Saturday 14 April 2018

Random thoughts March 2018 - Exercise For Chronic Pain, Importance Of Context In LBP, When Making Sense Of Imaging Findings Doesn't Work, Squats & Deadlifts for Reps vs Singles, and more

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.

Last fall I was listening to a podcast with Peter O'Sullivan and Karen Litzy at the same time I was reading Gift Of Injury by Stuart McGill and Brian Carroll.

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.

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