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How Specific Do Treatments For Pain Need To Be?

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

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

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

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

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

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

Can We Be Specific With Assessment?

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

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

It can also include

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

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

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

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

History

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

For certain presentations, the history is quite diagnostic.

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

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

Neurological and Orthopaedic Testing

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

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

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

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

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

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

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

Active Movement

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

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

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

Is it helpful to know? Most of the time.

Is it specific? No.

Passive Movement

See above.

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

Thus, not specific.

Still valuable, but not specific.

Palpation

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

They’re wrong. (3)

Palpation is not reliable, and thus definitely not specific.

Still valuable, but not specific.

Can We Be Specific With Treatment?

The short answer: it depends on the treatment.

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

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

Can any of them be specific?

Education

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

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

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

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

Manual Therapy



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

But it’s true.

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

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

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

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

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

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

Graded Exposure

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

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

There are two arguments about whether graded exposure is specific:

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

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

Here’s an example:

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

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

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

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

Movement Therapy/Exercise Rehab


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

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

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

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

Do We Even NEED To Be Specific?

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

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

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

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

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

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

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

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

Anyway, I digress.

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

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

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

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

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

Let’s Get Critical

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

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

The methods of intervention were pretty generic:

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

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

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

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

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

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

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

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

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

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

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

Conclusions

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

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

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

Nick Efthimiou Osteopath

 

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

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

 

 

Rehabilitation Is More Than Just Exercise

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

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

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

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

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

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

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

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

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

A slide from my Kettlebells for Rehab Workshop

My point is this:

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

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

The principles of stimulus and adaptation still hold.

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

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

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

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

So what happens when rehabilitation is inadequate?

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

Strength Training Is Not Rehabilitation

I have a weak back.

I need to train my core.

My knees aren’t as strong as they were.

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

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

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

But we do.

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

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

Strength training can definitely be part of a rehabilitation program.

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

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

Stretching Is Not Rehabilitation

The second common issue is “tightness”.

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

Therapists then perform an assessment.

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

If only it were that simple!

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

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

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

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

“Cardio” Is Not Rehabilitation

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

However, again, is it rehabilitation?

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

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

What Is Rehabilitation?

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

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

We don’t know it all.

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

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

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

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

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

How Do You Do It?

Educate, Educate, Educate

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

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

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

Sensory Rehabilitation Should Precede Motor Rehabilitation

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

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

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

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

Rehabilitation is similar.

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

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

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

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

Rehabilitation Should Be Contextual

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

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

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

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

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

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

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

Rehabilitation Shouldn’t Be Based Solely On Sets and Reps

Fixed set/rep schemes work great in theory.

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

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

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

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

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

Conclusions

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

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

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

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

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

 

Nick Efthimiou Osteopath

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

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

 

 

Your Body Is Not A Machine

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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.

 

 



 

 

Achilles Tendinopathy? Treat The Whole For Better Results

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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

Where to find us:

Nick Efthimiou (Osteopath) is currently consulting from Coburg Osteopathy & Heath Services.