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?

Summary

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.

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.

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.

Hindsight

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.

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!

As always thanks for reading

Adam

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!

Physio Training

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.

Physio Careers

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?

Summary

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!

As always thank for reading

Adam

In my last post, I discussed how many of us have low tolerance to many things that are hard, difficult, or painful. In this piece, I want to discuss how motivation won’t help you do things that are hard, difficult, or painful, and it doesn’t matter how motivated you think you are, I know you are a work-shy, bone idol, lazy loafer.

Now before you go ranting in the comments section let me explain why all of you are inherently lazy. Its because all humans are lazy, even the most devoted, dedicated, ardent SOB deep down is a lethargic lay about because evolution has taught us that conserving energy whenever possible is really smart.

Lion Jogging

This is because in a world where energy is finite and survival based on avoiding being eaten or starvation, conservation of energy is paramount, and this applies all life on our planet. For example, you don’t see many lions going for a morning jog before a day hunting, or a gorilla doing some press-ups to keep buff for the ladies. In nature, you will not see anything do something it doesn’t have to. And this is really no different for us humans.

To get a human to do something that requires a significant expenditure of energy they need a stimulus to act. This use to be things like fleeing from predators, chasing something to eat, or occasionally an urge to reproduce. It’s these basic instincts that motivate us and everything else to move, referred to flight, fight, and f**k

These days to get a human to expend energy without these basic instincts is really, really hard. Many know that regular exercise is beneficial for them, yet despite knowing this, many don’t do any, and it’s getting worse.

A recent depressing report found that many adults in the UK now sit on the toilet longer than they exercise per week. Our species is simply devolving away from exercise as we have lost most of our motivation to move.

Tinder Moves

Most of us in the modern world live in secure safe environments, with easy access to ample amounts of calorie-dense food and even easier access to members of the opposite sex (thanks tinder).

Basically, we have lost our basic flight, fight and f**k motivators to expend energy. And many try to replace these with other motivations. However, motivation is a really weak stimulus to get anything done consistently.

Simply put without flight, fight or f**k, motivation for anything else is very limited and very finite. In fact, motivation runs out extremely fast and very quickly for most of us.

Yet motivation is often hailed and promoted to be the answer to getting us moving more and exercising regularly. You only have to go on Insta-google-face-tweet-book to find a gazillion personal trainers, doctors, physios, and other exercise gurus giving their motivation tips, pictures, and videos to encourage humans to move and exercise more.

Chocolate Teapots

Personally, I think motivation is about as useful as a chocolate teapot. That’s because motivation only works when everything else is ok. Most people are motivated to exercise when they have no other major issues, hardships or problems in their lives.

Motivation is weak, discipline is key.

We should all move away from using motivation and focusing more on discipline. Many think motivation and discipline are the same things, they are not.

Motivation operates on the need for particular mental or emotional states to complete a task. Discipline is independent of and separate from moods or feelings.

Motivation is about trying to like doing stuff. Discipline is about doing it even if you don’t like it. Motivation will quit on you in the presence of hardship, discipline won’t!

Discipline is a key skill to master in life, and once you do you can master anything, even regular exercise. Once discipline is a regular trait you won’t need motivation to exercise or do anything else hard, difficult or awkward.

Smell Of It

Of course, if you have discipline and motivation together that’s a great bonus, but don’t rely on motivation as it will run out very quickly, even if you really like doing exercise, and I know this only too well.

I love to exercise in lots of different ways, rugby, boxing a bit of BJJ and these days mainly running and lifting heavy things. I’ve done these for as long as I can remember. I love the feeling, the rewards, and even the smells of exercise.

Yet despite this, there are many, many times when my motivation to exercise just isn’t there due to a bad day at work, feeling tired, bad weather, an ache, a busy schedule, the list of motivation thieves is long. All these things often and regularly reduce or completely steal my motivation to exercise.

However, despite no motivation, I still go and lift, or run not because I want to, because I need to. This is the difference between motivation and discipline, this is what I think needs to be educated, promoted and focused on more in the general population and our patients. More need to understand that it is still possible and essential to do things even when you don’t want to.

I know many of you will think I am yet again being too simplistic, too harsh, too uncaring towards those who don’t exercise regularly. I’m not, I’m just trying to highlight that trying to increase someones motivation to exercise is ineffective and insufficient and something else needs to be done.

Not Easy

I am well aware that this is no easy task and there are huge barriers to negotiate and overcome to do it, but there are ways to help improve discipline. Things like planning, setting routines, targets, rewards, back up plans and having a good support network. But without a doubt, the best way to start developing discipline is to start with small steps.

Any change is hard to tolerate but a small change is less hard.

There is an old tale that if you put a frog in boiling water it will jump out immediately as the change in temperature is too much. However, if you put a frog in warm water and slowly heat it up it won’t jump out as you bring it up to the boil. As nasty as this sounds the moral is don’t try to change too much too soon. Small changes done consistently can lead to big changes over time.

Research has looked at exercise compliance within physiotherapy and found it to be very low due to many multifactorial reasons (ref, ref, ref). I also know some research has come up with suggestions of how to address these (ref, ref, ref) and I think these recommendations are good. However, they tend to overlook or ignore the effect of an individuals discipline when it comes to exercising consistently.

Fun Or Functional

As a physio, I give exercises to patients because they address their problems and issues, such as a lack of strength, capacity, or confidence in a movement or a task. I don’t initially give exercises to my patients because I want to get them fitter or stronger, or because they enjoy them, or fit with their preferences.

Don’t get me wrong if I can find an exercise that a patient enjoys doing then that’s a bonus, but we don’t live in a perfect world. To be honest not many of my patients get overly-excited about the squats, deadlifts, or overhead presses I ask them to do.

I know some therapists think this is terrible, abhorrent, non-patient centred and that I should try harder to find exercises or activities that my patients like to do, but this is just not always possible, or practical, or the best thing to do.

Most busy physios simply don’t have the time or resources to explore all the patient’s preferences, potential barriers, or issues of why a patient may not do an exercise. Nor is it possible or practical for most physios to play around experimenting with different exercises or movements to find one that best suits the patient’s preferences the best.

Instead, most physios need to find exercises that are known to be effective at improving strength or capacity, that will do the job quickly and efficiently, and that a patient can do simply. This often means for me the exercise is a simple basic well-known and trusted one such as a squat, deadlift, or overhead press, not sexy, novel, exciting, or fun, just effective.

Summary

More need to realise that motivation is weak and discipline is key if they want to improve their health or have a better quality of life. Things such as eating healthier, going to bed earlier, and exercising more all require the trait of discipline. This doesn’t mean it has to be a complete ball ache or military regime all the time, but it does mean that life has to be occasionally hard, difficult and painful at times. 

As always thanks for reading

Adam

We all have different tolerances to different things such as how long we can concentrate, exercise, or put up with some people. I for one know that I have a very low tolerance for those who wear barefoot toe-shoes, have man buns, or take offence at everything they disagree with.

Our levels of tolerance both physical and psychological are due to many things such as our genetics, previous exposure, experiences, and even our education. Some people can tolerate exercising more than others because they do more of it, some can tolerate stress better due to previous experiences with it, and some can tolerate other people better because they have been taught to.

However, it is clear that more of the human population is becoming more intolerant of many things such as foods, textiles, and medications. And more people these days are also less tolerant of change, diversity, and differences of opinion, and many are intolerant of any difficulty or discomfort in their lives.

Our World Today

Most of us living in the modern developed world have a life of convenience and comfort. A world where we have ample access to food, water, shelter, and wifi. A world where you have technology and gadgets to make your life easier and effortless. A world where you can buy a device to put your socks on in the morning, a duvet that makes your bed, or a machine that opens your jars. We don’t even have to go to the supermarket anymore to lift our jars off shelves and carry them in a basket with home delivery and even unpacking services on demand.

We are living in a world where effort and exertion have mostly been removed, where any effort, struggle or strain is considered unnecessary and often avoided. Don’t get me wrong, this modern-day lack of difficulty does has some amazing positives, I for one am not complaining about my 5G wifi signal, my central heating, or my online grocery delivery. But the sheer amount of convenience and ease we have in our lives today also has drawbacks.

One of these drawbacks is that we have lost sight of what is actually difficult, hard, or inconvenient. What we consider challenging these days simply is not. Missing a meal, losing your wifi signal, or having to walk up the stairs because the lift broke are not difficult or serious issues, yet our modern lifestyles and lack of exposure to them often make them feel so.

Our Pain Today

This I believe is no different from our experiences of pain. Having a sore knee, an irritated shoulder, or some low back pain is often not a serious medical issue that needs to be assessed and treated. Most of our grandparents would not have seen a doctor or therapist for such things, instead, they would have just carried on understanding that things hurt from time to time.

If we were to look back just 2 or 3 generations I bet we would see that most people would NOT seek medical attention for back, knee or shoulder pain unless it was serious or had other sinister signs or features. This was of course due to access to medical services being far less back then, but I also think it was due to a difference in culture and attitude towards pain as well.

I often ask myself when I have a pain or an ache, what would my grandad do… and most of the time it would be to ignore it and crack on!

Many think that all pain and discomfort should be reduced or removed immediately. I think a lot of things that hurt just need to be tolerated and endured for a period of time. I truly believe that by reducing and removing pain too soon, too quickly, and too unnecessarily healthcare is contributing to society becoming less and less resilient to pain.

Earn Your Health

And if you want your body to look after you and give you less pain, you need to look after it. Many think being healthy is easy and an automatic right. It’s not. Of course, there is the lottery of genetic luck to get through first to avoid any congenital disability or disease. But if you have come out of that with good fortune then good health has to be earned with some hard work, self-control, and discipline, and the inconvenient truth is that many musculoskeletal conditions today are often consequences of our convenient lifestyles.

However, regardless, of why things hurt from time to time the key point is that often nothing needs to be ‘done’ for it other than reassuring the individual that it’s not serious, it will ease with time, and they will not harm themselves if they feel some pain on movement and they should try to carry on as normally as possible.

However, as much as some patients don’t like hearing this, a lot more healthcare professionals don’t like doing this even more. Many healthcare professionals just don’t feel comfortable telling people in pain that nothing needs to be done for either financial or egotistical reasons. Personally, I think many musculoskeletal conditions are over-treated with healthcare professionals pandering to patients while natural history makes them look good.

Frustrated

And please dont think this is just me being mean, cold, uncaring, or discompassionate, this is just me being open, honest, and frustrated at a system that I think is going the wrong way and screwing things up right royally. Healthcare has undoubtedly helped humanity hugely by reducing disease and pathology and increasing our lifespans. But healthcare has also inadvertently caused harm by making humanity less resilient and less tolerant to pains and problems due to its over-treatment.

If you want some proof then go look at the BMJ global burden of disease studies you can see that low back pain now consistently causes more disability and costs society far more than any other medical condition across the world, and this is despite many advances in our so-called modern pain management treatments.

In summary what healthcare is currently doing for musculoskeletal pain just isn’t working and something needs to change. Personally, I think this should start with more healthcare professionals recognising that they over-treat it, and all humans recognising that pain in life is inevitable, but suffering it is optional.

As always thanks for reading

Adam

I see more and more fitness and rehab professionals promoting the message of ‘don’t load a dysfunction’ and it annoys the hell out of me. This mantra displays a complete lack of understanding of the complexities of human movement, the multifactorial nature of injuries and pain, and the many uncertainties of rehab and recovery. Not to mention that no one can tell you what the hell a dysfunction actually is.

This message also has some negative and possibly harmful ramifications for those who love to exercise but even more annoyingly creates unnecessary barriers and restrictions for those who don’t like to exercise. So I want to spend the next 5 minutes discussing why I think many of these influential, well-known, and highly respected fitness and rehab professionals are wrong, and make a case for why we should be actually loading these so-called ‘dysfunctions’.

Loading Dysfunction

So first what is a ‘dysfunctional’ movement? Despite many claims, we actually have very little evidence that tells us what movements, activities or exercises are bad, dangerous, or harmful for us… if indeed there are any at all.

Many will claim that they can spot a dysfunctional movement or exercise just by looking at it. But the fact is when it comes to observing movement “beauty is in the eye of the beholder” meaning that what can look ugly and problematic for one person, can look perfectly fine to another.

The notion that we can tell what is good or bad movement just by looking at it is frankly nonsense. This overly simplistic and reductionist way of classifying human movement based on an individual’s observation alone needs to stop.

To put this as simply and clearly as I can… how we move is dictated by many things such as 1) individual factors; such as age, skeletal morphology, previous experience, current confidence, pain levels and so on. 2) task factors, such as the load, speed, intensity, complexity and so on, and finally, 3) environmental factors such as moving while being observed, or in a competitive situation, or using different equipment etc etc etc.

Therefore how we perform an exercise or any other movement is always going to be influenced by these many other factors, meaning that very often no two people will move the same, and often the same person won’t move the same way twice.

The Individual 

So when assessing any movement we need to recognise that we are all built differently and come in all different shapes and sizes and so we can not all move the same. Variations in our skeletal structure and geometry such as limb length and joint shape and angulation will influence how we move. For example, femoral length and pelvic geometry hugely affects how an individual squats as shown below (ref, ref).

So just because some ‘movement specialist’ with short femurs, open hip sockets, and a touch of genetic hypermobility can fold up like a deck chair when they squat… don’t think you will ever be able to if your bony geometry and genetics are completely different! And just because some ‘supple leopard’ can reach up between their shoulder blades and scratch the back of their own eyeballs, don’t think you will be able to if your shoulder and thoracic bony geometry won’t allow it (ref, ref).

It is important to recognise that what may look like ‘dysfunctional’ movement could be due to very non-modifiable genetic and or skeletal factors. However, this is very difficult to determine clinically without a lot of detailed, expensive, and unnecessary scanning and imaging, but it should always be considered nonetheless.

Now, of course, not all movement restrictions are due to non-modifiable bony factors, many can be due to the more modifiable soft tissue factors. Again determining if a movement restriction is modifiable or not can be difficult, but you can usually begin to realise that you may have some non-modifiable factors limiting your movement if you have tried to work on improving your movement for a few months and nothing has changed.

If this is the case then it may be time to start accepting that your movement isn’t going to look like someone else’s because of factors outside of your control and try not to get too frustrated or disheartened by your lack of progress in trying to imitate some flexible guru with completely different anatomy.

The Task

Our movements are also hugely affected by the task being done, and again this tends to be ignored by many movement gurus. For example, how an individual bends over to pick up a box of tissues from the floor will be, and should be, completely different from how they bend over to pick up a concrete slab from the floor.

Having someone move the same way regardless of the task’s intensity, speed, and purpose is simply batshit crazy, yet its something I see being promoted by many every day. You simply do not need to bend over the same way to do everything, in fact, this is inefficient and not functional.

You just do not need to brace your abdominal and pelvic floor muscles or keep your spine in neutral before you reach down to pick something small and light off the floor. Rather than helping and improving movement this can make many people move less and worse as they become overly focused, stressed, worried, and hypervigilant on small, tiny, innocuous things that are just not worth worrying about.

Variation in movement patterns is perversely something a lot of ‘movement specialists; understand or feel comfortable with. And movement variation occurs all the time and depending on the task and the load is much more useful than movement restriction (ref, ref).

Now, this is not to say that restricting variations in some movements, in some people, some of the time can be useful because it can. In some situations, in some circumstances, it can be very helpful to coach and constrain movement to help a person move more ‘efficiently’ during some tasks such as heavy repetitive lifting.

However, do not get fooled into the common belief that applying these movement constraints magically or significantly reduces the risk of injury. Many of our common assumptions about injury risk are being challenged more and more, with many studies in occupational manual handling showing how postural ergonomic and lifting advice doesn’t significantly reduce the incidence of back pain as we first thought, and in fact, may even be contributing to it. (ref, ref, ref, ref)

The Environment

Finally, we need to consider the environment as a confounding factor when we assess movement. As therapists and trainers, we often assess people moving in controlled, constrained, and ultimately false environments. Therefore any of the so-called movement dysfunctions we may or may not see here, may or may not occur in other settings or environments. We also need to recognise that just the effect of observing a subject move will affect how they move.

For example, how normally do you think a patient will be moving when being scrutinised in a cubicle, or gym when they are half undressed and feeling a little anxious or nervous? Do you think you will see the same movement strategy will be used when a subject is asked to perform drop landing off a box whilst being observed compared to when they are on a cold wet football pitch on a Tuesday night in Stoke, jumping for a ball whilst dodging an opposing player?

It’s not that simple!

So hopefully I have highlighted how all of our movements are based on many variables and what we think may be abnormal or dysfunctional could just in fact be normal and even advantageous variations.

We also need to recognise that the evidence tells us that many of the so-called postural and movement ‘dysfunctions’ we see in people with pain and disability are often seen in those WITHOUT any pain or disability. Things such as lumbar spine lordosis, thoracic kyphosis, scapula dyskinesis, knee valgus, femoral head CAM deformities, are all seen i people without any pain or pathology.

We also need to recognise that what we think are movement ‘dysfunctions’ may actually be optimisation strategies in the presence of pain, fear, or a lack of tolerance and capacity. Personally, I think this is one of the most common reasons I see people moving differently or awkwardly.

Why I load ‘dysfunctions’

So often it’s not the movement that needs to be corrected, it’s the pain, fear, lack of capacity or confidence in the movement that does. This is why I load so-called ‘dysfunctions‘.

I have realised that if I focus more on increasing an individual’s capacity and tolerance to so-called ‘dysfunctional’ movements, they often stop looking as ugly and awkward, and stop feeling as uncomfortable or difficult. When you build a person’s comprehensive capacity to move you often find the individual self-organises their movement strategies to become more efficient without you having to do much at all.

This is why I dont use any specific motor control drills or fancy coaching techniques anymore, Instead, I simply give a person the chance to build capacity and confidence in the movement and let their system gradually self-organise and find its most preferred strategy to get the job done. This often makes awkward ugly looking movements look much more efficient and ‘pretty’.

However, there have been times when I have also found that the observed ‘ugliness’ of a movement does not change, but again that also doesn’t really matter to me anymore either. As I said at the beginning of this blog ‘beauty is in the eye of the beholder’ and who am I to say what is an ugly movement or not.

All that I am really concerned about is does this movement feel comfortable and efficient to the person doing it? As far as I am concerned you can have the ugliest-looking movement in the world as long as you are confident, comfortable, and have the capacity, both physically and psychologically to tolerate it!

Summary 

So that’s my two cents on why I load ‘dysfunctional’ movements and why I disagree with many of the ‘movement specialists’ gurus on this topic. Remember that there is little evidence to say what is and what isn’t a dysfunctional movement but it’s damn well NOT just what it looks like to an observer.

As always thanks for reading

Adam

There isn’t a month, a week, sometimes a day that goes by where I don’t get accused of being biased on social media, the last one just yesterday. When people point out my bias it’s often not a shock or a revelation to me, as contrary to popular belief I am mostly aware of, and comfortable with, most of my biases.

However, in an attempt to avoid repeating myself time and time again when I next get accused of bias I thought I would write a blog on it. First I thought I would look at what bias is, how it can affect us all in some strange ways, but more importantly how some bias can be positive.

Bias is usually defined as “an inclination or prejudice for or against someone or something in a way that is considered unfair”. Bias is a human condition and no-one, and I mean no-one, is infallible to it, not even the best critical thinking academic online social media physio guru who likes to point them out in others all the bloody time.

Simply put if you have a brain, you have bias. However, bias is often seen as a negative or harmful trait, and yes a lot can be, but despite its reputation some biases can be good and advantageous.

Bias can be explicit or implicit meaning we have them intentionally or unintentionally. Usually, our unintentional implicit biases are the tricky little buggers that tend to make fools out of us, and before I discuss some positive biases I want to first go through some of the sneaky implicit biases can make you look like a dumbass!

Confirmation Bias

We all love to agree with people who agree with us and it is why we only tend to talk to and hang around with people who hold similar views and ideas. Confirmation bias is without a doubt one of the most difficult bias to be aware of and then overcome, as most of us tend to be put off by and avoid individuals or groups who hold different views and opinions. When we do engage with those we disagree with we often tend to blame them for the uncomfortable feelings we get rather than recognising it is our own confirmation bias making us feel insecure.

A perfect example of confirmation bias that I hear and see daily is when many moan about how nasty and confrontational social media is. Well, there is no doubt social media can be nasty at times but mostly it’s not that bad, it’s just that it’s not the nice, comfy, cosy, safe, echo chambers many are used to. Social media is a public domain where people will disagree with you in various different ways, and personally I think more need to stop whining about a difference of opinion online and start recognising that it’s their own confirmation bias that is being kicked around a bit.

Status Quo Bias

We all hate change, everyone does, it makes us feel uncomfortable and awkward no matter how flexible, open, and receptive to change you think you are. Humans are evolutionarily hardwired to be apprehensive, wary, and resistant to change, this often leads us to make choices and decisions that try to keep things the same. A classic example of this status quo bias that I see on EVERY course I do is that without fail is about 99% of people will sit in the same place on the second day despite having a choice to go to a different location.

Status Quo bias is also why most clinicians stick to their preferred assessment and treatment choices instead of changing or abandoning them when confronted with evidence to do so. The destructive nature of this bias in healthcare is the unwarranted assumption that change will make things worse and that if it works then why do I need to change.

Observational Bias

Have you noticed that as soon as you finished that weekend pelvic course suddenly everyone who came into the clinic had a pelvic asymmetry?  This is a classic example of observational bias, the effect of suddenly noticing things we didn’t notice before. This is not because these things are appearing more frequently, it’s just that you’ve been primed to look for them.

The trouble is, most don’t recognize this as a bias and actually start to believe these items or events are happening with increasing frequency. It explains how some therapists start to think things like poor posture and other modern-day behavioural habits are to blame for issues such as an increase in pain levels in the general population. It’s also why we often think that the appearance of certain things or events can’t possibly be a coincidence even though they are, such as when our patients get better after seeing us.

Negativity Bias

We tend to pay more attention to bad news and it’s not just because we’re morbid, its because we perceive negative news as being more important or profound. We also tend to give more credibility to bad news, perhaps because we’re suspicious of constant claims to the contrary. Also again evolutionarily, heeding bad news has tended to be more beneficial and adaptive than ignoring good news (e.g. ” sabre tooth tigers suck” vs. “this berry tastes good”). However, today, we run the real risk of dwelling on negativity at the expense of positivity and this is true in our day to day lives, the media, and of course healthcare and physiotherapy.

Positive Bias

In the world of research, a positive bias is a negative thing as it refers to the preference for publishers to publish research that has a positive or eventful outcome over research that has an uneventful or negative outcome. This can lead us to make errors in our judgement and thinking when choosing treatments and it is a huge problem in all aspects of healthcare, physio included. Without publishing the research that shows little, no, or even detrimental effects we tend to get a skewed view of the effects of some treatments such as dry needling, manual therapy, symptom modification procedures and so think they are more effective or safer than they actually are.

My Positive Bias

Now to finish this blog I want to discuss the bias that I get most accused of which is my clear, obvious, and intentional bias towards the use of exercise and activity over and above passive treatments such as manipulations, massage, electrotherapy, taping, needling etc for all painful musculoskeletal conditions and complaints.

Although the evidence on exercise for helping many painful conditions cannot be called strong and it does not consistently outperform all passive treatments, I don’t care! If two treatments work the same for pain, but one has greater impact on an individuals health, function, and many other secondary things, then for me it’s clinical unethical and immoral to not have a bias towards exercise and activity!

I will be the first to admit that the how and why exercise-based interventions help, or don’t help, painful conditions is not well understood, and I am aware that the process of doing the exercises may be more beneficial than the outcome for many people in pain.

We know exercise can create both physiological and psychological effects and trying to determine which of these is working more or less for some is near on impossible. However, just because we can’t say what is or isn’t helping with exercise-based interventions, doesn’t mean we can’t use them, and let not forget that all the same uncertainties surrounding ALL other treatments for pain such as manual therapy, electrotherapy, tapes and needles.

The argument I get a lot is that we should use both active AND passive treatments combined, however I disagree! The addition of passive modalities to exercise doesn’t seem to significantly enhance the effects of exercise when given alone! Also I think using too many treatments all at the same time can confuse and complicate things and distract time and attention away from them weaken the effects for many! 

So it is these factors which is why I have now abandoned all passive modalities from my practice as a physio completely and I don’t regret it or miss it one little bit… far from it, I wish I did it sooner!

My advocacy and promotion of abandoning mana therapy is what often causes a lot of anger and accusations of bias from many who continue to use them, even more so from those who teach them. This is often due to their own biases and so to combat this they are quick to accuse me of my own bias whilst ignoring their own.

Having a bias doesn’t automatically make an person or action bad, harmful or invalid. For example, I have a very strong bias that all racism and sexism is wrong and abhorrent. I also have a strong bias that putting your hand into a fire is not sensible. Are these bias flawed? Of course not!

Some biases are formed on information so strong and concrete that they are positive biases, and those that attempt to appeal to the exception or the middle ground and argue that we need to be as critical of all our biases is simply not true.

So, if someone has a bias towards exercise over passive treatments this is in my opinion a positive bias and one that I am proud to have. And to be honest its a bias I wish more Physio’s and healthcare professionals had. Could you imagine what our healthcare system would look like if every doctor, surgeon, therapist, nurse, assistant had a bias towards using physical activity and exercise over drugs, surgery, bed rest, tapes, braces, needles, massage, etc?

In summary, if being biased towards exercise is wrong, then to put it simply, I don’t want to be right!

As always thanks for reading

Adam

I was going to do another blog ranting about how batshit crazy our profession can be, but instead, I thought I would try a different approach. I thought can I find any common ground with those I think are batshit crazy and who I disagree with the most.

Now don’t worry I haven’t gone soft, I just thought I would try something different other than ranting and raving and see if I can find something that may help me understand others with ‘alternative’ views and opinions. Let’s see how it goes.

So this blog was triggered after I saw a post on Facebook from someone called David Weinstock who is a Natural Therapist, whatever that is. Anyway, he runs something called ‘Neurokinetic Therapy’ and he posted on Facebook his thoughts about how tattoos and belly button piercings can affect fascia and throw your “core off” causing dysfunctions, imbalances, problems, and pain (see the post below).

Now, clearly, this a load of complete and utter bollocks and needs to be questioned and challenged, and I did, as did many others. However, this didn’t go down to well with Mr Weinstock with me being blocked and so this blog was born.

Short Temper?

Now many tell me that I get blocked and cause disagreements because I am too harsh, too direct when I challenge stuff like this, and this is why I get resistance and kickback from people like this Weinstock character. Many say I would have more success if I ‘softened’ my approach and was more ‘polite’ and ‘respectful’.

Many think I have a short fuse and a fiery temper because I challenge stuff like this a lot robustly. But I don’t have a temper, I just have a quick and violent reaction to clear and obvious bull shit, and in my opinion, clear and obvious bullshit needs to be treated with disdain, not respect.

Usually, in my experience, those who make ridiculous claims like this will never listen to anyone who disagrees with them, no matter how nice, polite, or respectful they are. And this was proven yet again when this Weinstock character deleted ALL the questions, comments, critique, and piss-taking left on this post no matter how polite or rationale they were worded.

I see this happen all the time when anyone disagrees with those who have clear vested interests in selling a particular method, a special technique, or promoting a book or courses. When someone questions their claims they are instantly considered a threat to their business and reputation and so are often tarnished as being disrespectful for daring to ask a question no matter how its worded.

So when I see this kind of batshittery I often can’t be bothered with polite, respectful questioning anymore, there is no point, it gets you nowhere just as much as being more direct. First, you either get ignored or if they do engage, you end up going around in circles fighting logical fallacies and ad homs.

Instead, I think our efforts are better used not by trying to discuss anything with them but rather calling out this stupidity more publicly, more often

The world of crazy!

Now Weinstock and his Neurokinetic Therapy claptrap are not alone, there are many others who are just as coco-bananas, who promote their clear and obvious bull shit on social media, and who need to be called out more for it.

For example, Perry Nickelson and his ‘Stop Chasing Pain’, Ron Hruska and his ‘Postural Restoration Institute’, Tom Myers and his ‘Anatomy Trains’, Kelly Starrett and his ‘Supple Leopards and Mobility WODs’, and Naudi Aguilar and his ‘Functional Patterns’, and these clowns are just the tip of the stupid-berg…

All these individuals are notorious for making ridiculous, stupid, implausible, unsubstantiated, ‘say hello to my little friend’ crazy claims about being able to fix this, correct that, cure something faster, quicker, better than anyone else, and of course they want to sell you their books, courses, gadgets and gizmos. But more importantly, these individuals are notorious for ignoring different views and opinions, closing down disagreements and attacking anyone who dares question or challenges them or their methods.

So I thought is there ANYTHING I can find in their material and social media posts that I can work with, that I can connect with, that I can find some common ground with, that I can try to use to build a bridge to reach out and engage with them on a more positive footing.

So I dug around and looked deep into their web pages, and their online profiles, and blogs, and social media posts fighting hard to control my laughter, anger, and frustration. I looked and looked to see if there was ANY common ground…

And to put it simply, there isn’t… but, with some wishful thinking, some hard reading between the lines, and possibly clutching at some very thin straws I think I found a couple of things that we may have in common, so here they are…

No1: They want to help others (I think)?

I do think that most of these individuals have a genuine desire to help people in pain. Ok they have some bonkers, Lady Gaga ideas about how to do it, and they don’t seem to recognise other alternative explanations of why what they do does what it does, nor do they recognise the possible negative effects their methods could create. But then again, do I fully understand or recognise all the reasons why the things I do work? Probably not!

I think that there are very few malicious healthcare practitioners out there who are deliberately looking to rip vulnerable people off and don’t care about helping them. I remember seeing a video of Perry Nickelson a few months ago online where he was helping a very elderly gentleman walk after multiple strokes, and you could clearly see the joy on Perry’s face as he helped this man walk for the first time in months. Unfortunately, Perry was also promoting some stupid ass ‘Neuro Amino Frequency’ stickers/plasters that he had whacked on this gentleman’s body and head as being the reason for him being able to walk again, which clearly is complete and utter bull shit again.

In my opinion, most healthcare professionals are just not malicious people, just ignorant, misguided, and misinformed, who don’t recognise the uncertainty around what they do or realise the harmful consequences their methods or approaches have. However, I don’t feel that sorry for them as in this day and age ignorance isn’t an excuse. If these individuals chose to listen to alternative views and different opinions a little more they may start expanding their horizons and begin to realise there are other explanations.

No2: They get people moving!

They may have some screwy, squirrely, crackerjack ideas about how to do it, but most of those I disagree with do try to get people in pain to move more. Unfortunately, they do tend to focus on the small, innocuous, inconsequential details, and believe in so-called perfect posture, positioning, form for everything and anything. As much as this stupid reasoning about perfect form, or some insignificant muscle at 11% of MVIC whilst holding your breath and standing on a bosu ball makes me want to pull my face off, I think dumb movement is better than no movement.

Even the king jester of perfect alignment and correct posture Naudi ‘functional patterns’ Aguilar gets people moving a lot, and if I let you in on a little secret and you promise not to tell anyone…

*whispers very quietly* I sometimes use some of Naudi’s exercises with some of my patients!

I know its shocking, but the angry little cock womble does have some good ideas about novel movements from time to time. However, I draw the line at wrapping bands around my patient’s, giving them a gazillion instructions, and telling them this is the only way they can move.

No3: They want to make a difference!

One last thing I seem to have in common with all of these individuals is we all want to reach a big audience and spread our message, views and opinions far and wide, however, our motives are often very different.

Attracting attention in this day and age can be hard. In fact, it can be near on impossible as there is so much noise it can be difficult to get yourself heard and noticed. So at times an outrageous comment or statement can make people stop and take notice of you.

Now I am not saying this is right but I will admit I am guilty of this at times. I will often play devil’s advocate and take a much harder position than I actually have, even at times exaggerating it for effect… Except for my views about manual therapy, I haven’t exaggerated those… I hate it… that shits for real… Also, I do swear this much, that’s not for attention either!

The difference I have from those I disagree with, is I want to promote a more simple, honest, and pragmatic message that doing the simple things really well is often all that we need to do, but we need to be better at doing it. These others tend to promote the exact opposite, pushing a particular way, method, or technique that is complex and complicated and often not needed, nor backed by any evidence. I want to simplify, they want to complicate, and so this is where our common ground ends.

Summary

So there you go, some common-ish ground with those I disagree with. It was hard, really hard, actually nearly impossible, but I did it, I managed to find a couple of things I may have in common with those I don’t agree with, and actually this has made me reflect a little.

First, its made me think that I should do this more often before I go off on one, and second, that despite our differences around the unhinged, batshit crazy world of neuro amino frequency stickers, tattoos causing fascial adhesions, tight psoas muscles causing back pain, it may not matter that much if we are all just trying to help people in pain to move.

Actually, what the fuck am I on about… ignore that, bull shit ALWAYS needs to be called out as bull shit. Call it out, call out that fucking crazy bull shit… always! 

As always, thanks for reading

Adam

We all go through life with expectations. We expect our alarm clock to wake us up in the morning. We expect the traffic to be bad on the way to work. We expect a kiss from our partner when we get home. But when something doesn’t go as expected it tends to upset and annoy us, this is human nature, and this is no different for our patients.

I see more and more discussions on social media from therapists about how much they recognise patient expectations are vital to successful outcomes which is great. But what is not so great is how some are using this to justify the use of any treatment, even poorly supported interventions such as dry needles, stretchy tapes, machines that go bing, and of course manual therapy.

Predicting Success

Many justifying the use of these low-value interventions claiming they are acting under the guise of evidence-based practice because they are meeting patients expectations. To put this as simply as I can, this is a pathetic excuse.

There is a good deal of evidence that shows how patient expectations are important to predict successful outcomes for many interventions, but this doesn’t justify the use of low value interventions.

For example, one of the strongest predictive measure for successful physiotherapy treatment for shoulder pain was if the patient expects physiotherapy to help (ref). This is the same for chronic back pain (ref). This also applies to treatments such as manual therapy (ref), even my exercise therapy (ref) with higher expectations predicting greater success.

Simply put if a patient thinks an intervention will help them, it will, if they don’t, it won’t. From this, some clinicians have taken the position that they simply need to give interventions that a patient wants or expects to help them get better.

Lame Excuses

This is one of the lamest excuses and a complete a bastardisation of the research, and really daft lazy clinical reasoning. To put this as clearly as I can managing patients expectations doesn’t mean meeting them.

Just because research shows patient expectations can predict outcome doesn’t mean you do whatever the patient wants. For example, if a patient expects you to give them their massage treatment without your top or trousers on because it makes them feel better, you wouldn’t do it, would you?

So there clearly is a  line of what you as a professional healthcare clinician will do to meet a patient’s expectations, which is good. However, in my opinion, this line needs to be much, much higher than it is and definitely a long long way from doing treatments half-naked.

Hard Work

Many patients of mine do NOT have their expectations met, but they ALL have them managed, and I have found if I can manage them well even if I don’t meet them they still get successful results. However, I will be honest and say this isn’t easy and it doesn’t happen all the time.

Trying to manage or change a patient’s predetermined expectation is hard work. When patients don’t know what they want or need and have no prior expectations, these are much easier to manage.

However, more often than not patients do have an expectation of what they want or think they need. This will be either due to some advice or information from another healthcare provider or from some advice they got from a friend or the internet and Dr Google.

In this post-truth world of alternative facts and fake news, misinformation is rife and a lot of patients get some pretty skewed and erroneous ideas, beliefs, and expectations.

As responsible evidence-based clinicians, it is our moral and ethical duty to truthfully inform our patients on what the current scientific literature is saying. During this, we need to remain as unbiased and impartial as we can, which is easier said than done.

We need to present to the patient all the options available with clear, concise information about the pros, cons, risks and benefits, as well as explaining the uncertainty of how these treatments may or may not work. You may be thinking that this is a lot of work, and you’re right it is. But its called informed consent and is a fundamental principle of healthcare.

Meeting someone’s expectations is actually pretty easy, but that’s NOT your job as a healthcare professional. That’s what a receptionist, waiter, taxi driver, or prostitute does. Meeting a person’s expectations is what any good service provider does, however, healthcare professionals are NOT service providers.

Summary

Your role as a healthcare provider is to MANAGE patients expectations not automatically MEET them. This means carefully, compassionately, and honestly telling them that sometimes they don’t need what they think they need.

Yes, this is difficult, challenging and requires more time, more effort, often for less reward both financially and emotionally. But, it’s what you signed up for when you decided to be a healthcare professional, and if you don’t like it then I’m sure there are some tables needing waiting or taxis to be driven somewhere! 

As always thanks for reading

Adam

I often get asked by other physios ”what kind of physio are you?”. Often I reply ‘just an average one’ to wind them up because I know what they are really asking me is what are your qualifications and allegiance to a specific physio method or treatment?

Now there are many kinds of ‘method physio’ such as McKenzie physio, Maitland physio, Mulligan physio, a Cyriax physio, even a Cognitive Functional Therapy physio. And there are many kinds of ‘treatment physio’ such as a manual therapy physio, a pilates physio, a dry needling physio, a cold laser physio, a myofascial release physio, even intergrated functional systems physios.

Well, I am now proud and happy to say I am none of those, I’m just a plane boring bog standard physio. I’m not accredited, affiliated, or aligned with ANY specific methods, treatments, groups or gurus, and personally I don’t think any physio should be.

Now don’t get me wrong I think we can all learn some stuff from many of these methods and treatments, and I have! I’ve personally done many of these courses, jumped through their hoops of assessment and passed their pseudoscientific exams to earn post graduate ’qualifications’. But I don’t align myself with any of these methods or treatments when it comes to doing my day to day job seeing people in pain or with disability!

Personally I think most if not all of these groups, clans, and tribes within our profession cause more problems than benefits producing more bickering, backstabbing, infighting and endless pathetic claims of superiority over each other.

For example, when I was a young naive and impressionable physio I did my first MSK orthopaedic post graduate course with the Cyriax affiliated ‘Society of Orthopaedic Medicine’ or SoOM as its called, I was consistently belittled and looked down upon by those in another MSK orthopaedic special interest group called ‘The MACP’ which used to stand for ‘The Manipulation Association of Chartered Physiotherapists’ but changed its name to the ’Musculoskeletal Association of Chartered Physios’.

Because of this I then started to do my MACP post graduate training but kept coming across so much ego and elitism in their members and tutors that I left half way through my training unable to stomach it or them anymore. Still to this day because of these experiences I hold the MACP and most of its members in low regard. I have also had some personal and professional disagreements with some of their senior members and have found the MACP to be a seething nest of spiteful, vindictive, and narcissistic attitudes and actions.

The MACP often try to promote they are working hard to improve the standards and advance MSK physio, but in my opinion this is just a thin disguise for their real motive which is to get as many physios as they can to join their clan, pay their subscription fees, do their training, jump through their hoops of assessment and accreditation, and ultimately think and act exactly like they do.

I’ve lost count of the number of times I’ve seen or heard MACP physios thinking and acting the same, often claiming that they are better trained, better skilled than other physios because of their membership. Many think and have told me that because I haven’t completed the MACP training brainwashing or jumped through their hoops of accreditation that I am somehow less skilled, less capable, less of physio

I often get called by many MACP members in senior ESP, APP, FCP roles a ‘glorified personal trainer’ in some misguided and laughable belief that this is somehow an insult to me. Many think that because I dont use manual therapy, electrotherapy, dry needling, taping, or any other adjuncts to help people with pain or disability, preferring to use advice, education, movement, and exercise that I am not fit to call myself a physio.

Many think that because I dont use any passive treatments, tricks, gadgets or gizmos then that makes me less of a physio! This makes laugh and cry at the same time

For example, when some physios call me a glorified personal trainer it clearly shows their arrogance and ignorance in thinking that personal trainers are somehow beneath them. Even though personal training is largely an unregulated profession I think many, many physios could learn a thing or two from some personal trainers.

A lot of physios like to belittle or ridicule personal trainers for their lack of knowledge on anatomy, biomechanics, or because they don’t have formal qualifications or protected titles. However, when it comes to exercise prescription, planning, and programming most personal trainers put most physios to shame.

Physios are thought to be the ‘experts’ of exercise but I know first hand that most physio training does a really shitty job at educating and equipping them to understand, prescribe and program exercise effectively. Most physios training on exercise and rehab tends to reach the dizzying heights of how to prescribe safety googles before using Thera-band and how to walk up and down a flight of stairs, which can be important, but let’s not forget that without sufficient leg strength no one is walking up or down any stairs anytime soon.

So you would think it would be a good idea for physios to also learn how to develop sufficient leg strength in their patients. You would think it would be a good idea for the universities or special interest groups like the MACP to teach physios how to perform and teach exercises such as the squat, the deadlift, the overhead press, and many of the other basic strengthening exercises. Yet they don’t!

Most MACP or other accredited method/treatment courses couldn’t teach you the difference between a front squat, back squat, sumo squat, goblet squat, hack squat, pistol squat, split squat, half or quarter squat, let alone demonstrate them well. Most physios training does not teach them how to prescribe, dose, progress, regress, or execute exercise well.

Most physios training is just not focused on exercise or rehab, but rather on modalities and adjuncts like manual therapy, dry needling, and taping etc. Many physios are lead to believe that these treatments justify their role and their place in the healthcare system, and exercise is the simple easy bit that can be done at the end, or worst not at all!

This makes me both mad and sad. Physiotherapy is so much more than its treatments of manual therapy, electrotherapy, needling, even exercise.

Many physios feel the need to justify their existence by saying things like they break up scar tissue, release stiff joints, free fascial adhesions, or correct muscle imbalances or faulty biomechanics. Many physios just don’t feel confident to explain that what they do is assess, reassure, advise and try to get people moving more.

Many physios feel the need to exaggerate and conflate what they do to make themselves feel more important and more essential in the eyes of their patients, their peers, and other healthcare colleagues. Many physios just do not get taught or encouraged to see the value in simple, honest, things they do.

This is again both sad and maddening.

So I will try to change this by saying that as a physio I try help people in pain or with a disability to move and function better. I do this by assessing for any serious or sinister stuff, then advising and reassuring patients that its safe. I then try to look at ways to get them to move differently, get them a little stronger, fitter, and more robust both physically and psychologically.

I do this without any gadgets, gimmicks, magic tricks, or bull shit. I don’t correct faulty biomechanics, I don’t release fascia, I dont alter soft tissue tightness, spasm, tone, or flexibility, and I don’t miraculously cure or remove pain.

In summary, I’m just a physio!

As always thanks for reading
Adam