Random Thoughts April 2018 - Is Any Exercise Good Or Bad, How I Go About Challenging Patient Beliefs … Before I Actually Challenge Them, The “Bottom Up” Prioritization Pyramid – How I Wear Multiple Hats, And Are Trainers Bad At Coaching Or Just Uneducated

Are burpees (or any exercise) good or bad?

A lot of good discussion lately on burpees and whether exercises are good or bad.

My simple thoughts are it depends on ...

1) The medical/injury history of the individual

Someone who has flexion-aggravated back pain would be best served to temporarily stay away from burpees. Someone who has knee pain that worsens with repeated knee extensions may be best to take a break from the leg extension machine.

2) The baseline fitness level

Does the individual have the ability to perform the exercise "correctly?" Yes there is a wide range of correct form with many exercises but I'm not a fan of having someone squat with their knees moving in & out like a baby giraffe's legs and their back looking like its gonna collapse at any second.

By contrast to 1 & 2 people who are healthy & capable of doing these exercises properly are probably OK as long as they
- progress their volume appropriately
- provide appropriate rest & deloads
- don't max out all the f*cking time
- manage sleep, nutrition, hydration and psychosocial factors

3) The goals of the individual

The McGill and Weingroff biomechanically influenced guy in me uses the goals to determine the acceptable risk/benefit ratio of an exercise.

If you satisfy 1 & 2 - and enjoy doing burpees and/or competing in CrossFit or bootcamp or whatever that's fine - do em. If not there may be other options to give you a good workout with low impact.

If you're like me who enjoys powerlifting than heavy (by my standards :) ) squats & deads are a part of the sport. If you're training for general health/fitness there may be better options.

So the answer isn't as black & white as people think and requires some good reasoning behind it to make smart training decisions that will maximize results & minimize injury risk.

How I go about challenging patient beliefs … before I actually challenge them

On challenging patient beliefs...

It's tricky. I don't necessarily start by trying to confront patients or change their beliefs right from the get go as I found it gets more push back than anything else.

What I do do is

1) Just simply be a good person, listen to and validate the patients' story. Nothing replaces this.

2) Try to educate patients about all the different factors that can contribute to pain. I find when some patients hear about the false +ves on their imaging they feel invalidated and feel like we're brushing them off. This is a better strategy to listen to and acknowledge the patients concern but also still honour the complexity of pain.

3) I try to empower them by
- showing them what they can do and
- giving them a plan to manage pain and get back to what they want to do

4) Educate patients that hurt doesn't always mean harm and in certain situations (ie chronic pain, post surgery) where painful exercise/movement may be unavoidable - educate them on what level of pain & pain response is acceptable and what is going on.

5) Don't scare the shit out of them with nocebo-ic language

To me that steers the ship and gets it sailing in the right direction. Then later on, after the trust is built, we can start to work on changing beliefs.

Some people may disagree with some of my points, that's fair enough, but that's how I go about belief changes & empowering patients.

The “Bottom Up” Prioritization Pyramid – How I Wear Multiple Hats

Over the last week in the clinic I’ve been asked a lot how I manage being a physiotherapist, educating through my UW curriculum work & website, training for powerlifting, and also being there for my family without burning out.

It took me a lot of trial & error but I basically figured out what I call the “Bottom Up” Prioritization Pyramid which was influenced a lot by Stan Efferding, Will Kuenzel and Nicholas Licameli.

Let’s start with the foundation. The foundation enables you to fulfill your priorities, maintain morale & not burn out. For me that includes

-          7+ hours of sleep a night

-          Adequate high quality food in the right amounts

-          Adequate down time and contact with friends

This doesn’t mean be lazy as f*ck – it means build in proper recovery (both physically & psychologically) to enable you to do the hard work. You can only work or train as hard as what you can recover from. The size of the foundation enables you to determine how high you can go and how much time you can put into your other priorities. I don’t know of too many people (yes there are some) that function highly on 4-5 hours of sleep a night.

I design the rest of the pyramid from a bottom-up perspective. The #1 priority, whatever that is to you, is at the bottom as it has the most size (and time given to it) and is most influenced by the foundation. Priority #2 goes next and so on & so forth.

To give a visual example of what this looked like during my storm stayed week in Fergus.

Family time and contact was fairly minimal as I was storm-stayed and couldn’t see anyone. The lifting (which was modified due to the CPU Coaching Certification) was condensed & done earlier in the week. Hence my priority (on top of a 40 hour week of treating patients) was working on professional content for both my website and in my UW curriculum work.

The priorities change for me based on what I have on the go in my life and what time of the year it is. If I’m getting ready for a meet or losing bodyfat lifting is a bigger priority. If it’s a long weekend with family that becomes #1 priority. This enables me to manage multiple big priorities in life while keeping me from burning out.

If you’re someone who wears multiple hats I hope this helps you.

Are personal trainers bad at coaching exercises or just uneducated?

Quick rant for you trainers & strength coaches out there.

I'm tired of seeing posts like "if your client can't do X exercise or doesn't get X exercise than you are bad trainer/coach/person" all over the interwebz.

Maybe the problem is that the trainer wasn't properly educated in the first place.

Back in 2012 when I first started in cardiac rehab, aside from learning from Stu McGill, I was never trained on how to properly coach or teach exercises. And in physio school we didn't cover much exercise other than TVA/glutes/rotator cuff/scapular muscles. Even some of the big trainer certifications fall short in that regard.

When I help out at the UW KINNection event I see the way I was back in 2012 - underconfident, way too wordy with coaching, stumbling & fumbling, and unsure of what to do if an exercise was too hard for a client or if the client didn't get it.

Over the last 5-6 years my ability to coach/regress/progress/modify exercises has improved a lot thanks to learning from, networking, and working with top level trainers, strength coaches, and exercise-based therapists.

So keep in mind not every health or fitness has discovered these resources or has access to them when making comments online. Instead of berating someone's ability - take the time to show them some of what you're learned and pay it forward. It's likely that you didn't know this stuff before trainers, strength coaches or therapists showed you these tricks and tidbits either in person or through video.

Rant over.

The Most Underrated Tool In Your Rehab & Fitness Arsenal – The Short, Frequent, Daily Walk

Updated May 21, 2018

Photo courtesy Focus Fitness

                Before we get started I just want to say thank you and props to Jacob Lucs, Jordan Foley and Mark Giffin for an amazing weekend at the Canadian Powerlifting Union Coaching Workshop & Seminar at The Vault Barbell Club in Guelph two weekends ago.

In May of last year I got to meet former pro-bodybuilder & world record powerlifter Stan “the Rhino” Efferding. In addition to numerous other knowledge bombs in lifting & business – one of the big concepts he drew my attention to, through his presentation & videos, was the concept of the “10 minute walk.” In this article I discuss the concept of the 10 minute walk & the science behind. I also take the concept a step further to discuss how short, frequent, daily walks can be applied for various diseased, pained and healthy populations.

The 10 minute walk … and how it originated

The concept of the 10 minute walk started with research that was done in Australia on people with Type 2 Diabetes. Research showed that a 10 minute walk after each meal (3 times/day) was more effective than a single 30 minute daily walk for improving insulin sensitivity & glucose levels. An earlier study also showed that a 10 minute walk  times a day improved blood pressure more than single daily 30 minute walk. And an informal experiment that came out this year showed that doing 3-10 minute walks a day at a brisk pace resulted in more moderate to vigorous physical activity than doing the traditional 10,000 steps a day.

At this event, and in Stan’s later videos, he’s discussed how he’s used these 10 minute walks with his clients (including Hafthor Bjornsson and Brian Shaw) in combination with either a calorie deficit or surplus for weight loss or muscle gain goals, respectively. Stan recommends doing these walks 2-4 times a day after a meal.

 The benefits of walking have been well studied and include

-          Improved cardiovascular & metabolic health

-          Improved sleep

-          Improved mental health

Short, frequent walks also have many benefits compared to single walks such as

-          Ease of fitting into a busy schedule

-          Less monotony

-          More frequent activity & shorter sitting durations

Side note: sitting is not the new smoking like many would have you believe but, for most people, less sitting & more movement is overall better for health.

So as you can see 10 minute walks are definitely a great idea if you can do them but….

I work with clinical populations. They’ll never be able to tolerate three 10 minute walks daily!!

Some populations – be it due to deconditioning or pain may not be able to do these sessions. This doesn’t mean however that they can’t reap the benefits of short, frequent daily walks – just that the sessions have to be modified.

Some clinical populations that may not be ideal for these are

-          People who are contradicted for exercise due to cardiovascular or metabolic reasons. I recommend you look up the ACSM & CSEP guidelines for a full list of these contraindications.

-          People with weight bearing restrictions or limitations post fracture, dislocation, or surgery

-          People who have balance issues and are at high falls risk

Two populations that I use short, frequently, daily walks with a lot are

1) People with respiratory diseases

2) People with low back pain and/or lower limb pain

3) I also use these with people in cardiac rehab … but a discussion of cardiac rehab is outside of the scope of a quick 500-1000 word blog.

Getting back to those populations I mentioned earlier

1) People with respiratory diseases – I’m a big fan of interval training for people with COPD, asthma, and other conditions as its less monotonous and allows for more recovery & less shortness of breath. In these populations I’ll have clients walk for anywhere from between 15-60s at a 4-8/10 RPE (sometimes less than that), rest for 45-120s, and repeat for 8-30 minute long sessions. As with people with musculoskeletal pain, I like to increase the number of intervals before decreasing rest periods.

2) People with low back or lower limb musculoskeletal pain (i.e. OA)

Some research has shown interestingly enough that walking can be just as effective as core stability training for people with back pain. The trick is to have it dosed in a way that doesn’t increase long term symptoms.

For walking duration – I like to have these people stop just before their pain would increase. The frequency of walks is inversely proportional to the duration of walking that is tolerated. If someone has pain after 20 steps of walking I will have them walk for 15 step intervals as frequently as every couple hours through the day. If someone’s pain increases after 30 minutes of walking I may only have them walk twice daily for 20 minutes at a time. This technique was taught to me by professor Stuart McGill in his books Back Mechanic & Gift of Injury with Brian Carroll.

Sometimes; for people who are morbidly obese and are limited due to mobility limitations, balance issues, or musculoskeletal pain; I prefer replacing the walks with stationary bike rides – a tactic Stan has used with some of his larger clients. 

I hope this article shows why short, frequent walks are an underrated tool in the fitness arsenal as well as how to apply them to clinical populations that you may work with. As always - thanks for reading. 

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.

The McGill Method - Common Misconceptions

In collaboration with Professor Emeritus Stuart McGill, PhD

                In the Fall of 2010, when I was a student at the University of Waterloo, I first met Dr. Stuart McGill. He was gracious enough to take the time out of his day to answer a few questions that I had from reading his book Low Back Disorders over that summer. Since then, Stu has been a great friend and has “had my back” ever since. Because of my friendship with Dr. McGill over the years I get asked a lot about his work and get dragged into various social media threads concerning him, his philosophy, and his methodology.

                Quite often, despite all the interviews and podcasts he’s been in recently (thanks to his book Gift Of Injury with Brian Carroll which I highly recommend), I find a lot of people misinterpret Dr. McGill’s work, teaching and principles & criticize what they don’t know. When people ask me about Stu’s work or pull me into an online thread I find myself more clarifying misinterpretations of his work than anything else. Yes there are some things Stu and I do differently but I would say 90%+ of our philosophy & methods are the same.

                In this article I will discuss some of the common misconceptions about Stuart McGill’s work

1) The McGill method ignores psychosocial factors

This is one of the biggest criticisms and misconceptions of the McGill method, particularly by some of my colleagues who are renowned for their knowledge in pain science & the biopsychosocial model.

What people forget is that some of Dr. McGill’s vast research on sports injury risk prediction has looked at psychosocial factors as a risk factor for injury.

McGill has also stated in his Back Mechanic book, and in various interviews, that he looks at the personality types and factors of his clients. Are they Type A personalities who are competitive, hard-driving, ambitious and sometimes push too hard or are they Type B personalities who are more lazy, sedentary & need to be motivated? McGill also looks at life stresses and contextual factors that may be affecting the person’s pain. His extensive interview and assessment process of a patient probes their past impediments to success, many of which involve social and psychological variables. He works to address these impediments with custom strategies for each person.

Side note from Eric: In addition to a McGill style assessment I like to have my patients fill out the Orebro Questionnaire (link here) before the assessment to try to “catch” any psychosocial factors or maladaptive beliefs that may be problematic and predispose someone to a higher likelihood of chronic pain.

2) NO Spinal flexion when using McGill’s principles

This is the other, if not bigger, main criticism and misconception of Stuart McGill’s principles.

One of the big principles of the McGill method is minimizing movements that worsen pain. Both Stu and I find that the vast majority of our patients don’t tolerate flexion very well. I find that, using a repeated movement style of assessment, all but maybe 1-2 of my patients in the last 2.5 years were made progressively worse with repeated spinal flexion. Towards that end it makes sense to give people alternative ways to move and do their ADLs that are preferably less painful.

When I hear (or read) comments like “McGill said never do a situp again” or “McGill said never flex your spine again” – that reflects a big misunderstanding & stereotype again. McGill is a fan of moving in a way that achieves the end goal in the most “biomechanically friendly” way. Towards that end he (and I) encourage hip hinging whenever possible but also understand that some tasks & some sports require spinal movement. Examples of common athletes McGill works with who do have to move their spines are

-          Rowers, MMA and jiu jitsu fighters, gymnasts, tennis players, and strongmen who have to flex & extend their spines in their respective sports

-          And powerlifters who extend during the bench press

For these athletes McGill recommends programming training in a way that provides enough training stimulus to build the required fitness for those sports, but also incorporates deloads & emphasizes joint sparing movement strategies to allow the spine to recover & build capacity for further sport-specific training. Once a spine has desensitized from pain, and adapted with appropriate rehab, then he trains protective stabilization within the movements and tasks for the athlete – these must include deviated postures. His record for restoring back pained athletes from virtually all of the professional sports and many Olympic sports is hard to beat.

3) The McGill method is all about core stiffening and “The McGill Big 3”

Many people I talk to think that McGill’s principles are all about bracing and doing lots of core exercises. As McGill often so eloquently says “it depends.”

The McGill methods works to isolate the movements, postures and loads that worsen an individuals’ pain – than it directs a strategy to address the cause. For example in Brian Carroll’s case, fractured vertebral bone had to be calloused during the rehabilitation phase prior to programming performance training. Many other medical experts failed to accomplish this.

During some of McGill’s tests; which are further described in his books Low Back Disorders, Back Mechanic, and Gift of Injury; McGill will get his patients to do the test without bracing and then with bracing. If bracing reduces symptoms during these tests than bracing and core exercises are emphasized. If bracing increases symptoms the emphasis shifts to relaxing the core musculature.

McGill has documented how tuning core stiffness reduces pain in some whereas other patients may require relaxation of the core musculature. He has measured how tuning stiffness increases performance variables such as enhanced load bearing and strength, strike speed and power in MMA athletes, to name just a few. This involves strategic muscle pulsing at the distal joints reinforced with proximal linkage core stiffness.

Too often I see patients that have mindlessly done core exercises without any critical thinking about why they are doing them or the effect its having on their symptoms.

4) McGill’s research is all done on pig spines

Another issue where I see people dismissing McGill’s work is to say he used animal spines to reach his conclusions. Perhaps they read a single paper. About 10 percent of his publications involved animal spines. Studying any medical condition needs animal models to control variables in a scientific experiment – testing fifty identical human spines is not feasible. But his observations were scaled and verified in humans. For example, the mechanisms he documented leading to disc herniation have been matched by many other scientific groups.

What people may not realize is that his clinical work with people with back pain formed the questions he probed with his scientific experiments. The lab and the clinic were closely linked. And the findings from probing different back pain mechanisms were then used to desensitize pain and restore a foundation for performance training. When he expresses an opinion there is a body of evidence to support it obtained from the lab and the clinic.

I hope this article clears up some misconceptions about the McGill method and gives you a greater appreciation of his work. As always, thanks for reading.

Random Thoughts February 2018 - The Relationship Between Strength & Pain, How I Recover From My Busy Life, The Importance Of Keeping Active Patients Exercising Through Rehab, And The Place Of Manual Therapy In Rehab

        I'm revamping my "Random Thoughts" series. Instead of my traditional short article series I will release a monthly article which will compile Facebook/Twitter posts and other unpublished thoughts I have on various topics on rehab & fitness that are worth mentioning but don't have enough material to make it worth dedicating a full article to.

With that here are my random thoughts from the past month....

The Relationship Between Strength & Pain

Sometimes a lack of strength can be relevant in pain – particularly when there’s a “mismatch” between a person’s demands and their physical capabilities, regardless of whether its before/after their pain started. And there is some research that does show lack of strength to be a risk factor for certain injuries/pain conditions.

That being said

1) The correlation between strength and many musculoskeletal pain conditions isn’t as strong as most people think

2) Many clinical studies have shown that changes in strength don’t always correlate with symptoms

3) Given what we know about the complexities of pain and the biopsychosocial model … to suggest all pain is due to weakness is reductionist & out of line with the evidence

How I Recover From My Busy Life Of Treating, Educating, And Lifting 

Given all my roles as a practicing physiotherapist, doing the occasional consultant, helping with 2 university curriculums, and training for powerlifting … some people ask me how I do it all and not burn out. Admittedly this took me a good year to “get right” after burning out in the past and it will be something I will continue to adjust.

My strategies have included

1) Proper nutrition

2) Proper sleep – around 7-8 hours a night. I aim to go to bed & get up at approximately the same time daily.

3) Adequate down time

I try to pencil in at least an hour of down time at the end of the day to decompress. This enables me to reset myself & sleep a lot better.

4) Time management

Last year I learned I can only run 1-2 areas of my life (ie career, lifting, family) hard at any one point in time (props to Will Kuenzel for teaching me that)… and I need some downtime. Towards that end I prioritize what I need to do, schedule it in my todoist app and my google calendar app, and also put in adequate down time.

It’s part of me realizing, as Stan Efferding said “that you can be good at anything but you can’t be good at everything” much to the chagrin of my hardheaded, Type A personality. In Brian Carroll’s 10/20/Life book he emphasizes having phases where you’re more focused on a meet vs time where you’re more focused on your external life.

5) Active recovery

I’m not a big fan of ice baths or saunas. My recovery approach consists of

-          Twice weekly foam rolling & self ART

-          Daily 10 minute walks as per the advice of Stan Efferding (I don’t do these 3x/day as he recommends due to scheduling but I do do them twice daily)

-          Daily performance of my knee rehab (knee extensions in sitting McKenzie style) and back rehab (McGill Big 3). Even though I’m painfree on a day to day basis I still believe in doing these for rehab & active recovery.

6) Stress management

Pretty much all of these count as stress managers. The only thing I would add is using a lot of positive self-talk to make sure my head is right when dealing with any situation I’m in. 

The Importance Of Keeping Active Patients Exercising Through Rehab

When athletic & physically active patients ask me "what do you think of me doing <insert exercise/activity here>" my answer, unless there are contraindications or unless they're clearly not ready for it, is "let's see how you do with it."

Quite often, more than not, many otherwise healthy & fit patients are capable of doing far more than they think but sometimes the fear of pain/injury holds them back.

Some may disagree with me - but I always believe in giving physically active patients (short of any contraindications) stuff that they can do ideally properly & painfree as it 

1) Gets them on my side - and makes me not look like the 10th person telling them to "just rest" or "never run/squat/deadlift etc again" 
2) Will likely benefit their pain, healing and mood through the benefits of well tolerated movement & general exercise and
3) Gets them to trust & believe in their bodies more
4) Gives them a means to maintain/improve fitness
5) Makes the rehab process feel less like boring rehab

The Place Of Manual Therapy In Rehab

Manual therapy has a place if a patient can't tolerate a full session of exercise/education due to
1) High irritability
2) Deconditioning - let's face it we've all had those patients that are toast after 1-2 simple exercises
3) Contraindications due to surgeries or medical conditions that prevent the patient from doing much (if any) exercise

Some would say "I'd rather only have a patient do 2 minutes of exercise than make them dependent on me." While I appreciate that idea - there's only so much education you can do in a session & expect a patient to retain effectively. If I was a patient, paid for a 30 minute session, and only got 5-10 minutes of therapy I'd be pretty POed. That's where the passive therapies have their place.

That said - the research and guidelines are really trying to push away from passive therapies & more to movement/exercise, education, and psychosocial therapies in the management of musculoskeletal pain and that's where the vast majority of our treatments should fall in.

4 Ways We Can Make The Rehab Education System Better

Image courtesy of Ambro at FreeDigitalPhotos.net

When I was a kid the Star Wars prequel films were coming out. While I’m not as critical of them as many are – they certainly fell short when compared to the originals. I’m glad that the last few Star Wars movies (The Last Jedi, Rogue One, and The Force Awakens) have helped the franchise regain its former pride.

                One of the highlights of the prequels was Ian McDiarmid’s performance as Chancellor and later Emperor Palpatine. Palpatine’s brilliant, cunning and deceptive character stood out to me as the most interesting characters of movies I-VI.

                As someone who’s battled frustrations with the education system of rehab & fitness professionals I’ve asked myself – what would I do if I was made absolute ruler of the education system and could do what I wanted? I’m involved off & on with the University of Waterloo Kinesiology program and the Western University Physiotherapy program and have seen a lot of great change in the education systems (especially the former) but we still have ways to go in improving the education system as a whole.

After reading my colleague Nick Ferrara’s brilliant article earlier this year I’m eager to post some ways we can improve the education system. While it is directed towards PT school the principles can apply to all rehab professions (Kins, PTs, OTs, Chiros, ATCs) and even fitness professionals to some degree.

Side note: I’ve written about many of these topics in detail before (and have links where applicable) or will continue to write about them in more detail in future articles.

1) Emphasize pain science & the biopsychosocial model

A large body of research in the last three decades has shown that pain is not solely linked to injury and can be influenced by various biological, psychological and sociological factors. This is important to understand as many patients can be very fearful of their body & activity as they may think that their pain is due to damage. Health professionals, often well meaning, who think the same can sometimes feed into this cycle with negative language (please read this linked article if you haven’t already) as well as overrestrictive activity modifications which can feed into this negative cycle & promote disability.

Understanding that pain does not always mean damage & can be influenced by various factors can and should help with health professionals making better decisions for people with pain.

2) Educate professionals about real biomechanics – not pseudobiomechanical nonsense

This is a bias for me being friends (either in person or online) with many great biomechanics researchers such as Stuart McGill, Jack Callaghan and Tim Hewett.

Some may disagree – but I still think biomechanical research has huge merit in terms of understanding the loads and muscle activation levels associated with various exercises & movements as well as mechanisms of specific tissue injuries. This can go a long way in preventing injury as well as making smart exercise & movement decisions when rehabilitating from an acute injury.

That said – so much of what’s biomechanically taught in school revolves around many pseudobiomechanical variables such as upper/lower crossed syndrome, upslips/downslips/rotated pelvic bones, and hypermobile/hypomobile spinal segments (to name a few) that either can’t be reliably assessed or don’t correlate well with pain. Towards that end its critical to know when biomechanics is and isn’t important.

3) Teach manual therapy in a way that is simplified & in line with the evidence

I’ve talked to many new therapists who feel their manual therapy skills aren’t up to par with their colleagues as they can’t “detect” certain positioning or mobility defects and they can’t seem to “feel the joint.” As I’ve written about before – many manual therapy variables such as motion and positional palpation aren’t reliable, you can’t isolate a technique to one segment, and different techniques have shown equivalent results in RCTs for the same condition in some studies.

As such – understanding the true neural mechanisms of manual therapy & teaching it in line with the evidence, while robbing a few of the illusion of magic hands, will in my opinion create many more confident therapists moving forward.

4) Push more exercise & less passive treatment

One of the biggest gripes in my PT school experience, as with many I’ve talked to, is the lack of time spent teaching therapists to push forward what is often the most effective intervention for many (not all) musculoskeletal pain conditions – exercise. We cover the same manual therapy technique six times and learn all the ins & outs of an ultrasound machine but we don’t know how to coach, correct, progress, regress, and modify basic movements such as squatting, hip hinging, lunging, pushing, pulling, as well as more “traditional” PT exercises.

Most of my exercise knowledge has came from S&C coaches. While I’m not as knowledgeable as some when it comes to exercise – I realized the level of knowledge most PTs have with exercise when I attended a course in October and ended up being asked to teach a lot of cues and modifications I use with my patients on a day to day basis. What I thought was rudimentary, first line knowledge was something that most therapists apparently don’t know. This needs to change. I’m not saying you need to be a Brian Carroll, Eric Cressey or Chris Duffin of exercise knowledge – but having better knowledge, skills and confidence to recommend more exercise & less passive treatments can’t hurt.

So there’s my list of four ways we can improve the PT (and rehab) education system. 

An Evidence & Experience Based Critique Of The McKenzie Method (MDT)

Updated February 18, 2018           

            Before we get started I just want to say thank you who read my latest article in honour of #BellLetsTalk day and to those who opened up about their own personal stories. Mental health is a big issue worldwide and is an issue amongst us hard driving, Type A rehab & fitness professionals. It needs to be talked about more.

Back in the Spring of 2015 I did a physiotherapy placement at University Hospital in London, Ontario, Canada. There I met some fantastic therapists who taught me a lot about using the McKenzie Method aka Mechanical Diagnosis & Therapy (MDT) to treat both spinal & extremity problems. I’m very grateful for the experience as I’ve found repeated movement testing & exercising to be a useful tool to guide my exercise prescription in rehab. That said – every method of therapy has its limitations which I will address in this article.

Side note: before reading this you should have a thorough understanding of MDT through either taking the courses, working with MDT credentialed therapists and/or reading the books & research papers. I see too many people bastardize the method and say things like “oh my patient did 10 back extensions and didn’t feel better therefore McKenzie didn’t work.”

Side note 2: as with my other articles this will not be a comprehensive lit review just in the interest of keeping it easy to read. If you want I have attached a link to a comprehensive list of all papers on MDT.

The advantages of MDT

1) Simplification of HEP

Through the McKenzie method patients are often only given a very small number of exercises (1-3 on average) to do at home. Given some of the research that claims that up to 70% of patients don’t adhere to an exercise program … it doesn’t seem like a bad idea to give patients a small number of exercises that can, for the most part, be done anywhere and done often.

2) Thorough analysis of what movements, postures and loads are and aren’t tolerated by the patients

Going in hand with the above point … pain worsening with exercise can also be a big barrier to performance of a home exercise program. A reason why I’m a big fan of MDT is that you know which movements & exercises a patient will & won’t tolerate and can build a program around that.

Now there are some cases where a patient may not be able to tolerate anything without some increase in pain which I will elaborate on below.

3) Focus on active care & self management

As my friend Erson Religioso III wrote about one of the great aspects of MDT is it focuses on patient self-management & empowering the patient to control symptoms – something that is well in line with pain science & the biopsychosocial model … and something very underrated in today’s overuse of passive treatments.  

4) People who do have a directional preference tend to respond quite well

Some research in spinal pain and in the knees has shown that people who have a directional preference and perform the corresponding exercises have much better outcomes than people with a directional preference given traditional care.

5) The emphasis on functional testing vs pathoanatomical models

As I’ve written about before so much recent research has shown the discordance between imaging & symptoms. One of the advantages of MDT is it bases classification & treatment based on response to movements, loads, postures & repeated movements as opposed to just saying “oh your MRI shows degenerative disc disease, that’s what’s causing your back pain.”

The limitations of MDT

1) Sometimes repeated movements in every direction make a patient worse

My biggest critique against the McKenzie method is that sometimes (especially with necks) repeated movements (and positioning) in every direction worsen a patients symptoms and the patient doesn’t fit in with a “contractile dysfunction” presentation. When you hang your hat on one treatment method and all it does is worsen a patient’s symptoms that’s problematic and you need to be able to change gears.

Side note: Regardless of whether you’re a strict Maitland/McKenzie/SFMA/whatever therapist … or you’re an eclectic therapist I do believe you have to have a method or philosophy to consolidate all the information you have and know.

In these situations in spinal pain I often fall back on a Stu McGill-esque approach of using more isometric style exercises to help with pain relief and building fitness and later on returning them to full proper spinal movement. For extremities I often just have patients work within a range of motion & rep ranges that they can tolerate & then build up from there.

2) Utility with people with persistent pain

Research on chronic back pain and chronic neck pain has shown that MDT has produced results basically equivalent to a placebo or other general exercises.

The MDT books state that people with persistent pain may be worse with repeated movements in each direction. As I wrote above – people (with both acute & persistent pain) who have a directional preference often have a much better outcome performing those exercises … but people who don’t have a directional preference would get equal results with repeated movements or with any form of exercise. The books state in those situations (classified as ‘chronic’) working into some increase in pain with exercise may be acceptable, something line with a paper that came out last year, but great caution and monitoring of the exercise programs need to take place in order to minimize the chances of increasing central sensitization.  

3) Lack of comprehensiveness

To quote my friend Lars Avemarie

“When we reduce the cause (or solution) of pain to one single event, factor or biomechanical error we are in my opinion doing a disservice to our patients, and we are ourselves committing the fallacy of the single cause (also known as causal oversimplification).”

As I’ve written about before pain is complex and to assume that repeated movements in one direction will cure everyone’s pain is a major disservice.

The MDT books and research papers talk a lot about psychosocial factors in pain which is pretty good considering those books came out in 2003 long before a lot of the pain science information made it into mainstream therapy. But there are components of a comprehensive program that get missed through MDT such as pain science education, managing maladaptive beliefs around pain and managing other factors associated with certain conditions such as poor sleep and being overweight.

A simple way to tweak this is through adding other components to the rehab such as working on the kinetic chain, psychosocial factors & maldaptive beliefs, general health, strength/neuromuscular training, and workload management. Obviously all of these may not be relevant to each individual you work with but I do believe they need to be assessed. A very good paper recently came out in 2018 which summarizes a comprehensive assessment & treatment approach to people with low back pain.

The bottom line, as Stone Cold would say, is that MDT is a useful assessment & treatment model to determine what movements & postures a patient will tolerate and it has a lot of upside to it – but it needs to be looked at within a more comprehensive approach that is the biopsychosocial model.