Wednesday, 29 January 2020

My Experience With A Learning Disability, Anxiety And Depression Part 2: Understanding Mental Health For The Rehab & Fitness Professional



                Two years ago, in honour of Bell Let’s Talk Day, I wrote about the battles I’ve had with a learning disability, anxiety and depression. It was one of my most viewed articles and got shared by many big names and organizations in the rehab & fitness industry. A lot of people messaged me and opened up about their own battles.
                After all that, I misguidedly thought I was in the clear. But two phases in my life, over the past year and a half, had flared up some old issues (although nowhere near to the same extent as they were a few years ago). The first was being too busy and having too much on my plate – which went away when I decided to cut back on a bunch of projects & prioritize my physical health and time with others. It got to a point where I realized that more success didn’t mean more happiness. The second, which I’ll describe in more detail here, in honour of Bell Let’s Talk Day, is learning how to manage the stresses of working with a primarily “persistent-pain” population.

In my current job at least 90% of the people I deal with are people with persistent pain and/or post-concussive symptoms secondary to workplace injuries. The vast majority of these people have been to therapy elsewhere and made no (or very little) symptomatic or functional progress. It’s well established in the literature that work-related injuries, all things being equal, have worse outcomes than non-work related injuries. The reasons and hypotheses why are another story for another time – but needless to say I don’t work with the traditional “private practice” population.

The staff I work with, and the management I work under, are wonderful. That said – working with a complex population can wear on you from time to time. Admittedly I hesitated about posting this piece, but after hearing other stories of practitioners struggling with their own confidence & mental health – it needed to be shared.

At the end of the day – we are able to help the vast majority of my clients function and feel better than they did when therapy started … and I’ve had many people tell me that I’ve been able to do more for them and help them get much further along than previous providers did.

Side note: I don’t want to sound arrogant or get on a high horse – but the rehab education system needs to really educate providers more on proper care for people with persistent pain. This is something that, in my experience, gets neglected in a lot of schools which leads to problems. While I see a lot of people who have been mis-managed by previous community providers, heck I wouldn’t have known what to do with this demographic had I not done a ton of independent reading/coursework + gotten a lot of advice from coworkers.

Back on track – while I think I did “ok” there were times where I felt like I couldn’t get any patients better or accomplish anything if my life depended on it. And to be honest – I came damn near quitting on more than one occasion. The sad thing is I know I’m not the only who felt this way.

Towards that end I realized I needed to get some more help. Here are some of the strategies I’ve used to help with managing people with persistent pain…..

1) Understand that you’re not probably gonna be Superman.

If you’ve read any of my old articles (and if you have, thank you) you’re probably someone who values your work very highly and wants to go beyond the traditional “physio” status. You take a lot of provide in your work and you want to be great. That’s the mindset I had and still have. We want spectacular outcomes that are well above that and our colleagues … and our self pressure, combined with that of social media, makes us feel bad (and sometimes demoralized) when we don’t get there.

In the process of dealing with my own stuff I had to think “why did I think this way.” Part of it was the pressure of being surrounded by amazing people both in my job and in my network, and the bigger part was the desire to “pay it back” and make my successes worth the time others put into me. I know other professionals who feel a great deal of pressure to perform.

The problem with a strictly “outcome based” measure of success is that there are so many factors that go into a patient’s recovery, or lack thereof. Below is a table which barely just scratches the surface…

Injury-related factors
Patient factors
·         Type of injury
·         Severity of tissue trauma
·         Context of injury (i.e. traumatic vs non-traumatic, work vs sport related)
·         Management of injuries in acute, sub-acute and chronic phases
·         Prior fitness levels
·         Medical comorbidities (i.e. diabetes, smoking)
·         Previous injuries
·         Personality & motivation levels
·         Beliefs
·         Preferences
·         Lifestyle (i.e. diet, sleep, relationships)
Workplace factors
Psychosocial factors
·         Whether or not
o   Work is enjoyable
o   Work is considered safe
·         Demands of work
·         Positivity or negativity of interactions with coworkers (both prior to and subsequent to the injury)

·         Prior psychiatric history
·         Psychosocial factors arising from injury (i.e. PTSD)
·         Pain behaviours and beliefs,
·         Poor or excessive social support
·         Cultural beliefs about pain and activity and work
·         Family lifestyle

With all those factors going on – it makes you realize how complicated it is. When I look at many of the patients that I’ve struggled with – the main reasons are (starting with the most common) psychosocial, workplace related, medical comorbidities, and poor pacing strategies. And these all interrelate and don’t exist in a vacuum. For instance poor pacing may be related to psychosocial barriers.

These can also be tough things to change. To steal one of the quotes from Difficult Conversations “it’s not my responsibility to make things better; it’s my responsibility to do my best.” One of the best things I ever did in my career was let go of the desire to be “superman.”

2) Learn to manage the difficult conversations


The biggest thing I struggled with in this job, which was probably in part due to having Asperger’s which already makes communication difficult, is learning to have difficult conversations with clients pertaining to
·         Communicating realistic outcomes/prognoses
·         Setting realistic goals
·         And trying to motivate/navigate cases who
o   Don’t want to do therapy or aren’t buying in
o   Are using therapy as a means of secondary gain
o   Are fearful of going into any kind of pain or causing more damage
o   Don’t want to go to work … or are afraid of going to work
o   Get in “boom or bust” cycles where they overdo it, flare themselves up, rest, feel better, overdo it and repeat…

It’s tough as communication isn’t something we’re taught much in university – so you either have it or you don’t. I’ve found the following books to be helpful
·         Motivational Interviewing In Healthcare
·         Difficult Conversations
·         Crucial Conversations

Also having good psychologists/psychotherapists and occupational therapists is a must for this population.

3) Take time to remember what does go well


 When I was at Know Pain I asked Mike Stewart “how do you deal with this stuff.” He said that one of the strategies he uses is to look at 3 things that go well each day in the clinic. I’ve adopted that practice – and it has certainly helped put things perspective … especially when you have those moments where it seems like no one is getting better.

4) Understand that you will make mistakes and that professionals are also complex

With high performance demands and sometimes challenging clients it can be easy to beat yourself up over past mistakes/failures. Hell – I still struggle with this. With all the new information that comes out each year on exercise, patient communication, pain science, and the like I’ve found myself second-guessing cases all the time and thinking “damn I wish I knew this for the client I saw 2 years ago.”

At the end of the day – I remind myself that I did the best I could with the knowledge, experience, and confidence level that I could to manage the situation that I was in. And if I made a mistake (hell I don’t know if anyone is 100% perfect working in complex healthcare situations) I look back to see what caused it – and come up with a plan to handle the situation differently.

One of the things I learned from Difficult Conversations is that we are complex human beings and that our wishes, desires are all complex as we balance multiple things in our lives and our careers. It also takes acceptance that you will make mistakes. By learning and accepting this, it helped me greatly diminish that “all or nothing” thinking that can be bad for both people with Asperger’s and Type A personalities.

5) Learn to be present

Sometimes it can get easy to caught up in a lot of drama, worrying about the next patient or worrying about the next meeting. I’ve found simple things like mindfulness strategies (deep breathing, focusing on your feet and the environment around you) plus having a to-do-list to offload stuff that needs to be done later – help a lot with keeping me focused on the situation I’m in and not worrying about 20 things.

6) Don’t be afraid to ask for help

In the Fall of 2019 I reached out to my old psychotherapist and got set up with him. It was one of the best decisions I’ve ever made and has helped to give me useful strategies and keep me accountable through this process.

7) Remember to do the simple stuff like getting good sleep, nutrition, exercise, and time with friends/family.

This isn’t, and shouldn’t be, considered a “end-all be all” or fix for managing the stresses of working with a persistent pain population. It’s a tough clinical job … and is not for everyone. Heck – I’m by no means a master at all of these and find myself needing to reset. But – I hope you find these tricks helpful.

Have you found any strategies helpful? If so comment below or message me at bigericbowman@gmail.com. As always – thanks for reading.

Monday, 18 November 2019

Top 3 Things I Would Have Done Differently Over The Past 10 Years




               This September marked 10 years since the start of my entry into the rehab and fitness fields as a student in the Kinesiology program at the University of Waterloo. Over the past decade I’ve been blessed to graduate from 2 universities (and contribute to the curriculums of both universities & teach at one of them), get my PT license & strength coach certification, write for numerous websites & contribute to books, and meet a lot of great people along the way.
                One would look at it and say “you’ve had a successful career.” While I’m proud of my successes at a young age, especially despite some of the challenges I’ve had, I’d be lying if I said there weren’t some things I would have done differently.
When I look back 10 years to when I started my rehab/fitness journey and think of what went well & what didn't ... there are 3 things that stand out to me as "things I would have done differently."

Side note: A common regret identified by many is not spending enough time with others. I do agree with this partially – but I also believe that (to quote Stan Efferding) “you can be good at anything but you can’t be good at everything.” If you’re trying to achieve a high level of success in an endeavour; be it athletics, school, career, family, relationships; that endeavour(s) will take a greater time & effort commitment than other parts of your life. While I wish I could have spent more time with friends, particularly as a University of Waterloo student, the mature part of me realizes that I may have not gotten to where I am today.

With that in mind here are the 3 things I wish I would have done differently over the past 10 years -

1) (The big one) Done a better job of prioritizing my mental health.

This is easily my biggest regret. I’ve wrote about this in previous articles so I’m not going to beat this point up too much – and I want to write a piece on how I try to manage stresses of working with a predominantly persistent pain population.

I 100% believe that having less anxiety & depression would have likely made me more productive, healthier and likely even more successful than I was both in school and in my licensing exams. Seeing counsellors and psychotherapists was the best thing I’ve done in the last 5 years. It helped me feel & perform better … and I wouldn’t be where I am at today without it.

2) Spent more time learning about psychology & communication

This is more geared towards physio school and my first 2-3 years as a practicing physiotherapist.
So much education is focused on the sexy stuff like exercises, modalities and manual therapy techniques - particularly the latter two. But not enough time is spent on how to communicate with people (both in terms of teaching exercises/concepts and behaviour change), how to build rapport/alliance with people, and how to handle difficult conversations (particularly in healthcare).

I joke around that exercise prescription is the straightforward & easy part for most cases (athletes, people with chronic diseases are more complicated). Aspects like
·         Motivating people for health behaviour change
·         Coaching exercises
·         Teaching people about pain and pacing
·         Managing maladaptive beliefs and behaviours
·         Handling difficult conversations (i.e. dealing with difficult clients, goal setting/managing unrealistic expectations)
…are the hard parts and are often the limiting factors of the clients that I struggle with in my current job where 90% of my clientele have persistent pain and/or post concussive syndrome.

I wish I would have spent more time learning about those things - and I impress that on the students that I educate.

Resources that I recommend are…
·        For coaching exercises: anything by Nick Winkelman – a lot of his stuff can be found at ResearchGate or even just through Google
·         For behaviour change
o   The book Motivational Interviewing in Healthcare
o   BJSM has a good free course on motivational interviewing
·         For pain science education
o   Know Pain by Mike Stewart (a phenomenal course for communication in general)
o   Explain Pain
·         For handling difficult conversations
o   Difficult Conversations: How To Discuss What Matters Most
o   Crucial Conversations: Tips For Talking When Stakes Are High
o   Covalent Careers and Ignite Physio also have great resources on their sites


With Mike Stewart at his Know Pain course earlier this year

3) Hired a damn coach

In high school I tried training myself. My workouts consisted of half ROM bench presses, cheat curls, situps, leg extensions & endless running. While they helped me lose a lot of weight and improve my running & calisthenics performance – they weren’t what I needed to maximize my athleticism either for rugby (which I was training for at the time) or powerlifting. Plus whenever my deadlift got up to 225 I hurt my back and had to restart again. Until taking Stu McGill’s class in 2012 I never really learned how to strength train properly.

Using a 3x5 “Starting Strength” like style of training I made good progress for 8 months and then got hurt with patellofemoral pain and took too long to bust out of the “novice/early intermediate” training phase. Bear in mind this was when we didn’t know much about good PFPS rehab and the pain science information was just in the “infancy” stage of mainstream physiotherapy knowledge. It was also when the strength & conditioning scene really shifted from being influenced by Westside Barbell/multi-ply powerlifting to having programs geared towards raw lifting and general preparation for athletics.

I would have saved a lot of headaches and made a lot more progress earlier on had I have hired a good strength & conditioning coach, even to just sporadically audit my programming, - rather than waste time figuring it out myself.

That said, making years of mistakes did give me a lot of perspective and education which I've been able to apply to others.

Programming resources I recommend for therapists/trainers are
- The Ultimate Back: Enhancing Performance DVD and Ultimate Back Fitness & Performance by Stu McGill
- The 5/3/1 book series by Jim Wendler
- Mash Files by Mash Elite Performance
- Advances in Functional Training 2.0 by Mike Boyle
- 10/20/Life by Brian Carroll – hell even the warm up section is worth the price of the book
- Starting Strength by Mark Rippetoe
- The Juggernaut Method by Chad Wesley Smith
- The Vertical Diet and Peak Performance 3.0 by Stan Efferding

No one is perfect – and I’ve learned a lot from my mistakes that I’ve been able to apply to other professionals and students that I’ve educated. I hope this helps because that’s my article and as always – thanks for reading.

Monday, 8 July 2019

Barbells And Bone Health II: Osteoporosis


 Meme courtesy of Owned.com

Before we begin – no this isn’t Star Wars where the installments are recorded out of order. The original Barbells and Bone Health article focusing on weight training for younger adults is here https://rebel-performance.com/barbells-bone-health-review-literature-says-building-strong-bones/
                Osteoporosis is a condition that affects 1 in 4 women and 1 out of every 6-7 men. Osteoporosis is characterized by decreased bone mineral density causing an increased likelihood of fracture. 20% of men and 37% of women will die after fracturing their hip and many who suffer a fracture are likely to refracture. For people who have osteoporosis a fracture can cause a downward spiral of avoiding activity, becoming deconditioned, and then becoming more susceptible to a future fracture.
                Fortunately, a well designed exercise program can help to offset the losses in bone density that occur with age and may even allow people to slightly increase their bone density. The purpose of this article is to show you which exercises can help people with osteoporosis based on the research.

Disclaimer: As I’ve said before on the website the information here is tailored for health & fitness professionals and is not intended so much for the layperson. If you are someone with osteoporosis or significant risk factors I encourage you to work with health professionals (e.g. doctors, physical therapists, kinesiologists) whom have formal education in prescribing exercise for people with osteoporosis.  

Disclaimer 2: A lot of lay people I talk to get osteoporosis and osteoarthritis confused as they sound similar but are two different conditions. Please read here to understand the differences between the two conditions  http://www.osteoporosis.ca/osteoporosis-and-you/osteoporosis-and-osteoarthritis/

WHAT IS THE BEST EXERCISE TO HELP MY BONES?

The best exercises to help with bone density are weight training exercises and impact exercise. When a bone is loaded with more force than it’s used to, assuming it’s not so high as to cause a fracture, this starts a signalling process in the bone that causes bone building cells (osteoblasts) to lay down bone that adapts and remodels over time to get stronger.

The general guidelines for weight training for people with osteoporosis are as follows

-          Frequency: at least 2 times/week
-          Intensity/Time: 1-3 sets of 8-12 repetitions of each exercise
-          Type: 1 exercise per body part

Obviously I can’t give specifics without considering the individual, their health conditions, their general work capacity, and their goals but I hope this gives you something to start with.


 Daily balance exercise of up to 15-20 minutes per day is also recommended but obviously can be rather unfeasible due to time constraints. Balance needs to be challenged in order for it to be effective and balance exercises must be maintained as balance can decrease quickly.

Side note: I’ve found that balance exercises are sometimes the most challenging type of exercise to get people to do as some are very fearful of falling & will sometimes get more anxious during the exercise which decreases their balance & self-efficacy … and so on. With clients I find combining balance with strengthening or balance in daily activities works better than structured balance exercise. I also find, with these people, that you need to progress the exercises very slowly and also start wayyyyyyyy below their threshold – even if it looks like the exercises are fairly easy for them just to gain their trust.

The recommendations for impact exercise are…
-          For people with osteoporosis but without fractures: at least 50 moderate impacts a session (i.e. jogging, low level jumping, and hopping) are recommended and should be interspersed with walking activities. This may need to be modified for people with spinal or lower extremity pathology.
-          For people with vertebral or low trauma fractures brisk walking is recommended assuming that the individual is not at risk of falls

Again – this needs to be adjusted based on the individual. Some can tolerate this (or more) and some caan’t.

WHAT ABOUT POSTURAL EXERCISES?

The bulk of the research on postural corrective exercises (e.g. strengthening weak muscles and stretching tight muscles) doesn’t seem to be very effective in changing people’s posture, contrary to popular belief, but a small body of weaker evidence suggests that these exercises may be effective for very slightly reducing kyphosis in postmenopausal women.

Postural exercises should focus on the scapular muscles and the spinal erectors to improve endurance.

WHAT ABOUT YOGA AND SPINAL FLEXION EXERCISE?

For people at lower risk of fracture yoga doesn’t pose too many issues but for people with moderate to high risk of fracture yoga poses involving spinal flexion and/or twisting (particularly under high load, repetitively, and/or to end range) should be avoided. Biomechanics research has shown us that osteoporotic vertebrae are more likely to fracture under flexion and rotation loads. By the same token I would advise staying away from traditional core exercises such as situps, twists and leg raises as they involve similar motions.

Some lower risk people who have built up the tolerance, flexibility, coordination, and muscle tone may be able to do these in low volumes but many people would increase their likelihood of fracturing.


 Some reading this article may say “oh well they can adapt.” But the research as a whole (aside from outlier studies) shows that osteoporotic bones may slightly increase bone density, may maintain bone density, or may lose bone density at a slower rate than before. The adaptive capability of these bones is very limited.

WHAT ABOUT WALKING?

Walking and other forms of cardiovascular exercise such as cycling and swimming fail to produce significant increases in bone density in most people as those exercises don’t provide enough of a loading stimulus to stimulate bone growth. While these exercises have other physical and psychosocial benefits just walking, cycling or swimming won’t do much for improving bone density.

However, as stated above, brisk walking may (theoretically) provide an impact stimulus for people who have suffered osteoporotic fractures and may not tolerate other high impact activities.

WHAT ABOUT CALCIUM AND VITAMIN D?

Even though I’m not a doctor or a dietician I do get asked a lot about the effects of Calcium and Vitamin D on osteoporosis. A recent review has shown that calcium & vitamin D supplementation doesn’t reduce fracture risk in community dwelling older adults when compared to placebo. It may be helpful with increasing bone density but it doesn’t make as big of a dent on fracture risk as many think.

I can’t safely give specific recommendations for supplementation as I don’t know your blood profile, bone density, allergies, health conditions or what medications you’re taking. At the risk of overstepping my boundaries if you (or your clients) are interested in supplementation I strongly encourage you to talk to a registered dietician regarding it.

Osteoporosis is a condition that will continue to affect the health care system as the baby boomers age but proper exercise can help offset the natural decline in bone density with age and can also greatly improve quality of life.

As always thanks for reading


Monday, 27 May 2019

Product Review - The Ultimate Landmine Program by Meghan Callaway


               Ever since 2016 I’ve been a fan of fellow Canadian Strength Coach Meghan Callaway for her knowledge; attention to detail with exercise coaching; and authentic, no-nonsense approach to strength training nutrition as well as her authentic personality. If you follow her on social media you know she’s capable of some amazing feats of strength & coordination in some crazy exercises – some of which I’ve tried myself.
                When she asked me to review her upcoming product - The Ultimate Landmine Program I couldn’t wait to read it and review it.


 Side note: As with my review of her pullup program I am not an affiliate of Meghan and do not get any money for her products. I choose not to be an affiliate with anyone so that I can review products in an objective, unbiased fashion.

                If you’re reading this you might be wondering “what the heck is a landmine?” A landmine is a cylindrical strength training apparatus on a platform that is bolted to the floor. You can place one end of a barbell in the cylindrical portion of the apparatus – allowing you to press, pull, squat and lift the bar at various angles that are impossible to do with traditional “straight bar” movements. If you don’t have a landmine apparatus you can stick one end of the barbell in the corner of a gym or the corner of a squat rack as Meg describes.

                As you might have guessed – the program is all made up of landmine exercises. However – there is a supplement to the book which covers non-landmine exercises which can be added into the program. 

                The program consists of two progressive phases – each made up of three workouts a week that incorporate landmine variations of compound movements (i.e. squats, deadlifts, presses, rows) along with advanced core stability exercises. In Phase 2 the exercises are made more difficult by adding band resistance and/or adding extra components & movements to the exercises.

                As with the pullup program – Meghan is the most anal (I say that as a complement) person I’ve known (in-person or online) with regards to coaching proper exercise technique & ensuring proper form. In each exercise she also emphasizes total body tension and proper scapular control.

                When I reviewed the pullup program in 2017 my only hesitation was that I felt some of the exercises may not be appropriate for certain injuries (i.e. elbow, shoulder) or certain medical conditions (i.e. congenital laxity). By contrast I feel a lot more comfortable recommending this program to a general population. That said, an exercise that is appropriate for one may not be for another – and Meg would be the first to agree with it.

                The program also incorporates a lot of novel, less well known exercise variations. I must confess, coming from a powerlifting background that is highly specific and incorporates a narrow range of exercises, my training got stale – and I am looking forward to incorporating some of these exercises in my powerlifting training.

                The only critique I have is that there are common coaching cues that are repeated a lot through the book – which is what Meghan intended in order to reinforce proper form – but it does lengthen the book & the read.

                All in all I enjoyed Meg’s Landmine program and wish her all the best with her success.

Monday, 15 April 2019

When Do We Need Specific Exercises In Rehab?


                If you’ve followed the physical therapy literature over the last 5-10 years you’ll notice that more and more, the literature is challenging the longheld belief that you need to do X,Y and Z exercises to get out of pain. The ideas of “you need to activate your TVA” or “you need to get your scapula set first” are slowly (sometimes very slowly) becoming a thing of the past.
                With research like this it begs the question – do we need specific exercises in rehab? That is the topic of today’s article.

When are specific exercises needed?

Specific exercises are for specific adaptations in specific tissues and can also be influenced by your clients’ tolerances. Breaking this down by section ….

1) Specific adaptations

If your goal is to build the muscle & tendon strength necessary to withstand sprinting – doing 10 minutes of jump rope probably isn’t going to help. If your goal is to develop neuromuscular control of your knee to prevent a repeat ACL injury – doing bicep curls isn’t the best choice.

Some clients, particularly elderly and/or those with persistent pain, can be so weak and deconditioned that simple tasks like getting out of a chair can be very difficult. As much as I am all for people doing activities that they want – when you don’t have the baseline strength or mobility to do IADLS … that’s a big problem that needs to be addressed.

If your goal is to develop specific adaptations – be it strength, hypertrophy, power, endurance, mobility, and/or neuromuscular control – the exercise needs to be tailored towards that. Plain & simple.

Whether or not those adaptations are relevant to getting out of pain is up for debate as research has shown that improvements in strength, muscle timing, kinematics etc don’t always correlate with changes in clinical symptoms. I look at in terms of what the client needs from an activity demands perspective versus where they’re at.

2) Specific tissues

Over the course of the decade we’ve worked to move away from structural diagnoses – which is a much needed move for the better.

That said – some injuries, such as tendinopathies and muscle strains, do require more specific exercise to allow the area to heal, adapt & recover. Arm curls don’t do much for a hamstring strain nor does your biceps tendinopathy benefit much from calf stretches. Can general exercises help? Most definitely – but to rehabilitate the specific tissue you need specific loading.

It’s important to note that even within the category of “specific” exercises you have a large range of options to work with that can range from strengthening, mobility and neuromuscular exercise all the way to practicing the desired activity with some modifications as needed (i.e. “sprinting” with reduced speed). Again these are all based on the individual.

3) Based on your client’s specific tolerances

Sometimes, in more nociceptive presentations, people may not tolerate specific movements or postures and may tolerate others very well. In those cases, emphasizing exercises in well tolerated directions & postures is a wise decision – at least during the early stages of rehab. This is where approaches like the McGill method make a lot of sense as they take away what hurts and emphasize painfree movement & exercise.

How long painful movements are avoided, if at all, is a controversial topic that depends on numerous individual factors.

When are specific exercises not needed?

For more general pain relief where there are no major structural tissue concerns, and where there are no major physical deficits that need to be addressed, you can incorporate more general exercises and some more valued, leisurely activities such as walking, gardening, skiing, handyman work, whatever you like.

Best of both worlds

And to be honest – an ideal rehab program for most (not all) people incorporates valued activities that people enjoy & want/need to get back to as well as specific exercises to address specific physical deficits.

So there you have it – a very simple explanation of where specific and general exercises & activities fit within the scope of rehab. As always – thanks for reading.

Sunday, 3 March 2019

Pain Science Education: What It Is And What It Isn't



            Over the course of this weekend two main themes filled my social media feed. The first were videos of the amazing feats of strength from the various events at the Arnold Sports Festival (side note: props to two-time Arnold Strongman Classic champ Hafthor Bjornsson as well as to powerlifting world record breakers Blaine Sumner and Stefi Cohen for their successes). The other was this study that provided a systematic review & meta-analysis on pain science education (PNE). The article showed that…
·         PNE did not significantly reduce pain or disability
·         But PNE did reduce catastrophizing and kinesiophobia

It created a lot of controversy and debate amongst therapists from different backgrounds & ideologies as well as a need for clarification as to what PNE is and isn’t – the topic of this article.

What PNE isn’t

PNE is not

1) A cure or magic bullet

As we’ve discussed above pain science education doesn’t create significant improvements in pain. This review showed a reduction in pain of 3.2/100 – less than half a point on a 0-10 pain scale.

2) A standalone intervention

Some studies have shown better effectiveness of PNE mixed with exercise versus one or the other alone. Granted this is still being studied and is still up for debate.

3) An intervention that will produce the same results in everyone

Some qualitative studies have shown that PNE can create great reductions in fear and improvements with activity in some people but can be useless or even counterproductive with others.

Side note: studies like these, plus my own experiences, are why I disagree with (well meaning but misguided) practioners who think that everyone needs PNE. As with everything else the intervention needs to be tailored to the individual.

4) The only part of biopsychosocial rehabilitation

As Jarod Hall and Sandy Hilton say “pain science should be the air you breathe” – not something you just do to people. There are many components of biopsychosocial rehab (and proper rehab in general) including
·         Simply being a good person who’s attentive, caring and is a good listener
·         Acknowledging that there are numerous contributors to the pain experience, working to address these different areas and referring out for help when needed
·         Educating people on how to get back to a lifestyle that is meaningful for them through pacing
·         Also educating people on healthy lifestyle habits
·         Experiential learning & graded exposure to activities: to me this is a great way for people to experience that hurt doesn’t equal harm and that they can likely do more than what they’re capable of
·         Getting people more physically active
·         Using positive language & self-management skills to empower the patient and build their self-efficacy

What PNE is

PNE is

1) A means to explaining the science of pain and the contributing factors behind a person’s pain

2) A means to (hopefully) decrease some of the anxiety, fear and negative beliefs surrounding pain and a means to get people more physically active & working towards the lives they want to live.

I hope this article sheds some light for you (and others) on what PNE truly is & isn’t and where it fits in the grand scheme of things. As always – thanks for reading.





Tuesday, 12 February 2019

Is Strength Training The Newest Fad In Sports Injury Prevention?


Image courtesy Focus Fitness

Earlier this year I watched a video on Canadian trainer Omar Isuf’s YouTube channel where he interviewed DPT and 20x world record breaking (as of the time I’m writing this) powerlifter Stefi Cohen. As a physiotherapist who competes in powerlifting Stefi is definitely someone whom I greatly idolize for her insane athletic accomplishments as well as the success she’s had getting her DPT and starting a fantastic performance gym & company with her fiancĂ©e Hayden.
            In the video Omar asked Stefi about her thoughts on strength training as a means of preventing sports injuries and Stefi discussed that it may be or may not be a fad. She also brought up the fact that we seem to shift from fad to fad with common trends (over the last 2 decades) in sports injury reduction including (but not limited to) bracing, transverse abdominnis exercises, movement screening & functional movement, workload ratio and other topics. So it raises the question – is strength training a fad in sports injury prevention?

First the term “injury prevention” is a misnomer and should be changed to sports injury reduction as we can never truly prevent injuries. There are some injuries; particularly contact injuries; that you can’t prevent no matter what – short of completely removing yourself or your athletes from the sport.

Now that that’s out of the way let’s look at the evidence ….

A 2018 systematic review and meta-analysis in the British Journal of Sports Medicine (free access link here) showed that a 10% increase in strength training volume reduced sports injury risk by 4%. It’s a heterogenous paper with many different sports & many different protocols … but it gives us something to work with.

But with this evidence comes a few caveats, one more opinion based and one more evidence based

#1: Past a certain level of strength; which is sport & athlete specific; increasing strength comes with a point of diminishing returns. The stronger you get the harder it is to get stronger; from an eating, sleeping, rehab, and recovery perspective; plus there is (in my anecdotal opinion) a higher risk of injury as you push the envelope of maximal strength. For most athletes (excluding powerlifters, Olympic lifters & strongmen); past a certain level of strength; more time could be spent improving other components of athletic performance such as speed training, conditioning, and most importantly skill work over trying to get your athletes stronger.

#2: Sports injuries are multifactorial and can be influenced by training workload (and fluctuations in workload), sleep, psychosocial factors, nutrition, genetics, previous injury, movement skill, anatomy & anthropometrics, and other factors. As such we have to take a multi-faceted approach to sports injury reduction rather than simply relying on a single cure-all. I plan to elaborate on these topics on more detail in future articles for both my site and for Mash Elite Performance.

I hope this brief article provides some food for thought on a complex and popular topic. As always – thanks for reading.

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