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

Having a strong back helps improve your quality of life.

A strong back allows you to perform daily tasks with relative ease and is protective against injury.

The “back” isn’t an actual body part, but rather a descriptive term. In this article, it means the area from the base of the neck to the top of the pelvis.

Functionally, we can divide the back into two parts:

  • The lower back, which is primarily involved in lifting, carrying and supporting our upright posture
  • The upper back, which provides a foundation for the shoulder girdle and supports our head and neck

In a way, the back also encompasses the “core” and the “shoulder”, which is a good reminder that these are all labels that we give to the body – it functions as a whole, and the separation is only in the way we think about things.

So with that in mind, we can still use these concepts to help us build a strong back.

You don’t need expensive or fancy equipment. Muscles only respond to tension, which can be generated in a number of ways, with or without external weights

Barbells, dumbells, kettlebells, resistance bands, along with pull up bars and suspension trainers to leverage your own body weight are all fantastic ways to develop back strength, and of course, you have specialised machines that can help develop a strong back.

The key is to find an approach that works for your body and your situation.

Top Reasons To Build A Strong Back

  • The act of strength training is protective against back pain (1)
  • Strength training for the upper back was the best intervention for pain in desk bound office workers (2)
  • A strong back helps maintain your optimal posture (more on posture here)
  • The mid back is a common site for osteoporotic fractures – strength training prevents this (3)
  • After the legs, the back muscles are the biggest and strongest in the body, training them expends a lot of energy, helping maintain body composition and blood glucose levels (4)
  • Strong backs look good (don’t underestimate the importance of a positive self image)

Pull, Lift, Carry

There are 3 main actions you can perform with your back muscles:

  • Pulling actions, where you pull yourself towards something, or something towards you. Examples include chin ups, rows and climbing. These movements tend to develop predominantly upper back strength by working on the muscles the move the shoulder blades and arms.
  • Lifting actions, which are those actions where you pick something up (usually from the ground). Examples include deadlifts and power cleans.
  • Once you have picked something up, you can also carry the object for time or distance. Both lifting and carrying exercises develop both lower and upper back strength by working the muscles that stabilise the spine. They usually develop leg strength as well, so are very efficient exercises.

The Best Pulling Exercises

There are a variety of ways to train the pulling movement.

When you consider the freedom of movement the shoulder girdle has, it allows a high number of variations.

The Movements

The shoulder blade (scapula) has a number of ways it can move, but when it comes to pulling, the 3 we are concerned with are:

  1. Retraction: squeezing your shoulder blades together, as in when you perform a rowing action. Examples would be all the row variations in the world!
  2. Depression: pulling your shoulder blades down, as in when you pull yourself up to a bar/ledge. Examples would be chin ups and lat pulldowns.
  3. Upward rotation and elevation: when your shoulder blades turn upwards and raise, as in when you are pulling something in front of your body to your neck. Examples of these are upright rows, shrugs, high pulls, cleans and snatches.

For most people, I like body weight pulling exercises, like chin ups, inverted rows and climbs, though these are often very challenging and hard to scale down for beginners.

Where To Start

In the gym, cable rows and pulldowns, along with barbell and dumbell rows are the go to, with a large number of variation available via hand position, body angle and line of pull through the shoulder.

In practice, a $6 band from Kmart can be a great tool to enable you to perform pulling actions. Loop it around a post and pull it toward you. Loop it around your feet and pull it up. Loop it around a rafter/beam/tree branch and pull it down.

Do More Reps!

As a rule of thumb, pulling exercises are better as volume exercises, not intensity.

That is, perform a higher number of reps per set on average.

You can still load pulling exercises quite highly, but the combination of distraction force through the upper limb and ambiguous end point make it hard to do so as effectively as deadlifts, presses and squats.

Often Overlooked

One class of exercises that are often overlooked in both rehabilitation programs and fitness programs outside of the weightlifting/powerlifting world are shrugs and high pulls.

These train the upward rotation and elevation motion in the shoulder blades (shrugging), which strengthen the trapezius muscle.

A strong trapezius muscle supports healthy shoulder and neck function, but unfortunately, because many people with neck pain report a “tight” trapezius, these exercises were vilified. What was missed is that in these people, their trapezius feels “tight” because it is weak, and strengthening relieves their symptoms.

My Personal Favourites

So while my favourite pulling exercises are:

  • Chin ups (palms facing toward you) and pull ups (palms facing away from you)
  • Inverted rows (elbows high and elbows low)
  • High pull/upright row

In a perfect world, I would help all my clients develop competency and strength in these movements. But because I live and work in an imperfect world, and time, equipment and money are often limiting factors, the exercises I use most in clinical practice are:

  • Band pulldown
  • Band row
  • Band upright row

Deadlifts

The deadlift is a fantastic all-round back strength exercise. It also concurrently helps develop strong legs, particularly the posterior chain muscles, including the hamstrings and gluteals.

It involves picking up a weight implement (barbell, dumbell, kettlebell, etc) from the ground and then lowering it back down again.

There are countless deadlift variations, but my favourite is the barbell deadlift from blocks.

Rogue Metal Deadlift Blocks (https://www.roguecanada.ca/rogue-metal-pulling-blocks)

A close (equal) second is the trap bar deadlift and the kettlebell deadlift.

Why do I favour the barbell deadlift from blocks over other deadlift variations to build a strong back?

  • It allows us to infinitely and incrementally load the pattern, compared to kettlebells, which come in large jumps (usually 4 kg) and only go up to 48 kg in pro-grade style or (very large) 92 kg classic style.
  • We can control the range (rather than lifting based on the height of the weight plates) and ensure the movement is performed within a range that is safe for an individual’s mobility and strength.
  • It is better than a rack pull because the moment arm (from the centre of the bar to the load, not of the load on your spine) is larger (allows better leverage when starting the lift) and as a bonus, protects the bar.
  • Compared to the trap bar, the straight barbell requires a more bent over position, creating a large anterior shear moment on each vetebrae, which the back muscles have to resist, which develops high levels of strength in the spinal stabilisers.

The main downside to the barbell deadlift from blocks is it is more technically challenging/less intuitive than the trap bar or kettlebell deadlift. However, even though these are simpler, and some might argue more “functional” in that they require you to stand between the handle (like a wheelbarrow) or have the load between you (like lifting a heavy bag of fertiliser), I feel like they understimulate the back and posterior chain (relatively).

A second issue is equipment, while most gyms, and many clinics will have a barbell, not many have access to proper lifting blocks. A compromise is to use aerobic steps or weight plates, though they are just that, a compromise.

In reality, you can use a variety of deadlift variations, it doesn’t really matter, as long as you are developing the strength to pick things up from the ground.

Typically, deadlifts can be performed heavy for lower repetitions, or lighter for higher repetitions. They lend themselves well to both applications.

Not Quite Deadlifts

There are a number of exercises that have a similar pattern to the deadlift – the hip hinge movement – that aren’t quite the deadlift.

Think of exercises like:

  • Good mornings
  • Kettlebell swings
  • Back extensions
  • Reverse hypers

These are all great exercises.

They definitely have a place as deadlift alternatives or additions to deadlifts.

The reason I list them as a second tier, is because for most people, I seek maximum training economy, and with that in mind, deadlifts are more than enough stimulation. I would mostly use alternatives when deadlifts are not appropriate:

Loaded Carries

Loaded carries are an under utilised exercise in both performance and rehabilitation.

They are simple movements, but are definitely not simplistic.

Loaded carries can be performed in a few ways:

  • Bilateral loading
  • Unilateral loading

And with the load in different positions

  • By sides (farmer’s walks, suitcase carries)
  • In the rack position (with kettlebells or a barbell)
  • Yoke carries (across the shoulders)
  • Overhead

The most important thing to ensure with loaded carries is to retain postural integrity. The idea is to train dynamic stabilisation under load, not test your limits of how far you can carry a heavy object.

A good guideline is to work with 75% of your bodyweight for farmer’s walks. This might sound light for experienced athletes, but remember, we are trying to build strength, not test it. Building strength can be done with sub-maximal loads, and it allows for faster recovery and better movement patterns.

Conclusions

Pulls, deadlifts and carries are more than enough to build a strong back.

However, there are many other variations of exercises that can be used too.

I’m not in the business of vilifying movements, and given the low activity levels of the majority of Australians, almost any movement is good movement.

Whichever movements you choose, for most people 2-3 times per week is the optimal frequency to develop strength, while the exact amount volume of work you do is individual, the idea is to do more over time.

What I have listed here are the best back exercises for the majority of people, the majority of the time.

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

Do you need a stronger back?

If you feel like you could benefit from increased back strength and a holistic exercise program, then contact me to arrange a consultation. This can be done in person or online, depending on your location.

 

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) Exercise for the Prevention of Low Back Pain: Systematic Review and Meta-Analysis of Controlled Trials

(2) Effects of stretching exercise training and ergonomic modifications on musculoskeletal discomforts of office workers: a randomized controlled trial

(3) Heavy resistance training is safe and improves bone, function, and stature in postmenopausal women with low to very low bone mass: novel early findings from the LIFTMOR trial.

(4) Effects of Different Modes of Exercise Training on Glucose Control and Risk Factors for Complications in Type 2 Diabetic Patients

Career Advice For Osteopaths

As we approach the end of the 2018 academic year in Australia, a new cohort of student osteopaths are about to graduate and enter the next stage of their journey as an osteopath.

With this in mind I have reached out to a number of osteopaths, from new graduates to experienced practice owners, academics and entrepreneurs, to share with you some career advice in the form of a tweet (280 characters or less, although some couldn’t help themselves, and went a little longer).

The aim of this post is to help start you thinking about what you want from your career, and what you might have to do (or not do) to achieve that. I hope it will also save you some of the frustrations I (and many others) have gone through in the early stages of our careers.

A successful professional life looks different to everyone.

For some, it means making a lot of money. For others, it’s about having time flexibility. Others still want to have a big reputation and sphere of influence. Many want to be anonymous instead.

There is no one way to define success, however there are some common practices between all who have achieved success in their own way:

  • Self awareness
  • Patience
  • Flexibility
  • Discipline
  • Reflection
  • Mentorship

Whether you are a student, a recent graduate or an experienced professional, there is always potential upside in hearing from others what they believe to be important to achieving professional success.

If I have seen further it is by standing on the shoulders of giants. – Isaac Newton

Absorb What Is Useful

When it comes to receiving advice, it’s important to take what is relevant to you on board, and not get too caught up in the rest. I’ve tried to reach out to a variety of practitioners, with different professional skills and experience, to give a broad perspective on osteopathy.

Absorb what is useful. Reject what is useless. Add what is essentially your own. – Bruce Lee

So, without further ado, posted in the order I received them, the advice for new osteopaths:

Giles Gyer

Giles is an osteopath (2012 graduate of College of Osteopaths, London), medical acupuncturist and sports/remedial massage therapist and is the co-found of OMT Training, a teaching organisation for manual and physical therapists. I don’t know Giles personally, but apparently we look similar enough for a colleague to use his image (from Google Images) on a PowerPoint slide when introducing me, so he had to be part of this piece. His advice is:

“YOU are the most important person in the treatment room” the key to longevity within osteopathy is to look after your body and your hands.. Don’t use techniques that compromise your joints especially your thumbs and back.. Be opened minded to other professions, they’ve got some great skills and techniques you can steal!!

Follow Giles on Twitter and OMT Training on Instagram.

Aaron Anderson

Aaron is an Australian trained Osteopath. He completed his studies in Australia – Osteopathy with Distinction (RMIT), Sport Science (University of Ballarat). Aaron treats both adults and children. Aaron operates Movement Squared, both in Melbourne and Hong Kong locations (definitely a long commute), and additionally has been an onsite practitioner in both the corporate and sports performance world. He is currently completing a Masters in High Performance Sport through ACU. His advice is:

I recommended to my Associate try to excel in Anatomy and HVLA. These fields can easily put you in the top 10%. Be out and about in person. That’s when people will enquire directly about making an appointment. Still better than running an awesome social media campaign in my experience.

Find out more about Aaron and his business Movement Squared or follow Aaron on Twitter.

Jena Chang

Jena is an osteopath who graduated from RMIT in 2013. She works in private practice at Box Hill Osteopathy and Complete Health Osteopathy and Pilates. Her advice to new osteopaths is:

RE: job hunting
If they are interviewing you, you have a right to interview them back. Finding the right workplace is essential in your growth and development as your as your emotional well-being! Never settle for less.

Follow Jena on Instagram (side note: I love Jena’s content, it’s so positive) and Facebook.

Bruce Duncan

In over twenty five years as an Osteopath, Bruce has treated people from all walks of life. He has been Osteopath to the Australian Open Tennis Tournament since 2004, and at the Hawthorn Football Club since 2015. A graduate of RMIT, class of 1992, Bruce founded North Carlton Osteopathy in 1998. His advice is:

Interpersonal skills maketh the osteopath. Diagnostic & hands-on skills are a given, but connecting with warmth, understanding & empathy will take you next level. Build trust and take ownership of their management together.

Follow Bruce via North Carlton Osteo on Instagram and Facebook.

Alison Sim

Alison is an osteopath and pain management specialist. She graduated from Victoria University in 2001 and went on to complete her Masters in Pain Management from Sydney University Medical School and Royal North Shore Pain Management Research Institute. Alison works in private practice at Brighton Spinal and Sports Clinic and Pain Matrix in Geelong, treating people with chronic pain, and runs an education company for allied health professionals, Beyond Mechanical Pain.

Stay flexible in your thinking and humble about your role. Listen and learn from your patients. Keep a strong focus on life outside of work. Keep learning and evolving for your whole career.

Follow Alison’s work via Beyond Mechanical Pain on Twitter and Facebook.

Claire Reed

Claire is in her first year of practice as an osteopath, after graduating from RMIT with the class of 2017. Claire primarily works at Coburg Osteopathy & Health Services, and earlier this year organised the #3058Workout, a massive charity exercise day that raised over $11,000 for cancer council. She has had a great start to her career, no doubt with more to come. Her advice is:

Keep reading and asking questions. Your colleagues are your greatest resource and supporters so use them, ask them questions and observe them as often as you can.

Follow Claire on Instagram.

Nathan Kelly

Nathan, The Surfing Osteopath, a graduate of the class of 2013 from Southern Cross University, owns and operates Universal Health & Performance on the Gold Coast. He practices in an evidence informed manner, utilising traditional osteopathic techniques, dry needling and strength and conditioning principles to help people with injury management and rehab as well as performance enhancement. His advice is:

You’ve spent the last 5 years learning everyone else’s version of osteopathy, it’s now time to spend the next few years exploring how you want yours to look. Osteopathy is a framework which you can build from, and that’s the brilliant part of this job; the exterior is yours to create. The heart of osteopathy is inherently punk, it was born out of rebellion and questioning of the status quo. So keep asking questions, keep studying the human condition and keep osteopathy punk.

You can follow Nathan on his popular Instagram page.

Jacqueline Shergold

Jacquieline (Jacqui) graduated with me from Victoria University in the class of 2011, and since graduating has worked in private practice in Ireland, studied a Diploma in Paediatric Osteopathy at the Osteopathic Centre for Children (OCC) in London and now works as part of a multi-disciplinary team at a specialist baby treatment centre. Her advice is:

Listen. Listen to your instincts. Listen to your peers and mentors. Listen to your patients and listen to what their bodies need and want. Listen to podcasts and go to conferences/workshops/lectures. Take time to listen and you’ll be amazed at what you hear.

For more information, check out her practice website or connect with her on LinkedIn.

Jade Scott

Jade is a graduate of Victoria University, in the class of 2001. She is the owner and director of Western Region Health, one of Australia’s largest osteopathic practices. Jade has been involved in clinical education for a number of years and has an extensive graduate mentorship program in place in her practice and was involved in the development of the 5th year student internship program. Recently Jade has been presenting to osteopathic and allied health business owners on employment models in healthcare. Jade still practices and has a particular interest in maternal and paediatric health. Her advice is:

Don’t confuse confidence with conviction

Never underestimate the need to ‘fake it till you make it’

Social recognition is the key to filling your books

A patient’s financial situation should never cloud your ability to deliver their best treatment plan
Always go above and beyond

‘See how you go’ is not an option

‘Find, it fix it, leave it alone’ should be replaced with ‘find it, fix it, address the predisposing factors and maintain health’

Money is a wonderful byproduct of loving what you do

Core values make us the best at what we do (professionalism, integrity, respect, care and innovation)

If you surround yourself with brilliant people, remarkable things happen…

You can find out more about Jade via Western Region Health and follow them on Facebook for the latest updates.

Shane Buntman

Shane is a graduate of the Victoria University program, class of 2004. He currently operates a large practice across two locations in Melbourne’s CBD – Melbourne Osteopathy Sports Injury Centre. Shane has previously worked in the UK, and before osteopathy studied biology and genetics, as well as worked as  remedial massage therapist. Shane is passionate about developing the profession of osteopathy, and writes for Osteopathy Australia in their quarterly magazine on the topic of business in healthcare/osteopathy. Shane’s advice is:

Every time you step into the consulting room think ‘I’m representing the entire profession Osteopathy’.

It’s not about how interesting you can be, it about how interested you can be in others.

You can find out more about Shane via the MOSIC website and follow them on Facebook and Instagram.

Jon Marshall

Jon, owner of Back in Health Osteo is an osteopath and acupuncturist with clinic locations in Melbourne and Singapore, where he is currently based. Jon graduated from the program at RMIT in the class of 2008, and in 2011 he completed his Masters of Acupuncture, having previously studied a diploma prior to osteopathy. He is a master of the Japanese martial art Aikido and he founded the Melbourne Budo Academy in 2010, which teaches Aikido, Brazilian Jiu Jitsu, Shinkendo (Japanese swordsmanship),  Japanese Jujutsu, and Judo. He also teaches dry needling and cupping courses through his education company, Manual Medicine Australia. His advice is:The greatest thing that I would like to impress on you is that your learning NEVER stops.

Keep all your textbooks and don’t burn your notes. You will refer to them and keep learning from them over your entire working life; they have been written by some real giants in the Osteopathic world and we are lucky to be able to stand on their shoulders.

Don’t be overwhelmed, everything you have learnt in the course takes years to sink in, just keep learning and studying.

Be a generalist before a specialist. Be a Manual Medicine Master.

Work on yourself professionally and personally.

Don’t put down similar professions as it is unprofessional and it makes you sound like a knob. Everyone has something to teach us and never stop honing your craft.

Get together with colleagues, attend seminars and maximise your potential and be the very best Osteopath you can be.

Don’t get lazy or complacent, go out and chase your dreams.

Leaving Melbourne, while hard may be the best decision you ever make professionally…..

You have one of the best jobs for work life balance.

Keep healthy, take regular breaks and taste those sweet fruits!

The future is bright!

You can follow Jon’s clinics on Instagram and Facebook.

Tina Maio

Tina is a highly experienced osteopath who graduated from the osteopathy program at Victoria University in 1999, having also completed a Physical Education degree there previously. Tina owns and consults at Coburg Osteopathy and Health Services, where she treats people from all walks of life, but has established a reputation for her work with athletes, from the junior level all the way through to elites. Tina is particularly known for her work with golfers, with her current stable of players on the US PGA Tour, Nationwide Tour, European Tour, One Asia Tour, Japanese Tour and PGA and LPGA. Tina has presented locally and internationally in sports osteopathy and sports medicine. She is on the leadership committee for the Clinical Practice Group in Sports Osteopathy through Osteopathy Australia and is a clinical advisor for EMS Swiss Dolorclast. Her advice is:

Allocate time to professional development that excites you, it will create lightbulb 💡 moments that will fuel your passion for wanting to help others. Be committed to you career, but don’t abandon your personal life. Remember that working with people in pain is exhausting so take steps to look after yourself.

You can follow Tina through the Coburg Osteopathy Instagram and Facebook pages.

Nigel Roff

Nigel graduated from RMIT in the class of 1993. He practiced in Sydney for 6 years before establishing Willsmere Health Osteopaths in Kew, Victoria in 2000.  He practises patient-centred care with an emphasis on current evidence-based practice. He has a special interest in distance running and the treatment of injuries associated with running, and can also provide training advice. Nigel describes himself as having “No specialisations, I just treat people and their nervous systems”, but he also describes himself as a “hack runner”, so he is definitely modest (he recently competed the Chicago marathon, which is fairly far from “hack”). Nigel is an example of a practitioner who has built a successful career in osteopathy without having a high profile, except with his patients, where it counts most. His advice is:

Assume nothing, actively listen to your patients, they will tell you what’s wrong. You may not be able to help but that’s ok. And finally you are not responsible for your patients problems.

You can follow Nigel on Twitter or Facebook.

Anne Cooper

Anne is a former nurse and a 1989 graduate of the International College of Osteopaths, making her the most experienced practitioner on this list. She founded what is now Central Sydney Osteopathy in 1990 and has had a huge influence on the profession over the years. She has been president of Osteopathy Australia, and is now a life member, she is currently president of the NSW Osteopathic Council and has previously sat on the Osteopathy Board of Australia. Anne calls herself a dinosaur, but dinosaurs are extinct, while she is still overseeing a busy practice and seeing patients. Her advice is:

A new business is like any newborn; feed it when it asks to be fortified, nurture it, love it and help it grow strong and robust. That means 100% attention. Meet your patients needs, and very soon they will meet yours.

Osteopathy is medicine, not sports science. The human form, and what ails it, is not a predictable equation. Our job is simply to assist homeostasis. Treat what you find in that one unique patient, not what you’ve been told you should find.

If you think your patients should reflect your own image, then you’ll struggle. Appeal to ALL types. Old, young, fat, normal and thin, non/sporty, sick, well, straight, gay, black coffee and white, mums, overworked, unemployed.

When you graduate you don’t chat about technique at conferences and reunions. You talk business. So get it right from the start. This is a physical job, output exactly matches input, and if you get it right from the start you’ll enjoy a comfortable lifestyle and a deeply satisfying career.

You can follow Anne via the Central Sydney Osteopathy Facebook page.

 

Della Buttigieg

Della is a graduate of the Victoria University program, class of 2003. She is the founder of Melbourne Osteohealth, and a lecturer at Victoria University. She is a caring and passionate osteopath with particular interest in pain and rehabilitation for long term health and function. She firmly believes that the key to preventing many health problems from developing and recurring lies in educating our patients; arming them with an understanding of the their pain and teaching them how to reduce or eliminate it. Recently she has been involved in presenting on both the theory and application of pain science to clinical practice for allied health professionals. Her advice is:

What most patients want is someone who can help them feel good again and while better movement, more sleep and a balanced diet are a good start, humans never feel better than when they are having fun… prescribe fun!

You can follow Della via Melbourne Osteohealth on Instagram and Facebook.

Heath Williams

Heath is the founder of Principle Four Osteopathy, Corporate Work Health Australia and Ergawell. He is a graduate of Victoria University, class of 2003, and currently lectures there along with Southern Cross University, primarily in rehabilitation. Heath previously has worked in the UK and Sweden, and is currently a member of the Osteopathy Australian Clinical Practice Group for Occupational Health and Safety. Heath has a big focus on continuing education, and has undertaken numerous courses, workshops and seminars covering topics as diverse as manual therapy and exercise rehabilitation all the way through to communication. His advice is:

Be curious and open to opportunities! Learn from your own experiences, your clients and your colleagues and say yes to opportunities. Life will never be dull and work will always be fun and engaging.

You can follow Heath on his popular Instagram or Facebook pages.

Josh Lamaro

Josh is a graduate of the Victoria University osteopathy program. He owns Paleo Osteo in Bendigo and Torquay in Victoria, which is an “evolutionary medicine and nutrition clinic”. He has a special interest in the treatment of chronic conditions such as fibromyalgia, chronic fatigue syndrome, and auto-immnune diseases using the modern and traditional principles employed by Osteopaths. Certified in anti-ageing medicine through the Australasian Academy of Anti-Ageing Medicine, Josh uses functional medicine principles to help address his patients’ health in a wholistic manner. His advice is:

There is an alarming trend in osteopathic education at the moment that is tending away from what osteopathy really is.

There is a tendency to look for the “tissue causing the symptoms” and eradicate or palliate the symptoms. The ancient wisdom of the body is that it is always seeking balance, and will find it irrespective of the minds influence on what is “normal.”

A metaphor might be something like a boat sinking due to a hole in the bow of the hull. The passengers on the boat necessarily have to run to the rear of the boat to counterbalance it away from the sinking end. This could be seen as an “abnormal” distribution of human weight on a vessel (analogous to abnormal lab tests, abnormal tissue tonus etc,) but without this shift having occurred, the result would be far more disastrous. It is therefore of little use to usher the passengers back down the front (medicate/palliate/undo local “restriction,”) rather, what must be done is to seek the true reason the body is needing to find balance in this way.

Asking “why?” til one can no longer ask it anymore lands you somewhere in the realm of where to begin.

You can follow Josh on Facebook and Twitter.

Stephen King

Stephen is dual qualified as an osteopath and physiotherapist. He graduated from the Victoria University osteopathy program in the class of 2010, and the University of South Australia physiotherapy program in 2013. He is the director of Movement Assessment Technologies (MAT), which teaches allied health professionals about movement assessment and functional rehabilitation, The Injury Rehab Centre, a practice in Cheltenham, Melbourne which integrates the concepts taught through MAT and the host of the 21st Century Physio podcast, where he interviews industry leaders about the future of physiotherapy and allied health. Prior to working as a clinician he was a personal trainer and strength and conditioning coach, which is where his interest in movement started, and nowadays he spends his time helping professionals get better outcomes for their clients and patients. His advice is:

My top 3 things that I wish I knew as a new grad.

  1. Do not take everything from Uni as fact – a lot of what you learnt is out of date (it’s not 1898).
  2. Osteopathy is more than a 3x3m room. Think outside the box, set goals and work hard.
  3. Be the change you want to see.

You can follow Stephen via MAT on Facebook, Instagram and YouTube and through The Injury Rehab Centre on Facebook and Instagram.

Dr Nic Lucas, PhD

Nic is an osteopath, medical researcher, lecturer turned entrepreneur. Having completed his osteopathic studies at Victoria University in 1999, he went on to further studies at the University of Newcastle in epidemiology and pain medicine, before completing his PhD in diagnostic medicine at The University of Sydney. While at uni, Nic founded the International Journal of Osteopathic Medicine (IJOM) and served as an executive editor for 19 years and sold to Elsevier, the world’s largest medical publisher. He also started the Student Osteopathic Medicine Association (SOMA), helped develop the osteopathic course at The University of Western Sydney, where he went on to lecture for almost 9 years, and sat on numerous osteopathic committees and registration boards. After selling his two osteopathic practices, he has moved into coaching online entrepeneurs with his company X10 Entrepreneur.

Are you an Osteopath, or are you qualified as an Osteopath? Big difference. Don’t lose sight of yourself in a Title. Your identity is greater than your qualification. You can go anywhere, do anything. There’s never been more opportunity. Don’t ask for permission to go be awesome AF.

You can follow Nic on Facebook, Instagram or check out his website.

Summary

You probably started to sense a trend with the advice given.

While a few of the quotes mentioned technique, the majority talked about attitude, and the big picture.

Common themes were personal growth, education, self-care and listening/communication. This might not make sense now, but when you see such diversity in methods, all with similar results, then you have to look deeper at what is being done.

At the end of the day, this is just a milestone in your life journey. Graduating may feel like “everything” right now, but over time, you will grow and it will become “something”.

You have the opportunity to make an impact on people’s lives, which is an amazing privilege.  I wish you every success in your future, both personally and professionally, and hope that this blog helps you in some way.

Finally, start building your network. The internet makes this easier than ever before, and will strengthen your professional life immensely.

Good luck!

Class of 2011 at Victoria University (phone cameras have come a LONG way since then).

 

Nick Efthimiou Osteopath

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

You can follow Nick on Facebook, Instagram, Twitter and connect with him on LinkedIn and Snapchat.

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 Specific Do Treatments For Pain Need To Be?

Specific; On TargetPain is what drives people to consult a medical professional more than any other symptom.

The vast majority of pain is benign, somatic (musculoskeletal) in nature, though some somatic pain has a visceral component.

Most of the time, complex examinations and treatment rituals are performed, in order to diagnose and treat said pain.

Patients feel like they are getting good value, practitioners feel like they are providing it.

But is it necessary to go through all these examinations, and aim for all these specific hands on, taping and exercise techniques to help people get better?

I’m going to argue, that no, it isn’t.

Can We Be Specific With Assessment?

A typical assessment of someone in pain consists of the following:

  • History
  • Neurological and orthopaedic testing
  • Active movement
  • Passive movement
  • Palpation/provocation

It can also include

  • Functional/task specific assessment
  • Capacity testing: strength, endurance etc

Based on all of this, a clinician then formulates a diagnosis, which dictates a management plan.

However, and this is a massive “however”, it could very well be that we are wasting our time.

Let’s have a look at each of those components, and see how specific they can be.

History

The clinical history is probably the most important part of an initial consultation. Combined with general information about a patient (age, occupation, family status etc) and how they carry themselves, a clinician can hypothesise a working diagnosis prior to any further assessment, which usually serves to confirm or refute the diagnosis.

For certain presentations, the history is quite diagnostic.

For example, neuropathic pain occurs when there is damage to a nerve, causing it to have what’s called an ectopic discharge. Without going into too much depth, when patients complain of burning, lancinating pain, often that will point us towards a diagnosis of neuropathic pain.

On the flip side, a recent study questioned whether commonly held true concept of clicking in the knee being related to meniscal damage. It was shown that equal numbers of people with and without meniscal injuries experience things like clicking and catching. (1)

Neurological and Orthopaedic Testing

The neurological examination consists of things like a cranial nerve examination, reflex testing, sensory testing and motor/strength testing, along with neurodynamic testing.

Unfortunately, neurodynamic testing often yields false positives (so not that specific).

Strength testing, at least the manual version, is very unreliable, and thus not specific.

Isokinetic strength testing is more reliable, however most clinics do not have this equipment. Some clinics have hand-held dynamometers, which increase reliability of strength testing. (2)

Additionally, strength testing only tells us there may or may not be a weakness, not why. Additionally, strength is not related to pain, though it is important for both injury risk and activities of daily living.

Sensory testing is helpful, while reflexes don’t really tell us much except that reflexes are there or not.

Orthopaedic tests, those which clinicians use to rule in/out certain tissue based injuries are notoriously unreliable. Even those which have demonstrated high sensitivity and specificity are subject to error as a result of neurological changes when we are in pain.

Active Movement

Okay, by now you should be sensing where I’m going with this.

Active movement tests the ability to perform that movement. Yes, certain tissues/structures are involved in certain movements, but that doesn’t mean that movement is a specific test.

For example, raising your arm out to the side as high as you can involves multiple muscles acting at the shoulder joint. If it hurts to do so, it implicates all these muscles involved, as well as the tendons, ligaments, joint, nerves etc.

Is it helpful to know? Most of the time.

Is it specific? No.

Passive Movement

See above.

Yes, passive movement takes muscles out of the picture, at least from a contractile point of view. That doesn’t mean that if active movement hurts, and passive doesn’t, that the problem is with a muscle.

Thus, not specific.

Still valuable, but not specific.

Palpation

Most practitioners, especially osteopaths, believe their palpation skills are reliable means of assessment.

They’re wrong. (3)

Palpation is not reliable, and thus definitely not specific.

Still valuable, but not specific.

Can We Be Specific With Treatment?

The short answer: it depends on the treatment.

Let’s look at my common methods of treating pain:

  • Education
  • Manual therapy
  • Graded exposure
  • Movement therapy/exercise rehab

Can any of them be specific?

Education

Education can address specific themes and topics, but the challenge with education, as is the case with any communication, is that what is heard and understood is not always what is intended. We are at mercy of the interpretation of the receiver. Language is more than words. It is influenced heavily by our social circles and our cultural experiences. (4)

But because teaching people about their pain, how to manage it and how to prevent future flare ups is a hugely important part of practice, this means these are simply challenges to be overcome.

I’ve said before, that education is the only thing that stays with a patient after they finish working with me. The caveat to this is, education that is effective. Saying things is not educating. Helping someone understand is educating.

As important as it is, I think it is a stretch to say it has a specific effect on pain. We can’t measure the effect it has, and say what amount of pain reduction was attributable to what amount and type of education.

Manual Therapy



I’m going to upset a lot of my colleagues by saying you can’t be that specific with manual therapy.

But it’s true.

Think about it, all we can truly touch is the skin. Not muscles, not ligaments or tendons, and not bones. The skin.

We can direct force to deeper lying tissues, like those mentioned previously, but this depends on the magnitude and direction of the force, as well as where the target tissues are situated.

Physics dictate that the only force that can be efficiently transmitted to bone has to be perpendicular to bone. Any horizontal or tangential force is dissipated by the frictionless interface of the skin/fascia. (5)

Another strike against the blow of specificity is the way the body is innervated. No one section is supplied by a single neurological level. Hence, because of convergence of multiple levels, we end up with less specificity.

Finally, when it comes to spinal movement, there is a plethora of research showing that you cannot isolate movement to a single vertebral level. Even neck manipulations, which allow the best contacts compared to thoracic and lumbar manipulations, result in movement of adjacent interverterbal joints.

So strike specificity off the list of things manual therapy is.

Graded Exposure

What about graded exposure? Many people conflate graded exposure with exercise rehabilitation. There are similarities, in that they are both (should be) progressive. However, graded exposure borrows from psychological research, and in theory, addresses psychological factors relating to pain and activities just as much as the physical factors. It’s kind of obvious when you think about it: gradually doing the things that hurt, or that you are worried about hurting makes it easier to do them over time.

Worried about bending over to garden all day? Let’s start with kneeling for a short period of time. Then you can gradually (the graded part) do more (the exposure part) until you are bending over gardening all day

There are two arguments about whether graded exposure is specific:

  1. It works for the specific task/scenario, hence it has a specific effect
  2. The same can be achieved in other means, hence it doesn’t

In my experience, the former holds true more so than the latter.

Here’s an example:

A patient of mine who was very active injured himself playing hockey. The injury came about because he wasn’t physically prepared for the demands of hockey, despite being physically fit and active. That and plain old bad luck – he simply moved in a way that loaded his back too much, which was in part due to the circumstances of the game at that moment.

After history and assessment, I was able to narrow it down to a diagnosis of “acute low back pain, without referred pain” (remember, we can’t really be that specific).

Treatment was manual therapy (didn’t really make a big difference), stay active (kind of hurt, but didn’t make things worse), some gym work for posterior chain (was able to train, but didn’t help pain), time (definitely made a difference) and gradually increasing hockey load (really helped).

Does that mean it (graded exposure) has specific effects that cannot be achieved any other way? I really don’t know. Let’s call this a maybe, at best.

Movement Therapy/Exercise Rehab


Like manual therapy, the fact that so many approaches can work holds the answer: if everything works, then nothing works. 

Or less cynically (and this is my position, because we know this works for many pain presentations), if everything works, the effects are non-specific.

Honestly, aside from the specific adaptations of exercise, which can definitely be important to an individual based on their capacity (power, strength, endurance, mobility etc), or lack thereof, when it comes to pain, the most important thing is to do something, do it appropriately (not too much, not too little) and continue to do it (consistency).

This can shatter the hearts (and wallets) of professionals who espouse a specific approach as “the only approach”. Of course it works. But not because of the reasons you say it works.

Do We Even NEED To Be Specific?

So here is the big question, or rather two questions:

  1. How specific do we need in order to be effective?
  2. Can we be that specific?

We could argue that currently, we are not very effective at treating low back pain, for example. Most of the time we can help people manage it, and the condition takes it’s natural history, which for most, is a resolution over a long enough time-frame.

But could we be more effective if we were able to be more specific?

There is still so much unknown about pain, that it is very difficult to answer.

We do know that pain typically has a blend of biological factors, including local tissue factors and central nervous system factors. We also know that pain consists of psycho-emotional-social components, which play a large role in the nature and course of pain.

We can’t measure the exact contribution of each, and nor can we isolate tissue factors – even evidence of tissue damage on imaging or surgery is at best, correlated with pain. Sacreligious? Perhaps, but, if we go “full academic”, you can’t separate the non-tissue factors from the resolution of pain. For years, surgeons thought sub-acromial impingement improved because of surgical decompression (it didn’t) (6). Same with arthroscopic surgery for arthritic knee pain (7).

Clinically, I have seen people with total and partial knee replacements still experiencing pain, more than 12, and in some cases 24 months post surgery. This doesn’t mean there is no effect of the surgery, but we aren’t 100% sure what it is.

Anyway, I digress.

With most non-specific pain presentations, by nature, we can improve people with non-specific interventions.

Neck pain for no apparent reason? Here’s a scientific valid approach:

  1. Rule out serious pathology.
  2. Rule out tissue injury (via history and assessment).
  3. Rule out complications/comorbid factors.
  4. Educate.
  5. Provide coping strategies
  6. Neuromodulate with chosen intervention, if desired (see above).
  7. Improve function (see above).
  8. Let time and physiology do the rest.

We can apply this concept to nearly all non-specific pain and be evidence based.

In fact, you can apply this to many instances of specific pain too.

Let’s Get Critical

Earlier this year a study on managing lateral hip pain (gluteal tendinopathy/trochanteric bursitis) was published in BMJ:  Education plus exercise versus corticosteroid injection use versus a wait and see approach on global outcome and pain from gluteal tendinopathy: prospective, single blinded, randomised clinical trial (8)

 After critiquing this study, you could easily come to the conclusion that there was a lot of confirmation bias taking place in how much effect these interventions were having, and how much of that effect was due to the specific nature of the intervention (there was no general exercise arm as a comparison).

The methods of intervention were pretty generic:

  1. Education (basically, avoid compression of the tendons by not sitting and moving in certain ways) and exercise (a standardised hip exercise protocol) was one group
  2. Corticosteroid injection was another
  3. Wait and see was the third

Everyone got really excited on social media when this was published, because “exercise works!”, and “I do exercise with my patients” so there was lots of back patting and confirmation bias all around.

However, in my opinion, the interventions didn’t result in that much improvement over a wait and see approach in the main outcome measure (Visual Analogue Scale or VAS, a numerical pain scale). In fact, average pain intensity (score out of 10) changed from 5 to 3 in the wait and see group, while the intervention groups (education + exercise or corticosteroid injection) improved from 5 to 2 on average (there was only a minor difference between the two groups).

Consider the cost for that 10% improvement over wait and see:

  • The education + exercise was 14 sessions, which, if we take an average of $80 per consult, is $1120.
  • A corticosteroid injection under ultrasound guidance, ranges from between $150 and $300 on average.

So was all that effort of exercise, expense of education and injections worth it? Yes, in the short term, there was a big difference at 8 weeks over wait and see. However, if you told someone they had to spend $1000 over 8 weeks to end up 10% better than doing nothing at a year, how many people would still take that option?

Now let’s look at the other main outcome measure, the Global Rating of Change or GROC. The GROC is a single-item instrument that asks each patient to indicate whether and to what extent they perceive change has occurred, typically relative to the date of the initiation of care. The GROC uses a Likert scale to indicate the direction of change (ie, worsening or improvement) and the extent of change (ie, “tiny” to “very great”).  (9)

However, there is contention that the GROC doesn’t reflect functional changes (9), as it is a subjective assessment, but unlike the VAS it isn’t assessing pain, which is subjective, but the participants perception that something has changed. The problem with this, is the recency illusion and the availability heuristic inherently skew the results.

So when we look at the GROC scores: we see that at 8 weeks there is a big difference between the education + exercise and wait/see group, which makes sense, because the education/exercise program was 8 weeks long. But over time that difference was reduced, which is explained as follows:

Our data showed that a patient’s current FS exerts a strong bias on perception of change, even for short recall periods (fewer than 30 days), and this effect increased as transition time lengthened. (9)

So where does that leave us? Time to draw some conclusions.

Conclusions

That was really a long winded way of saying, no, we don’t need to be specific, because even when we try, we can’t be.

The constituents of good care are listed above. This much is clear, though some will debate the manual therapy aspect, others debate the exercise aspect, the moderates will say these 4 interventions are all good in various degrees.

What is emerging, is that what you do isn’t as important as how you do it, and who you do it with (the therapeutic alliance is a big predictor of outcomes in pain). It is also important to not do the wrong things – i.e. those that are clearly ineffective, but moreso, those that actively do harm.

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.

 

 

Rehabilitation Is More Than Just Exercise

Exercise is NOT a magical pill – it is great for many things though.

There is a current trend to treat painful problems with exercise, conflating it as rehabilitation.

Before I elaborate, let me make a few things clear:

  • Done correctly, exercise is a good thing, for most people
  • Exercise can be part of the recovery process from pain and injury
  • Exercise has many health benefits
  • I promote exercise actively – if you follow my social media accounts you’d see that

However, exercise is not therapy, nor is exercise rehabilitation.

Yes, exercise can be part of rehabilitation, but it isn’t the same as rehabilitation.

We must keep in mind, however, that motor skill learning and exercise are not synonymous. – Stevans and Hall, 1998

I teach a workshop that talks about using kettlebells for rehab.

In it, I present this argument that performance training and rehab are on the same continuum, with health somewhere to the right of middle.

A slide from my Kettlebells for Rehab Workshop

My point is this:

Performance training is aiming to maximise performance of a particular task.

Rehab is aiming to improve physical performance in one or more aspects.

The principles of stimulus and adaptation still hold.

What doesn’t hold is that you can use performance training to achieve a rehab goal, if the deficit is not performance related.

There is a saying that you can’t put fitness on top of dysfunction.

That’s not completely true, but nor is it true that simply adding load makes things better.

Solely focusing on resolving dysfunction (whatever that means) and solely focusing on building capacity (performance) are both inadequate.

So what happens when rehabilitation is inadequate?

  1. Presenting issue (often pain or injury) is not adequately resolved
  2. Increased risk of future injury
  3. Impaired performance (be it at sport, work or activities of daily living)

Strength Training Is Not Rehabilitation

I have a weak back.

I need to train my core.

My knees aren’t as strong as they were.

Almost every day I hear stories from patients correlating their pain with weakness.

There is a meme floating around about the relationship between strength and pain that is growing in power and becoming really hard to undo.

If there was a direct link between strength and pain, we would not see strong high level athletes suffering from chronic pain.

But we do.

The main reason I suspect we see this link is two fold:

  1. Visually, strong people fill our idea of health and fitness.
  2. Simplicity: it is easier to blame on weakness, teach somebody how to strengthen the so called weaknesses and then use strength as an outcome measure.

Strength training can definitely be part of a rehabilitation program.

But getting strong alone is not the reason we see improvements in pain.

Strength training, done properly, improves movement quality, load tolerance and builds confidence. All these contribute to improving pain in certain conditions.

Stretching Is Not Rehabilitation

The second common issue is “tightness”.

People often feel tight and cite this as a reason they need to stretch.

Therapists then perform an assessment.

They say this feels tight, this is weak. Stretch this. Strengthen that.

If only it were that simple!

Stretching is a valuable technique. I use it as part of my own personal exercise programs, and often prescribe stretching to patients.

Stretching has value beyond lengthening muscles (which it actually doesn’t do*), like improving body awareness (interoception) and relaxing both body and mind. All of this can help people in pain improve.

But alone, stretching is not rehabilitation. In fact, changes to flexibility are not associated with improvements in pain.

Oh and by the way, feeling tight doesn’t actually correlate with being “stiffer”. This has been shown in research. One is a perception of the body, the other is a physical property.

“Cardio” Is Not Rehabilitation

Whether it is going for a run, stationary cycling or walking – all these forms of exercise can have positive effects on health, pain and function.

However, again, is it rehabilitation?

Time again we see improvements with these (and other) cardio activities, which do not correlate to improvements in fitness or endurance.

Again, this isn’t to say cardio exercise has no value in a rehabilitation program, it is simply saying, that cardio in and of itself is not rehabilitation.

What Is Rehabilitation?

Comprehensive rehabilitation should involve restoring optimal function to both the sensory and motor systems, in a manner that builds resilience and enhances adaptability.

Huh? Does that sound complicated? It kind of is. We are talking about the body, which still remains a mystery to us.

We don’t know it all.

But what we do know, is that rehabilitation should be tailored to the individual, and process based.

It should include education and a graded exposure that takes context into account.

It should have objective outcomes that measure improvements in function, but should also focus on resolving the presenting pain or injury as best as possible as well.

Exercise can definitely (and usually should) be part of this process, but I have seen many fit and “dysfunctional” people over the years, along with many people who have “rehabbed” themselves to become stronger and fitter but still suffering from their initial complaints.

There of course, is a balancing act – it’s not always about the pain – and often improving function in spite of pain is the best outcome, but that doesn’t make exercise alone magically turn into rehab.

How Do You Do It?

Educate, Educate, Educate

Without properly educating someone about what they are doing and why they are doing it, rehabilitation lacks meaning. When things lack meaning we don’t give them appropriate focus, which leads to lack of results.

This is why the who treatment encounter should be centred around education from the beginning.

Create the appropriate context, and then each intervention fits into that context.

Sensory Rehabilitation Should Precede Motor Rehabilitation

When somebody has referred pain down their arm or leg, I will test their reflexes.

A reflex tests both the sensory and motor function of the related nerves.

The body has to sense the stimulus (the tap of the reflex hammer on the tendon) and then respond to it.

If you have impaired sensory function, but your motor function is fine, then you won’t demonstrate normal reflexes.

Rehabilitation is similar.

If you have impaired sensory function, your motor function (movement, strength etc) will not be at the level it should be.

Initially, rehabilitation should aim to restore sensory function – this can be achieved in many ways with manual therapy/taping (sensory nerve stimulation), body awareness exercises (enhancing interoception), mobility/flexibility exercises (enhances sensory input), motor control exercises (enhances proprioception).

If someone displays poor sensory awareness, improving this will often develop their motor qualities concurrently, as outputs are a product of inputs and processing.

This is why simply exercising doesn’t always improve things. It’s not just what you do, but how you do it.

Rehabilitation Should Be Contextual

Soldiers in the army face numerous challenges when deployed. An uncertain and continually changing environment, unpredictable tactics from enemies, and the threat of death create extremely high stress situations.

In these high stress situations, our brains go into survival mode – thinking decreases and insinctive behaviour increases – unfortunately, what is instinctive is often dangerous, so these behaviours must be stopped.

As a result, training for soldiers involves as real as possible simulations, to cause an adaptation to the brain.

As the soldiers are exposed to realistic threatening scenarios, they become less and less sensitive – their brains do not enter survival mode as easily – allowing them to think and act intelligently, even under extreme stress.

With pain, our brains are protecting us from a threat, real or perceived. If you experience pain while you are working, and you work in a fast paced financial office, rehabilitation in a calm clinic room only goes so far.

Rehab should progess in context, from safe and secure to challenging and confronting, to allow the brain to adapt its response.

This is one of the most overlooked aspects of rehabilitation, in my opinion. It is why education is so important, and also one of the hardest things to do.

Rehabilitation Shouldn’t Be Based Solely On Sets and Reps

Fixed set/rep schemes work great in theory.

However, given the dynamic nature of the human body, some days we can do more, some days it’s less.

Creating an environment or set of parameters that allows you to “fail forward” is usually more optimal than grinding out movement to achieve a number.

One of the ways this can be achieved is with self-limiting exercises.

Another is with auto-regulation using a “rating of perceived exertion” (RPE) scale. This requires good sensory awareness. See earlier point.

While exercise is often focused on achieving a number, to ensure progression, rehab is slightly different. Numbers can play a role, but shouldn’t be the main focus. Quality and feelings should, at least in the beginning.

Conclusions

Exercise is definitely an important part of the rehabilitation process, but what we have learnt in recent years is that it doesn’t matter as much what you do, but rather that you do something and how you do that something.

When we frame exercise in terms of capacity (load, volume, range of motion etc) without paying attention to the contextual factors involved in someone’s presentation, we are missing a large part of the problem at hand.

And while it is easy to measure strength and endurance gains, it is much harder to measure gains in body awareness, confidence and resilience.

I myself have been guilty of defaulting to the former many times, purely because patients often demand something tangible, and this is what I am familiar with.

The challenge for everyone involved in rehabilitation from pain and injury is to bring the bigger picture into focus, and to really shift the emphasis towards rehabilitating people, not problems.

 

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.

 

 

11 Important Things To Know About Pain

As someone who spends his life thinking about how to better understand pain, I have reached the point where I have amassed a great deal of knowledge on the topic.

The problem with knowing a lot about a topic is, it is easy to fall victim to the curse of knowledge.

The curse of knowledge is best explained by this example:

In 1990, a Stanford University graduate student in psychology named Elizabeth Newton illustrated the curse of knowledge by studying a simple game in which she assigned people to one of two roles: “tapper” or “listener.” Each tapper was asked to pick a well-known song, such as “Happy Birthday,” and tap out the rhythm on a table. The listener’s job was to guess the song.

Over the course of Newton’s experiment, 120 songs were tapped out. Listeners guessed only three of the songs correctly: a success ratio of 2.5%. But before they guessed, Newton asked the tappers to predict the probability that listeners would guess correctly. They predicted 50%. The tappers got their message across one time in 40, but they thought they would get it across one time in two. Why?

When a tapper taps, it is impossible for her to avoid hearing the tune playing along to her taps. Meanwhile, all the listener can hear is a kind of bizarre Morse code. Yet the tappers were flabbergasted by how hard the listeners had to work to pick up the tune.

The problem is that once we know something—say, the melody of a song—we find it hard to imagine not knowing it. Our knowledge has “cursed” us. We have difficulty sharing it with others, because we can’t readily re-create their state of mind.

I, like many health professionals (and experts in every area) often struggle to convey our knowledge to our patients. This is a huge problem, as education (transferring knowledge), is one of the key strategies we can use to help people.

We say one thing, and with it we are thinking of many other things implicitly, based on our years of accumulated knowledge and experience. Unfortunately, patients only hear what we say, and not everything else that we are thinking of when we say it. To make matters worse, patients will often hear all of what we say, but truly understand even less.

So what’s the solution? How do I make this information as clear as possible?

Simple:

  • Use concrete, not abstract, language.
  • Use examples that relate to you.
  • Repeat the key concepts, over and over, until they stick.

With this in mind, here are 11 important things to know about pain.

1) Pain does not equal tissue damage

This is the most important thing to understand about pain.

Pain is not a marker of tissue damage.

Yes, it does occur with injuries that involve tissue damage. That is not in dispute. However, there are countless examples of people experiencing tissue damage and not feeling any pain. There are also many examples of people experiencing very minor or no actual tissue damage and a lot of pain.

Think about stubbing your toe. Often there is no discernible tissue damage, yet stubbing your toe hurts, a lot. However, after you look down and examine it, often the pain quickly subsides.

Or what about the examples of people who have been shot and don’t realise this until later!

Additionally, the intensity of pain we experience is not a direct measure of the severity of what is wrong. A paper cut hurts immensely, at least at first, but it is hardly a serious injury. On the other hand, many people with life-threatening cancers feel little no pain, especially in the early stages of the disease.

So if pain is not a measure of tissue damage, what is it?

2) Pain is protective

Pain is a protective “feeling” we experience with our conscious awareness.

Huh?

Well you can’t be unconscious and experience pain, by definition. That’s how anaesthetics work.

I’m going off on a tangent here, back to the point. Pain is protective.

Whether it is protective of an injured body part or protective of a threat to our brain’s concept of self pain is a biological process that is meant to keep us safe.

 

Imagine if, instead of being told that her sore knee is because of wear and tear, a doctor tells her patient that her knee pain is because her NERVOUS SYSTEM is being PROTECTIVE of it. ~ Imagine this doctor then tells her patient that to deal with the pain she needs to become more ADAPTABLE and RESILIENT, and that she can do this by improving her flexibility, strength and endurance with EXERCISE and ACTIVITY. ~ Imagine if this doctor also told her patient that STRESS and FEAR makes her PAIN WORSE, and that she not only needs to become more physically adaptable and resilient, but more MENTALLY as well, and that this is possible because even into older age, the BRAIN and nervous system CAN LEARN and CHANGE for the better! ~ #integrativeosteopathy #osteopathy #osteo #pain #neuroscience #exerciseismedicine #positivevibes

A post shared by Nick Efthimiou (@integrativeosteopathyau) on

That sentence is complicated, so read it again, and then I’ll break it down.

Pain can be protective of an injured body part. Most of us would have experienced this, but as I said above, it doesn’t measure damage. Pain can protect a previously injured body part too, often way before it is at any risk of being injured again. This is what happens when people talk about having a bad ____ (insert body part here).

Pain can also be predicatively protective. That is, we feel pain in anticipation of something happening to us. I see this lots with people who have low back pain – before they even move they feel pain, even though nothing has happened except a thought!

Finally, pain can also be protective of our concept of self. Our concept of self is the idea of “I”. It is who we think of when we think in the first person. The concept of self has been discussed anddebated in religious and philosophical circles for millennia.

The self is an individual person as the object of his or her own reflective consciousness – Wikipedia

When you understand this, you can see how pain that comes on for “no reason” can be explained as being protective of the self.

If you experience pain after intense periods of stress, then this is an example of your brain (we’ll get to that) deeming that stress as “threatening”, and along with the corresponding changes in a biochemistry during periods of stress, producing pain to get you to change your behaviours

3) Pain is produced by the brain and localised to the body

You don’t see with your eyes.

Your eyes have cells in them that respond to stimulation by light. Once stimulated, these cells send the information signal, via the optic nerve, to the brain. It is the brain which composes the “image” that we see. Interestingly, our brain doesn’t always produce an objectively accurate image. Unless we are really paying attention, it will often give us a generalised image, that is predictive, based on previous experiences. This is why eye-witness testimony is not considered reliable enough to convict as a stand alone evidence. It is thought this is to save energy.

The same goes for all our sensory experiences. Our brains produce a conscious experience based on input from the sensory nerves.

 

Most people are familiar with taste, touch, smell and hearing, which along with sight make up the “5 senses”. However, our brain is also receiving sensory information from many other nerves throughout the body. This gives us interoception (our sense of our internal body) and proprioception (our sense of our body’s position).

Along with the sensory stimuli mentioned, we also have sensory stimuli we are unaware of.

Nociception.

Nociception is “noise” from the body. Sensory nerves that respond to thermal, mechanical or chemical stimulation are constantly sending signals to the spinal cord. Most of this is blocked, because it is just that – noise. However, when when those nerves are stimulated to a greater degree – think an injury, or contacting a hot surface – then your brain becomes aware of the change to the noise levels.

Think about how you can hear your name spoken at a noisy party.

Your brain, not knowing exactly what is going on, will respond by producing pain, and will decide to protect the area where the increased nociception is coming from.

How does it do that?

With pain of course!

To make matters even more complex, we can have pain in the absence of nociception – think of amputees with phantom limb pain – but the majority of pain people experience is either the result of increased nociception or decreased inhibition of nociception.

More on that later.

4) Chronic pain is different to acute pain

Acute pain is usually a response to either a tissue injury or other immediate threat, it subsides as the injury or threat does.

Chronic pain is the result of changes to the nervous system which make it more sensitive. This means the nervous system and brain become “hyper protective”, generating pain with little or no provoking stimulus.

Whether you or someone you know has chronic back pain, arthritis, headaches or some other chronic pain condition (like fibromyalgia), it is important to know that in cases like this, the problem is pain, and it is the same mechanisms that are involved across the board.

How can this be? How can low back pain be the same as a headache or arthritis?

The changes that take place in the nervous system, predominantly take place in the central nervous system (brain and spinal cord). This is like the central control room for our nervous system. Thus if something is wrong with the central control room, then everything linked to it (which is everything), can be affected.

Of course, there are local (or peripheral) factors involved, which contribute to the pain being localised, but there is often a large central nervous system component to chronic pain.

As a result, chronic pain needs to be addressed as a problem in its own right, and not treated like acute pain.

5) Recurrent pain and multisite pain are both forms of chronic pain

Some people experience recurrent pain. That is pain that “comes and goes”.  They will often think that each episode is a discrete event, that is, it is the same problem happening over and over again. It gets better for a while, then it happens again.

Others experience pain in multiple body regions. They might all be one sided, or they cross midline and are above and below the waist. There may or may not be a pattern (often this pattern is explained in biomechanical terms by well meaning practitioners, but that’s another issue altogether).

This is not the case.

Both recurrent pain and multisite pain are forms of chronic pain, and need to be managed as such.

Often multisite pain starts as a single site, and progresses to multisite, chronic pain. In these cases it can be considered a progression of the same condition. It is important to understand the distinction between these presentations of pain, because chronic pain requires different management to acute pain (see no. 4).

6) Pain is never simple, even when it seems so

It may seem like some pain is simple.

You twist your ankle and it hurts.

Or, you drink lift too much and end up in pain.

We think like this because our brains like linear “cause and effect” relationships.

However, pain is not linear. It is emergent.

A linear process is when one thing progresses to another. In simple terms, it is when A + B = C.

An emergent process is when two or more things combine to form something that doesn’t share the properties of the things that make it up.

Because of this, and all the invisible and unconscious factors that contribute to us experiencing pain, we can never say that pain is simple.

When you twist an ankle, all the associations with twisted ankles you have ever experienced that are buried in your brain are activated. The meaning and context of the ankle twist comes into play (a soccer player who will miss the final will experience different feelings to someone who gets out of duties they didn’t want to do because of the injury). Sometimes the nociception doesn’t represent tissue damage at all, but spikes due to a sudden increase in load.

Why does this even matter?

Because chronic pain starts as acute pain, and in some cases, it was considered “simple”.

7) Pain is not caused by “poor posture”, weak muscles or being “out of alignment”

 


If you have understood everything up until now, this should make sense.

However, many people still think of pain being caused by these things, because we observe these things when people are in pain.

It is the common error of attribution: correlation is not causation.

When you experience pain, you might be weak, or stand/sit differently or even look and feel like you are twisted or bent. There is no disputing this.

But it doesn’t cause pain.

More likely, these things are caused by pain.

They are defensive, or protective behaviours.

8) Osteopaths (and other practitioners) don’t “fix” pain

You might think this is a strange statement to make.

Why else would you pay to see an osteopath then?

Well, there are lots of reasons, but when it comes to pain, the resolution can only come from within your own body and brain.

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A good osteopath will do everything in their power to help remove the barriers to recovery, and facilitate the physiological and psychological processes that need to take place, but no one can change you on the inside from the outside.

Even pain relieving drugs can only work if you are in the right context – morphine doesn’t always help, while sometimes a placebo pill works better than the real thing.

So if you are looking to be “fixed”, it is unlikely to happen as you want. This is probably the hardest thing to accept as both a patient and a practitioner.

9) Everything can “work”

There are claims from therapists, doctors and other kinds of healers about all kinds of treatments for all kinds of pain.

It’s likely all of these people have numerous success stories to confirm that what they do works.

But just as an osteopath can’t fix someone (see no. 8), everything can work for pain.

This is because the brain has the ability to produce pain relieving chemicals, in the right circumstances.

These pain relieving chemicals are extremely powerful, and when the context is right – belief, expectation and ritual all come into play – then the brain, in anticipation of what’s to come and in response to what has happened sends out all these amazing substances to help you deal with pain. This process is called descending modulation (or inhibition).

This is not a bad thing at all. It is actually the goal of many therapies, including osteopathy and exercise rehabilitation.

The problem comes, when interventions are sold in misleading ways, i.e. they are sold as doing something unrealistic or impossible.

In simple terms, if something sounds too good to be true (amazing success rate, top secret, revolutionary) or can only be done by a particular person, it is unlikely that the intervention is really doing what is claimed.

That’s not to say it doesn’t work, only that is doesn’t work because of what is claimed.

10) Inflammation is a good thing

Many people take anti-inflammatory medications for pain without a prescription. They don’t work (at least for low back pain).

Many others use ice after sustaining injuries.

The majority of people doing this don’t know why they are doing it. If you asked them, they might mention something about stopping inflammation.

If you asked them why they want to do this, they might say it helps with pain and recovery.

Now what is more likely?

Our bodies have, over thousands of years, evolved highly effective mechanisms for dealing with injury, part of which is the inflammatory process, or this process is an error of biology and must be stopped?

Inflammation is the body’s way of healing.

Yes, it can be painful, but pain is a protective response. And you know what needs protecting? Injured tissues.

That is not to say you need to completely rest an injured tissue by the way. It is simply saying that suppressing inflammation (particularly with drugs) can impair and delay healing.

Finally, chronic inflammation is not a good thing. However, it is usually the result of other issues, and while suppressing it relieves the inflammation, it doesn’t address the reasons why it is happening. Like chronic pain, chronic inflammation needs a different approach to acute inflammation.

Oh and one more thing,

11) How you live is more important than what you do

 

Most people in pain are looking for a fix.

Be it medication, treatments of various kinds, a specific exercise or even surgery.

The issue here, is that for many pain problems, these interventions all have low effect sizes. That means, they work, but not by very much. Hence the cost and risks often outweigh the benefits.

What is most important, particularly for sufferers of chronic pain, is living well, despite your pain.

Healthy lifestyle habits contribute to healthy bodies and brains.

Healthy bodies and brains experience less pain overall, and when they do experience pain, respond better to interventions.

That is not to say all treatments for pain don’t work.

Nor is it to say how you live can solve all types of pain.

It is simply saying, that your lifestyle plays a large role in your likelihood of developing and recovering from pain.

Think about it. If someone leads an unhealthy, high stress lifestyle, barely sleeping and consuming lots of drugs and alcohol, do you think it matters what kind techniques an osteopath uses, or what type of exercise they do?

Do you think it will make any difference in the grand scheme of things?

Conclusions

I consult with people in pain on a daily basis.

I work with them to try and help them feel and live better.

Sometimes, their pain goes away. Sometimes it doesn’t. Sometimes it gets worse. We are not predictable like a machine.

It is a really hard job, and while many practitioners love to talk about their success rate, I think if you take a big picture view, it is unlikely any single practitioner gets results above and beyond what the statistics say they should for the patient base they work with.

I do believe there are practitioners who would do worse, simply because this information about pain is still not common knowledge, even among health professionals, but to do better is unlikely.

Thus, if someone has a long waiting list, it doesn’t necessarily mean they are the best therapist, it simply means they have a lot of people waiting for their services.

When you choose a therapist to help you, it is less about what kind of therapist they are, and more about how they work, and whether that suits you. A good way to know if they are up to date with the research is to ask them about some of the topics above. They don’t have to agree, but if they have no idea, or dismiss things outright, that might be a hint.

Pain is a mystery, but that doesn’t mean you can’t reduce it, or live well with it. After all, it’s not just about the 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.

 

 



 

 

References

The Curse of Knowledge

Self