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.

 

 



 

 

Movement Quality, Health and Fitness

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

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

We crawl before we walk.

We walk before we run.

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

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

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

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

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

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

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

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

Can you see the problem?

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

What happens when we hit 40, 50 and beyond?

Fitness First, Then Injury?

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

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

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

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

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

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

Get Healthy First

What should you do instead?

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

Sounds too easy?

That’s the point.

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

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

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

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

All this walking will:

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

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

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

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

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

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

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

With nutrition, change one meal at a time.

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

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

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

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

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

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

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

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

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

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

Then Move Well

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

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

The problem is, movement quality is hard to measure.

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

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

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

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

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

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

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

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

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

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

Next, Develop Your Fitness

You need fitness too.

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

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

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

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

It is basically your margin for error.

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

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

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

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

High Training Loads Protect Against Injury

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

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

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

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

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

Conclusions

This is a lifetime process.

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

It’s definitely not easy.

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

You will have periods where it all seems so hard.

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

 

 

Nick Efthimiou Osteopath

 

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

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

 

 


 

 

References

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

(1) Australian Daily Steps

(2) Movement Reserve: Enhancing the Physiological Buffer Zone

(3) FMS and Aerobic Fitness Predict Injury

(4) Monitoring Athlete Training Loads: Consensus Statement

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

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

Puzzle

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

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

Allow me to let Malcolm Gladwell explain (1):

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

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

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

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

The Case Against Diagnostic Imaging

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

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

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

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

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

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

This means:

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

What About Physical Assessments?

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

We can break physical assessment into 3 components:

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

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

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

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

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

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

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

Even Histories Can Be Misleading

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

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

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

What exactly then does a good clinician need to know?

Is this pain dangerous?

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

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

Is this pain affected by movement or position?

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

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

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

What is your current autonomic state?

Your autonomic state says a lot about you.

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

What are the barriers to recovery?

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

Factors that can affect recovery include:

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

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

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

The Downside of Irrationality

Human beings are irrational. This is a fact.

Being irrational has positives, the most obvious being love.

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

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

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

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

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

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

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

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

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

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

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

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

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

Conclusions

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

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

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

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

 

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

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

 

Nick Efthimiou Osteopath

 

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

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

 

 



 

 

 

References

(1) Enron’s Open Secrets

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

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

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

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

(6) Metastability and emergent performance of dynamic interceptive actions

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

(8) Different contexts, different pains, different experiences

(9) Nocebo hyperalgesia and the startle response

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

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

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

The Role Of Movement In The Treatment Of Pain

Movement

What is the role of movement in the treatment and management of pain?

We know physiotherapists have long time incorporated exercise(s) into their practice, but now osteopaths, chiropractors and other remedial therapists have started introducing exercise and movement as part of their treatment approach to pain.

Does this improve outcomes for people in pain?

As someone who has an exercise background, and a practice based in a gym (with a large number of patients who are active themselves), I’m a big proponent of empowering people with active management strategies to both help manage pain and improve health and fitness.

Large scale research projects have confirmed that an active, movement based approach is superior to a passive treatment approach for the management and treatment of many pain conditions.

Whilst the many benefits of exercise and movement are commonly known and widely promoted, the message can be misconstrued when context is not provided.

To understand the role of movement in the treatment of pain requires an understanding of pain.

Unfortunately, many people do not learn about pain when they seek treatment for pain, which leads to incorrect ideas and beliefs, that can make their pain worse.

The Dark Side of Exercise Therapy for Pain

In general, encouraging people to take an active role in their recovery from pain is a good thing.

Problems arise when exercise and movement is billed as being the treatment or “fix” for pain.

Unfortunately, nothing can “fix” pain, not manual therapy, not exercise, not medication, not surgery.

The reason being, pain is not a thing, pain is an experience, an active process. All of those methods create a change within your body and brain, so that your brain can resolve things.

So, as always, the context in which anything, including movement, is performed to help with pain is paramount.

What’s the big deal?

Many times, I have seen people who have been told to stand/walk/move in a certain way, because if they don’t “their pain will get worse”.

Others, rightly or wrongly, interpret their failure to improve as their fault, if they have been made to believe that exercise is what is needed to fix their pain, due to poor compliance. I often view poor compliance as not as the fault of the client, but of the therapist.

If someone can’t do something, then what has been given to them is too much for them at that point in time.

And yes, people still need to take responsibility for their actions, but the job of a health practitioner is to show the path in actionable steps, not unload a volume of information onto their patients (they could use google for that).

What’s In A Name?

Throughout this post, I have used “movement” and “exercise” interchangeably.

Whilst it is true that exercise is movement, it is also true that not all movement is exercise.

Exercise is purposeful physical exertion/activity performed to create a physical adaptation.

Movement is a preferred term, because it doesn’t have the connotations to exertion.

You shouldn’t need to exert yourself (physically) to overcome pain.

Mechanisms of Movement in the Treatment of Pain

We don’t actually know exactly what happens when pain resolves.

To clarify, we know that pain is an emergent property, that is, it has biological, psychological and social/environmental components, but it is not any one of these, nor does 1+1 = 2.

This means, that treatments for pain can be specific only up to a certain point.

Why does spinal surgery improve outcomes for some people, but not all? If pain were only physical, then surgery would always work, but we are not bodies, but people, and this needs to be considered in the treatment of pain.

That’s not to say we have no idea what helps pain, we do, generally, but what helps pain for any specific person at any specific time is going to vary.

One thing we do know, is that “all pain is neurogenic”, that is, all pain originates in the nervous system.

So for any intervention to help in the resolution of pain, it must have some effect on the nervous system.

Thankfully, we know that movement has a great effect on the nervous system.

Novel Input

Our brains crave novel sensory input. It is why we are generally attracted to “new and shiny”.

When we experience pain, it is an output of the brain, based on all the current sensory inputs from both the body and the brain itself (confusing? read this).

In theory, by providing novel sensory inputs, we can alter the outputs, including pain.

With movement, if we can “show” the brain a different way, then sometimes that is what is needed to “teach” it how to produce the desired output.

For example, let’s say you experienced low back pain that hurt when you bent forward.

If we change the context of your bending by having your feet in a split position and bending to the side, that might be enough of a different sensory input to change the output of pain.

Cortical Mapping

Our body is in our brain. We have a “map” of our body within our brain, such that when certain peripheral nerves are stimulated, a corresponding brain area is activated.

Conversely, stimulating that brain area with electrodes will cause a vague sensation in that region of the body.

When we have pain, we know that our “body map” is impaired. That is, we can’t clearly recognise our affected body parts like we can the unaffected ones.

Deliberate movement can help with cortical mapping, once again, by increasing the amount of information coming from an affected area.

Touch can help, but we seem to have a better response to active movement, likely because more brain areas are involved, resulting in a more pronounced stimulus.

Neural Mobilisation

This is little bit easier to understand for many people, because it is more of a direct mechanical effect.

Nerves are everywhere in our body. We have km’s of them.

They pass through “tunnels” of soft tissue all over the body.

They can get stuck or deformed.

When they are stuck of deformed, they will fire more rapidly and strongly.

Movement, can either directly, or indirectly mobilise the nervous system, freeing up your nerves to slide and glide freely, which is exactly what they want to do.

Descending Modulation

Our brains are pretty cool.

In addition to being able to recognise a bunch of pixels lit up on a screen into shapes (letters) as meaningful, they can produce a whole host of chemicals that can block pain at the level of the spine.

Aside: there are 3 levels where you can block pain. Peripheral, spinal and brain.

Movement can facilitate the production of pain relieveing chemicals, like endogenous opoidids. Much better than buying them at the pharmacy, because your brain is never going to get the dose wrong.

Improved Mood

There is a correlation between mood disorders like anxierty and depression and pain.

Regular and meaningful movement is correlated with improved moods, as is exercise.

You can probably see where I’m going with this.

So Movement is Medicine After All?

Definitely.

But just as taking the right medication, in the right dose for the right problem is paramount, using movement as an intervention for pain is the same.

More is not better if all you are doing is reinforcing the same behaviours that lead to or maintain your pain.

Think of it like this: there is the skill to perform a movement, and the capacity to perform it. If you have the skill, but limited capacity, you need to improve your capacity and vice versa.

Conclusions

Movement is important in treatment of mechanical pain.

Active movement is superior to passive movement in most cases.

The mechanisms of how movement affects pain are not specifically known, but there are plausible ideas, all of which must involve the nervous system.

These effects are what would be called “non-specific effects”. Whilst there are potentially “specific effects” occurring as well, we don’t know enough as yet to harness these more precisely.

In terms of pain: inputs + processing = output (pain).

To change pain, we are attempting to change our inputs, be it movement, education, cognitive behavioural therapy, manual therapy or something else.

Whatever it takes to get a change is what “works” for that person, in that moment.

 

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

Coming soon!

Why Mobility Exercises Don’t Work, And What To Do Instead

Man with great mobility doing yoga with laptop

You don’t wake up one day suddenly stiff, it only feels like that.

Mobility, like most skills, exists on a “use it or lose” basis.

Unfortunately, for most of us adults, our daily lives don’t incorporate much “using it”, so we end up “losing it”.

The best way to maintain mobility if your life doesn’t have you climbing trees and crawling around on a daily basis is through exercise, but, if you have already lost a large amount of mobility, then you’ll have to work specifically to regain it, exercise alone is often not enough.

If you ask google “how to increase mobility”, the top 5 results say roughly the same thing: stretch, foam roll, perform dynamic “joint mobility” and “activation” exercises.

These are valid, but incomplete strategies.

The reason being, lack of mobility is usually not a true range of motion issue – I could lie you down on a treatment table and passively move your joints through a much greater range of motion than you can demonstrate – but rather, a stability issue.

Instability is perceived as a threat by the central nervous system, so protectively, it shuts down range of motion so you can’t cause yourself any harm.

Thus, the underlying cause of limited mobility is neurological.

So, in order to improve mobility in the real world, you must go deeper than foam rolling and targeted stretching/joint exercises and “release the brakes”.

If you don’t, you will just end up spinning your wheels, because when improperly applied, mobility exercises don’t work.

This is because you can’t force the body to do anything, it will resist in an effort to maintain equilibrium.

Now, there are definitely cases where there are physical changes to soft tissues and joint structures that limit mobility, but, outside of diseases and trauma, these physical changes usually occur as a result of the limited mobility caused by the nervous system (use or lose it principle).

So, if you have lost mobility over time, how do you get it back? There are many ways, this is the process I’ve found effective and use with my patients:

Osteopathic Manual Therapy

Being an osteopath, I like to start with manual therapy, but not for the reasons you might think.

Manual therapy doesn’t change tissue length, nor does it “put you back into place” or “re-align” you.

What manual can do, and in the hands of a skilled practitioner, does very well, is provide the body with a chance to change.

Movement, or motor output, is the result of complex co-ordination that takes place in the brain, based in part, on sensory information provided by the peripheral nervous system.

Nociception, the transmission of “danger” signals to the brain and spinal cord from nerves located throughout the body can inhibit motor output.

Nociception is related to, but not the same as, pain. You probably know that if something hurts, it usually doesn’t work well. This can also happen when that something doesn’t necessarily hurt, but the nerves are hyper-active anyway.

Because the body functions as a whole, when one area isn’t moving properly as a result of this increased nociception, then there is a chain reaction throughout the rest of the body.

By using manual therapy, we can inhibit nociception, change motor output and affect a change throughout the rest of the body – often decreasing pain and increasing mobility.

Often manual therapy alone is enough, especially if the issue is relatively new or minor, and new, dysfunctional patterns have not had time to become ingrained. If the problem has been around longer, or is not responding to manual therapy alone, we can move to the next step.

Restore Reflexive Stability

Reflexive stability is the term physiologists give to the near instantaneous adjustments that take place when we move.

This allows us to move safely and effectively, and usually efficiently.

With disuse and pain, this response is dulled, and one of the results is an increase in stiffness, which is designed to protect us in the absence of true stability.

To restore this, you have to go back to fundamental movement patterns, progressing to the next only when you have reached mastery each position/stage.

As mentioned earlier, most stiffness is the result of instability, rather than a true range of motion issue. With this in mind, regaining lost reflexive stability is an effective way to improve mobility by addressing the underlying cause.

Reflexive stability exercises are by nature, whole body movements, performed in progressively more challenging positions/postures.

For the vast majority of people, a combination of manual therapy and reflexive stability exercises will improve most mobility deficits.

For an example of reflexive stability in action, try this simple test:

Perform a squat, noting your depth and the amount of tension involved in achieving it.

Now, get down on your hands and knees and perform 60 seconds of quadruped rocking (below):

After 60 seconds, get up and retest your squat.

If you notice an improvement, then you just witnessed the benefits of reflexive stability. If it was the same for you, then either you don’t have a deficit, or your deficit is elsewhere.

Maintaining Reflexive Stability

After you have gone through the progressions, moving from ground based to upright, the easiest way to maintain your reflexive stability and build your health is by walking properly and walking regularly.

Walking is largely reflexive – a lot of the control occurs at a spinal, not brain level – which means that once you have restored your reflexes, maintaining them simply requires using them.

Now, any old shuffle won’t do, what you want in order to reap the benefits, is to walk with a contra-lateral arm swing, looking up. Ambling down the street with your phone in your hand and your eyes on your phone isn’t going to help you, it’s only going to re-inforce the issues the caused you stiffness in the first place.

For most people, especially those of you who don’t exercise, these two steps alone are enough to restore the mobility you need to go about your daily living.

If you are exercising and/or you want to take things even further, then we can add a few more steps.

Active Stretching and Functional Movement

If you have addressed potential issues with manual therapy and general (reflexive) stability work, but you’re still not getting the specific mobility improvements you want, it is time to begin more targeted work.

One form of targeted mobility work I like to use is “active stretching”.

Active stretching is probably just another name for PNF (Proprioceptive Neuromuscular Facilitation) stretching, but it’s simpler for my patients to understand, so I prefer that.

Active stretching is where you are stretching a muscle group whilst simultaneously activating opposing or synergistic muscle groups – essentially adding stability to the newly explored range of motion.

I’ve found this to be far more effective than passive static stretching, and it really helps people “get” what a joint position is supposed to feel like.

If you then use this increased joint range of motion in more demanding, functional tasks, then you “teach” the body that this range is okay to use, because you are adding strength/stability to a previously weak/unstable position.

This results in an increase in mobility.

In the following example I shared on Instagram, I’m using an active hip flexor stretch, followed by an isolated glute activation exercise before reinforcing the new pattern under load with a barbell squat:

If the problem was at the ankle instead/as well as at the hips, another sequence might involve an active calf stretch (demonstrated below), followed by a dynamic mobilisation of the ankle joint before squatting.

Again, these exercises are not only addressing range/length of a joint/tissue, but improving stability, which, as we discussed, is often the real driver of joint mobility.

The functional exercise then reinforces the pattern, and once repeated enough times, in correct fashion, it is usually enough on its own to maintain the improvements in mobility.

Whilst I demonstrated the example with a barbell squat, this isn’t necessary, you might simply perform a full squat position, as millions of people around the world do on a daily basis, in order to maintain mobility.

As always, the execution will depend on your needs and wants, but the underlying principles remain the same.

An Aside On Exercise Technique

In the examples above, the active stretching is then reinforced by the high demands imposed by the squat.

However, if you are squatting with poor form, then you are undoing the effects of the active stretching.

Good form is easy to spot – it is controlled, stable and smooth. Whilst everyone has different body shapes and sizes, thus the execution of movements will look different, the ability to perform controlled movement should be universal.

It’s also important to understand that if you skip straight to exercise, without addressing the stability issues first, then your body will simply “survive” the exercise by using whatever movement pattern is strongest, optimal or not.

Once you have addressed these issues, using optimal exercise technique reduces the need for continuing mobility work – once you’ve got it, maintaining it is easy – this is why in countries where people continue to squat throughout their life, mobility deficits are less common.

Maintaining Mobility

Maintaining mobility is relatively simple: use what you have got.

If you are coming to this article with restrictions, then it is still simple: regain what you’ve lost, then use it to keep it.

If you go to all the effort and expense of getting treatment and performing the work to regain mobility, only to continue with the lifestyle that got you needing treatment in the first place, then chances are, you’ll end up back where you started, given a long enough time frame.

Because we don’t have many (any) physical demands to survive anymore, we have to deliberately perform tasks that challenge us physically, including our range of motion.

This goes against human nature, which is to conserve as much of our energy as possible – it’s wired into our brains to do this – so, what I recommend is to build mobility maintaining activities into your day.

Examples of mobility maintaining activities are:

  • Walking properly (as discussed earlier) instead of driving short distances
  • Sitting on the floor to watch TV instead of on a couch
  • Squatting instead of bending to pick things up from the ground

Whilst these activities are not going to prepare you for a Cirque de Soleil audition, they will help with your activities of daily living (ADL) and your quality of life.

Beyond this, exercise, particularly full range of motion strength training, in all its forms, is the best way to maintain, and even improve mobility.

Conclusions

Mobility exercises need to be used in context. If you use them when you have an underlying stability issue, either at the stiff segment or elsewhere in the body, they will not be effective.

Used in a sensible, principle based approach, like the one I outlined above, they can play a valuable role in regaining mobility.

Once you have restored lost mobility, it’s much easier to maintain. This can be done by incorporating activities into your day that require you to use extra mobility.

Walking is one of the best general exercises, if you do it well, and can help maintain good health, including mobility.

For more focused efforts, full range of motion strength training is probably the best way to maintain and even improve joint mobility, once you are moving correctly.
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

Nociception and motor function

Cutaneous afferent regulation of motor control

Feed forward control and movement stability

Physiological basis of functional joint stability

Training the Core

Lower motor function, Lederman, E., The Science and Practice of Manual Therapy, pp 99-100