Random thoughts - misapplying low-load studies to high-load activities

                A concern that I’ve seen lately over the last few months is people taking study findings involving lifting low-level loads (ie 30-70 lbs) and trying to apply them to high level strength athletics (powerlifting, strongman etc).

From an external validity standpoint it’s tough to compare a 30 lb crate lift to a 6+ wheel per side deadlift. If you follow Stuart McGill’s research many of the weights that top strength athletes lift are at or near the spine’s load tolerance.

I’ll confess – since being a student in Stu McGill’s class 5 years ago I’m not the spine flexion Nazi I used to be. Assuming the individual has no back conditions that would contradict spine flexion (i.e. symptomatic disc herniation, moderate-severe osteoporosis) I have no problem with low load/unloaded spine flexion … and yes I think we can tolerate some loaded flexion as long as they’re all programmed & progressed appropriately.

That said – I am still leary of excessive spine flexion (there’s always some no matter how hard we try to prevent it) when lifting heavy shit as the loads are much higher and as such the potential for injury is higher. Again read Stu McGill’s research if you don’t believe me. Chris Duffin made this point (paraphrased) on a podcast with Craig Liebenson recently ….

“ People post pictures on social media of an athlete lifting with a rounded back to say “it’s ok to lift that way” or “it’s fine to flex your spine” yet the (well meaning) people posting these pics know how much back pain those athletes suffer with and sometimes get during/immediately after those lifts.”

                Now anyone who understands pain science & the biopsychosocial model should know that pain (which doesn’t always indicate injury) can be influenced by a variety of factors such as

-          Overall training workload & training load errors

-          Psychosocial factors: eg stress, anxiety, poor social support

-          Movement & exercise technique

-          Tissue tolerance & strength

-          General health factors such as poor sleep, smoking, and being overweight

… so I would be out of line to say that all strength athletes have pain due to their technique but I find it tough to say “how you lift doesn’t matter” when it comes to loads close to the body’s tolerance.

This doesn’t mean that we have to say “if you lift with a rounded back once your back will explode.” Some lifters, such as the great Konstantin Konstaninovs, pull with a rounded back all the time.

                But we have to acknowledge the fact that during high load situations the potential for injury is much greater as the loads are much closer to the body’s tolerance … and the way we move can move the loads closer to (or over) the body’s tolerance or further down and away from it. We are starting to get some research on how disc tissue can adapt to load & exercise (free access here https://www.researchgate.net/publication/316262547_Running_exercise_strengthens_the_intervertebral_disc)  and I hope that with further research we can figure out how to better build spinal tolerance to flexion exercise and other activities. 

Simplifying the manual therapy process

Before getting this week’s article started I have a couple announcements

1) I’m currently halfway through Charlie Weingroff’s DVD T=R3 and am loving it so far. I hope to do a review of it for the blog.

2) As next Monday is a long weekend I will not be posting a new article that week. Tune in in 2 weeks for my next piece -3 applications of Interval Training for Health.

Now getting to the point of my story…

            I understand that I’ll get a ton of flack for saying this but it needs to be said anyways – manual therapy is not this complex, high skilled task that many therapists like to think it is. It’s not so simple that just anyone can do it, it requires you to apply force safely & to know contraindications, but it isn’t this fancy skill that requires tens of thousands of dollars in training to get results with.

            It’s important for me to write about this as I see many new therapists that are underconfident and feel like their manual therapy skills aren’t up to par with their colleagues. Plus many therapists, myself included, feel (or have felt) very frustrated when they can’t “find” these pseudobiomechanical faults that other, more experienced therapists can.

            In this article I will go over why manual therapy is not the high skill activity that it’s portrayed to be and how to simplify it …..

Disclaimer: this isn’t going to be a debate about whether or not to use manual therapy. I see enough bickering about it on Facebook and quite frankly I have better things to do with my time than get into an endless debate on the topic.

Disclaimer 2: to keep this article short & not bogged down in references this is not a systematic review by any stretch.

With that out of the way – here is why and how manual therapy should be simplified.

Part 1: Assessment

In spinal/SI joint pain cases many therapists will assess each spinal segment to determine which ones are hyper or hypomobile. However – these assessments are shown to be unreliable^1–4..

“Well you just haven’t developed the magic hands yet”

That’s the most common argument I see when this evidence gets presented. However, these assessments are unreliable even amongst experienced therapists – debunking the skill argument.

Realistically – vertebral segments move a few degrees each and the SI joint only moves a maximum of 4-8 mm.

In SI joint pain therapists sometimes try to palpate pelvic position to detect “upslips,” “downslips,” and “rotated innominates.” These positional assessments are also unreliable^4,5.

Part 2: Treatment

Back in PT school I always remember my instructors telling me “you just want to isolate that one segment” and “you only want to move that segment.” However – research has shown that spinal manual therapy directed to one segment actually affects multiple segments and in one study increased ROM at a different segment than the one being mobilized⁶!!!!!

A small body of research has also questioned the concave-convex rule of joint arthrokinematics. For instance, in people with frozen shoulder, a posterior glide was more effective in increasing shoulder external rotation than an anterior glide⁷.

Lastly, some studies have compared different manual therapy techniques for the same condition and shown that they provide equal effects on pain & disability^8,9.

Now before you’re all ready to lynch me…

I’m not saying that manual therapy needs to be dumped – it just needs to be reconceptualised within a scientific framework. Manual therapy techniques provide non-specific effects on muscle tension, pain, and other variables through neurological mechanisms¹⁰.

Side note – please read this free open access paper on the mechanisms of manual therapy if you haven’t https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2775050/.

The best way of approaching manual therapy is to keep your approach simple. Some research in spinal pain suggests that the best techniques are the ones you’re most comfortable & confident performing¹¹. So pick a few techniques for each area that you’re comfortable with, make sure there are no contraindications or precautions, use a reasonable amount of force and don’t aggressively crank on the patient (when in doubt gentler is better) and keep it simple.

Anyways if you’ve made it this far and haven’t clicked out of the article I just want to say thank you and congratulations on reading and reconceptualising your view of manual therapy in a way that’s in line with the scientific literature.

Take home points

-          Many manual therapy assessment tests (e.g. spinal segmental hyper/hypomobility, SI jt positioning) lack reliability even amongst experienced therapists

-          Spinal manual therapy affects multiple joints not just the one you are targeting

-          Some studies have shown different manual therapy techniques produce the same results for the same condition

-          Manual therapy has non-specific neurological effects

-          Some research suggests that the best techniques are the ones you are comfortable performing

References

1.           Herzog W, Read LJ, Conway PJ, Shaw LD, McEwen MC. Reliability of motion palpation procedures to detect sacroiliac joint fixations. J Manipulative Physiol Ther. 1989;12(2):86-92. http://www.ncbi.nlm.nih.gov/pubmed/2715742. Accessed July 21, 2017.

2.           Walker BF, Koppenhaver SL, Stomski NJ, Hebert JJ. Interrater Reliability of Motion Palpation in the Thoracic Spine. Evid Based Complement Alternat Med. 2015;2015:815407. doi:10.1155/2015/815407.

3.           Kilby J, Heneghan NR, Maybury M. Manual palpation of lumbo-pelvic landmarks: A validity study. Man Ther. 2012;17(3):259-262. doi:10.1016/j.math.2011.08.008.

4.           Huijbregts PA. Spinal Motion Palpation: A Review of Reliability Studies. J Man Manip Ther. 2002;10(1):24-39. doi:10.1179/106698102792209585.

5.           Cooperstein R, Hickey M. The reliability of palpating the posterior superior iliac spine: a systematic review. J Can Chiropr Assoc. 2016;60(1):36-46. http://www.ncbi.nlm.nih.gov/pubmed/27069265. Accessed July 21, 2017.

6.           Branney J, Breen AC. Does inter-vertebral range of motion increase after spinal manipulation? A prospective cohort study. Chiropr Man Therap. 2014;22(1):24. doi:10.1186/s12998-014-0024-9.

7.           Neumann DA. The Convex-Concave Rules of Arthrokinematics: Flawed or Perhaps Just Misinterpreted? J Orthop Sport Phys Ther. 2012;42(2):53-55. doi:10.2519/jospt.2012.0103.

8.           Langevin P, Desmeules F, Lamothe M, Robitaille S, Roy J-S. Comparison of 2 Manual Therapy and Exercise Protocols for Cervical Radiculopathy: A Randomized Clinical Trial Evaluating Short-Term Effects. J Orthop Sport Phys Ther. 2015;45(1):4-17. doi:10.2519/jospt.2015.5211.

9.           Aquino RL, Caires PM, Furtado FC, Loureiro A V., Ferreira PH, Ferreira ML. Applying Joint Mobilization at Different Cervical Vertebral Levels does not Influence Immediate Pain Reduction in Patients with Chronic Neck Pain: A Randomized Clinical Trial. J Man Manip Ther. 2009;17(2):95-100. doi:10.1179/106698109790824686.

10.         Bialosky JE, Bishop MD, Price DD, Robinson ME, George SZ. The mechanisms of manual therapy in the treatment of musculoskeletal pain: a comprehensive model. Man Ther. 2009;14(5):531-538. doi:10.1016/j.math.2008.09.001.

11.         Chiradejnant A, Maher CG, Latimer J, Stepkovitch N. Efficacy of “therapist-selected” versus “randomly selected” mobilisation techniques for the treatment of low back pain: A randomised controlled trial. Aust J Physiother. 2003;49(4):233-241. doi:10.1016/S0004-9514(14)60139-2.

Impinging on the impingement theory

Updated September 23, 2017

                In the 1970s and 80s Neer coined the term “subacromial impingement syndrome” (SIS) where he claimed that irritation of the rotator cuff, biceps tendon, and/or subacromial bursa contributed to rotator cuff tears & shoulder pain. This theory has been widely accepted & taught in the education system¹.

                However a series of research studies and reviews over the last 5-6 years has greatly questioned the concept of subacromial impingement syndrome. In this week’s article I question the idea of SIS and provide some simpler ideas for management.

Is the acromion really to blame?

                Some of the most commonly cited flaws to the SIS theory revolve around the acromion.

                In theory a larger acromion would be more likely to cause shoulder pain but the research has shown no correlation between acromion size and shoulder pain. Also many rotator cuff tears shown in SIS appear on the underside of the tendon, not on the surface of the tendon. Research suggests that atraumatic tears occur due to intrinsic tendon changes rather than extrinsic irritation. Lastly research has shown that subacromial decompression surgery (also known as acromioplasty) is no better than a placebo surgery².

                A 2017 paper showed no correlation between shoulder pain related function and acromio-humeral distance³.

What about the scapula?

                Many therapists cite that poor scapular position and scapular dyskinesia contribute to shoulder pain. However – research comparing scapular position amongst people with and without SIS has shown no difference between the two groups⁴. Its also more likely that scapular dyskinesia and the often cited upper trap/lower trap imbalances are a consequence of pain rather than a cause of pain⁵.

                No correlation has been found between changes in scapular movement patterns and changes in shoulder pain⁶. In addition exercises designed to address specific deficits in SIS have been shown to be no better than general shoulder strengthening exercises^7,8.

Side note: Jeremy Lewis has came out with the Shoulder Symptom Modification Procedure which looks at modifying scapular, thoracic, cervical and humeral head positions to see if doing so reduces pain during shoulder movements. It is entirely possible that for certain people certain postures may be symptomatic, like in certain people with LBP, but for the time being this is what we know based on the research^2,7.

               

Alternative theories and titles for SIS

                One biomechanical theory for pain with abduction is that certain fibres of the rotator cuff are under increased mechanical strain during abduction. In addition it is likely that physiological and neurological changes through the tendon and the nervous system contribute to the sensitivity experienced during flexion and abduction in people with SIS⁷.

                Some researchers and therapists have proposed alternative titles for the clinical presentation such as Jeremy Lewis’s terms “rotator cuff related shoulder pain” and “subacromial pain syndrome⁶.” My colleague Derek Griffin prefers to just use the term “shoulder pain.”

What do we do now?

                After reading this article it sounds like I’ve ripped on everything that therapists do. While it may seem that way the point is just to reconceptualise how we view shoulder pain and shoulder rehabilitation. Effective therapy strategies for SIS include

1) Well tolerated strengthening exercises for the shoulder, rotator cuff, and scapula … essentially what most physios do⁹

Image courtesy https://www.focusfitness.net/

2) Managing psychosocial factors and maladaptive beliefs about the shoulder, pain, and activity

3) Some research supports manual therapy although this is more conflicting⁹

                While this article may sound like a rant – the purpose isn’t to take away from how physiotherapists view & manage SIS but rather to reframe it in a way that’s in line with current literature.

References

1.          Neer CS. Impingement lesions. Clin Orthop Relat Res. 1983;(173):70-77. http://www.ncbi.nlm.nih.gov/pubmed/6825348. Accessed July 23, 2017.

2.          Lewis JS. Subacromial impingement syndrome: a musculoskeletal condition or a clinical illusion? Phys Ther Rev. 2011;16(5):388-398. doi:10.1179/1743288X11Y.0000000027.

3.          Navarro-Ledesma S, Struyf F, Labajos-Manzanares MT, Fernandez-Sanchez M, Morales-Asencio JM, Luque-Suarez A. Does the acromiohumeral distance matter in chronic rotator cuff related shoulder pain? Musculoskelet Sci Pract. 2017;29:38-42. doi:10.1016/j.msksp.2017.02.011.

4.          McQuade KJ, Borstad J, de Oliveira AS. Critical and Theoretical Perspective on Scapular Stabilization: What Does It Really Mean, and Are We on the Right Track? Phys Ther. 2016;96(8):1162-1169. doi:10.2522/ptj.20140230.

5.          Camargo PR, Alburquerque-Sendín F, Avila MA, Haik MN, Vieira A, Salvini TF. Effects of Stretching and Strengthening Exercises, With and Without Manual Therapy, on Scapular Kinematics, Function, and Pain in Individuals With Shoulder Impingement: A Randomized Controlled Trial. J Orthop Sport Phys Ther. 2015;45(12):984-997. doi:10.2519/jospt.2015.5939.

6.          Shire AR, Stæhr TAB, Overby JB, Bastholm Dahl M, Sandell Jacobsen J, Høyrup Christiansen D. Specific or general exercise strategy for subacromial impingement syndrome–does it matter? A systematic literature review and meta analysis. BMC Musculoskelet Disord. 2017;18(1):158. doi:10.1186/s12891-017-1518-0.

7.          Lewis J, McCreesh K, Roy J-S, Ginn K. Rotator Cuff Tendinopathy: Navigating the Diagnosis-Management Conundrum. J Orthop Sports Phys Ther. 2015;45(11):923-937. doi:10.2519/jospt.2015.5941.

8.          Lewis J. Rotator cuff related shoulder pain: Assessment, management and uncertainties. Man Ther. 2016;23:57-68. doi:10.1016/j.math.2016.03.009.

9.          Gebremariam L, Hay EM, van der Sande R, Rinkel WD, Koes BW, Huisstede BMA. Subacromial impingement syndrome—effectiveness of physiotherapy and manual therapy. Br J Sports Med. 2014;48(16):1202-1208. doi:10.1136/bjsports-2012-091802.