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Are you sitting comfortably: the myth of good posture

22 Mar 2018

low ceiling

That’s the Guardian’s (5/3/18) headline – not mine – for an article in which two well regarded physical therapists and researchers explain why it doesn’t matter how we sit, or what posture we assume because there is no evidence to support an association between sitting and back or neck pain.

Slouch on: bad posture not bad for your back (https://twitter.com/RadioNational)

This was the heading of a radio interview posted on Twitter featuring another two physiotherapists and researchers from Western Australia, in December 2016.

Confused by this message?  You should be!  It was not so long ago that we were being told that sitting was the new smoking (and maybe it still is, because sitting may well have health implications well beyond back and neck pain).   I agree with a lot of what these researchers say but I worry that sometimes these, dare I say it headline grabbing statements, are sending out a message that is too simplistic.

This is a bit of a long post, so go to the last three paragraphs if you want to cut to the chase.  Read on if you want a better understanding of why we are getting mixed messages about sitting.

I took a look at the paper behind the Twitter headline.  To cut a long research paper short, the researchers looked at participants’ normal sitting posture and took lots of measurements relating to it – that bit is fine – then had them respond to a questionnaire that asked them a whole range of psycho -social questions – how stressed are you? how much sleep do you get? as well as how many hours are you on the computer per week? playing games on the computer per week? exercise? They also got a raft of questions about neck pain: do they/have they suffered neck pain?  what duration? is it worse when you sit? etc.

I often feel like I need to go back to college and do a research module in order to be confident about critiquing a research paper, but not in this case.  I reckon my seven-year-old daughter would see one problem with this research in no time.  The radio presenter is straight onto it: the study was done on 17 year olds!

The researcher’s response to this is that in another study he has done, one in five seventeen year olds suffered neck or back pain.  I haven’t looked at the latter paper yet, but again, it doesn’t ring true in my experience – though I accept there may be many reasons why I don’t see these patients. I will be take a look at the paper and report back.  Don’t get me wrong – interviewee Peter O’Sullivan is a good guy and says a lot of good things in the radio interview above.

I looked at a 2010 systematic review of the association between sitting and low back pain.  It forms part of the limited body of evidence that fails to show an association between LBP and sitting.  Of the five papers with data of good enough quality to include in the study, only three were prospective studies.

A prospective study is the ideal for answering this kind of question (note the paper discussed above was not prospective).  You start with a group of healthy participants and you follow them for a number of years – the more the better –  during which time they report on a variety of variables, including some very specific to sitting.  You’d want to know about the nature of the sitting – desktop computer, laptop, duration of time over the week, number of hours without a break and so on and so on, as well as all the psycho- social factors and other bio factors – exercise, other tasks.  And of course you’d want them to report on pain.

But one of the prospective studies was of construction workers – I’m sure I don’t need to explain further (they didn’t do much sitting). One was on newly employed workers (same problem as the 17 year olds, and it was only a two year study).  The third was on nurses, which would seem to have more validity but it was only for a 12 month study and was from 2004 (not in itself a problem except for the point that I’m coming to re laptops).

My point here is that when experts say there is no evidence to support a hypothesis – in this case “slouched sitting causes low back (or neck) pain” –  we need to be sure that the research to which they are referring is rigorous enough. In my opinion the results thrown up by the current body of research are questionable.  We just don’t have sufficient evidence yet to say conclusively that how we sit and for how long is unimportant to back and neck pain.

A great litmus test in these situations is to apply common sense.  Imagine you were made to crouch in a room with a low ceiling for a few hours.  Do you think your neck or back might start aching?  Similarly, if you sit at a laptop – which often combines a degree of slouch with looking down – for eight hours a day (doesn’t count if you separate the screen and keyboard) I’d predict that the odds of your suffering back or neck pain would go up.  Whether you do or not would depend on a whole lot of other factors.

Once again, biomechanics – the study of forces (like gravity) on living organisms (us) matters.  Don’t worry too much about how you sit, but be sure to fidget and take breaks from sitting.  The body has an amazing ability to compensate, but there is a threshold at which the body’s natural reserve will be used up.  Sitting staring into a laptop for eight hours a day, five days a week, perhaps combined with some other biomechanical or psycho-social factors could easily push you past that threshold.

I’ve not moved from my computer for two hours and my back hurts – seriously!

(Image: still from Being John Malkovich)

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Make Coordination and Variability a Priority

18 Jan 2018

hula-hoop-feature

Key message 1: Coordination plays a key role in our having ease of movement and staying injury free

Key message 2:  We can improve our coordination

Key message 3: We also need variability in the tasks or exercises we undertake.

Coordination is what makes some people move with ease, grace and fluidity while others’ movement appears laboured, difficult, and sometimes painful.

Good coordination really amounts to the activation of the right muscles, in the right sequence, at the right time for the performance of a particular task and helps to keep us pain free and avoid injury.  It also contributes to other motor abilities such as mobility, stability, balance, and strength (sport-specific strength training can be described as coordination against resistance*).

Coordination, therefore, should be a prime training objective.

Coordination can be improved with any task, movement, or exercise using tweaks in the way in which the task/movement is done, and then progressively tweaking back towards the intended task. It requires practice and repetition.

A practical application might be improving coordination during an forward lunge. Initial tweaks might involve holding the back of a chair or wall while lunging; starting with stepping and progressing to a lunge; stepping out wide; adding a hand reach across the body.

But coordination alone is not enough.  It will not prepare you for the unpredictable or unaccustomed –  having your children jump on and hang off you  (a particular favourite of my girls), tripping up or stumbling, changes in terrain or training surface.  For these things we need adaptability, and to acquire adaptability we need to vary the exercises or tasks we do, and the way we do them.

What might that mean in practice?

If you like to squat at the gym, then you might vary the way you squat: play with foot position – staggered, wide, narrow, toes in/out; vary the weights you use: hand weights, bar, medicine ball; vary the rate and rhythm of the squat; take small steps within the squat position – lateral, forward, backward etc.

If you go to a Pilates class and the exercises are the same every week then maybe try a different class.

If you are digging, weeding, or raking the garden, try to vary the way you work, even if it is only a slight change to the way your body would prefer to perform the task.

For a more significant challenge to your coordination try a dance or Zumba class.

Or just play – with the kids or grandchildren, frisbee, hula!

The upshot is that just as we need to keep challenging our brains in new and interesting ways in order to keep our memories and other cognitive functions sharp, so we need to stimulate our motor system in new and interesting ways in order to stay physically sharp.

Use it or lose it!

* Frans Bosch – Strength Training and Coordination: An integrative Approach

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Why Biomechanics Matter

01 Dec 2017

paratroopers

Key message 1: Psychology is always important.  Pain is an output of the brain; it is one of the ways the brain lets us know that it perceives a threat.

Key message 2: Biomechanics is the study of forces (mechanics) and their effect on living systems (bio).

Key message 3: We are a living system interacting with a physical world of forces.

Key message 4: Biomechanics is always important.

There has been a huge shift to the biopsychosocial model in manual therapy in the last decade and understanding how psychological factors influence our experience of pain has and continues to change the way physical therapists communicate with, educate, and treat patients.

I think it would be fair to say that while psychological considerations have been in the ascendency, the idea that biomechanics doesn’t matter has been gaining some traction.

Why biomechanics matter

So just in case you are thinking – in the light of my pain series – that pain is all in the brain, then let me explain in broad terms why biomechanics matters hugely.  This might seem blindingly obvious; to say that biomechanics doesn’t matter is like saying gravity doesn’t matter. The more important question might be: when is biomechanics important and when are psychological factors important?

Eric Meira (aka the science PT) uses a great analogy of asking a bunch of paratroopers how they’d feel about being asked to jump out of a plane at 11000 feet without a parachute?  “Scared of getting injured you idiot” comes the reply.  Is a psychological intervention appropriate in this case to help them overcome their fear of injury? Of course not!

What are they scared of? Not being able to handle the huge amount of force with which their mass suddenly decelerates as it hits the ground.  F=ma.  Biomechanics! (Eric Meira)

In a similar way, it’s not enough to tell someone that it is safe to jump, bend, or run when they are in pain.  The role of the physical therapist is to enable successful movement, train, and educate in such a way that it is safe to do those things; provide the necessary safety equipment (motion, coordination and control) and training to use it (at different speeds, positions, and with different loads).   Otherwise fear is a rational response.

When psychology is key

Sometimes we just become fearful of movement, or of re-injuring ourselves.  This may be because we have had an MRI scan that showed a bulging disc in our low back, or because our back has “gone” during lifting in the past, or a therapist or surgeon has told us not to make a certain movement with our back, knee, or shoulder.

The analogy now is that you are simply asking someone to step out of a plane that is sitting on the ground.   The individual needs to be shown that they have the motion, and control of that motion, to pursue meaningful activities with confidence.  And that means gradually progressing the level of difficulty of the activity and ideally moving beyond it, so that it can be performed at greater speed, with more load than necessary, and in more extreme joint positions.  You’ll hear me refer to this as building in a “buffer zone” of function.

In summary:

  • Psychology always needs to be considered
  • Biomechanics is the study of forces in living systems
  • We are a living system interacting with gravity and ground reaction force
  • Biomechanics matter
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Understanding pain part 4: persistent pain

08 Nov 2017

Pirate attack (640x396)

Key message 1: pain is an output of the brain in response to multiple inputs.  Inputs come not just from pain sensors, but also from memories, beliefs and attitudes, fear, stress, fatigue and so on.

Key message 2: sometimes the output of pain exceeds the need for pain.  The danger has passed, but the brain is still receiving information that vigilance is needed and pain persists.

Key message 3: understanding the pain mechanism can help us to “self-audit” i.e., ask ourselves what other inputs may be fueling or sustaining our pain experience?

Key message 4:  we are inherently adaptable and can habituate to pain.  With the right help and a staged return to meaningful activities our response to danger signals from our tissues can diminish.

In part one of this series I used Greg Lehman‘s analogy between the way an alarm sounded by a ship’s lookout gets passed up the chain of command to the Captain and how nociceptors ( the body’s pain sensors) pass information up to the brain.  At various levels in the chain of command a decision is made as to whether the alarm warrants action – and so gets passed further up the chain – or can be ignored.

Sighting a light off on the starboard side would be a normal occurrence on a ship and on hearing the lookout’s alarm the first mate/spinal cord may decide there is no reason to notify the Captain.  If, on the other hand the ship was navigating pirate infested waters then the first mate would be sure to notify the Captain and she may well decide to change course.

Persistent pain/Sensitisation

The ship may have left the pirate infested waters where vigilance was necessary to protect it, but if the fear of pirates remains it can stay on high alert and be over-sensitive to information it receives.  In the same way the body can continue to experience pain long after the potential threat has passed.  We become “sensitised”:  pain becomes a learned response.  Sensitisation, as it is called, has to be considered whenever someone has been experiencing pain for a prolonged period of time.

Habituation

The opposite of sensitisation is habituation.  Habituation means that for the same input over time the output is smaller.  If you get into a hot bath with cold feet the water can at first seem intolerably hot, but very soon we habituate to the temperature and it feels fine.  It’s the same with pain.  We can start to build our tolerance to performing meaningful activities, which can lead to habituation and less pain.  We know that pain doesn’t always mean damage and that we can gradually “turn down” our response to danger signals from our tissues.

When you have been experiencing pain for a long time it is important to return to physical activity just as it is after a shorter episode of pain.  The progression back to exercise will be slower and there may well be setbacks along the way.  Understanding that this is the case can help to overcome any setbacks.

The Captain (brain) can also send information back down the chain.  She can say it’s okay, we know what those lights are; you don’t need to worry about them anymore – the danger has passed.

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Abdominal exercises sitting and using lunge sequences

07 Nov 2017

Abdominal exercises performed upright and in our normal relationship to gravity have better carryover to daily activities like lifting children into car seats (one of my own personal training objectives!).  I show a couple of examples here from which you can extrapolate.  The possibilities are, of course, endless.

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Understanding Pain – part 3: why load is good

18 Oct 2017

56-yo-lifting-weights-and-trying-to-lose-fat-weight-lifting-q-and-a

The majority of patients I see in clinic have non-specific pain, that is, it cannot be attributed to a specific pathology like a fracture, tear, or sprain.  Nevertheless, the pain alarm has been triggered indicating that action needs to be taken.

It can feel like a joint is out of place, but we know that most joints don’t go out of place unless there is significant trauma.  It’s more accurate to think of the body in its current state as being unable to find a solution to performing a particular movement.

The purpose of what I do as an osteopath/movement therapist is to enable the body to find a solution by giving it more movement options; to allow it to take another path; a path that doesn’t keep using the same fatigued, sensitised, and sometimes degenerate tissue.

A way of making that process more effective is to work with the body upright and moving, and, provided the area in question isn’t too painful, to start applying load (resistance) to the painful area at an early stage.

Load could mean use of a weight or resistance band, but could equally be a step, lunge, jump, squat (lower body) or a push-up (upper body), which make use of gravity and ground reaction force acting on the mass of the body.

What does load do?  In a nutshell it accelerates an adaptive process within the body.  What do I mean by adaptive process?

In simple terms, I mean tissues like muscles and tendon become stronger; new healthy tissue gets laid down around the damaged or degenerate tissue.

Our nervous system adapts and learns to coordinate movements differently, and with greater speed and efficiency.

But there is a further benefit.  You are able to lift weight or bend with weights.  You might still experience a little pain, perhaps no pain.  You don’t just feel stronger physically, you feel stronger mentally.  You have less of a sense of vulnerability, less fear, less need for your protective mechanism.

You have less pain!

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Understanding Pain – Part 2: Pain doesn’t mean damage

28 Sep 2017

pain

A few facts about damage and pain:

  • 96% of athletes younger than 22 will show changes on an MRI that some people call “abnormal”. But since everyone has them how “abnormal” can they be? (Rajaswaran 2014)
  • 37% of 20 year olds with NO PAIN have disc degeneration in their spine (Brinjikji 2015)
  • 57% of 20-50 year olds with no hip pain will have cartilage and ligament tears (Tresch 2016)

Source: Pain Guidebook – Greg Lehman

Key message 1: pain does not mean damage

Key message 2: damage shown on scan results does not necessarily mean it is the source of your pain.

Key message 3: pain is multidimensional; it is an output of the brain in response to a whole range of inputs not just relating to pain receptors but also to sleep, anxiety, fear, beliefs and so on.

Damage is poorly correlated to pain.  You can have damage – it might show clearly on a scan – and not have pain.  Conversely you can be in pain, without there being any tissue damage.  You can, of course, have damage and have pain  – think fractured bone, sprained ankle –  though not necessarily so.

The concept of pain without damage is perhaps a surprising one.  In  what circumstances might we have pain without damage?  In circumstances in which the brain perceives sufficient threat to the body to trigger the pain alarm.

And for good reason.  There may well be an issue of tissues becoming overloaded: perhaps you have not built up sufficient capacity (flexibility, strength, coordination) to undertake the activity  you are engaging in.

Perhaps you have a limitation elsewhere in the body that is restricting another part’s ability to find movement solutions e.g., make small changes in position during prolonged periods of sitting,  or load the lower extremity efficiently during running/walking.

But remember, the pain response is also multi-dimensional. So it may be an increase in stress, anxiety, or lack of sleep that lowers the threshold at which the brain triggers the pain alarm.

Key message 1: pain does not mean damage

Key message 2: damage shown on scan results does not necessarily mean it is the source of your pain.

Key message 3: pain is multidimensional; it is an output of the brain in response to a whole range of inputs not just relating to pain receptors but also to sleep, anxiety, fear, beliefs and so on.

Implications:

  • An MRI scan showing a bulging disc, or tendinopathy doesn’t mean you are destined to be in pain or that you will damage yourself further by continuing to move or exercise.
  • Get moving as best you can; you won’t damage yourself and it’s okay to feel some pain, though be careful not to push through pain too much, especially if doing so makes it worse – this can cause you to become more sensitised ( a delicate path to be trodden sometimes).
  • Try to self-audit and deal with those areas that may be contributing to your pain – stress, fear, sleep.
  • You are adaptable and can overcome pain. (More about adaptability in the next newsletter)

 

 

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Understanding Pain – Part 1: The Process of Pain

19 Sep 2017

If we want to understand how best to treat and rehabilitate ourselves after an episode of pain then it helps to have an understanding of the mechanism of pain, the things that influence it, and the circumstances which might give rise to it.

To understand anything about pain you need first to understand the process of pain. In this short series on the subject of pain I’ve re-worked content from “Pain Guidebook” – a free downloadable resource produced by Canadian physiotherapist, researcher, and educator Greg Lehman (http://www.greglehman.ca/) –   in order to deliver a few bite-size explanations about different aspects of pain science.  The guidebook makes use of analogies that make the mechanism of pain easy to understand.

Key messages 1: Pain is an output of the brain and is multi-factorial; it is affected by more than just body tissues (though they remain important).  Our emotions, beliefs and attitudes, stress levels, sleep, all affect pain.

Key message 2: We can become “sensitised to pain”.  That is, the response to pain sensors being triggered can be “turned-up” or “turned-down” by other factors – expectations, past experiences, beliefs etc. (This can lead to persistent pain)

and perhaps the most significant message:

Key message 3: You can have pain without damage. (subject of next blog entry)

Implication for rehabilitation: We have many ways of coming at pain and need to consider what other factors may be influencing our pain response.  Understanding the mechanism of pain can help us get back to meaningful activity, exercise, and worry less about experiencing pain (pain doesn’t necessarily mean damage).

Pain can be described as: “an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage”

 

The process of pain – nociceptors

Sensors called nociceptors get triggered by a noxious (unpleasant) stimuli and send a message to the spinal cord.

Nociceptors are like the look-out on a ship. They report when they see something. They don’t always care if it’s a massive ship or some small dingy. The look-out just says that there is a light off in the distance and sends that information on to someone else – let’s say the first mate (which can be thought of as the spinal cord).

The first mate can has to make a decision whether this information is important enough to send up to the Captain (brain) or whether to just ignore it.

If the light gets reported to the Captain then he decides whether to ignore it or whether to sound an alarm and trigger a change of course.

The Captain’s response (like the brain’s) will be influenced by many factors – where the ship is, what has being happening in the past, and insight from other officers. The brain works the same way. Expectations, past experiences, beliefs, attitude and emotions can all influence how much or whether you have pain. This is why for the same information (e.g. same nociception) you can have vastly different pain responses.

But let’s go back to the first mate (spinal cord level) His decision will depend on a lot of factors. If the Captain previously told the first mate that there might be some issues with Pirates in the area you bet that the first mate will send that information to the Captain and the Situation Room. If the first mate is nervous, ignored something in the past and got in trouble, that first mate will probably be sending on more information.

Nociception works the same way. Based on descending (instructions from the brain) inhibition (turning down) or facilitation (turning up) from the brain the spinal cord can alter its sensitivity and alter how much signal gets sent up to the brain.

The brain doesn’t just produce pain just like the Captain won’t just sound an alarm. The Captain will do other things as well. There are a bunch of decisions to make and all are meant to help protect. Pain can occur but so can muscle tightness, releasing of different chemicals or a stress reaction.

Any information that convinces you and your brain that you might need protection or that increases your danger alarm can contribute to your pain. This is why we say pain is more about sensitivity than damage. Yes, damage can certainly be a factor in pain but it is not the only factor. And you don’t need damage to have ongoing pain. You and your nervous system can become sensitized. And this sensitivity can come from a number of areas in your life. Depression, anxiety, rumination, fear of movement, a low sense of control, the loss of meaningful activites or poor coping strategies are factors that might influence your sensitivity and ongoing pain.

Key messages 1: Pain is an output of the brain and is multi-factorial; it is affected by more than just body tissues (though these are of course factors).  Our emotions, beliefs and attitudes, stress levels, sleep, all affect pain.

Key message 2: We can become “sensitised to pain”.  That is, the response to pain sensors being triggered can be “turned-up” or “turned-down” by other factors – expectations, past experiences, beliefs etc. (This can lead to persistent pain)

And perhaps the most significant message:

Key message 3: You can have pain without damage.

The next blog entry will delve deeper into the poor correlation between pain and damage.

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A shoulder problem that started at the foot

22 Feb 2017

My sister asked me to take a look at my 12 year old niece Grace at the weekend, as she was worried about a lump on her shoulder (she also has left knee pain). 

The lump turned out to be her collar bone, which was more pronounced on the left due to compensations occurring through her body because of an unstable left foot. The photo below shows the position of the foot, though it is really how the foot is functioning that is the problem.

The foot has also caused limitation of her left hip as the big muscles of the hip attempt to control it.  Her knee, caught in the middle, is taking the hit.

“She’s all wonky” exclaimed my sister before instructing her daughter to stand up straight and roll her foot out. “I think that’s what Katie has” said my mum “She’s getting insoles”.

I was struck by how little my family know about my professional beliefs and the principles by which I am guided – drawing on success; highlighting the positive; the body’s immense intelligence and ability to adapt and take a different path; the subconscious nature of movement and need to re-pattern movement without too much conscious thought on the part of the patient. 

As soon as Grace takes a step, gravity, ground reaction force, and the mass and momentum of the body will drive the foot and conscious attempts at controlling the motion will at best fail and at worst cause a problem elsewhere.

So we have commenced functional exercises directed at stabilising the foot and reversing the compensations in the hip and trunk. 

No conscious holding of a position, no insoles (unless we find we need them), just the use of the principles of movement to direct the body to take a new path.

Grace's feet and ankles; the left ankle/foot rolls inwards

Grace’s feet and ankles; the left ankle/foot rolls inwards

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