The eternal struggle for outcomes in physiotherapy is in large part due to compliance, or lack thereof. I’m going to break this concept down and attempt to arrive at some strategies. Non-compliance for exercise in physiotherapy has reported to be as high as 70% (Ref). Personally, I always knew compliance rates in physiotherapy were low, but to think it could be as low as 30% for any HEP is quite sobering. Of course, it is not so cut and dry as there are many nuances and intricacies in the massive issue of treatment adherence and by no means is physiotherapy alone in low compliance rates. But I would like to hazard a guess, that if not ‘sold’ well, compliance rates can be much higher than 70%.
So why so low?
A systematic review by Jack et al in 2010 (Ref) outlined factors affecting barriers to treatment adherence in physiotherapy outpatient clinics, these will seem obvious to the clinician, but appropriately researched (all cohorts, however):
-High levels of pain: I think physios are already pretty damn good at understanding patient’s experiences and beliefs about pain. It is one of the central tenants of our profession to challenge mal-adaptive responses to pain, so in this barrier, physiotherapists are already doing enough.
- Low levels of physical activity (PA): Again, this would seem like common-sense to the tuned in practitioner but in particular some interesting issues include poor programme organisation and leadership and poor education. Issues like poor history of exercise, perceived physical frailty, perceived poor health and readiness to change are other barriers to change, which make a fair bit of sense.
- Self-efficacy: If your patients have low confidence in your ability to undertake the exercises prescribed they will hardly go out of their way to actually do them. Again, this is something I think is done quite poorly; explained in the clinic on paper but never actually demonstrated and confronting patient’s low self-efficacy levels.
- Depression, anxiety & helplessness: Something that impacts on the entire picture of treatment of someone coming to the clinic, and something that should be at the forefront of ‘tackling’ as soon as possible.
- Low levels of social activity
- Patient’s perception of barriers to exercise: Now I think this can entail everything like, oh, say, the entirety of life, so in reality this is HUGE! So every time you hear, ‘I couldn’t do my exercises because I couldn’t find 5 minutes between walking from my desk at work to the printer,’ this is a perception thing, even though you have sold the ‘exercise thing’ phenomenally and removed seemingly every single barrier possible. I think this relates to the (transtheoretical) stage of change they are currently in and there are there are obviously other nuances here that complicate these perceptions (like depression, anxiety and helplessness above). There is evidence that implementing coping plans may help patients to overcome difficulties (Ref), but there are other strategies that may be of benefit that I will outline below.
In a newer systematic review, Beinart et al 2013 (Ref) (11 RCTs and 3 cohorts), outlined that distress levels, whether higher or lower were not overly associated with adherence in chronic low back pain patients. Higher pain levels were very weakly associated with lower adherence and the same can be said for disability levels.
So what can be done?
1. Communication is key.
Lonsdale et al 2017 (Ref) performed a large (n=308) well-designed RCT across multiple centres in Ireland. 50 physios delivered either a control intervention consisting of standard care for chronic low back pain patients or the treatment intervention, which consisted of motivational interviewing techniques designed to upgrade adherence. More on these techniques can be found here. When physiotherapists were trained in communication to increase adherence in 2 main (related) theoretical realms:
2. Building motivation to exercise
Chan et al 2009 (Ref) , designed a retrospective cohort (n=115), where participants were asked to recall their experience of ACL rehab and using algorithms they determined a level of therapist ‘autonomy-supportive’ behaviour; they demonstrated that when therapist behaviour was more autonomy-supportive, this had increased effect on motivation and subsequently (apparently adherence).
Beinart’s systematic review demonstrated that only one individual patient factor had moderate evidence to be associated with adherence:
The above points demonstrate, that building intrinsic motivation to exercise in individuals, increases self-efficacy and gives the individual a perception that they can actually do some exercise. Herein, lies the crux of it; if you tell them they can do it, they may actually do some activity, and THEN they may do some of your home exercises as well! Halleluyah!
Supervision has been shown to be a very positive factor in improving exercise adherence (Ref , Ref ). I think this has been pretty well understood for a while, it generally crops up in most large reviews for any treatment intervention, and I am remiss to even mention this as the general gist of this post is to explore factors related to exercises you prescribe for patients when you can’t watch them, but this is important; supervise your patients doing their exercises, if only for a wee bit. It helps.
4. The art of the sell
If you can sell your program, and I mean really sell it, not just ‘promote’ it, then you can project an increase in uptake. I think more physiotherapists do need to understand more sales principles, we are a profession that has always been behind other professions like chiropractors and osteopaths in ‘the art of the deal’. And in turn, if more physios can use good sales technique, spend less time selling an individual treatment and more time selling self-management; well that seems like a world-changing idea to me.
I think this is very underutilised; as an S&C I have the benefit of seeing things from two professional backgrounds. Physiotherapists are again, typically very poor at periodisation. Periodisation is the cycling of various aspects of a training program, or exercise regime. In S&C, variation of exercises, load, volume etc. etc. etc. is the key component to optimal physical performance; physiotherapists generally produce a horribly repetitive linear progressive overload with not much extra stimulus for the patient. If patients were exposed to more principles of periodisation in their home exercise programs, they would remain more interested and the ‘learning effect’ from mastering one exercise which links to their problematic movement, would cross over into their overall pain issue and promote more self-efficacy. For example when prescribing for shoulder pain with trouble through forward flexion and horizontal push patterns programming scapular push-ups is great, but periodising not only the sets and reps over your rehab program will help maintain motivation, but accessory exercises – like a cable paloff press - will help challenge the neural control mechanisms and enhance capacity in the movement.
Compliance; one of the biggest issues facing the musculoskeletal chronic pain burden on society. Inherently really very difficult to achieve for any treatment, but physiotherapy is evidently abysmal at it. So try more strategies, but remember, communication is key and motivation is king.
It is time to step up; we’ve all got to become leaders.
A topic that makes a lot of people very passionate, but particularly me. This is written from a perspective of a clinician with an awareness of the inadequacies of the healthcare system but also the profession in general.
Physiotherapy, as a profession, is in a wonderful position to truly lead the health system out of the curative, illness-sustaining model and into a new preventative, wellness-promoting model. This system, that is designed to keep people unhealthy, is also designed to keep people in pain; and until things change chronic pain will continue to be a massive burden on today’s society. I think allied health, in general, can become a leading field to change the public’s perception about musculoskeletal pain but I can focus on physiotherapy as it is my field of knowledge; if you can extend this to your own practice in another field, let me know!
A good definition of leadership is (Ref),
‘a social influence process through which emergent coordination (involving social order) and change (i.e. new values, attitudes, approaches, behaviours, etc) are constructed and produced’
Traditional leadership theories are underpinned by the explicit and implicit qualities of leaders. The issue with this approach is it tends to undervalue a few things and overvalues the power of the ‘position’ of being a leader (Ref). Some of the things that traditional theory undervalue are:
The position of leadership that we find ourselves, as clinicians, is the ultimate leverage to influence change. I think there is a world of untapped potential and the intricacies of leadership should be demonstrated more in clinical interactions to produce better outcomes. This means the position of leadership is taken for what it is, but also the process of leadership is promoted amongst the profession (and allied health in general), in order to effect change. So I’ve listed 5 key areas for enhancing leadership in every clinical scenario, which, in my opinion should become the basis for driving outcomes towards a better system and healthier population.
1. Every encounter is an opportunity to show leadership.
As may be evident from the introduction, every single time you interact with a patient, you are being given opportunities to lead. No one else is going to lead the ship, and the patient has given you implicit permission to lead them through their injury/rehabilitation/psychosocial issues/unhelpful beliefs, so step up and lead, it is that simple. There are enough great resources out there to enhance your skills for treatment, and it is the duty of every health professional to stay abreast of the evidence. But clinical treatment is about more than evidence-based or evidence-informed decision making; leadership, in my view is a massive missing element.
2. Leadership is a two-way process, so take your cues from the patient.
Traditional theory explains leadership as a dyadic relationship, and for the most part, when referring to clinical management this is true. It is mostly a relationship between two people looking to effect change. But it is not a one-way street; effective leadership is understanding the nuances of promoting intrinsic motivation. This means listening to the patient and responding to their cues; sometimes they want to demonstrate leadership, and sometimes they will be asking for leadership from you. Take these and ‘guide the ship to the destination’.
3. Communication is key.
A good friend/mentor of mine is known to say, ‘everything in life rises and falls on leadership and leadership rises and falls on communication.’ It is pretty evident that communication is key in our professions, but in some scenarios if we really listen and take cues from both the verbal and non-verbal communication we are receiving, we can have the biggest influence.
4. Great expectations… it's about challenging, not just meeting, expectations.
Meeting patient expectations has been extensively written about in this and other blogs. Part of the reason the Western world finds itself in a position where musculoskeletal pain has become one of the most burdensome conditions is that expectations have simply been met. Too many clinicians have foregone a leadership role and public expectations are met and not challenged. For me, the best clinicians, challenge expectations and demonstrate leadership in everything they do. If more of us are willing to do this, then maybe there is a way out of this mess. If we are taking cues from the patient and remaining aligned with their values then these challenges can result in permanent and important change.
5. Bring everyone into your leadership circle.
In clinical scenarios sometimes this may involve asking other professionals around you to show more leadership. In a complex system like the healthcare system, too much focus has been placed on individual leadership for too long, to the detriment of the public (Ref). We need to make it our mission to raise those around us to change outcomes, not just perpetuate the same outcomes. Importantly, this involves the biggest stakeholder; the patients themselves! Asking our patients to become leaders and continue to challenge the system around them, will develop more resilient humans, who are ready to forge new paths out of pain and into health and wellbeing.
Our ultimate aim, as health professionals, is to obtain better outcomes for all patients and create social value by enhancing quality of life, promoting health and returning patients back to wellbeing. So to me, this means we all need to step up and begin to develop our own individual leadership capacity and demonstrate this with each and every patient. On top of this, asking those around you to do the same, and asking the patient to demonstrate some leadership of their own will be an important step to reversing health trends that have continued unabated for the last 20 years (Ref).
If you have any thoughts, please share them, and thanks for reading.
I have sat down to write this blog every week now for about 3 months; is this a serious case of writer’s block or something deeper? This is a particular debate, which looms large in our profession and musculoskeletal medicine in general, and not for one second do I propose that my opinion is weighty or even valuable in this argument, but I wanted to write something that I would be happy to look back on and know that it was written with honesty and clarity as to any pre-existing personal biases. Because in the argument for or against manual therapy, this is something that is not done by either side very well. Pain, and your own treatment of it is an emotive issue, and it is YOUR practice that this impacts, the way YOU treat people every day; of course, YOU are going to take along some inherent bias and whether you like it or not. This is going to impact how you will read the evidence.
In all honesty, my exposure to various groups on social media sites has me thinking I’m brain-washed against manual therapy, so I set about looking at the literature on manual therapy with a view to have an objective stance, and really just look for once at the conclusions that get drawn in the literature. But, I will warn you, this blog is written by a physiotherapist with a bias towards exercise.
There, I said it.
And I have gone about unpacking this topic and trying to form a slightly different perspective on the debate; that is, as a sensible mid-career physiotherapist with the aforementioned bias, ‘Is manual therapy extinct-as-we-know-it or here to stay?’ What do we do with it as we lead the profession forward? Do we throw the baby out with the bathwater?
The dichotomising of the issue is difficult to swallow for me and I hoped to write this blog to come to a more moderate conclusion on the issue, perhaps a third way. As always, this is an opinion piece, with a weighing up of current literature; make of it what you will and I encourage you to comment and share if you want to continue a more moderate debate on the topic.
The one caveat that I have to stipulate for this debate is that I have gravitated towards a review of the literature on low back pain (without radiculopathy), as it has become a topic I’m regularly blogging about and one of the most burdensome conditions facing our society; kind of important.
Manual therapy is incredibly varied
Something I have heard more than a few times from other physios and a common thread presented for the use of manual therapy is that it is as heterogeneous as low back pain presentations and any research investigating it cannot approximate the intricate factors that go into successful manual therapy, like experience and confidence.
It is true that manual therapy does tend to get lumped into the same basket; in various clinical practice guidelines (CPG), spinal manipulative therapy (SMT) will be lumped in with mobilisation, see 2012 JOSPT CPG (Ref) and a most recent Danish CPG (Ref). But in others these vastly different approaches are correctly separated – see Australian guidelines by Australian Acute Musculoskeletal Pain Guidelines (Ref).
I can see how this might be a frustrating scene for a manual therapist, but exercise therapy is very much as heterogeneous as manual therapy, so I’m not sure how much this argument stands up. Come to think of it, pretty much all of what a physiotherapist does is so non-specific and convoluted that it may not ever be possible to research what exactly makes us successful, if we are at all.
So, in all of the various types, what type of manual therapy is best?
In acute pain:
A very objective and fitting review, the comparative guidelines by the Agency for Healthcare Research and Quality group in the US, found when spinal manipulation was separated out, it seems to come to a higher effect size when compared to sham or no treatment (Ref).
Cleland et al 2009 has shown that manipulative thrust better than non-thrust (compared to your bog-standard lumbar PA) in acute low back pain (less than 16 days n=112). Cruser et al in 2012 designed a fairly low quality trial, in military personnel, which makes a pretty outrageous conclusion that osteopathic manipulative therapy in soldiers with a new onset of low back pain is effective in reducing pain. This is disappointing for me, as when looking at the results, it is pretty clear that the one consistent statistically significant aspect throughout the follow-up points is actually just the interaction of time itself. A study in natural healing at its finest.
Another example of a study which seems to be unable to distinguish between natural healing and treatment effect is by Hancock et al in 2007, this is another study used by the most recent Danish guidelines for the treatment of low back pain to back-up the recommendation for the use of manual therapy in acute low back pain.
Hsieh et al in 2002 couldn’t seem to distinguish between three types of manual therapy when applied to 200 people with subacute low back pain randomly. When their four treatment arms were analysed as a collective, joint manipulation, myofascial therapy and combined joint manipulation and myofascial therapy, no group was found to have had a superior effect on pain or disability with 3 weeks and 6-month follow-up.
SMT does seem to have a better effect in a good trial by Goldby et al 2006 in pain only (not in function or even quality of life). This was amongst the best studies I’ve read on manual therapy and is one I will use again.
But a bogus study by Aure et al in 2003, demonstrating superior effects of manual therapy over exercise should serve to demonstrate the confounders involved in all low back pain research; they found significantly better improvements in a small cohort (n=49) in not just pain, but function and disability. It is fairly demonstrative of a typical situation of experienced manual therapists pitted against exercise therapists, the exercise therapists are not allowed to put hands on and the patients with chronic back pain, who have probably had benefit from manual therapy in the past feel robbed, and the manual therapists in the study do their thing and also instruct patients to continue to move more, provide reassurance and reduce fear avoidance.
Physios seem to be good at it
Menke's awesome 2014 meta-analysis pooled treatment effect sizes of 56 studies involving manual therapy; this involved 6397 measurements of patients with acute low back pain and 2455 measurements of patients with low back pain for more than 12 weeks. In acute pain settings, physiotherapists seem to have the best outcomes when administering spinal manipulative therapy in 22 studies (Ref).
That has to count for something, right? The pessimist in me thinks that physiotherapists are just better at designing robust trials with more validity and, heck, maybe we even give better chocolates to study participants over chiropractors and osteopaths. But seriously, maybe this is another reason why manual therapy is so emotive and hard to separate in terms of fact and fiction; the clinical guru-ism is still at-large!! Clinical treatment is a very special thing and something that people want to be good at, plus it’s kind of good for your bank balance.
Does manual therapy help pain in the first 4-6 weeks?
Going straight to the top of the evidence ladder, let’s have a look at the Cochrane review performed 2012 on acute low back pain (Ref).
‘No high-quality evidence was provided for any comparison, outcome, or time interval; therefore, no strong conclusions or recommendations can be made for the use of SMT for acute low-back pain.’
It is worth noting, that only 8 of 16 included studies were published later than 2000. This major limitation of the study is even accepted by the authors. Does manual therapy from the 1970s bare resemblance to the manual therapy performed currently? Some might say yes, but I would think some things have moved on.
Depending on who produces the clinical guideline and other assorted research, it appears manual therapy may have an effect on acute pain. In Koes et al 2010’s summary of national clinical practice guidelines (CPG) 11 of 15 national CPGs support the use of manipulative therapy in the first month of low back pain (Ref). Is this a sign of a broken system or should this be taken as a sign that manual therapy has some effectiveness?
Small effect sizes and non-specific effects
It’s not for a lack of fair-quality trials that the debate still rages amongst social media and scientific-literature-at-large. The above clearly shows that there is no paucity of evidence for manual therapy; all randomised control trial and all with pretty large samples (>100).
Effects in these studies, however, are generally small changes; generally, a couple of point changes in VAS scales and rarely changes in validated questionnaires. When pooled together, these effect sizes generally get diluted down to insignificant (see Cochrane reviews). Menke's 2014 review makes this ‘diluting’ effect fairly clear when added together with the myriad of other non-specific effects involved in any treatment scenario. When other factors like placebo, contextual, regression to the mean and natural history all together are accounted for, the treatment effect in manual therapy interventions over the years only amounts to 3% of change.
Wow 3%; most of us wouldn’t scratch ourselves for 3% change in any symptom. Again, it is pretty sobering to think that natural history and simply just therapeutic alliance results in most of the results we see day to day,
‘Results here support cautious observation, monitored exercise, and authoritative encouragement—services not requiring a licensed professional.’
And herein lies the crux of the argument against manual therapy. I continue to ask myself is this 3% clinically relevant when guiding a case down the path toward discharge and empowerment?
Do we intervene early?
Good quote from Childs et al's 2012 review of the literature (Ref):
‘Current CPGs for LBP mostly recommend delaying referral to physical therapists for at least 4 weeks following initial primary care consultation. This “wait and see” approach is based on the belief that most patients with LBP will recover rapidly, and intervening quickly would not be cost-effective. Furthermore, it is believed by some that early intervention may impede recovery for some patients by excessively “medicalizing” the condition. However, the evidence clearly indicates that this belief and approach to managing LBP must be challenged.'
In my opinion, if done well, LBP is not over medicalised by early referral to health professional. Appropriate education and advice can go a long way to changing beliefs, for the better, for long-term. If done poorly, however, this is exactly what happens, and what has been happening for 30 or more years; conditions do get over medicalised and patients do get dependent on someone helping them out of pain.
How much of this is directly manual therapy’s fault? I think the same problem presents itself with exercise as well; there is still the element of patient interaction and treatment seeking. If you use a sledge hammer or a wrecking ball, you can still demolish a house.
So then, is exercise perfect?
Taken directly from the Cochrane review performed in 2005 on exercise therapy in NSLBP (Ref);
‘Exercise therapy appears to be slightly effective at decreasing pain and improving function in adults with chronic low-back pain, particularly in healthcare populations. In subacute low-back pain there is some evidence that a graded activity program improves absenteeism outcomes, though evidence for other types of exercise is unclear. In acute low-back pain, exercise therapy is as effective as either no treatment or other conservative treatments.’
Part of the driving force behind writing this blog was to explore and present manual therapy research, on a selfish note to re-orient my bias but also to stimulate more thought amongst mid-career or young physiotherapists like myself and for that reason I won’t labour on exercise literature. Effect sizes in various reviews do seem to be significant and something that, obviously, those who share my bias hang their hat on.
But is it all rosy? I would like to point readers to my original blog post on the pathologising of pain; if exercise prescription by allied health professionals was the answer and the cure, then wouldn’t we have seen an impact in the last 10 years in low back pain burden? Assuming that in the last ten years, some form of exercise has been prescribed by even the most devout of manual therapists, then surely there should be some impact on low back burden of disease.. A good study to illustrate this is one performed in 240 people in Sydney, Australia by Ferreira et al (Ref). One on one delivered manual therapy versus one on one delivered motor control retraining (the dreaded TrA and multifidus!) trumped a supervised group exercise class, where 8 participants could sometimes be involved. Now, we know what happened to the hypothesis that participants can’t find their TrA after a bout of low back pain – hog wash – but it was still better than just getting some patients moving for an hour. There may be one specific reason to this; attention. The sanctum of the cubicle and the treatment relationship has a lot to answer for in this study. It may also have a lot to answer for in low back pain research in general. It may be better to get someone to exercise because it has specific physiological effects yes, but you know what, they’ll probably come back.. For exercises for another injury or ache.. Are those of us who share a preponderance for exercise really better than those who don’t share the same enthusiasm? If the system is set up to let people fail, and repeat business is what puts money in your pocket, what is the difference?
So, in conclusion, I have taken 3 months to go around in circles with my thought process. I’m going to break this down simply and in dot points, because if you haven’t stopped reading by now, you are either: a) in need of some dot points or b) on holiday and have way too much time on your hands or c) strange.
Manual therapy cons:
Manual therapy pros:
So, dinosaur or lung fish?
Until patients begin to come to physiotherapy without those expectations then this clinical dance will continue on. Changing these expectations will take many, many years; it will involve the education of other medical professionals like surgeons and GPs and more concerted efforts by our professional bodies to promote what sets physiotherapy apart from other professions.
To change this perception of the public and ensure expectations do not include passive therapies I think boils down to one simple factor and this is explained by the following statement, ‘if the practice next door stops offering a quick fix for patients’ pain, then I will too.’ This is service delivery at its finest, and it reduces physiotherapy to the lowest common denominator; market forces necessitate supply and demand and while there is demand for passive therapies you would be stupid to assume someone out there somewhere is not going to take advantage of that.
So, for negative reasons, that is why manual therapy is sticking around. Because it can be used to pedal profits and physiotherapists have got mouths to feed. I’ve said before that private practice is probably where physiotherapy can expect to see its long-term destination and public outpatient physiotherapy departments days are numbered purely because it is not a necessary public service (in the privatisation of today’s society, heck even electricity isn’t deemed necessary enough for much governmental regulation, so no offense to public practitioners out there); it’s simply good business to promote some form of manual therapy while the public still expects this.
I would like to challenge the issues that are commonly brought up in today’s social media platforms; if repeat business is your aim, then do we really need to blame manual therapy so much? Or are there much the same issues with exercise therapy, even if the effect sizes are larger? Let me know your thoughts on this blog. Thanks for reading.
My rehab timeline. This has been in the wall in my clinic for over a year (so no this isn’t plagiarised from anyone).
This has been of great effect in explaining the rehabilitation process, in tendon loading discussions and even in pain management. This has lots of uses and is widely applicable, you can adapt your own story to this, but please don’t bastardise too much! The central tenants of this diagram are:
The human being is typically a ‘boom-buster’ if left to their own devices. There will be periods of ‘over-reaching’, of excess that inevitably lead to periods of shortcoming and deprivation. We see this following an injury; if left to their own devices, the patient can progress well but without guidance they will reach rapidly toward an unsustainable level.
With external guidance and correct progressive loading, the human being (the system) can achieve a lasting, durable progression or rehabilitation.
Unfortunately, the human being is myopic and biased. If improvement is slow and progressive, a small trough in symptoms may seem devastating. It is very often required to remind the patient of their progress through a rehabilitation. But, more importantly, this can extend to recovery and progress through any issue. The reflection on the process as a whole (improvement) and macroscopic viewpoint is always necessary to a) teach and b) practice, as it is sometimes ‘hard to see the forest for the trees’.
Please comment and let me know your feedback. Thanks for reading and letting me lay some of my shit on ya.
For some more background on 'boom-busting' systems, you may want to read a little on capitalism, we are all put through this kind of cycle on a fairly regular basis. A student of mine recently got me talking about the injustice in the world's economy and this little ditty came up (https://www.youtube.com/watch?v=6lIqNjC1RKU) check it out and give respect for the man that made economic warfare a PG-rated affair... What I'd love to know is, do we just not see the forest for the trees?
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
Connor Gleadhill, APAM. S&C. B. PHTY (Hons).
Lead Physiotherapist, NSW Police Force RECON program.
Thoughts from an average physio with an overactive mind.