Your Body Is Not A Machine

Back of man with arms elevated exposing machine internals.

What a machine!

Food is fuel!

The heart is a pump.

The brain is a computer. Inputs. Outputs. Processing.

Analogies likening the body to a machine have been around for centuries, if not longer.

They exist in almost every culture.

They shape the way people think about their bodies.

They are wrong.

Your body is not a machine, and that is an extremely good thing.

Your body is a biological entity, which adapts over time to the stimuli it is exposed to.

Moreover, your body is part of you and you are part of your body – the separation is an illusion of the mind.

Let’s look at this a little more deeply.

Why Do We Use Machine Analogies?

In a word: simplicity (even I succumbed to computer based analogies in this post – my understanding is better now).

Even the most complex machines are computers are created by, and hence can be understood by humans.

When it comes to our body, our brain, our mind – we really don’t know that much.

We are learning at an astounding rate, but almost all research in human biology and psychology ends with the dreaded statement more research is needed.

So, to simplify things, we use analogies of machines. To the non-technical minded person, machines are complex, but we have an idea about them because of our interaction with them in daily life.

But, in the process of simplifying, we have made things too simplistic, and as a result, our explanations lead to incorrect ideas.

Incorrect Ideas Lead To Poor Health Behaviours

Many people are afraid of activity due to a fear that they will “wear out” their body.

You hear doctors described arthritis as “wear and tear” all the time.

This leads people to stop doing the very things that would improve their condition – exercise.

We see similar problems with the “hardware/software” analogies used (I have been guilty of this in the past).

When people are told their brain is like a computer, it is very limiting.

Computers cannot create.

Computers cannot feel.

Computers cannot express themselves.

At this point in time, computers can only do what they are programmed to do.

If we think our brain is like a computer, then it is becomes a tool for processing information, rather than the core of our experience.

Additionally, a computer can be reset. While we all love the idea of a clean slate (new diet on Monday, new year’s resolutions etc), in reality, everything we have experienced in our lives shapes us in ways seen and unseen, which affects what we do, think and feel going forward, which shapes us further, in a big, ever expanding circular fashion.

What Kind Of Analogies Should We Use Instead?

When it comes to adaptation, which is the hallmark of living organisms, I like to use examples from nature, like this tree from a Facebook post I made a couple of years ago.

I love how, despite the challenges of an unfamiliar, urban environment presented to this tree, it manages to adapt and thrive. This is true across all of biology. Species, both plant and animal, will do whatever they can to adapt to their environment in order to survive and reproduce.

From an evolutionary biology perspective, this is what our primary purpose of life is.

Now, as humans, we have higher aims – creation, expression, fulfilment, enlightment etc – but deep down, these biological imperatives are still there.

Instead of saying “the body is a car that needs servicing and alignment”, why not say the body is like a tree, it grows until maturity, then it endures good seasons and bad throughout its lifespan, but it adapts and survives?

Instead of saying “the heart is like a pump”, why not describe it as a river that keeps flowing to maintain it’s own health – sometimes it flows faster, sometimes it flows slower, but it still flows?

Instead of saying “what a machine”, why not say what an amazing person?

Why It’s So Important To Get This Right

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!

Conclusions

Medical and allied health practitioners need to lead the charge towards healthier attitudes towards bodies, pain, injury and ageing.

More needs to be done to build confidence in people’s health, especially in the face of pain and ageing – two big drivers of fear.

This can be achieved by stopping the use of machine based analogies and encouraging people to build strength and resilience in the face of pain, rather than retreat and avoid aggravation.

The evidence is clear: while short term rest in the case of tissue injury and post surgery is sometimes warranted, the sooner people resume activity, the better their outcomes.

We also know that expectations drive outcomes. This means more positive messages about recovery and less fear based mechanical analogies.

It’s time practice started reflecting the evidence, it’s been around for a while now.

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.

 

 



 

 

3 Unconventional Reasons To Stretch

Stretching is most commonly thought of as a way to increase flexibility.

What is often overlooked, is that stretching has other benefits, which are equally important to most people – especially those who feel tight, wound up and stiff as a result of a busy and stressful lifestyle.

Previously, I have discussed why flexibility is important for both fitness and ageing well. In essence, if we don’t use it (range of motion), we lose it, and stretching can help us regain lost range of motion. However, long term, our habitual activities will play a bigger role in maintaining adequate range of motion, which is why it is important to move regularly and in a variety of ways.

I have also looked at why mobility training (including stretching) doesn’t always work to improve flexibility, if you are stiff because you lack stability and control in a certain range of motion.

Because stretching doesn’t seem to do what people originally thought it did (lengthen muscles), it has been dismissed as ineffective and a waste of time by some trainers and clinicians.

This overlooks the following benefits:

Stretching Relieves Stress

This is one of my favourite reasons to stretch, particularly in the evening, when I’m winding down for bed.

Stretching stimulates the autonomic nervous system (ANS), shifting it towards the “rest and recover” parasympathetic state, and away from the “fight or flight” sympathetic state.

For most people, anything that helps them become more balanced in the ANS is a win.

Shifting towards a more parasympathetic state helps with:

  • Sleep quality
  • Recovery from exercise
  • Mental health
  • Tissue healing
  • Digestion and elimination

Whilst meditation, breathing exercises and even prayer can help reduce stress and improve ANS balance, I like to prescribe stretching for most people, because mentally it is easier to “do something”.

Focusing on the stretch, including breathing is a form of mindfulness meditation, which potential physical benefits as well.

It’s worth mentioning, that a lot of “tightness” is simply a physical stress response – it’s considered protective by the brain.

So, if nothing else, stretch, particularly in the evenings, to reduce stretch and calm both your body and your mind.

Stretching Can Help Manage Blood Sugar Levels In Diabetics

Diabetes is a growing problem in Australia and much of the world.

Type 2 diabetes (non-insulin dependent) is becoming more and more prevalent, and is primarily a lifestyle condition.

The challenge for most people with type-2 diabetes is managing blood sugar levels, particularly after meals.

There is a large amount of research that shows exercise can help manage blood sugar levels, both throughout the day and immediately after meals.

A recent study out of India looked to compare the effects of stretching and resistance exercise on post meal blood sugar levels.

What they found, was that both forms of activity reduced post meal blood sugar levels – returning them to fasting levels.

However, there was not a significant difference between the groups.

This is important, because passive stretching is easily performed at home, doesn’t require any equipment (save for maybe a stretching strap) and can be performed by people who may not easily perform other exercises (like walking or resistance exercise) due to health complications.

The Real Benefit: Improved Cellular Energy Production?

Impaired cellular energy production (mitochondrial dysfunction if you must know) is implicated in a range of conditions. Most relevant to me as an osteopath, is fibromyalgia and chronic fatigue syndrome.

If these conditions are affected by impaired cellular energy production, and stretching helps improve cellular energy production, can stretching help with these conditions?

If you’re interested in the science:

A study showed that passive stretching increases heat production and oxygen consumption in muscles. This leads to an increase in the metabolic activity in these muscles thus causing reduction in the blood glucose level due to the incorporation of glucose transporter type-4 (GLUT-4) into the stretched muscles. Stretching increases the level of nitric oxide by single passive stretch of 20%. Nitric oxide also influences the incorporation of GLUT-4 thus facilitating its activity. PSS is also known to alter the microcirculation thereby reducing tissue oxygen exchange. This resultant ischemia facilitates the translocation of GLUT-4 into the sarcolemma. Additional related studies on PSS demonstrate an increase in glycogen breakdown at the cellular level and support the effectiveness of PSS in reducing blood sugar level by stimulating the activity of protein kinase B, further improving glucose uptake by the stretched muscle cells.

What this is saying, is that stretching helps cells use glucose (sugar) and oxygen, which is aerobic metabolism. This produces energy and heat.

It might be a long bow to draw, but I think there is definitely potential for people with chronic conditions that cause low energy/high fatigue to benefit from stretching as a form of exercise that doesn’t aggravated their symptoms too much.

Stretching Can Cause Muscle Growth

Years ago I used to read a lot of strength training/body building forums. This was before social media became the force it is today, and so discussions would carry on over longer periods of time, reaching a quite a level of depth.

One interesting discussion was started by a man with the screen name DoggCrapp (real name Dante Trudel), who came up with an interesting and very effective style of training that was quite counter to the popular high volume routines that were considered standard bodybuilding approach.

I mention this, because Dante was ahead of his time in a few areas. One was the effect of stretching on muscle growth.

Here is a quote from him:

Extreme stretching can have myriad benefits if done correctly: recovery, fascia size and potential hyperplasia, which is still only theory.

What is interesting, is that more than a decade later, researchers have demonstrated that prolonged stretching can increase muscle size.

Here is an excerpt from the abstract:

This study demonstrates that stretch training is a viable modality to alter muscle architecture of the human gastrocnemius through lengthening of muscle fascicles, decreasing pennation angles, and increasing muscle thickness

Now, I wouldn’t get excited and think that stretching is all you need to grow bigger muscles.

I would suggest that this is reason enough to include stretching as part of an overall fitness program – hypertrophy is a potential benefit, even if the effect is small.

The other effect of stretching, particularly longer holds, is the potential change in muscle architecture. Chronically shortened/stiffened muscles have a lower growth potential as their cross sectional area is decreased. Additionally, a flexible muscle has a higher activation potential (muscles that are stretched first demonstrate high motor unit activation). This is why Dante focused on stretching: in addition to the potential muscle growth, he observed that the bodybuilders with the best respective muscles also had the best flexibility in those muscles.

This isn’t just value for athletes, bodybuilders or people looking to bulk up. It can be a helpful way for people in pain to load their muscles and help them grow.

For example, someone with knee pain might not tolerate compressive loading, but they find that they can stretch their thigh muscles without pain. If that person has lost muscle size and strength in the process, this could go some way to helping that.

Stretching Does Not Impair Speed And Power

One of the big arguments against stretching, especially before any form of sports of exercise, is the negative effect of stretching on power.

This has been documented in multiple studies, which have been the basis for widespread dismisal of pre-training/event stretching.

However, as with many things in the training world, there was a massive over reaction. This had lead to programming mistakes that, over the long term, lead to worse movement quality and potentially injury.

Firstly, the documented power drops were minor – nothing for the recreational athlete or gym goer to worry about.

Secondly, the effects were transient, lasting about 15 minutes. Interestingly, there are some studies that show an equal drop off in vertical jump height between groups who stretched and groups who rested. This suggests that there is more to the decrease in power than stretching – perhaps lowered nervous system activity is involved?

Thirdly, recent research suggests that stretching might not have any negative effect as once thought.

Although it’s far from conclusive, I see this as a reason to stretch – you’re unlikely to negatively impact your performance in a meaningful way, unless you’re approaching the world record in a power event.

With no negatives, there are potential positives to pre-training and event stretching.

Improved flexibility, even if transient, can be helpful.

However, going back to the first point in this post, getting into a more balanced autonomic state may help performance.

Ask any elite athletic if they prefer to be jittery and overstimulated, or calm before an event.

You’ll probably get a split of answers, but what will be common is they will want to have focus and clarity. A balanced ANS provides that.

So stretching can improve joint range of motion and balance the ANS in the short term – both desirable prior to training and competing.

Conclusions

Stretching has copped a bad rap in recent years based on the fact that it doesn’t do what we thought it did (lengthen muscles) and that it isn’t as effective at reducing injury as strength training (I have my thoughts on that below).

However, there are many reasons to stretch – including these 3.

More importantly, stretching has stood the test of time – from martial arts to yoga – flexibility training in the form of stretching has been trialled by humans for long periods and found to be beneficial.

Whilst some will always want double-blind randomised controlled trials to justify everything they do, with stretching, the risk is low, the cost is negligible (maybe a mat and a strap) and the potential returns are high. To me, it’s a no brainer that stretching is at least worth trying.

If you want to implement stretching into your daily routine, subscribe to my mailing list below and I’ll send you a copy of my 40 page eBook ‘Active Stretching’. This covers the theory and practice of stretching in simple terms, with colour photographs and descriptions of how to stretch each muscle group.

 

 

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

Stretching increases heart rate variability in healthy athletes complaining about limited muscular flexibility

Acute Effects of Stretching Exercise on the Heart Rate Variability in Subjects With Low Flexibility Levels

Acute Changes in Autonomic Nerve Activity during Passive Static Stretching

The Effect of Neural Stretching Technique on Sympathetic Outflow to the Lower Limbs

Effects of stretching on menopausal and depressive symptoms in middle-aged women: a randomized controlled trial

Immediate effect of passive static stretching versus resistance exercises on postprandial blood sugar levels in type 2 diabetes mellitus: a randomized clinical trial

Effects of passive static stretching on blood glucose levels in patients with type 2 diabetes mellitus

Twenty minutes of passive stretching lowers glucose levels in an at-risk population: an experimental study.

Stretch training induces unequal adaptation in muscle fascicles and thickness in medial and lateral gastrocnemii.

Time course of changes in vertical-jumping ability after static stretching.

The effect of static, ballistic, and proprioceptive neuromuscular facilitation stretching on vertical jump performance.

STATIC STRETCHING DOES NOT REDUCE VARIABILITY, JUMP AND SPEED PERFORMANCE

Achilles Tendinopathy? Treat The Whole For Better Results

Statue of the Achilles, wounded by an arrow through his heel – Achillion Palace, Corfu island, Greece

The Achilles tendon is one of the coolest tendons in the body.

While many body parts are named in Latin or Ancient Greek, the Achilles tendon draws its name directly from Greek mythology.

For those who don’t know the story:

Achilles was a hero in Greek mythology and one of the main characters that participated in the Trojan War. He was also the protagonist of Homer’s epic, the Iliad. 

When Achilles was born, his mother wanted to make him immortal and thus, dipped him in the river Styx. However, she did not realise that his heel, by which she held him, was not touched by the waters, and so that was the only part of his body that remained mortal. (1)

Achilles was then struck down in battle by an arrow through his heel, or more accurately, his tendon, hence we name it the Achilles tendon.

The Achilles Tendon Is Strong

The job of a tendon is to transmit the force developed by a muscle to the bone to which it attaches. The Achilles tendon is one of the thickest and strongest in the body, and allows us to walk, run and jump efficiently. It’s almost like having our own springs in our legs. In fact, when we run, the Achilles tendon deals with forces up to 12.5 times our body weight – for me, currently weighing around 87 kg, that is 1087.5 kg!

But It Still Gets Injured

One of the most common forms of injury to the Achilles tendon is to develop an “overuse tendinopathy”.

An overuse tendinopathy, or more accurately, an overload tendinopathy, occurs when the loading on the tendon causes an increased rate of tissue breakdown, beyond which the body can keep up with. This results in inflammation, swelling and pain localised to the tendon.

Side note: all tissues in the body are in a constant state of breakdown and building, it’s when the rate of breakdown is increased beyond the body’s repair capacity, or the body’s repair capacity is impaired, that we see problems.

We Don’t Know Exactly Why

Researchers haven’t been able to isolate a single variable that causes Achilles tendinopathy (surprising eh?), but the following are implicated:

  • Running (recreationally and competitively)
  • Participation in other sports like track and field, racquet sports, volleyball and soccer
  • Use of certain antibiotics (fluoriquines)
  • Biomechanical issues at the feet
  • Age, gender, height and weight
  • Injury history, like previous ankle sprains

What we don’t know, is exactly what happens that makes the tendon painful.

We Don’t Even Know Why They Get Better

With Achilles tendinopathy, we will often see symptoms that correlate with structural changes early on in the clinical history, but as the condition progresses and goes on for longer, this correlation becomes weaker and weaker.

In fact, in many cases, it has been shown that diminished or even absent pain is accompanied by little to no structural change to the tendon!

We Do Know What NOT To Do

You’d think that simple rest would therefore be best for an Achilles tendinopathy, however, that’s not the case. Too much rest and we lose conditioning of the tissues, and thus our capacity is reduced, leading to recurrence, only this time it takes less and less loading to aggravate.

We also know that taking anti-inflammatory drugs is not the best approach either. Firstly, there isn’t strong evidence to suggest inflammation is the primary cause of pain. Secondly, anti-inflammatory drugs have side effects. Thirdly, anti-inflammatory drugs can impair healing.

Stretching tendons also gets a bad rap, though I’m not sure why this is a blanket no. Some tendon injuries respond to being stretched (it’s simply a form of load), while others do not. You’ll see why below.

We Also Know What Works

In the physiotherapy world, where much of the research on tendinopathies is done, load management strategies combined with targeted exercises are currently the treatment with the best supporting evidence.

The actual type and dosing of the exercises has not been fully established, though we do know that you can push the loading higher than you would expect, even if it is painful.

You can use different types of exercises:

  • Eccentric where you load the lengthening portion of movement
  • Isometric: where you load the tendon without lengthening or shortening it
  • Concentric/Eccentric: where you load the tendon in a full range of motion (lengthening and shortening)

To my knowledge, the best approach has not been established in research, and in my experience, different people respond better to different approaches.

This might have something to do with some recent research that suggests there are different types of tendinopathy: compressive, shear and friction, and tensile.

As the names suggest, these imply that the tendinopathy occurs as a result of different types of tendon loading, which makes sense to me. It also makes sense that if there are different aggravating loads, the exercises which have the most benefit will also differ.

The evidence suggests avoid those loading mechanisms which are aggravating (load management), whilst stimulating the tendon with loads that don’t aggravate it.

For most people, isometrics are a good, neutral, place to start.

You can do these in a variety of ways, but one of the most accessible is to sit with your thighs under a table and feet on a block, then press your thighs into the table by raising your heels. You want to be about 70% of your maximum contraction, at least to begin with. Hold that contraction for up to 45 seconds (though I will often break it down to 3×15 second holds per set). Over time you can increase the intensity of the contraction and then progress to dynamic loading.

Sometimes exercises will hurt while you do them. That’s okay. As long as your pain doesn’t spike, or get really bad afterwards, you are stressing the tissues in a positive way.

Hands On Treatment?

This is something I learnt from my colleague, osteopath Cameron Kealy who runs Recharge Osteopathy in Melbourne, along with teaching at Victoria University.

There aren’t any studies (to my knowledge on this), just clinical observations.

Cameron will treat Achilles tendinopathy with a localised technique. He will grasp the tendon and find a position where tension is relieved and hold it – often for 5-10 mins – waiting for a tissue texture change. He will then check and treat the pelvis and upper neck. Another osteopath, Walter McKone, has also suggested the key to relieving Achilles tendinopathy is optimising blood flow by treating the pelvis.

Success leaves clues, even when there aren’t studies.

Now, we know that manual therapy doesn’t change the structure of tissues.

What is happening is likely an effect of working with the sensory nerves around the tendon.

But if a person’s pain decreases, allowing them to load again and return to activity, I’m all for it.

This Makes It Work Even Better!


At the moment, one thing that all this focus on localised exercise for tendinopathy is doing, is forgetting that the injured and painful tendon is part of the body, which is considered a whole.

After all, the blood that supplies our tendons also supplies everything else.

The nervous system that perceives the tendon also perceives everything else.

The nutrients delivered to the tendon are, you guessed it, also the nutrients delivered to everything else.

Once we have labelled the tendinopathy, the more important thing to do is to look at the health of the person.

In fact, this is the premise of osteopathy: find the health within the person, and remove the barriers to that health being expressed.

After all, it isn’t lack of exercises that cause a tendinopathy, it is lack of capacity. Exercise can increase physical capacity, no doubt about it.

However, lack of capacity can be cause by sub-optimal physiological function, and not just poor load tolerance. For example, impaired blood flow.

And, as I have discussed before, it is often easier and more efficient to “remove the handbrakes” to performance/health, than it is trying to force adaptations.

Enter The ANS

The autonomic nervous system (ANS) regulates physiological function in our bodies.

It is controlled by lower brain centres – that means we don’t have direct conscious control over it. This is a good thing, as regulating all the systems in our body is a lot of work.

Having a balanced ANS is important for health. When the ANS is over or understimulated, so that it skews towards one state too much, health is affected.

This is where it gets really interesting.

The School Of Physiotherapy at The University of Otago has been doing some interesting research (and research that should be done by osteopathic schools, but that’s another issue altogether) on the effects of manual therapy and the ANS.

Recently, one of their PhD students looked at whether spinal manipulation, delivered to the thoracic spine (which is where many important ANS centres are located) would have any effect on recovery from Achilles tendinopathy.

First, they did a review on the effects of manipulation and the ANS. That is, they looked at all the research on the topic to see if manipulation affected ANS function in any way. They found a positive relationship.

Then, to look at whether this would affect recovery from Achilles tendinopathy, the researchers created two groups: a control, which received usual care for Achilles tendinopathy (read: exercises) and the intervention group, which received usual care plus spinal manipulation.

The group receiving the spinal manipulation made better improvements in both pain and function compared to the usual care group.

Whilst only a pilot study, this is promising. It suggests that improving whole body, or rather whole person, health and function, is the most optimal way to treat Achilles tendinopathy.

Future studies will need to look at whether this was a specific effect of spinal manipulation, or a general effect of manual therapy, however, my gut feeling is that the researchers are onto something.

Don’t Forget The One Percenters

Finally, when we are really seeking above average results, we can add the extras, which can help take things from good to great.

These extras wouldn’t be classed as treatment on their own, but they enhance what you are doing already.

In my opinion, these extras are what should define private healthcare. This is what you are paying for. Not just “usual care”, which is offered by the public health system, but exceptional care, with exceptional results to match.

Some of these “one percenters” can include:

  • A tailored, not generic exercise plan
  • Specific nutritional strategies, including supplementation advice
  • Behavioural and mindset coaching (we know that mindset is an important factor in recovery from injury)

These are not specific to Achilles tendinopathy, but they can definitely play a role in addition to the treatments mentioned above.

Conclusions

If you are suffering from Achilles tendinopathy, the two most important things you can do to manage/treat it are:

  1. Load management: avoiding/reducing aggravating movements initially
  2. Build capacity: use loading/exercise strategies to build capacity in the tissue and inhibit pain

However, while these strategies would give you the majority of benefits, if you are looking to optimise your recovery, then there are more options available.

I’ve outlined some of these options, which you give you a clue as to how you can really enhance your recovery from an Achilles tendinopathy injury.

As with everything, it comes down to you.

The two big questions any osteopath worth their salt should ask are: what do you want, and what can you do to achieve it?

Some interventions are not realistic because of cost, availability or other reasons. Whatever your situation, your treatment approach should be optimised for you.

That means treatment for Achilles tendinopathy should have a whole person focus, and not just a tendon focus.

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) Achilles

(2) Throw Away The Anti-Inflammatories & Start Loading Your Damaged Tendons

(3) Infographic – Tendinopathy – Thou shalt load. But how? With Dr Ebonie Rio

(4) Exploring the changes in pain, function and sympathetic activity when a thoracic spine manipulation is used as an adjunct to the treatemnt of Achilles tendinopathy

Further Reading

Why Achilles Tendon Problems Don’t Heal

Recharge Osteopathic Clinic

Why You Should Choose Conservative Health Care

,

You can’t cut out pain. – every *good* orthopaedic surgeon ever

Despite what we know about pain, many people are subjected to poor medical management for their pain on a daily basis.

From the recommendations of medications that don’t work for certain conditions (ahem, anti-inflammatory drugs and low back pain), to expensive courses of passive therapies that have extremely low effect sizes.

Not only do these treatments not work very well, they are is an enormous waste of everyone’s resources. To make matters worse, many of these management strategies are not benign, meaning they have the potential for negative side effects.

When it comes to poor medical management, over the counter medications and ineffective passive therapies are the (very small) tip of the iceberg. Many costly, and potentially dangerous drugs, invasive therapies like injections, nerve blocks and the “grand-daddy” of them all, surgery all carry high risk profiles and for very small benefit, especially over the long term.

It’s right about now that I should add some moderation to this post:

I’m not saying these treatments are completely worthless all the time. In fact, I have had many patients who have benefited from the right prescription or surgery over the years.

What I’m saying, is that these treatments often come with big costs and risks that are not fully disclosed when they are recommended (although nearly every surgeon does a better job at explaining the risks of their treatments to patients, many still overplay the benefits or don’t fully explain the alternatives).

With this in mind, the sleeping giant in the treatment of most painful problems, especially those involving the musculoskeletal system is good conservative health care.

I emphasise the good, because there is so much bad out there.

No, I’m not trying to be negative and put down other health professionals. I am simply stating, that based on my experiences with patients (and supported by research), many have not had adequate conservative care to begin with, which is how they’ve ended up with chronic conditions in the first place.

What Is Conservative Health Care?

Conservative health care is based around interventions designed to avoid radical medical therapeutic measures or operative procedures. 

They are typically lower in cost than more aggressive treatments, which a much safer risk profile.

The downside is that some conservative treatments don’t have a large effect size, and many work in general, not specific ways.

Some examples of conservative health care include:

  • Education, advice and reassurance
  • Lifestyle changes
  • Dietary changes, including supplementation
  • Exercise based interventions
  • Physical/manual therapy
  • Certain medications

When Should You Seek Out Conservative Health Care?

Conservative health care is not appropriate for all health problems.

Serious and life threatening conditions typically need more aggressive and/or invasive treatments. Examples of such conditions include major infections, cancer, organ diseases and major trauma (though there are many more).

When conservative health care is most optimal, is when a condition is chronic and stable, or progresses slowly, when the condition is self-limiting (i.e. it will resolve with time, and symptomatic management is all that is required) and when the condition is non-specific (it can’t be attributed to a single cause), like many low back pain presentations.

Usually, a general practitioner will be able to advise you when conservative options are suitable, so that’s often a good place to start.

Conservative Treatment For Pain

Pain is the number one reason people consult their GPs, however, a lot of pain is very poorly managed from the begining, leading to the progression towards chronic and more debilitating pain.

This is where I feel that conservative management can really shine.

Almost every chronic condition will improve to some degree from improving your health generally.

Additionally, many chronic pain presentations will benefit just as much, if not more in the long run, from good conservative management.

Unfortunately, many people miss out on receiving good conservative care when they need it most, leading to them needing/wanting more aggressive treatment options when their condition has progressed.

The Benefits of Conservative Health Care

Conservative health care has a number of benefits for all parties involved: patients, practitioners and 3rd party payers (insurance companies, governments etc).

One of the biggest benefits is economic.

Let’s take chronic low back pain as an example, because it is so prevalent, and so widely researched.

The cost of these conditions to the Australian economy in 2012 was more than $A55 billion. Back pain and osteoarthritis, the most common of musculoskeletal conditions, accounted for 52% and 41% of cost respectively.

When we look at the costs, most people intuitively think of the cost of treatment (consultations, investigations like imaging, medication etc), however, the bigger cost is the indriect cost, that is the cost to society and the individual of lost income, productivity and quality of life as a result of their condition.

While the direct costs of chronic conditions is around A$9 billion annually, the indirect costs are a staggering A$54 billion annually!

With such high costs, you’d think that prioritising excellent conservative care from the outset would be high on the agenda for all involved.

Unfortunately, many clinicians do not follow the clinical care guidelines which are developed by compiling the best evidence from researchers around the world. In fact, only 20% of low back pain patients received care inline with the guidelines.

These guidelines are designed to ensure the best possible management of each condition, yet with only one in five people getting treatment based around them, many are missing out and going on to develop chronic pain, which ends up costing them in time, money and quality of life.

Other benefits of conservative health care include:

  • Safety – by definition, most conservative health care is low risk.
  • Availability – there are typically many more health professionals able to deliver conservative health care than specialists who deliver more invasive treatments.
  • Sustainability – conservative approaches can typically be maintained over the long term, which can help manage chronic conditions.

What stops people getting good conservative treatment?

I believe that most of the time, most people are doing the best they can. As a result, the lack of implementation of clinical guidelines for conservative care is not down to any one factor, but here are a few:

  • Market forces – funding for public health services is always stretched, so GPs cannot spend adequate time educating patients. Private practice clinicians are often limited in the number of times they can see someone due to a patient’s ability to afford treatment.
  • Expectations – patients often want to be “fixed”, not understanding, or wanting to participate in more active management for their conditions.
  • Practitioner knowledge and skill – most health practitioners are skilled in diagnosis and treatment, not in facilitating behavioural change. This makes it hard to create long term, empowered change.

With this in mind, we can see the challenges that need to be overcome to offer the best available conservative care.

What is needed to improve conservative treatment?

  1. Government and insurance companies need to appreciate the long term cost savings conservative care offers, and fund it accordingly. If a surgery costs $20,000 spread across direct and indirect costs, and that surgery could have been prevented by 2 years of physical/exercise therapy, then even at $100 per session, twice per week, you are coming out at break even. However once you add in the rehabilitation costs of surgery, and the costs of the increased risk, the physical therapy option is actually cheaper.
  2. Patients need to take responsibility for their thoughts and actions. Yes, circumstances can affect everyone, which can make life harder and less fair for some, however, taking 100% responsibility for how you respond and act will mean that you are in the best frame of mind to improve your situation and your condition.
  3. Educational institutions need to adapt to the changing demands on healthcare and focus more on communication and behaviour change. Simply increasing the awareness of this important skill will lead to those interested healthcare practitioners pursuing further education.
  4. Health practitioners must accept that they can always improve, and seek out ways to develop their skills to better serve their patients. This includes seeking out appropriate continuing education, but it also means enhancing their networks and their ability to utilise these networks to benefit their patients.

The Big Two

Of all these factors, the two most important are economic and cultural forces.

Money is always an influence on how we make decisions, and many people simply don’t have the financial freedom required to pursue optimal conservative care, especially privately.

While there are always those who are living on the edge, and literally have no room in their household budgets for anything about the essentials of living (housing, food, transport and utilities), there are many more who claim that health care is too expensive. Yet these people walk around with the latest iPhone on a high monthly plan, or drink/smoke/gamble regularly. For these people, who may be on average incomes, it is simply a matter of choice and priorities*.

This is where culture becomes important.

Our culture in Australian is heavily influenced by commercial interests.

Unfortunately, there is a lot of money to be made in selling treatments for conditions that offer a simple solution to a person’s health problem.

Whilst they appeal to our emotions, simple solutions are usually inadequate for complex problems.

So when you propose a long term course of conservative care, which involves active participation by patients, it is often a tough sell.

It is made even tougher by the massive marketing budgets pharmaceutical companies and medical device companies have. They use these to influence our culture.  Every night on TV there are commercials for different types of pain medications. Ironically, if most people spent just 30 minutes less watching TV, and decided to go for a walk instead, they probably wouldn’t need them anywhere near as much.

A Different Perspective

If instead of thinking in terms of expense (cost and time/energy), you changed focus to investment, then immediately you have changed your perspective on health.

When you invest in a term deposit, at the end of the term you have more money than when you started.

Conservative health care, done properly, is an investment.

Yes, you are spending time, money and energy to change your health, which has an initial up front cost. But, by the end of the treatment program, you should have improved health, reduced pain, better function and an overall better quality of life.

Get more years out of your life, and get more life out of your years.

These improvements can be thought of as your return on investment. Like a term deposit, conservative treatment is mostly safe, offers fairly predictable outcomes and is overall, low risk.

Once you have restored your health, the idea is to maintain it (just like you would with wealth). Usually this means you need to continue your healthy habits which you established during treatment.

A final word on perspective; if you are in debt, you must pay back your debt before you can invest. The bigger your debt, the more work and time it takes to repay. The same school of thought applies to health. While things can change quickly, true healing from chronic conditions, or even severe acute conditions, takes time.

If that puts you off, think about it like this: time will pass, regardless of what you do or don’t do. If you do nothing, you will be in the same, if not worse situation in a year or ten.

Conclusions

Conservative care is extremely important from both a public health and individual perspective. Delivered optimally, it saves money, improves outcomes and reduces the need for interventions with higher side effect or risk profiles.

There are some barriers to delivering good conservative health care at the population level. On an individual level, the two most important variables can usually be overcome.

If you are a patient: when you are seeking out a health care provider, discuss long term strategies and look for providers who will incorporate an active management plan.

If you are a practitioner, you should look to improve your communication and behavioural change skills. Telling someone what to do isn’t good healthcare. Guiding them through the process of how to do it is.

 

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.

 

 



 

 

 

Notes

*For those who are truly struggling, most universities with allied health programs have student teaching clinics. These allow students to provide supervised care at reduced costs. In special circumstances, the fees can even be waived. Bottom line, no matter your circumstances, if you are really set on helping yourself, you can find a way.

References

(1) Medibank: Chronic pain costs economy more than $22bn a year

(2) Pain drain: the economic and social costs of chronic pain

(3) The burden of musculoskeletal conditions in Australia: a detailed analysis of the Australian Burden of Disease Study 2011

The Easy Way To Improve Athletic Performance

Athletic performance can always be improved to some degree.

It doesn’t matter how old you are, what genetics you landed or what you did or didn’t do in the past, you can still improve.

All of those factors will affect your absolute potential, but the ability to improve is universal, thanks to biology.

There are many factors that go into improving athletic performance, this article will focus on those that have the biggest impact.

There Is No Easy Way

Was the title of this article clickbait? No. I meant easy in relative terms. You’ll see why shortly.

The biggest (controllable) factor in athletic performance is always going to be the amount of work done.

Hard work beats talent when talent doesn’t work hard.

This improves both skill and capacity, which are both involved in athletic performance to various degrees. However, one thing that often gets overlooked, is economy.

Being Economical Is A Good Thing

So what is economy, when it comes to athletic performance?

Economy is the energy cost of performing a task. In endurance activities, this is measured by oxygen consumption, which is analogous to fuel efficiency in a car.

In strength or power based activities, it is a little harder to measure economy, because in a matter of a single lift, throw or jump, peak values are more important than sustained values. However, you can measure maximum force production along with muscle activation and then compare it to the task at hand to get a gauge of economy.

As an aside: efficiency is not economy.

Efficiency refers to the conversion of total work done to productive work.

In a car, the engine has about 25% efficiency, which means that most of the energy is converted to heat and other forms of energy which do not propel the car forward.

There is debate among sport scientists as to how much efficiency can be improved, if at all. That there is debate, suggests it is not the easiest attribute to change, when compared to something like economy.

Generally speaking, being economical is a good thing, because it means you can sustain a higher output for longer, whatever size your total output is.

Factors Influencing Economy

  1. Skill: whatever you do, there is a skill component. Thus, the more you practice the skill of movement, the more economical you become. This is due to the law of specificity (you get better at what you do) having task specific improvements in both motor control and tissue adaptations. This is true whether it comes to running and jumping or playing a ball sport.
  2. Anthropometry: you don’t need to have a degree in biomechanics to appreciate some body types are better suited to certain activities. Tall people with long limbs and great cardiovascular systems make good rowers. Tall and powerful people make good jumpers. The better suited you are to a task physically, the more economical you will be.
  3. General movement ability: Better movers will have an easier time learning the specific task skills (motor learning is a skill in and of itself) and have less/more efficient internal resistance when performing movements. Internal resistance can be thought of as the different intrinsic factors that impede movement/output.

You can hopefully appreciate that anthropometry is hard to change, outside of gaining and losing weight (which is still fairly difficult to change beyond a certain point).

That leaves us with the skill of performing the task or general biomotor ability as our targets to improve athletic performance.

Considering that getting better at running by running more and running faster is actually quite hard work, it becomes obvious that the easy way to improve athletic performance is to improve your general movement ability, and more specifically, reduce your internal resistance as much as possible.

Performance Is An Output

Before I describe the easy way to improve performance, and give specific examples, it is important that you understand a simple model of human function.

Basically, this says that performance is an output, governed by inputs and processing.

An output that is dependent on multiple variables can be improved in multiple ways.

The typical way is to try and change the output by affecting processing.

Think of someone learning to swing a golf club with a coach. The coach might demonstrate what a swing should like like, explain the mechanics and theory of the swing and perhaps provide feedback via video.

This can work, but it is not always the most efficient way to go about things, due to the way we learn movement. When we perform a task, our brain is only concerned with whether that task is completed. However, with no reference point as to what the completed task should look or feel like, it simply doesn’t know what it needs to change in the execution to become better at the task.

If we can give better inputs – sensory information from both the external (outside the body) and internal environments – then the brain has a better time in learning the task, because it has more information it can process, which multiplies the potential for better outputs (performance).

It is usually easier to provide better sensory information to the body than it is to improve skill and capacity, hence, this is the “easy” way to improve athletic performance.

How Do You Improve Inputs?

Improving your inputs, with the end goal of becoming more economical and thus improving your athletic performance can be done in a number of ways. In my experience, these have a synergistic effect – the more you use over time, the better.

Focus On End Points

The first change to sensory input you should give yourself, is exposure to the “end points” of movement.

Continuing with the golf swing example, this would we the top of the back swing and the top of the follow through. By learning these positions, your brain builds a “memory” from which it can determine success or failure of the planned task. What happens in the middle will be inherently variable anyway (more on that later), but if you can get the end points right, you are off to a good start.

Find The Path Of Least Resistance

What happens between the end points will be determined by what your body can and can’t do.

Remember I mentioned internal resistance as a factor affecting your general movement ability? Think of the internal resistance like an anchor or handbrake – it won’t necessarily stop you, but it will definitely slow you down and effect economy.

Generally speaking, most people should have a certain range of motion available to them at each region throughout their body. There is always some individual variance, but enough people have been measured to find that we all fit within a range.

We can lose this range for a number of reasons. In the Selective Functional Movement Assessment (SFMA), fundamental patterns are assessed, and if they are painful or dysfunctional (including lack of range or poor control), these movements are further broken down to find the limitation.

These limitations can be caused by a number of factors, which are categorised as:

  • Joint mobility dysfunctions
  • Tissue extensibility dysfunctions
  • Stability/motor control dysfunctions

Regardless of the system, it becomes obvious that you probably can’t resolve a mobility issue with stability drills and vice-versa.

These dysfunctions (the term is theirs, not mine – I prefer adaptations or defensive outputs, because they are usually protective against something the brain is worried about) will contribute to your internal resistance with movement.

By addressing them, you take the brakes off and without getting stronger, more powerful, fitter or more skillful, you are free to express your full ability, and thus you improve your athletic performance.

Allow Variability

When we perform any repetitive task there is an inherent variability involved. No two repetitions are exactly the same. This is a good thing. It helps us manage fatigue and minimise loading on any single tissues.

Movement variability is a factor in economy too.

Ideally, we have low end point variability (you hit the golf ball dead centre every time), but enough variability within the movement to utilise the most effective path at that instant in time.

Reducing internal resistance facilitates variability, whilst providing feedback ensures that the variability enhances, not detracts from performance (novices demonstrate more variability than experienced athletes, by definition reducing economy).

Give Feedback

This is similar to, but not the same as learning the end points of a movement. Feedback should be objective and external initially, which progresses to a subjective and internal “calibration”.

It is easier to express this with an example.

When learning to hit a golf ball, initially you are focused on simply hitting the ball. If you make contact, then the hit is deemed successful. This is an objective and external source of feedback. You either hit the ball, or you don’t. After repeatedly hitting the ball, you begin to learn what it should feel like, which is a form of subjective and internal calibration.

Taking this further, you want to hit it in a certain direction. If the ball lands where you were aiming, you get an objective, external feedback of success. With repetition, you start to feel when you are striking the ball well and how this correlates to the direction of the shot.

With more focused practice still, you begin to calibrate the feel of the swing with the direction and distance of the ball. All of this happens unconsciously, because you are getting more sensory input about the task.

Over time this leads to improved skill and thus better economy. End result? You guessed it, improved athletic performance.

Where Do You Start?

To know what you need to do to improve your athletic performance, you must start with an appropriate assessment.

A good assessment will look at all the factors involved in athletic performance, including those related to health, and from there you will be able to devise a more specific approach targeted to your needs.

From there, you need to have outcome measures, which usually comes down to your specific athletic event. If you are a runner, then your run times are the outcome measures. If you are a golfer, your driving distance and accuracy and your handicap become the outcome measures.

Once you have established your needs, have a base of outcome measures to compare against, you simply apply the interventions as you need, with the aim of improving the sensory inputs and processing sides of the equation before you retest after the appropriate amount of time.

Conclusions

It is impossible to reduce performance down to one or two factors – we are human after all, and thus very complex.

What I wanted to illustrate with this article, was that to improve your athletic or physical performance, you don’t always have to push harder and harder on the output side of the equation.

Often working smarter on the input and processing side of the equation will yield much better results, with much less effort.

There is an expression in performance circles:

Strength is not built, it is granted to you by your nervous system.

When it comes to athletic performance, the concept is the same.

If you have lots of “anchors” weighing down your performance, it is going to be easier and more effective to cut them loose than it is trying to crank the engine harder in order to go faster.

 

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.