How I Assess And Treat People With Low Back Pain Part 2: Treatment

In Part 1 of this series I discussed how I assess people with Low Back Pain (LBP). In this article I get down to the treatment side of things. I want to thank everyone who took the time to read the article & provide such useful feedback. Hence this article is out later than desired as I wanted to reformat it & do it right.

Disclaimers: As I said in Part 1 this is not intended to be medical advice. Plus I don’t expect that everyone’s going to agree with every single point that I make – that’s fine. Also this is going to be a long article and is very context and assessment dependent. It’s not a recipe.

My approach comes down to 4 basic tenets

1) Minimize what exacerbates the issue

I didn’t say “take away” or “remove” as for some people, such as patients with chronic pain and central sensitization, that may not be realistically doable. But I still believe in modifying and reducing (and if possible eliminating) what exacerbates the issue. These can be

-          Specific movements, postures, loads, behaviours, activities (or volumes of activities) or repeated movements OR

-          General health factors such as poor sleep, stress, depression, or being overweight

Going step by step through these…

Movement/Posture: My movement recommendations depend a lot on the mechanism.

If someone is aggravated by very specific directions or postures (i.e. what some would consider flexion intolerant or extension intolerant) than yes I get people to move in a way that’s not provocative (or is at least less provocative). This may involve using a neutral spine/hip hinge technique (I teach a modified sumo lift technique for people with sciatica and for tall people), emphasis on using the gluteal muscles more (they are never turned off short of a neurological injury) and bracing … or conversely relaxing the core musculature and breathing deeply as some patients are very tense & guarded and need to relax.

 For posture – oddly enough (and there’s a bit of research and anecdotal support on this) that some people tend to sit or stand in the same posture that provokes their symptoms and some are very rigid & overprotective!!! For these people I will have them adjust their lordotic curve to find a position that’s comfortable for them. I’m more of a fan of teaching people how to find movements & postures that are comfortable for them rather than trying to find an ideal.

One of the reasons why I look at movements and repeated movements is to give people ways to do their day to day tasks that (hopefully) don’t aggravate their symptoms. While I’m not a fan of telling people to avoid movements forever it doesn’t make sense to force people through movements that can aggravate and worsen their symptoms with repetition. Sometimes you need to take a break from the exacerbating issues to facilitate recovery. How long movements are avoided is a contentious topic that depends on a variety of different factors.

For people who have more of a central sensitization (CS) pattern it may be that everything (including hip hinging) hurts to some degree. In these populations I’m not as concerned about movement technique as I am about other variables (more on that below) but I will still teach some biomechanical principles (i.e. keeping loads to the body, avoiding excessive muscle tensing or bracing) to make things easier in theory.

General health: In terms of other risk factors and contributors to LBP

-          Sleep: I educate patients on simple sleep hygiene (which I will write about in another article) and on the importance of sleep. Past that if there are other issues I will refer to sleep specialists especially if I have bigger clientele who may have sleep apnea or people who may have major psychosocial issues.

-          Stress, Anxiety, Depression and other psychosocial factors: I’m gonna get some heat for saying this but I don’t believe; unless it’s related to movement, injury, pain or activity; that physios should be trying to treat psychosocial factors other than educating patients about their importance, giving them some exercise to do (which can help with psychosocial factors) and again referring out.

-          Body weight management: Same principles apply – educate the patient about the importance of it, get them moving, and if need be refer out to other health professionals who can help fill in the blanks with diet and hormone management.

The 2^nd key principle of my approach to back pain is that

2) Well tolerated movement & exercise are good

A lot of research has shown that general exercise and “core stability” exercises are equally effective for LBP management. While I don’t disagree with the research I’ve found (anecdotally) that some people with LBP may not tolerate certain exercises well – be it core training, walking, cycling, general strength training, or directional exercises.

For home exercises my first go to are generally repeated movement/McKenzie style assessments based on the directional preference of the person I’m working with. If a client I’m working with doesn’t have a directional preference my home exercises are generally

-          For more nociceptive/neuropathic cases: usually exercises that address “painless dysfunctions” (I hate the term but that’s what people understand) that may limit an individual’s ability to move in non-painful (or less painful) patterns such a lack of hip, ankle or shoulder mobility and/or a lack of hip/core strength or endurance

-          For people with more of a CS presentation: some people I work with who have CS are insanely deconditioned and have some MAJOR mobility or strength limitations. In those situations I give people 1-2 low dose exercises (ie sets of 2-5 2-4x/day working into a bit of pain but not blowing through it) to either address these limitations or maintain the mobility that’s already there

In the clinic I am also a fan of core, glute, and general cardiovascular exercise for most people with LBP who tolerate them. Some may criticize me – but given the poor adherence of patients to home exercise programs I’d rather see them do a few exercises in the clinic rather than f*cking around with a TENS machine or ultrasound. For people who tend to have more of a CS presentation I spend more time talking and a lot less time with exercise & manual therapy.

3) Address negative beliefs about movement, the body, pain and activity

As I said above I’m not a fan of physios trying to be psychiatrists. Just as you wouldn’t want a personal trainer trying to treat a client’s broken arm … I don’t believe a physio should be trying to treat a client’s PTSD from combat or trying to grief counsel a mother who’s lost her kid.

But anything related to movement, activity, pain, injury or the body is within our ballpark IMO.

Therapists such as Peter O’Sullivan have written about the importance of beliefs as they relate to LBP. While pain science education is important sometimes patient education has to take different paths based on the individual.

In my experience some people respond quite well to pain science education and others have a hard time changing their view of pain. Behaviour change and belief change is a long, time consuming process for some people and some may never change their beliefs. We as a society have become so engrained in the idea that pain is always due to “issues in the tissues” that some patients may never change their beliefs. We as therapists have to accept that we can’t change everyone.

In more “non-specific” cases I point out how a patient’s pain is due to changes in their nervous system and body that make them more sensitive and more likely to experience pain. This allows me to put a “feeler” out there to determine if the patient is interested in more pain science education. If they are – great. If not, no harm no foul.  If they want to learn more than I will draw a bubble diagram outlining all the factors contributing to the situation and will go into more detail about pain science in coming appointments.

In patients where there is a legit tissue injury, or in cases where a patient is dead-set that their MRI findings are the cause of the problem, I point out how a lot of back injuries can heal given proper management.

A big component of my work is positive coaching and cueing. Some health and fitness professionals freak patients out by pointing out numerous dysfunctions that either can’t be reliably assessed and/or don’t correlate well with pain. I don’t coach certain people to do certain movements or exercises by saying “do this or your back will explode.” I coach movement and positional strategies in a way that empowers patients to move in ways that are comfortable for them. Sometimes showing people ways to move and exercise that are comfortable for them alleviates a lot of the anxiety and enables people to trust in their bodies a lot more.

I also believe that getting people to do things they never thought they could do (within reason of course) and progressively working them towards the activities they want to do also helps build confidence & change beliefs.

4) Build people back to the activities that they want to do

This is where we tackle the first elephant in the room … spinal flexion

 Yes – most of my patients that I see on Day 1 (arguably over 97%) don’t tolerate much spinal flexion. As such I try to minimize that in the early stages. However, while I’m still reluctant to have people flex 100 million times a day or to do it under heavy load, I do believe we should be able to move our spines as needed.

When patients are getting closer to full recovery I start to ease them back into spinal movements through low-load exercises such as cat camels & prayer stretches and progress them to being able to move fully in standing. There are however situations where I will stick to the “minimize spinal movement” approach such as….

-          People with a recurrent flexion or extension or motion intolerant low back pain that is more nociceptive and/or neuropathic in nature

-          People with moderate to severe osteoporosis who are at higher risk of fracture

-          Athletes who require a great degree of spinal stiffness in their sports such as powerlifters

In these three populations I often encourage people to hip hinge as much as possible. I don’t say “don’t bend your back or your spine will blow out” but I do believe that hip hinging is a better option to achieve their goals.

If a certain exercise or activity is a goal of the individual (e.g. returning to walking) than the activity itself (or some close derivative) is part of the exercise program and is progressed based on the individual’s activity tolerance in increments of 5-20% per week based on how the patient responds. As Tim Gabbett has said (yes his research is in athletes but I believe it applies here too) people respond differently to different increases in activity and as such you have to be flexible to adjust the rate of progression to your clients tolerance.

For people with nociceptive or neuropathic pain I prefer having people do activities in shorter bursts, stopping just before their pain would increase, and repeating those bursts through the day. I find anecdotally that many of my patients who use this technique for walking or activities experience a huge increase in their pain free walking tolerance within a couple weeks.

For people who have more CS with walking (or any activity) I just advise that it’s OK to work into a little bit of pain, not to blow aggressively blow through pain, and work with them to slowly increase the amount that’s done.

 What about the other elephant in the room – manual therapy?

I’ll confess that I use manual therapy less than most therapists do. If it’s a patient that’s had chronic back pain for years and has already sought out a bunch of passive treatment modalities than manual therapy isn’t going to be the first thing that I’ll do with them. In addition I find manual therapy, no matter how gently its done, just makes some people really sore.

By the same token if I have a case that’s so irritable that they can barely tolerate any activity, someone who’s overdone it, or someone who is limited in ability to exercise due to deconditioning or medical comorbidities, than manual therapy (or even modalities) can play a role but in my opinion it’s not as important for overall treatment as many therapists think.

When doing manual therapy for the back (or for other joints) I try to direct it towards painless limitations (I hate the word dysfunctions) first and then afterwards painful areas. Since manual therapy’s effects are non-specific, if I can reduce pain and improve function in another of the body that kills 2 birds with 1 stone.

So that is basically how I go about treating people with LBP. As always, thanks for reading.

How I Assess & Treat People With Low Back Pain Part 1: Assessment

I get asked all the time, especially when people find out I’m a physiotherapist, “what can I do for my back pain” or “what exercises can I do for my back?” These are understandable questions as Low Back Pain (LBP) is the leading cause of disability worldwide costing the health care system millions of dollars in assessment, diagnosis and treatment.

When it comes to LBP assessment and treatment we are in a bit of a difficult spot as the vast majority (80-90% of LBP) cases are not attributable to a specific diagnosis such as a disc pressing on a nerve root, a fracture, or a lumbar muscle strain. As such most LBP cases get lumped into the “non-specific LBP” category. While attempts have been made to subgroup LBP patients the validity of most subgroups have been called into question over the last several years.

In terms of treatment the same conundrum exists as many treatment approaches are equally effective for LBP, no form of exercise seems to be better than the other, and the validity of clinical prediction rules has also came under scrutiny over recent years.

This leaves us in a bit of a tough situation – what do we do for people with LBP? Well in my article I will address how I personally assess & manage someone with LBP in the clinic….

Disclaimer 1: This is for professionals and is not intended to be medical advice. If you have any symptoms such as fevers, chills, night sweats, unremitting night pain, unexplained weight loss, sickness or unwellness, tingling/numbness in the groin, changes in bowel/bladder function and/or a loss of sexual function you may have symptoms suggestive of a serious medical pathology and may need to seek medical attention as soon as possible.

Disclaimer 2: The topic of individualized management in LBP is a controversial one so I accept full well that people (you the reader included) may or may not agree on all the points here but I do hope you will give it a read.

Side note: at the time I was working on this article I happened on this paper which is very very similar to my approach (aside from a few subtleties)

FIRST THINGS FIRST – RULE OUT RED FLAGS AND SERIOUS TISSUE PATHOLOGY

The most important reason as to why someone in pain should see a doctor and/or a physical therapist is to make sure, if anything else, that there are no major health concerns that need to be medically managed.

In the research 1-2% of LBP cases are attributable to a serious pathology such as fracture, cancer, infection, inflammatory condition, or cauda equina syndrome among others. I will not go over the symptoms suggestive of these conditions but I suggest updating yourself on these regularly if you are a professional.

AVOID UNNECESSARY IMAGING

Imaging is indicated for LBP patients if they have symptoms suggestive of a red flag or serious tissue pathology and/or if they have a significant neurological deficit (i.e. dermatomal loss of sensation and/or myotomal weakness) that isn’t improving with conservative management. This applies to a small percentage of people with LBP.

Unfortunately medical imaging is overused, particularly in the US. Now I understand that its easy for doctors to feel pressured to send patients for imaging, but a lot of research suggests that people with LBP who don’t have an indication for imaging are actually worse off getting an X-ray or MRI.

Also – its important to keep in mind that 80% of people with LBP have 1+ symptoms suggestive of a red flag condition yet only 1-2% have them. As such its important to have good clinical reasoning to order special tests.

But won’t the X-ray or MRI show me what’s wrong?

The problem is numerous studies have shown that lots of PAINFREE people have degenerated discs, arthritis, and disc lesions among other things. See the chart below for examples.

Patients often freak out about what their MRI findings say while they may be incidental.

WHAT DO I LOOK FOR IN SOMEONE WITH LBP?

I look at pain from a biopsychosocial perspective. Breaking it down

Bio – general health factors (e.g. fitness, comorbidities); aggravating/relieving movements, postures, and loads; sleep;

Side note: a lot of research claims that biomechanical factors don’t correlate with LBP which isn’t necessarily wrong but I do believe biomechanics shouldn’t be ignored. Sometimes people do have pain with specific movements/postures which may be due to overuse of those movements/postures, guarding, kinesiophobia, or other factors.

Psychosocial – factors that can be related to movement, injury and pain such as fear avoidance, catastrophizing, kinesiophobia, other maladaptive beliefs and passive coping; as well as psychosocial factors such as stress, anxiety, work situation, and depression

I also look at what the patient is working towards (in terms of occupational and/or sporting demands) as well as their goals.

Prior to assessment I’ll have each patient fill out the Orebro Questionnaire – a questionnaire designed to detect psychosocial factors & factors that can place someone at an increased likelihood of chronic pain. I’m not as interested in the overall score as I am in the score of individual items.

SUBJECTIVE ASSESSMENT

Peter O’Sullivan taught me to open my assessment with “tell me your story.” I say that, shut up, and let the patient say what they have to say. I find this gives me probably 65-70% of the useful information I need and it gives the patient a chance to get whatever they need to get out there & off their back. Sometimes just talking can be therapeutic.

Examples of specific questions (aside from ones to rule out red flags) that I’ll ask are

-          Any recent life changes in your family, work, hobbies, or financial life? You don’t have to tell me the specifics if you don’t want to.

-          Have you had any X-rays or MRIs recently?

-          Have you gotten any advice from your doctors, friends/family members, or the internet on what is going on and how to address it?

-          What do you think is going on?

-          How have you been doing in managing this?

-          Any stress, anxiety or depression?

-          Any issues with sleep before or after this started?

-          How has this impacted your life?

-          Where do you see yourself in 6 months?

-          What would you like to do that you aren’t already doing?

-          Have you had to stop or modify any activities?

-          What do you think would happen to you if you did <insert activity here>?

Some may disagree with me, but aside from workers comp cases, I don’t ask a lot of questions specifically about pain except for

-          Whether it’s constant or intermittent

-          Type

-          Aggravating/relieving factors

I find the 0-10 pain scale highly subjective plus I don’t like the idea of feeding into a patient who may be ultra pain focused & causing them to ruminate about it even more.

Two papers I recommend for people wanting to learn more about a good biopsychosocial subjective history are the papers “Listening Is Therapy” and Peter O’Sullivan’s recent “Cognitive Functional Therapy” paper.

OBJECTIVE ASSESSMENT

My objective assessment is basically a hybrid of the McKenzie (MDT) assessment as well as the assessment Stu McGill describes in his books Low Back Disorders, Back Mechanic and Gift Of Injury. These assessments guide my exercise, movement & postural recommendations towards what is more tolerable and (temporarily) away from what’s not tolerated in the early going. For the sake of not giving away their work (and keeping this article from getting ridiculously long) I recommend you buy and read those books.

In addition to these I also do a simple neurological assessment (ie dermatomes, myotomes, reflexes & cord signs). As I’ve written about before motion palpation & positional palpation are unreliable so I just quite frankly don’t bother with them.

I also, in a SFMA-ish style, will look at gross function of the surrounding joints (ie hips, shoulders, ankles) to see if a deficit in one of those areas may be causing a client to have to “overdo” painful movements due to a lack of mobility, strength, or motor control at a distal joint. An example of this could be someone who has pain with lumbar flexion but has to flex the lumbar spine everytime they bend over due to a lack of hip mobility.

This isn’t so much of a subgrouping approach but it enables me to pick and choose what is important to the individual’s treatment plan. I’ve had patients with no psychosocial factors and patients with a ton of psychosocial factors involved.

I hope this helps give you an idea of how I assess people with LBP. In Part 2 of this series I get down to the treatment side of things. As always - thanks for reading.

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.