So, you've hurt your back . . .
(Superhero picture source)
It turns out my osteopathic superpowers have failed to prevent me from another episode of low back pain (1). While frustrating, it is a useful lesson in learning to practise what I preach when it comes to minor injuries. This is a short post which I will elaborate on in more detail over the next few weeks.
You’ve just hurt yourself, what next?
If you are worried or concerned, get it checked out; if your back or whatever else ‘just doesn’t feel right’ or you are getting odd symptoms, go and see someone.
The approach I am about to outline won’t work for everything or everyone and is not intended to replace a consultation from a registered healthcare professional.
Essentially, the approach boils down to:
exercise and education.
In a little more detail:
Once more. This time with feeling.
Most musculo-skeletal injuries get better on their own. They just need time, the right beliefs, information and appropriate loading. Some problems need a more involved approach, which may occasionally involve drugs or surgery. However, for ‘minor’ issues, the advice I give out usually revolves around the following points.
Most people know this one.
Read this by Tom Goom for a more up-to-date take on this. (Yup, him again. There’a a reason he and his buddy Adam Meakins keep cropping up in my posts).
The ‘R’ in R.I.C.E. means relative rest not total rest. The body needs rest to heal but it also needs movement. Keep as active as you can. Within sensible, tolerable limits, activity will encourage healing. Go for a walk, stand up, do a little shuffle in your chair if you’re sitting down while reading this post. Don’t go crazy but do something.
It’s useful to think of the pain on a scale of 0 - 10: from no pain to the worst possible pain in the world.
If you’re at the bottom end, i.e. 1, 2 or maybe 3, that’s ok (as long as the condition doesn’t get worse and any worsening of pain is temporary). If you start pushing into 4 and over, I would be more careful and back off from whatever you’re doing. Pain doesn’t always mean you’re doing damage but it is not something I encourage people to ‘embrace too warmly’, particularly in acute conditions.
Why does it hurt?
Our understanding of pain is changing. Understanding WHY and HOW something may hurt could help with long-term resolution of the pain. Pain is a warning signal from the brain that something maybe amiss. I have touched on this briefly here and there are several links in that blog post to some excellent resources. For the time being, watch this and this. Download this by Greg Lehman.
Mobility rather than stretching
Stretching is not a bad thing. However, I don’t generally advise sustained, passive stretching for a sore joint, muscle or nerve. This can also apply to chronic conditions but is most relevant for acute presentations. If you really, really, really want to do some stretching, think mobility. Go gently into a position and come out of it straight away. This way you get the benefits of movement without the possible side-effects of stretching.
What side effects?
If you have an acute muscle or ligament strain/ sprain, the fibres need time to knit together. Stretching (or any kind of excessive loading) is not going to allow that.
Acute tendonopathies (a more up-to-date term for tendonitis) do not respond well to stretch. I tried it - to make sure. It didn’t work, it hurt (I know this is n=1, anecdotal, bottom-of-the-heap evidence).
Nerves have around a 4% tolerance to stretch. They don’t like being pulled around too much, especially when sensitised.
Showers rather than baths
Sometimes a ‘good soak’ can help acute issues. Sometimes it makes them worse. Why? Heat can help muscle spasms but it can aggravate inflammation. Inflammation, combined with a lack of movement, possibly in a slightly stretched position (such as lying in a bath) is not always the best thing to do in acutely painful situations.
Showers give you the benefit of the heat and minimise the risk of the other potential problems.
Hot baths (as with stretching etc.) are not a bad thing to do, they are just not always the panacea that some people make them out to be.
A ‘no-brainer’ that gets overlooked by some. There appears to be a macho element to how little sleep we can get away with these days. Wide-eyed people, fueled by energy drinks, stomp along streets clutching ever-larger cups of take-away coffee. Stop it. Go to bed. Sleep. Your body and your brain will thank you for it in the morning.
Use the time off to work out what may have happened. Learn from the injury so you are less likely to experience the same thing again. You don’t have to do this straight away, a break is good. Don’t over-analyse things either (note to self!). Instead, use the time positively to see if you can change/ tweak/ modify your training/life to reduce the chances of another episode recurring.
Respect the pain but don’t fear it
Don’t avoid positions or activities, modify them so they are relatively pain-free. For instance, replacing round-back forward bends with flat-back forward bends is fine as a short term strategy if it helps with the pain. However, you need to work to try and regain the ability of pain-free round-back bending when possible. Otherwise, you run the risk of your ‘emergency pattern’ becoming your ‘default pattern’. This can lead to developing an increasing intolerance (both physical and psychological) to the initial ’problem movement’.
A slow return to play
This ties in with the previous point. When things start easing up, consider a SLOW, PROGRESSIVE return to the same thing you were doing when you hurt yourself (read this for more detail). For example:
Movement and understanding
Various things drive tissue healing and musculo-skeletal health: beliefs, tissue loading, diet, genetics, sleep, drugs etc. Some of these we have more control over than others. It’s more productive to concentrate on those that we have more chance of affecting rather than those we can’t.
My short post ended up a little lengthier than I anticipated. I will go into more detail about some of the above in the near future but you have an idea of my approach to minor injury management.
So, the next time you hurt yourself . . .
(WARNING: SOUND BITE ALERT!)
Keep it simple:
eat, sleep, move, laugh & love.
Usually, that’s all you need.
Thanks for reading,
(1) 'Snatch-back'. I can just about deadlift 1.75% my own body weight and can press just over 50% b/w (I know, I know, I'm working on it . . .). I thought I should be able to snatch an empty barbell. Apparently not. A useful lesson that sends me back to the drawing board. Again. My pride hurts as much as my back does.
(2) Patterns of movement, as with posture, are poorly correlated with pain. There is so much variety to pain-free movement; it is not always reliable to state that a certain way of moving is problematic. When that movement is loaded/ weight-bearing/ explosive, I would be more inclined to go with the ‘industry-standard way of moving’. This also seems to vary depending on which expert is talking.
(3) I’m not talking about the number of limbs and heads we have, that’s usually a given. I’m referring to the ‘internal’ anatomy, the lumps, bumps and bits that are not as obvious. We all look different on the outside, why should we all look the same on the inside?
Just squat, bro'.
I have read and heard a lot over the last six months or so about running being bad for you (1). It supposedly wears out the joints, destroys your knees, causes muscle catabolism, physical armageddon etc. This is as opposed to squats, hinging patterns (i.e. deadlifts), pulling exercises and being able to resist rotation, which are all 'primal/ fundamental/ essential' movement patterns (or whatever the latest buzz word is) (2).
Don't get me wrong, I am not against squatting, deadlifting etc. Competence in these movements is highly beneficial (3), and would help us all to some degree or another:
Now, let’s look at:
Stop using extreme examples to demonise normal behaviour
Weight, distance, speed etc. are all relative to the individual. Being able to squat the equivalent of a small family car (complete with wet dog in the boot) isn't always good for you, unless you've trained for it. Similarly, running isn't always the 'best' exercise for everyone all the time. It depends on the individual at that moment, their training history, physical status, wants, needs and all the other biopsychosocial factors at play (see an earlier post of mine for a brief intro on this).
We’ve all seen the obligatory train-crash videos on the internet of someone missing a squat and hurting themselves, or running and pulling up short with an injury. Does this, therefore, invalidate all types of squats and running for everyone?
Sometimes, it may be advisable not to run (or squat) for a while or at least balance it with something to complement it. Occasionally, running or squatting may be contraindicated. But generally, most people should be able to do some kind of exercise (4).
picture courtesy of @AdamMeakins. The Sports Physio.
Exercise choices are not always 'either/or'
Not every exercise is suitable for everyone at all times, but not many exercises are inherently 'bad'. I sometimes wonder why people sit on opposite sides of the fence throwing hyperbole at each other to see what sticks. Are they doing it:
Heard of the nocebo effect?
Such attitudes can do more harm than good. They help fuel the ‘don’t-do-this-or-else’ approach to treatment/ exercise/ life that seems common these days. This holds people back when we should be empowering them.
You’re crazy! You're saying I should make my granny run a marathon.
It depends, I haven’t met your granny. But that kind of statement is typical of many discussions these days; hearing what you want to hear and distorting the facts to suit you. It is something best left in the playground but now seems the front line tactic of choice in many quarters, especially those in a position of (perceived) authority and with vested interests.
My son’s granny is almost 70 and planning a tough mudder next year to celebrate, having raced her first at the age of 68. One of my fathers-in-law (it's complicated) is just past 70 and can’t walk any reasonable distance, but is fine on his bike. Which one of these am I going to encourage to run? Which one will I suggest to maybe just stick to cycling for now? Would I advise either of them to squat? Probably, yes. But only if they wanted to and then well within their physical capabilities (see this on exercise 'dosing' and this earlier post of mine on exercise and my unscientific take on 'slow' progress).
And then you could look at this 95 year old who only started exercising at around 60 and broke the 200m world record in early 2015. Maybe he is a ‘genetic outlier’ who can tolerate this naturally. Maybe we should not look for excuses for our behaviour, and congratulate him on his.
The choice, execution and grading of any exercise needs to be taken on an individual basis. High diving with a grade 3 spondylolisthesis would probably take a lot of positive thought to deal with. Sprinting shortly after a recent hamstring tear and maximal squats on an acute disc would also not be my first choice of intervention.
Instead of jumping on the latest bash-the-exercise bandwagon and prescribing everyone several sets of 'brace and tuck, pull back and down and NEVER-FLEX-YOUR-SPINE!’ (5), why don't we celebrate the fact that someone wants to exercise? Why don’t we work with them to achieve it where possible, even if it is running. Besides, if our ancestors hadn't been able to run, I suspect many of you wouldn't be here today reading this post.
"Hey look, a lion/ enemy soldier/ live volcano!”
"Just squat, bro', that's all you need.'"
Thanks for reading.
(1) Which type of running do they mean? Jogging? Trail running? Marathons? Sprinting? Middle distance? Treadmill? Hills? Barefoot? Extreme? Or are they lumping all 'running' into one heap just as some endurance athletes appear to do with anything involving any kind of dumbbell or barbell?
(2) I feel I should mention how much I love deadlifts at this point just to get my 'man card' validated. That seems to be how this kind of post usually runs. I do. I love deadlifts and squats, I'm just not particularly good at them. Yet.
(3) Exactly how we do these is material for another post. Briefly, I think that unloaded movements have a lot more biomechanical give and take than loaded movements.
(4) Even if it's Crossfit or prancercise. I admit to struggling with one of these, but that's my issue.
(5) If we should never flex our spines, why do we have joints in the spine? Yes, flexing the spine (or any joint) and loading it beyond what it can tolerate is a problem. However, flexion or any other vectors are not problems (neither is sitting, but let’s not go there today…).
(6) There are various people you can look at for all things squat/ lifting related. Try these for a varied approach: Bret Contreras, Tony Gentilcore, Ben Bruno, Eric Cressey, Mark Rippetoe, Jim Wendler and Mike Robertson (Some are more old-school, others more evidence based, all have something to offer). As regards running, check out Mr Tom Goom aka The Running Physio (Mr Goom, if you're reading this, apologies for spelling your name wrong in my previous post).
(This post was first published on my other website.)
In my other life I’m an osteopath (think badly dressed chiropractor). I regularly see people with bad backs (1). In the book Lieutenant Franklin hurts his back (have I mentioned recently I’ve written a book?).
Before you read on, please be aware that this is more of an opinion piece on pain science rather than a fully referenced document. It's also longer than the previous blogs. It does tie in with Lieutenant Franklin, Dr. Swann and the other characters and it doesn’t take a huge leap to see why pain science became part of the plot.
What would happen if a government treated anything non-scientific like alcohol in 1920’s America?
I’ve tried to explore this idea in the story. I've also attempted to present some current concepts about pain without being too preachy, heavy-handed or 'ranty'. Given that pain is a great leveler, I think it's useful if people in pain have an idea of what may be happening. I don't believe I've detracted from the plot too much but I’ve pulled into the mix some concepts in manual therapy which are now being challenged. Keeping it simple, they essentially they boil down to:
In the red corner ("You shouldn't use that colour, it's inflammatory and associated with danger. You're influencing your reader already.")
In the blue corner (I think you can guess by now which model I prefer).
Some of the above may be dismissed as semantics but language is important (says the man trying to write a book). In my next post I'll teach your grandmother how to suck eggs (see this by Matt Low and this by Martin Bonnevie-Svendsen on Adam Meakins' Sports Physio site on the role of language in therapy).
Our knowledge and assumptions need to be challenged.
There are a lot of grey areas in therapy which are sometimes glossed over or avoided by practitioners. This can be for various reasons, some more benign than others. I don’t think there are many therapists deliberately setting out to mislead patients (though I have met a few I wonder about) but I think there are questions that need to be asked.
Is 'experience' a synonym for 'bias'?
Facing up to questions is not always easy when your career has been built upon a certain set of beliefs, you identify with these beliefs and your income is riding on them. But if you are so insecure that you can't deal with sensible questioning then you need a new job. You could consider becoming a cult leader charging exorbitant fees in pursuit of enlightenment or a guru selling a 'new' treatment or exercise regime (read this by Bret Contreras). We should have moved on from judging a technique's efficacy on its age, how esoteric or holistic it seems, or purely on the basis that the 'father' of the profession had a long white beard. (If that continues, in a few years we'll have health policy being dictated by ageing hipsters. Or Santa).
Massage makes most people feel good
Partly due to the bio-psycho-social model, my thoughts on what I'm actually doing as a therapist have changed over the years. With these changes have come more questions than answers (I'm hoping this is a sign of progress). These views may change again, though it'll be easier for me if they don't.
For the record, I believe that manual therapy is a ‘good thing’. I think it merits a supportive/ adjunctive role in dealing with pain and physical issues. This role still applies even if its efficacy is more due to psychological/ neurological reasons than mechanical. I don’t see this or the placebo effect as negative. The caveat with this is that we need to be honest about what we are doing, what we do and don't know and open about the limitations. Just like with medicines, a short-term dose is usually ok, long-term treatment should be avoided if possible (unless the massage is just for ‘TLC’).
I'm biased. I use manual therapy in my job. I also teach other people ‘how’ to massage. This means I may not be as impartial as I should be when talking about it, no matter how much I try.
For a very accessible intro into the bio-psycho-social model of pain, see these links:
Understanding pain: What to do about it in less than 5 minutes? (An animation).
Why things hurt. (A short, humorous TedX Adelaide talk by Professor Lorimer Moseley).
A blog post by Todd Hargrove.
A free download by Dr. Greg Lehman.
Explain Pain ebook by Lorimer Moseley and David Butler. Not free but HIGHLY RECOMMENDED! (And I hope I haven’t just blatantly plagiarised the book in this blog.)
How does this relate to Lieutenant Franklin, Nascimento, Dr. Swann, Orr and the bone-setter? In a few months I hope you'll be able to find out for yourself. The feedback from beta readers is trickling in and I'm cautiously optimistic.
* * *
(1) Not bad backs, PEOPLE with a bad back. Big difference. Backs, whether ‘bad' or 'good’, usually have a person attached to them and that person has a brain and a nervous system. A person's beliefs and expectations are probably more important in pain management than any physical treatment.
(2) I am by no means an expert in this field but I have had experience of dealing with it from both sides of the fence. Anyone who claims to be an expert deserves a respectful grilling. After all, if they’re an expert they should be able to answer the questions (yet should we trust someone who claims to have all the answers?).
(3) There is also a small section on sitting and posture in the book, which has survived the editing so far. In future I may address this in more detail in a blog. For now I'll simply say that I think a lack of movement is more relevant than sitting itself. When assessed in isolation, 'poor' posture is not the same thing as, nor predictive of, pain. See this by Ped Carnicero (have I got your name right?) and this by Todd Hargrove again.
(4) Pain nerves don’t exist. Nociceptive nerves exist but these are more like ‘possible problem’ nerves ('Apollo 13 nerves') rather than pain nerves. They do not transmit pain, just a warning that something may not be ok. Pain can exist without nociceptive activity.
(5) These are not my descriptions. If anyone can point me in the direction of who said this initially, I will happily reference them.
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The January Gym Syndrome
(This blog first appeared on my other website in January 2015)
The January Gym Syndrome is not just limited to January. It is just when it is most pronounced, unlike ILS or TTSCAAPBOIP Syndromes*, which are more of a warm weather problem. The January Gym Syndrome is a concept I explain to my clients/ patients (depending on your preference for the word) and it is my contribution to the over-medicalisation of our world. Please bear in mind when you read this that:
The January Gym Syndrome
Person X has renewed their annual New Year Resolutions and is determined to get fit. Again. This person goes into the gym on Jan 2nd, still partially hung-over and picks up every weight they can see, even the dusty ones usually reserved for some kind of weird shrugging variation (that is more of a gurning exercise filmed for their mates rather than anything else). As a result they hurt themselves, or are sore for days, or find that they get to mid-February and things aren’t going the way they thought they should. They have stopped losing weight (though numbers on the scales aren’t everything), their deadlift has stalled, their run times aren’t changing, they keep falling off the bosu as they bicep curl in the squat rack and the skinny kid in the baggy t-shirt and mismatched training gear is still warming up with a weight way over their maximum. Slowly but surely the doubt sets in, the injuries mount up or mutate into something more persistent, the enthusiasm wanes and person X quits.
“I tried. It didn’t work. Anyway, I’m too busy with work/ kids/ family and there’s a new film out tonight.”
That is understandable up to a point (see below). Sometimes there is so much going on that something has to give and exercise is often the first to go. We all have different priorities and only you can make that call. I get a little annoyed by the it-only-takes-20-minutes-a-day type posts that swagger around the net which pay no attention to what may be going on in that person's life. Some people are running at full capacity anyway and don’t have another only-20-minutes, parents in particular. The smug posts of buff people posing in yoga pants and tight muscle vests droning on about the stuff on the inside being the most important don’t help things either.
However, if you replace the word 'exercise' with 'movement', things may become easier to achieve. I hope to talk more about this at a later date but there are simple ways of moving more;
All of these can be hugely beneficial and more easy to fit into your day than a 'formal', scheduled session. It's also worth bearing in mind the long-term benefits. Physical activity is well documented as one of the fundamentals of health, including prevention and treatment of more ‘medical’ conditions.e.g.:
Popularity is sometimes confused with efficacy.
It makes sense to try and do something but how do you get started? The obvious thing is to talk to someone;
The last option has its own potential problems; not every expert hiding behind a keyboard is what they seem (the irony of that last statement). Popularity is sometimes confused with efficacy and not every opinion is a fact, a problem rampant in manual therapy. I strongly recommend the above options first if you are new to exercise/ activity but if none of the above appeal to you, aren’t possible or you want to do it alone, then you may want to bear the following in mind.
I appreciate that none of these points are unique or new. The last two have been made much more eloquently by many people, such as Jim Wendler in his strength training manuals 5/3/1 and Beyond 5/3/1, who talks about starting light and making slow progress. Tom Goon (@tomgoon) aka The Running Physio has a very good, detailed post relating to running here. Lifting or running may not be your thing, these are just examples to illustrate my point.
Consider getting some coaching before you start. It doesn't need to be three times a week for ever (similarly you should question a physical therapist if their treatment plan appears to have you coming back once a week or month until the next New Year). It is better to try to learn how to do something right from the outset, rather than wasting time further down the line.
It may also be possible to apply these principles to other areas that often seem to crop up in NY resolutions lists;
A sensible progression appropriate for you.
Some people appear to be able to do the shock tactic and get away with it, others seem to struggle, go cold-turkey and quit. The idea of a slow, sensible progression appropriate for the individual is not new but seems to be lost in a have-every-thing now approach. If you finish frustrated, thinking that you could have done more, the next time you train you can do more. If you finish so sore and beaten up that you can’t sit down for a week, you have blisters, ‘a joint in your neck is in the wrong position and needs putting back**’ or your 'ribus maximus is playing up because of an imbalance in your upper plantaris sling' (more on therapeutic doublespeak at a later date), you may be a little more reluctant to go back and may have also stalled your progress. Hurting yourself or someone else is easy; getting healthier, fitter, stronger or quicker isn’t if you have no idea of what to do other than stretch, stroll on a treadmill, curl, pose and refuel on liquid sugar. Unfortunately, the reams and reams of virtual paper of conflicting advice on the internet don’t make it any easier.
Slow progress is still progress.
Start light, short or slow depending on your activity, take small steps and you can keep going forwards. Surely it is a better mindset to be in - a cycle of positive reinforcement, success breeding success - rather than a boom and bust approach that may only reinforce the idea that you can’t do it. Common sense? Definitely, but sometimes the obvious things need repeating. It is NOT a guaranteed way of avoiding injury; you do stuff, things can happen, but at least it goes someway towards minimising that risk. The alternative of not doing anything is not really a long-term option.
As for what type of exercise you do; that’s a whole other, never-ending post and something that is out of my area (though foolishly, I may attempt it). An important factor to remember is that it has to be fun, or at the very least you don’t mind doing it, something I feel is often overlooked. You can have the best, most expensive program/ plan in the world but if it just sits in your gym bag taunting you from under your shiny new shoes, then it is doing nothing for you except possibly adding another layer of ‘I failed’ to your attitude towards exercise.
I realise that this post leaves out many important issues such as motivation, goals, resources, money, time and has only touched on others e.g. a suitable exercise/ activity for you, how you go about it and the crucial factor of progression. However, what I have attempted to show is one possible solution to a common problem, the January Gym Syndrome.
Moderation is not always a bad thing.
* Tight-t-shirt-cross-arms-and-push-biceps-out-in-photo Syndrome
** It isn’t and doesn’t. Ever. If a joint in your neck is ‘out’ or ‘in the wrong position’ you go to a hospital or a morgue, not a physical therapist.