, they remain as our postural reflexes.

For an example, sit tall or stand, close your eyes and let your body sway. Once you hit a certain point, your righting reflex will kick in so you don’t fall over.

Sedentary lives devoid of rich tactile and movement based sensory stimuli can lead to diminished postural reflexes.

One way to “get these back” is to perform reflexive exercises.

These exercises aren’t like traditional exercises which focus on strength, power or endurance. These develop the qualities that underpin movement, which allow us to express and developed strength, power and endurance.

These are performed in a sequence, from most stable to least stable, and from least complex to most complex.

The positions we can use are:

    • Lying.
    • Quadruped (hands and knees).

  • Kneeling and 1/2 kneeling
  • Standing – bilateral stance, split stance and single leg stance

In terms of complexity, we can progress by:

    • Single joint movement

    • Multiple joint movement
    • Contra-lateral arm/leg movement
    • Contral-lateral arm/leg movement that crosses the midline of the body

 

Reflexive exercises are usually rhythmic and self-limiting (you can only perform them correctly, or not at all), which make them fantastic for not only improving posture specifically, but fundamental movement ability in general.*

Can Osteopathy Improve Posture?

Yes, but not in the way you probably think.

Most people assume that if they walk into an osteopath’s office, and come out after a series of treatments standing taller and feeling “lighter”, that the osteopath has somehow “straightened them up” as you would a stack of blocks.

In reality, osteopathy will affect the 3 aspects of posture described earlier:

  1. Interacting with a personable and affable practitioner can help improve your mood, emotions and mindset.
  2. An osteopath can help you identify your habitual activities and positions, as well as help ease some of the strains that these induce using manual techniques.
  3. Finally, an osteopath can help “re-ignite” your postural reflexes, both by using manual techniques to help improve body awareness and help address any issues that might be negatively affecting them, as well as through exercises as described above.

Conclusions

Posture is very poorly correlated with pain, which goes against much of the information you may have read online or heard from health practitioners.

Most of the time, things that are helpful for treating pain, like manual therapy, exercise and cognitive/emotional therapies will also have a positive effect on posture.

In most cases though, treating pain does not require a specific focus on posture, at least in the traditional sense.

 

Nick Efthimiou Osteopath

 

This blog post was written by Dr Nick Efthimiou (Osteopath), founder of Integrative Osteopathy.

This blog post is meant as an educational tool only. It is not a replacement for medical advice from a qualified and registered health professional.

 

 



 

 

 

References

*I will post up some examples of reflexive exercises on my Instagram and Facebook pages over the next few weeks, so connect with me on those channels to make sure you don’t miss them.

(1) Harris, P., Nagy, S., Vardaxis, N., Mosby’s Dictionary of Medicine, Nursing and Health Professions

(2) Rational Emotive Behaviour Therapy