Most commonly flexibility refers to the absolute range of motion possible within a joint or series of joints and may be either static or dynamic and it is fairly clear that if done regularly stretching does seem to make an athlete more flexible (Ref). Whether this effect is, in fact, of benefit within an athletic population needs careful consideration by the practitioner/coach.
In order to reduce the risk of injury, strengthening has been shown to be more protective by a bulk of evidence, most notably a large systematic review by Lauersen et al in 2014. You’ve probably heard, ‘you can’t go wrong getting strong,’ and it’s a fairly decent homage to the most powerful component to any rehabilitation program – strength. But do we throw the baby out with the bathwater? JUST strengthening everything, all the time, for all population groups, is maybe not the most efficient way forward. Similarly, performing massive amounts of flexibility training may have limited effect after a certain point for certain individuals.
Long-term flexibility training has been hypothesised to enhance muscle tendon unit compliance, theoretically increasing the ability to store and release elastic energy within the stretch shortening cycle of muscular performance (Ref). It has been demonstrated, however, that runners who are more flexible have a reduced running economy (Ref). It is obvious that some sports require more flexibility in order to perform to high levels (like gymnastics) and the requirement for flexibility training would seem obvious in these cases. Coaches/clnicians may employ flexibility training as a component of programming for any sport, however, and it is unclear as to the guidelines and most appropriate setting for this kind of training. Questions about flexibility training’s effectiveness and its place in high performance settings remain pervasive in the literature.
Generally, populations fit into a bell-curve distributions – otherwise known as ‘normal distribution’ – the athletic or ‘weekend warrior’ population is no different. For those at either end of the spectrum, there will be a world of difference between the effectiveness of flexibility programs. For those people who are very inflexible, effectiveness of flexibility training will undoubtedly be high – spend your time here, this is ‘bang for buck’ in order to accomplish increased range of motion (if that is desired for your task). For those who may have increased flexibility to begin with, flexibility training will not be as effective and would certainly be time-intensive and will not result in great gains.
To conclude, it is always worth asking, does this person need to be more flexible? Although it may not reduce my risk of injury when looked at in comparison to strengthening, but do not discount it. But if using it, what is the time-versus-reward ratio going to look like for your athlete or patient and is that time better spent doing something else?
After a brief interlude, I thought I’d begin my writing again my starting on a mini blog, in lieu of my upcoming piece de resistance on ‘manual therapy; lung fish or dinosaur’, which is something I'm finding very difficult to get finished.
I have recently listened to Ido Portal on one of my new favourite podcasts – The School of Greatness, with Lewis Howes – if you’re not on to this, do yourself a favour and give it a listen. Very inspiring and very engaging. I was particularly interested in his most recent podcast with Ido Portal; Ido is one of my biggest influences, both professionally but also in my thinking and motivation. By no means am I as immersed in the movement culture as others in my area, but I use Ido’s methods with my patients every day and I continue to develop in my own movement practice (very) slowly, but surely. I have been ‘ticking away’ at both this and strength and conditioning practices for about 3 years, it has truly revolutionised the way I practice, and definitely the way I live.
So what is it about the movement culture that is useful?
Although eerily similar to a modern-day Marcus Aurelius, in the same breath inspiring and cripplingly contradictory, Ido’s greatest gift to the general populace in my opinion is stimulating a level of thinking in the every-day human (and clinician) that today’s society is NOT suitable for health, community and (obviously) movement. The ultimate trend to buck is the typical ‘daily grind training’ concept that is rife in today’s aesthetically drive social media world, and his movement culture does this exceptionally well; movement is something that happens through every aspect of life, we should enjoy ALL aspects of movement that we do every minute of every day and should enjoy it for its incredible diversity without pigeon-holing it into your ‘best WOD’ or your ‘daily glute workout guide’. Not that there aren’t other similar copy-cat movement practices or ‘groups’ out there that are very similar to the ‘Ido method’, but no other groups in my opinion invest in – and place importance on – the absolute very basics of movement like Ido does; like proprioception ad basic co-ordination. It’s simply more encompassing.
This is something I find incredibly useful in my clinical practice; through some of Ido’s methods, I am able to demonstrate that movement is something to be enjoyed and is a privilege. Most other methods that I’ve tried don’t quite have the buy-in, and his methods are incredibly powerful in painful populations that we physiotherapists deal with daily. Painting a ‘movement picture’ for the patient from the ground-up, shows them the very basics of movement all the way up to complex, dynamic ‘tricks’; this means each individual will pick and choose a take-away from each level, some may stop at the basic levels but each will be able to invest more in their bodies, their movement and their health. This is generally the beginning of a road to a more invigorated body, and fulfilled and dynamic life.
So if you’re not using Ido’s methods as a physiotherapist or allied health practitioner, you should probably attend a course or two and soak in his knowledge. Maybe add another string to your bow, or become entrenched in the culture and change your life. Generally, these cultures tend not to be the most inclusive, just like Crossfit or Yoga, there will always be those who don’t fit or disagree with the methods or outcomes. But paradoxically, the movement culture does allow for social connectedness for those who need this to get moving (as does Crossfit or Yoga). Whether it is ‘functional’ (whatever that means) in this day and age I tend to disagree with, but then again what kind of movement method is functional for the desk-bound society we live in today? For me the functional training for today’s society, would probably be to just simply practice sitting.. sitting really well.. you know, that kind of thing. Anything you do to offset this – Any KIND OF MOVEMENT – is beneficial. So have at it.
I’m now writing again, so please continue to read if you enjoy the blog, and wait for some more in-depth pieces in coming weeks and months.
This blog will be as much about aesthetics as it will be about the use of social media within our profession, as I’m sure we are all aware these are intrinsically linked nowadays. The fantastic Jack O’Brien has contributed to this instalment; I recently had the pleasure of sitting down for a coffee with Jack, I was electrified with the contents of our discussion and genuinely surprised that with so much time between catch ups that we seem to be on the same wavelength with a lot of things. He has truly understood and embraced the philosophy of this blog. For the purpose of this blog we define aesthetics as ‘having a sense of the beautiful; characterised by a love of beauty’.
I tell everyone who contributes to this blog that this is not about regurgitating the latest evidence you have read. Any monkey who has attended tertiary education can do that; what I am trying to stimulate through all of this is novel thought. This blog is about leading the (very) small cohort of readers into new concepts and thought processes of their own. So, thank you for reading. Read on to hear what Jack has to say, and my take on a few things, into aesthetics and its impact on the health realm. The title is a play on the Neil Young song of a similar title, if you haven’t heard it, go and listen; it is about heroin addiction, which is generally a pretty rough road as you can imagine. I think we can all agree that chasing aesthetics can be addictive; but this might not be as rough a road as the H train.
Aesthetics and the good.
Physical training is a fascinating concept.
All throughout history, humans have harnessed the power of simple training philosophy in order to survive, thrive and excel at life in all its facets.
Primitively, the primary purpose of training was purely function - how could you become a successful and efficient hunter; a stronger gatherer; a resilient, fearsome, tough warrior; a desirable mate.
Fast forward to the 21st century, and physical training has taken on a whole new meaning. Although these outcomes may still be the desired outcome for some people, training can now take on many different meanings.
Training could be all manner of things:
-A social, community outlet
-For aesthetic or vain endeavours
-For specific competitive sports
-To counter-balance our terrible diets and activity patterns of the 21st century.
-To maintain an appearance for the social pecking order and to attract a relationship.
As a consequence, the pursuit of these things has caused a myriad of challenges.
We now have training methodologies that have such a narrow outcome in mind, it is at the expense of other things.
We have large populations subscribing to mind-sets and concepts that promise the world, yet are false, hollow and misleading - much less based on evidence.
No one is saying that training with specific endeavours in mind is a problem - heck, having goals is a key element to get results.
What could be said, though, is that the pursuit of a goal at the expense (and ridicule) of all else is a sure-fire way to:
a) attract attention and victimise yourself, and
b) leave yourself vulnerable to the downsides or side-effects that are unavoidable in a polarised environment.
Put simply, if defining aesthetics as relating to the sense of beauty, this can be a hell of a powerful driver for improvement. In an evolutionary sense, aesthetic drives are used by many species to continue their existence. Frail and lame animals are subject to a high risk of failure to mate and replicate; they are not appealing in an aesthetic sense - this is the basis behind species remaining robust and healthy.
But are human beings much different? I think we have become different. The aesthetic drive has taken on an entirely different property for us, and as with many things referring to aesthetics in evolutionary terms has become quite moot especially when thinking about current and future human societies. Through the internet and social media modern human species now experience a multiplying effect on a few fronts; one of which is aesthetics and its impact. Aesthetics is different now.
It is still a driver for the human race; it will ultimately drive many humans towards goals, some of which have been listed by Jack. Yes, one of them is the drive to train, the drive to counteract the numerous ways in which our societies now become unhealthy. We are now so far removed from the natural world, however, that the aesthetic drive behind human being’s own evolution is now morphing into one which might not be as closely linked to natural selection as it once was – it might not be closely linked to health all that much anymore either. So, onto the dark side of aesthetics.
The dark side
The consequences of a pursuit of vanity.
Let’s be clear - the problem here isn’t vanity, or training for aesthetics.
The problem is the pursuit of aesthetics AT THE EXPENSE OF, AND IN OPPOSITION TO, ALL OTHER METHODS AND EVIDENCE.
Training for aesthetics is completely understandable and rational - as social humans, we want to look good, feel good and compete against others.
We want to look good naked, feel comfortable in our skin and have a healthy self-esteem, self-image and self-confidence. We want to be strong and dominant. There are plenty of healthy drivers behind the aesthetic pursuit.
When it becomes unhealthy is, in the absence of regulated and sensible competition, the pursuit engages in unrealistic, unsustainable and unhealthy habits.
However, the same can be said for any training, not just bodybuilding.
It doesn’t take a rocket scientist to observe that CrossFit has a certain reputation (valid or not, I’m not passing judgement on that) that can easily tip over from healthy to unhealthy.
The same can be said for powerlifters, long distance walkers and tennis players. The list is endless.
Here’s the main take away:
Health is imperative.
Goals are important.
And an holistic, moderate, considered approach that accounts (and controls for) for any potential negative consequences will always win in the end.
Jack has made probably the most salient point; aesthetics become unhealthy in the pursuit of unsustainable practices. If driven purely by aesthetics; that’s OK and plenty of people do still remain healthy. My argument essentially follows this rabbit hole down a little further; health has become a commodity, and very linked with aesthetics. The use of aesthetics, however, has become more extremist and more isolating. I do think that some people are able to practice moderation, but not a lot, probably not the entire human race. Social media has allowed these extreme images to become way more accessible than previously was possible.
It’s a numbers game really; now at least 80% of the world’s population own a television set (ref) and Facebook has 1.94 billion users. The aesthetic drive is now influenced by so much more media; extreme images are now mainlined into our families 24/7. The loudest voice is the one that gets heard the most and no one really wants to listen to a moderate message of much, especially not when it comes to aesthetics. I don’t think this has been the case throughout much of human history, as we see strange aesthetics crop up at every turn in the human society’s development. But now it seems just far more prolific; many more people have access to these images and ascribe to a certain extreme practice as the one for them. What is the worst thing here is that our children now do not have a choice in this; they are consistently exposed to extreme images, aesthetics and lifestyle practices.
This is not the forum for bagging out social media; but those of you who know me know that I do not to use it a great deal for personal things. For me personally, it comes down to a choice between what you want to portray and engage in; you always have a choice and as a private person I choose most things to remain between my closer connections. Far be it for me to cast an opinion on that choice; this is not the moral high ground. This is, however, a comment on what social media could be doing to human being’s aesthetic drive and its impact on population health.
Clinically, I see a few isolated issues with uneducated people following popular aesthetics on mainstream media. People may develop:
These syndromes would be great to write up just as Janda did with posture and maybe more applicable to the way we understand loading in the human system now, but I don’t think that even this stuff has not a hell of a lot to do with pain prevalence in people. People develop these issues due to a lack of adequate information and education to the contrary.
On a more global scale I think we can all agree on a huge mental health burden of constant visual stress and warped aesthetic drives of young females and males will be significant in future years. Physical health may follow this also; the ever-increasing pursuit of aesthetics over anything else because of the over-exposure to extreme images in all forms of media.
What role do health professionals have to play?
As alluded to in previous articles on this blog, the nature and landscape of health care, and specifically physiotherapy, is changing drastically.
There is a raft of new evidence, and model of practice, sweeping our profession - and for the better!
Our role is now less about being the ‘guru with the magic hands’, and more about being a patient’s ‘trusted advisor’ - someone who is across the current evidence and best practice (in a way that is meaningful to real life) and can apply that in a specific way to a given circumstance or presentation.
Our role, as physiotherapists, is to advise, guide and steer those who come to us for advice towards THEIR desired goals in a way that controls for potential negative outcomes, and optimises that patient’s biomechanics, attitudes, beliefs and desires.
THEREFORE, our approach MUST be different for each patient - there is no room for cookie-cutter approaches.
It also means that our approach must be TRULY patient-centred on their goals and desired outcomes, and applying our holistic knowledge to that scenario (which will OFTEN mean not just RCT-proven methods!)
Patient centred care is not just applying gold standard to everything. TRUE patient centred care is applying our collective knowledge to achieve an outcome as close to desirable as possible.
In summary, the damage done by polarised training modalities is not simply the fault of the uneducated athlete or weekend warrior. We as professionals are as much to blame.
We have the privilege of having one of the most scientific and respected professions, and it is our role to be a trusted advisor in a truly patient-centred approach to help people achieve their desired outcomes is a healthy, sustainable and enjoyable manner.
And how much fun is that!?
I couldn’t put it better myself; our roles as physiotherapists is about educating and leading patients into healthier choices whilst empowering them to achieve their own goals. If this is aesthetically driven, have at it, but retain the most important commodity for the patient – their own health. Maybe try to steer clear of the points mentioned briefly above.. More to come on a lot of this. Stay tuned!
What have movement screens done for you lately? Why the movement screen was never meant to predict injury.
The humble screen, my how you have grown! So big and useful you have grown! What great things you can do now movement screen! Not just a little movement screen anymore are you?
Thank you for tuning into another instalment of my blog. I had planned to write this blog before the more recent BJSM post and other interesting media outlets, so this is quite topical at present and seemingly serendipitous.
The rise of the movement screen
Informally, the process of movement screening has probably been around for as long as humans have walked the earth; humans have always assessed and evaluated the way another human moves. On screening movement you can check if the other caveman is threatening, welcoming, wounded or lame, stronger or weaker than you and you can make a quick decision from there. Formally, this process is newer. It comes in many forms; check out these links for some examples:
- Australian Rugby Union has a few, here is a brief description of one.
The most prolific of all movement screens has been the Functional Movement Screen, created by four very smart blokes with an incredible amount of work; I don’t think anyone will ever doubt that. Very troubling is the fact that most of their literature comes endorsed by the very system they are trying to investigate. Here is a very quick summary of the literature on the FMS:
- Reliability: Established early in the piece but Teyhen et al in 2012 provided some backing for this. This was only within 2 raters and 10 participants mind you. Two recent systematic reviews and meta-analyses, one in 2016 and one in 2017 show that the FMS does at least have good inter and intra-rater reliability. It seems common sense, that a systematic approach to look at something should demonstrate that it is pretty hard to mess up and go too far off track.
- Performance association: A big trial by Chapman, Laymon & Arnold demonstrated that track and field athletes with a lower score on the FMS did not improve in performance like their counterparts who scored higher. Athletes that had 1 or more asymmetry performed worse than those who were symmetrical and athletes that scored 1 on the deep squat movement performed worse than those who scored 2 or 3. It would seem intuitive that athletes who have a left-right difference won’t perform as well in a sport that is largely single-legged. It would also seem intuitive that those athletes that can’t perform a squat very well, the very exercise that is prolific in many strength and conditioning programs, won’t be very efficient in enhancing their performance; because the coach can’t get them to squat!
- Injury risk prediction: Proposed in a seminal paper by Kyle Kiesel in 2007. Now one of the main-stays of their literature arsenal and the most hotly-debated topic. Some of the main headlines –
So, the FMS has fairly rapidly moved from being the darling of the health and fitness world, capable of so much, to being downtrodden by the mainstream sports medicine literature.
So what is the crux of the question? Injuries are about more than movement.
The movement screen was never designed to predict injury. Something as complicated as injury cannot be predicted on movement alone.
Movement is one small (BUT INCREDIBLY COMPLEX) part of the process. Let’s put it this way, you don’t even have to move to get injured; think postural pain in athletes. Screening is one small part of the process towards finding out more about an athlete or a patient and their ability to move. A part of your data gathering process, if you want to make it systematic, then you need to use a systematic approach. It is finding out whether they can actually just perform the ‘basic’ movement patterns that most modern day practitioners use in order to strengthen or rehabilitate someone. After you find out if they can or can’t do the movement pattern you require – or screen them - the authors of FMS have proposed you then assess their performance in these – or similar – movement patterns. If there are any issues along the way you stop and assess the actual reason why they can’t do it.
There is no diagnostic process in a screen, nor was there every meant to be. There is no prediction of injury from a screen and in my opinion Kyle Kiesel made a huge error in reasoning when he proposed injury risk association. So why don’t we all accept this, move on and stop arguing a moot point. It will be (or now has been?) advantageous for the field of health and fitness to stop thinking of the FMS as a magic bullet, but throwing stones doesn’t really get anyone anywhere.
Screening is just one part of the process. Generally a screen leads to a dichotomised outcome; in a movement screen's case it is, 'can the athlete perform the movement you are after or not?' If not, it is down to the clinician to determine why not. Again, a screen does not diagnose anything. Let alone, crystal ball into future athletic endeavours and predict injury. Injury is about (amongst a myriad of others):
- Appropriate loading; see Gabbett's 2016 landmark paper,
- External variables out of the control of the athlete and/or coach,
- Stress and mental wellness,
And yes, then the massive topic of movement; neuromuscular control, stability, muscle mechanical 'hardware', efficiency of contraction. It just isn't all about whether they can perform a squat or lunge. What is needed is to plug movement screening values into a multi-logistic regression model with other variables like loading and stress and then determine the exact weighting of movement screening amongst other injury variables in predictive strength.
Does it even assess movement?
This is, in my opinion, probably the argument we ought to be having instead of whether movement screens can predict injury. Movement is formed from billions of inputs and one glorious output. It is the ultimate in complex behaviour, at least in my opinion. I work with what it arguably the most popular movement screen - the FMS - every day, so I think I can speak on its utility to a certain degree of qualification.
Besides what the above paragraphs may look like I actually think the FMS is an incredibly useful tool for the following reasons:
I think it’s a big omission to not have any pulling movements in the FMS, but for 20+ years of thought and effort, I do honestly think it is a great overall screen of basic human movement patterns.
The only real negative I personally have with the FMS is its structure. Funnily enough this is probably its biggest strength. Human movement is insanely complex, beautiful, wide-ranging and it is hard to think that you can gather all the information you need to with a screen of 7 basic tasks. I have a background of Ido Portal’s movement approach and read a fair bit into Frans Bosch, so my view on this is that movement is too complex to even attempt to box it in. What may be a 'flaw' for one person, may be a strength to another. Some of the best athletes out there have what are traditionally considered movement flaws.
Systemising your approach to assessing an athlete's movement is STILL important though, and if your strength and conditioning or rehabilitation program includes the elements of the FMS, then use it! It is simpler and fairly comprehensive for most programs out there. But why the hell does the squat archetype have to be with the toes pointed forward? Different squats for different hips folks..
But I may leave the question of ‘whether the movement screen actually screens movement’ up to you. What do you think?
Better late than never.. That seems to be a theme for me of late. Sometimes life just gets busy though.
Thanks to the talented Robbie McCullagh, strength and conditioning coach with the NSW Police Force, for delivering his reflective and insightful thoughts on this ever growing topic. I asked for definitions of the terms; mobility, stability, strength and flexibility and then an application of these components within high performance scenarios AND rehabilitation scenarios. To stimulate more of a debate, if you feel so inclined, share your knowledge and provide me with your thoughts!
Mobility: The freedom of movement. From an S&C perspective this is mostly seen by an athlete who can or can’t get into the posture you are asking for (e.g. a lunge pattern) or to achieves the range by taking it away from another area (. e.g Overhead deep squat, you will commonly see and athlete achieve full depth but the arms and head are in correct alignment). Probably the most confusing for a S&C coach as the reason for that mobility restriction could be several things.
Stability: The skill to have static contractions of a group of muscles to control a joint. When most S&C first hear of “stability” they think about a joint that is locked and doesn’t move. Although a locked ankle that may not over pronate is beneficial (i.e rigid strapping tape), stability for me must be more than that and be a motor control skill of the athlete that can be turned on and off when required.
Strength: The ability to produce and absorb force with another object. Simple but very important.
Flexibility: The ability of soft tissue and joints to move through a range of motion. It is not just the sarcomeres but also the tendon and joint health itself.
How do you see the interaction of these leading to increase performance?
All 4 are constantly coming in and out of play when addressing performance objectives with an athlete and the level to which each play is dependent on the task at hand.
The easiest scapegoat for an S&C when something is lacking is the strength component. Strength is so important in athletic movement patterns that enough is never really enough. A strong athlete you can make fast, powerful, reactive, durable and efficient in all movement patterns (i.e a high performer). The only reason we don’t constantly chase strength is the effort to reward ratio becomes too large and we lose focus of the other athletic attributes.
Although strength is the easy scapegoat it’s not always the best when increasing performance levels. You can throw plates on the bar every week but if you don’t have the flexibility, mobility and stability you aren’t going to improve. Sometimes the best way to increase performance can be addressing the weakest link or as a good physio once told me, take the handbrake off. For example, if the athlete can’t get into postures to generate or absorb force in a task then it doesn’t matter how big their squat, deadlift or bench is; their force transfer doesn’t exist so their performance outcome will suffer due to a mobility issue. Another strategy for addressing the weakest link is increasing stability of a joint so muscles have a stable base to work from. Common joints this applies to are the shoulder and hip. So many athletic movements require the arms and legs and as mentioned, if the base is unstable (e.g. shoulder girdle or pelvis) it’s hard to be efficient in transferring 100% of the force generated to another object.
How do you see the interaction of these leading to rehabilitation?
Not much changes when coaching rehabilitation because all 4 components are still required before you can confidently discharge someone from the rehab group. Over the years I tend to look for mobility, stability, strength and flexibility concerns in slightly a different light of importance in the rehab population. As with performance outcomes, all are still important and addressed but in most cases mobility needs to be frequently re-assessed as the first limiting factor. Weather the mechanism of injury is acute and the limb has been mobilised or it is an overuse injury in both cases mobility exercises will be programmed regularly throughout the rehabilitation.
While mobility is usually the first adaptation we are looking for, stability and strength are just as important. Strength still needs to be the driving force and big picture goal of the program. Too often I think as practitioners we address the swelling, the pain and range of motion of the limb but neglect the strength component before discharge occurs. We often return them to day to day strength capacity (i.e it feels easy to move around) but what if often needed is strength capacity to compete in their sport or if possible with a capacity that is above those that the athlete is exposed to in their sport. When load is greater than the athlete’s capacity even on discharge, I would be recommending the strength training should still be included and prioritised in their fitness training. Even in the absence of pain, when training or competition loads are greater than the athlete’s capacity the chances of re-injury are still high. It’s hard to prioritise when your players need to train and compete but a simple solution to this is coach the athletes through progressions and regressions of the movement patterns required. Manipulate the environment with changes in base of support and mechanical load into the limbs and match it to that of the sport/ requirements as supplementary work during their normal training sessions (e.g. warm ups, movement preps etc).
Mobility: Mobility is best described as the athlete’s ability to reach the intended range in a specific skill; it is a weight bearing and multi-joint concept (Ref). Mobility, therefore, is highly dependent on stability and coordination of multiple joints. It can subsequently confusingly be associated with coordinated movement and is espoused to precede a highly-developed locomotor apparatus; a strategy of preventing accidents from happening (Ref). This confusing ‘catch-all’ term has led to a wide discrepancy in what is currently termed mobility training. A solution may be to use the term ‘early motor control’ in some drills instead of ‘mobility’ to avoid confusion. To my knowledge there have been no long-term trials or review studies on the effectiveness on mobility training on performance in comparison to programs without mobility training included.
Stability: Although the concept of stability is very easy to grasp - ‘the state of being stable’ - a definition for this within athletic endeavours becomes more convoluted (Ref). The author contends there are four main important realms of stability within human performance; kinetic chain (upper and lower), girdle, lumbopelvic and trunkal. It is easiest to look at stability as the opposite of energy leakage through a skill performance. This definition is very dependent on Frans Bosch’s work, whether you love or hate him, I think looking at this concept in a more scientific manner is appropriate. A chemical reaction reaches equilibrium when stable, and thus a human body should be stable when there is no ‘lost energy’ and the system has the ability to apply strength to its fullest capacity.
Strength: The application of force. Also simple and in my opinion the only factor amongst these four which is absolutely necessary. Absolute strength is quite different to specific strength, and we can really only test very specific strength. For example 1 RM testing depends on a lot of coordinated movements to occur in the right order, not necessarily on absolute strength. To that end, I don’t think the concept of ‘strength’ is quite done developing yet.
Flexibility: Flexibility refers to the absolute range of motion possible within a joint or series of joints and may be either static or dynamic (Ref). This depends on pretty much every kind of tissue you can imagine surrounding and within the joint.
How do you see the interaction of these leading to increase performance?
A very common, applicable reductionist approach is the mobility, stability model of athletic performance (Ref). Although this is a very useful paradigm to use, it is important to note that more mobility in particular areas may not enhance athletic performance. It may not be functional to the athletic endeavour to garner incredible amounts of ankle range of motion to enable sitting into a deep squat if an athlete cannot control their lower kinetic chain enough to hop and land. In fact, authors have importantly ensured this model remains only a thought model to guide regular strength training practices (Ref). These constructs obviously impact on the skill being performed, and in my opinion they are interdependent. These constructs must be considered together and an ideal balance between the three factors within the individual must be appreciated in order to perform the skill to its fullest capacity.
Strength is an integral component to any high-performance scenario. I think of strength as a vector moving through the ‘playing field’ of flexibility, mobility and stability. We can appreciate that enhancing strength in the wrong direction can be the difference between adding strength to a system which will never be efficient enough to apply any force properly (i.e., too much stability or too much flexibility). Whereas strength applied in the right direction can ensure strength is applied very efficiently and no force is lost. So just adding strength, without consideration for the requirements of the individual is like putting more load on an inefficient system
How do you see the interaction of these leading to rehabilitation?
I don’t see a huge deal of difference, in fact strength generally becomes more important. The integration of mobility, stability and flexibility needs to be assessed before undertaking strength training principles. Athletic injuries and injuries in general are incredibly hard to predict but following an injury, it may be possible to ascertain why they occurred and what mix of flexibility, mobility and stability may have gone wrong. This would give you a head start in rehabilitation, a good assessment of the ‘playing field’ and ‘direction’ you need to move in is of prime importance.
Not everyone needs more flexibility and not everyone needs more stability. In the experienced clinician’s practice, this model happens automatically and is simply intrinsic to successful rehabilitation. In my experience, mobility is increasingly included in 'early motor control' in rehabilitation contexts (Ref). Mobility is an important concept to keep in mind in rehabilitation, but I think it's important to note that not everyone needs to go through mobility first and then onto stabilising joints that you have just made 'mobile'. Instead of going through this as a matter-of-fact, an assessment of what exactly the athlete needs in particular scenarios is important. Mobilising an ankle to enable a lower squat may make it easier to program squats into your rehab, but will this new-found range lead to issues when the athlete has to put everything back into their specific skill again?
Progressing from closed to open skills and into game-play is what is done currently, and when done successfully I would propose it is, essentially moving in the ‘playing field’ in the right direction toward the green light again. More thought as to what mix of mobility, stability, flexibility and strengthening may lead to simply less 'doubling handling' of needless (mobility, stability or flexibility) practices.
Hear me now.. This is a tight little diddy for your ears. Enjoy any of this guy's stuff actually, it's all good. www.youtube.com/watch?v=ndzuvH82gBg
I’ll make no bones about it; I have certainly had my doubts about remaining in the profession. I’m sure this resonates with other young physiotherapists in my position. Generally, physiotherapists (NOTE: this does not apply to me) are graduating from university coming from families of high achievers and are owners of immensely high secondary-school leaving scores, good social skills and athletic ability to match. I generally would attest that most physiotherapy graduates nowadays could have been anything they wanted to be; thrilling that they have chosen physiotherapy. Like me, some of these graduates may have witnessed a glass ceiling fly rapidly toward them. But what is buoying, is that this glass ceiling is continually smashed and replaced ever higher by those pioneers of the profession. And I would like to reiterate my total and utter support for this wonderful profession, as I have had a slight renaissance in my own career, helping me realise how much value it can provide both to every patient, to society at large and to ourselves. I am using this particular post to reconcile some of the thoughts and feelings that may be commonplace in our profession, especially amongst the younger generation of our profession, but not verbalised amongst peers. Thoughts that I have certainly had, and worked through, to help me fall back in love with the profession as a whole. So who, for that matter, are we? And where are we going? I will work through these questions from an average physiotherapist’s perspective.
Like every post in this blog, this should create more questions than solutions, in contrast to the norm in today’s blog-logged media-sphere. Don’t look for solace here.
Out of the primordial soup.. And to the…trees?
I’m sure I’m not alone in feeling pride of being part of a profession that has carved out an immense reputation from a position of subservient lackeys in rehabilitation hospitals; physiotherapy has certainly solidified its place on the face of healthcare. Starting out in the 19th century, originally working as mainly massage therapists, physiotherapy has now grown into the beast it is today. Multifaceted, evidence based, respected and even, well, even treating beasts. We are now independent primary care mavericks, capable of accurate diagnosis and case management that is, in my opinion, unparalleled by other professionals who sit in the sphere. We are capable of doing and being much more than a pair of therapeutic hands to patients; we can change lives through real behaviour change and let’s be honest, even the best surgeons can sometimes be guilty of perpetuating damaging health beliefs. But we mustn’t kid ourselves; the medical profession has about 4000 years on our own development as professionals. And so, we are truly in the infancy of a burgeoning profession. My guess is as good as yours as to how much development can continue, but we hope it’s a lot. These are some points currently on the table regarding extending scope of practice and my take:
From out of the primordial ooze physiotherapists have thrived into the adolescents we are now; more simian than human at the moment. But in the future, we should be recognised as a primary care giver with no equal, a central contact point between all the specialties and other avenues for care. That is what I see at least.
The darlings no more? Exercise or die!
From such a positive note, I’m going to give my spin on where I see the profession currently. Not so positive.
With the failings of manual therapy and with the electro-crazed practice of the 80s and 90s slowly diminishing, we seem to be moving into another era of physiotherapy. Gaining back what is rightfully ours.. exercise right!? We should be doing this better than any other professionals because we originally started out in hospitals doing rehabilitation exercises right!?
Well I hate to be the bearer of bad news, but I sucked at exercise prescription coming out of university because we did a whole one course on the entire prescription and program design malarkey.. I am now a strength and conditioning coach purely because I recognised my failings in one of the most valuable assets to any physiotherapists arsenal; exercise prescription. The majority of our profession just don’t have the adequate knowledge in this area to apply it efficiently.
There may just be some professionals that have and always will do this better than us. Namely those that actually do specialise in exercise.. as their ONLY form of treatment. I’m talking the exercise physiologists, the strength and conditioning coaches (the true ones, not the pretend ones like me). Possibly we can all work together in the future in a lovely rose-coloured, barbell-infused, chalk-exuding erotic future but maybe some professionals may lose out. I’d like to wager that with numbers on our side, it probably won’t be physiotherapists. It does leave a slightly bitter taste in my mouth that professionals who specialise in exercise are being encroached upon by professionals who once specialised in putting sound waves into your skin; somehow magically vibrating a meniscal repair into repairing itself like me boogying to the Beibs.. Come on, it’s OK to like Beiber. But for now physiotherapists are amongst the leading professionals dealing out the panacea with gusto and in the future I see most professionals becoming more like coaches than the traditional manual therapists. See my previous blog on ‘The placebo effect’ for more on my take about manual therapy’s place in the profession (REF). Physiotherapists are already wonderfully placed to use manual therapy sparingly to enhance patient trust and confidence in their own bodies. No other exercise profession has this ability. Put together with our diagnostic capabilities and developing exercise prescription abilities, I do see a rosey future indeed for physiotherapists. Teenage years are tough though..
The art in the profession...
I don’t succumb to the clinician and researcher dichotomy, but there is evidently still a divide between research and clinical practice (Ref). Without a doubt, though, physiotherapists are amongst the best professionals with utilising and adopting research in clinical practice (Ref). We have always been less ‘art’ than most other professions, and we are getting better all the time. Critical analysis of evidence and integration into clinical practice has, and will, always be a strength of the profession. In fact, current clinical practice seems to be more closely aligned with research practice that it ever has been. And certainly, cutting edge clinical practice, seems to have vastly outstripped any research quantification when it comes to exercise practice. Maybe now, we need research to catch up to clinical practice and investigate or debunk some of the things we see in popular media formats every day.
Getting social.. The Wild West
Which brings us to novel technologies and media.. This would seem to be the main reason as to why clinical practice and research are so closely tracking nowadays. Never before has current evidence been more available, literally at your fingertips. The never-ending barrage of information from the interwebbings, twitter, Instagram, Snapchat and Facebook has armed an entire generation with… well information. It is still up to the clinician to utilise their own critical analysis skills in these spheres; to adapt and adopt as they see fit. I’m not going to say every bit of information is useable.. Because it’s just not. In fact, I do have some reservations about this new ‘wild west’. The volume, speed and directness of the information on various social media platforms do make me think it is slightly more difficult to apply typical critical analyses. The problem, in my mind, comes from a conclusion made and applied to peer-reviewed research by a second-hand source online, which then duplicates and infiltrates practice. There is not so much need to go directly to the source anymore, and potentially judgement errors based on another’s false conclusions could become more of an issue than ever before. Third-party social media posts are a student’s wet-dream, but can also be problematic purely because they may be followed without question. But then again, we all must learn and I have certainly been guilty of this.
It truly is the Wild West for most of the profession; particularly our more respected and experienced clinicians. The dearth of their knowledge remains untapped outside the realm of cyber space and it continues to be a case of the loudest voice gets heard the most. Meaning the most eye-catching and engaging posts are those made by clinicians who are ‘good’ on social media, tending to be the youngest (generalising here). Generally these posts don’t offer much in the way of truly practice-shaping information. Posts that would be of more value are those made by clinicians with many more years’ worth of experience but they sure as hell wouldn’t be as sexy and naturally my feed wouldn’t include these... In the future, I do see the older generation of clinicians, those worth learning the bulk of clinical know-how from; putting out some hyper-sexy eye-catching posts (the APA has even written a guide to help! Eek; Ref). I also would like to see some more regulation of student’s social media-learning and content designed specifically for social media; potentially courses that sound like, ‘Online critical analysis and social media research methodology; TWEETER1111’ will be commonplace in various health degrees.
No conclusions.. Just dance. https://www.youtube.com/watch?v=fRh_vgS2dFE
My Proposed explanation for an ineffectual system
If the fact that pain from musculoskeletal sources continues to be, basically, the most burdensome chronic condition faced by developed countries (Ref) has irked you as much as it has me, then you won't mind this aside from the regular playbook. The 'State of the Union' address is coming up, I promise you. My first post, on the pathologising of pain, caused some confusion with some so this might help clear that up.
So why is the pathologising of pain a bad thing? Because it leads to a massive burden; yet another that our generation now has to live with. I have developed a model on how, I believe, the pathologising of pain has directly attributed to a global burden and potential solutions to this. It is useful to think of pain, not as you may know it, but as a third variable - a 'meme' if you will. A social gene that propagates throughout society depending on its utility.
In my opinion the current healthcare system's over-diagnosis, over-investigation and over-treatment has lead entire populations into a state of dysfunctional pain beliefs and has lead to reward systems reinforcing these. Our society is now, effectively, in a 'hyper-pain' state, where pain is not transiently troublesome as it may have been in the 1920s. It is permanent, it permeates society, it is monetised and it has an entire industry devoted to it. Maybe the best thing for society is to keep moving, get less obese, get less sedentary and - low and behold - to be left alone and let natural history do what it does best.. resolve issues. Only intervening significantly in the truly pathological cases might be a start. This goes hand in hand with the message from most of the mainstream physiotherapy media for the last 5 years; simple advice is the cornerstone of all treatment. This gives the power back into the patient's hands and reduces any risk of destructive pain beliefs. And as always I'm keeping this discussion localised to my profession, as I am only qualified to do so, but I wonder what would happen if surgeons had more stringent regulations on operating for pain in all areas of the body?
In my 'ideal world' pain is incorporated into public health campaigns, so EVERYONE knows the value of truly pathological pain and the mechanisms through which these come about. Our red flag, spinal cord compression, cauda equina and radiculopathy screening questionnaires should be in the hands of everyone to utilise. Everyone should have the awareness of the natural history of low back pain. A push toward normalising the 'minor' types of pain and injuries, so these do not become larger issues, should be implemented. Lastly, and the toughest one, is building a system around regulating the over-treatment (with passive modalities) that is rife amongst some industry sectors. Health insurance companies already cap the amount of rebates you will receive, but maybe tougher regulation of this has to exist? Possibly health insurance companies should go further to reward you for less visits to the ch(.. almost said it...) - ah nearest practitioner - similar to the way they reward healthy lifestyle behaviours. This is in the 'private' sector; the public sector may have to rely more on educational strategies starting at basic, primary-age, levels.
Well now that the nastiness of money has been dealt with, stick with me for a brief word on placebo. There is a dearth of literature on the topic and I would invite the reader to the Resources tab for more information; there will be plenty more goodies popping up in there from time to time, so don’t be shy.
Placebo; a wonderful effect (Ref). One that all manner of professionals in the western medical world should be well aware of. It is mediated by our endogenous opioid system and is very reliant on expectations, which is obviously important in our treatment realm. A couple of brainy people used neuroimaging studies (PET and opioid selective radiotransmitter) in healthy volunteers and those who showed a large response to a placebo effect were more likely to have lower reported levels of pain (Ref). In other words, if your endogenous ‘modulating’ opioid system is highly tuned, you can experience a higher level of placebo pain relief. Another study demonstrated that with all else accounted for, the individual variance in pain came down to participants’ internal affective state during pain and the affective quality of pain (it is worth noting that this is in only 20 healthy males.... pain capacity questionable!? But then again they were Italian…) (Ref). In other words, how they felt whilst in pain and to what ‘expectation’ they attributed to the pain (Ref). Indeed, placebo works better when you think it will work (Ref).
In the land of placebo, expectation is king.
Manual therapy and the more traditional ilk of physiotherapy have a questionable position in any (sensible) clinician’s mind surely (Ref, Ref). Low back pain is the most burdensome condition that we will encounter as an industry. We are not alone, in physiotherapy, in the futility of our measures. It seems most primary care treatments are generally all about as useless as each other (Ref) and the relapsing-remitting course of low back pain may continue unabated whether we intervene or not (Ref, Ref). For a young physiotherapist like me it engenders a somewhat untenable position for manual therapy; knowing that a core skill is really no better than placebo. We have popular media constantly reminding us of the power of exercise and the drawbacks of manual therapy (Ref) @trustmephysiotherapist. So we evolve or die and upskill (like I have done) in other more effective areas.
But do we throw out the baby with the bathwater? And what will the APA do if everyone stops going to manual therapy courses!? More seriously, where does this leave an entire generation of new physiotherapists, who are classically trained, but all too aware of the failings of this approach? What does the tidal wave of graduates actually do with their hands!?
I would like to present an argument for the use of manual therapy born from the philosophy of 'harnessing the placebo'. A tough muscular release can be just another way to enhance the capability of a patient’s endogenous opioid system; just like the muscle that gets bigger when you use it ie. Exercise for the placebo/pain system! They never knew they could go through that much pain and still move! I have always been of the mindset that, in the land of the placebo, physiotherapists need to let go of some professional pride and just 'harness the placebo'. Use it for good not bad. What we are really after in the finality of things, is behaviour change, and Pavlov’s Dogs did not stop salivating overnight. Play the long game; accept that a bit of placebo in the form of hands-on may garner some trust, which might allow you to challenge your patients’ expectations and conditioned responses to pain and exercise. In fact, from my clinical experience, remaining completely hands-off may be the nocebo that we all dread. Patients are coming to us because, in large part, a series of conditioned responses in their past. Until patients stop coming to physiotherapists expecting exactly what the chiropractor does, manual therapy can be a crucial ally to be used to our advantage. Moving patients towards positive attributions of pain and reducing fear avoidance conditioning is where the profession is headed, but I’m not sure about the medical system as a whole.
The issue of overdependence, that is espoused to come from solely manual therapy and other adjuncts, may derive moreso from a system that generates a conditioned response to pain. Patients are over diagnosed and overprescribed from top down with poor language choices throughout the entire process. The RACGP guidelines on musculoskeletal disorders proves for interesting reading (Ref). And then yes, then they are probably over treated with the wildly inefficient use of manual therapy from various professions. This creates a perfect storm of endogenous opioid weaklings incapable of their own placebo, with warped belief systems, expectations and reward systems around pain.
To conclude from this month - the payment paradox and placebo - if private physiotherapy is the way forward, we may be destined for a generation of practitioners that cease to value manual therapy; this might lose the power of the placebo for the entire profession! Manual therapy can be useful to alter patients’ expectations and conditioned responses, if done in combination with good education. Use manual therapy sparingly ALWAYS with education, remember you are not treating pain, and invest in what your patient values...
Wait you already do that!? Well I guess I’ll just lay this dank beat on you then, because this has obviously been of no use https://www.youtube.com/watch?v=jBuwC4VJi50 . In honour of the late great... and our profession of course!
Following on from last month’s blog on the pathologising and monetisation of pain, I’m delving further into the capitalist machine of health and welfare. The public-private practice divide in physiotherapy encapsulates other issues surrounding access to healthcare and the social constructs around this. But we’re staying fairly microscopic with this post, don’t worry. This will also be delivered in two parts, as it blew out a touch.. Who knew these topics were so involved.
After graduating I was certain I needed more experience in every aspect of physiotherapy and began cutting my teeth in the public sector outpatient departments and orthopaedic wards. I have since worked privately in a typical musculoskeletal clinic, I have run my own business and now I am fortunate enough to be in a third party payment position. So having been to both corners I feel I am in some position to ask important questions.
So that’s what I’m doing; you will hear from both the public side and the private side in a debate about the value of payment in physiotherapy (and hopefully this extends to other health areas in time).
“I will take your money and provide the advice that you need to stop giving me your money”
A refreshing push toward using the simple things well is becoming apparent in physiotherapy literature and popular media. I have felt hamstrung by the payment paradox through various stages of my career. The best practitioners I know are excellent diagnosticians capable of determining the root cause of musculoskeletal disorders. They will provide appropriate advice to create empowered, active copers through behaviour change; essentially ensuring patients do not come back. Are we, as physiotherapists, doing ourselves out of a job? In ensuring your business thrives, the ‘ethos’ of physiotherapy (in my opinion) seems muddied. Does payment simply propagate the system and cycle of ongoing dependency?
I asked the following three questions to the most esteemed public and private practitioners that I am aware of in my immediate vicinity; if you need to know more about these legends, please click on the links to their Linkedin profiles. Chris Barnett and Steve McCullagh.
- Do you think, as a public/private service, a patient not paying/paying for your time has an impact on YOUR service as a practitioner? Explain your response.
- Do you think, as a public/private service, patients not paying/paying for your time has an impact on the outcomes of your service?
- If so (above), why? If not (above), why not?
CB: For me the question is about behaviour change and does a fee paying structure change the behaviour and hence the outcome?
Some private health insurance companies in the (United) States take the opposite approach and pay their members for healthy behaviours and ultimately outcomes.
For example $500 for 10% weight loss and $500 bonus for keeping it off for 1 year. Charging people to get healthy is a bit like a gymnasium model; everyone starts off paying their monthly premium but then soon drops out.
Receiving a service for free, such as a public physiotherapy could actually be an issue of equity. Social determinants of health tell us that the people who can least afford high quality nutritious food and, gym memberships have the poorest health outcomes. Charging this community will not, in my opinion, lead to better outcomes but price them out of the market. However, that's not to say that the relatively wealthy middle classes (the worried well) would do better with a payment structure that equated to a commitment and behaviour change.
So it's a question of value, and for me public patients are still 'paying' with their relatively exorbitant car park fees, their bus tickets, their time to get child care, and will only attend if they value the service that is being offered. That's a service that respectful of their rights, non-judgmental, truly patient-centred and collaborative.
There have been attempts to charge people for non-attendance in public sector, I'm not sure of the outcomes of these ventures, but think SMS reminders and other avenues such as Telehealth that are built around the patient are good options.
SM: Do you think, as a private service, a patient paying for your time has an impact on YOUR service as a practitioner? Explain your response.
When a patient pays; their expectations for the services are stronger, and need to be addressed more, than a patient who is not paying for the service. For me personally, there is very little difference between the actual services provided. When a patient is paying, I will be more attentive to their expectations (due to the strength of these), but I will invariably be attempting to lead them down the same journey as the patient who is not paying.
Do you think, as a private service, patients paying for your time have an impact on the outcomes of your service?
I find the challenge with paying patients is educating and getting to the bottom of what a truly successful outcome is. Education that just the absence of pain, is not a true success and is likely, temporary. The underlying activities, pathology, strength or conditioning has not been adequately addressed. Often patients who are paying, will 'self discharge' in the absence of pain, as their ingrained expectation is no pain = job done.
When a patient is not paying, they are generally more open to continuing beyond this asymptomatic period; to a baseline and performance phase of their rehabilitation and long term outcomes.
This 'self discharging' needs to be addressed at the outset. This involves clear explanation of what the pathology is, how the recovery will track, the patients expectations and focusing not on pain and disability, but what the patients real success and goals are, in the medium to long term. If you can achieve these outcomes in a timely and cost effective manner, patients will love you for it! If they need to keep returning for flare ups, re-injury, failure or similar injuries, they wont be singing your praises for long.
There is a common theme; both practitioners make it clear to be successful you need to be attentive to patient values and collaborate toward a combined goal. I think it truly does come down to a question of value. What does the patient in front of you value? Social constructs may dictate how your patient will value being free of pain versus enhanced function and quality of life; I would hazard a guess that only in some specific circumstances do these values align with your own as a practitioner. I have been to both sides of the divide and in my view the only things you are really trying to create in individual patients is behaviour change; again both practitioners above champion this with their own language.
In my view, I don’t think physiotherapy has quite the staying power when combating other more powerful social constructs (education, lifestyle habits, and socioeconomic status) in the public environment. I know I would rather put a roof over my babies’ head over buying a gym membership; I think presuming the success of outpatient physiotherapy in a public environment is looking through some slightly rose-tinted glasses. Heck, the buy-in for improved health and function has already occurred when someone has paid for the service. In a private environment, however, I think the monetisation of pain leads to a muddied message from even the best practitioners. I know myself I found it difficult to give a guilt-free message of empowerment and self-reliance. But I think the future of physiotherapy certainly lies more with the private enterprises; what they will look like in years to come is another thing altogether.
End of part 1.
Just like this post, this song delivers so much and then ends halfway through... leaving you wanting and a little empty inside. But it rocks and you should listen to it. Then have some chocolate to ease the pain of humanity going to shit. https://www.youtube.com/watch?v=mdSf1RFKcsE
This blog is purely an expression of a wandering mind; it should only serve to open up discussion points and I do not claim to be an authority on any matters. If you do feel like getting in touch, by all means do so, but please respond to this blog only when presenting an open mindset as that is all I am espousing in the finality of things.
As I am a physiotherapist, I will begin this blog with topics that I am equipped to discuss. This is the run sheet for the first year of my blog. If this seems like something you might be interested in, stay tuned:
Setting the tone
I will deliver more about myself in upcoming blogs and explain more about the specific context from which my particular viewpoints are formed. I will state at the outset, however, that I deal with the ‘painful person’ every day, just as many of you do. This is my job, my bread and butter; we treat pain first and foremost. My constant pondering has lead me to the important question;
“Am I part of the problem?”
Pain and its evolution
This is not the forum for elaborating on the evolution and subsequent description of various physiological, neurophysiological, behavioural and social aspects to the pain picture. And I won’t. Suffice to say, there is a plethora of reading on the subject (1-5).
From Descartes almost 400 years ago, through to Melzack and Wall of the 1960s and even to the current pioneers in the field of pain science like Lorimer Moseley, Michael Sullivan and the Neuro Orthopaedic Institute (NOI) group, I don’t think anyone has argued that pain works. Pain is essential to survival. Pain behaviour and the communication of these sensations will increase our chances of survival, not only as individuals but as a species. Further, the human being’s ability to empathise with another who is experiencing pain is an enduring reminder of the really quite altruistic aspects of society as a whole. We all recognise somebody in pain, and will all lend a hand to comfort; more often than not this hand is in digital form nowadays.
But what is it about pain that you have a problem with?
While most types of pain result in a loss of Quality of Life, I am particularly concerned about the tidal wave of Years Lived (or Lost?) with/to Disability (YLDs) due to musculoskeletal conditions that we seem to be experiencing. Low back pain is a notable inclusion into musculoskeletal disorders by most definitions (alongside arthritic conditions and osteoporosis). Low back pain is placed by The Global Burden of Diseases study as ranked first for disease burden within Australia and New Zealand from 1990 through to 2010 (6). AIHW places musculoskeletal problems 2nd and low back pain as 3rd in disease burden in 2011; let’s call a spade a spade and hand the ‘pain’ we (health professsionals) deal with the number two spot (7). In essence, for people that continue to live, pain is really only eclipsed by mental illness. And I think the mental health community and its advocates have done something incredibly insightful that we, in the health field, have yet to do.
So what? Pain is a big issue, that’s why there are so many of us.
To expand; I think ‘us’ as a health professional collective may have a lot more to answer for than we would care to admit.
“Am I part of the problem?”
I think about this all the time. What exactly is the simple act of my interaction (let alone intervention) with this patient doing to the global system? As you might see, in the next post, I will explain a little more about why I’m in a luxurious position to seriously consider this thought. I want to make it clear that I am not taking the moral high ground here, I’m simply in a lucky position and have thus far experienced, first-hand, multiple different contexts of care. I am going to address the elephant; hello elephant.
There is an industry devoted to treating pain, and you’re telling me that by doing my job I’m adding to a global burden?
Well yes, I am.
F**$ you pal, and the horse you rode in on.
Understandable. To extrapolate, let us consider the Global Disease Burden study; if an industry was devoted to managing a certain phenomenon, doesn’t it seem logical that in 20 years that particular industry could have made a certain impact? But then again why would we want low back pain to come off the number one and/or two spots? Yes, before you mention it, I do also consider an ageing, more obese, less active population and an improved management of other chronic health conditions to confound these results. I still contend, however, this argument is valid and the answer may be subtler than just blaming it on fat people not moving around; there may be a subversive, pervasive force at play that is not yet fully realised. What exactly is the social value of pain in today's world, in the Darwinian sense? Has the original utility of pain (to ensure survival of our species) attenuated somewhat due to the myriad of things the sufferer can get/buy/take/seek out? Pain is no longer associated with survival as closely as it once was. The modern mavericks for pain science have given us a lot of fantastic understanding, and I have to demonstrate my bias here; I think physiotherapists do the best job of incorporating this into practice than any other health professional out there. But therein lies the crux of my argument; does it make the impact on a population level that is required to reduce a global burden such as this? I don’t have an answer, but I do have a few points that may address the issue:
1. Change the response to pain and the behaviour of an industry devoted to it.
Do we need to start to change our own response to the everyday back patient that walks in the door? Does pain need to become the by-product and not the main intervention source for all professionals working in the musculoskeletal realm? Again, I think physiotherapists do the most by way of instilling confidence, focusing on function and restoring ability where disability may flourish instead, but as an industry do we need to start shifting our perceptions? Accuracy of language and appropriate use of resources is needed on a population level to make the impact that is necessary. We would need to recognise, and one day appropriately deal with, those people that may propogate pain throughout the population, essentially returning pockets of the population back to 'pain-normal'. The STarT Back group out of the UK (Keele University) have made good headway in this regards, by way of stratifying the number of sessions given to patients according to psychosocial and behavioural response to an episode. In a fairly robust randomised control trial, a structured approach such as this was shown to result in greater mean health benefit (in Quality Adjusted Life Years) and fewer work days lost because of back pain (Hills et al 2011) (8, 9).
2. Normalising pain, like a similar push in the mental health realm, may mean social reinforcements to pain behaviour may also change.
With this, starting young is the key; again I don’t have many answers for this, but this is where it must start. We have all come across family units with a long history of chronic pain; children in these units have been indoctrinated and don't have a choice in what vaues they will ascribe to pain. These family units theoretically skew a population into 'pain-positive' rather than 'pain-normal'. A social environment that opens a discussion on why moving and living through pain (from musculoskeletal sources) is a normal process may have the ability to change the current context of pain. A top down approach with public education would potentially be necessary in this regard. I’m not, in any way, comparing pain to smoking, but public campaigns worked to change societal behaviours around this. Surely a measured public campaign from Governmental sources (instead of any one particular professional body) may eventually be a logical place to start?
So in conclusion, I don’t foresee a changing of the physiology of pain in the human being. Pain still works, it keeps us alive. What happens when you pathologise something so much, however, is that it becomes a problem. For ALL of us. Yes, it means more business for us in the future, but at what cost for society en mass? I foresee that to tackle this global issue, a perception shift is needed.
Here's a link to a song that will soothe the cerebral synapses, or potentially anger them further.. If against all odds you stuck in until the end of the post.. Enjoy this banger, go on, you deserve it.. https://www.youtube.com/watch?v=mVR10CD2Alk
References in Resources tab.
Connor Gleadhill, APAM. S&C. B. PHTY (Hons).
Lead Physiotherapist, NSW Police Force RECON and RESTART programs.
Thoughts from an average physio with an overactive mind.