Movement Quality, Health and Fitness

When it comes to movement quality and fitness, nature had it right all along.

Developing movement quality before fitness is hard-wired into us.

We crawl before we walk.

We walk before we run.

First we develop the quality and control of movement. Then we start doing more of it, which develops our capacity of movement (fitness).

This is the pathway that humans have followed forever, until recently.

Now, around about the age of 5, we send children off to school, where they learn to sit still. We even give out stickers to the kids who do it best.

At this age, things aren’t too bad though. We have about 4 years of movement “training” under our belts compared to 1 year of sitting.

Fast forward to age 10, and that ratio is now 4:6, not great, but still not too bad.

Let’s accelerate to 18, when most kids, now young adults are graduating from high school.

They’ve now been sitting for the majority of their day for 14 of their 18 years.

Many would have played sports recreationally, and suffered injury as a result.

Can you see the problem?

And we are only looking at an 18 year old, who for all intents and purposes, is in the peak of youth, and physical potential.

What happens when we hit 40, 50 and beyond?

Fitness First, Then Injury?

You’d think getting fitter and healthier would be easy. Our bodies are designed to thrive after all.

The problem is, people start out with poor general health.

Think of the average person over 30. They are likely over stressed, possibly anxious or depressed. Body functions like their digestion, elimination and breathing are dysfunctional. Their physiology is impacted by poor sleep quality and quantity, and abnormal light exposure. And, they aren’t moving at all, with the average Australian clocking in at a measly 4000 steps per day. (1)

For the average person who decides to take action and make themselves healthier, it’s an uphill battle before they’ve started.

So when they start exercising with intense, and often short term programs, they are actually adding more stress on to an already stressed body. Combine this with a restrictive diet, and the situation becomes even worse.

It doesn’t take a genius to work out that this might be too much.

Get Healthy First

What should you do instead?

Before you jump head first into an intense exercise program, commit to walking*.

Sounds too easy?

That’s the point.

If you walk daily, you experience a myriad of health benefits that compound. This sets you up for more intense work in the future, if that’s your goal.

Walking is sustainable, so you can do it for the rest of your life (and you should).

You can walk outside, which is ideal, but if weather or safety doesn’t permit, you can walk on a treadmill.

The whole point of starting with walking, is that it is supposed to be mentally and physically achievable. Success breeds success.

All this walking will:

  • Reduce your stress levels
  • Improve your body composition
  • Improve your cardiovascular health
  • Allow you some “down time” in our constant “on” world

This in term will help you sleep better, so your mood improves as your brain and hormones start to balance out.

As a result, it becomes easier to improve your diet, because you aren’t fighting against a stressed out and fatigued brain that wants quick fixes of sugary, salty and fatty convenience foods.

The principles of a healthy diet are simple. Changing your diet is not, because it is about changing your habits.

For most, the best approach is to work with a dietitian or nutritionist. Because in most cases, it isn’t a lack of information that stops people making change. Everyone knows they should eat more vegetables, but most don’t eat enough.

If you can’t, or don’t want to, you can try and change yourself.

For the best chance of success, you want to change one thing at a time. This is why I recommend walking first. It establishes a healthy habit which can have a snowball effect.

With nutrition, change one meal at a time.

Check out the Australian dietary guidelines. Then, starting with breakfast, look to improve your diet one meal at a time. Once a breakfast becomes a healthy habit, move on to lunch and so on.

If you can start walking regularly, and get your diet in order, you are more than half way to a healthy lifestyle that minimises your risk of all kinds of diseases.

This also enhances your quality of life, which is often overlooked – it’s not just how long you live, but how well you live.

This process might take time. Months, even years for some. So it is important to learn how to relax, both physically and mentally.

You can’t keep putting stress upon stress and expect good results, let alone good health.

Learning how to relax physically and mentally allows your body to recover, which is when your body repairs and your health improves.

Everyone is different, but I find things like having a spa/steam, getting a massage, going for a walk and reading a book great ways to relax either alone, or with family/friends.

Again, the challenge here is more mental, the feeling of being in a “rush” to get fit.

It’s funny, because usually this rush is felt after years of doing nothing. Hence the appeal of “12 week programs”. A better approach would be a “12 month program”, but often this is felt as being too slow. The same people who feel 12 months is too long will undoubtedly be saying “wow, that year has just flown by” come December.

The simple act of getting healthier will improve your fitness, but trying to get fit when you aren’t healthy won’t improve your health, and can often harm it.

Then Move Well

Movement quality, like health, is often skipped over in the chase for capacity.

Like skipping the “get healthy” stage, skipping movement quality is a recipe for future injury.

The problem is, movement quality is hard to measure.

Doctors will be able to tell you whether you are healthy enough to exercise with intensity, they won’t be able to tell you if you are ready for a loaded squat or running.

There is no one way to move well, but there are common features on moving well. Think of watching a high level dancer. It likes smooth, controlled, almost effortless. They are moving well.

Moving well is a lifetime endeavour (are you sensing a theme?), but to start out, you can perform some simple tests to see what your starting point is like.

  • Can you touch your toes?
  • Can you reach over and under your shoulders and touch your fingertips, without straining?
  • Can you squat to below parallel without your heels rising or losing your balance?
  • Can you stand on one leg with your knee lifted above your hip for more than 10 seconds?
  • Can you perform a plank for 30 seconds? What about a push up? What about 5?

Most of these movements are simple, yet involve a lot of physical capability. If you can’t perform them, are you ready to be running for 30 minutes or performing “functional high intensity workouts”?

If you lack some fundamental movement quality, you don’t have to put your fitness on hold – remember, improving your health, in this case your movement quality, will improve your fitness.

Improving your movement quality doesn’t mean you don’t get to use load either. Load can often be corrective.

But it does mean identifying why you aren’t moving well.

If you have a mobility issue, simply adding load won’t resolve it. Likewise, if you aren’t moving well because of impaired sensory function, you will want to address that.

Moving well is a continual process, but after you have established a healthy base, you will likely want to build capacity.

Next, Develop Your Fitness

You need fitness too.

Especially later in life, when having low physical capacity becomes problematic.

The key though, is to build your fitness/capacity before you get older. The earlier you start, the better, but it’s never too late. Never.

How much fitness, or capacity do you need? Enough to do what you need to do, with a little left over.

This left-over is termed the physiological buffer zone (2).

It is basically your margin for error.

The bigger your buffer zone, the more you can do without breaking down, getting injured or ending up in pain.

A favourite study of mine showed that in US Marine recruits, those with low Functional Movement Screen (FMS, a simple screen to assess movement quality) scores and a low 3 mile run time had a much high probability of getting injured during physical training (3).

Both the run and the FMS were predictive, but the combination was much higher.

This suggests that moving well, or being fit alone is beneficial, but moving well *and* being fit has a compounding effect.

High Training Loads Protect Against Injury

Lots of recent research in sports science is showing that high training loads are protective of injury. (4)

This means, the more work you do, the more resilient you become.

However, how you get to those high training loads matters.

If there is a sudden jump in workload, that is a big risk factor for injury, so you have to build up slowly. If you look to fit people for inspiration, and try and model what they are doing, you are failing to take into account that it likely to them years to achieve their current level.

Monitoring your workload is important, so that you can know when to push and when to back off. A good personal trainer or exercise physiologist can help you, and will accelerate your progress.

Conclusions

This is a lifetime process.

If you do it correctly, focusing on health as your priority, then you set yourself up for a lifetime of benefits.

It’s definitely not easy.

You will have periods where you feel like it is all clicking.

You will have periods where it all seems so hard.

But, if you establish healthy habits, then you can continue with the behaviours that benefit you no matter what life throws at you.

 

 

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

*If you are unable to walk due to disability, then a similar low intensity replacement is ideal, but for able bodied people, walking is the best option.

(1) Australian Daily Steps

(2) Movement Reserve: Enhancing the Physiological Buffer Zone

(3) FMS and Aerobic Fitness Predict Injury

(4) Monitoring Athlete Training Loads: Consensus Statement

(5) Andrew Read and Greg Dea seminar, September 2016: Advanced Program Design

Tightness Is A Stress Response: Get Regular Treatment To Reduce It

Visceral manipulation.

Most people think tightness is a muscle problem.

In actual fact, tightness is a stress problem.

The key to managing stress is not to eliminate it completely.

Instead, aim to reduce what you can, and better respond to what you can’t.

[Let’s get this out of the way: tightness is not a scientific or physiological term. But we all know what someone means when they say it. In physiology we talk about shortness, stiffness and muscle tone.]

We Are Like An Oil Burner

I have heard world renowned strength coach Charles Poliquin describe us as an oil burner.

Our output is the flame, which can only be as big as the oil reserve allows.

Everything we do, both positive and negative, burns some oil, to keep the flame going.

If you are like most people, you are over stressed, under slept and nutrient deficient.

You have ever increasing work demands. You want to spend as much quality time with your family as possible. You do try and get to the gym or go for a run, but some weeks you simply can’t make it.

That’s a lot of burning, and not much refilling.

Add all this together, and your brain puts you in fight or flight mode.

Now if someone was about to hit you, would you be tense or relaxed?

Well to your brain, stress is stress. Whether it is a fight, a work deadline or your kid getting sick.

Tightness Protects Us Against Stress In The Short Term

You can see that an increased muscle tone is the result of stress, but can you see the benefit?

A muscle, or joint that is tight is protective against stress, in the short term.

That increased stiffness helps to resistance against external disturbance.

But this protective behaviour comes at a cost: it impairs function.

Tight tissues use more energy, don’t drain properly and can’t contract efficiently. (1)

We aren’t designed for sustained bouts of stress. So when this stress isn’t alleviated, the effects become noticeable.

Be Proactive, Not Reactive

Most people think of going to see an osteopath when they are in pain.

This is like deciding to eat healthy after you’ve had a heart attack. It’s better than nothing, but optimal would have been to eat well all along.

Now, I’m not saying that getting regular treatments will prevent pain and injury.

I’m not even saying that eating well prevents heart attacks.

These are complex events, with lots of factors, seen and unseen that contribute.

That doesn’t mean do nothing.

You can learn to tune into your body, and learn to understand your response to stress.

I don’t recommend thinking about your health from a reactive point of view.

You can learn to get in tune with your body and take the measures to manage stress, in all its forms.

When it comes to getting a treatment, exercise and most things health, being proactive is almost always superior to being reactive.

Use A Systematic Approach To Assess and Measure Changes

A treatment should make you better. That is obvious.

But how do we know?

Anyone can identify areas of tightness and then rub a little and call it a treatment.

To me, a good osteopathic treatment is about working out why.

A systematic approach to assessment takes away the guesswork.

You can then apply the interventions where it is most needed.

This enhances efficiency, giving you the biggest response in the shortest time.

It also allows you to reassess, to measure change.

After all, “what gets measured, gets managed”. More on that next.

Oh, And It Doesn’t Need To Hurt

Remember when I said tightness is a stress response?

That means that you don’t always need deep tissue work that is painful to relieve it.

There are many gentle techniques that do just as a good a job, without the pain.

After all, does it make sense to relieve stress with more stress in the form of an intensive treatment?

There is definitely a time and a place for deep work, but don’t think that because something doesn’t hurt it is ineffective.

How Do You Know How Often?

I have never been a fan of routine “maintenance” treatments.

First, an osteopath doesn’t maintain you.

Second, how often you need treatment should be based on your physiology, not the calendar.

So what you need is a way to keep score. A way to interpret your physiology.

The Old School Way: Wellness Monitoring

Wellness monitoring is an effective way to keep track of your physical and mental state.

Used by sporting teams as a way to monitor their athletes, it is a great way for non-athletes to keep on top of their stress levels.

Wellness monitoring records how you feel and what you did on a day to day basis, given you a score.

This score then indicates when you are over stressed/under recovered.

You can start to correlate this to how tight you feel.

I have linked to a good example of wellness monitoring in the references.

The New School Way: HRV Apps

I’ve talked about Heart Rate Variability (HRV) before, but it’s worth mentioning again.

HRV is a measure of your physiological state.

Lower HRV indicates higher stress levels.

The leading app on the market, HRV4Training allows you to use your phone’s camera to record your HRV. This is much more convenient than using a chest strap every morning. Unfortunately, until now, it has only been available on iPhone. The good news is, in the next week it will launch on the Google Play store.

I will be purchasing it.

By tracking HRV, you can not only see your physiological state, but the effects of your lifestyle.

You can then use this info, correlated to your muscle tone to decide how often to get a treatment.

And of course, you can then use the info to see the effects of treatment.

Or, You can go by feel

At the end of the day, only you know how you feel. If you are feeling tight and stiff, then it’s a good time to get a treatment.

Do you need to be in pain?

No.

We are aiming to be proactive, remember?

This means understanding your body, and intervening before the onset of pain or injury.

The old cliche rings true: “An ounce of prevention is worth a pound of cure”.

 

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) Will add reference tomorrow, the book is at work

(2)Why Do Muscles Feel Tight

(3) Wellness Monitoring

How To Overcome Recurrent Pain

 I have a bad back.

People often say that when they come to me with recurrent low back pain.

You could replace back with knee, hip, shoulder, elbow or any other painful body part.

I’ve heard it all.

But I’m here to dispel the myth of bad body parts.

There’s Usually A Reason

It’s impossible to determine cause and effect in a complex system.

But when people tell me there was no reason for their pain, I dig a little deeper.

What usually emerges is that something had changed before the onset of pain.

Of course this doesn’t mean that change is the cause of their pain, only that something changed.

Sometimes this change occurs so gradually, it’s barely perceptible.

Pain Is Protective

Usually, we will feel pain before we have done anything serious – as in injury.

Pain is a protective output of the brain.

It is generally a good thing, that keeps us safe, but it can become a problem in and of itself.

When you experience pain it usually means that your brain is trying to protect you .

You feel pain in a body part, but your brain is trying to protect you as much as it is trying to protect your sore body part.

After all, you are what’s important to your brain. Without you, it ceases to exist.

The Recurrent Pain Cycle

Recurrent pain cycle

What we can see is a pretty typical cycle for many people.

The problem is, they never get better until something breaks that cycle.

As you can see, something is missing. Change.

If we could create meaningful and lasting change, maybe we would have less recurrent pain?

Resilience and Adaptability

Resilience is not about being strong, though that is a component.

Resilience is able being able to withstand a variety of stressors.

Adaptability is about being able to responds to a variety of stressors.

These stressors can be physical, psychological, environmental or whatever else.

How do we develop this?

Desensitise

Graded exposure is a psychological technique.

It involves exposing yourself to situations that scare you, in a manner that allows you to control your fear.

Over time, you become less fearful and can increase your exposure.

Often pain is associated with movements, social settings or other contexts.

By applying the principles of graded exposure to pain, we can desensitise your response to certain contexts.

Desensitising is the first step to breaking the recurrent pain cycle.

Optimise Your Senses

Having limited sensory input can affect pain.

Sensory input is the information your brain receives from nerves throughout the body. This can be from muscles, tendons joints and organs.

When the brain receives better sensory input, it can better interpret each situation and respond accordingly.

There are 3 main impairments to sensory input relevant to osteopaths:

  1. Past injuries that haven’t been completely rehabilitated
  2. Soft tissues and joints that are stiff and/or immobile
  3. Under-stimulation due to lack of use

Improving your sensory input improves your adaptability.

Yet, even with perfect sensory input, you can only adapt as much as your health allows.

Adaptability isn’t only a neurological attribute.  Or even a physiological attribute.

Adaptability is a human attribute.

Load: Progressively and Contextually

Loading develops resilience.

But, if you are not adaptable, then you can only load so far before you break down.

This is why we seek to enhance adaptability and resilience.

Loading about more than lifting weights.

It is about challenging yourself across a variety of environments, contexts, movements etc.

Remember, resilience is not only physical.

Resilience, like adaptability is a human attribute.

Humans are physical, psychological, emotional and spiritual.

It is important to development resilience across all the entire human spectrum.

Conclusions

Recurrent pain is a form of chronic pain.

People often don’t consider it chronic, because it isn’t constant.

To break the recurrent pain cycle, you need to identify why your pain is recurring.

Then you need take the necessary steps to change.

This can be hard, which is why you should get help along the way.

Only when you create meaningful change will your pain change in a meaningful way.

 

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.

 

 



 

 

How To Build Strong Legs (And Why It’s Important)


Having strong, well balanced legs are a key component of having a healthy, high functioning body.

Our legs are anatomically suited to producing both high levels of force and for walking and running long distances.

This means we need to develop both functions – strength and stability through full range of motion along with the endurance to be able to walk and/or run for distance.

You can build strong legs using expensive gym machines, time tested free weights, with your body weight or using a combination of all three.

Lots can go wrong with your legs:

  • Ankle sprains are the most common lower limb injury (1)
  • Knee injuries are common in athletes and ACL tears are one of the most debilitating sports injuries you can suffer, with females especially susceptible (2)
  • Additionally both the patellar and Achilles tendons are common sites for tendinopathies
  • The knee and hip are most common sites for osteoarthritis (3)

Strength training can be used to both prevent and manage all of these conditions, but done improperly can be a cause of injury itself.

Benefits of Strong Legs

Some of the specific benefits of developing strong legs include:

  • You live longer (4)
  • Greater independence as you age (4)
  • Decreased lower limb injury risk (5)
  • Decreased risk of falls (6)
  • Improved endurance performance (7)
  • Improved speed and power
  • Increased lean body mass – decreased risk of metabolic diseases (8)
  • Improved rehabilitation outcomes after injury (9)
  • Strong legs look good

The 3 Stances

Before we go into how to build strong legs, it helps to understand the different ways we can load the lower body, and the different effects each has.

As humans, we can essentially adopt 3 foot positions.

Most people will favour one side when standing, accelerating, jumping and landing, or just getting through the household chores, which can develop functional asymmetries.

Functional asymmetries are side to side differences in mobility or stability that are not associated with your body’s structure. Functional asymmetries are a modifiable risk factor for future injury (10).

To minimise functional asymmetries and develop strong, well balance legs, requires working in each of the 3 stances.

Bilateral Stance

Bilateral stance involves both feet being on the ground in the same horizontal plane, without movement. It is the most stable, and hence strongest position, and we can lift the heaviest loads in bilateral stance.

Split Stance

In a split stance, both our feet are on the ground, but in a different horizontal plane. Split stance requires the leading leg to be stable through the hip and knee while the trailing leg must display mobility at those joints. You see a split stance being adopted when we need a blend of stability and mobility, for example, if you were chopping wood or throwing a ball.

Single Leg Stance

Single leg stance is displayed when we have one foot completely off the ground. This can be for a moment, as in when we are running, or when we need increased mobility, like when we reach for something on the ground.

Single leg stance requires high levels of stability in the stance leg and trunk to allow you to express the mobility it facilitates.

Use Single Leg Exercises First

Before undertaking a strengthening program for your legs, it’s wise to have an assessment with a qualified and experienced professional.

A good assessment acts like a road map – showing you where you currently are and where you need to go to improve your function and strength.

Most people will tend towards either being stiffer and more stable or flexible and less stable. Typically, we will see the most benefit from developing what you lack – so a stiff person will benefit from developing flexibility and mobility and vice versa.

If the assessment reveals you have a functional asymmetry, then a good place to start your leg strength program is with single leg exercises.

Single leg exercises are a great way to develop the required flexibility and stability at the same time, and help balance out differences between each leg that may have developed over time.

It’s best to start with a split stance, which gives you a nice blend between stability and mobility, versus true single leg stance, which requires stability levels beyond what most possess without training.

Examples of split stance exercises are:

  • Split squats (where the feet remain in contact with the ground throughout)
  • Lunges (where one foot leaves the ground momentarily)
  • Step ups

You can build tremendous strength with single leg exercises alone, but it is still important to develop strength in a bilateral stance as well, in particular with the squat pattern, which is a fundamental human movement.

Squats For Total Body Strength

The squat is simply the best lower body exercise you can do, if you can do it properly.

Squatting demonstrates ankle, knee, hip and spine mobility and trunk stability in the most fundamental human movement pattern – it’s how we first get up from the ground to be able to walk.

It is well worth the time and energy to develop your ability to squat well through a full range of motion.

For rehab patients, I like to teach the squat from the bottom up, which is after all, how we first learnt it. I find that by getting someone into the bottom position of a squat comfortably, the rest takes care of itself.

Surprisingly, my older patients do really well with this method as well, as they are already close to the ground, the risk (and fear) of falling is much lower. Once they are familiar with the bottom position, it is a matter of getting strong enough to stand up.

The most common issues with the squat tend to be at the ankles, followed by the hips.

To work around this, you can begin squatting with your heels elevated while you work towards an unassisted squat.

Conclusions

Strong legs are for more than just fitness fanatics, they are crucial to living a healthy and active life.

It’s important to not only build strong legs, but develop balance and mobility that allows you to move freely.

To do this, it’s important to have an assessment and develop a plan that meets you where you are at, and takes you where you need to go.

While structured exercise is not essential for health, when it comes to developing strong legs, the simple truth is that the majority of Australians are not physically active enough to develop and maintain adequate leg strength throughout their lifetime, and so need a structured program to make up for it.

Not all programs are designed equally though, so for the sake of safety, efficiency and effectiveness, it pays to seek out qualified professionals to help guide you, especially in the early stages of building leg strength.
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) Incidence of Lower Extremity Injuries in US Emergency Departments

(2) Epidemiology of Lower Extremity Injuries in US High School Athletes

(3) Epidemiology of Osteoarthritis in Australia

(4) Leg Strength and Physical Function In Older Adults

(5) Strength Training Reduces Injury Rate in Elite Junior Soccer Players

(6) Effect of Leg Strength on Falls and Balance of the Elderly

(7) Effects of Strength Training on Endurance Capacity In Top Level Athletes

(8) Increased Leg Strength per Body Weight Associated with Improvements in Metabolic Syndrome in Japanese Men

(9) Merits of Exercise Therapy Before and After Major Surgery

(10) Prediction of injury by limited and asymmetrical fundamental movement patterns in american football players

 

Pain Is A Mystery, But How Do You Solve It?

Puzzle

It is easy to think of pain as a simple puzzle. Find the missing pieces, put it all together in the right order and then voila, you feel better.

Unfortunately, as much as we’d like things to be this simple, it’s not the case, and pain is more like a mystery.

Allow me to let Malcolm Gladwell explain (1):

The national-security expert Gregory Treverton has famously made a distinction between puzzles and mysteries. Osama bin Laden’s whereabouts are a puzzle. We can’t find him because we don’t have enough information. The key to the puzzle will probably come from someone close to bin Laden, and until we can find that source bin Laden will remain at large.

The problem of what would happen in Iraq after the toppling of Saddam Hussein was, by contrast, a mystery. It wasn’t a question that had a simple, factual answer. Mysteries require judgments and the assessment of uncertainty, and the hard part is not that we have too little information but that we have too much. – Malcolm Gladwell

Although it seems like there a new discoveries about pain being published almost monthly. So much about is still unknown.

And, because pain is invisible and has many unconscious components, we simply cannot know why you, or any individual is experiencing pain at a particular moment.

The Case Against Diagnostic Imaging

You would think that being able to visualise the structure of the body would be helpful to clinicians treating pain.

It turns out that this isn’t quite the case.

Firstly, there is a large, and growing, body of research that shows there is very poor correlation between the structure of our bodies and symptoms of pain.

From disc injuries (2) to degeneration (3)  and even partial or full thickness tendon tears (4), most of us are walking around with structural “damage” that would show up on diagnostic imaging (X-ray, CT, MRI etc).

Secondly, and most interesting to me, is due to the fact that the interpretation and reporting on diagnostic imaging varies wildly.

In a recent study on MRI reporting and interpretation (5), a woman with low back pain and neurological referral was sent for an MRI at 10 different locations. The results reported 49 total findings, with not one interpretive finding consistent across all 10, and only 1 finding consistent across 9 of the 10 reports.

This means:

  1. MRIs require skill to interpret, and not all radiologists are equally skilled, thus, it matters where you get an MRI done.
  2. Radiologists working in isolation from the patient, are assessing an image, not a person, and have to make a lot of assumptions, even with a comprehensive history.

What About Physical Assessments?

Physical assessments are a necessity for clinicians, but which assessments are valuable, and which just add confusion?

We can break physical assessment into 3 components:

  1. Vital signs like pulse, blood pressure and breathing
  2. Neuro-orthopaedic examinations that are designed to rule in or rule out specific pathology or conditions
  3. Functional assessment designed to determine an individual’s movement competency and capacity

It is the third area which is the most “grey”.

This is because human movement, being an emergent property, is not an easy thing to classify (6).

We can define good and poor movement, but again the definitions are somewhat arbitrary, and their are many exceptions who fall outside those defined ranges who do not have an consequences (injury, pain etc).

This isn’t to say their isn’t such thing as good movement, bad movement or better movement, but only that it is person specific.

So if we use a movement assessment to gain insight to a person’s movement at that moment in time, in those conditions (in the clinic for example)then we can look for a movements that can be better.

If we identify movement that could be better, we can challenge to brain to improve movement, with a variety of techniques.

Even Histories Can Be Misleading

A good clinician will help someone in pain by creating the right context, or environment for them to heal.

To do this, a good clinician will know what they need to know, and more importantly, what they don’t.

By focusing only on the important, relevant, information, a good clinician minimises the chance of nocebo, and maximises the chances for recovery.

What exactly then does a good clinician need to know?

Is this pain dangerous?

When consulting with a patient, first, we want to rule out risk – some musculoskeletal pain can be caused by serious pathological conditions that need medical intervention. We have to rule these out first, and when in doubt, err on the side of conservative.

As a caveat to the above section on imaging, an “unnecessary” X-ray is a small price to pay if the alternative is missing an early cancer diagnosis. This does not mean imaging should be routine!

Is this pain affected by movement or position?

Mechanical pain is characterised by changes related to movement or position. If the answer to this question is yes, this rules in mechanical pain as a diagnosis. This does not yet rule out other origins of pain.

We can follow this up with more exploratory questions around which movement or positions feel good and which don’t.

Combined with the assessment findings, this will give us some more insight into how to proceed with treatment.

What is your current autonomic state?

Your autonomic state says a lot about you.

If you are wound up tightly – in a sympathetic or stressed state, characterised by elevated heart rate and blood pressure, shallow breathing and decreased blood flow to the periphery of the body (including the skin) – then it will be hard to resolve your pain until you enter a more balanced autonomic tone.

What are the barriers to recovery?

These are often implied, and a good clinician will be able to identify these as much from what a patient doesn’t say, as what they do.

Factors that can affect recovery include:

  • Age
  • Disease
  • Nutrition
  • Thoughts
  • Comorbid conditions – anxiety, depression, high blood pressure etc
  • Medications
  • Family and friends
  • Employment, or lack thereof

As always, it’s not simple, and it’s definitely not linear.

We are, after all, dealing with people – you know, those confusing, irrational beings who like to “go out”, but not for too long, because then they have to “go home” (Seinfeld reference, video below).

The Downside of Irrationality

Human beings are irrational. This is a fact.

Being irrational has positives, the most obvious being love.

Love is a fantastic human emotion that is completely irrational. If we were completely rational beings, then we wouldn’t spend so many of our resources chasing love, or any feeling for that matter.

But, this is exactly why too much information does not help us treat pain.

Too much information can lead us to make false assumptions and draw erroneous conclusions.

This doesn’t help patients seeking help for pain at all.

Pain has very tenuous links to tissue damage, body structure, posture, strength, symmetry and stability. (8,9)

Investigating these to a high level, and then describing pain as a result of these findings is not only inaccurate, but also harmful. (9, 10)

Every time someone is told their pain is the result of the above findings, a link is made in their brain. This is called a neurotag. Think of it like a storage file in the brain. (11, 12)

If a clinician, family member or friend tells someone with low back pain they lack “core stability”, then this is added to the low back pain neurotag.

Then, because of the way our brains function, when we have existing knowledge, we look for examples to confirm this knowledge – this is called confirmation bias.

So the person with low back pain, who has been told their pain is caused by a lack of core stability, finds “evidence” to support this.

If their back hurts when they lift something, they blame their lack of core stability. If their back hurts after activity, it’s core stability’s fault.

They forget to focus on the times that they lifted something without pain, or that activity didn’t hurt.

This is just one simple example. There are many others like it.

Conclusions

Mysteries are interesting to us as humans – as long as we get closure and the mystery is solved in the end. This is the basis of the “open loop”*  TV shows, movies and books use to keep their audiences engaged.

Unfortunately life is not like a movie. We don’t always get a neat and tidy closure.**

The challenge facing any clinician, when we treat people in pain, is to focus only the important and relevant information, and to educate patients on why this is so.

The even bigger challenge, is helping patients face the reality that the mystery of pain can’t always be solved, no matter how much (or little) information you have.

 

*An open loop is used by writers whereby earlier in the story they introduce something, but don’t address it immediately, in order to keep your attention, because you want to find out what happens next.

**Except not all movies or TV shows have closure. One of the greatest TV shows of all time, The Sopranos, has a famous ending that didn’t give it’s audience the closer they were hoping for.

 

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) Enron’s Open Secrets

(2) MRI findings of lumbar spine in people without back pain

(3) Abnormal magnetic-resonance scans of the lumbar spine in asymptomatic subjects. A prospective investigation

(4) MRI findings in throwing shoulders: abnormalities in professional handball players

(5) Variability in diagnostic error rates of 10 MRI centers performing lumbar spine MRI examinations on the same patient within a 3-week period

(6) Metastability and emergent performance of dynamic interceptive actions

(7) The fall of the postural-structural-biomechanical model in manual and physical therapies: exemplified by lower back pain

(8) Different contexts, different pains, different experiences

(9) Nocebo hyperalgesia and the startle response

(10) Context as a drug: some consequences of placebo research for primary care

(11) Pain really is in the mind, but not in the way you think

(12) Reinstatement of pain-related brain activation during the recognition of neutral images previously paired with nociceptive stimuli