I don’t care how open-minded, motivated, or ambitious you think you are, you suck at changing your mind, your opinions, and most definitely you suck at changing your actions and behaviours! But don’t worry, it’s not just you, everyone sucks at change… and I mean everyone!
So it’s that time of year again when we all start to think about making some changes to our lives. Be that eating a little less, exercising a little more, or just doing something different. However, most of us will not stick to our New Year’s resolutions with some research showing 25% fail within the first week and as little as 8% are ever achieved.
So it’s safe to say that behaviour change is difficult for all of us, and it frustrates the hell out of me when I see physios and other healthcare professionals talking about behaviour change as if it’s something that occurs easily. However, I also get just s frustrated at those who over-complicate the shit out of behaviour change using loads of neuro-psycho-social-science babble that they don’t even understand themselves.
Personally, I think behaviour change is actually pretty simple in theory but incredibly difficult in practice, and so I want to discuss a few of the common issues and barriers that occur when we attempt to change our behaviour such as trying to exercise a bit more or eat a bit less and also look at some simple but not easy ways to try and overcome them.
Lower Your Expectations
The first issue with change is that we all tend to expect it to occur quickly and so we all tend to get very demoralised and demotivated when it doesn’t. Simply put change doesn’t happen overnight, and if it does it usually happens due to things out of our control or despite of what we may or may not have done.
When we do attempt to change things such as eating less or exercising more we often totally underestimate how long it takes for these changes to be noticed. For example, 1 month of eating in a sensible calorie deficit will, if your lucky, lose you about 5lb or 2.5kg in weight, and the effect of this on your body composition will be minimal to negligible.
So to avoid getting demotivated and demoralised set your expectations much lower than you anticipated, and then set them even lower still. If you thought 3-6 months of dieting was going make you look like a toned goddess or a rippling adonis, reset those expections to hopfully looking less like a wet sack of sand or unset custard tart when you take your clothes off rather than Brad Pitt or Kate Moss back in the 90’s
Break The Habit
Without doubt one of the biggest challenges of behaviour change is overcoming our innate ingrained habits. Habits are automatic behaviours that we learn over time, and they can become extremely difficult to break. Our habits can become so automatic that we don’t even know when they are occurring and they can be triggered by things we don’t even notice such as a smell, a location, or the presence of a certain person or object. To overcome this it is important to identify these triggers that lead to our bad habits and either remove the trigger completely or replace the habit with another healthier one.
For example, if you find yourself automatically reaching for the chocolate cookies in the evening once you’ve sat down on the sofa with your cup of tea and your favorite soap opera. Either remove all the chocolate biscuits from your house making it harder to get a damn cookie, or replace those delicious cookies with something else healthier if not a little less delicious. Personally, I find replacing habits rather than trying to remove them a much better strategy as my old ‘primeval lizard brain’ doesn’t feel as hard done by and is less likely to hit the ‘fuck it button’ and give up on it completely.
Another challenge of behaviour change is self-control. Self-control is our ability to resist temptation or overcome our impulses, and it can be a significant problem when trying to change our behaviour. For example, if you are trying to quit smoking or drinking, you will have to resist the urge to smoke when you are stressed or in social situations where others are smoking and drinking.
Self-control can be challenging because it requires both mental and physical effort, which can be difficult to maintain over time. To overcome this it is important to develop strategies for self-control, such as setting goals, creating a plan, and enlisting the support of friends and family but most importantly not relying on ‘motivation’ to keep you going.
I have discussed the issues with motivationbefore, explaining how it can be a powerful but short-lasting stimulus to help us pursue our goals and to make behaviour changes. Motivation is incredibly difficult, if not impossible to maintain for the long term, especially if we encounter setbacks along the way. To overcome the issue with motivation I think it’s vital to not rely on it much at all and rather develop some experience and exposure to doing things when you feel the LEAST motivated to do them.
Developing some exposure and self-discipline to ‘getting shit done’ when you’re not motivated is essential to changing your behaviour. Developing some resilience to doing things when you feel like doing them the least will give you the ability to take some control and ownership over your behaviours. However, this isn’t easy and there will be lots of times when you fail to do this, and that’s ok and just as essential to deal with.
How you deal with inevitable failures is another key feature of behaviour change. Those who give up and hit the ‘fuck it button’ won’t change. Those who accept and learn from their failures, don’t beat themselves up, or look to blame others will have more chances of succeeding.
A nice rule for dealing with the inevitable failures of behaviour change such as missed training sessions or eating those secretly stashed chocolate cookies is don’t fail twice in a row. Failing once is to be expected and often due to things outside of your control, failing twice in quick succession is often a choice.
Ditch The Haters
Another challenge of behaviour change is overcoming the many barriers you will face. Barriers are external factors that can make it difficult for us to change our behaviour, things such as conflicting priorities, a lack of resources, or often a lack of support. Although you should never rely on others’ support to change your behavior, surrounding yourself with people who do support you does make it easier.
However, what’s more important here is you remove yourself as far as possible from those who look to put doubts in your mind, discourage you, or ridicule your attempts for change. Although using the hater’s negative emotions can fuel your fire, it will eventually make you bitter and bring you down to their sad and pathetic level of existence… so “fuck the haters” and keep on keeping on!
So in conclusion, changing our behavior can be a hugely difficult and challenging process, and it is not uncommon for us to struggle and fail to make lasting changes to our behavior. However, it’s not impossible, and you can succeed. Understanding and recognising some of the challenges that arise such as overcoming unconscious habits, developing self-control, not relying on motivation, and dealing with failure will help you.
So good luck with your New Year’s resolutions and although many do fail please take heart that those who do make a commitment to change at this time of year are still 10x more likely to succeed than at any other time of the year.
Happy New Year and all the best for a healthy and prosperous 2023
“Why isn’t this feeling like it did when you first did it? This doesn’t make any sense… what the hell am I supposed to do now?”
This was what a patient said to me about 5-6 years ago, who was suffering from severe sub-acromial shoulder pain as I was trying to find a way to reduce her pain on movement, just like I had achieved 10 minutes ago when I used the Scapula Assistance Test on her. Unfortunately, I didn’t have a good answer to give her, and this was also the last time I used this test and many others like it… let me explain why.
The Scapula Assistance Test is a commonly used shoulder symptom modification test first described by Ben Kibler in 1998 in which a therapist attempts to ‘assist’ the scapula into upward rotation as a person lifts their arm to see if this reduces their painful shoulder experience. There are many other tests that can be done around a painful shoulder to try and reduce a painful movement, most of them conceived by Jeremy Lewis in his Shoulder Symptom Modification Procedure (SSMP).
But symptom modification tests have also described around many other body areas such as elbows, hands, knees, hips, necks and backs and they sometimes go by the names NAGS, SNAGS, or MWM’s as conceived by Brian Mulligan.
However, I now just refer to all these kinds of tests as ‘clinical magic tricks’.
Now I was taught many of these ‘clinical magic tricks’ by some very well-known and influential physios on their courses and they assured me that if you can get a patient’s painful movement to quickly change using their ‘techniques’ it will help patients understand their pain is changeable and help them move more and with more confidence and improve their prognosis and outcomes (ref).
However, after a few years of using them, I began to realise this was not always true, in fact, I found it was often not true at all.
I began to notice that these ‘clinical magic tricks’ were first of all not reliable or reproducible on the same patient which lead me to conduct my first clinical research trial to check my observations under more controlled conditions (ref). Not only did I find very little reliability or reproducibility, but I also noticed that these ‘clinical magic tricks’ can have some negative and detrimental effects for some patients that no one ever mentions or talks about.
I found that sometimes if I suddenly and dramatically reduced a patient’s painful movement with one of these tricks… after the shock and excitement had calmed down it left many patients, and myself, feeling a little confused and uncertain about what had just happened, and what should be done next.
I found these tricks confused me and my patients the most when we couldn’t repeat the results the next time we tried them, or if we couldn’t reproduce the results without me pushing, pressing, or pulling on them. This left both of us feeling unsure and uncertain about what was going on and what we should do.
I mean just think about it for a second… if you had a pain that suddenly changed or disappeared completely when someone pressed or pushed something, only for it to reappear just as suddenly unless someone was pushing or pressing you, do you think you would be reassured or confused?
I was also taught that the way to explain these tricks to patients if they worked was based around a biomechanical explanation such as the scapula or another joint was out of position, misaligned, or not moving correctly, or that a muscle was weak or unbalanced. But this is just outdated reductionist bullshit.
First, there is no evidence that when we push or pull on someone’s scapula or any other joint and they feel less pain, it tells us if their muscles are or are not functioning (ref). Next, there is no evidence that pushing or pulling on a scapula actually significantly changes the scapula position or movement (ref). And finally, we see no difference in the effects of these symptom modification tests when we compare them against sham or placebo tests, telling us that the biomechanical explanations can not explain the results alone (ref).
Simply put there are many, many probable reasons why someone’s pain changes as we push, press, and pull on their scapula or any other body part. It could be due to increased proprioceptive input from the therapists’ hands, or increased feelings of safety and security for the patient as they move, or expectation violation as they move… the list of alternative explanations as to how these clinical magic tricks reduce pain is almost endless.
And if we do try to explain the complex and multifactorial nature of pain and how there is a lot of uncertainty in the why or how their pain changed as we do these clinical magic tricks this, in my opinion often doesn’t help reassure many people, instead, it just adds another level of confusion and more uncertainty unnecessarily into an already confusing and uncertain situation.
And finally, I was also told that these symptom modification tests help us direct our treatment interventions better. But again this is a complete load of bullshit. Just because you reduce someone’s pain by assisting their scapula it doesn’t mean you need to or can give treatments or exercises that change the scapula’s movement or position well at all (ref).
So using these symptom modification tests or clinical magic tricks to reduce pain just doesn’t sit well for me today in many clinical situations where I have fully listened to the patient’s history, thoroughly assessed their movement and pain levels, and reassured myself, and hopefully, the patient as well that there is nothing serious or harmful to be concerned about.
It also doesn’t make sense for me to spend time explaining and reassuring patients that the natural history of their issues is complex but favorable, and then discuss with them how they can continue to do things they need or love to do without any fear of doing any further harm or detriment to themselves or their prognosis, only to suddenly say…. “but hey… lets still try to reduce this perfectly safe yet unpleasant pain anyway”. This seems like such a huge contradiction.
So there you go… that’s a very quick look at the Scapula Assistance Test and the other symptom modification procedures or tests that are often recommended and promoted to help reduce painful movements. And although I do understand why they can be appealing and attractive to learn and use in clinical practice, and they can help some patients, sometimes, for a short while… please do not be fooled into thinking they are reliable, diagnostic, or essential to do with most people.
In fact, I would argue that these clinical magic tricks are often more for the therapist’s benefit than the patients, giving therapists a sense of utility, usefulness, and skill in being able to fix and correct things. For most patients, they are not really that useful or that beneficial, and as I have mentioned they can have some negative and detrimental effects that no one ever discusses or talks about, which I hope this blog changes.
Vested Interests and Weak Egos
Now I know this blog will upset some people, usually those with vested interests and strong biases into teaching these ‘clinical magic tricks’ as well as a few other therapists with fragile egos and low emotional intelligence who often hide behind anonymous social media accounts and cannot tolerate anyone questioning, challenging, or criticizing their beliefs or ways of practicing (see below for a perfect recent example)
However, please do not let either the gurus or trolls put you off from questioning, challenging, or criticizing anything with their lame personal attacks claiming you need to ‘do more research’ or ‘criticize less’ as this reflects more about their issues and insecurities rather than yours.
As always thanks for reading, and please stay skeptical, keep questioning and remember there are no sacred cows in physio… even those who teach ‘clinical magic tricks’.
So it’s been a while since I’ve blogged and even longer since I’ve had a guest blogger on The Sports Physio. However, I am really pleased to introduce you all to Marcus Blumensaat who has done an awesome post on that tricky and elusive question of… how much exercise is enough?
Why do we even care to know?
Many people do not like to exercise. At all. They do not want to perform exercises even if they have been told by a health care professional that it will help them to recover, heal or rehabilitate an ‘injury’. In my opinion, getting people to perform their prescribed exercises is one of, if not the most, challenging things we face as musculoskeletal (MSK) health care practitioners.
Many people don’t even meet public health exercise recommendations that have been shown to decrease all-cause mortality by 40%.1 40%!!! I suppose they are on the ‘we are here for a good time, not a long time’ train. Fair enough, I have been on and off that train many times. I usually buy a ticket when a freshly baked chocolate chip cookie is in front of me.
Back to the clinical setting… if a person is seeking our help and we have employed our critical thinking in a biopsychosocial (BPS) framework and have determined that the performance of exercise would be beneficial to the case at hand, the answer to this question, ‘what is the minimal effective dose?’, is very important indeed.
If we knew the minimum effective dosage of exercise, one would assume that we would increase the odds of the people we are working with actually performing the prescribed exercise(s). With the end result being better clinical outcomes, i.e., happier, healthier people!
Thus, it would be to everyone’s advantage if we could figure out what the minimal effective dose of exercise is for different pathologies and pain. Simple.
Like most questions in the MSK world regarding pathologies, pain, and rehabilitation, this one of ‘what is the minimal effective dose of exercise?’ is shrouded in uncertainty.
If one exercises (pun intended) their critical thinking skills when contemplating this question, it should become obvious that there are a few details that need to be clarified before trying to come up with an answer.
Most importantly, what is the desired ‘outcome’ or ‘effect’ that you are trying to stimulate in the person by having them perform the prescribed exercise? In other words, what are you hoping to accomplish by having the person perform the exercise?
Are you hoping to change their ‘capacity’ in some way to better handle the loads* that they face in life? Perhaps the goal is an increase in strength or range of motion.
* Load is the burden (single or multiple mechanical, psychological, or social stressors) that is applied to a human biological system (including subcellular elements, a single cell, tissues, one or more multiple organ systems, or the individual).2
Are you trying to decrease someone’s fear of movement (kinesiophobia) or increase someone’s confidence in using their body?
Are you trying to help them improve their mental health? Perhaps attempting to help decrease their stress levels or symptoms of anxiety or depression?
Are you trying to alter their pain experience? Help to decrease their self-reported level of pain?
Or are you trying to stimulate mechanotransduction in tissues thought to be in need of morphological or structural change?
Reflecting on and having a clear understanding of what you are trying to accomplish by having someone perform a certain exercise, will drastically affect not only your choice of exercise but also the variables (frequency, intensity, volume, rest) of your exercise prescription.
The ‘minimal effective dose’ will look very different for each of the above-mentioned ‘goals’ or desired ’outcomes’.
When it comes to strength and other physiological ‘capacities’, I would like to say that there is some certainty around the prescription variables to stimulate adaptations; but, even in this realm, there is new research coming to light that questions our old beliefs.
Strength & Conditioning
There are many components of physical fitness we could talk about, strength, power, aerobic capacity, aerobic power, anaerobic power, range of motion, etc. I would like to keep this blog focused more on pathology and pain so we will only briefly discuss the strength and conditioning (S&C) realm.
Many of these components of physical ‘capacity’ have generally accepted ‘minimal effective doses’ to stimulate desired adaptations at a population level. However, even some of these long-held beliefs are being challenged by studies and systematic reviews that have recently been published.
For instance, there was a great review3 that looked at the traditional ‘repetition continuum’ (Figure 1) which postulates that heavy load training optimizes/increases maximal strength, moderate load training optimizes/increases muscle hypertrophy, and low-load training optimizes/increases local muscular endurance.
Based on emerging evidence, the authors proposed a new paradigm whereby muscular adaptations can be obtained, and in some cases optimized, across a wide spectrum of loading zones (Figure 2). So, in some instances, it is not necessary to expose someone to as heavy loads as once thought to stimulate change.
This is especially true for stimulating muscle hypertrophy where the literature indicates that similar whole muscle growth (i.e., muscle thickness, cross-sectional area) can be achieved across a wide spectrum of loading ranges ≥ ~30% 1 Repetition Maximum (RM).
More recently, a randomized controlled trial was performed that compared moderate load (70% 1RM) with low load (30% 1RM) and measured lean body mass (LBM), 1RM strength and Fat Mass Loss after twelve weeks. Their study showed that twelve weeks of high-intensity functional training with either low or moderate loads resulted in an equal increase in LBM and 1-RM strength (Figure 3).4
So it seems the minimal effective dose may be lower than what we thought in the past.
These new findings have major implications for clinical practice as it is much easier to implement lower load exercises with people than heavier loads. Oftentimes people don’t have access to the equipment necessary to perform the heavier loads. Some people are scared that they are going to hurt themselves with the heavier loads. Some clinicians are scared that they are going to hurt people with such heavy loads.
From a practicality standpoint, anytime I see a randomized controlled trial (RCT) or systematic review (SR) that shows we can be effective with lower ‘loads’ than previously thought, I am stoked, do some fist pumps, and eat another chocolate chip cookie.
Ingesting cookies is one way to get a mental lift, exercise is another.
Exercise has long been shown to have positive effects on mental health.5 In an MSK clinical setting, decreasing someone’s anxiety or depression will not usually be one of your primary goals; however, decreasing someone’s fear around movement and their associated fear-avoidant behaviours is a common goal you may prioritize.
Graded exposure to feared movements is a fantastic approach to decrease fear around them. The exercise prescription for graded exposure to reduce fear will look vastly different than for S&C purposes as you are trying to create psychological changes versus physical changes.
One thing that you would want to be mindful of is not creating a pain flare as this could further exacerbate the fear-avoidant behaviour and unhelpful beliefs around movement that the person already possesses. In these cases, it would be incredibly important to start at a very minimal dose that is easily tolerated. Let the person experience that they can perform a version of the feared movement with no repercussions. This helps reduce their negative expectations and can start to create new, positive expectations around the feared movements.
“Reassurance is a bloody good pain killer”
I believe that experienced physical reassurance is more powerful than verbal reassurance. In other words, a person is far more likely to have less fear and more confidence around feared movements if they experience they are safe when performing them versus being told that they are safe to perform them.
Simply begin at a tolerable dose for the individual and gradually progress. This initial, tolerable dose will usually be much less than the dose required to stimulate the physical changes that you would be looking for in an S&C setting or even in a clinical setting when trying to stimulate mechanotransduction of some sort.
When it comes to pathologies we see in the clinic, there are some accepted minimal effective doses for exercise prescription, but they too continue to evolve and change. Let us look at a couple of the most common conditions that we see in a clinical setting – tendinopathy and OA.
It is widely accepted that progressive tendon loading programs are the most effective conservative approach in the treatment of tendinopathy.6 Traditionally it was thought that to effect change in tendons you had to use heavy loads (70% 1RM). A recent study showed that in fact, you may not have to.
In a recent RCT it was found that there was no superior effect of exercising with a high load (90% 1RM) magnitude compared with a moderate load (55% 1RM) magnitude for the clinical outcome, tendon structure, or tendon function in the treatment of patellar tendinopathy.7
Regarding OA, a recent study looked at high-intensity strength training versus low-intensity strength training versus an attention control group (received 60 min educational workshops biweekly for 6 months and monthly thereafter). There was not a significant difference in self-reported pain between the three groups of subjects. In other words, low-intensity training was just as effective at decreasing self-reported pain in individuals with knee OA as high-intensity training.8
What is fascinating from this study is the group who did not perform strength training and only participated in regular educational workshops did equally as well as the two exercise groups!
Perhaps we are seeing the power of high-quality patient ‘education’ at play here?! In my opinion, we can often have a more powerful effect on clinical outcomes with the ‘education’ that we deliver versus any exercise prescription or passive therapy that we perform.
Often, ruling out red flags, reassuring the person (when indicated), encouraging the resumption of meaningful/valued activities at a tolerable level, and letting natural history do its thing is all we need to do to see successful clinical outcomes!
Just so that my movement optimism bias isn’t getting worried, I think it is worth clarifying that there is a copious amount of research showing that exercise of all types, including strength training, benefits those with OA and is a primary recommendation in clinical practice guidelines.9-13
It should be noted that there is not a significant difference in effect between the different types of land-based exercise interventions.14 The most beneficial exercise is probably just the one that the person is actually going to perform!
First off, let’s get on the same page regarding pain. I will assume that those of you reading this blog understand that pain is multifactorial (Figure 4) and rarely mediated by only one ‘thing’.
Even when we are talking about someone who has had a trauma, such as falling off a ladder, their resultant self-reported pain levels are affected by numerous factors. Things such as previous experiences, beliefs, emotional factors (stress, fear, anxiety, etc.), and quality of sleep, to name but a few.
Though we know that exercise helps reduce self-reported pain16, we do not know how it does this.
Pain is so multifactorial, and the concurrent effects of exercise are so numerous, that the potential combinations of ways that exercise could decrease pain are nearly infinite. I believe that it is a little presumptuous for us to think that we can explain the physiological and psychological mechanisms simultaneously occurring during exercise and exactly how those mechanisms are decreasing pain in an individual.
On any given day, exercise probably decreases pain in different ways in each individual case due to ever-changing contextual factors. Exercise also probably decreases pain in different ways from individual to individual due to the heterogeneity of the biopsychosocial factors in each person’s life.
In relation to this, there are many unknowns when it comes to the minimal effective dose of exercise to reduce pain.
In my opinion, there is not, and there may never be, an exact ‘recipe’ that exists for the minimal effective dose of exercise.
Although there is a significant amount of evidence in the literature suggesting exercise as an efficacious modality for the treatment of chronic pain, there is virtually no knowledge of the appropriate dose of exercise for a given disease or patient type.16
At the centre of this uncertainty, is the uniqueness of each human being.
N = 1 → Person-Centred Care
The minimal effective dose of exercise depends not only on what you are trying to accomplish but also on who the person in front of you is. Randomized Controlled Trials (RCTs) and Systematic Reviews (SRs) show us population-level data, but we are attempting to use that data to help guide our care of individuals that we see in a clinical setting.
In the clinical setting n=1.
A dose that is effective for one person may not be effective for another person.
What may be enough of a dose to change someone’s fear around a movement, may not be enough to change another person’s fear around the same movement.
A dose that is effective for reducing someone’s knee pain related to OA may not be effective for someone else who is suffering from knee pain related to OA.
For that matter, a dose that is effective for a person on Tuesday may not be effective for the same person on Friday!!!
Simplifying with a Person-Centred, Macro Persepective Approach in a Biopsychosocial Framework
Yes, the irony of the above heading was intended.
I believe we often overcomplicate things by trying to figure out specific recipes of sets, reps, intensity, duration, and frequency when prescribing exercise to simulate a change in physical ‘capacities’ or stimulate mechanotransduction. If we simply revisit the most basic principles of human physiology, it may allow us to simplify our approach.
The Overload Principle states that cells, tissues, organs, and systems adapt to loads that exceed what they are normally required to do. While the Specificity Principle states that overload results in adaptations specific to those cells, tissues, organs, or systems that have been overloaded.
You simply need to prescribe exercise at a level that is more than the person is currently adapted to and you will be stimulating adaptations.
This is an n=1 approach that accounts for individual heterogeneity in the population. The person who is performing the exercise simply needs to feel like it is difficult, challenging and is harder than other things that they are currently doing in their life.
This last point is very important. Though I have cited a couple of studies that have shown you can often be effective with a smaller dose than was once thought necessary, I feel that we often are under-loading people with our exercise prescription dosages.
By considering all the demands in a person’s life, you may realize that the exercise dosage you have prescribed is not harder than many other tasks that they must perform in life with the same tissues. Thus, you probably are not stimulating the adaptations that you are hoping to.
If you and the people you are working with are not seeing the changes that were hoped for, increasing the dosage would be one of the first things that you should consider doing.
I believe a person-centred approach is even more important when the primary goal of the exercise prescription is to help improve someone’s mental health, or to reduce their pain or kinesiophobia.
There is so much more uncertainty with these outcomes due to the increased involvement of psychological factors relative to cases where a physical change is the main outcome being measured.
Knowing the person in front of you will help you to better tailor your exercise prescription. Are they timid, fearful, anxious, depressed? Are they confident, happy, or resilient?
Do they have past experiences with pain, with pain in this region of their body? Has someone close to them experienced similar pain? Do they persist through pain? Or do they avoid feeling pain?
Do they have support? Do they want to change? Is pain a major part of their identity?
The reason that finding a minimal effective dose of exercise is so difficult is that we are all so different. The answers to the above questions, as well as to numerous other relevant questions, will be vastly different for each person we see in our clinics.
Let’s just have a little fun and say that we figure out the minimal effective dose for the person in front of us. Now the real challenge is having them perform the frickin exercises!!!
To me, this is the biggest challenge in prescribing exercise and/or movement in the health care setting. Earlier this year, I wrote a blog in which I touched on some strategies to help increase adherence to prescribed exercises. You can prescribe the perfect exercise at the perfect dose, but it doesn’t matter if the person does not perform it.
I digress…this blog may not have provided any concrete answers to ‘what is the minimal effective dose of exercise?’, but I hope that it got your cogs rotating (your upstairs cogs that is) on some of the pertinent topics surrounding exercise dosage in MSK health care.
It also stroked my movement optimism bias, touching on some of the different ways that exercise can stimulate positive changes in people’s lives.
Delving deeper into this topic reinforced to me the importance of n=1 in the clinical setting. In my opinion, it is so vitally important to work in a person-centred manner.
Who is the person in front of you? Where are they? And where do they want to be? The answers to these questions can help the two of you collaborate and determine a starting point of what to do, and how much, how often, and how intensely to do it. From there, it is a process of trial and error, re-evaluating and modifying according to the person’s reaction to the initial prescription.
Though we may not know with certainty what the minimal effective dose is, I hope that we continue to encourage people to move more and challenge themselves physically because there are so many primary and secondary benefits associated with movement. As I like to say, “Every move counts.” And as a wise man once said…
Zhao, M., Veeranki, S., Magnussen, C., Xi, B. (2020). Recommended physical activity and all cause and cause specific mortality in US adults: Prospective cohort study. BMJ, 370:m2031. https://doi.org/10.1136/bmj.m2031
Soligard, T., Schwellnus, M., Alonso, J., et al. (2016). How much is too much? (Part 1) International Olympic Committee consensus statement on load in sport and risk of injury. British Journal of Sports Medicine, 50(17), 1030-1041. Doi: http://dx.doi.org/10.1136/bjsports-2016-096581
Schoenfeld, B. J., Grgic, J., Van Every, D. W., & Plotkin, D. L. (2021). Loading Recommendations for Muscle Strength, Hypertrophy, and Local Endurance: A Re-Examination of the Repetition Continuum. Sports (Basel, Switzerland), 9(2), 32. https://doi.org/10.3390/sports9020032
Kapsis, D. P., Tsoukos, A., Psarraki, M. P., Douda, H. T., Smilios, I., & Bogdanis, G. C. (2022). Changes in Body Composition and Strength after 12 Weeks of High-Intensity Functional Training with Two Different Loads in Physically Active Men and Women: A Randomized Controlled Study. Sports (Basel, Switzerland), 10(1), 7. https://doi.org/10.3390/sports10010007
Sharma, A., Madaan, V., & Petty, F. D. (2006). Exercise for mental health. Primary care companion to the Journal of clinical psychiatry, 8(2), 106. https://doi.org/10.4088/pcc.v08n0208a
Millar, N. L., Silbernagel, K. G., Thorborg, K., Kirwan, P. D., Galatz, L. M., Abrams, G. D., Murrell, G., McInnes, I. B., & Rodeo, S. A. (2021). Tendinopathy. Nature reviews. Disease primers, 7(1), 1. https://doi.org/10.1038/s41572-020-00234-1
Agergaard, A., Svensson, R., Malmgaard-Clausen, N., Couppé, C., Hjortshoej, M., Doessing, S., Kjaer, M., Magnusson, S. (2021) Clinical outcomes, structure, and function improve with both heavy and moderate loads in the treatment of patellar tendinopathy: A randomized clinical trial. Am J Sports Med;49(4):982-993. doi: 10.1177/0363546520988741.
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McAlindon TE, Bannuru RR, Sullivan MC, et al. (2014) OARSI guidelines for the non-surgical management of knee osteoarthritis. Osteoarthritis Cartilage, 22, 363–88.
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There is a common and popular belief that you should keep your back straight, stiff, and neutral as Switzerland when you lift things to reduce your risk of back pain and injury, and this is one of the most divisive debates I regularly have with so many people. However, it’s just not true!
Now before you all rush off to the comments section to post some PubMed links of your favourite moustached spine-saving guru’s research… Let me make it as clear as I possibly can, that I’m not saying we don’t have to or should NEVER lift some things, sometimes, with stiff, straight spines.
All I am saying is don’t be fooled into thinking that lifting something with a stiffer, straighter, more neutral spine reduces your risk of back pain or spinal injury. Because it’s just not that simple!
Where’s Your Evidence?
But where’s your proof and evidence for this Adam… I can all hear you all screaming through your laptops and mobile phones. Well, my evidence that lifting with stiffer, straighter spines doesn’t help reduce low back includes hundreds of thousands, if not millions of people over decades who have all been taught to lift things with stiff, straight backs, day in, day out at work.
The evidence I am talking about are the papers looking into the effectiveness, or rather I should say, the ineffectiveness of Workplace Manual Handling Training at reducing the rates of occupational back pain and injury.
So workplace Health and Safety Laws and compulsory Manual Handling Training was introduced in the UK over 50 years ago back in the early 1970s in an effort to protect employees from unfair and unsafe working environments and practices, as well as protect employers from high levels of employee absence and litigation due to workplace injuries. (ref)
These laws stated that all employers had to regularly educate and train all their employees, in both manual and non-manual based jobs on the importance and need for correct posture, workplace ergonomics and safe lifting techniques. This meant all employees are taught to lift anything weighing over 10kg close to the body and with a straight spine to avoid the risk of a back injury.
However, the unfortunate and unconformable facts are that these laws and this training haven’t reduced the incidence or prevalence of back pain or injuries in the workplace (ref). Now there are many questions as to why these workplace manual handling guidelines haven’t reduced rates of back pain or injury in the workplace, such as they weren’t adhered to by employees, or they were conducted properly by employers, or because back pain and injuries are multifactorial and not easily solved by simply asking people to pick things up a certain way.
Either way, the evidence tells us that Manual Handling Training that attempts to teach and train people to lift things with straight, stiff, neutral spines clearly does NOT reduce the risk, or rates of workplace back pain or injury significantly (ref, ref, ref). Yet it still continues on as if it does… this is utter madness… not to mention a day of my life wasted every year working in the NHS!
Burying Dead Bodies
So if keeping our backs stiff and straight when lifting things at work doesn’t significantly reduce our chances of getting back pain, what about when training at the gym? Or at home lifting the laundry basket? Or out in the woods trying to dispose of that pesky dead body you’ve had hanging around for a while? Well, the answer is… we just don’t know as there’s no substantial robust evidence either way.
However, I doubt that lifting technique is a significant factor in most back pains or injuries, in most people, most of the time. Even though a lot of back pain occurs when lifting, it doesn’t mean the lifting was the cause of the back pain. All back pain is complex and multifactorial, meaning it’s never caused by one, sole, isolated, independent factor such as how you lift something (ref).
Yes ok, lifting technique may have a part to play in some back pain, in some people, but if it does, it’s a small part, and usually the last contributing factor in a long list. For most people who hurt their back lifting there will be many other factors that contributed for far longer and far more, things such as their age, ability, strength, endurance, rest, recovery, capacity, capability, confidence, experience, exposure etc. All of these factors and many others determine if someone may or may not get an episode of back pain as they lift something.
When it comes to the risks of back pain and injury when lifting it may not matter that much how you lift things, but rather if you are ready and prepared to lift things, both physically and psychologically.
Lift With Your Back
It could also be argued that the constant advice to only lift with a straight back could be one of the reasons FOR the increasing amounts of back pain in our populations (ref). Constantly telling people to avoid bending, flexing, and twisting their backs under loads, can leave them weakened, deconditioned and under-prepared to tolerate these stress and strains when they inevitably occur in life.
It’s simply impossible, not to mention highly impractical, to avoid spinal flexion under loads and other forces such as shear and compression. It is, therefore, in my opinion, essential to prepare our spines to tolerate these loads and forces with gradual graded exposure to ensure they are robust and resilient.
Our constant advice to constantly avoid spinal movements outside of neutral is, in my opinion, a significant reason for the steady increase in chronic persistent back pain. I think all spines, in all people, need to be exposed to all movements, and all varieties of loads and forces, including spinal flexion when lifting things,
I think being exposed to and prepared for spinal flexion under load is both sensible and very much needed for many. However, as always there are exceptions to every rule, and I will admit that there are some people who find spinal flexion under loads to be painful and provocative and so avoiding this for a period of time to let it settle is sensible.
However, this avoidance should never be permanent, because for me the craziest thing any physio, coach, or trainer can do is ask someone to only do something, like lifting, one way all the time, forever. This would be like asking someone to only eat one type of food forever, drink one type of beer forever, or listen to one physio on the internet forever. This would be both disturbing and depressing and we would never dream of telling people this, so why is it any different with movement and exercises such as lifting.
So I hope you found this short read around lifting interesting, and I hope I have managed to convince or sway you a bit that simply educating, coaching, or telling someone to lift things with a straight back doesn’t automatically reduce their risk of back pain or injury.
So until next time… stay frosty… and remember you can’t go wrong trying to get strong… Now go lift something, those dead bodies ain’t gonna bury themselves!
Have you heard people say that being overweight is a choice? Or that it’s just about calories in versus calories out? Well, misinformed statements like this are often said by those with little understanding or recognition of the complex and multifactorial nature of obesity and are just… big fat lies!
As someone who has struggled with my own weight from a young age and who was bullied for being the ‘fat kid’, I’ve had a personal interest in weight management for as long as I can remember. In fact, I think it’s one of the reasons why I entered healthcare and why I’m such a strong advocate for exercise, having found it to be the best way to control my own weight after trying and failing many other methods.
Although exercise has, and still does help me manage my own weight I know it’s not the answer for everyone, and I have slowly come to understand that weight management is a complex and complicated topic that goes far beyond just exercise and calories. Unfortunately, many healthcare and fitness professionals have not and many still believe that being overweight is a simple condition brought on by choosing to eat too much and exercise too little.
Calories In / Calories Out
This is bullshit, in fact, if I hear another fitness professional say ‘calories in v’s calories out’ without any context I think I will drop kick them in their fart box, because although in principle this sounds accurate and simple, it’s just not this simple or accurate. The causes of weight gain and obesity are in fact far more complex than just ‘calories in calories out’ involving physiology, psychology, and sociology.
Saying obesity is as simple as calories in versus calories out is no different than saying poverty is as simple as money in versus money out, or depression is simply happiness in versus sadness out! I think we can all agree that no-one chooses to be depressed or poor so why is it any different for obesity?
In the late 1990s, obesity was classed by the World Health Organisation as a global pandemic due to the direct links it has to increases in many other diseases such as diabetes, hypertension, cardiovascular disease, osteoarthritis, some forms of cancer, and mental health issues such as depression (ref).
There is still much debate around if obesity should be considered a ‘disease’. But when you consider a disease is defined as…
A condition that impairs function and reduces life expectancy
A condition that leaves an individual more susceptible to other diseases
A genetic impairment that leads to other functional impairment
Obesity checks all of these, even the last one! Yes obesity is a genetic impairment. There is now some strong evidence that shows obesity is dictated a lot by genetic factors as demonstrated in multiple identical twin studies, done in multiple countries, on various different aged individuals (ref).
It is also known that genetic variations can increase an individuals propensity to obesity such as leptin and POM-C receptor deficiencies (ref, ref). Our genes play an important role in how we all respond differently to the foods we eat, the number of calories we consume, and the environments we consume them in.
For example, have you ever wondered why two people who eating the same types and amounts of food often have completely different weights and body fat percentages? Well an interesting study conducted on 12 pairs of identical twins closely monitored the affects of overfeeding them by 1000 calories a day, everyday, for 100 days, and found weight gains were very similar for each twin, but varied hugely between the pairs of twins from 4kg to 13kg (ref).
This clearly shows how genetics has a role in determining how much weight is gained based on the calories consumed. There have also been a number of studies that looked into the effects of genetics on weight gain in rats to try and see if they could find any more answers.
In one study 100 rats were all fed the same high-calorie diet for a few months. Again they got a lot of variation in amounts of weight gained by the rats, with a bell shape curve with a few of the rats not putting on any weight at all, a few rats putting on huge amounts of weight, and most of the other rats falling somewhere in between (ref).
Now the interesting part with this study is they then took the rats from this trial who didn’t put on any weight and bred them together, as well as taking the rats who put on the most weight in the trial and bred them together. And after a few rounds of breeding these different weight gaining rats they got two very different types of rat.
In the first group of rats they got offspring who were very diet-resistant, that is rats whose weight did NOT increase when they over-consumed calories. However, in the other group of rats they got obesity-prone offspring who gained weight very quickly and very easily with overconsumption of calories.
What’s also interesting is that if you take these obesity-prone rats and place them on a low-calorie diet they lost weight, but as soon as their calories were returned back to normal baseline amount their weight quickly returned back to their starting obese weight, even though they were not over consuming calories. Meaning you can get an obese prone rat to lose weight, but unless you keep it on low calories forever its inherent nature is to be an obese rat.
The same thing most likely applies to humans. If you were to take a thousand children and weigh them, their weight will also be distributed in a bell-shaped curve. Some skinny kids, some kids in the middle, and some overweight kids. Some of the skinny kids will remain skinny throughout their life, and some of the obese kids will stay obese throughout life, meaning you could argue that their weight, to some degree, is predetermined.
Now, of course, it’s not just this simple as humans have had the same genes for 100’s if not 1000’s of years, and it’s only recently that obesity has become a bigger problem, so how do we explain this? Well, the obvious answer is the sudden increase in the easy access to very calorie-rich food.
It is now extremely easy to eat your entire daily quota of calories in a single meal that doesn’t cost much and doesn’t leave you satisfied for long. High-calorific meals full of calories dense corn starches and sugars, not to mention sugary drinks and alcohol that can contain 100’s if not 1000’s of calories without providing much satiety mean we over-consume really easily.
Although our genes play a big role in our weight, our environment also plays a huge role too. The readily available abundance of calories in many modern lifestyles is a relatively ‘new thing’ in human evolution, and it appears our genes haven’t quite managed to adapt and it’s not certain if they ever will.
In our history, genetic selection has prepared and equipped us much better for famine rather than feast, and for good reason. Food used to be scarce and infrequent, and periods of starvation were common throughout human history. Obviously, this was difficult and unpleasant to deal with, but is the opposite scenario we now face any better?
So if obesity is a disease the question we need to ask, just like we would for any other disease, is how can we prevent, treat, or even cure it? Well just like any complex disease there will not be any one single simple quick fix or solution. However, one interesting area that could hold a lot of potential is how our neurophysiology can affect our behaviour.
A neurotransmitter called GLP-1 has been shown to affect nerve cells that control whether we feel full or not, and so dictate if we eat or not, and GLP-1 has been found in both our brains and our guts literally allowing them to ‘speak’ to each other (ref). Research has shown that if you increase levels of GLP-1 your desire to eat is significantly reduced and even halted, acting a bit like the full signal on your cars fuel tank and although more work is needed there are some promising results here (ref)
Of course, GLP-1 or any one neurotransmitter in isolation is not the whole answer to obesity and there are numerous other avenues of research into physiology, psychology, and behaviour change needed, not to mention a huge shift in governmental and societal approaches and beliefs to food and weight management. However, research like this does give us some insight into the complexity of obesity and some hope that there are solutions for this growing pandemic.
Moving forward we all have to recognise that if anyone wants to loose some weight they often have to change their behaviour but also their environment to do this, which isn’t always easy or possible to do. However, if we want to change a populations weight then its essential that we all change the environment so that it is suitable and conducive to weight lose for everyone, and not just for those in privilege!
Lose some weight, lose some pain
Personally I think a lot more healthcare and fitness professionals need to be much better educated into the complexity of obesity, and far better educated and equipped to help and support those with it. A recent paper has highlighted how obesity is highly prevalent in chronic pain populations, and as a physio, I have found helping some people lose some weight can be a great way to help them lose some pain (ref).
Not only does losing weight decrease some of the physical and mechanical loads on our bodies which may be sensitive or irritated, but it can also, and probably more so, help to lower systematic inflammation levels and improve a host of other metabolic and neuroimmune functions.
More importantly, I think helping someone in chronic pain lose some weight by helping them find some strategies that work for them in their current situation, can help improve their confidence and self-efficacy which can in turn, help them gain control and ownership over many other aspects of their lives which may help mediate their pain.
Again, I am not going to say this is simple or easy to do, but from my own personal experience I know how much better I felt once I gained control over my own weight, and I think many others will do too.
Do people with the same musculoskeletal diagnosis need the same treatment to get better? Do those with tendinopathy always need to load it? Do those with chronic low back pain always need pain education or spinal manipulation? Well, the simple answer is no, but also yes! Confused? So am I… so let me try to expand a bit more.
The topic of using standardised evidence-based treatments and protocols for specific pathologies and diagnoses in musculoskeletal physiotherapy is something I have always been interested in. But I have been thinking about it more recently due to the growing research that highlights there is very little difference in outcomes with different treatments for individuals with similar problems or pathologies (ref, ref, ref).
IT’S A SHAM!
This is also true when our physio treatments are occasionally compared to shams or placebos, with research again often finding very little difference in outcomes (ref, ref, ref). Now, I don’t want to get too nihilistic or despondent here but the awkward and uncomfortable truth for musculoskeletal physiotherapy is that a lot of its treatments just don’t seem to do much over and above placebo, time, and natural history, be that massage or manipulations, needles, tapes, suction cups, scrappy tools or electro machines that go bing.
This is also true for our exercise-based treatments, be that simple strengthening, stretching, or mobilising exercises, even the overly complicated motor control corrective exercise claptrap. They all seem to do very similar things for most people with similar problems and pathologies, and that is they don’t do much more than distract people in pain whilst natural history kicks in (ref).
So this has left me wondering if it really matters that much in the big ol’ grand scheme of things what the hell us physios get our patients doing if it all has similar effects and is all not that much better than doing nothing? Does it really matter if someone with back pain gets spinal manipulations or deadlifts? Does it really matter if someone with patellofemoral knee pain gets k-tape or glute exercises?
Well, again yes it does and no it doesn’t! Still confused… well hold on a bit longer and I will try and clarify soon!
EVIDENCE-BASED PRACTICE AND GLACIERS
Since physiotherapy began to research and investigate what it does there has been a slow shift towards using evidence-based interventions, and I mean a really slooooow shift… think glacial speeds. Anyway, this slow adoption of evidence-based treatments has thankfully meant a reduction in less effective treatments and outright woo and quackery being used within the profession. But it also means more people with similar diagnoses are now given similar looking treatments and protocols.
A classic scenario here is someone with Achilles tendinopathy. Ten years ago, they would have had a wide range of treatments from tendon friction massages, calf muscle massages, taping, acupuncture, therapeutic ultrasound, as well as a range of stretches and exercises of the lower leg, and other areas to address so-called dysfunctional movements thought to have caused the pathology.
However, since more research has been conducted into Achilles tendinopathy most are now simply given advice, load management, and specific exercises to load the tendon. Often these exercises are slow, heavy, eccentric, types of exercise to reflect those used in the well-known research trials.
Now don’t get me wrong, I think the removal of the wasteful and outdated treatments is great, I mean friction massages were a bugger for my fingers and thumbs. But, where I think this adoption of evidence based practice is not such a good thing is when treatments are limited to only what the research trials did.
THE INDIVIDUAL WITHIN THE MEAN
Limiting our clinical treatments to exactly replicate what was conducted in research trials fails to recognise an individual’s response to an evidence-based treatment. Only using one particular type, style, or dose of treatment based on a research trial protocol is a failure of evidence-based practice and sound clinical reasoning.
It’s important to remember that a lot of research trials report their findings as an ‘average effect size’. This is often presented with ‘confidence intervals’ to show the spread of that effect over 95% of the subjects in that trial, meaning in very simplistic and not totally accurate terms, the smaller or bigger the spread of the confidence intervals, the smaller or bigger the variation in that treatment’s effects.
Often what happens in research trials is a few individuals get an amazing response from the treatment, some get a good result, others average, some only have minimal effects, and a few get negative and adverse responses. The reasons for this variation are complex and uncertain but often it’s due to differences in subjects’ characteristics such as their health, culture, concerns, beliefs, past experiences, occupational and/or social status.
It can also be due to variations in the clinicians or researchers characteristics who are conducting the trial, such as their training, experience, beliefs, and biases as well. And finally, it can also be due to differences in the application or administering of the treatment such as variations in setting, location, instructions, level of compliance, and timing of the outcome measurement.
All these differences in patient, clinician, and intervention characteristics are termed ‘clinical heterogeneity’ and they all have the potential to significantly confound research results which can lead to inaccurate conclusions being drawn about what does and doesn’t work, and why, and for who. Currently, a lot of healthcare research does a poor job at recognising and/or controlling for clinical heterogeneity and as a consequence, this can and does affect the results and conclusions often made (ref).
SCIENCE IS BROKEN!
Now before some of you rush down to the comments section to tell me “Science is broken” or “I don’t need research to tell me what treatments work” just stop because I am not saying research can’t tell us what treatments do or do not help people. I am just highlighting that often there is a lot of uncertainty in the how much, the why, and the who they can or cannot help.
I am also not saying that we should suddenly ignore research or abandon the scientific method of investigating our treatments, going back to our clinical observations which have consistently been shown to be unreliable and full of biases (ref). What I am saying is that we should recognise the variations in responses to our evidence-based treatments and be more flexible and less specific and constrained in our prescriptions and application of them.
This however is not a green light to go wild and totally off-piste from research-based guidelines, rather to consider tinkering and tailoring with evidence-based treatment parameters and prescriptions more to fit the individual in front of you or based on their response.
Just because one particular type, method, or dose of exercise or even manual therapy has been shown to help individuals with a particular problem or pathology in a randomised controlled trial, this doesn’t mean it helps everyone equally. This means you don’t have to use the same treatments for all people with the same diagnosis, and you can fiddle and adjust the settings, parameters, dosages, and application of a treatment when in the clinic to suit your patients response or situation.
Friction massages suck ass… stop doing them!
Research isn’t perfect but it’s the best method we have to work out what may or may not help our patients, so embrace it!
Look at the effect size of a treatment to get an idea of how much it may help your patients… but don’t get too excited!
Look at the confidence intervals to get an idea of how much variation there may be in that effect!
Look at the subjects in the trial and consider if they reflect your patients.
Be more flexible in your prescription and application of evidence-based treatments
Remember there’s always an individual response buried within a mean effect.
Last week on the 22nd December I was diagnosed with COVID and whilst I am in isolation, I thought I would add my experiences of this to the ever-growing narratives of millions of others who have done the same. Please be aware that these are my own personal experiences and musings and can not and do not constitute medical advice or guidance for others.
So the first thing to say is that currently in the UK where I live rates of COVID infection are very, very, high with approximately 100,00 to 120,00 new infections being reported every day. Most of these are thought to be the new Omicron variant which early data shows is much more transmissible than other variants, but thankfully it appears not as virulent or ‘aggressive’ as other past COVID variants in its effects or symptoms, whether this is due to the mutations of this Omicron variant or widespread vaccinations is not fully known.
Either way I have not been told which variant I have but statistically, it’s most likely to be Omicron, and the fact that I had no symptoms at the time of my diagnosis would also lead me to believe it was the milder Omicron variant. In fact my COVID infection was only found due to routine swabbing I have at work in which all patient-facing NHS staff are given weekly PCR tests to help protect the vulnerable patients they see.
So after having had weekly PCR swabs at work for nearly 18 months my very last swab of the year before I took a couple of weeks of much needed annual leave came back positive. This was a most unwelcomed announcement just before Christmas and my birthday as I had to cancel plans to see friends and family, but it was also a bit of a surprise because as I said I had absolutely no symptoms at all.
Symptoms for COVID infections are wide and varied with well over 50 different symptoms being documented and more being added regularly. However the most common symptoms of COVID for most are cold or flu-like symptoms, loss of smell and/or taste, and fatigue and fever, all of which I had none, and neither did my wife who has also now tested positive after my result was announced.
Where and how I acquired COVID is uncertain as I have been taking all the usual protective steps of always wearing a mask indoors and in public or crowded spaces, washing my hands regularly, and practising social distancing, and I haven’t been anywhere public recently. The only two places where I do come into closer contact with people regularly are at work or when training in the gym and despite taking the usual precautions I guess they are the most likely sources of my infection.
Both myself and my wife are fit and healthy with no other significant medical issues, and we are both double vaccinated and recently boosted. This may also be a reason why we both haven’t had any symptoms prior to being diagnosed. However, since finding out our COVID status both of us have now noticed some symptoms which is confusing and frustrating for us as we are not sure if these are psychosomatic in origin due to us knowing we have COVID or if they are just slower emerging symptoms.
Since our diagnosis, my wife has developed some mild cold-like symptoms of a sore throat, an intermittent cough, and some muscle aches. I, however, have not developed these symptoms but am getting regular night sweats and have noticed my average resting heart rate has risen by around 10-15 bpm from approx 55 bpm to around 65-70 bpm.
I have also noticed that the couple of times I have tried to exercise since my diagnosis (in complete isolation I hasten to add) my energy levels are much lower and my RPE is far higher. I have also found myself sleeping 9-10 hours over the last few nights (even with the night sweats) and nodding off a few times during the day, something I never do, however, this might also be due to increased quantities of port and cheese I have had over the festive season.
However, as I said I am not sure if these symptoms are due to the virus, the festive season, or just because I am being more hypervigilant and over analysing things far more than usual since being told I have COVID. Either way, I do feel ‘off-kilter’ and not my usual self.
As much as it’s been a pain in the arse having to isolate right when I wanted to see friends and family over the festive season, I am grateful to only have had very mild symptoms and I do think the vaccines and boosters are the reason here. I am also grateful that my asymptomatic infected carcass was detected with routine swabbing meaning I wasn’t inadvertently infecting others less fortunate or not as well protected as myself.
Tomorrow will be my 6th day since my official diagnosis and when I can take my first lateral flow test to see if it’s negative and if it is again on day 7 I can stop isolating. It will also be interesting to see how long these ‘symptoms’ and feelings I have to take to clear up after the virus has left my body, and I will keep you posted on how it goes in a few weeks time
Until then, thanks for reading, and I wish you all a Happy New Year and hope you take care of yourself and others and remember to mask up, give space, and wash your hands often.
There is no denying that trying to keep focused and motivated on something that is hard, effortful, and tough to do can be really challenging and difficult over extended periods of time. That’s especially true with exercise and especially true during the holiday and festive seasons with lots more distractions, diversions, and interruptions to our normal daily lives and schedules.
Having struggled to engage in regular exercise throughout my life I know how easy it can be to get distracted and sidelined from it at any time but even more so during the holiday periods. So I thought I would share some of my tips and tactics I have found helped keep me going when it felt like everything around me was trying to get me to stop.
Tip No 1: Don’t Hit The ‘Fuck It Button’
It’s important to recognise that life is full of ups and downs, easy patches and tough times and so there will be many times when we have to prioritise what we do and when we do it. Now, no matter how much drive, enthusiasm, passion and commitment you have to exercise, no matter how focused, determined or bloody-minded you are to exercise, there will be times when other things will get in the way of exercising regularly.
When this happens it’s important NOT to hit what I call the ‘fuck it button’ in our minds. This ‘fuck it button’ is our innate tendency to cancel and write off all our plans and goals when we encounter a temporary setback or small change in our best-made plans.
This happens a lot with exercise and training schedules when we miss a workout or run. Instead of just accepting it and moving on to tomorrow, we hit the ‘fuck it button’ and decide to write the whole week of training off, which then because we’ve missed a whole weeks training we decide to cancel the rest of the month, and very easily one missed run or workout can soon turn into… “well I might as well not bother at all now.”
When something does happen and you miss a workout for whatever reason it’s important to not blame off yourself, which is easier said than done. I know that when I haven’t been able to exercise due to my workload or other personal commitments I often feel guilty and ashamed, thinking I should have done it if I really wanted to. However, I have recognised that at times other things have greater priority and importance to me than exercise and so now I am better at accepting missing a few sessions now and then.
As important as regular exercise is, it’s simply should not be the only thing that has importance in our lives. Missing a few workouts or runs now and then has very little effect on our health, strength, endurance in the grand scheme of things, and as long as we don’t hit the ‘fuck it button’when we do miss a workout or run now and then and get back to it when we can then missing exercise now and then is ok.
Tip No 2: Focus On The Journey
Having goals with all types of exercise is great, but often they are not the best way to keep you exercising for life. For example, let’s say you want to exercises to lose 10-20lbs in weight, or add another 10-20kg to your squat, or even run 5K in under 20 minutes. You work hard for 3-6 months and achieve this goal… great stuff… job well done… but now what… sub 18 minute 5K, another 20kg or 20lbs?
Well yes possibly adding more goals after you achieve your original one can be useful, but I have learnt over many years of exercising and making many goals that when you achieve them it’s very easy to get lost and distracted unless you have learnt to appreciate and understand the processes of how you achieved those goals.
For me losing 20lbs in weight is not as important as developing the skills, knowledge, and discipline of knowing, tracking, and monitoring your weekly calories and macros. For me adding another 20kg to your back squat is not as impressive as learning how to progress and regress the volume and intensity of a training schedule to achieve it over a couple of months.
Without understanding, appreciating, and focusing on the skills and knowledge needed to achieve goals with exercise you will soon find yourself lost when you do achieve them.
Tip No 3: Surround Yourself With Like Minded People
Personally, I think humans are way too tribal and all too often sit in their segregated groups nodding and agreeing with each other and hating on any others who act, think, and even look differently to themselves. This group mentally is an unfortunate but normal part of our human nature and we all do this, myself included, but I think it’s getting worse and causing more and more issues and more and more problems in the world, increasing ignorance, prejudice and hate as a consequence.
However, when it comes to exercise I do think it’s vital for you to go and find your tribe, your clan, your inner circle and immerse yourself as deep as you can inside it. If you want to stay motivated, encouraged and committed to regular exercise surrounding yourself with like-minded people and having a strong support group helps immensely.
Whether that’s a running club, a CrossFit box, a gym, a Facebook group or a forum it doesn’t matter, just go and find those who share your interest, curiosity, passion, and drive for what you want to do and let them help and shield you from all the negativity, criticism, and bullshit that often surrounds all types of exercise. There is nothing worse than seeing people trying to exercise regularly being put off by some hateful trolls on the internet, or some bellend telling them they are doing it all wrong or that it’s not the best type.
Despite many claims made there is NO one type of exercise that will suit EVERYONE nor should it. Exercise just like humans comes in all shapes and sizes and so there is a type of exercise out there to suit everyone, you just need to find it and stick with it. And as much as I have my own biases and preferences when it comes to exercise I know that ALL exercise is great and no type is more superior to another… except maybe for squats and deadlifts!
I’m only joking… kinda!
Tip No 4: Keep It Fun
A favourite saying of mine is ‘when shit is fun, shit gets done’. There is no doubt that fun things get done more often than boring things and this definitely applies to exercise. Dragging yourself through something you loathe and hate just won’t last long, doing something you enjoy and value will.
Now don’t get me wrong I don’t think exercise has to make you skip around like a butterfly in a daisy field with your heart singing, in fact, I would argue exercise shouldn’t feel fun most of the time when doing it. For exercise to be beneficial it simply has to be challenging, difficult, intense and hard work and this just doesn’t feel pleasant, nice, or fun, in fact, it can feel downright horrible and nasty.
Many confuse and conflate exercise with physical activity when in fact they are two very distinct and different things, and both have benefits, and both should be done regularly. Physical activity, which is just simply unstructured physical movement such as walking, gardening, doing housework and other chores etc doesn’t have to be effortful, intense, or hard work, exercise does!
However, if you can learn to love the effort and learn to embrace the suck during tough, difficult, and intense exercise it does make doing it regularly easier. One way to do this is to find meaning in what you’re doing, not just when you’re doing it.
For example, I always question my reasons for running when I’m actually running and my lungs are burning and legs are throbbing. But when I stop and feel a sense of achievement of having run a few miles as well as now being able to have that extra portion of pie without feeling guilty and still able to maintain my bodyweight that’s when I really value running.
Tip No 5: Keep It Varied
Another favourite saying of mine is ‘don’t keep doing the same thing and expect to get different results’. This applies to so many things in life but especially to exercise. Now there is no doubt that focusing on one type of exercise can and does make you better at it, and if that’s what you want to do then I suggest you do that.
But unless you have dreams, aspirations and plans to become a world champion in a specific type of exercise there is no need to ONLY do that exercise. And I would still argue even if you are planning to be a world champion in something there is still room for doing some other stuff.
Doing various different types of exercise can keep you mentally engaged, interested and motivated but also can help you physically as well. Our bodies are very good at adapting to the stimuli we apply to them, but if that stimulus becomes consistent and regular it can lose its effect.
Giving our bodies and minds different stimuli from time to time can be a bit of a shock and feel uncomfortable but it can also help keep us adapting and progressing in many other ways. So if you are a runner, do some weights or go for a swim now and then. If you are a weight lifter, do some yoga or tai-chi now and then, and if you are a professional kickboxer… well you sir can just do whatever the hell you like!
My point here however is very simple… exercise variety is the spice of life… and the source of happy healthy bodies
So there you go a few tips on how you can keep your mojo strong when trying to exercise for life. I will say however that sometimes all the tips in the world just won’t help you and at times we just have to suck it up and grind it out. Life can be difficult, tough, unfair and hard bloody work and sometimes you just have to get your head down, move forwards, or sideways, or upwards or whichever way you have to go and smash it… just remember that tough times don’t last, tough people do!
Just in case you missed it, the latest physio brouhaha is now erupting on social media around some low back pain guidelines recently published that have come under a lot of criticism. This has also now devolved into arguments around tone, professionalism, but also academic copyright infringement.
This all starts with a tweet posted by the excellent Physio Meets Science Twitter account who consistently share and signpost therapists to many of the latest publications and research articles, if you don’t follow them go and follow them now. They recently posted a tweet that contained a link to an open-access clinical guideline on low back pain in a journal called JOSPT here and included three screenshots of the title page and two of the tables from this 60-page document (see below)
As you can see this tweet was ‘liked’ over 450 times and retweeted over 100 times, that’s some great engagement for a research paper, you might be thinking that JOSPT would be buzzing at all that interest and information dissemination. The tweet was also quoted tweeted by a few, myself included giving some thoughts and opinions on this guideline, some positive, some not so.
Now my own opinions were not that positive because on my initial quick scan of this guideline I thought this guideline was not very clear for the average physio (like me) who often skim reads these things and goes to the pretty pictures and tables to get a feel for the outcomes and results. I thought these had been very confusingly worded using a tiered system of SHOULD use, MAY use, and CAN use in their recommendations for specific treatments, and the tables had been poorly designed inferring a superiority of manual therapy treatment over and above other treatments, which when you dig down into the actual guidelines small print it actually doesn’t support (see below).
In my opinion, these clinical guidelines are often looked at by hard-working, time-strapped clinicians with at best mediocre statistical and methodology literacy, just like myself, to see if what they are doing is right and if there is any need to change or adjust their practice. Therefore I think it is imperative that researchers, authors, and publishers of these kinds of guidelines make their findings crystal clear and easy to read in a synopsis or table, and not bury the finer details or caveats in a small section of a massive 60-page document.
On further reading of the guideline, I also have other issues with it like the exclusion of some well-known back pain trials not being explained or justified clearly, not using the PRISMA or GRADE systems casting doubts about its methodological rigour, and separating ‘soft tissue mobilisation’ treatments which are claimed to be skilled techniques of moving specific tissues such as fascia and ligaments, from ‘massage’ which it states are general movements of the muscles alone. This ridiculous separation of basically the same treatments is both confusing and unnecessary, I mean just how the hell do you move muscles and not the fascia and vice versa
Anyway, I digress, so the comments and discussion around this guideline continued to develop and many others started to give more in-depth, specific, and skilled critical reviews of issues with this guideline. These threads again created more and more discussion and debate, but then suddenly these threads and the original tweet from Physio Meets Science disappeared and I was asked by some as to why.
Now I had no idea, so I reached out to Physio Meets Science and asked them why their tweet was deleted. They replied and told me that JOSPT had contacted them and asked that they delete the tweet for copyright infringement.
Now, this didn’t sound right to me as their original tweet included the link to the free available, open-access guideline and they only shared 2 images from the 60-page document, hardly breaching copyright rules if you ask me. I also had some messages from colleagues about rumours that someone was upset at all the negative attention and criticism this guideline was getting and had asked JOSPT for these tweets to be deleted. Now again this didn’t sound right to me and so I thought I would ask JOSPT directly if these rumours were true (see below).
The reply I got from JOSPT was firm and definite no and that tweets were asked to be deleted only due to copyright infringes.
However, I was still confused at this response because as I understand under ‘fair use policy’ copyrighted material can be shared publicly for the purposes of education, comment, discussion, and critique as long as the original source is fully referenced and no money or profit is being made. So I asked them twice if they could expand a bit more on what copyright has been infringed and why. But I got no response.
I did however get a direct message a few hours later from JOSPT now asking for my tweet to be deleted due to it infringing copyright, and advising me that I may only post cropped or partial images but must refrain from posting full figures or complete pages (see below)… PS: I’m also not a Dr.
So I then decided to seek some legal advice of my own from a past patient and now friend of mine who also just happens to be a very successful lawyer in the US to gain some clarification on copyright and fair use policy. After some checking, he came back to me and agreed that my tweet does not infringe copyright law. So I replied to JOSPT as such outlining my reasons and explaining that I will not be deleting my tweet.
Within a few hours of sending that message, I then received what I can only describe as an overly aggressive and condescending email from a JOSPT copy editor threatening legal action unless I deleted the tweet within 24 hours.
In this email, he stated that the fair use policy doesn’t apply to academic journals and is more for newspaper articles and book reviews, and only for comments that are written in a professional tone. He also went on to say that they are not asking some others to delete their tweets as their comments are professional and constructive in tone, whereas he thinks mine were not.
He also went on to state that the sharing of information on Twitter does NOT qualify as ‘educational’, which is just ridiculous, and that the screenshotting of full pages or images is not allowed. However, screenshots of partial or cropped images are, which I just don’t understand, I mean why is cropping images ok but not using a full one, and how much should they be cropped by, and what should be cropped?
So I replied that although I strongly disagree with everything stated I have neither the time, energy, or disposable income to get into a legal battle over copyright infringement, and so deleted my tweet under duress. I did explain that I am not happy about it or being threatened and shall be explaining and sharing what has happened and why my tweet has been deleted on my social media and with this blog, but so far I’ve had no further response from JOSPT.
So there you go, that’s the current situation with another physio online fracas… or #CopyrightGate if you will. I’m sure there is more to come on this and I haven’t heard the last. However, I’m both upset and annoyed at this whole fiasco of being threatened and labelled as a malicious and destructive force by JOSPT just for wanting to share my criticism of their guideline. And so I want to encourage further open and honest discussion and debate on this topic of copyright and sharing and dissemination of publications from both sides, journals, researchers, clinicians and the general public.
But for now, these interactions with JOSPT have done very little to reassure me that the rumours of attempted censorship and diversion away from negative comments and criticism are false. Unfortunately, I now find it very hard to believe that JOSPT asked for these tweets to be deleted solely for copyright infringement reasons and it leaves me with a very unpleasant feeling.
The current academic and scientific publishing industry has some major issues and it has come under some much-needed scrutiny and criticism lately. Not only do academic journals such as JOSPT have a monopoly on what gets published and how, they also get researchers and reviewers to work for them for free, charge extortionate fees to subscribers and institutions, and make huge profits that are not used for advancing of scientific endeavours rather line the pockets of corporations and shareholders.
But it now appears that some journals are also attempting to control and police what is discussed, debated and critiqued after publication. For a good insight into just how screwed up the current academic publication system is check out this astounding Twitter thread here by Cory Doctorow.
Personally, I feel this whole copyright enforcement debacle is being used intermittently and strategically when it suits some journals or their associates as a very thin disguise to manage, limit, or censor comments, suppress criticism, and divert attention away from certain publications. Because, when was the last time you heard of someone being threatened with legal action for sharing a publication or an image of an outcome graph or chart when it’s getting positive feedback and rave reviews?
As always thanks for reading, and let’s see if I get any further threats of legal action about this blog.
As you may know, I recently had an acute episode of low back pain with some left leg radiculopathy when deadlifting a few weeks ago. As painful and frustrating as this was I thought it would be a great opportunity to document and share my experiences of the ups and downs of an episode of back pain and you can watch this on my Instagram page here.
This journey has been a painful, stressful, and frustrating one, but also an enlightening experience that has highlighted and re-iterated some important things for me. The first and most important thing is never underestimate just how bloody hard it is to tolerate and endure severe pain for extended periods, nor how easy it is to worry and think the worst about what’s causing it, and if it will get better.
Knowledge without Experience is Bullshit!
Despite my training, knowledge, and 20+ years of clinical experience managing people with all types of pain, and knowing that the research shows many episodes of back pain and radiculopathy improve favourably over time. There is NOTHING like some first-hand experience of living with searing, unrelenting neuropathic pain to really put things into perspective about how this information doesn’t make things feel any better or stop you from worrying any less.
Despite knowing things heal and recover with time, I didn’t care that much at 3 am in the morning whilst lying on the living room floor trying to find a position that eased my agonizing leg pain a little. Despite knowing my pain will improve and my prognosis is good I still had doubts, concerns, and occasionally thought the worst.
These last few weeks of severe pain, lack of sleep, and bone-deep fatigue have hammered home that if I’ve struggled to reassure myself at times, just how good am I at reassuring others? This episode has also reminded me that when pain is severe, constant, and unrelenting it can take control of you and your thoughts, and no matter how tough, resilient, or double hard you think you are it adversely affects you.
I cringe a little now when I think back to the times I have tried to reassure those with similar pains to mine, by carefully and compassionately explaining how they have no signs or symptoms that indicate they have anything to worry about or need further imaging or invasive treatments. And how they will feel a lot better in a few weeks and should try to reduce and control their pain with some simple exercises, a bit of analgesia, hot or cold packs, and by staying as active as much as possible.
This recent painful episode of mine has made me think, how effective was/am I doing this, and does it actually help anyone? Well, judging by some of the messages I’ve received it seems that it does as many have told me they found it really useful to hear me talking about these feelings and emotions publicly, and by simply acknowledging and normalising these doubts and concerns it has helped others understand that it is perfectly normal and natural to have them as well.
I have also been really grateful for all the kind, encouraging, and supportive messages I have received over these last few weeks as these have really helped me stay positive and motivated through some tough times. These messages have also re-iterated to me just how important and useful some simple, honest, kind, genuine, support, and encouragement can be when you’re in pain, tired, frustrated, and thinking the worst.
Positive and Negative!
However, what I haven’t enjoyed, nor was I expecting when sharing my updates were the number of attacks, accusations, and nasty comments I got from others. Don’t get me wrong, I’m not naïve enough to think I wouldn’t get any, as I know you can’t put anything on the internet these days without some troll posting something hateful, and I’m well aware that I’m not everyone’s ‘cup of tea’ rubbing many up the wrong way with my views and opinions on things.
But I did not anticipate that I would get so many nasty, snide, and snarky comments from so many so-called kind, caring, and compassionate clinicians who are clearly revelling and rejoicing in my current predicament. Again, don’t get me wrong, I expected and hoped for some piss-taking and teasing, but never did I think so many would be so excited to see me hurt or use this episode as an opportunity to attack me and my reputation.
During these last few weeks, I have been accused of being unprofessional, inexperienced, and a shit physio, and these are just the comments I have seen as I’m also told many more have been said in closed forums and private social media groups. It seems that some turd juggling wassocks out there think physios should never get back pain or be injured, and if they do it somehow means they are less skilled or knowledgeable than others. I guess this also means these useless fart bubbles think doctors shouldn’t get sick, surgeons shouldn’t need operations, and professional athletes shouldn’t get injured either.
You Deserve It!
I have also been told by some so-called ‘therapists’ that I deserve my pain and have earned my injury with my reckless approach to training and terrible lifting technique. This is even though theres no evidence that any lifting technique increases or reduces the risk of back pain (ref) heavy lifting is not a common cause of discogenic back pain (ref), and this is my first significant lifting related injury in nearly 30 years of continuous deadlift training whilst doing a near-maximal effort 2.5 x bodyweight lift.
It seems that these arse biscuits think all injuries are avoidable and if you do get injured when exercising it’s your own fault. These mouth breathers also seem to think their so-called perfect form and correct lifting technique they demonstrate with less than bodyweight loads is the solution to the prevention of all back injuries.
Well, newsflash bell ends, anyone can maintain a pretty looking posture when they lift light-weights, but trust me it will soon turn ugly when you increase the load or the intensity, which they would know if they actually did that from time to time. What these comments highlight is just how many dumb arsed therapists are completely oblivious to what heavy intense exercise looks and feels like.
When these idiots expect everyone to move the same way lifting heavy-weights as they do lifting light-weights, they are as clueless as someone who thinks a runner should sprint the same way they jog. These clowns fail to recognise that all movement is complex and hugely dictated by the task which includes the loads, speeds, intensities, and complexity and that all injuries are multifactional and never due to a sole factor alone.
Yes ok, maybe higher loads, speeds, and intensities may have higher injury risks, and yes, you may reduce these risks by reducing loads, speeds, and intensities, but don’t kid yourself for one second into thinking this eliminates it.
These comments also demonstrate how fearful and risk-averse some therapists are to exercise and training. Don’t get me wrong I’m all for being sensible and I do like to build things up steadily and progressively in most people for most things. But to think you should always move the same, or always avoid high loads, high speeds, high intensities to avoid injury is both ignorant and impractical.
During these last few weeks, I have also been accused of being in denial, stubborn, ignorant, arrogant and some more colourful things ending in ‘T’ for not getting assessed or having a particular type of passive treatment for my pains. Some of these odious little cretins have even tried to accuse me of being dangerous and reckless, and even tried to blame me for making my symptoms worse, despite them improving, as well as the growing global back pain epidemic.
It seems that these dripping dishrags think a physio with 20+ years’ experience who has read widely around pain, pathology, and its treatment cannot make a rational, informed clinical assessment and judgement of their own condition. And it seems some of these egotistical flap dragons think that they can assess and manage me across social media from thousands of miles away far better than I can manage myself.
Heal Thy Self!
And to those who think they are being clever by quoting ‘a physician who treats himself has a fool for a patient’ also need to shut the hell up because physicians can and do treat themselves when they have signs and symptoms of simple common illnesses. And just as a physician can recognise the signs and symptoms in themselves of simple common illness that has favourable natural history, doesn’t need further investigations or interventions, so a physio should be able to do the same with a common and simple musculoskeletal injury or pain.
What these comments highlight is just how many therapists do not understand normal healing and natural resolution times, and how they do not, or cannot accept that there are many people who do not want treatment straight away, who are happy to wait and see how things go, and who can carry on despite their pain rather than rush to reduce or remove it.
These comments also highlight how arrogant and insecure many therapists are in not wanting to accept or admit that they are not needed as much as they think they are, or the reason why many of those they see and ‘treat’ get better with it often instead just time working in the background.
All these accusations and attacks also highlight how petty and pathetic some can be when they see others saying or doing things they disagree with, and how some have very delicate and fragile egos combined with large inferiority complexes meaning they quickly get jealous, vexed, and bitter towards anyone who questions what they do or achieves more than they have.
Finally, this back issue of mine has confirmed to me yet again just how much variation there is in physiotherapy practice, with so many different opinions, ideas, and suggestions of tests, investigations, and treatments for something as common and relatively ‘simple’ as an acute episode of low back pain with a touch of radiculopathy.
As much as I understand variation in all things is often a good thing as it gives options, if we as a profession can’t agree on some simple core principles of who, how, and what to do for the most common musculoskeletal issues, then we are in serious trouble. Because as much as I know, there is variation in other areas of healthcare such as medicine, and many doctors have many different ideas, opinions, and suggestions about how to manage something like a common cold, I’m sure all would agree that a common cold doesn’t need complex assessments, unnecessary investigations, or regular expensive treatments.
Until we can get a better handle on this variation within physiotherapy there is only going to be increasing confusion and chaos around our assessments and treatments, which I fear will lose us the trust and respect of not only other healthcare professionals but also the public. And if we lose the trust and respect of the public physiotherapy will be quickly pushed out to the fringes of healthcare along with the other quacks and nutjobs who claim miracle cures and quick fixes with their trinkets and charms.
As always thanks for reading
If you would like to learn more about an evidence-informed, no bullshit approach to the assessment and management of low back pain then I am running a short webinar on Tuesday 28th Sept at 7pm BST.
To find out more or to reserve your place please click the image below or this link here
When people are confronted with an argument or criticism against their current position, they tend to challenge the opposing view. This is perfectly normal behaviour and something I, you, and everyone else does. However, what often happens when doing this is we attempt to weaken our oppositions argument by either inadvertently or deliberating misrepresenting it. This is called straw-manning.
A strawman is a common and devious form of argument that gives the impression of refuting an opposing argument by distorting it to make it easier to attack. Using a strawman appears to challenge an opponent’s argument when it actually attacks a version of that argument which an opponent hasn’t stated or doesn’t necessarily support.
I often encounter strawman arguments around my criticisms of manual therapy, such as I advocate a no-touch or hands-off approach, or that I think all manual therapists are malicious or malevolent which is utter nonsense and nothing I have stated or implied at all. Recently two editorials have been published here and here which have further straw-manned many of my arguments and criticisms towards manual therapy and these are now doing the rounds on social media.
In these articles, some of my blogs and opinions have been described as demonising, destructive, and unfairly and inaccurately attacking manual therapy. They go on to explain how this is causing international concern, has adverse consequences to the profession and patients, and how they wish to provide evidence-based information about manual therapy.
Well, that’s also what I want to do and these opening claims in these articles are the first, but by no means the last strawman arguments. Attempting to position my real and valid criticisms about the over complexity, over-promotion, overuse and general ego and elitism around manual therapy as demonising, destructive, or inaccurate is a classic tactic to deflect attention away from the points I am trying to make.
However, I must admit that I’m a little surprised and flattered that the blogs I wrote many years ago are still creating such strong and emotional responses from some of the higher ranks of the manual therapy world. This does give me hope that if I can do this, anyone can, and if more of us continue to question and challenge the nonsense around physiotherapy it can create change for the better.
As these articles are now circulating widely I feel obliged to respond to these allegations of ‘demonisation’ and destruction, and so will in this blog highlight what I consider to be the strawmen arguments and reiterate again what my actual arguments are against manual therapy. I will attempt to keep this short and sweet, and hopefully as calm and rational as I can, but I make no promises.
Strawman No1: Manual Therapy Has No Unique Specific Effects
This first claim is an absolute doozy of a strawman. My actual argument against the specificity of manual therapy is and always has been around the training, beliefs, and ideology that it needs to be administered or applied in a specific way, not that it doesn’t create any physiological effects as claimed.
My argument against the specificity of manual therapy is that it doesn’t matter who, where, how or what type of manual therapy you use, you get similar results based more on the ritual and contextual effects of manual therapy, not its specific or technical skill (ref, ref, ref, ref, ref, ref, ref). My argument against the specificity of manual therapy is that no type or technique needs extensive, extended, or expensive training to do it well.
My argument about specificity is also NOT that manual therapy doesn’t create any neurophysiological effects, rather that it doesn’t create the many structural effects often claimed it does such as repositioning or loosening joints, releasing fascia, or breaking down scar tissue or adhesions (ref, ref, ref, ref)
Finally, all the so-called specific neurophysiological pain modulatory effects described as occurring due to manual therapy in these articles are actually not unique to manual therapy, being seen to also occur during exercise and activity (ref, ref)
Strawman No2: The Use Of Manual Therapy Leads to Patient Reliance, Dependency, and Low Self Efficacy.
I absolutely do believe that some manual therapy techniques given by some manual therapists have the potential to lead some patients’ to dependence, reliance and reduced self-efficacy. I will accept, as I have done many times before, that I have no evidence to support this other than my own anecdotal clinical experiences. I will also admit that this is not unique to manual therapy treatments and can also occur with other treatments such as acupuncture, electrotherapy, taping, and even corrective exercise treatments as well.
However, I regularly see and hear far more patients tell me that they need to get their pelvis pushed back in, or a muscle knot released, or adhesions broken down by a therapist regularly. I have had patients tell me they have seen therapists weekly for years on end having manual therapy treatments in a misguided and misinformed belief that they are essential for a pain-free life and necessary to prevent things from getting worse.
If this is not the definition of creating reliance, dependency, and a loss of self-efficacy then I don’t know what is. As I said I do recognise that this is just my anecdotal experience, and I will say again I have no idea how often this happens, other than I see and hear it a lot.
The strawman presented here is the classic fallacy of “absence of evidence equals evidence of absence”. Now, this quote is often used and abused by nut-jobs and quacks to claim all sorts of stupid and ridiculous things but that doesn’t mean the statement is invalid. Just because something hasn’t been formally investigated or researched doesn’t mean it doesn’t exist.
I believe that well-controlled studies are needed on large samples of patients who routinely see manual therapists for regular treatments, and they are surveyed in an unbiased way about why they attend and what their beliefs and understanding of what these treatments are doing. I’m sure this would highlight that there is indeed a lot of potentially detrimental narratives and behaviours being promoted widely around many manual therapy treatments.
Failing that anyone who thinks that there is no issue here could simply and go onto Instagram and search the hashtags #Physiotherapy #PhysicalTherapy #Chiropractic for about 5-10 minutes to get a sample of some of the utter nonsense and bullshit in and around manual therapy that I witness daily.
Strawman No3: Manual Therapy Provides Short Term Changes Which Do Not Equate to Long Term Changes
The claim in these articles that manual therapy produces short term changes which in turn leads to better long-term outcomes and prognosis is actually not that well supported (ref). However, there is no denying that those who do get quick and dramatic changes in their pain within treatment sessions usually do go on to do well in the long term.
However, what these quick short-term improvements in symptoms most likely highlight is an individual with fewer complications and confounding factors adversely affecting their presentation and natural prognosis, not the effects of the treatment itself (ref). Individuals with fewer medical and psychosocial complications are more likely to have a favourable natural history of their condition regardless of the type of treatment they receive. Often the treatments they receive are unfairly given credit for what is essentially natural history with some placebo and contextual effects sprinkled on top.
There has never been an argument from me that manual therapy cannot quickly reduce symptoms in some people. My argument is simply this is not unique to manual therapy and often affects those with favourable natural histories. My other bigger question is should we be judging our success in how much or how quickly we reduce symptoms in those we see, especially in those with favourable natural histories?
Would it be better to clearly, carefully, and compassionately reassure those we see with mild to moderate pain and favourable natural histories that this is normal and ok to experience and endure for a short period of time. Should we be encouraging more of those we see with MSK pains to tolerate them more rather than reduce and remove them all the time?
Strawman No4: Manual Therapy Techniques Are Based On Outdated, Inappropriate Philosophies That Were Derived To Support Guru’s Theories
Actually, this one isn’t a strawman as it’s not contested in the article, and it’s good to see this finally acknowledged by others in the manual therapy world. The amount of ego, elitism, and arrogance of many of the gurus and others who promote, practise, and teach manual therapy has always been one of my biggest criticisms against it.
The number of therapists who are made to feel worthless, inferior, and unskilled simply because they can’t palpate some fictitious dysfunction or pseudo structural abnormally made up by some half-witted manual therapy egomanic is astounding. If more manual therapy advocates and teachers were less elitist and exclusive and more honest and rational then I’m sure myself and many others would not have as much of an issue with it as we do.
However, I do find it really hypocritical that this article labels this criticism I have of manual therapy as demonising and destructive yet agrees with it.
Strawman No5: Manual Therapists Lack Skills In Communication, Reassurance, And Empathy
This strawman misrepresents my issue on manual therapists communication completely here. It’s not that manual therapists can’t communicate, reassure, or emphasise well with their patients, rather it’s WHAT they communicate and HOW they reassure their patients that’s my concern. Many patients who are told their spine is out of alignment, or their pelvis is unstable, or their muscles are unbalanced are told this by manual therapists taught and trained to believe these things by those gurus and egomaniacs mentioned above to justify using their manual therapy treatments.
Many manual therapists are actually very good and very proficient communicators when they explain to patients why they have pain and how it can be solved. They often display lots of empathy and confidence which adds credibility to their outdated and inaccurate narratives giving patients the reassuring impression that they are in the hands of an expert who knows what’s wrong and how to fix it… usually in 8-12 weekly treatments, with regular monthly maintenance sessions to ensure it doesn’t come back.
Strawman No6: Manual Therapy Does Not Fit Within Value Based Healthcare
You can argue if manual therapy is a high or low-value treatment as much as you like, but this won’t change the fact that currently in the UK, and most of the world, the National Health Services are at breaking point. Public Health Services simply cannot afford the resources to give patients with MSK issues passive treatments to temporarily modulate pain when self-administered hot water bottles or over the counter analgesia can do the same thing.
Decades of underfunding, chronic mismanagement, and a rapidly growing obesity and sedentary epidemic, with an increasingly ill and infirmed population, not to mention the current COVID pandemic, means all healthcare services are stretched. Some difficult and tough decisions need to be made in terms of prioritising what treatments are considered effective and efficient and it is my belief that manual therapy is just not one of them.
Yes ok, the argument in private healthcare settings is different and it may be argued that if an individual has the finances, time, and resources to have manual therapy then there is little issue here. But my argument on the value of manual therapy has always been about public healthcare services.
Strawman No7: Manual Therapy Causes As Much Harm As Help
There is no argument that severe adverse events from manual therapy are rare and most of the transient adverse reactions are also not that common (ref). However, what these articles do not take into account are the potential nocebic and psychological harms that could be occurring due to the outdated and inaccurate narratives and explanations around manual therapy treatments and the burden these may take on some individuals. As mentioned there is no evidence on this, but as also mentioned absence of evidence doesn’t equal evidence of absence.
Strawman No8: We Cant Identify Candidates For Manual Therapy Which Means Techniques Are Unnecessary.
I’m not sure what this last point is really arguing, to be honest. Maybe it’s that Clinical Prediction Rules can help therapists identify which patients are going to respond better to certain types of manual therapy treatment even though they have not been seen to stand the test of time well (ref). Or maybe it’s just that the way to see of manual therapy works on someone is to try it for a few sessions and check the outcomes.
Well as mentioned those that get good responses from manual therapy treatments, most likely would get good responses from any other contextually and placebo rich treatments, or even just time alone due to favourable personal circumstances and natural histories. Again my argument here goes back to the misguided belief and teaching that manual therapy needs to be given to those who have a detailed skilled and specific assessment looking for pseudo dysfunctions and made up structural abnormalities.
So that’s my response and rebuttal to the so-called demonising of manual therapy. As I said I found these articles disappointing and hypocritical that some real and valid criticisms of manual therapy within physiotherapy have been twisted and distorted and perversely demonised.
Although I disagree a lot with this article I recognise that this was written before myself and Chad Cook one of the authors had a face-to-face debate in which we were able to express our positions a lot better away from the limitations of social media, and I would urge you all to watch it to get more of a nuanced view of both sides of the debate here.
I also want to state that when I use the term manual therapists here, I will always precede this with some, most, or many… never all. I know there are some excellent evidence-based manual therapists out there, and I am even fortunate enough to call some of them my friends and colleagues.
I also do not think most manual therapists who fall foul for many of the things discussed here do it knowingly or maliciously, rather they are only following the guidance of what they have been taught and lead to believe by others they trust and respect.
I am also aware that outdated misinformed beliefs, ideas, methods, and treatments are not unique to just the field of manual therapy, with corrective exercise, electrotherapy, dry needling, strength and conditioning, even surgery and medicine all having their fair share of the above. I also want to stress that being taught and hoodwinked by manual therapies training about these things is not a sign of stupidity or ignorance. I myself at the start of my physiotherapy career and during my extensive post graduate manual therapy training was taught and believed many of the outdated, non-sensical, pseudo-scientific things mentioned here.
However, the only way to reduce and untimely remove these is with continued debate, discussion and dare I say a bit of disagreement. This should be welcomed by all but especially by those in positions of respect and authority, and not labelled as demonising, destructive, harmful or unprofessional.
Robust, heated, passionate debate and disagreement should be seen as a sign of a progressive, open-minded, profession, keen to progress and advance. And yes it may not suit everyone and it can be a little frustrating and annoying at times but we all need to recognise that it’s not demonising or destructive.
So my plea to all who may be invested and involved in this profession is to please keep questioning, challenging, debating and disagreeing on all kinds of things, and don’t let those in positions of respect and authority put you off by claiming you are being destructive or demonising. Because if they succeed in shutting down and stopping debate and criticism then we are lost as a profession.
A recent trial looking at the use of steroid injections and exercises for shoulder pain called the GRASP trial has recently been published in The Lancet this month with some interesting results. But yet again, just like there was with the recent SExSI trial there have been some comments and claims thrown around on social media misrepresenting what this trial shows. So this short blog is my attempt to clarify what the GRASP trial does and doesn’t show.
First things first I would like to congratulate all the authors and contributors to this trial as I do recognise doing research like this, as well as this, is both difficult, challenging, and time-consuming. So to get to the conclusion first the GRASP trial which stands for Getting it Right Addressing Shoulder Pain states that progressive exercise is NOT superior to best practice advice and that a steroid injection only offers a small, short-lasting clinically and statically insignificant effect on shoulder pain.
From this conclusion, I have been disappointed to see yet again some physios getting a bit too excited to say how exercise doesn’t help people with shoulder pain, and weaponising this study just as they did with the SExSI trial a few weeks ago to have a dig at my active treatment approach and ethos of ‘you cant go wrong getting strong’. Well, to put this simply as I can these individuals are wrong and misinterpreting and/or misunderstanding what this trial actually shows, usually because they haven’t read it in full just to have a pathetic pop at me instead. So let’s try and help them out a bit.
What is the GRASP?
The GRASP was a multi-centre, pragmatic superiority non-blinded randomised controlled trial, in which 708 patients (average age of around 55) with unilateral non-traumatic sub-acromial shoulder pain, of approx 4 months in duration were randomly allocated to one of 4 treatment conditions. Steroid injection + Best Practice Advice, or No Steroid Injection + Best Practice Advice, or Steroid Injection + Progressive Exercise, or No Steroid + Progressive Exercise.
The first thing which I think has confused and possibly misled a few people about this study is its title and the naming of the treatment groups which I do think at first glance give a false impression that this trial is comparing stand-alone advice with progressive exercises, with or without steroid injections. This is not so.
The ‘Best Practice’ group did have only one session with a physio lasting 1 hour in which they were given advice and education about shoulder pain, reassurance that the pain was not dangerous or harmful or anything serious or sinister. But they were also advised to do progressive exercise 5 x a week following a simple program of exercises with both leaflet and online video support. This group had no formal follow up sessions planned although they could get in contact with a physio if they had any issues.
The ‘Progressive Exercise’ group only differed from the ‘best practice’ group in that they had all of the above but also had up to an additional 5 follow up sessions with a physio over a 4 month period. The ‘progressive exercise’ group just like the ‘best practice’ group still had to do very similar exercises independently themselves 5 x week.
So basically both the ‘best practice’ and ‘progressive exercise’ groups had exactly the same advice, education, and reassurance and both groups were told to exercise 5 x week independently. The only difference is the ‘progressive exercise’ group had the option to attend 5 follow up sessions, which many did not with only around 25% attending the full 6 sessions either due to the physios deeming them fit for discharge or subjects not attending.
Personally, I think these groups would have been better named ‘single session’ and ‘multi session’ not ‘best practice’ and ‘progressive exercise’ as this gives a false impression that only one group had advice and the other group only exercised. In fact, the title of this study also appears to say it compares the effects of advice v progressive exercise on shoulder pain when it clearly doesn’t just do this. This study really compares the effect of single v’s multiple physio appointments in those with shoulder pain, and of course the effect of a single steroid injection.
We also don’t really know if ANY of the groups exercised that much as one of the biggest limitations of this study is that exercise adherence was not strictly monitored. Although the completed exercise rates in this trial were reported in the main paper as being around 90% for the best practice / single session group, and around 75% for the progressive exercise / multi session group they relied on subject self-reporting which often over-estimates adherence.
What I found interesting was in the supplementary files, the individual breakdown of how many subjects reported doing the exercises 5 x week for the first 8 weeks was around 43% for the single session only group, and about 60% for the multi-session group. This dropped to 15% for the single session group, and 18% for the multi session group by 6 months, and at 1 year it was less than 1% in both groups. This clearly shows that a lot of subjects were doing much less or nothing in both groups. We also don’t know how long, how intense, and which exercises the subjects were doing, which again I think is a huge limitation to this study.
So with this in mind, we have to consider that it could be that once educated, reassured, and given some attention and resources, those with shoulder pain improved with time and perhaps some occasional exercise of various intensity, duration, and type. Without a comparative group who were truly only given just advice alone with reassurance to carry on with their usual tasks and activities, we won’t know how much is from the advice or the exercise, but I am will to bet that there is a strong natural history effect here once people with shoulder pain are seen and reassured well.
The other interesting point with the GRASP study was the lack of significant effect of the steroid injection. Steroid shots are given a lot for people with shoulder pain and many are told that it will reduce pain to allow them to move more and do exercises better. And indeed the GRASP trial did show this, in some, for a short period of time.
However, it also shows that steroid injections are not as effective as many think and perhaps not the first thing to reach for in those with shoulder pain. Remember that the average duration of pain for subjects in this trial was 4 months and in terms of sub-acromial shoulder pain that can be classed as still ‘early days’. Personally, I would not often consider recommending a steroid injection for ‘simple’ non-traumatic sub-acromial shoulder pain in the first 6 months, and preferably 12 months.
So there you go a quick review of the GRASP trial which despite some dubious group naming is an excellent trial showing how steroids are not as effective or necessary as many think, and how advice and reassurance and maybe a little bit of exercise for a short period of time can help those with sub-acromial shoulder pain.
Once again to all my special fans out there, this unfortunately for you doesn’t give you any evidence or support that exercise doesn’t help people with shoulder pain, at best you can say it amuses them whilst natural history kicks in, just like most other treatments. However, if you are going to use a treatment to amuse a patient whilst natural history kicks in, why not use one that has a host of positive physiological and psychological benefits rather than all your silly poking, prodding, stabbing, scrapping or sticking them with stuff.
As always thanks for reading and remember, you can’t go wrong getting strong…
Also if you are interested in a fun, engaging and enlightening weekend taking a look at the evidence and how best to assess and manage people with shoulder pain then check out my LIVE+ONLINE and Face-2-Face Shoulder Complex courses here
The term ‘failed physiotherapy’ is a common one used by many doctors, surgeons, and physiotherapists. It is often used to justify further treatments and interventions but also to shift blame from physios to patients for not getting results that were expected?
To me, the term failed physiotherapy screams out poor communication, low motivation, shitty relationship building skills and general therapist apathy. I actually don’t think patients fail physiotherapy at all, I think more often physiotherapists fail patients, but also that the physiotherapy profession fails both physiotherapists and patients alike.
Over the years I’ve seen and heard many physios blame their patients for not making the progress they wanted or expected, and I still continue to see and hear it today. I will admit, much to my shame that I have done this myself in the past, often because it’s easier to blame others for a poor result rather than admit your own faults and failings.
No one likes to admit their own faults and failings and physios often find themselves in demanding and difficult situations that set them up to fail a lot of the time. This, in my opinion, is the crux of failed physiotherapy, either it’s due to inadequate teaching and training at universities and many postgraduate courses, but it’s also due to overloaded, underfunded, poorly managed working environments, with little to no support, guidance, or respect from other healthcare professionals!
In my experience, those physios who ‘fail’ patients at physiotherapy the most are those who are in the worst working environments, with the least support, and have the poorest training and understanding of how to develop a good working relationship with a frustrated, stressed out, worried and concerned person in pain!
Trust, Respect, Reassurance
It’s known that the therapeutic relationship a patient has with their physio and vice-versa can hugely dictate their outcome (ref, ref). And although not conclusive there is evidence that those therapeutic relationships that have the highest levels of trust, respect, and reassurance often tend to get the highest outcomes regardless of the severity or chronicity of the issues (ref, ref, ref,).
However, there is no doubt that developing good therapeutic relationships can be challenging and difficult to achieve at times. Why we don’t develop good relationships sometimes can be due to many things such as prejudices, prior experiences, personal choices and a multitude of other factors. All human relationships including professional ones are complex, nuanced and multifactorial and one of the many joys and frustrations of being human.
That being said one of the biggest factors for failed relationships between physios and patients I think is simply a lack of time, empathy, and understanding on both sides. Physios often don’t understand, appreciate, or recognise patients concerns, frustrations, or situations as much as they should, and patients I don’t think understand, appreciate or recognise physiotherapists pressures, demands, and limitations as much as they could.
I am in no way blaming patients here or justifying the poor, lazy, uncaring, apathetic physiotherapy that is rife within the profession. I am just trying to point out that it happens a lot due to a lack of support, guidance, leadership, respect, and recognition that many physiotherapists get.
If more physios were given better working environments with better caseloads that gave them time to breathe between patients, or better reimbursements for doing the simple things really well like education and exercise, or better recognition for the effort, time, and training they do, or were better respected for their place within healthcare, I’m sure many would try harder, go further, and listen more to patients in an effort to get them better results.
However, regardless of the current healthcare systems and its shitty limitations, more physios need to realise that if a patient isn’t making progress or they aren’t following their advice or recommendations it’s not automatically the patient’s fault, and before they label them as non-compliant or failing physiotherapy they should reflect on and try to find out why the patient isn’t progressing.
A lack of patient progress can be due to many factors, such as simply insufficient time to let things settle or take effect. It could also be due to a misdiagnosis of something else masquerading as something else. But the most common reason for lack of progress I think is that the patient just hasn’t started or changed anything significantly since starting physio.
The classic scenario here is a patient not doing their home exercise program given to them by a physio to help a specific issue or to just get them moving more, and it’s a situation I’ve encountered many, many times. I used to think these patients were lazy or lacking discipline, or that I hadn’t found the right exercise for them to do that they found fun or engaging.
I now know it’s often non of those things and more because the patient simply doesn’t understand why they need to do these exercises, and that I haven’t helped them connect the process of doing them to an outcome that’s meaningful. A common misconception in physio rehab is that patients will only do exercises if they like and enjoy them. That’s just not true. People put effort into things that are important to them, regardless if they like or dislike them.
Take me and running as a perfect example here, I do it 3 times a week and have done so for most of my life, but I don’t ‘enjoy’ it, in fact, I find running tedious and mind-numbing. I run because I understand that cardiovascular training is good for my health, gives my body a different stimulus from the weights I usually do. But it more importantly means I can eat more, and I love to eat more. Running also has very few barriers or obstacles for me being quick, cheap and very easy to do.
This is what physios need to do with patients more, help them understand the why better and help them connect the process of what you’re asking them to do to something that has an important and personal meaning for them. Physios also need to check more for barriers or obstacles that may get in the way, prevent, or deter patients from doing what they have been asked to do such as lack of equipment, poor environment, or time constraints.
A recent example of mine was an elderly female patient I saw with low back pain who had never done any resistance exercise in her life and had no interest in doing any now. She was a busy working grandmother with little spare time but her main issue was she couldn’t pick up her youngest granddaughter anymore without her back hurting.
This key piece of information was simply found out by asking the question ‘what is the main thing your back pain is stopping you from doing currently’ and this clearly this was her most meaningful goal. Now all I had to do was help her understand the how and why to get there. I did this by asking her to judge how much her granddaughter weighed, which she estimated was around 4 stone (25kg). I then asked her to start lifting half that weight using a rucksack filled with books and bottles off the floor and to pretend it was her granddaughter when she was smaller.
I then got her to focus on lifting her ‘small granddaughter’ 3 x week doing a few sets each session until she felt her back tiring or aching. I asked her to add 2-5kg into the rucksack each week depending on how she felt until she reached the goal of her granddaughter’s weight.
The beauty of this was that she soon realised if she wanted to continue on picking up her constantly growing granddaughter she should keep trying to lift heavier and heavier weights. In the last session I saw her for a few months ago she was regularly lifting 35-40kg, had little in the way of back pain, but more importantly, had a desire to keep doing these granddaughter rucksacks lifts a few times a week for the foreseeable future.
Now don’t get me wrong it’s not always like this, with it often being much harder to find a meaningful personal goal for some patients that you can attach a treatment process to. This may be because some patients just haven’t thought that much about it and just need longer to think about it, other times it’s because their pain although annoying and frustrating actually isn’t actually stopping them from doing the things they value.
It’s in these cases that I think ‘formal’ physiotherapy treatment is often not be needed. These patients I think simply need to recognise how they are still continuing on despite the pain, being reassured that this is great and ok to continue to do, and perhaps that they just need to give it a bit more time or make a few simple activity or lifestyle modifications to help.
I think many patients are told they fail physiotherapy simply because their pain hasn’t suddenly or miraculously improved or disappeared, when in fact they don’t need the pain to improve or disappear because they are managing it very well. Some patients just need advice and reassurance that it’s ok to do this and to keep going and give things more time.
Some patients are also just not ready for physiotherapy at that time due to other factors going on in their lives meaning they can’t or don’t want to change anything currently. Again this isn’t them failing physiotherapy, this is just them being not ready for physiotherapy yet.
So that’s my quick look into the horrible term ‘failed physiotherapy’. In summary, patients don’t fail physiotherapy, rather physiotherapists often fail patients due to their apathy, lack of empathy, poor training and understanding.
But it should also be recognised that the physiotherapy profession fails both physiotherapists and patients with its culture of quick fixes and silly treatments, not to mention its woeful underfunding, poor working environments, inadequate leadership, outdated training and general lack of respect or recognition for what they do. And until these issues are addressed, I fear many more will continue to fail physiotherapy!
As always thanks for reading
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A recent trial on ‘strengthening’ exercises for shoulder pain called the SExSI trial has just been published this week with some interesting results and even more interesting reactions and comments being thrown around on social media. In fact, its been really disappointing to see some individuals twist and contort what this trial shows just to try and have a cheap shot at strength exercise and a favourite saying of mine… ‘you can’t go wrong getting strong‘
In fact, I think it’s totally pathetic to see some well-known, influential physios gleefully misrepresenting my position on strengthening exercise for those in pain. But what I have found more astounding is those who are trying to claim that strengthening exercises don’t help those with pain, and some who think those who strongly advocate strengthening exercises for patients are the modern-day equivalents of those who advocate correct posture.
So in this blog, I’m going to discuss what this SExSI trial does and doesn’t tell us about strengthening exercises and shoulder pain, as well as defend the use and promotion of strengthening exercises in physiotherapy, and finally respond to some of the asinine comments about getting strong and those who advocate it.
However, before I begin I want to first congratulate the authors of the SExSI trial as I know it’s bloody hard to do research, but also for coming up with such a great acronym for the study. So the ‘SExSI trial’ which stands for Strengthening Exercise for Shoulder Impingement, randomised 200 people, aged between 18-65 who had long-lasting shoulder pain for an average of 10 months, to have either ‘usual physiotherapy’ or usual physiotherapy plus ‘three additional’ strengthening exercises over a 16 week period.
These three additional exercises were added one every 5 weeks and were 1) supported ER at 45º of scaption 2) scaption raises between 0-45º, and 3) unsupported ER again at 45º of scaption. They used rubber bands to add resistance and monitored the total time under tension using a sensor attached to the band.
They gave instructions to increase the resistance if subjects felt they could do more than the recommended reps and have no pain flare-up, or decrease it if they could not do the recommended reps or had a pain flare. They asked them to do 3 sets of the first exercise with 1-minute rest every day for the first 5 weeks, but as the 2nd and 3rd exercises were added they asked them to do just 2 sets per exercise every other day. The total time under tension for these exercises over the 16 week period was calculated to be an additional 12 hours which they suggested was optimal for muscle protein synthesis and strength gains (ref).
They used the SPADI as their primary outcome measure as well as measured the subject’s shoulder abduction and external rotation ‘strength’ using dynamometry. After 16 weeks 156 of the original 200 patients completed the trial and they found NO significant difference between SPADI scores or shoulder strength measurements between the two groups.
Their conclusions were “adding a large dose of shoulder strengthening exercise to current nonoperative care for long-standing subacromial shoulder impingement did not result in a superior outcome for shoulder-specific disability after 4 months.”
From this conclusion, it seems that some soft-skinned therapists and pasty professors who couldn’t deadlift their way out of a wet paper bag, or show you one end of a dumbbell from another are suggesting that strengthening exercises don’t help, or are not needed for those with shoulder pain.
First things first, this trial doesn’t actually show strengthening exercises don’t improve shoulder pain. In fact, this trial DOESN’T show ANY changes in strength OR pain levels at all. Call me old fashioned but I think for a strengthening exercise to be classed as a strengthening exercise it has to at least increase… strength.
If a resistance exercise doesn’t increase strength then it’s best called a… resistance exercise, and this may come as a shock to some physios and professors out there but not all resistance exercises increase strength. In fact, many do not.
Anyone who has tried to get stronger knows it takes more than just a few minutes of pulling a poxy physio band for a few weeks and also knows it’s not easy to do. In fact, trying to get stronger is hard as hell, requiring a lot of effort, intensity, volume, and most of all consistency.
Yes, there are some initial easier gained early increases in strength in the first few weeks of training, especially in those inexperienced to resistance-based exercises mostly due to neural adaptions (ref, ref). But to achieve significant tissue structural changes such as muscle hypertrophy (not hyperplasia as some professors who should know better are claiming as this only accounts for about 5% of muscle adaption in humans (ref, ref) requires regular intense resistance-based exercise, with sufficient dietary protein, rest, and recovery done over a long duration.
What the SExSi trial actually showed is that these particular exercises, at this dosage, in this population, does NOT increase shoulder strength or reduce shoulder pain, and that’s not surprising when we look a little closer at them.
The exercises in the SExSI trial did not strengthen the subjects because of the very low volume and I suspect insufficient intensity, but more likely just due to the fact they have pain because individuals in pain do not respond to stimuli such as touch, temperature and stress/strain the same as individuals without pain (ref). I also guess there may be an element of subject boredom, disinterest, and lack of motivation that may also have had an effect on why they didn’t improve in strength and pain levels.
The authors note that the subjects did not achieve anywhere near the total time under tension they wanted during the 16 weeks to achieve muscle protein synthesis. The aim was to get subjects to perform an additional 12 hours of time under tension, however, they only achieved on average just 2.9 hours, with 1.6 hours done in the first 5 weeks, 0.8 hours in the next 5 weeks, and just 0.6 hours for the last weeks. This equates to just 36 mins over the whole of the last 5 weeks, that’s just 7.2 mins a week, or 2.4 mins a session.
Again this is not surprising, because no one wants to do anything for a long time when in pain. However, I would NOT expect anyone with or without pain except for the most severely de-conditioned individual to get stronger by pulling a rubber band for just 2.4 mins 3 times a week. If it was this simple and easy to get stronger all our patients and everyone else would be walking around like Thor and looking like Arnold.
The ‘additional’ exercise group in the SExSI trial actually spent on average 16 mins a week LESS time exercising than the usual care group. This shows the subjects were not happy or engaged with their exercises for whatever reasons, maybe it was boredom, maybe it was pain, maybe it was lack of support from the physios etc who knows, either way, these exercises were just not done. To be fair the authors do attempt to adjust for this difference in their post hoc analysis, but I still suggest that these exercises were not done at any sufficient volume or intensity to make any meaningful tissue adaptions.
These exercises were also chosen to strengthen the rotator cuff muscles but only in a limited range of movement of just 45º of elevation to avoid aggravating pain. The assumption here is that the cuff muscles were the source of the subjects long-lasting shoulder pain and that restricting their range of movement and avoiding pain is the best way to help them.
In my experience, this is not the case at all. Maybe, these exercises are an option to start with for those with severe shoulder pain for the first few weeks, but not for 4 months solid. To ask subjects with long-lasting shoulder pain to only do 3 exercises, below 45º of elevation and avoid pain for 16 weeks is in my opinion not evidence-based progressive rehab. In fact, encouraging some pain during rehab has been seen to have beneficial effects in many chronic musculoskeletal painful conditions, including shoulder pain (ref, ref).
Also, remember this trial made no changes in subjects pain, and so it’s not surprising that there were no changes in their strength. It’s well known and well researched that pain inhibits muscle function (ref, ref, ref). Basically, it’s really hard to produce force/torque/power/work when it hurts (ref).
So what the SExSI trial found was three, limited range of movement, shoulder exercises, done at low volume over 4 months, avoiding pain does not improve shoulder strength or reduce pain. What this trial does NOT show is strengthening exercises don’t help people with shoulder pain.
Pathetic and Pedantic
I really just can’t understand some of the comments I’ve seen around this trial or the growing criticism of resistance-based exercises by some so-called evidence-based clinicians. I do understand that a few are genuinely trying to be fair and equal in their critique of all interventions, but many others are just trying to be edgy contrarians with their pathetic, petty, and pedantic comments and constant misrepresentations of those, like myself, who advocate and promote strengthening and resistance-based exercises a lot.
To claim those of us who promote and advocate getting stronger as PART of a patient-centred management approach are the modern-day equivalents of those who tell patients they need to improve their posture is a ridiculous comparison and a narrow-minded, reductionist view of the many benefits that resistance-based exercises have.
I find it ironic that those who seem to critique resistance-based exercises the most are often those who look like they use them the least. I also find it highly ironic that those who like to remind us that pain and pathology are multifactorial, and treatments and interventions for pain are multidimensional in their mechanisms of effect, only focus on the effects that resistance-based exercises have on tissue structure and patients pain levels when it suits their agenda.
Resistance-based exercises help pain, pathology, AND people via a multitude of pathways, process and mechanisms, both physiological and psychological. Resistance-based exercises affect people positively.
I am also struggling to contain my frustration with the increasing criticism of resistance-based exercise by some who think it doesn’t get the same level of critique as other interventions because I see the exact opposite. All I see on social media and in clinical practice are lots and lots of promotion and propaganda by clinicians for silly, over-complicated, pseudoscientific, active and passive interventions and very little advocacy for simple robust resistance exercise.
I argue that resistance-based exercises are one of the least used interventions within a lot of physiotherapy for many reasons such as lack of training, knowledge, confidence, and equipment. But also because they are seen by many physios to be not sexy, skilled, or sciencey enough to warrant their time or attention.
All too often I see and hear patients who have had months of massage, needling, cupping, pelvic tilting, and transverse abdominus clenching with little to no advice, guidance, or encouragement to do any robust generic resistance-based exercises or activities.
And yes, I am well aware that resistance-based exercises do not outperform any other type of exercise or even some of the pseudoscientific passive claptrap for reducing pain. But what resistance-based exercises DO outperform EVERYTHING else on is their effect on an individuals health, wellness, function and quality of life (ref, ref).
Despite some claims that strength-based exercises are not effective for pain, there are actually numerous studies (admittedly some better than others) that do demonstrate resistance-based exercises help reduce pain (ref, ref, ref). What a lot of these studies don’t prove is that resistance-based exercises actually get people stronger as this is often not measured or assessed.
These trials also don’t tell us HOW or WHY resistance-based exercises reduce pain or improve function. It may be more the act of doing them rather than the results. It could be the surrounding contextual and psychological factors around resistance-based exercises such as reducing feelings of fear and fragility, challenging beliefs and expectations, or improving pain self-efficacy that helps reduce pain, not the physiological effects of tissue adaptions such as muscle hypertrophy (ref).
I also know and accept that being strong or getting stronger is not sufficient to reduce either the intensity or frequency of pain experienced throughout life. I know this only too damn well myself as well as seeing many other strong people in pain, sometimes frequently, and sometimes lasting a long time.
However, what stronger people do have is significantly fewer risks of many diseases, illnesses, age-related disabilities, and other conditions which are often accompanied by pain. Being stronger may not prevent you from having pain in life, but it will equip you better for coping with and overcoming it.
There is also NO evidence that getting people stronger is either harmful or detrimental for many painful conditions, so again I really can’t understand why there is so much criticism, snarkiness, and bitterness towards a simple, cheap, and effective method of helping people in pain or with a disability, or those who advocate for it regularly and passionately. Personally, I think if some of these exercise contrarians used as much energy actually doing some resistance-based exercise as they do on questioning it they may find it more worthwhile.
So I’m going to continue on promoting the use of resistance and strength-based exercises in all those we see with pain or disability, and I will continue to use my phrase of ‘you can’t go wrong getting strong’ until I am blue in the face.And I really don’t give AF if some don’t like it because it’s a short, catchy, easily remembered, slogan, that fits beautifully on a nice cotton t-shirt, that grabs attention and promotes strength-based exercise to everyone.
Finally to those who critique the role of strength-based exercises in physiotherapy ask yourselves why you do this and carefully consider if what you are doing maybe detering clinicians and patients from engaging with it even more than they currently are?
NowI’m sure some will whine, moan, and even complain to the authorities about this blog as they have done before, but honestly, I don’t give AF again. Because if I have to spend my evenings writing blogs defending how being vocal, passionate, and biased towards strength-based exercise in physiotherapy is not wrong, I don’t want to be right.
As always thanks for reading
If you want to find out more about how to get shoulders SExSI strong make sure you check out my upcoming LIVE+ONLINE Shoulder Complex courses here
One of the biggest dilemmas I still have as a physio, even after 20 years of practice, is trying to decide if I should ask someone to avoid things that cause pain or ask them to do the opposite and confront it. Trying to figure out who, when, and why we should ask to avoid or confront pain can be really tricky and difficult as hell to get right.
The first thing to say is there are no right or wrong answers here. Unless you find yourself ALWAYS advising those in pain to stop doing everything that hurts, or you find yourself ALWAYS advising those in pain to ALWAYS do things that cause pain, then you are most definitely doing it wrong.
The facts are not everyone in pain needs to stop doing painful tasks, activities or exercises, but some do! And not everyone in pain needs to start doing painful tasks, activities or exercises, but some do! Some people in pain need advice and guidance to stop doing painful things for a while, others need reassurance and encouragement to start. But who, when, why, how much, and for how long for are where it all gets a little tricky and uncertain.
As much as we try, people just don’t fit into nice neat little boxes or follow rules or guidelines very well. Yet we healthcare clinicians still try to cram people into sub-groups and categories using arbitrary generic factors such as their age, diagnosis, chronicity, and pain levels. But the uncomfortable truth is that no two people in pain are alike, even if they are the same age, have the same diagnosis, or even the same pain levels, yet we assume these factors inform us that we should treat them the same.
When I see clinical guidelines and recommendations stating those with certain ages or certain pathologies should have similar treatments, like all those under 50 years of age with rotator cuff tears should have surgery, or all Achilles tendinopathies should do rehab that causes pain, or all those with lumbar radiculopathy should never do anything that hurts, I get rather frustrated. That’s not to say I never follow these guidelines, it’s just that I don’t think it’s as simple as this when deciding who, when, and why pain is or is not advisable in rehab.
I don’t think deciding ‘who’ should avoid or confront their pain really has that much to do with ‘why’ they have pain. That’s not to say I think diagnosis or pathology isn’t important in our decision making before you all jump on that false dichotomy bandwagon and ride it to the comments section. It always has been, and always will be rule number one to first and foremost assess and screen those in pain for any serious or sinister pathologies.
Rule No 1:
It goes without saying that ALL clinicians should ensure that someone in pain doesn’t have an underlying serious or sinister issue that could cause them further harm or detriment if left untreated. Things like fractures, major soft tissue injuries, tumours, blood clots etc are all essential to check for in those in pain as these need urgent medical treatment and therapy is not the place for them to be.
However, when there are no clear signs or symptoms of any serious or sinister pathology and the diagnosis is more musculoskeletal, but less certain in its specific source, as it often tends to be in most we see in pain, then deciding if I do I or don’t I recommend painful or pain-free tasks or exercises becomes tricker.
These days deciding if I suggest a person in pain does or doesn’t continue on with something that hurts is not only based on their diagnosis, but more on what they have already been doing, how that has made them feel, and how it has gone so far.
No one in pain goes to see a physio immediately, even with acute issues in private settings, usually, there is a period of at least a few days, if not a few weeks or months or longer where they’ve been struggling on with their pain as best as they can before deciding to seek some advice and assistance. Over the years I have realised that it’s not the diagnosis that helps decide if they should or shouldn’t do painful things, it’s more about what they have been doing already with their pain that does.
Now, this is not complex, complicated, rocket science, or any other science for that matter, this is just 20 years of experience in dealing with various people, in various levels of pain, for various different reasons and is a principle so simple its almost embarrassing, but it seems to work… most of the time.
As the father of modern medicine Sir William Osler was famous for saying “listen to your patients they are telling you their diagnosis” I also think listening to your patients also tells you their treatment plan. Asking a few more questions and listening to what someone has already done whilst in pain, why they’ve done that, how that made them feel and most importantly how it has responded pretty much tells you what their management plan should be.
In a nutshell, if someone in pain (with no signs or symptoms of anything serious) tells me they have been mostly continuing on with painful tasks, activities, or sports, pushing into pain regularly and often, and this hasn’t helped or settled things down over a period of time, and this is making them feel upset, anxious, and/or frustrated, I often would suggest they try and do the exact opposite as their treatment. I told ya… not rocket science!
In this situation, I would spend time with this person trying to find ways, means, and strategies to reduce their pain on the movements and tasks that hurt them the most. I would also advise and reassure them that doing something different for a while can be beneficial, and I may even suggest they stop doing something altogether for a period of time.
Rest isn’t Evil
In these days of “can’t go wrong getting strong”, “just load it” and “no pain no gain” it seems that advising someone to stop, rest up, and avoid pain is frowned upon and considered to be bad advice. It isn’t.
I see many people in pain who just continue to push, press, poke and hammer on with painful tasks, activities and exercises, aggravating, irritating and sensitising the shit out of themselves and their tissues in a belief this is beneficial. Sometimes it can be, but often it isn’t.
These individuals regardless of their pathology or diagnosis often need advice, reassurance and sometimes permission to stop doing things that hurt. They also need a lot of distraction and amusement with something else whilst they are avoiding or stopping painful tasks or exercises and so I often give them rehab that works them hard but doesn’t provoke their pain.
I may even suggest they try some manual therapy, taping, quacupuncture or other temporary passive pain modulation treatment thingy if they want to try it (as long as it doesn’t waste too much time, money, or distract them away from other things). I know, I know, I can hear your jaws hitting the floor from here, but my argument against these things has never been they cant help some people, just they shouldn’t be used on everyone, and certainly not in the belief they are skilled, special, or super effective.
Rocket Science Again!
However, if someone in pain tells me they have already stopped doing things that hurt and have avoided their pain in tasks and activities as much as possible for weeks, months, or even longer, and they are worried about making it worse or express concerns about doing harm or damage, and this hasn’t helped settle down or reduce their pain, then I would probably suggest that they need reassurance, encouragement, and motivation to start doing things that hurt a bit… again… its not rocket science.
As Albert Einstein’s said “the definition of insanity is doing the same thing over and over again, but expecting different results” and this is no different with things that hurt. As much as we clinicians don’t like to admit or discuss it, many things that cause pain in musculoskeletal medicine have a very favourable natural history. That is they tend to get better on their own over time thanks to the remarkable adaptable and self-regulating ability of human physiology.
However, when this doesn’t look like it’s happening its often because something is getting in the way of natural history, and yes this can be other pathology and as I’ve already mentioned should be checked for as best as able, but more commonly in my experience, this is due to an individual either avoiding or confronting their pain too much, too often, or too little, for too long.
Our job as clinicians and therapists is therefore very simple, but not very easy. First, we must, to the best of our training, skill, and ability exclude any serious and sinister pathology that could be causing someone persistent pain. Next, we need to identify what, how, and why a person in pain has been dealing with their pain so far, either avoiding or confronting it. Then decide if this is, or is not a successful strategy and if it needs to be continued or more often than not changed to do the opposite. As I said… it really isn’t rocket science!
A few weeks ago I posted a short article from the Guardian about the use of Graded Exercise Therapy or GET as its often referred to and its use for those with Long COVID. To my surprise, this created a lot of response and reaction that I was not expecting, and as I know very little about Long COVID I thought I should do some further reading and share my thoughts on what I’ve found so far.
The first thing to mention about GET is that it seems to be surrounded by a lot of emotion, anger, and accusations that I have no desire to get involved with at all. A lot of this hostility appears to revolve around some researchers and advocates of GET being accused of callous, malicious, and harmful behaviour by some Chronic Fatigue Syndrome and Myalgic Encephalomyelitis groups or CFS/ME for short (ref, ref)
This is because GET has been seen to significantly exacerbate, worsen, and prolong symptoms in many of those with CFS/ME and other post-viral fatigue syndromes to which Long COVID is thought to, in part, belong. There have also been accusations of GET advocates not listening or believing those with CFS/ME calling them lazy, malingerers, and even fakers who are disrupting their scientific studies. This has allegedly led some GET researchers to receive official complaints, hate mail, and even death threats which is just crazy.
Now, as I said I do not want to get involved in any of this toxicity other than to say calling anyone suffering from any symptom a faker or malingerer is abhorrent and horrible, even more so if you are a healthcare professional. But then so is making false allegations and death threats to anyone especially someone trying to help others by conducting research into a mostly unknown condition. Anyway regardless of who may, or may not have said what this nastiness just needs to stop and the time and energy directed elsewhere.
What is Long COVID?
So after a few weeks of reading around Long COVID, CFS/ME and GET I will admit that I still know very little about it, and there are clearly still a lot of uncertainties, unknowns, and speculations going on by some armchair experts and amateur bloggers to which I am now adding to. There are also a lot of attacks and accusations being flung at anyone who does share an opinion, express a view, or write a blog on this topic and so it is with some trepidation that I write this as I am sure there will be some mistakes and misinterpretations within it… so if you’re reading this #BeKind.
Long COVID is still a largely unknown condition with many varied symptoms, no clear diagnostic criteria, and no firm ideas about how best to manage or treat it. Long COVID is thought to be a collection of many different syndromes that can manifest in many different ways (ref). One type of Long COVID that appears to be most uncertain is one that has no signs of any adverse organ deficits or clear objective tests and is thought to possibly be a post-viral syndrome which is also known to occur after many other viral infections such as Ebola, Dengue, Zika, even Herpes and good old traditional influenza (ref).
This type of Long COVID is believed to share a lot of similarities with CFS/ME such as profound generalised post-exertional fatigue, loss of muscle power, pain, and malaise often reported to be delayed in onset and quite unlike the ‘fatigue’ experienced by healthy people (ref). This type of Long COVID is also thought to cause cognitive issues such as difficulty concentrating and ‘brain fog’, as well as symptoms of unprovoked breathlessness, increased heart rate, dizziness, difficulty sleeping, anxiety, and depression (ref).
The causes of many Long COVID symptoms are currently just not well understood but are clearly a mix of physiological, psychological, and social factors. One of the strongest theories of post-viral syndromes is that they may be due, in part, to a process known as mitochondrial hijacking (ref). Mitochondria are our tiny yet extremely powerful ‘engines’ in all of our cells providing energy for all its chemical cellular reactions to occur, and without them, nothing happens. Once inside our cells, a virus like COVID-19 is thought to invade our mitochondria and hijack them to provide energy for their own replication rather than doing their original jobs, slowing down and even stopping our normal cellular processes (ref, ref).
How Long is Long COVID?
The simple answer is no-one really knows how long Long COVID lasts, but some estimates suggest that 1 in 7 people may suffer from Long COVID like symptoms for up to 4 weeks, 1 in 20 up to 8 weeks, and 1 in 45 with symptoms lasting more than 12 weeks (ref). It also seems older age, higher BMI, and female gender are greater risk factors for longer Long COVID (ref).
This clearly means that a lot of people will have Long COVID symptoms when you consider that in the UK alone we had 4.27 million known infections at the time of writing this blog, and these are only the infections we know about. There is also no doubt that many physios and other therapists will start to see more and more people with COVID related issues that affect their function and ability in an effort to help them with their recovery, which leads us back to the topic of what should we be advising and recommending to those with Long COVID symptoms to do in terms of exercise and activity.
Now there is no denying that there simply isn’t enough information yet to say definitively what is or is not the best advice. But using what we do know based on current knowledge and experiences of other post-viral fatigue syndromes, rest, recuperation, and convalescence is without a doubt, an important factor in recovery. However, there is also no denying that as clinicians and human beings are all pretty crap at recommending and engaging with rest, recuperation and convalescence with it often being viewed negatively as lazy, idol, and unproductive.
And there is no doubt that too much time away from activity, work, and other tasks can be detrimental and unhelpful, but so can pushing too hard, too quickly with post-viral syndromes as this just doesn’t help them recover faster or better (ref). So where does this leave us with our recommendations for activity and exercise? Should we tell those with Long COVID to do nothing, a little now and then, or more than that?
Long COVID and Exercise
A lot of the debate and disagreement I have seen around the topic of Long COVD, CFS/ME and exercise seems to revolve around differences in the interpretation of the words exercise, activity, graded and pacing. For example, some strongly suggest that all exercise is to be avoided and only paced activity is to be recommended, in fact, this is now in the UKs national NICE guidelines for CFS/ME here.
However, this is where I have some difficulty I think due to differences in interpretation of what is, and what is not, considered an exercise or an activity. For example, some define exercise as something that is always planned, structured, repetitive, intentional and progressive that either improves or maintains fitness, whereas activity is not. I disagree and think this is a narrow and limited definition of exercise which can often be unplanned, unstructured, unintentional, and not progressive, and conversely, at times activity can be structured, planned, intentional, and progressive and also help improve or maintain fitness.
Others think it is the task itself that differentiates an exercise from an activity, for example walking is an activity, running is an exercise. Again I disagree because what I think defines what is, and what is not an exercise or an activity is based on the individuals perceived level of effort doing the task, not the actual task itself.
For example, walking for some can be perceived as very effortful and so could be classed as exercise, however, for others running can be perceived as not effortful and so would be an activity and only classed as exercise when it reaches an intensity where it feels challenging.
I do agree that exercise and activity are not the same, but my simpler definition of exercise is basically anything an individual feels challenging and effortful. This can therefore mean that for some getting out of bed, lifting a coffee cup, or sitting upright in a chair can be classed as exercise, such as when recovering from an extended period of inactivity say after admission on an ITU, or due to a post-viral syndrome such as Long COVID.
Now it’s important to say that post-viral syndromes are not physiologically the same as deconditioning from extended periods of inactivity, however, although they are completely different in cause and effect I don’t think this means the underlying principles of managing them needs to be completely different. In my opinion, anyone with fatigue or deconditioning regardless of the cause should first steadily work within their tolerance levels, ensuring sufficient rest and recovery, and let the processes of time, homeostasis, and adaption do the rest.
For those with Long COVID or any other post-viral syndrome this means asking them to internally monitor their own feelings of pain/energy/fatigue hour by hour, day by day, week by week, doing what they can, when they can, avoiding boom or bust cycles, and of course, resting and recovering when needed. One way of helping with this is to use wearable heart rate monitors to ensure that during exercise or activity they don’t go above their anaerobic threshold. A simple way to calculate this is to use approximately 55% of your max heart rate which can be done by subtracting your age from 220 and multiplying that number by 0.55, so for myself that would be 220-47 = 173 x 0.55 = 95 bpm, a target zone of 10% either side is then suggested so for me that’s between 85 and 105 bpm (ref).
Now if you decide to call this graded exercise therapy, paced activity treatment, or anything else I don’t think it really matters that much in my humble opinion. This simply is probably best described as individualised person-centred or patient-focused care or any other term you may want to use.
Managing and supporting those with post-viral fatigue syndromes also means carefully and compassionately explaining and reassuring them about the unpredictable and multifactorial nature of their symptoms and how many physical, psychological, environmental, and societal factors can affect them. It also means being empathetic, understanding but most importantly being honest and optimistic about the condition and prognosis which is that symptoms should get better over time, some may take longer than others, but there are things you can do to help.
For more on self-management with Long COVID check out this awesome FREE resource from PainToolKit.org here.
Chronic Fatigue and Chronic Pain
After reading a fair bit on post-viral syndromes these last few weeks I see a lot of similarities between chronic fatigue and chronic pain. Although different in presentations and symptoms they are both multifactorial, multidimensional, highly individual, complex conditions, that have both physiological and psychological components (ref). They both also often have no clear diagnosis or prognosis, with no clear definitive tests, scans, or objective markers, and often no clear reliable signs or symptoms, and of course no clear treatments.
Another similarity between chronic fatigue and chronic pain is that there is a lack of recognition, understanding, and social support around them both, with unfortunately a lot of stigmatism and prejudice also surrounding them both. This often produces a lot of mistrust, anger, frustration, and resentment in those who suffer from either.
One final thing I would like to discuss about both chronic fatigue and chronic pain is how there is also so much easily accessible, poorly controlled information, speculation, conjecture, and hypothesising around them which I think has the very real potential for negative cognitive priming to occur and affect individuals symptoms and prognosis.
Cognitive priming is a well-researched phenomenon in which words, pictures, and conversations have been shown to enhance an individual’s perceived intensity of their symptoms and behaviours (ref, ref). The mechanisms of cognitive priming are complex and highly individual and in no way mean or imply that an individual’s symptoms are not real or genuine, just that they can be affected and altered both positively or negatively by information you receive and assimilate.
I know this only too well with my own feelings of fatigue, anxiety, and depression recently being hugely affected by the information I read and conversations I have to know that cognitive priming affects us all in many ways. Again I want to stress that I am in no way, at all, in any shape or form, denying that symptoms are real, faked, or made up, just that they can be affected by what we see, hear, and read, and at the moment there is so much on Long COVID everywhere.
However, in my opinion, a lot of this information on Long COVID in the scientific journals, news, and of course social media is confusing, contradictory, speculative, and often pessimistic, downbeat, and negative. Even some of the official sites and support groups are full of rumours, speculations, fears, reluctancy and hesitancy, which I can understand given the current situation, but which also, in my opinion, can be negatively priming many with Long COVID symptoms and could be harmful and detrimental to their progress as highlighted in this recent article here.
So that was my brief review of Long COVID, physio and exercise. As I said at the start I have only just scratched the surface and there are still many unknowns and uncertainties. I understand that this can be confusing, upsetting, and frustrating if you are experiencing Long COVID symptoms currently, especially if you have experienced prejudice, disbelief, scepticism and stigmatism by those who don’t understand it, and I apologise for their ignorance and behaviour!
My advice is to please try and ignore these people and try and stay positive, take things slowly and steadily, and focus on one day at a time and progress will follow. Also please try to be patient with yourself and others, particularly some of us healthcare professionals who do genuinely do want to learn more and try and help support you, but who will also make mistakes and errors along the way.
And finally, my last words are to all the healthcare professionals clinicians who may be reading this, please recognise that we actually know very little about Long COVID and post-viral syndromes, so please don’t think that there is a best way to help someone with it. Instead listen to your patients more, respect and trust what they tell you, and you won’t go too far wrong.
As always thanks for reading
For more info on Long COVID and physiotherapy see this site here
For a FREE online introductory tutorial on Long COVID please see Physiopedia.com here
For more info on CFS/ME and physio see this site here
So it’s the start of a New Year and often it’s a time when many look to change some aspect of their lives, be that exercising more, eating less, or learning a new skill. However, for me, this year my New Years resolutions are that I want to stop going around in circles on social media as much and try to have more productive discussions and debates.
I don’t know about you, but I am tired of having the same old discussions, about the same old issues, with the same old people, with no one prepared to change their views or opinions. As much as these discussions can be useful for others watching and help get different views, ideas and opinions aired, after engaging in these kinds of discussions for years and years I really want to try and move some of them forward, and so I have thought hard, reflected, contemplated, and listened to some advice from others about how I can do this.
Stop Trying To Win
When critical thinking or logical reasoning becomes a weapon, it ceases to be a useful tool. I have realised that if you are using your critical thinking or logical reasoning skills to only win arguments I can guarantee that you will not be using them well.
I have learnt that entering into debates and discussions with the aim of trying to win them is both futile and kind of pathetic. I have realised that no one is keeping count of the debates and arguments you have won except you, and all those that you think you’ve won, you most likely haven’t.
The whole point of entering into any debate or argument is to try and learn something from it, not win it. Having this change in mindset has helped me hugely in the way I interact and engage, or more often, don’t engage with some others. Having this mindset doesn’t mean you can’t stand your ground and fight for your opinions, ideas and position robustly; it just means you don’t assume or expect the other side to change their opinions, ideas or position easily.
Also, when entering into a debate with someone you disagree with, first ensure that you fully understand their position and/or premise. All too often I have found that many who disagree with me do so because they have misunderstood or misinterpreted my position due to only having a small piece of the full story, or a tiny glimpse of my opinions as a whole, especially on the topic of manual therapy, and especially on social media.
Having learned from this happening to me so often, I try to avoid doing it to others by ensuring I have understood their position and arguments as fully as I can before I start to discuss with them further. Doing this can often mean you find out that actually, you don’t need to argue about anything at all.
Stop Engaging As Much
You don’t have to attend every argument you are invited to. Recognising when to pick your debates, arguments, and battles is a key skill to master for your own health and well-being and one I am still working on.
I get a lot of emails, messages, comments, and remarks about various things I write about or post on social media these days, but I don’t respond to most of them. Some people get quite annoyed and frustrated at this, thinking I am aloof, arrogant, or full of myself. I am not.
I have just learnt that after many fruitless, circular discussions that often end up spiralling downwards into personal attacks and other such unpleasantries that mine and the other parties time and energy would have been better spent elsewhere. Recognising when this is happening or likely to happen and then withholding or withdrawing is often in the best interests of everyone.
However, despite withholding comment a lot these days I do still get some usual suspects trying to provoke a reaction out of me by thinly disguising a genuine question or comment as a personal attack or misrepresentation of my opinion. This is usually because they are upset or envious of my position and/or platform.
But again, I have learnt that rather than defend myself against these wassocks they are simply best ignored and avoided completely, and so I often place them on mute for them to moan and whine to themselves and their 23 followers. This is not because I am unable to respond to them, rather because I am unwilling to. And I honestly can’t recommend the mute button on social media enough… It’s a godsend!
Stop Assuming The Worse
Having said that I have also learnt to never assume malevolence in others when ignorance can explain it better. And never assume ignorance when incompetence can explain it better. And never assume incompetence when a simple mistake is the most likely explanation.
I will always give someone I don’t know the benefit of the doubt when they say or post something that I consider inaccurate, misleading, or just plain stupid. Whether you like to admit it or not, we are all too quick to judge others and often assume the worst of them, and I include myself here.
If this last year has taught me anything its that everyone is dealing with their own personal and professional issues that you don’t know about, and if you did they would make your problems look insignificant. So, give more people more room for more mistakes.
Giving people the benefit of the doubt when they say or do stupid shit is crucial these days because it’s so easy to make a simple mistake, misspeak or just be mislead or misinformed by others. However, if the usual suspects do keep on doing or saying stupid shit repeatedly despite others comments and critique then, by all means, call them out on it
Stop Spreading Bullshit
The last and most important point I want to make about social media discussions is about calling out pseudo-science, alternative facts, or straight-up bullshit. Despite some claiming otherwise, all healthcare professionals have a duty and responsibility to highlight bullshit circulating on social media about health, disease, pain and treatments whenever we see it.
Calling bullshit is essential for our profession to progress, but also to help protect our patients and the public from misinformation and making poor choices. However, there is no doubt that calling bullshit is both difficult and challenging and it has to be done appropriately, responsibly, and respectfully.
The first thing we can all do to help reduce the amount of bullshit circulating on social media is to, and I can’t emphasize this enough is… STOP PRODUCING AND SHARING BULLSHIT OURSELVES.
If you are going to call bullshit on others, being full of shit yourself is about as hypocritical as it comes, and I hate hypocrites.
I have learnt that carelessly calling bullshit on others whilst being guilty of it myself is a quick way to make enemies of strangers, and strangers of friends.
So, again I don’t think I can emphasize this enough… CHECK YOUR FACTS AND SOURCES THOROUGHLY before clicking that retweet/share/like button!
Just because that high impact journal publishes a paper showing your favourite type of exercise outperforms something else, doesn’t mean its worthy of sharing with others when you check the study design and find is about as robust as a chocolate teapot. Or just because that well-respected media source quotes some statistics on the latest treatment doesn’t mean they have interpreted them correctly or accurately.
Also, just because some Insta-Face-Tweet-book guru with a gazillion followers does something fancy or flashy on social media doesn’t mean its effective or evidence based. And conversely, just because that eminent Professor has written a pithy editorial highlighting the flaws in some social media gurus thinking doesn’t mean their thoughts or opinions are anymore valid, correct, or accurate.
The rate at which bullshit spreads on social media these days is both staggering and frightening, and I know full well that I have, at times, been an unwilling and unknowing part of it. However, if we all try to work a little bit harder, to think a little bit more, and check our sources and facts a little bit better we can help reduce this.
So there we go, a few New Year’s resolutions that are a little different from the usual exercise more / eat less. I am hoping to stick to these as best as I can through 2021 and beyond but like most New Year’s resolutions, I’m sure there will be some relapses and setbacks along the way, so #BeKind!
However, with some patience and perseverance, I’m sure that we all can improve our social media discussions and behaviours a little bit more. And on that note, I would just like to wish you all a happy and healthy 2021 and don’t forget about that mute button… honestly use it more…. You won’t regret it!
I listened to an interesting podcast on the ‘myths of manual therapy’ recently in which I was referred to as a ‘well-known Twitter personality’ who has been misleading therapists with my blogs on manual therapy. Well, of course, I strongly disagree with this… I actually consider myself more as an Instagram Guru than a Twitter personality these days.
But in all seriousness, I do have some points I want to raise about some of the claims made in this podcast with Chad Cook about a blog he wrote in German about the myths of manual therapy. First things first, despite disagreeing with Chad a lot around the topic of manual therapy, I agree with him a lot on other things and have no personal ‘beef’ with him, despite his digs, occasional character assassinations, and misrepresentations of my views on manual therapy that I see and hear from him .
However, putting all that to one side and for the sake of progress I would like to talk about four points Chad brings up in this short podcast. The first is that manual therapy adds value and improves patients’ experiences. Second is that self-efficacy is a deeply rooted and difficult trait to change. Third, there is no evidence that manual therapy causes dependence in patients. And finally, the use of manual therapy helps identify patients who have better outcomes.
Does manual therapy improve patients’ experiences?
I certainly agree with Chad when he says at the beginning of this podcast patient experiences are strongly linked with their outcomes. However, I strongly disagree when he says that patients experience more value with ‘hands-on’ and less value with ‘hands-off’ approaches.
This is because the experience and value a patient feels they get from any healthcare appointment is not just about what treatments they get, more about how they were treated.
You simply don’t magically and miraculously improve a patients experience of a healthcare appointment by touching them. You improve a patients experience of an appointment by listening, validating, empathising, explaining, reassuring, educating, and planning with them. If you don’t do any of the above well it really doesn’t matter if you touch them or not.
This persistent argument of improving patients experiences or meeting their expectation as justification for using manual therapy is, in my opinion, a rather lame and flimsy one. First because its been well documented that using patient satisfaction is a pretty ineffective way to measure a treatments efficacy or effectiveness (ref, ref, ref).
But also because despite all the criticisms around manual therapy no one has actually said don’t touch patients. In all my constant criticisms against manual therapy I have NEVER said anywhere at any time don’t touch patients. Just the opposite in fact.
I have written blogs, posted thoughts, opinions and many papers highlighting the importance and power of touch to patients to examine, reassure, facilitate, and encourage them.
There has never been any argument from me that using touch as a clinician is important and helps improve a patients experiences, usually by giving them the reassurance they have been fully examined and their issues are taken seriously. But this still doesn’t mean you have to use manual therapy treatments.
Is self-efficacy deeply rooted and difficult to change?
In the podcast, Chad also mentions that self-efficacy is a deeply rooted trait and that ‘it’s extremely difficult to change’. He also says that some (and I assume he is again referring to me here) clearly don’t understand it and haven’t read much about self-efficacy. Well, Chad, I’m no self-efficacy expert but I have read enough to think you are mistaken here.
The first issue is what does Chad mean by self-efficacy is deeply rooted. Self-efficacy of what? Self-efficacy on its own is not a thing as discussed by my mate Ben Cormack here. Self-efficacy is an individual’s judgement of their capability to do a specific task in a specific situation, therefore it is highly context dependant (ref).
For example, currently, I have very high ‘deadlift’ self-efficacy meaning I feel very capable to pick heavy things off the floor in a gym. However, this doesn’t mean I will have the same high levels of deadlift self-efficacy if I have low back pain.
Also, I currently have low ‘car maintenance’ self-efficacy meaning I don’t have a clue how to service my car these days with all its technology and gadgets. This means I also have very low ‘I’m broken down on the side of motorway’ self-efficacy. However, when I arrange some roadside assistance I very quickly change my low ‘I’m broken down on the side of the motorway’ self-efficacy to high.
So when Chad says self-efficacy is a deeply rooted trait and extremely hard to change I disagree, because it depends hugely on what the task and situation is.
When it comes to patient’s we usually refer to their pain self-efficacy. But again, what type of pain are we talking about? Back, shoulder, hip, little finger? Acute, chronic, mild, moderate, or severe? Because when it comes to pain self-efficacy different locations, types, and severity of pain can create different levels of self-efficacy in the same individual.
For example, a patient with chronic low back pain may have very low self-efficacy to bend forward and pick up a kettlebell during their physio session yet have much higher self-efficacy to bend forward and pick up their child up at home. What appears to be low and deeply rooted in one context may not be so much in another.
A final point I want to make in regard to self-efficacy is that it has been found to be a mediating factor in low back pain and disability (ref). However, we don’t actually have much evidence to show that improving self-efficacy is what helps reduce pain or disability, or that our interventions change it, which leads me nicely onto my third point.
Does manual therapy create dependence in patients?
In the podcast, Chad mentions that he has searched and scoured the evidence base in both a scoping and systematic way looking for any evidence of manual therapy creating dependence in patients and found none. From this, it appears, and I may be mistaken here, that he implies manual therapy doesn’t create dependence in patients.
This is a logical fallacy of mistaking an absence of evidence as evidence of absence, which is a saying often abused by quacks trying to justify woo. But putting aside the crystal healers and chakra cleansers Chad can NOT say that just because there is no evidence of manual therapy creating dependence in patients that it doesn’t occur or that can’t do this.
I must admit it was surprising and frustrating for me that my own efforts in searching the evidence base have also been unable to find any papers that show patients can become dependent on certain treatments such as manual therapy. This is because it goes against my 20+ years of front-line clinical experience of hearing and seeing 100’s if not 1000’s of patients demonstrating dependency on all forms of massage, manipulations, needles, injections, taping, and electrotherapy treatments.
But on further thought its not really that surprising, as to do this type of research I think would be extremely challenging and difficult to do well, and probably why no one has tried yet. The first issue is in trying to design a study looking for dependence on manual therapy or other passive treatments that is ethical, and as well controlled as possible to avoid the many possible confounding factors such as clinician and researcher equipoise and bias, but also trying to work out how to rate or judge dependence.
I don’t know about you but in my experience those who are most dependant on things tend to not be aware, recognise, or admit that they are dependent on things. Therefore, simply asking patients do you think you are dependent on X won’t work and asking clinicians the same will also have issues.
I do agree with points raised in the podcast that most patients are not stupid and don’t become dependent simply or easily. However, patients are often very trusting towards clinicians and I have seen far too many clever and intelligent people tell me that they go and see ‘their guy’ 5-6 times a year to get their pelvis put back in, or that muscle knot rubbed out for 5, 10 even 20+ years because they like, trust, and believe them to know it happens.
Will this ever be demonstrated in the evidence? I don’t know! Will this ever change? I don’t know! All I do know is I hear and see patients regularly receiving unnecessary treatments due to some false, misleading narrative given ignorantly or deliberately by some therapists providing them for payment.
Does manual therapy improve outcomes?
The final point I want to discuss is Chads points he raises around within and between session changes, that is patients who feel immediate improvements (within session) and those who feel delayed improvements (between session).
Chad discusses how there is evidence to show patients who have immediate within session changes have a small to moderate likelihood for good long-term outcomes, and those who have positive between session changes have very strong predictions of good outcomes in the long term. From this, and again I may have misinterpreted this, it appears Chad implies that manual therapy can therefore help improve patient’s outcomes.
However, I have some questions here. The first is couldn’t both these within and between session changes just be seen in patients with favourable natural histories improving regardless of the treatments they receive? I mean just because a patient gets some manual therapy and then displays some improvement next session doesn’t mean the manual therapy was the cause of that.
It could be those that have good within or between session improvements with manual therapy, or any other treatment, may just be those with low-risk factors, and conditions with favourable natural histories improving regardless.
Also, I maybe a little slow here but is it really that surprising that patients who show signs of improvement, tend to improve more than those who don’t show signs of improvement? Or am I missing something a bit deeper here with these studies?
So that’s my review of Chad’s recent podcast on his German blog in which I get a brief mention… I think. It’s a shame its not available in English as I would like to read it to make sure I am not misrepresenting Chads positions on his myth-busting of manual therapy because I know how annoying and frustrating that can be.
Now just in case, anyone is still unclear on what my position on manual therapy is I will lay it out once more. I believe that most manual therapy used in musculoskeletal therapy is overcomplicated, over-hyped, and overused. It is surrounded by a tonne of ego, elitism, and some absolute throbbers full of bluff and bravado who teach it, with ignorant, ill-informed, misleading and potentially harmful narratives about what it does and how it does it.
I think manual therapy is a low-value treatment because of its small, unreliable, short-lasting effects making it not worth the time, energy, and costs to provide it. This is not to say manual therapy doesn’t do anything for anyone, rather, that its best provided by those who can offer it at more reasonable costs to those who have a low risk of it not distracting them away from other more important interventions for their pain or disability.
When it comes to exercise I’m a strong advocate for both resistance and cardiovascular training to be done frequently and consistently, and usually the harder, heavier, and more intense it is the better I think it is. However, over the last few years, I have come to realise that there is also a place and a need for the more easy, more relaxing, less intense exercise in our lives.
Don’t get me wrong I don’t think low-intensity activity should detract or divert attention away from the many, many physical health benefits of hard, higher-intensity exercise which are well-researched, well-known and well-documented (ref, ref). But when it comes to improving our general wellness and mental health I have found a new love for lower-intensity more easy-going exercise.
Lockdown Mojo Loss
So this all came about at the beginning of the first COVID lockdown when I found my motivation and dedication to engage in my regular higher-intensity exercise was slipping. Without knowing it I soon came to realise that I went to the gym to help get my higher-intensity training done. It turns out that I actually love doing this kind of exercise only in the environment of a gym with all its sounds, smells and atmosphere, and trying to do it at home just wasn’t the same, and so I found it harder to get shit done. Basically, I had a lockdown exercise mojo loss.
Now some of you maybe think well you just need to drink a cup of concrete Meakins and get ya head down and get that shit done. And I agree, I did but I also realised that I need some help and support to do this and so I reached out to a personal trainer friend of mine called Louis Calvert to help me with some online coaching and accountability.
Now part of Louis grand plan for me was to start to focus on the number of steps per day I took, something that I have never done before, and thought I didn’t need to being a fit healthy and highly active physiotherapist on the go all the day. To begin with Louis set me a daily target of 8000 steps a day to achieve something I thought was very easy to do and if I’m being honest a little bit insulting to be asked to do.
So at first, I was very reluctant to do it and actually said to Louis that I would rather run 8000 steps per day than walk them. My reasoning for this was I thought walking for the sake of walking was boring, daft and a complete waste of time. My mentality was back then if you have time to go for a walk, go for a run or a workout instead.
However, Louis convinced me to give it a go for a while, particularly when he showed me that my average daily step count for the last week was only around 3000 steps something that took me by surprise. So slightly embarrassed I relented and began to focus on trying to achieve 8000 steps per day on top of my other resistance and cardio training.
And as predicted, I hated it, finding it dull and boring and was literally watching my step counter slowly, painfully, creep up to its target each day. I also got annoyed with walking ‘interfering’ with my other usual daily activities making me get up an extra 45 minutes earlier than usual to go and get a few thousand steps in before work, going for a walk during my lunch break, or walking after I’ve done a workout or got back from work.
However, after about 6 weeks something really strange started to happen, I started to find I began to look forward to my walks and I actually increased my daily step target to 10,000, and then 12,000 steps a day.
I found I was enjoying these calm moments in the early morning before everyone else was up. I loved watching the sunrise in the peace and quiet before the chaos of life kicked in for the day, I became fond of the feeling of walking on a cold misty morning. I started to relish my lunchtime walks between clinics to unwind and decompress from the stress of work, and even when it was raining or dark I found the sound of my footsteps in the puddles and mud almost soothing and cathartic.
Without knowing it a few months of walking regularly and I had become a walking addict. I start to find myself going for small short walks whenever and wherever I could.
I also started to notice some other surprising benefits from all this walking, the main one was my mind slowed down. Now this may not sound like much of a benefit, but for me, with my mind and thoughts often rushing around at 100mph and feeling stressed and jumbled a lot, I felt calmer, more relaxed, and a lot more ‘I don’t really give that much of a shit’ since walking every day
I didn’t think that I was that uptight or stressed but after my mind calmed I realsied that I do have a tendency for speaking before thinking, deliberating too much on stupid stuff, and giving too much of a shit about things and people that don’t really matter.
I found walking more has given me more time to think and organise my thoughts better and I am in a much calmer and stress-free place than I’m used to, which allows me a better perspective on things. My 10 to 12,000 steps a day have been what many others call ‘taking a deep breath and counting to 10’, I’ve just realised that I need to count to 10,000.
But it’s not just psychological and mental health benefits that I’ve noticed since walking daily, there have been some rather surprising physical ones as well. First of all my stamina on my usual long Sunday runs has improved, which may also be due to my increased resistance training. But I do think spending an extra 90-120mins a day every day on my feet has helped reduce the tired fatigued and heavy feeling I used to get in my legs on my long runs.
I have also lost a lot of body fat since walking, which again has surprised me and is no doubt mostly due to my lower-calorie diet, higher levels of resistance training, and a new love for jumping rope. But the daily walking has, I’m sure helped place me in a calorie deficit, burning fat, and stopped me stuffing my face unnecessarily as it now occupies a lot of my spare time.
So I am converted when it comes to daily walking and have started to promote it more, to more. Although many talk about reaching the magical 10,000 steps a day target as a holy grail, I don’t actually think it needs to be that much for more many people. The 10,000-step target first became popular in Japan after a pedometer was launched there called Menpo-Kei which when translated literally means the 10,000 steps meter (ref).
However, research has shown that when it comes to walking, some is always better than none, and increasing the number of steps by as little as an extra 1000 steps can have positive benefits for a lot of sedentary people (ref). In fact there have been some recommendations for achieving just 5000 steps a day for most as this can have some pretty big changes in sedentary individuals’ health status (ref).
Also, a recent study has shown that when it comes to steps more does not automatically equal better, with any extra steps taken above 10,000 a day not shown to have much significant impact on health or mortalilty (ref).
So in summary I hope my experiences may have motivated you to consider walking more. If like me you can’t see the point or the benefit please just give it a go for 6 weeks and I bet that you will start to see and feel the change.
My tips are try to make time in your life to walk intentionally every day, fitting it in when and where ever you can, don’t worry too much about step targets, but do get a step tracker to get an idea of how far you’re going. My other tips is to get some comfortable shoes, a warm waterproof coat, and finally relax and enjoy it. Don’t think about rushing to get your walk done, take it at a comfortable pace, stop now and then to look around you and take in the scenery and start to enjoy the time you have walking.
Over the last 4 weeks, myself and Ben Cormack have been interviewing patients on the ‘Better Clinician Project’ to gain their insights and experiences of healthcare and the clinicians working within it. I have found these discussions an invaluable resource and have learnt so much from them and I urge you all to go watch them now here.
I know that as a clinician you may be thinking, why do I need to listen to more patients when I’m already listening to so many of my own? Because I used to think like that, but there are a number of very good reasons to listen to patients reflecting about their interactions with other clinicians as it can give us insight into what our current patients may be feeling and thinking but not telling us.
You don’t know much
I don’t care how good you may think you are at communicating I will guarantee that most of your patients won’t be telling you everything they know or feel, and this is perfectly normal. But by listening to other patients it can allow us to appreciate the feelings and emotions our current patients may not be expressing to us for various reasons.
Throughout these discussions, there have been some common themes emerging that I think are vital for all clinicians to consider, not only to help improve your relationships with patients but also your results. And these things are not huge or complex things but rather relatively small and simple changes you can make in what you already do.
Things like spending a little more time really listening to patients, making sure they feel heard and understood, but most importantly ensuring that all your patient’s pains and problems are clearly validated even if you can’t explain or don’t fully understand them.
This was powerfully demonstrated in the chat we had with Keith recently who shared his story of persistent pain after a road traffic accident 34 years ago. This accident left him with severe abdominal injuries and having to endure multiple surgeries. Yet despite all this, his pain persisted and after many interactions with many doctors, surgeons, and therapists over many years, all telling him they’ve fixed everything and done all they can, even that his pain was all in his head he became more and more disillusioned.
He explained how he was also becoming more and more frustrated and angrier and angrier with healthcare and clinicians until one day whilst going through yet another assessment, answering yet again the same old questions, one doctor stopped filling out his form, put down his pen, turned around and said:“it’s ok, I believe you”. For Keith, this one sentence completely transformed his entire shitty journey with healthcare so far and started him moving forward on his long road to recovery.
I just don’t think I can emphasise the importance of validating all of our patient’s pains and problems enough, and that’s even if we can’t explain or don’t understand them fully. Simply demonstrating your trust and belief in what a patient is telling you helps build strong working relationships and most importantly successful outcomes.
Whether you like to admit it or not, the fact is without first earning your patient’s trust and respect all your fancy or even non-fancy treatments will just not work that well.
Many healthcare professionals don’t like to accept this, thinking their treatment successes come from their skills in administering or delivering them. But often what we do to help those we see isn’t only about WHAT we do, but more often about HOW we do it.
For example, it’s known that giving an effective, evidence-based treatment such as education or exercise in a shitty therapeutic environment does not produce good results. Yet conversely giving a shitty ineffective non-evidence-based treatment in a nice and caring therapeutic environment can work well. (ref, ref, ref)
This fact often goes unnoticed by many clinicians, with those who get shitty results with effective evidence-based treatments often blaming patients when in fact it’s their crappy communication and rotten rapport-building skills. And conversely, those clinicians who get great results with shitty non-evidence-based treatments failing to recognise that it’s their good communication and relationship building skills.
This is one of the most frustrating things I see in clinical practice and the research, and it drives me nuts. Clinicians using effective treatments with shitty communication and relationship skills tend to underestimate their role in improving outcomes, yet those with good communication and relationship skills using shitty treatments also underestimate their role in the success of their results.
If more clinicians could find that perfect yet elusive and individual mix of good communication skills, strong rapport building, and effective evidence-based treatments then we would see far more successful results.
So please make sure you go and watch all of our Patients Perspectives interviews on the Better Clinician Project. We think these are so valuable for all clinicians that we have made them all freely available for everyone to watch.
Both myself and Ben would like to thank Amy, Pete, Kat, and Keith for talking to us on the BCP and sharing their stories. We know that it can be awkward and difficult to talk about this stuff particularly to other clinicians and we really do value their time, honesty and frankness.
If you want to check out more of what we do at the BCP in an effort to make us all a little bit ‘better’ check out the project below.
First things first, a disclaimer, I earn an income from teaching a course on shoulder assessment and rehab, as well as an online education platform which some individuals like to highlight in an effort to embarrass or shame me or invalidate my views on physiotherapy education and post graduate courses. They don’t do either.
I’ve been teaching physios for well over 10 years now and although I’m still a clinician at heart working both in the NHS and private practice, I do now also consider myself an educator, a teacher, a sage from a stage, a guide from the side, or whatever else you want to call someone who attempts to impart knowledge onto others, and I’m very proud of it. Anyway, I have skin the game in this argument and so of course this will affects my views.
Well meaning but misguided
The main premise of the editorial is “journals are well-placed to shape practice if they choose to take an active role in knowledge translation by accrediting quality courses.”. This, in my opinion, is well-meaning but misguided in thinking accrediting continuing education courses will improve the quality of them.
Most of my thoughts on this can be neatly summarized by my mate Erik Meria who did a very nice thread on this here.
I understand and share the authors desire to improve the quality of continuing education within the profession, and agree with them when they say many courses are ‘questionable’ in quality and content. For example, a quick look through a well-known course provider’s list finds courses on quackery such as electro-dry needling, cupping, even myofascial release with sink plungers.
However, having journal editors accredit quality courses will NOT help reduce the number of these bad and questionable courses and could in fact reduce the number of good quality courses even more. Shitty courses will not disappear or be any less popular just because there is an accreditation scheme by a few journals.
The simple reason questionable and dubious courses thrive is due to the demand for them. Many therapists just do not have the scientific literacy or critical thinking skills to recognise that these courses are peddling placebos and snake oil under pseudoscience and flimsy excuses of emerging evidence.
Instead of trying to regulate and accredit those who produce shitty courses, I think we should focus more on improving the critical thinking skills of those who go on shitty courses. Once therapists can start to see that these shitty courses are pseudoscience and quackery that wastes time, money, and don’t actually help patients much at all the better.
The other issue is that journal editors are the best people to judge what is and what isn’t a quality post-graduate course. I appreciate that many journal editors are smart, intelligent people, and often have good knowledge of the evidence base. Although from some limited personal experience with some journal editors I also know this isn’t guaranteed.
However, being a journal editor is no measure of being a good judge of the quality of a course or another’s ability to teach well. A good high-quality course is at least about the best quality evidence available but this is not sufficient for a good course, trust me I know having been on many courses presenting the latest evidence but in a dull, boring, and instantly forgettable way.
There are many other factors that make for a good learning experience other than just the evidence presented. Presentation style, graphics and visuals, speaker enthusiasm and personality, practical demonstrations etc, the list goes on and on. All these factors are essential for a quality course, not just the reference list.
Conflicts of Interest
The other concern I have with journal editors accrediting others’ courses will be their bias and vested interests affecting their judgement. And I’m not just talking about financial conflicts of interest that the editorial mentioned.
There are many other conflicts of interest other than financial to also consider. For example, I know damn well that many journal editors would not approve or accredit my course due to previous professional disagreements and personal dislike towards me, as well as issues they have with my social media platform, its reach, and my own views and opinions.
Don’t get me wrong I would gladly and confidently submit my course for scrutiny and review to anyone if I thought it would be truly fair and impartial. However, from previous experience of dealing with editors and peer reviewers who reject things on nothing more than personal dislike I know it often won’t be reviewed either fairly or unbiasedly.
I also know from past experience that handing your materials over to those to review and accredit it, who teach similar courses and subjects as you, leaves your work open to being copied and plagiarised as I have seen personally happen to me a few times to my utter frustration and dismay.
So, in summary, I agree with the editorial that shitty courses are a problem in physio, but I disagree that journals policing and accrediting post-graduate courses is the solution. Instead, improving therapists levels of critical thinking and decision-making is the way forward here and then it comes down to the basic economics of removing the demand, and the supply will cease.
As always thanks for reading, and be sure to check out my upcoming non-accreditted but ‘high quality’ evidence-based Painful Shoulder courses below!
I posted on Twitter how I was NOT in favour of the recent proposal to change the national regulations for physiotherapists in the UK to prescribe and modify stronger pain medications such as Codeine and Gabapentin here. This created a lot of mixed reactions and so I thought I would expand on this a bit more here.
To put this as clearly as I can I don’t think its the role of ANY physiotherapist to prescribe ANY medications let alone strong analgesics with potentially serious side effects and harms. I do understand and recognise that the physio profession must adapt and progress to help those we see in pain within an ever-changing healthcare system. I just don’t think prescribing medications is the way we should be doing this.
In my opinion, the physiotherapy profession continues to be distracted by the biomedical world of pain management, with many physios focusing on the medical management of pain with injections and medications rather than other alternatives that can be just as effective and far less harmful.
This is not to say that I don’t think injections or medications can’t and shouldn’t be used to help those in pain when indicated, I just don’t think it’s within the role of the physiotherapy profession, and I say this as a trained and qualified ‘injection therapist’ myself.
I know this sounds hypocritical, but as an Extended Scope Practitioner working in a busy Trauma and Orthopaedic department, it was seen as essential that I had the training and ability to administer ultrasound-guided corticosteroid injections under a local patient-guided directive. And as much as I love working in this role, I do not enjoy this aspect of my job.
I am all for advancing skills in physiotherapy but I think there are some lines that should not be crossed. Mixing the physio and medical roles too much I believe leads to both confusion and dilution of the effectiveness for patients.
Just as I wouldn’t expect a doctor to spend the time designing and prescribing an individually tailored rehab program for a patient after an MSK injury, I wouldn’t expect a physio to prescribe and administer medications to a patient after an MSK injury.
Personally, I believe all physios who currently inject and/or prescribe medications, and I include myself here, do a far less effective job at advising, educating and more importantly rehabbing patients back to good robust functional levels.
This is simply because they have far less time to plan and implement rehab programs, discuss lifestyle modifications, and give behavioural and motivational advice with patients, as they are instead discussing the pros and cons of injections, medications, or surgery, which from my own experience takes a lot of time and effort.
Don’t get me wrong I think advising patients about the pros and cons of injections and medications is a worthwhile use of time, even if it’s not the most rewarding, I just don’t think physios need to be trained in the administering or prescription of medications them to do this.
Longer ≠ Better
The main argument for physios to be trained in prescribing medications is that they’re better placed to advise patients as they see them more and for longer than doctors. This is believed to make them better judges of what and how much mediation is needed. But I call bull shit on that.
Spending longer with patients doesn’t automatically mean you get to know them any better, or make you a better judge of what the issues may or may not be. In fact, I think spending longer with patients can sometimes cloud and affect your professional judgement as you develop personal attachments that can make you prone to over or even underestimating things in patients.
Advising ≠ Administering
The other argument for physios to prescribe medications is that they are often asked about medications by patients and because they are not trained to prescribe them they can not give any advice about them. Again I call bull shit on this.
I absolutely 100% agree that all physios do need more training on pharmacology and medications, and this should begin at the undergraduate level. The time spent learning massage, manipulations, or spinal segment motion palpation could be spent beter on learning drug physiology, mechanisms, and interactions.
If physios had more basic training and education on pharmacology they could be better placed to give patients recommendations without the need to prescribe or modify them, and this is no different with any other factor such as diet, stress, or smoking. Giving advice about something doesn’t mean you have to administer it.
Faster ≠ Better
Finally, one of the main arguments for physios to prescribe more medications is that it’s more convenient for patients, and avoids any delay of them being in pain, as well as easing the pressure on doctors appointment schedules and time. But again I call bull shit on this.
Yes, many doctors are under huge pressures on their time and appointment schedules, and yes many patients do find it difficult to make appointments to see them, and yes there are often delays. But this is due to ineffective healthcare management and infrastructure at a national governmental level and will not be easily fixed nor impacted on significantly by more physios prescribing medications.
I also think there are some very good and well-justified reasons why there should be some inconvenience and delay between a lot of patients with non-acute, non-traumatic pain and their ability to access strong pain killers like Codeine and Gabapentin. Faster, quicker, more readily available access to treatment doesn’t always equal better quality of care.
Advocating a delay in accessing pain control can come across as cold, uncaring and discompassionate, but I think it can be beneficial for some patients for a number of reasons. First, it simply allows for a short period of time to see if pain naturally reduces. It can also allow an individual to experience a brief exposure to an unpleasant stimulus which could help them develop more resilience and robustness against it. And finally, it can help put off and deter those looking for medications for secondary gains and of course avoid the complications and risks this has.
Now I’m in no way advocating that we let patients suffer unnecessarily or needlessly for extended periods, just hat popping a pill or having an injection immediately at the first hint of pain isn’t how or why they should be used.
More = Better
Around this argument is the complaint that it’s often difficult for physios to get in contact with doctors to discuss patients medications, and so if they can independently prescribe them this avoids this issue and will be better for patients. Again, I call bull shit on this.
I don’t deny that it is often very difficult if you work outside of a multi-disciplinary team environment to get in contact with doctors and other healthcare professionals, it’s difficult at times even working within one. However, avoiding and circumnavigating this communication issue is NOT the answer to help patients, in fact, it could have the exact opposite effect.
One thing I have learnt after 20 years working in healthcare is the more connections, links, access, and communication you can have with other clinicians the better it will be for you and your patients. If your ability to contact another healthcare provider to ask for some advice or guidance is difficult or obstructed, I would strongly urge you to improve this as quickly as you can, NOT avoid or ignore it.
All healthcare professionals, including physios, need to stop thinking and working in their little isolated silos thinking they can help patients all by themselves. All clinicians should be looking to work and integrate more with other clinicians, as this allows each to help, support, and more importantly, learn from each other, which ultimately helps patients and avoids duplication, error, and confusion with their management.
So once again I do NOT support the idea that more physios should be prescribing or modifying more medications. I do understand the arguments of quicker, faster, more convenient pain control for patients, but as I have argued above I think these are not justified.
I do support the notion that all physios need to learn more around medications to be able to offer simple advice and guidance to patients. However, I don’t think they need to prescribe or modify them as this can cause confusion for patients and lead to potential barriers and disagreements between doctors and prescribing physios.
Finally, I think ALL physios should be focusing on other ways and means to help patients in pain away from medications and injections. I think more physios need to look to specialise and advance in things we do best, which is getting patients moving more, making lifestyle modifications, and long term behavioural changes.
I have a confession to make. I don’t use that many outcome measures with my patients! I know admitting this may be shocking, almost sacrilegious to some evidence-based clinicians, and it may leave me open to some criticism. But before you do, hear me out as to why I think outcome measures don’t help most patients or therapists that use them.
Outcome measures are simply something that quantifies and records a dependent variable, such as pain or function, that is being affected by an independent variable such as treatment and interventions. There are literally hundreds of outcome measures available in musculoskeletal medicine and they come in all different variations and varieties
There is no doubt that outcome measures have helped healthcare move away from eminence based practice which relied upon biased and unreliable observations and personal opinions of what clinicians thought did or did not work, towards more reliable and unbiased ways of recording what does or doesn’t work. However, I think many outcome measures in clinical practice today are not used well and offer very little for patients and clinicians.
The Early Days
From the start of my career as a physio, I was taught to use all varieties and variations of outcome measures with my patients to ‘prove’ the effectiveness of my interventions and justify what I was doing. And that’s exactly what I did for many many years, but these days I hardly use any outcome measures.
You may be thinking, how do I know if what I am doing is effective or working. You may also be thinking that I’m a huge hypocrite for always going on about the need for more evidence in physiotherapy, yet here I am saying I don’t collect evidence of my interventions with my patients.
Well, your right this is contradictory behaviour, and if I am being honest this is not the first time I have been a big old hot mess of contradiction. I do think the physio profession desperately needs more evidence to demonstrate what it does or doesn’t do is effective, I just don’t think my day to day collection of outcome measures with my patients helps achieve this in any way shape or form.
I don’t think most outcome measures are useful for most clinicians in normal everyday clinical encounters for a number of reasons. First, a lot of the data collected with many outcome measures is rarely collated, analysed, or used for anything useful. Secondly, most outcome measures create frustration and unnecessary barriers between patients and clinicians. And lastly, outcome measures don’t actually measure what many think they are measuring.
Unless involved in research or a clinical trial most data obtained on outcome measures is not used for anything meaningful. Most data collected in outcome measures is collected by clinicians on orders of their managers, insurance companies, or other professional organisations often for the sake of paperwork purposes, legal documentation, or just to be seen to be doing the right thing.
Outcome measure scores mean very little to patients and most outcome scores are not used to check if patients are actually getting better. Instead, a lot of outcome measure data is used to rate and assess if clinicians are effective rather than if patients are improving.
This is not what outcome measures are designed for. I have been appraised many times throughout my career by managers checking my patient’s outcome scores. I have even been given specific outcome measure targets to achieve in some clinics I’ve worked at.
There’s an old saying that goes “as soon as a measure becomes a target, it ceases to be a good measure”. This is because when a measure becomes a target our biases and errors increase during the recording of the measurements as we attempt to obtain the target.
This affects both the reliability and accuracy of the outcome measure and gives us skewed perceptions and results of treatments and clinicians’ effectiveness. There is also another saying that goes “what is mismeasured is mismanaged”. Meaning that misusing outcome measures to rate clinicians rather than patients often leads to patients being mismanaged.
They Don’t Do What You Think They Do
Many clinicians collect outcome measures in the mistaken belief that they prove the ‘effectiveness’ of their treatments and interventions. They don’t. Outcome measures measure patients’ outcomes not the effects of treatments or interventions given to them. That sounds bloody confusing so let me clarify it a little more.
Basically, there are many things that can affect a patient’s outcome other than just the treatment they receive. Things like time, beliefs, expectations, reassurance, placebo, and many other factors which I have discussed before. Outcome measures therefore also ‘measure’ the effects of these things as well, not just the effects of treatments received.
A common misunderstanding made by many clinicians is that when an outcome measure score improves or worsens it must mean their treatment was the cause of this. It doesn’t. Just because a patient improves, or deteriorates after treatment it doesn’t mean it was because of the treatment, as patients can and do improve and deteriorate despite the treatment they receive. (ref)
Many also misinterpret patients’ responses recorded in outcome measures. For example, the Pain Self Efficacy Questionnaire (PSEQ) is often used to assess patients’ fear of movement when doing tasks when in pain. However, the Pain Self Efficacy Questionnaire only measures a patient’s confidence to do the tasks described in the questionnaire, and this doesn’t transfer well to other tasks.
Just because a patient scores high in self-efficacy to do household chores on the PSEQ when they have back pain, this doesn’t mean they will have high levels of self-efficacy to do kettlebell swings or bird-dog exercises during their rehab. It’s important to remember that outcome measures only measure what the outcome measure is measuring, they do not inform us about other things.
Another factor to consider is that patients may fill out outcome measures based on information they have to recall from the past which may be poor and inaccurate. They may also answer questions in a specific way due to concerns about the effects or impact their answers may have on future treatments or interactions with clinicians.
Outcome measures also create a lot of unnecessary barriers to patient-clinician communication and therapeutic relationship building. I often see a lot of confusion, frustration, and apathy in patients as they struggle to fill out questionnaires and answer a long list of boring meaningless questions, or try to give a simple single word or numerical score on something that is complex and complicated.
For example, does the number 7 really explain and describe the severity, intensity or frequency of an individual’s experience of back pain? Does ‘sometimes’ or ‘occasionally’ on a tick box really convey the frustration and anxiety someone has with their sleep being disturbed?
Some outcome measures can also take 15-20 minutes to complete, and often the questions mean very little to those filling them out. A classic example I come across is with the Oxford Shoulder Score (OSS) which I have to use a lot in my current role. There is a question in this about the level of difficulty combing or washing hair which always gets bald men rather annoyed and perplexed!
Outcome measures can not and do not capture the complexity or uniqueness of individuals’ pain and disability well, yet many clinicians use these measures to identify patients’ problems and disabilities instead of actually asking them what their actual problems and disabilities are.
Just because someone says they have a lot of difficulty washing their hair, or a lot of back pain when doing household chores on a questionnaire, this does not mean these are meaningful goals for them to achieve. They may be far more concerned about not being able to play with their kids, sleep through the night, or do their job far more than they are concerned about their doing their hair or household chores.
Not Completely Useless
However, although I’ve been very critical of outcome measures and think they are not used well and offer little for most, I don’t want you to think I am completely dismissing them, or that I don’t collect any information from my patients at all.
As I have said I think most outcome measures are often best suited for research purposes and clinical trials. However, there is one outcome measure that I use regularly with a lot of my patients which is validated, quick, and simple, but more importantly, doesn’t create any unnecessary barriers or frustrations with my patients, and this is the Patient-Specific Functional Score (PSFS).
The PSFS involves asking the patient what are 1 to 3 things that are important and meaningful to them that they are having difficulty with currently because of their pain or issues now. This could be anything from brushing their hair to playing tiddlywinks, it doesn’t matter, it’s up to the patient to decide, not a bloody questionnaire.
They then rate how difficult it is for them to do these things on a simple scale from 0 to 10, with 0 being impossible, and 10 being no problem at all. These tasks are then reassessed at various time points throughout their treatment to see how progress is or is not going. I find this outcome measure to be one of the most simple, meaningful, and least obtrusive ones out there and one that I think should be used often in clinical practice.
So there you go that’s my quick look at why I think many outcome measures suck in physio. To summarise…
* Don’t use outcome measures to measure a clinician’s effectiveness
* Don’t think outcome measures only measure a treatment’s effectiveness
* Don’t ask bald men to fill out the Oxford Shoulder Score
* Do use the Patient-Specific Functional Score more
It’s been a tough few weeks for exercise in healthcare both on social media and in the research. A recent systematic review has shown it provides little to no benefit for acute low back pain. Then a very interesting blog called it ‘snake oil’ and a ‘dirty word’. And finally, a discussion on twitter questioned my favourite slogan of ‘you can’t go wrong getting strong’.
It’s fair to say that exercise, as a treatment for pain and disability, has a lot of critics, questions, and uncertainties around its efficacy and effectiveness. And although I am, and always will be, a very ‘strong’ advocate for exercise within healthcare I have to reflect and ask myself why do I use it as a treatment so much?
If I am being brutally honest I use exercise with most of my patients because I am biased towards it, but also because I think it’s expected and assumed by patients that’s what us physios should do. There is a very strong tradition and culture that physios give out exercises when you go to see them for pains and problems, just like doctors give out medications, chiros give out back cracks, and surgeons slice and dice.
Although I think exercise has many benefits and is one of the most evidence-based and supported treatments we physios have, I think it’s often over-complicated, but under-promoted, however, I don’t think it’s sufficient to help many in pain and disability improve and I don’t think many patients actually ‘need’ it as a treatment.
Now before you all go lose your minds and head down to the comments section to call me a hypocrite or express disgust, disappointment, or just to gloat and say ‘I told you so’ keep reading on a little bit longer.
Let me explain!
I think we can all agree that all pain and disability is individual, complex, and multifactorial. From the enigma that is non-specific low back pain, to something as ‘simple’ as an Achilles tendinopathy all aches and pains can confuse and confound us, regardless of the cause of the severity of pain or level of disability we really just don’t know what is needed to be addressed to help them.
For example, when someone has low back or Achilles pain do we need to ask them to move more or less? Do we need to increase their strength, power, or endurance? Do we need to improve their knowledge, confidence, or pain self-efficacy? Maybe they just need to lose some weight, stop smoking, sleep a bit better, and relax more??? The factors to consider are almost endless.
Now there are some conditions where we do have a better understanding of what needs to be addressed more to help some improve, for example after an ACLR ‘it’s the quad’ as my mate Erik Meira would immediately say. But for many other pains and disabilities, the list of factors and variables is long and complex.
But to think that addressing just one factor will be sufficient is both naive and ignorant, even Erik reluctantly admits that it is actually more than just the quad to return to play after an ACLR. However, I think many therapists are failing with their exercise treatments because of their limited and reductionist way of thinking about it and in their use of it.
Using exercise monosyllabically just to increase someone’s strength, power, or even confidence when they have complex, multifactorial issues is only going to partially help or simply just fail. Working with patients with pain and disability we can NOT use exercise like S&C coaches working with athletes who often only have simple single factors to address such as strength, power, or endurance.
You’re not an S&C Coach!
It really is great to see more and more physios improving their exercise understanding and prescription skills and something I hope continues. However, I am concerned that more and more physios are using exercises with their patients like S&C coaches use them with their athletes, replacing poor old Mrs Miggins 3×10 shitty banded external rotations for 5×5 90% 1RM overhead KB presses at a tempo of 3301, coz S&C gainzzz baaaby!
Don’t get me wrong I think it’s great to try and get as many patients, even Mrs Miggins as strong and powerful as possible using S&C principles, but if you think it’s only about increasing strength or power for pain and disability then you and your patients are going to be disappointed.
S&C has become a bit of buzz word recently in rehab and many S&C coaches are training physios and are being revered like messiahs and the second coming, here to save physios from the error of their ways with their big biceps, fancy periodisation programmes, and 0-2 reps in reserve.
Don’t get me wrong I’m glad that physios are learning better exercise prescription from S&C coaches at last. But like I said earlier I think many physios give out exercises because it’s expected that’s what they should do rather than thinking that’s what they should do.
Also, physios often give exercises without involving the patients into the process because it’s 1) believed they should know best, 2) justifies their existence and fees, and 3) helps with the illusion of being more skilled and specific.
This is a mistake and something that I think needs a monumental shift in culture and training. To make exercise more successful we need a joint and collaborative approach working alongside patients expectations, beliefs and abilities, helping to guide and motivate them accordingly.
However, much as I hate to admit this, the uncomfortable truth is that most things we physios see tends to have a favourable natural history and often gets better with nothing more than time. Basically meaning that they get better no matter what exercises we give or what other treatments we do or don’t do with them. (ref, ref, ref)
This is a hard pill to swallow and accept for many physios and other therapists, especially after spending years of hard work and dedicated study learning about the complexity of human anatomy, physiology, and pathology and its treatment. To be told that it doesn’t really matter what you do with your patients because they will get better, or won’t regardless, is both a slap in the face and kick in the ego-testicles.
And I get it, I still hate that awkward feeling even after 20 years of practice of assessing a patient fully, checking that there is nothing serious or sinister, realising their issues, pain, and disability will most likely improve with little more than time, reassurance, and simple advice to keep moving as much as they can. This makes you feel a little embarrassed and useless inside, like your not doing enough to justify your fees, that your skills, efforts and dedication in helping others is worth little and actually not that important or needed.
So to mask these feelings I think a lot of us tend to over conflate and over complicate what we do and say, hoping to fill that awkward gap of waiting for natural history to kick in by over-treating and doing more than really is needed. Be that with some fancy advice, education, manual therapy, joint manips, colourful tape, cupping, scrapping tools, pointy needles, machines that go bing, or fancier exercises.
Still use it!
However, although I have been quite critical of exercise highlighting its small effects on pain, and how it doesn’t outperform placebo, and how I think most patients don’t actually ‘need it’ to get better. I still strongly advocate and recommend it with all the patients I see.
Yeah, I know what a hypocrite right, but hear me out. Although I don’t think formal specific exercise is needed for many pains and disability, I do think formal specific exercise is needed for general health and well being.
Now I have seen a lot of debate and discussion recently on this topic with some saying healthcare clinicians shouldn’t be so dogmatic, prescriptive, or harsh with their exercise recommendations. That they need to understand and appreciate not everyone enjoys or likes exercise and instead prefers general activity and other types of movement, and these are just as important for health and well being.
But I think these discussions are confusing two very different things, that is exercise and activity, and although used interchangeably they are not the same. It’s also not that one is better than another, its that BOTH are essential for an individuals health and well being, and BOTH should be encouraged and advocated more.
Go hard or go home!
General recreational activity and other lower-intensity movements are great and an essential component for an individuals health and well being. But no matter how much you wriggle, worm, contort or twist it you just can not escape from the harsh facts that regular intense, robust, difficult, awkward, even painful exercise is ALSO essential for and individuals health and well being. (ref, ref)
As much as movement matters, so does intensity, and to think you can go through life at a constant low intensity without needing to challenge your body and mind hard and often is both misguided and mistaken (ref). Our bodies and minds respond to the stresses and pressures they are exposed to, toughening and hardening them. Without stress and pressure, there is no robustness or resilence.
Now, I have also seen some comments from some acupuncturists with delusions of grandeur who think that we should only be focusing on treating an individuals pain and disability, not using exercise for health, well being, robustness and resilience. They also claim that using the secondary benefits of exercise as a justification for its treatment for pain and disability is just an excuse.
Well, I think these are pathetic, asinine, narrow-minded comments used by some clinicians more interested in their own agendas of trying to justify their use of passive interventions for helping pain and disability.
I see this a lot recently with clinicians and researchers trying to justify the use of things like manual therapy or acupuncture by comparing their pain-reducing effects to those of exercise. This is like trying to justify the nutritional benefits of doughnuts by comparing their effects on satisfaction to sticks of broccoli. They’re just not comparable.
Exercise and pain
As I’ve already mentioned exercise doesn’t demonstrate strong effects for most pains or disabilities, but that doesn’t mean it doesn’t reduce pain at all. Exercise has been shown to reduce pain via various different mechanisms, such as endogenous opioid analgesia, diffuse noxious inhibitory control, habituation, conditioned pain modulation, and expectancy violation.
The issue is that most studies are small, with a high risk of bias, and normally done on healthy individuals (ref). I am well aware that exercise for pain is not a panacea and its effects on pain can be similar to most other treatments such as analgesia, injections, acupuncture, manipulations, massage etc.
However, if I am going to choose a treatment for someone’s pain and or disability out of all those that are available that all have similar effects, then I am far more comfortable choosing one that has some well known, well researched, positive secondary effects on an individuals health and well being. This is not ‘excuse based practice’, this is ‘exercise-based practice’.
My blogs are a lot like buses, you wait for ages then two appear together. I was not planning to write another blog so soon after my last one, but, I was made aware of a recently published editorial and response letter discussing a ‘puerile anti manual therapy trend’ and ‘self-perceived social media experts’ that I have been referenced in. So I thought a reply was warranted.
Another reason my blogs are a bit like buses is just like buses have passengers who want to go somewhere, it’s the driver who decides what route, how fast, and what potholes it goes over. So as ‘passengers’ of my blog, I would suggest holding on tightly because this bus is going down some rough roads. If you think this is not the right bus for you then I would suggest getting off now.
Been Here Before
The first thing to say is that I have been here many, many, many times before responding to these kinds of pathetic whiney publications from the higher ranks of the manual therapy community, moaning about those who question and challenge its use and usefulness.
I was in two minds whether to give these silly articles any time at all as I really don’t think they are worth it. They are published in a low-value journal, written very poorly, and don’t construct much of an argument at all. I also don’t know the authors and so don’t really care what they think of me or my blogs.
However, as I have been referenced I thought a response from me may get the discussions around the efficacy and effectiveness of manual therapy going again, and it gives me another opportunity to have another rant about the egos and elitism of the manual therapy gurus which is something I love to do.
Insecurity and Desperation
So my first thought after reading these ‘glorified blogs’ is that they scream of insecurity and desperation from those whose identities and careers are deeply embedded within their manual therapy interventions. If these authors are that concerned to reference a blog I wrote a few years ago as a significant threat to manual therapy they must be standing on some very thin ice, or I am massively underestimating the influence of my blogs.
These editorials are nothing more than weak appeals to antiquity and authority wrapped up in a very thin disguise of professional concern. They are basically saying that manual therapy has been around for a long time so therefore it must be good, and as a profession, we have always used it so therefore we should continue to do so.
It’s honestly some of the worst justification for manual therapy I have ever read. They even try to use the current chronic pain epidemic and opioid crisis as grounds for the continued use of manual therapy. What they don’t provide, however, are any plausible arguments or evidence that manual therapy can do anything about these issues.
Conflicts of Interest
When I see these kinds of editorial, papers, and reactions it often leads me to suspect that there may be some personal bias and conflicts of interests camouflaged as ‘professional concern’. So I did some background investigation into the authors, who I will state again I have had no interaction with at all, and do not know in any way. I found that the lead author and a co-author are both faculty members of well known manual therapy institutions and they both teach post-graduate manual therapy continuing education courses, therefore earn incomes from manual therapy.
Now there is absolutely nothing wrong with this, but it is a clear conflict of interest and so should be clearly disclosed to the readers of this article, which it is not. In fact, the authors declare no conflict of interest (see image below) which is another reason why I think this journal and editorial board are poor, it literally took me 2 minutes to find this out.
Anyway, the authors of this piece continue to moan away in that usual passive-aggressive academical way, about how the profession is in danger of losing its identity if it abandons manual therapy blah blah blah. They also appear to blame ‘charismatic presenters’ and accuse those who are ‘anti manual therapy’ of being ill-informed and biased. Which I find hugely hypocritical especially in light of them not declaring their own biases.
Exercise Not Manual Therapy
Also, despite what they claim in this editorial the modern physiotherapy profession was NOT born from manual therapy but from EXERCISE. One of the earliest documented origins of physiotherapy as a profession dates back to Per Henrik Ling from Sweden who founded the Royal Central Institute of Gymnastics in 1813 (ref). The UK physiotherapy profession evolved after the first world war to help aid wounded soldiers back to function, and originally we’re called remedial gymnasts (ref). Yes, they used massage and other things, but their foundation was always exercise.
But putting that aside the physiotherapy profession is simply NOT defined by ANY intervention, be that manual therapy or exercise. Just as medicine is NOT defined by any one drug or surgery by any one procedure. One of the biggest reasons I challenge and critique manual therapy so much is NOT because I don’t think it can’t help people. It can, for some, for a bit, for a short while. It’s just not that special, skilled or specific that many like to think or claim.
I criticise manual therapy because I just don’t think it deserves the time, energy, effort, respect, or reverence it gets from therapists or patients. Manual therapy is a pretty low-value treatment that doesn’t need years of dedicated study or practice, or thousands of pounds, dollars, yen, or shekels spent on it to perfect. Personally, I think manual therapy sucks because of its arrogant, aloof, egotistical and elitist attitude that many of its gurus, tutors, and associations have.
Sick and Tired
I am sick and tired of soft-skinned megalomanic manual therapists thinking they have some sort of intellectual superiority or moral high ground over other therapists just because they crack a few necks and give out back rubs.
I am sick and tired of hearing many dedicated young physios telling me they feel demoralised and discouraged because they are made to feel foolish and inferior by these self-obsessed narcissistic wassocks who think they can feel sacrums move or a multifidus fire late.
I am sick and tired of the manual therapy fraternities who are more interested in monthly subscriptions than patient benefits, whose members look down and belittle others because they haven’t passed their group’s pseudo-scientific entrance exams and hazing rituals.
I am sick and tired of all the bluff, bluster, and bull shit that constantly oozes from the manual therapy community, such as muscle knots, fascial adhesions, overactive psoas, underactive glutes, wonky thoracic rings, or twisted pelvic joints.
Manual Therapy Sucks
I will say again that Manual Therapy Sucks NOT because it doesn’t or can’t help some in pain or with a disabilit. Manual therapy SUCKS because of all the above. If manual therapy could rid itself of all the over-complicated pseudo-scientific egotistical narcissistic bollocks and pathetic whiney editorials that infests and surrounds it then I think it could be more effective for more than it currently is.
I will however still continue to argue that manual therapy as a treatment does not belong in an evidence-based healthcare profession being administered by highly trained degree qualified clinicians due to the time-cost/reward ratio. Instead, manual therapy should be given as a service by less qualified non-diagnostic therapists at lower costs and greater reward ratio for patients.
ALL these points I make do NOT apply to ALL manual therapists, just a good few of those in so-called positions of authority. I know many excellent manual therapists who use their hands-on techniques simply, rationally, and within a patient-centred well-rounded treatment program. I know many excellent manual therapists who also join me in my rants and share my frustrations against the bullshit and bollocks in their midst. For them, I am forever grateful.
I will end by saying that these pathetic pieces of writing are only more fuel to my fire that proves the manual therapy dinosaurs are becoming more and more threatened that their days of rule, reign, and regulation are coming to an end. And in my opinion the sooner the better. Viva la revolution.
I’ve been trying for many years to get myself and other physios, therapists, trainers and coaches comfortable with simplicity in our assessments and interventions. Unfortunately, I don’t think I’ve been very successful as I constantly find myself confronted with many who over-complicate what they do, how they do it, and why they do it.
Why so many people are attracted to complex and complicated methods over simpler ones is ironically both complex and complicated, but it’s mostly due to something called ‘complexity bias’ which is a trait that we all suffer from that gives undue credence and priority to complex ideas, concepts, and methods over simpler ones.
Complexity bias states that when faced with two competing theories, we are often more likely to choose the more complex one rather than the simpler one. As a result, when we are confronted by a problem, we tend to overlook or ignore simpler solutions and hunt for more complex difficult ones.
You Have A Bias Towards Complexity
Now if you don’t believe me that you just love to make things more complicated for yourself than you need to, just try this little experiment out for me. All I want you to do, using as simple logic as you can, is tell me what you think the next number in this sequence is…
3, 5, 7…
Now I bet most of you immediately thought of 9 as it’s the very clear simple and obvious answer in a list of ascending odd numbers. However, I bet a few of you smarter cookies may have thought of 11 thinking this is the next number in a list of ascending prime numbers. Well, both of these answers to this problem are correct, and they are simple and straight-forward solutions to this problem. But there’s an even simpler answer that I bet all of you overlooked and nicely highlights our bias towards complexity.
The numbers 3, 5, and 7 are indeed ascending odd, and ascending prime numbers, but they are first and foremost simply just ascending numbers. Our natural inherent bias towards complexity and pattern recognition immediately overlooked the simpler answer of ascending numbers and saw the more complex solution of ascending odd or ascending prime numbers instead.
So although you are still correct and solved this problem by saying the numbers 9 or 11 as a solution, you would have not fully understood why you were correct or how you solved the problem. Our complexity bias can therefore not only cause us to make inaccurate or incomplete conclusions to problems but more importantly, it can make it unnecessarily difficult for us to continue solving simple problems.
Our complexity biases often make things much harder for us and others around us than they need to be, they also can give us a false illusion of solving a problem. For example, when we treat people with pain or injury with say some manual therapy, or a bit of tape, or even our exercise our complexity bias tends to assume it’s our treatments that have helped when in fact there could be a much simpler explanation of time and reassurance helping someone underneath or treatments.
We Prefer Complex Over Simple
Now don’t worry if you feel a little foolish now for not recognising 3, 5, and 7 are simply just ascending numbers because back in 1989 a study conducted on 91 mathematic students at Santa Barbara University in California found they all did exactly the same thing when asked to work out the rule on a set of three ascending numbers. Highlighting how complexity bias can affect all of us no matter our intelligence or interlect.
Humans are without doubt very very complex both psychologically but also physically containing many individual parts that combine to form a collective that often can’t be separated from its components. We’re made up of trillions of cells, billions of neurons, thousands of muscles, tendons, ligaments, bones and sinew. Our many systems are interwoven and interdependent on each other and although we have amazing adaptability and resilience there are times when these parts, components and systems can fail leading us to develop pathology, pain, injury and illness.
Yet despite all this complexity for how and why we get pathology, injury and pain, our interventions and treatments can often be very simple and straight-forward. Unfortunately, many clinicians in healthcare do not feel confident or comfortable in thinking this way due to the time and effort they have invested into learning all the complexity of the human body and its diseases and pathologies.
So many clinicians look for complex and complicated reasons and solutions for patients’ pains and problems, without first considering more simpler straight-forward ones first. For example, physios are quick to blame a patient’s shoulder pain on faulty scapula biomechanics rather than recognising they have just played a little too much tennis last week. Or they will associate a patients neck pain on their excessive foot pronation, that’s causing increased knee valgus, hip adduction, and anterior pelvic tilt, which is then adversely affecting their deep oblique spiral fascial sling or some other bollocks, rather than recognising the patient has just recently lost their job, is stressed out to the max, and hasn’t slept well in weeks.
This issue of over-complication occurs not only in our roles as healthcare clinicians but also in all aspects of our lives, with many companies’ actually playing on marketing to our complexity biases all the time. They often do this by incorporating confusing language or insignificant details into their product packaging or advertising to hook us with complexity, such as we are more likely to buy face cream with ‘peptides’ in it, foods with ‘probiotics’, and TV’s with ‘4K HD’, even those these terms mean very little to most of us.
Complex Is Not Chaos
We also have a habit of trying to make sense and solve things that can not be solved seeing complexity and patterns where only chaos exists. This can manifest in many forms, such as seeing conspiracy theories, having superstitions, and falling for logical fallacies.
The distinction between complex and chaos is not just a semantic one as it can have some pretty dire consequences. For example, when we perceive something as complicated when it is in fact chaotic, we are more likely to think it is predictable and therefore controllable.
This can mean we waste a lot of time, energy, effort in trying to control the uncontrollable and ignoring the simpler controllable. This can lead us to make mistakes such as trying to predict who is going to get injured when playing sports and fool ourselves that our movement screens and other tests are controlling the many chaotic factors that contribute to injury and so ignore other controllable factors such as load and recovery management. (ref).
Complexity bias is an interesting dilemma because it seems to go against the other cognitive biases we suffer from that occur to save us mental energy and effort such as confirmation bias which allows us to avoid the effort of updating our beliefs. But complexity bias is, in fact, another mental shortcut allowing us to actually think less by sidestepping the need to understand complex issues.
The Problem With Complexity
The other issue with thinking or intervening with more complexity is that it has more chance of going wrong. The more individual parts a complex system has the greater the chance it has to break down. Complex systems are difficult to maintain because addressing one of its constituent parts inevitably affects another.
This is why complexity is far LESS common in the natural world than you think because it’s unsustainable without a lot of effort, constant maintenance, self-organisation, and/or adaptation. Instead its often chaos that tends to disguise itself as complexity.
Complexity Bias and Language
Another area where we can suffer from over complexity is in our language. We have all had a conversation with or been guilty ourselves of using big fancy words, complex jargon, and 10 words when 1 would have sufficed. We have all heard people say things that we do not understand, but which we do not question for fear of appearing dumb and stupid.
I see so much biomechanical, medical jargon, and downright neuro-babble used by physios, therapists, trainers and coaches often to give them the illusion of knowledge, skill, and intelligence when in fact I think it’s often just a smokescreen to hide their inadequacies and inferiorities. When therapists and trainers use this kind of complexity in their language they create barriers that reduce the chances of others understanding them, which may be non-intentional for some but I think it is often used intentionally by many as a deterrent to others questioning or challenging them.
One of my favourite papers demonstrating this over complexity in language is Gordon Pennycooks’ 2015 study brilliantly titled ‘On the reception and detection of pseudo-profound bullshit’. In this, he uses four trials that demonstrate how people are more inclined to rate random, vague, complex-sounding bollocks as both profound, scientific, and intelligent. He even used one of social media’s biggest neuro-babblers Deepak Chopra’s tweets for this.
Unnecessarily complex language is not only annoying, but it can also be harmful. The use of jargon in areas such as healthcare can and does leave patients confused, alienated, and removed from important decisions. It also leads other clinicians to believe that they are not intelligent enough to challenge what others are saying, meaning poor practice, errors and mistakes are often not questioned or avoided.
Now don’t get me wrong I think some technical terms and jargon does have its place in healthcare, in some specific contexts, and sometimes its absolutely vital. But in everyday communication, its use is an attempt to sound more intelligent and deter any questioning, challenge and/or critique.
So how Can We Overcome Complexity Bias?
The most effective tool we have for overcoming complexity bias is Occam’s razor. Also known as the principle of parsimony, Occam’s razor suggests that the simplest solution or explanation is usually the correct one.
An important point to note is that Occam’s razor does NOT state that the simplest hypothesis IS the correct one, rather that it is the best option based on the available evidence currently until new information is received. Occams Razor can be really useful in situations where empirical data is difficult to collect, such as when deciding what’s the most likely cause of shoulder pain in this tennis player in front of me… is it their faulty scapula movements which I don’t know if they are faulty because I didn’t assess them before they had pain, or from his increased training due to competition coming up that they just told me about?
So that’s my little trip through some reasons why you hate simplicity and prefer complexity.I hope you have found it useful and remember any fool can and often does make anything more complicated. However, it takes a touch of genius and a lot of courage to move in the opposite direction and make things as simple as possible, without making them simpler.
As always thanks for reading, and if you want to try and find some simplicity in shoulder pain then please come and check out my LIVE+ONLINE courses below and here.
I want to voice my very real and very genuine concerns for the safety of all healthcare workers, including many of my physiotherapy colleagues who are being placed at unnecessary risk when working with COVID19 patients due to some ridiculous guidelines on personal protective equipment, often abbreviated to PPE.
Whilst on the topic of abbreviations I also want to say that if I hear ‘AGP’ which stands for ‘Aerosol Generating Procedure’ being misused or abused by some government official, NHS manager, or other misinformed numpty to justify why one healthcare worker gets full ‘SAS style’ PPE and another gets a food apron and a pair of poorly fitting rubber gloves when working with COVID patients I’m going to blow a gasket.
This ridiculous and quite frankly non-evidenced based guideline on PPE needs to change immediately, otherwise I fear more doctors, nurses, physios, careers, cleaners, porters, etc are going to suffer unnecessarily.
I don’t say this to be dramatic or spread fear or anxiety among my fellow healthcare workers, I say this as I have real concerns that many of my selfless, dedicated and brave colleagues are being, at best misinformed, or at worst deliberately misled.
I have mentioned a number of times on social media how I am both confused and concerned at the hugely different levels of PPE being worn in pictures of physios attending to COVD19 patients.
The response I get back is that government, NHS, and CSP, guidelines state that full PPE (that is a viral filtering FFP3 face mask or respirator, face visor, full length surgical gown, hat, double gloves, and foot protection) is only needed when there is a risk of AGPs producing airborne viral particles such as during ITU intubations, extubations, or rolling a ventilated patient. All other interactions with COVID patients need only a basic non-viral filtering mask, apron, and gloves as they don’t produce airborne viral particles.
This is simply complete and utter bollocks, not true, correct, or accurate in anyway based on plenty of evidence that clearly shows viral aerosols are generated with not just with intubations, but also with coughing, sneezing, and even breathing (ref, ref, ref, ref, ref, ref, ref).
Any COVID19 patient who is breathing should be considered an aerosol generating subject (AGS), and any time a healthcare worker is working in close proximity, ie less than 2m, it should be considered an an aerosol generating exposure (AGE). This includes all nursing, caring, and of course physiotherapy that helps COVID19 patients clean, mobilise, or rehab for ITU acquired weakness (blog on that coming out very soon).
I think many physios and healthcare workers who work on medical and recovery wards, as well as those in care homes and the community are being exposed to the COVID19 virus without adequate protection. Personally, I think one of the safest places to work as a healthcare professional currently in the UK is in an ITU department due to the higher levels of PPE they get compared to other areas.
Although thankfully COVID19 has a low complication and mortality rate, and appears to affect the elderly and those with other health issues more severely, it’s just NOT this simple. The reasons why some young, fit, and healthy individuals develop more severe symptoms is complex and still not fully understood in these early days, but it does appear that higher initial viral loads maybe an important factor to consider (ref, ref).
It does appear that individuals who come into contact with either a lot of virus at once or via repeated exposures over time can develop more severe symptoms and complications without any other risk factors. This potentially means healthcare workers who are in regular close proximity to COVID19 patients are potentially at higher risk of being exposed to higher initial viral loads and more severe symptoms and complications (ref, ref).
Again I have no wish to scare or worry any of the amazing, dedicated, hardworking, and heroic frontline healthcare workers including my fellow physiotherapists, I just want them to be as safe and as protected as possible during these unprecedented and difficult times.
I would therefore ask ALL physios and ALL healthcare workers working with ALL COVID19 patients in ALL areas including medical and rehab wards, care homes, and in the community to re-evaluate their PPE guidelines. I would ask all healthcare workers NOT to blindly accept their current PPE guidelines or accept that full PPE is only needed in ITUs or when AGPs are likely.
I would ask ALL healthcare workers to consider ALL COVID19 patients as aerosol generating subjects just by breathing and therefore working in close proximity to them potentially increases you risk of being exposed to higher levels of COVID19 virus. And just because a COVID19 patient is NOT on ITU and is improving doesn’t mean they are any less infectious or risky for to work with.
Please remember that those infected with COVID19 are highly infectious long after they have recovered from the worst of their symptoms, with some studies showing some COVID19 patients being positive and infectious for up to 4-5 weeks after the onset of their symptoms. (ref, ref)
I therefore plead with ALL healthcare managers and ALL senior members of hospital, care, and community staff not to take flippant, unnecessary risks with your staffs health and safety due to some flimsy, nonsensical, non-evidence based government or local NHS trust guidelines. I would plead with you ALL to see that these guidelines have been drawn up more to protect PPS supplies and resources rather than to protect humans.
I would plead with you ALL to look at the evidence and re-evaluate the risks yourselves and make your own fully informed decision to decide if standing next to a breathing COVID19 positive patient is safe without full PPE for yourself or others.
Finally, I would ask all managers and team leaders to NOT think of those who raise concerns about lack of PPE as being difficult, obstructive, or lacking courage, but rather as genuinely concerned and justified. And if you are a healthcare worker and you feel unsafe or insufficiently equipped to do your job, please raise your concerns and if they are not acknowledged and met consider refusing to put yourself in harms way.
One thing I learnt very early on in my military training before becoming a physio is there is a HUGE difference between being brave and being reckless. Thinking you are being brave by helping others by taking unnecessary risks only tends to create two problems rather than solving one.
As always thanks for reading, and please take care of yourselves, and others, and please stay safe if you are working with or close to COVID19.
Whilst you made it this far could you please consider signing this petition for public enquiry into the governments lack of planning and preparation to adequately supply and protect all healthcare workers with PPE during this COVID crisis. Thanks
So as the dust settles but before the memories fade I thought I would put down some thoughts and reflections from another excellent Danish Sports Medicine Conference more simply called ‘Sport Kongres’ which is, in my opinion, one of the best annual sports medicine conferences in the world, although the Norwegians do come very close as well.
This is my 4th time at Sports Kongres although I’ve had a gap of 4 years since the last time I attended back in 2016 so I was interested to see how it has changed and progressed.
One thing that hasn’t changed thankfully is this conference is extremely well organised and packs a HUGE amount of content in 2 and a half days, with 4 simultaneous streams of talks and workshops making is hard to decide what to go and watch but also giving a huge choice of options based on your interests and experience.
Due to my flights, I, unfortunately, missed the opening key note lectures on ACL rehab and groin pain, but I did hear that Per Holmich was promoting the role of psoas palpation and was looking for me to demonstrate this on which would have been tempting as I don’t get many offers from men (or women these days) wanting to touch my groin, so I may have taken him up on his offer.
The first session I did make was after lunch and was on the management of traumatic ACJ injuries. The first speaker who was an orthopaedic surgeon highlighted how the traditional Rockwood classification system of ACJ injury is poorly correlated with pain and disability and doesn’t guide us how best to manage ACJ injuries, which was music to my ears.
Often the claim made with ACJ injuries is grades 1-2 are always rehab-able, grade 3s are 50/50, and all grades 4-6 need surgical stabilisation. However, I think this is nonsense and have personally seen ACJ grades 4-5 do very well without the need for surgery, even returning to high-level sporting activity. But I have also seen many grade 2’s do very poorly and continue to have high amounts of pain and not be able to return to basic activities.
The reasons for this I think are many, things such as age, occupation, level of sport, fear, anxiety, threat, and a host of other psychosocial factors, which unfortunately were not mentioned or considered by the speakers. Instead, they only focused on the biomechanical features, which although are surely a factor they are still only a part of the bigger picture.
Anyway, there was a suggestion that I really liked in that we should move away from using the traditional Rockwood ACJ injury classifications and instead use a much more simple system instead. That is ACJ injuries are either stable or not stable. This I think is a great idea as personally I think those ACJ injuries that tend do the best without the need for surgery are not just those with small amounts of displacement but how much this displacement moves on tasks and activities.
For example, I see some ACJ injuries that have huge displacements on x-rays which don’t move around much when they move their arm, whereas I see some other ACJ injuries that have no or minimal displacement on x-rays yet move around a lot on some activities and exercises. Its this dynamic ACJ movement not the static displacement on scans that I think predicts if an ACJ injury is going to settle or not without any surgical intervention.
It was also suggested that horizontal movement is far more painful and provocative than vertical displacement. The theory is if the lateral end of the clavicle is rubbing across the top of the acromion this tends to cause more problems than if its vertically displaced with a gap between the bones. It may even be that the larger vertical gap the less pain and disability they may have
Going Wrong Getting Strong!
The next speaker was a physio and was talking about an exercise rehab protocol she designed for ACJ injuries which I found very disappointing. First was because of the focus and attention on the use of silly little exercises at the beginning, which I know have a role in many sports injuries at the start when we are trying to get a person to take it easy, let things heal, and keep them occupied, but why don’t we just all be a little more open and honest about this and say thats what these exercises do, occupy and distract the person for a while before we start the real rehab, instead of talking about alignment and optimal fucking motor control bull shit!
Anyway, the far more disappointing thing for me and one that I saw on a few other talks was how they prescribed their ‘strengthening’ exercises with only the sets and reps described without any mention of the load, or intensity, or % of 1RM, RPE or even RIR.
This sloppy lazy habit that many physios have with exercise prescription drives me up the wall, and its even worse if you’re presenting your rehab protocol at a Sports Conference. If you are going to call an exercise ‘strengthening’ it needs to fit the definition what the research tells us causes muscle adaption and strength to be gained.
Now before my buddy Greg Lehman or any other of you false dichotomy building knob heads kick-off, I am WELL AWARE that you don’t need to get stronger to get out of pain, and that many different sets and rep ranges can cause muscle tissue adaptions and get people stronger.
So yes you could use 3×10, or 5×30, or 23×452, and get the same strength gains… BUT only if the intensity of those set and reps is sufficient to signal the metabolic pathways for muscle tissue adaption, and this usually requires the reps to work close to fatigue or at least an RPE of 7-8 or RIR of 2-3 as far as I am aware.
Prescribing 3×10 or 5×30 and calling them ‘strengthening’ exercises without describing what intensity or effort you want these sets and reps to be done at is pointless, lazy and ineffective. I could do 3×10 at 20% of my 1RM and get no strength adaptions, or I could them at 70-80% of my 1RM, or use an RPE of 8, or even an RIR of 2 and get stronger.
The next session I attended was on Achilles Tendinopathy and started off with a very interesting talk highlighting how nearly a 1/4 of all those with Achilles tendinopathy still have pain and disability up to 10 years later, and how symptoms at 1 year match those at 10 years with patients stagnating. Now again the reasons behind this are many and multifactorial but again I do think poor loading is a key issue hear!
Next up was a paper on isometrics for Achilles tendinopathy and unfortunately, I wasn’t allowed to take any photos or share the results with you due to it currently being in review for publication soon, but lets just say that this is going to rock the isometric advocates boat a lot and hopefully make many realise that isometrics are not a panacea for pain and dont work that well for some.
The last session of the day was on over diagnosis in medicine and sports medicine. The first speaker tried to define what over diagnosis is, which is finding something that never needs treatment but gets treatment. The example used was prostate cancer which has had a huge increase in detection rates yet the mortality rate of those who die because of prostate cancer hasn’t changed at all. It was also pointed out that this often gets misrepresented as there being a high survival rate for prostate cancer when it actually hasn’t changed at all, its actually got a low mortality rate, and always has.
This was an interesting session although a little heavy on the statistics for my simple brain so I left early to hit the awesome hotel gym with its fully kitted up S&C facilities and do some deadlifts before everyone else clogged it up.
In the evening there was poster presentations and a get together which I thoroughly enjoyed thanks to the copious and constant free red wine, and after some eye opening conversations about PhD projects, conflicts of interest, student finances and me trying to do some drunken handstands in the lobby and failing dismally, I called it a night, or rather early morning.
The Morning Afternoon After
The next morning was a bit hazy, mainly as I was in bed nursing a mofo of a hangover, but I dragged myself out for the afternoon sessions and went into the talks on traumatic shoulder instability in athletes. The first speaker was an Italian surgeon who went through the bony factors that can lead some shoulder to have ongoing instability after trauma.
The one I found most interesting was his finding on the Hill Sachs lesions and how the location of these was far more important that the size or depth. Hills Sachs lesion can be classified as either ‘on track’ or ‘off track’ if they cross the line of the humeral heads articulating surface on the glenoid and these tend to create further episodes of instability, and the more medial the Hill Sachs Lesion is the greater the chance of it being off track.
Next was a talk on surgical management of SLAP lesions and the results from a placebo-controlled surgical trial that showed no difference in pain or disability if a SLAP was repaired, debrided, pretended to be operated on (eg placebo). This was interesting study but the population were mostly around 40 years old and not regular over head athletes so we cant extrapolate this study to another population, however, it still highlights the placebo effect of surgery and all that we do in healthcare.
Finally was a talk on SLAP rehabilitation and how EMG data could possibly help us select exercises that have higher or lower forces acting on the biceps complex. For me this was way too over-complicated, complex, and unnecessary. I do understand that EMG can give us some idea of what muscles are working and how much when doing exercises, but what they don’t tell us is how much pain or effort an individual feels when doing them.
For me the far easier, simpler and I would argue evidenced-based way to select rehab exercises is not from EMG studies done on healthy people in laboratories, but based on your patients issues, goals and more importantly how the exercise feels for them in terms of its pain and effort.
The final session was presentations from 6 studies selected for their value and promise on advancing sports medicine all aiming for the first prize. In the running was my mate from Dublin Paul Kirwan who did his recent PhD on GTN + exercise for Achilles tendinopathy, which he found had no extra benefit, and eventually came 2nd in the competition.
The winner was Mikkel Bek Clausen with his RCT looking at the addition of extra strengthening exercises on sub acromial pain and function which has the best study acronym ever, the SExSI trail (Shoulder Exercise Shoulder Impingement). Anyway, long story short, ‘extra’ strengthening exercises (and these were strengthening exercises as Mikkel did a good job of measuring the load, TUT, and effort) had no extra effect on pain levels than standard shoulder exercises alone, highlighting once again that strengthen is not necessary to reduce pain, but exercise most definitely is!
There was also a very interesting study from the UK presented on blood flow restriction training for post-op ACL’s compared to traditional strengthening which found similar gains in strength but better results in function, this is believed to be due to less knee swelling and pain due to the lighter loads being used on BFR training.
After the presentations, it was time for the famous Sports Kongres gala party. Now I dont want to distract attention away too much from the academic content and quality but all I will say is that the gala dinner was yet again a highlight of the conference even with a stinking hangover still from the night before to start with.
The atmosphere, fun, and games had were just second to none. Tell me where else in the world would you get physios, doctors, surgeons, PhDs, professors and students all dancing, bouncing, limboing, crowd diving, neck wrestling, and doing no hands get downs and back up competitions at 3 am… nowhere except at Sports Kongres
So once again thanks to the Danish Sports Medicine Association for organising an excellent conference. Thanks to everyone who came and said hello and all your kind comments about my blogs and ‘antics’ on social media being a positive influence for you to be more critical or just give you the confidence to stay in the profession.
So it’s the end of the year and the end of a decade, it’s also the end of me be doing my 100 reps a day challenges that I have been posting on social media for the past 5 months under the hashtag of #Team100. So when things that come to an end its good to look back and reflect a little on what they have taught you.
I know it seems strange to be stopping a physical challenge for the new year when many are thinking about starting one, but after more than 150 continuous days of posting videos of me doing exercises, I think its time to move on. I will, however, be trying to continue the habit of doing a 100 push-ups, or sit-ups, or squats, or even the dreaded burpees a day, I just won’t be filming them anymore.
These challenges have been an interesting experience that has not only got me fitter and stronger but has also given me some useful insights into the challenges, issues, and barriers that everyone faces when trying to increase their physical activity. It has also given me some ideas of how to overcome these issues and barriers myself and for those I see and manage as a physio.
There is no doubt that participating in any daily physical activity is difficult for many reasons. Things such as lack of time, motivation, resources, support and encouragement being the most common, and for patients, there is also pain and disability to consider, all things I have discussed in previous posts here.
I have personally found these challenges not only physically difficult at times causing me pain, soreness, and fatigue, but I have also found them extremely challenging due to there monotony, boredom, and just the time it takes to do and film them, with my work, travel and other training commitments often getting in the way. It’s been these time and boredom factors that I have found far harder to deal with and overcome than the soreness and effort ones, and I’m sure it no different for many of our patients.
So what have I found to be the solution to overcome these time and boredom barriers to daily repetitive, and challenging exercise? Well don’t get too excited as its nothing that clever, or special, or groundbreaking, in fact, it’s something rather plain and simple… its accountability.
Without a doubt, I think the biggest reason for me being so committed, dedicated, and disciplined with these tough and sometimes boring challenges for more than 150 consecutive days is that I made a rather large and public declaration to 1000’s of you on social media that I would do them.
I’ve found that there is nothing like some public accountability to others and a little bit of peer pressure to get you up off your arse and get shit done. I know many think that motivation, discipline, and resilience which I have discussed before here and here should be internal, but do not exclude the external factors that also contribute to someone being a tough, steely-eyed, disciplined, and motivated fucker.
I think it’s far easier to let yourself down than it is to let others down, and the more people you have the opportunity to disappoint and let down, I think the less likely you will.
Don’t get me wrong there are also a host of other positive motivators for declaring and posting these challenges on social media in front of 1000’s of friends and strangers that I have found beneficial as well. The likes, comments, reposts, and seeing others taking part in the challenges themselves were all huge positive motivators for me, especially seeing a 93 year old grandma doing her arm raises…
However, as nice as it was to get encouraging comments, 100’s of likes, and many reposts during these challenges, the bigger motivator for me was my fear of being thought of or being called a letdown, a disappointment, or a loser for not doing them. I know many motivational or behavioural experts will say that positive reinforcement and motivation always outperform, outlast, and outweigh negative motivators, but after doing these challenges I’m not so sure that’s true for everyone.
I now often use what I have learnt about the powerful effects of accountability from these challenges with many of my patients. I now often ask patients to consider not only just telling their close family about their rehab program and schedule, but also to consider posting it on their social media for all of their close and not so close friends and family to see.
Social Media Rehab
I ask patients to make a pledge on social media about their rehab and then film themselves doing it and post it online so as many others can see it. I explain that hopefully, it will give them some motivation to get it done, as well as give others the opportunity to watch and encourage them with it. It will also give them a visual record of their progress so they can see how they are improving over time.
I know this is only an anecdote, so don’t take my word for it at all, but I would guess that I see many of my patient’s adherence to rehab rates go from around 30-40% to 80-90% when they do this.
I also think this is a great way to help not just patients succeed with their rehab but also ANYONE succeed with their goals or resolutions.
New Year Resolutions
The new year is often a time when many make resolutions to get fitter, lose weight, or make some other lifestyle change, and I see many resolution naysayers and sceptics saying they are a waste of time, don’t last, and so don’t bother. This pisses me off no end!
I have discussed the issues with new years resolutions before here and how they often don’t last, with some studies showing 25% don’t last even 1 week and only 8% are actually achieved for many reasons which I won’t go into again.
However New Years resolutions don’t fail just because they are made in the new year, resolutions fail just as often (if not more often) when they are made at any time. Again the reasons and solutions for these I’ve discussed in my other blog which you can go and read if you want here.
Personally I have loved doing these 100 reps a day challenges, and I would like to thank all who have joined in, especially the legends that are Bill Vicenzino and Andrew McCauley who have without doubt been the two most committed and dedicated members of #Team100.
In summary, I think if more physio and healthcare professionals were to engage or experience a monthly physical challenge like #Team100, or even just try and do the rehab protocol or program they ask their patients to do, they will get great insights into the barriers and issues their patients face.
More importantly, if more physios experienced for themselves what they ask their patients to do, I think it would hugely improve their rehab programming and planning. I think many physios will soon recognise the stupidity and irrationality of what they often ask patients to do, and they won’t roll their eyes as much when patients tell them that they haven’t done their exercises.
So once again thanks to everyone who joined in, supported, shared, commented or just eye-rolled at my monthly 100 reps a day challenge. I wish you all a Happy New Year and good luck with any goals or resolutions you have made for 2020 and hope you consider the power of social media accountability.
I have discussed the issues with opioid painkillers before in some of my earlier blogs, and I have also seen the problems they can cause first hand in some of my patients. So in an effort to raise more awareness about the risks and side effects of opioids I am delighted to give you a guest blog from Jason Shiers a Psychotherapist at UK Addiction Treatment.
How do I know if I’m addicted to my pain medication?
In 2017-18, 5.6 million adults in England were prescribed opioid painkillers – 13% of the population (ref). But when do the health risks of opioid medications cancel out the benefits?
In the short term, opioids can be effective painkillers. They offer patients fast relief from severe or distressing pain. In hospital settings, opioids such as morphine, fentanyl and codeine are used routinely to manage pain associated with accidents, surgery, illness or childbirth.
Experts agree, however, that long-term opioid prescribing for chronic, non-cancer pain is not beneficial for most people. (ref) Over time, opioids become less effective at reducing pain, as the brain adapts and drug tolerance sets in.
If you’ve been taking opioid painkillers for months or years for back pain, it’s essential to review your usage regularly with your doctor and/or an addiction expert. It isn’t always obvious that opioid addiction has set in, particularly if you also have symptoms from a chronic pain condition.
If you feel mentally or physically unwell or your pain becomes unmanageable again, please don’t assume the answer is more opioids – they may, in fact, be the cause of your worst symptoms.
Signs and symptoms of opioid dependence
1. Recurring or obsessive thoughts about opioids
Opioid addiction usually involves a mental preoccupation with getting and taking more drugs. The way people experience this is unique, however. For example:
Do you clock-watch until you can take your next dose of opioids?
Is it often hard to concentrate at work or college?
Does the thought of running out of painkillers make you feel agitated or upset?
Do you resent activities that get in the way of using painkillers – such as social events, driving or playing with your kids?
Is it hard to imagine a life without opioids
2. Taking more opioids than your doctor has prescribed
Changing your dose of opioids without consulting your doctor is a sign of dependence. This includes taking more of an existing prescription drug, purchasing opioids online or from a dealer, stockpiling medications and taking over-the-counter codeine with another prescribed painkiller.
Of course, you can still get addicted to opioids if you stick to the prescribed dose – but it’s much more likely that you’ll get timely support if you discuss changes with your prescriber.
3. Your pain is getting worse
Due to changes in the brain, typically the same dose of an opioid drug will become less effective at blocking pain signals over time. If your back pain has returned or it’s getting worse, this can be a sign of opioid tolerance.
It’s easy to mistake the return of your pain for an escalation in your original condition. Always seek an assessment for dependence, particularly if you’ve been taking more opioids to get the same effect.
4. Cycles of opioid withdrawal
How do you feel as opioids wear off? What physical or psychological symptoms do you have? If you miss a dose, how do you feel?
Though it can be hard to track and measure symptoms objectively, it’s useful to build awareness of any negative side effects connected with your opioid use.
It is essential to seek medical help to detox safely from opioids if you have become dependent.
5. Hiding your opioid use
If you’re covering up your use of opioids, whether that’s from family, friends or co-workers, then it could be a sign of dependence.
This includes playing down the amount of opioids you use, visiting different pharmacies to buy over-the-counter codeine, hiding drugs at home or taking opioids in secret.
6. Using opioid painkillers continuously for months or years
Opioids are physically and psychologically addictive. With continuous use over months or years, you will probably experience moderate to severe withdrawal symptoms if you stop suddenly without help.
Often, this keeps people locked into addictive cycles of using more opioids to relieve physical or psychological discomfort. If you’re also dealing with a chronic pain condition, the addiction can also exacerbate your symptoms.
7. Withdrawal from the things you enjoy
Have you lost interest in your work or studies? Do leisure activities that you once enjoyed feel exhausting? Is it hard to sit through a family meal or enjoy a conversation with friends?
If you’re a regular opioid user, then shifts in your usual behaviour patterns may indicate an addiction – particularly if you feel less choice and control about what’s happening in your life.
The Benefits of a Non-Drug Approach
If you get addicted to opioids, what is the best way to treat your addiction? And how can you manage a chronic pain condition going forward?
If you have a chronic pain condition, the thought of life without opioids may be very frightening. Understandably, you might be concerned about your pain becoming too much again. It’s vital to develop a range of support and skills to address your condition.
Talking therapies, peer support groups, treatments such as mental resilience techniques like mindfulness and meditation, graded exercise programmes (overseen by a professional fitness instructor), physiotherapy and non-addictive painkillers can all be useful alternatives to opioids.
If you need any further information or assistance then please check out the UKAT website here
For the last three weeks, I’ve been travelling, teaching and talking to lots of healthcare professionals in Australia about shoulders, pain, and the healthcare system. So whilst I’m sat on a plane for 24 hours on my way home I thought I would reflect on some of the conversations I had down under.
The first thing to say is as much as I love Australia and think it’s an amazing country with great people, fabulous coastlines, vibrant cities, diverse cultures, great food and belting beer, why is it so far away from everything else. It feels like I’ve been sat on this plane, wedged into my seat, breathing other peoples recycled farts forever and there’s still another 6 hours to go!!!
But besides the long arsed journey, I’ve really enjoyed my time in the land of the kangaroo and digeridoo meeting lots of great people. I would like to thank everyone again who came along to the courses for your time, feedback, and participation (except for the two ladies on one course who looked like a couple of bulldogs licking piss off a thistle all weekend). I would also like to thank all those who helped organise and/or hosted me on this trip as well.
PT’s v EP’s
So the first thing I want to discuss that I found interesting on this trip was the tensions I saw between some of the physios and exercise physiologists or EP’s. In case you don’t know what an EP is they are a new-ish profession in Australia that provides exercise and rehab interventions to patients with cardiovascular, metabolic, neurological and some MSK issues.
During my trip, I heard quite a bit of tit-for-tat backstabbing from both physios and EP’s with the physios slagging off some EP’s for treading on their toes and seeing patients they should be seeing, and the EP’s ragging on the physios for doing and saying stupid things to some of their clients.
I found this disappointing but not that unsurprising as historically there has always been rivalry and backstabbing between all allied health professions. I often hear physios, osteos, chiros, and some others claiming that their profession is better, more effective, more evidenced-based than another one.
Now I’m not one for sitting on the fence or hiding my biases but when it comes to saying what I think the best profession is, I don’t think there is one. I see just as much good, bad, and ugly practice in all of the professions pretty equally… except for maybe the chiropractic profession which does seem to have its unfair share of wackos and quacks.
Anyway, back on topic, I am unaware of any EP’s working in our healthcare system in the UK and I am undecided if we should have them or not. Don’t get me wrong I think what EP’s do in Australia is great, really important, extremely worthwhile, and very much needed. However, my thinking is shouldn’t what EP’s do also be what physios do?
Personally I think Aussie physios have slipped up and missed a golden opportunity to prove their worth and help the health of their population by trying to do what EP’s now do. Instead, I think too many physios have wasted their and their patients time, energy, and resources by fucking about and fannying around with their silly passive treatments like manual therapy and machines that go buzz or bing.
I’ve talked before here how I believe the MSK physio profession in the UK is far too reactive to the conditions it sees and how it should be trying to be more proactive on prevention and the promotion of exercise and activity in those at high risk of poor health. I think if UK physios are not very careful then we may see our healthcare systems soon look to EP’s to step into the role that physios should have been doing for decades.
Over or under treating ?
Another regular discussion I had with some physios down under was about how many of them felt frustrated and uncertain in how to find the balance between booking patients in for follow up sessions or trying to get them to self-manage. Many told me they try to get patients to take ownership and have an active role in their own recovery, which is great, but this often means they don’t come back for follow-ups and so they either get their managers chastising them for low retention rates or find it hard to earn a reasonable income.
Well if it’s any consolation this is a dilemma I still have even after 15+ years as an MSK physio, and I think it’s one that all honest and ethical healthcare professionals the world over have. I think the biggest issue we all have is trying to decide when does OVER or UNDER treatment of a patient start?
I think many physios should take a close look at the patients they currently see the most compared to those they see the least, because I think many will see that they OVER treat patients with problems and conditions that have very favourable natural histories, and high chances of successful outcomes. But I also think many physios UNDER treat patients with complex conditions and difficult problems and backgrounds who have low chances of successful outcomes.
This is what I call the physio over/under treatment paradox!
Many physios like to over-treat the quick and easy things that mostly get better on their own, things like ankle or muscle sprains, even non-specific low back pain in patients with low psychosocial risk factors. Yet many physios often abandon, give up, or wash their hands of the harder more complex patients with conditions and problems that aren’t quick or easy to manage, things like the diabetic frozen shoulder or the widespread persistent pain patient from a lower socioeconomic background.
If physios were more focused on doing more to help those that need our help and support the most, and less worried and concerned about seeing to those who don’t really need our help then things would be better for everyone both patients and physios.
One of the simplest ways I find helps to navigate this over/under treating paradox is to just ask the patient what they expect and think they need from you. Ask your patients if they want a one-off session for some advice and guidance, or regular check-ups to keep them focused and progressing. Or do they even want more frequent sessions to do their rehab under supervision to help motivate, encourage, and ensure it gets done?
One of the most common phrases I used on this trip was “if you’re going to over-treat a patient for their pain or disability you better be over-treating them with exercise”. Or a much simpler way I found of saying it was ‘rehab the fuck out of your patients’
I think many physios don’t like to get their patients in regularly for rehab sessions, because they are ill-equipped to do it, both in resources and training. But I also think many physios don’t like to ‘just’ do rehab or exercise with patients because they believe its beneath them.
Many physios think that if they are not seeing a patient in their consulting rooms using their silly little machines or their super-duper magic hands then they are not doing their job. This is just utter nonsense and more physios need to get down off their high horses and get into gyms more with their patients and help them move and get active.
So there we go just a couple of thoughts from my time down under. I do understand that for any healthcare professional with a straight moral compass it can be really challenging to find a comfortable balance between earning an income to live a comfortable life without feeling like a shyster screwing the system or patients out of their money.
And this isn’t helped by the fact that most healthcare systems are set up to financially reward the giving of treatment rather than the results of treatment, and unfortunately, the promotion of self-management, quick results, and effective early discharge is currently a pretty shitty business model.
So until this changes please continue to over treat your patients with exercise and rehab the fuck out of themfor a win/win situation!
It’s been a while since I’ve posted anything due to some stuff getting in the way of other stuff, but I’m back and I want to talk about something I’m very interested in, resilience.I strive every day with every patient I see to try to restore, improve, or enhance their resiliency in the face of their pain and/or disability. This may be by encouraging them to continue with activities or tasks that hurt, or getting them to exercise a little more, or just to make some small lifestyle change.
However, after reading this excellent article on resiliency here I’ve had a rather sudden and dramatic realisation that I’ve probably NOT been doing this as well as I thought, and I have probably been approaching it in completely the wrong way.
In this article, Dr Ungar a professor of social science and a family therapist eloquently highlights how an individual can have all the internal resources of resiliency such as knowledge, motivation, and a plan, yet these will be of little use without a supportive environment in which to action them in. He also points out that if the external resources are not available then we are better off trying to change these first before we try to change individuals.
Striving to improve the ability of an individual to continue on in the face of adversity, such as pain, disease or disability will just not work when their families, workplaces, communities, healthcare providers, and governments fail to provide sufficient resources, care, or support.
This realisation hit me like a tonne of bricks! There I’ve been for years trying to get my patients robust and resilient to their pains and disabilities, yet there I’ve been largely ignoring and overlooking their environment that may impede, limit, or even prevent it.
This article has made me recognise that I’ve been getting frustrated with some patients and rather harshly and unfairly blaming them for having a lack of resiliency when this may have been more due to factors outside of their control rather than any fault of their own.
Are you really resilient?
This article has also made me reflect on my own resiliency. I like to think of myself as a pretty resilient person having overcome my fair share of issues in life such as being bullied through most of my school years, suffering unexpected family bereavement, a break down of a very close meaningful relationship, a sudden and unexpected loss of employment forcing a complete career change. I used to think that I overcame these issues through my resilience and robustness, and I suppose I did to an extent, but I can now see that my own resilience is largely due to my environment and social context.
The first thing to consider is that I am a middle-class white heterosexual male, meaning that I am already in a more advantageous position than many others due to long-standing, hard-wired prejudices and biases in our society. I also come from a loving and supportive family who work hard and although not the wealthiest have never had to go without much. It’s these environmental and social factors that I now recognise have mostly made me resilient, or have they?
I do now wonder how I would behave and cope if I didn’t have these experiences and opportunities growing up and found myself in other difficult situations such as living in a different social class, suffering a sudden chronic injury or illness, or being made homeless. I recognise its all well and good me talking about how resilient I think I am whilst sitting on my comfy sofa, with my central heating on, drinking a glass of red wine, whilst blogging on my Macbook!
When it comes to trying to understand resilience in others I think a good place to start is to recognise that for most people resilience is nurtured not inherent. That is it’s far easier to be a tough, robust, irrepressible fucker when your upbringing and environment allows it.
Unfortunately, we are now living in an age of dissolving resiliency due to our increasingly easier upbringings, lifestyles, and environments. Our society is losing sight of what is difficult, tough, and challenging and as a consequence, we are becoming less tenacious, hardy and healthy.
As health care professionals we need to recognise when a patients background and/or their environment is not conducive to them being resilient and try to improve this first before attempting to improve the individual. This may simply mean offering them more time, support, and encouragement, and not getting frustrated or annoyed when they don’t or can’t do their home exercise program, and being more patient and understanding when they take longer to progress.
In hindsight, I now think I have been guilty of not supporting some patients as well as I could have who I thought lacked will power, commitment, and resilience. I often couldn’t understand or tolerate those who didn’t do the simplest of rehab exercises I gave them, or who came up with ‘excuses’ as to why they didn’t do them.
However, I can now see that perhaps their environment and current situation wasn’t suited for them to commit or engage with a simple rehab program or lifestyle change, and perhaps my frustration and lack of support was the worst thing I could have done for them. Looking back now what I should have done is tried to create a more stable and encouraging environment for them to become more resilient in by asking them to come and do their home exercise program with me supporting and motivating them along the way.
I know this sounds contradictory but for some people to become resilient they need others to help them become resilient. This is where physios and other healthcare providers need to take a close look at each individuals situation and background and decide if they need to step up and do more to help develop resiliency.
Don’t get me wrong, I’m not saying we need to suddenly start getting all those who have missed a weeks home exercise plan in 3 x week for 6-12 months giving them life coaching and cognitive behavioural therapy along the way. But I do think we need to with those whose environments and current situations are not the best for them to engage in regular rehab or lifestyle changes offer them more than we currently do.
The huge problem here is, of course, the lack of resources and staff to do this. Currently, the UK’s National Healthcare Service just doesn’t have the capacity or ability to offer many patients in persistent pain or with a long term disability extended regular care and rehab to any great extent. And I don’t I think private practice should do this, as there is a real risk of financial gain and profits overriding patient care and treatment.
Resilience takes resilience
Another thing to consider is that it takes a lot of resilience to develop someone else’s resilience. To ask physiotherapists or any other healthcare professional to become better at developing patients resiliency they will also need a supportive nurturing encouraging environment, and this is also currently lacking everywhere across the board.
Most physios are simply not given the time, resources or support to develop resilience in the patients they see. Many physios in both the public and private sectors are asked to see as many patients as they can with the primary focus on productivity and profits and patient outcomes and results coming second.
I know this first hand from 15+ years of experience working in both the public and private sector, being asked to see 15-20 patients a day, 5-6 days a week, with any gaps in my diary or dip in my ‘utilisation’ being questioned by my managers as ‘not working hard enough’. I can tell you this is a really shitty working environment and has done shit balls for my empathy and compassion which, unfortunately, meant my patients were the ones who suffered.
Until healthcare employers, managers, commissioners and of course the governmental big wigs recognise that they need to look after those who are looking after patients better, giving them more time, support and resources nothing is going to change quickly.
But to end on a more positive note I would ask all healthcare professionals reading this to go and read the article on resiliency in full, and the next time a patient says they haven’t taken your advice, or done their home exercise programme, take a breath, pause for a second, and before you write them off for having no resilience ask yourself, would you if you were in their shoes!
Whether you like to admit it or not uncertainty exists in everything including ALL aspects of healthcare. There is uncertainty in our assessments, diagnoses, prognoses, and of course our treatments. Being uncertain in healthcare occurs a lot, yet conversely, not many are willing to admit it or talk about it.
And that’s perfectly natural as when we are faced with any uncertainty it makes us feel deeply uncomfortable, awkward, and foolish. Instinctively we avoid, ignore, or deny situations of uncertainty, and this is becoming the norm in our over-confident, unabashed, ego-driven society!
Being uncertain goes against our human nature that we have evolved to be sure in our thinking and decisions which is essential for our survival. Humans, therefore, tend to trust and gravitate towards those who are certain, all knowing, and have answers, over those who don’t. A perfect example of this is on social media.
You only have to look at healthcare professionals with 1000’s of followers to see that their popularity is formed and based most of the time on certainty. They will often display conviction that they have the truth, answers, and knowledge to help those in need.
Rarely will you see a popular social media healthcare ‘celebrity’ express doubt or uncertainty. This needs to change! We all need to acknowledge, admit, and accept uncertainty better, but this ain’t easy, in fact, it’s really bloody difficult!
I don’t know things!
I hate not knowing things, it’s one of the reasons why I read so much in an attempt to learn more and understand things better. But the cruel, cold, heartless paradox of knowledge is the more you learn the more you realise how little you actually know, Dunning and Kruger have a lot to answer for!
I also hate being in a position of having to admit not knowing what to do, or how best to proceed, or more commonly what to say to a patient when they ask me whats the cause of their pain. But this happens a lot in my work. A helluva lot!!!
If you are a well-read evidenced-based healthcare professional, you will realise that our ability to diagnose the cause of someone’s pain is notoriously difficult and uncertain due to many of our tests and procedures being riddled with low specificity, poor reliability, and even worse validity.
This doesn’t mean we give up or become lazy and don’t bother trying to diagnose a patients pain. It just means we realise and recognise that AFTER we have done a full and thorough assessment to the best of our ability, we are often able to rule out anything serious or sinister, but are often left unsure why someone has pain or what is causing it.
Being uncertain in front of patients used to make me feel awkward, foolish and stupid, and it still does at times. This used to make me feel annoyed, frustrated, even angry and it still does at times. However, slowly, steadily, gradually I have learnt to tolerate the uncertainty in myknowledge and my work, and I now think I am getting better at expressing it and passing it onto my patients. But it still isn’t easy!
One of my favourite researchers in uncertainty who has helped me deal with it better is Dr Arabella Simpkin. You may have read her excellent editorial in the New England Journal of Medicine back in 2016 here. If not please go read it now, it is a wonderful piece of writing that summarises and reflects all the issues I am trying to make.
Tips for uncertainty
Dr Simkin has also co-authored this paper here recently published that attempts to give all healthcare professionals ‘tips for thriving in the face of clinical uncertainty’. Again this is a really insightful, useful, and topical paper and I would urge you all to read it in full. I have summarised the key tips they suggest for thriving with uncertainty in healthcare below.
No 1: Be prepared
Try to identify as many areas of uncertainty that you have. Things such as particular pathologies, patients, or procedures that you feel unsure or unclear about. Then to the best of your ability try to reduce this by reading, practising, asking colleagues for assistance. Next prepare yourself for how you will act and react when confronted with not knowing something in front of a patient. Think about what you will say, and how you will say it, and plan what you will do and who can assist you.
No 2: Recognise the type of uncertainty
Is the uncertainty a knowable unknown, or a truly unknown unknown? Diagnosing the type of uncertainty can help you clarify and plan a path forward to suggest appropriate management strategies. The three classifications of uncertainty are…
Sources; such as issues with probability, ambiguity, and complexity
Issues; such as lack of knowledge, practical experience, or personal skills
Locus: who is the uncertainty with, the clinician or the patient
No 3: Be aware of biases
The desire for certainty leaves all of us open to cognitive biases, the main ones to be aware of are…
Availability Bias; Making a diagnosis based on information easily remembered and recalled rather than what’s more likely and probable.
Anchoring Bias: Settling on a diagnosis early on in the assessment and not amending it when new information becomes available.
Representativeness: Comparing a case to previous typical cases via pattern recognition but ignoring other atypical features present.
No 4: Have a plan
Ensure you have a ‘safety net’ for all cases of uncertainty, don’t just ignore them or wash your hands of them. Building a mechanism of follow up into your practice gives clinicians a chance to correct their treatment plan as time and the ‘illness’ evolves if a wrong decision was made in the early stages when limited information was available.
No 5: Have a network
Surround yourself with colleagues and peers who you feel comfortable and safe in expressing uncertainty and doubt with. Use them as a soundboard to share ideas and gage opinion on what to do and how to proceed.
However, try not to only limit this group to ‘your tribe’ or speciality. Use and employ colleagues from other areas and disciplines of healthcare for a wider more varied view.
No 6: Be a role model
Talking openly about uncertainty helps normalise it and can help set a culture that embraces uncertainty. Never be afraid to say ‘I don’t know’. It can help others around you gain the confidence to do the same and help others realise that sharing uncertainty is what good healthcare culture should be.
No 7: Promote curiosity
Curiosity is a basic element of understanding and a key motivator for learning. Appreciate and reward others for expressing curiosity and make time to discuss and answer questions. Use ‘how’ and ‘why’ questions rather than ‘what’ and ‘when’, and consider using the more flexible word ‘hypothesis’ more than the fixed and rigid ‘diagnosis’
No 8: Discuss uncertainty openly with patients
This, in my opinion, is the most important, and the most the challenging aspect of uncertainty in healthcare. However, the question is not whether we should share uncertainty with our patients but how best to do it without losing their confidence or causing them anxiety.
Although we all worry about the negative effects of admitting uncertainty to patients there is research that suggests expressions of uncertainty can lead to stronger patient-clinician relationships (ref). When clinicians are open and honest in response to patients questions using phrases such as ‘i don’t know‘ or ‘its not clear’ there is often higher patient engagement and satisfaction (ref).
In my experience, no patient likes to be fobbed off or bull shitted too and often they know when this is being done. So when asked a question that you can not, or do not know how to answer, do not fear saying ‘I don’t know’. Expressing uncertainty to your patients doesn’t make you appear ignorant, inexperienced, or foolish. If anything being too confident and certain can make you appear arrogant, aloof, and an arsehole.
I have found that once you get over your own inadequacy issues and inferiority complexes and start to say ‘I don’t know’ more often, it does get easier. I have also found the key to success in expressing uncertainty with patients is to do it compassionately, empathetically, but most important of all, do it confidently.
I am often uncertain as to exactly what, where, or why someone has pain, but I am often confident that there is nothing serious or sinister and that they can get a good outcome with time, rehab, lifestyle modifications and that I will do my best to help, support, and encourage them to achieve this.
So in summary, as a healthcare professional learn to be confidently uncertain in an ever-increasingly certain world!
When involved a debate or an argument it’s very easy for the main points to get lost or twisted amongst the claims, counterclaims, or the general shit flinging that tends to occur. This happens a lot in many discussions, but it occurs the most whenever I’m involved in a debate about manual therapy and its role within the physiotherapy profession.
It’s no secret that I have had my fair share of disagreements over the years with many of the leaders, gurus, and celebrities of all the manual therapy treatments such as joint manipulations, mobilisations with movements, soft tissue massage, and myofascial release. I have made public and voiced my frustrations, dislikes, and even hatred of all these interventions many times on social media and in my blogs for years, and I will continue to do so.
It’s also fair to say that I have some strong polarising opinions about ALL manual therapy, but believe it or not, I welcome the disagreements they create. Despite many of the physiotherapy top brass and elite claiming that these arguments are harmful and detrimental for the profession, I think the opposite.
As George Patton famously said, “if everyone is agreeing, then someone isn’t thinking”. In my opinion, open, honest, passionate, heated disagreement is a sign of a profession and the individuals within it trying to sort out what’s good from bad, better from worse, less wrong and more likely right. It’s disagreements that often drive change and progress.
However, as much as I welcome the disagreements and debates around my views on manual therapy what annoys and frustrates me the most is when people twist, contort or misrepresent them. This usually occurs due to others ignorance, stupidity, or simply because they dislike me.
So when I read a spectacular misrepresentation of my arguments around manual therapy by someone I consider neither ignorant or stupid and who I like and respect, I was a little surprised and taken aback. These were my feelings when I read Roger Kerry’s recent piece titled ‘Hands on, hands off: is that even a thing?
In this article, Roger references a few of my blogs and appears to have highlighted me as the reprehensible social media pariah of physiotherapy! Underneath his extensive vocabulary, fancy words, and charming rhetoric, Roger attempts to paint me and others who question and challenge manual therapy on social media as ‘non-differentiating, tired, and vacuous’ and more annoyingly that we advocate a ‘hands-off’ approach.
This is a breathtakingly inaccurate and frustrating straw man argument that I hear often from manual therapy supporters in an attempt to undermine and distract attention away from my real arguments against manual therapy as a healthcare treatment.
I find it ironic that at the start of this article Roger states the hands-on, hands-off debate is a false dichotomy when actually none of my arguments against manual therapy are about hands on or hands off. Rogers choice of words in using ‘hands-on, hands-off’ rather than ‘manual therapy, or no manual therapy’ is a deliberate ploy to misrepresent my position and in doing so he has essentially created his own false dichotomy, which is kind of strange for a professor of philosophy.
My arguments for reducing, removing, and even abandoning manual therapy by the physiotherapy profession is not, nor ever has been about suggesting that physiotherapists stop touching their patients. This is an absurd but clever distraction away from my true positions against manual therapy as a healthcare intervention.
So I will reiterate once again why I think manual therapy ‘sucks’ and why I think it should be abandoned by most physiotherapists. My first reason is due to the constant and continued misinformation about what manual therapy does, and how it does it. Despite it being 2019 and a large evidence base many physios still stubbornly and dogmatically teach and explain that manual therapy corrects and adjusts faulty joint positions or mobility issues, that it lengthens and releases muscles, fascia and other soft tissues when it simply can not, and does not (ref).
Another reason I think manual therapy should be ‘abandoned’ is due to it being over-complicated, over-hyped, over-used, and over-priced for what it achieves (ref). Most manual therapy at best gives some people, some small, short-lasting transient effects on their pain which may or may not affect their function (ref). If manual therapy were a drug it would never be prescribed as its effects are so low and cost so high when compared to other simpler cheaper alternatives (ref).
My other argument for ‘leaving’ manual therapy behind is that its a huge distraction for therapists and patients, stealing their time and attention away from active rehabilitation interventions that have bigger and better health benefits (ref). In the UK most MSK physios have very limited time with patients, anywhere from 2 to 8 sessions that last between 20-45 minutes on average (ref). In this time they have to gain a history, do a physical exam, consider any imaging and investigations, develop a working diagnosis, formulate a treatment plan, give advice and education, and practice and rehearse rehabilitation strategies.
If all of the above is being done thoroughly and to the best ability there simply can not be enough time for the application of manual therapy. When manual therapy is used what often tends to get compromised is the active rehabilitation. I know many physios disagree with me here and they say they can do both manual therapy and active rehabilitation well, but I call bullshit on that.
When I used to use manual therapy in my practice it always reduced the time I had with patients to explore, experiment, and rehearse movements and exercises, and tinker with loading parameters. I know this is anecdotal so can’t be trusted but I hear many patients telling me about physiotherapy sessions in which they had manual therapy and how either no rehab was given at all, or if it was, it was at the end of the session given as an after-thought, usually, by the physio handing them a sheet of photocopied exercises to do at home with no explanation or practice to ensure they could do them, or that they were even beneficial for them.
Finally and by no means least, I simply hate ALL manual therapy for the pompous arrogant elitism and showmanship that surrounds ALL of it and most of those that use and teach it. No matter how well presented and explained manual therapy instils a belief of skill, specialism, and superiority that it simply doesn’t deserve.
Manual therapy also instils a notion and belief that physios ‘fix’ patients rather than help them. Manual therapy takes our profession away from our rehabilitation and exercise foundations and closer to the loons and quacks in the complementary and alternative medicine fields with their crystals and chakras.
I personally believe that most physios use manual therapy more for their own benefit than that of their patients. Manual therapy is often there to pander and pamper patients rather than genuinely help them. Manual therapy makes the therapist feel special and needed, and hides their inability to prescribe good quality robust rehab or address the harder, tougher more difficult factors around a patients pain and disability.
I know many think I am unprofessional and harmful to our profession for saying this! I don’t care, because I actually think physios fannying around with manual therapy distracting patients from things they need to do and adversely affecting their outcomes is far more unprofessional and far more harmful to our profession.
NO manual therapy doesn’t mean NO touching
However, as much as I dislike/hate/loathe manual therapy for all the reasons above, I will state again that I have never suggested or implied that physiotherapists should stop touching their patients and go ‘hands-off’. In fact I recently wrote a blog saying just the opposite here.
Touch and palpation is a basic, fundamental, and vitally important part of any good thorough evidenced-based physical assessment. Although its use diagnostically is poor I cannot emphasise enough the importance of all physiotherapists taking the time care and attention to palpate their patients.
Not only does palpation stop you missing important and vital signs of pathology such as swelling, heat and deformity, it also gives patients the reassurance that you as a healthcare professional have taken their issues and concerns seriously and have examined them thoroughly. One of my ‘many’ pet peeves is listening to patients tell me that some bone idle, lazy, and incompetent healthcare professional didn’t even observe or palpate an area of concern of theirs.
However, as frustrating as it is listening to that, listening to patients who tell me that some other therapist has palpated them and found a bone out of place, or something misaligned, or a muscle knot, or fascial adhesion is far more frustrating, far more common, and a damn sight harder to deal with. The biggest reason these ridiculous, fear-inducing explanations are given to patients is due to therapists being taught and lead to believe that they can feel and diagnose things with palpation that the evidence and simple common sense tells us they cannot (ref).
Physiotherapists often develop these beliefs during their manual therapy training and why I think most of it is best avoided as it continues to be surrounded by so much outdated, non-evidenced nonsense. Roger talks in his article about the reputation of our profession being at risk if we were to go ‘hands-off’ and I agree. But I also think the reputation of our profession is in danger of being adversely affected by the woo and pseudo-science that manual therapy is riddled with.
Until manual therapy is taught in a more simple, rationale, and evidenced-based way I think most healthcare professionals are better off without it. More therapists and patients need to recognise that there is no magic, skill, or specificity in any manual therapy that costs thousands of pounds, euros, or dollars to learn, or that takes years of dedicated practice to master and perfect.
This leads to another of my arguments for physiotherapists to abandon manual therapy, that is they are not the best professionals to be providing it. Physiotherapists are autonomous diagnostic healthcare professionals who studied for 3-5 years to assess, diagnose, and manage those in pain and with disability. They are not best utilised cracking necks, giving back rubs, or applying hot packs.
For any manual therapy to be effective I believe it needs to be given by therapists who are solely focused on it, who work in calm relaxing environments, who can take the time and attention to work on the patient’s body slowly, methodically, and holistically. This is just not how physiotherapists use manual therapy, instead it’s usually rushed and done in a few minutes or less, in environments that are far from relaxing, and often they are focused on other things around the patient’s care.
Physios training, skills and time are simply better used for other things. This is not meant to sound arrogant, condescending, or conceited just honest, rationale, and pragmatic. I see a physio giving a patient a massage the same way as I see a cardio-thoracic surgeon emptying a patients bed pan. Its not that they couldn’t or shouldn’t do it, its that they are better trained and skilled for other things!
Although it frustrates the hell out of me that the manual therapy debate is often contorted and bastardised into a hands-on, hands-off false dichotomy, I am happy that the debate is still here be had. Despite what Roger tries to present in his article, the well-rehearsed manual therapy debate is far from tired or vacuous, it is an important discussion to be had, and it’s not just a construct of today’s modern social media.
The debate about the pros and cons of manual therapy within physiotherapy has been raging for decades long before I got involved, and long before social media was around. The likes of the late great Robin McKenzie, Louis Gifford, Max Zusman, Jules Rothstein were all known for questioning and challenging the over-use, over-complication, and utter bollocks that surrounds manual therapy long before Insta-Google-Face-Tweetbook was ever invented.
Social media isn’t to blame for these debates and disagreements as they have been always been around. All social media has done is make these discussions, debates and arguments more known and accessible which is a good thing. Again, some will argue that this is harmful to our profession and we should be focusing on other more important things, I disagree.
If you’ve made it this far, very well done!!!
Physiotherapy as a science-based profession needs to accept that disagreements are essential for progress. Science and philosophy thrive on discourse. Discourse drives interest, intrigue and investigation. What is far more dangerous and harmful to our profession is dogma, apathy, and lethargy from stagnation and suppression of thoughts and ideas and beliefs, and that what we’ve always done is what we should always do.
Physiotherapy needs to evolve, advance and grow, and to do this it needs to shake off some debris and detritus from the good old days and this means moving on and away from massages and manipulations, but not from palpation and touch.
There is a common saying that three of the most dangerous words used in healthcare are ‘in my experience’ as relying on it can cause some big problems. However, I think there are another three words being used a lot recently that can be just as dangerous, these are ‘research has shown’!
Healthcare has moved away from individuals experience-based practice to a more scientific evidence-based practice in an effort to reduce clinicians bias and ignorance adversely affecting patients care and treatment. This includes physiotherapy where historically clinical experience has often been highly respected and revered over and above science, research and evidence.
Clinical experience is no doubt useful for many things, in fact, I think for some things it is probably the most reliable thing we have (ref). However, clinical experience should never be fully trusted or solely relied upon. History is littered with examples of where experts have relied on their experience too much and been very very wrong at huge costs to others (ref).
Evidence-based practice within physiotherapy is slowly being adopted with more physios reading, engaging, and participating with research which is a great thing. And as much as I’m an advocate for research and evidence, it needs to be recognised that evidence-based practice has some pitfalls if not used and implemented carefully and sensibly.
Unfortunately, I see many physios using research and evidence not carefully or sensibly. In fact, I see some physios using research like a drunk uses a lampost, more for support than illumination. That is they only find research to support what they already think and use it to justify what they already do.
Some therapists think they are evidence-based clinicians if they find a research paper demonstrating that a treatment they use ‘works’ (usually by the p-value being <0.5). But this is NOT how evidence-based practice works!
Evidence-based practice is the very difficult and complex skill of interpreting, synthesizing, weighing, and implementing the whole of the evidence base in its entirety to support our methods, treatments and interventions. It’s not the reading of one, two, or even a few papers that already support your own beliefs. If you’re basing your practice on one or two research papers it’s usually because you have only read one or two research papers and are ignorant of others that may challenge or question them.
Many healthcare professionals, and I will include myself here at times, cherry-pick the evidence-base, using what they want, and ignoring what they don’t want. Most use Pubmed like they use Google doing a quick keyword search, often not going past the first page of results, and clicking on the first paper that catches their eye. This means they often find what they want to know, rather than what they need to know. It also means they get very skewed views and beliefs about what they think works, and what they think doesn’t.
One of the issues with the evidence-base is that there are literally 100’s of papers published to support anything you want, especially in the field of physiotherapy which is notorious for publishing bad science, with lots of low-quality, highly biased, poorly designed research trials (ref). For example, you can find papers showing howwoolly pantscure low back pain, ultrasound appliedclockwiseis more effective, and even spinal manipulationreverses death. There is literally citable research out there to supportwhat you want, or don’t want, such as K-tapehelps, or itdoesn’t, manual therapyhelps, or itdoesn’t, even exercisehelps, or itdoesn’t.
There is literally a shit tonne of shit research out there, and this quagmire of crap is being defecated daily, and means you have to wade waist-deep through the crap to find the good stuff. This is time-consuming, difficult, frustrating, and hard work, and means good quality research is very hard to find and often goes unnoticed, whereas bad research is very easy to find and often gets promoted.
Many say that science and evidence-based practice is broken because of these issues, but that’s nonsense. Evidence-based practice isn’t broken, it’s just very, very, very hard to do well, and often it’s abused and misused by those who don’t understand it. Evidence is a tool, and like any tool, it’s only as good as the person using it.
Unfortunately, levels of scientific literacy and understanding are terrible within the general public and not that much better in healthcare, with most clinicians not able to tell the difference between good quality, rigorous, ethical research from poor quality, flawed, biased research.
It still amazes me how many healthcare professionals hold a Bachelor of Science yet couldn’t tell you the difference between specificity or sensitivity, reliability or validity, efficacy or effectiveness, statistically significant or clinically meaningful. And don’t even get me started on how many clinicians do not understand the issues with p-values, the role of effect sizes, blinding, control groups, randomisation, power, publication bias, data mining, p-hacking, HARKing and the reproduction crisis.
Some really useful resources for better understanding of all the issues I’ve just mentioned can be foundhereandhere, and also check out theScience Dailywebsite and theEverything Hertzpodcast as well, as I often find these excellent resources for improving your understanding of research, statistics and the basic scientific method.
A common misunderstanding of evidence-based practice is that many think it will give them clear and definitive answers. Sometimes it can, but often it doesn’t. Research never really proves anything true. Research often just tells us what’s more probable and less wrong!
Many think research and evidence will give them quick, simple, easy answers to messy, complex and confusing questions about how they should assess, diagnose and manage people with pain. It won’t, not at all. If anything reading research can make things even harder and more complicated, which is why many give up after trying for a bit.
Reading research doesn’t give clinicians answers, it gives them an appreciation of uncertainty and an ability to recognise the probability of what’s less wrong and what’s more right. But only if they’re able to think critically, have good levels of scientific literacy, and more importantly be tolerant of complexity and uncertainty.
Many healthcare professionals lack tolerance to uncertainty as they don’t want to look ignorant or stupid to others. For example, no patient wants to hear or see a clinician dithering and dallying, stuttering and stammering scratching their head wondering what to do next.
A lack of tolerance to uncertainty in healthcare is also due to societal pressures and deeply rooted constructs that healthcare professionals should always know what to do when patients come to see them. It is still assumed by many that the clinician alone decides what to do and how to proceed rather than it being a shared process between the patient and the clinician.
Due to these issues, many clinicians hide and mask their uncertainty by abusing and misusing the research to give them an air of confidence and certainty. This also avoids them having to have difficult and awkward discussions with patients about the uncertainty and complexity of treatments and outcomes.
As I said at the beginning there is no doubt that clinical experience can be useful in some situations, but using it alone is fraught with problems. But, there is also no doubt that relying on poorly conducted, highly biased, and methodologically flawed research has just as many problems.
Healthcare professionals need to be careful that phrases like “I know this works” or “This is what I have always done” are not mindlessly replaced with “the evidence says” or “research has shown”.
Musculoskeletal physiotherapy I think is going through an identity crisis. I don’t mean the kind that makes it dye its hair, wear leather trousers, or tries to impress other professions half its age. Rather I think musculoskeletal physiotherapy is struggling to find its place and purpose in healthcare system and so is trying to do new things and is loosing sight of what its real role should be.
The physiotherapy profession has produced a huge amount of research in the last 20 years in an attempt to demonstrate its worth and effectiveness. However, a lot of it highlights that physiotherapy has little to no significant effect above placebos, natural history, or regression to the mean, and people are beginning to notice (ref).
This has created a lot of debate within physio with many advocates fighting hard for their cherished treatments, and others like myself questioning their worth. Some have talked about this crisis with blogs telling us how‘physio will eat itself’and books called‘The End of Physiotherapy’both of which I urge you to read.
However, physiotherapy continues to desperately search for evidence to prove it worth and earn its place within healthcare, with debates and arguments raging on about what are the best treatments for this pathology or that problem. But has physiotherapy and many within it (including myself) focused its efforts and energy in the wrong place? Has physiotherapy lost sight of what it could be preventing rather than what it can treat, and is it in need of a drastic shift in its identity of what it does and how it does it as a profession?
Treat or Prevent?
The vast majority of physiotherapy research and physios themselves invest a lot of their time, energy and effort into diagnosing and treating pathology, disease, and disability. This is clearly important and should be continued, but what about the other side of the coin? What about our efforts in the prevention of pathology, disease, and disability?
Does the physiotherapy profession invest as much time, energy, and effort trying to prevent disease, and disability as it does trying to treat it? Does the physiotherapy profession place as much importance and relevance on the promotion of health and wellness as it does on the treatment of sickness and illness?
Simply put… HELL NO!!!
Most, if not all of physiotherapy’s training, research, practice, and effort is focused on the reduction of pain and the improvement of function in those WITH disease or pathology. Very little, if any time, attention, or resources are given to ideas, methods or strategies to prevent or reduce the prevalence of disease and pathology.
Simply put… Physiotherapy is a reactive profession, not a proactive one!
And this applies not just to physiotherapy but to all of healthcare, with the National Health Service in the UK better described as the National Sick Service as it does very little to help educate, influence or change the nations behaviour to help improve its health.
Now I am not just trying to be hyper-critical or overly negative here, and I know there are some within the NHS and some physios who do work proactively in some health promotion roles, but they are in the minority, and they are not well supported, funded, seen or heard. This, in my opinion, needs to change drastically.
Currently, physiotherapy along with many other healthcare sickcare professions are bogged down in the endless ever-increasing pressures of treating pain, pathology, disease, and disability to do much about the prevention or reduction of them. This is a classic vicious cycle if there ever was one, and it’s one that is leading us into a right royal shitstorm.
Tsunami of Disease
With an ever-increasing ageing population that is doing less and less physical activity, with poorer and poorer lifestyle behaviours, declining health, and greater co-morbidities, are inevitable and our healthcare system is facing a tsunami of chronic illnesses and disabilities that it can never hope to manage and is going to be swamped very soon.
It is estimated that by 2050 the UK’s population will have expanded by another 10 million people with a significant increase in those over the age of 60 (ref). This increasing elderly population will have far higher rates of chronic long lasting morbidities such as obesity, diabetes, and cardiovascular disease, that will require long term treatments and support.
It is estimated that in just 10 years over half of the UKs population will be clinically obese and the associated health issues of this alone will cost the NHS a staggering £25 billion (ref). Thats more than all the budgets for research into cardiovascular disease, cancer, and diabetes combined (ref).
There is no way our healthcare or financial systems can cope with this, and if they only keep focusing on treating rather than preventing disease it will soon find itself overrun by the chronically ill and disabled needing constant care. Therefore, more time, effort, resources and opportunities need to be placed as a priority into the prevention of disease and illness, and I think the physiotherapy profession is in a prime position to help here.
However, as I said the physiotherapy profession is very much focused on only the diagnosis and treatment of disease and illness rather than the promotion of health and wellness. And if you don’t believe me just take a look at its recent training, career structure, and its position within health care and society in general, especially now with it emphasis on first contact, extended scope, and advanced practitioners who essentially are cheaper, poorly trained, and less skilled GPs and specialist registrars!
Currently, in most physiotherapy training very little time is spent on health and wellness promotion and advocacy. This needs to change! More emphasis, time, and energy are needed to train and enthuse current and future physios on the importance of health promotion and advocacy in all those they see.
physios need more support, encouragement, training and skills in how to communicate, motivate and encourage behavioural change in all those they see with some minor aches and pains or injury, knowing how to overcome barriers and obstacles to healthy lifestyles, far more than they need to know what settings to use on an ultrasound machine, where to place an acupuncture needle, or how to go a grade 3 mobilisation on L4/5.
Most if not all musculoskeletal physiotherapy career pathways are focused on and dedicated towards extended or advanced skills in diagnosis and treatment, there are virtually no career options for those physios who want to focus on health and wellness promotion. This needs to change!
For an MSK physiotherapist to progress their career they have to do further training in either manual therapy, acupuncture, dry needling, diagnostic imaging, injections, blood tests, even prescribing medications. For an MSK physio to be seen as advanced, enhanced, or specialised they have to twist, contort, and turn themselves into some bastardised version of a doctor, registrar, or radiologist. I know this because I have done it myself, and I don’t like it.
And this is not to be disparaging, negative or critical of all the ESPs, APPs, or FCPs or whatever you want to call them, as again I am one, and I know there are some excellent ones doing some excellent work. But where are the Extended Scope Physios in health promotion?
Where are the Advanced Physio Practitioners in exercise and activity prescription? Where are the First Contact Physios in schools educating children on the importance of healthy lifestyles?
The MSK physiotherapy profession needs to take a long hard look at its training and career structure, and stop placing as much emphasis and credence on skills that only diagnose or treat those with pain and pathology. It needs to start to place more emphasis, training, focus on skills and attributes that promote health and wellness. Simply put we need more physios enthusiastic and striving to become health and wellness advocates, not junior doctors.
Physio in society
Currently, most if not all MSK physiotherapy is positioned in reactive roles, treating people with problems sent to them. It is also still very much seen as a junior, inferior, even subservient profession to other medical professions. This needs to change!
More MSK physiotherapy needs to position itself outside of hospitals and medical centres, and into gyms, health centres, and even schools. Health promotion and advocacy should begin from a young age and physiotherapy should be lobbying governments and pressuring policymakers about the benefits of placing physiotherapists and health and wellness teachers into the national curriculum.
MSK physiotherapy wants to try and position itself as being seen as a profession that helps promote health and wellness as much as it helps treat disease and illness. Our leaders and societies need to do more to push this forward using lobbying and other political pressure.
With the World Congress of Physiotherapy currently on in Geneva this weekend, it is encouraging to see the odd slide and comment about this already, but more needs to be done and I do wonder how much of this is talk and how much action will come of it?
As I mentioned at the beginning, the MSK physiotherapy profession needs a drastic shift in its identity and thinking of what it is, what it does, and where its role and worth lies. Is it in the diagnosing and treatment of pain and pathology, which hasn’t been shown to be that great or effective, or is it more in the prevention and reduction of pain and pathology through the promotion and advocacy of health and wellness?
Obviously, the answer is both! But at the moment MSK physiotherapy is very much focused on the treating more than the preventing, it’s more reactive than proactive, and if it wants to survive and be taken seriously as a ‘health care’ profession this needs to change!
More and more physios are now discussing the so-called negative, detrimental, and harmful effects of using ice for the treatment of acute or sports injuries or even for soreness felt after exercise. Some even claim that icing everything should be abandoned completely. I think this is utterly crazy and of all the stupid, ridiculous, and ineffective things physios should stop doing, using some ice now and then is NOT one of them!
There is still a lot of confusion and misunderstanding around the long-standing and simple process of icing after an injury or exercise. This treatment is sometimes called ‘cryotherapy’ by some to make it sound more sexy and scientific, with some saying it’s the best thing ever, others saying it’s the worst thing ever.
So the aim of this short blog is to see who is more right, or less wrong, and decide if using ice is good, bad, or somewhere in-between.
Now there are many ways to apply cryotherapy from the application of a bag of ice or frozen peas to the immersion of a body part into buckets of cold water. There are even fancy pumped cold water compression devices and even full-body cryo-chambers that use liquid nitrogen at temperatures below -100*C! And you will see physios running around sports grounds and arenas with buckets of ice water, bags of ice, and even freeze guns.
Time to stop icing?
Icing after an injury or strenuous exercise has been around for as long as I can remember, and a lot longer than that. However you choose to do it, most cryotherapy methods are simple, safe, and effective for many things that ache or niggle. However, more and more healthcare professionals are calling for a ‘cease and desist’ to using cryotherapy because of some possible detrimental effects it can have on our natural healing processes.
This includes Dr Gabe Mirkin who came up with the well-known acronym R.I.C.E standing for Rest, Ice, Compression, Elevation back in 1978 (ref). The main argument made by him and many others is that using cryotherapy after an injury or intense exercise causes blood vessels to reduce or close, reducing blood flow, which may delay normal tissue inflammatory healing processes (ref).
When any tissue is damaged there is an inflammatory response which starts with blood vessels opening, called vasodilation. This increases the transportation of inflammatory cells and other things that help tissue healing such macrophages that release a hormone called Insulin-like Growth Factor Number 1 (IGF-1) which is a key in any tissue repair.
Inflammation isn’t bad!
To this day, many people, both patients, and healthcare professionals alike still see inflammation as a bad, negative, and harmful process rather than good, positive, and helpful one.
It amazes me when I hear a doctor or physio say that they need to reduce inflammation as if its some kind of pathology or disease! Inflammation is an amazing process and the first stage of healing after an injury repairing and remodelling damaged tissue. Without inflammation, you cannot have tissue adaption.
So inflammation after an acute injury or exercise is something that should in fact be encouraged, not interfered, impeded, or got in the way of. This is where cryotherapy is thought to be detrimental by causing vasoconstriction of blood vessels, reducing blood flow and transportation of cells like macrophages and hormones like IGF-1 to the damaged tissues.
However, before we all panic, lose our minds, and throw out all our ice trays let’s put these concerns into some perspective.
Ice doesn’t reduce inflammation much!
Cryotherapy as a method of reducing inflammation is kind of pathetic. In fact, it’s really pathetic, especially in comparison to other anti-inflammatory treatments such as Cortico-Steroids or Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) that have well documented strong and long-lasting anti-inflammatory effects (ref, ref).
Comparing cryotherapy’s anti-inflammatory effects to things like NSAIDs or Cortico-Steroids is like comparing… and I am not over exaggerating here… the effects of a water pistol to a thermonuclear warhead.
Using some ice or a bucket of cold water for 10-20 minutes may create a temporary reduction in blood flow and may be a temporary reduction in inflammation, but when it comes to impeding or affecting the natural inflammatory processes it is simply insignificant in the grand scheme of things, and there is plenty of research to support this (ref, ref, ref).
Ice doesn’t change tissue temperature much!
Another thing to consider is that the application of cold or hot things to our bodies often doesn’t significantly affect the temperature of our tissues. Our bodies are very very good at maintaining a steady constant temperature of 38.7 +/- 1*C. This is called thermoregulation and is a vital process that keeps us happy and healthy. If our tissue temperature were easily altered by a bag of ice or a bucket of cold water then a host of harmful catastrophic events would occur.
Most studies that have looked at the temperature changes with either topical hot or cold application only tend to find significant temperature change effects in the skin and very superficial tissues, anything below 1cm in depth is just not affected that much (ref, ref, ref)
Now, this is not to say that no significant temperature changes occur in any deeper tissues, as there are some areas and some people that are affected by heating or cooling more than others. Adipose tissue, more simply called body fat, is a bloody good insulator and so body parts and individuals that are covered with more or less of it, will be more or less susceptible to temperature changes from things like cryotherapy (ref).
Therefore the thinner the individual or the less fat there is around a body part the more likely it will be affected by topical heating or cooling, with some studies finding temperature changes in some knee joints of up to 9*C which is very significant (ref, ref). However, the thing to consider is that as soon as the hot or cold source is removed from the tissues the re-warming or re-cooling process occurs very quickly, usually within a few minutes especially if the patients move around a bit (ref).
Ice doesn’t help or harm performance much!
The effects of cryotherapy on performance are also small, but yet again some are claiming that it should be abandoned completely. Now sitting in ice baths after marathons or rugby games is something that many people do, myself included in the past, in a belief that it helps reduce soreness or improve recovery, and there are some studies that support this a little (ref).
However, some other studies have found that cryotherapy after strenuous exercise doesn’t significantly affect soreness, and may actually impede the inflammatory process again possibly having detrimental effects on tissues repair and adaption, even reducing muscle strength and power (ref, ref, ref).
Recent systematic reviews, however, are far less clear (ref, ref). They find cryotherapy after sport appears to not affect performance or recovery either positively or negatively, but may be beneficial for athletes perceptions of recovery. It may be that cryotherapy works more via psychological effects such as meeting athletes expectations, rituals, beliefs and of course giving a good old dose of placebo effect rather than any true physiological effects.
Therefore my approach to any athlete at any level who wants to ice after exercise is crack on. If an athlete wants to ice because they think it helps, it most likely will. I don’t think it’s necessary and so won’t recommend it if they don’t and certainly won’t force it on anyone.
So if you want to jump in that ice bath for a few minutes and get yaWim Hofon, or use that crazy expensive cryo-chamber after a tough game or run, crack on. Personally, I don’t do ice baths anymore now that I know what I know… I find it’s very hard to get placebo effects when you’re better informed.
Ice does reduce pain!
However, the one thing that cryotherapy can do is reduce pain. Don’t get me wrong it’s not the best or strongest pain killer, and again comparing it to the effects of something like morphine or cortico-steroids is just silly, and it won’t dramatically improve outcomes if it is or isn’t used (ref). But ice appears to be better at reducing some pains more than others such as post-operative knee and shoulder pain more than muscular back pain (ref, ref, ref, ref)
Applying an ice pack to something that’s sore or hurts is a simple, cheap and more importantly safe method of analgesia, and for that, it should be promoted and used more than it is. I am always amazed at the number of patients I see who want a steroid injection for some recent mild pain without even trying something like an ice pack or paracetamol first. And I think the anti-ice brigade is not helping things here by harping on about the possible small transient negative effects cryotherapy may have but overlooking the small transient POSITIVE effects it also has.
Again this doesn’t mean I think ice or any other cryotherapy has to be used for pain, as I’ve said many times before I think we, and I mean us as a society here, look to remove or reduce pain way too soon, way too often, for way too many things that just niggle, ache, annoy, or frustrate us for a period of time. Rather I think more of us need to learn to tolerate pain a little more, for a little longer, but if you have to find something to help reduce pain why wouldn’t you first use something as simple and safe like ice.
As I said at the start, of all the things physios need to think about reducing, removing, or abandoning in their treatment of things that hurt, ice and cryotherapy comes waaaaaay down the list.
How about more physios and other clinicians think about removing and abandoning the more expensive, time consuming, dubious, and infinitely more stupid treatments for pain like dry needling, cupping, spinal manipulations, andmachines that go bing.
How about physios and other clinicians think about removing and abandoning the more dangerous and risky treatments like steroid injections, opioids, and unnecessary surgeries before worrying too much about telling people to stop using a bit of ice now and then.
I’ve been blown away by the response and feedback from my recent blog onabandoning manual therapy. In less than 24 hours I have had numerous emails and messages from many of you experiencing the same problems and pressures to use manual therapy by your colleagues, managers, and patients, not because it helps that much, but rather because it’s expected.
It’s great to hear that many of you now don’t feel as isolated or alone knowing that others are in the same position. It’s also great to hear that many of you are now prepared to challenge this culture around manual therapy, which is exactly what I hoped the blog would achieve.
However, there has been some criticism, some constructive, some not so much. This is good, it keeps me on my toes and thinking hard, and I always think it means I’m doing something right if I piss certain people off. There have also been a few fallacies thrown around such as I only critique manual therapy as I’m no good at it and that I need more experience and training in it.
Well, there is no denying that experience and training can help you become a better therapist, but experience or training of manual therapy does not make you a better therapist. For example, some research has found that therapists experience, specialist training, and certifications do not improve patients outcomes with low back painhere. And, a systematic reviewherehas shown that more experience may actually be a risk of lower quality of care, possibly due to overconfidence as discussedhere.
However, the main point I want to talk about today is the most common justification I have heard from therapists for using manual therapy, in that is it helps patients buy into more active treatments such as exercise. I must hear this justification daily, and I will admit it was one I used to use and believe myself. I don’t anymore.
The common belief that many therapists have is if a patient with back pain, shoulder pain, knee pain, or any other pain has a bit of manual therapy first it will help them do their exercises better and more often. This is unfortunately complete and utter bull shit.
There is zero evidence, nil, nada, zilch, fuck all… that patients who get manual therapy will do their exercises any better or more often than those who don’t get manual therapy. In fact, there is evidenceherethat shows even using strong pain-relieving steroid injections in arthritic knees and subacromial shoulder painherebefore exercise doesn’t significantly improve the effects of exercise, so why would we think a bit of massage will?
There is no doubt or argument from me that exercise adherence of our patients when in pain is poor. In fact, it’s terrible, as low as 20% as found in some researchhere. But don’t be fooled or mislead into thinking that a bit of rubbing or poking will solve, correct or even significantly change this.
What will change patients adherence with exercise when in pain is talking about their concerns and worries, identifying any possible obstacles and barriers, and coming up with simple practical solutions to overcome them as discussedhere. What won’t significantly improve exercise adherence when in pain is a bit of massage or manipulation.
Over the years dealing with many types of people in pain I have come to the conclusion that the simplest and easiest way to get patients to adhere to their exercises when in pain, is to physically supervise, encourage, motivate, and reassure them as they are doing them. I find, and most research supports this, that around 6-12 sessions of exercise therapy (possibly up to 24 sessions for some) done under supervision over 3-6 months for most MSK conditions will ALWAYS outperform 6-12 sessions of any other type of therapy.
I truly believe that if more physios used their time and sessions with patients to actually do the exercises with them, sometimes multiple times a week, rather than faffing around with manual therapy and other passive modalities we would see far better results and outcomes. Patients then wouldn’t then be tempted to seek other more invasive, expensive and risky treatments, and lets not forget that they would also get the many other positive health benefits of exercise as a pleasant side effect.
Yes ok ideally in a perfect world we would like all our patients to be motivated and dedicated to doing their exercises without us having to babysit them. But news flash people we don’t live in a perfect world, we live in a world ofreducing toleranceand low motivation, not to mention poor lifestyle choices and terrible health habits.
In my opinion, physios who spend their time with patients only talking, massaging, manipulating, poking or sticking them, leaving the exercise for the last 5 minutes of the session, handing them a poorly photocopied sheet of shitty exercises to be done at home are the bane of my life and a cancer in our profession.
This lazy, bone idle, disinterested, apathetic attitude towards exercise belittles and devalues the importance and benefit of exercise therapy for many MSK conditions. If a therapist is disinterested, bored, apathetic about exercise, you can guarantee patients will be as well. Is it any surprise that so many patients ‘fail physio’ with this lacklustre approach to exercise and rehab?
Also, don’t think that by giving some patients a bit of manual therapy you will help move them away from wanting it, which is another common justification I hear for its use. I know there are patients who do only want a few sessions of rubbing and poking and then they will be fine, but there are also plenty of patients who ONLY want the rubbing and poking continuously.
I see a good few patients who are fixated on getting hands-on treatments and addicted to the crack, the joint crack that is. These patients only want a joint popping or a muscle rubbed and have little to no interest in the active side of their treatment.
Don’t think you can change this by giving them a few sessions of manual therapy and then all of a sudden they will buy into what you want them to do. Giving a manual therapy ‘addict’ more manual therapy isn’t going to help them want it less. ‘One last fix’ is often used as an excuse by many addicts but it often fails as it just perpetuates and continues the vicious circle of stimulus and reward. One last fix is never one last fix!
To break a habit a clean break is needed with support, motivation, and sometimes a distraction. The best way to move someone away from manual therapy is not to give them more but instead give them something else to focus on, like exercise.
Finally to wrap this up please remember that you don’t need ANY treatment to keep patients coming back. Also, remember that focusing on getting patients to come back is actually a pretty shitty way to work. Instead, physios should be focusing on getting patients better and NOT needing to come back as quickly as possible. Also, remember that patients will return to a therapist who they trust and believe is able to help them with the issues and problems they have, and this has NOTHING to do with what type of treatments you do, or don’t use.