Sometimes exercise
and even physio aren't the best options for people with pain
One of the hardest things I had to learn in my career is
that exercise, and sometimes even physio as a whole, is not a cure or even the
best option for everyone with pain.
Yes, for many (not all) musculoskeletal pain conditions
exercise is well supported and for many (not all) conditions can be the most
effective treatment. And I still 100% stand by the fact that I believe every
patient (short of medical contradictions or being super irritable (see below))
should do some form of exercise or movement
activity.
Sometimes exercise (I include movement therapies in here)
need to be combined with more psychosocially and behaviourally oriented
therapies to help address patients' fears & negative beliefs about
movement, activity, pain, injury and the body.
That said - sometimes the key drivers' of a patients'
pain are things that may not be addressable (or addressable to a small degree)
by exercise. I've had it occasionally where the main drivers of patients' pain
were issues outside of (what I consider) a physiotherapists scope of practice
such as life/family/relationship stress, poor sleep, financial issues or PTSD.
If these outside drivers are what's contributing to the issue, and a patient's
pain is so highly irritable that I can't do much of anything without flaring
them up, than I have no problem referring them to other professionals who can
help with the above issues.
Props to Lars Avemarie and Greg Lehman for helping my
hard-headed personality see this.
Continuing
Education Tips
Some Saturday morning continuing education thoughts
1) The more I go with continuing education, the more I
find "less is more." I used to try for an hour a day - as that was
what a lot of top people in my field who I looked up to did.
Over time I did find it very hard from a time and energy
perspective to get that in. In addition I also found it very tough to do an
hour a day of continuing education & retain it all.
As such I do anywhere from 1.5-8 hours of continuing
education a week. The lower numbers are when I'm busy with family stuff and/or
running a fat loss or meet peaking phase when my time is shorter and my energy
levels are lower. The higher numbers are more during a hypertrophy/work capacity/or
basic strength phase, doing a weekend course, and/or when I'm not busy with
family stuff - there my time & energy are greater. I found these hours
worked better for retention of material.
2) If you're on the road a lot like I am and/or don't
have the energy or desire to sit down & read a lot of research podcasts are
a wonderful thing. Podcasts that have handouts or note packages are ideal as
you can listen to them when on the road/cooking/cleaning etc and don't have to
worry about taking notes.
3) As my old Western prof Dave Walton said "in
school you'll learn what'll treat 70-80% of your patients." When it comes
to continuing education - a podcast you listen to, course you do, or article
you read may only help 0.5-2% of your clientele ... but when you start putting
those 0.5-2% together it adds up A LOT.
Importance of
context in LBP
Long post ... reflecting on a podcast interview I
listened to with
Craig
Liebenson yesterday.
One thing that gets lost a lot is the context of the
message
As he said there is a definite disconnect between the
pain science and RCT literature on low back pain ... and the real world
clinical work. The tough thing about LBP research is that
1) Most people with LBP do get better naturally
without any treatment and
2) It is such a broad, heterogenous population.
Taking the high numbers - if you figure 90% of people get back pain and 90% of
back pain cases are "non-specific" (ie not nerve roots or red flags)
than that's 81% of the population. Two people with back pain can be vastly
different in terms of the bio-psycho-social factors that can be contributing to
their pain.
I get asked a lot about Gift of Injury and was going to
write a formal review for my website on the book but chose not to as Stu was
concerned it would be a conflict of interest on my part. All in all, I really
loved the book and my only wish was that it had a bit more on psychosocial
factors & LBP. But at the end of the day; in the context of Brian's legit
symptomatic injuries, his psychosocial & general health profile, and his
top level powerlifting goals; I agree 100% with the approach that he and McGill
took and use a similar approach with lifters & gym rats that I work with.
Some would say that O'Sullivan's approach may be a total
180 to McGill but as Pete even said "I don't work with powerlifters."
For people who's back pain is not due to a symptomatic injury, aren't pushing
their back to the limit through high end activities, and are fearful of bending
and movement .... I don't necessarily see a problem with teaching them that
some spinal movement is OK and shouldn't be feared. While I am a fan of
"spine sparing" in people who's LBP is related to an injury ... and
in certain clinical populations (ie osteoporosis, bone cancer) or athletes who
require spinal stiffness (ie powerlifters) ... I'd like to think we can move
our backs as needed without feeling like they're going to blow out on us.
I'm a big fan of both men and even their approaches may
be vastly different a lot can be learned from both if you appreciate the
contexts behind her message ... something that gets lost a lot in internet info
and in social media.
Not fixing what’s not broken in a consultation
Tip I learned from
Stuart McGill
When I consult with someone who trains regularly, be it in
a physical therapy role or as a separate fitness consult for a painfree client,
I try not to change too much of what they're doing. If they're getting results
and are happy with their current program why "fix what's not broken."
What I will do is tweak any technique or any programming
issues that may increase the clients' risk of injuries, impact recovery, or
impair performance.
I find this helps me better connect with clients too as
I'm not "overhauling" their program - rather I'm tweaking it.
When making sense
of false positive imaging findings doesn’t work
Communication
tip I've learned ...
Sometimes when I try to explain the false positive findings on MRIs, X-Rays etc
the message goes in 1 ear & out the other. Sometimes patients are so
dead-set that that's what's causing their pain that those explanations won't
change them.
In those situations I like to take a different route which can involve
1) Emphasizing
all the different factors involved with pain
2) Describing
how tissues can heal, remodel and adapt to load
3) Showing
patients what they can do to help them feel confident about their body
Just a tip I've found useful for anyone who feels the same way I do
Squatting/deadlifting for reps vs singles –
which is safer
Squatting/deadlifting for reps vs singles - which is
safer? It's a debatable topic but the answer isn't as black & white as you
may think.
- Advantages of doing higher reps
i) Greater hypertrophy stimulus: this is self-explanatory
ii) Less joint and CNS load: I've met and talked to some older lifters and
former powerlifters who's bodies (anecdotally) tolerate repetition training a
lot better than heavy training
- Advantages of doing singles
i) Big one - less potential for form degradation: Some lifters, especially fast
twitch ones such as a Brian Carroll, can't maintain form for any more than 1-3
repetitions. Quite often I see people (especially in the deadlift) who have 1-2
good looking reps and the rest look like shit. I can count on my one hand the
number of people who I've seen that can do deadlifts for sets of 8+ with what I
consider "acceptable" form.
ii) Greater neural stimulus & higher neural
specificity
The answer as to "which is better" has to be
made on an individual basis based on the person's injury history, fitness levels,
and goals.
Also I quite often hear of injured weight training
clients being automatically told by their doctor/physio/chiro to "use less
weight and do more reps" without further investigating why an injury
occurred
- Maybe it's a workload issue and they're doing too much too soon?
- Maybe it's a technique issue?
- Maybe there are major psychosocial factors going on that are making the body
more sensitive?
- Maybe there are sleep issues going on? Given the amount of strength athletes
who have sleep apnea & other sleep issues this shouldn't be forgotten about
but often is.
I hope this provides some food for thought on a grey and
debatable area.
Commonalities between rehab &
performance training
When you think about it, and I just had this realization
after reading a colleague's post on Facebook, a lot of the key things I look
for in successful rehab & in performance training overlap by quite a bit.
Simple key concepts such as
1) Carrying a positive mindset about yourself and your ability to achieve your
goal
2) Getting proper, consistent, high quality sleep
3) Managing stressors (both physical and
psychological) well
4) Appropriately progressing your workload to build
fitness & function while minimizing injury risk
... all apply to both rehab & performance
training
Exercise for
chronic pain – is there a place?
I'm seeing a lot of interesting threads lately on the
topic of exercise for chronic pain.
Nothing wrong with exercise for chronic pain as long as
its programmed appropriately. In my own experience a lot of people I work with
who have chronic pain have major mobility limitations and are concerned about
further decline as they age. I'm a big believer of giving people with chronic
pain some exercise with the purpose of maintaining or improving mobility &
fitness.
The problem is when
articles (and therapists - I was guilty of this too) think that exercise by
itself is a cure for the complex, multifactorial problem that is pain and fail
to address the other factors such as psychological factors; maladaptive
beliefs; sociological factors/environments; poor general health issues such as
obesity, poor sleep & smoking; and other issues that may be significant
drivers' of an individual's pain.
Exercise has a place in rehab for persistent pain but it
should be part of a multidimensional and multidisciplinary game plan to address
the complex, multifactorial issue that is pain.
Can we really 100%
assess psychosocial factors on Day 1?
One thing I’ve noticed in my career is that sometimes
patients won’t open up to you about psychosocial factors (or other things in
their life) until a few weeks into therapy. This is human nature to some degree
as we, as Nick Tumminello noted in a recent video, have barriers with new
people on what we do & don’t share.
What this means from a practical rehab standpoint is
1) Do the best you can to be a good person, build rapport
with your patient and listen to their story.
2) You may not be able to obtain 100% of all the
patients’ psychosocial factors & details on Day 1.
