Pleasant does not equate to Effective

Some very pertinent meanderings of Paul Ingraham of

“Essentially every pleasant sensation and experience has therapeutic qualities. These therapeutic qualities are not unimportant, but they’re not the same thing as an effective therapy. There’s a good reason why your physical therapist never prescribes ice cream. Here’s the last big stretching mystery I’d like to cover: how can stretching be so pleasant without (apparently) doing much measurable good? Look at this pattern:

  • Stretching feels great … but it’s over-rated and nowhere near as medically or athletically useful as most people think.
  • Massage feels even better … but its effects on pain are notoriously mild and fleeting.
  • Chiropractic “adjustments” can feel scrumptious, even addictive, especially in that cinder-block-rigid area between the shoulder blades … but in most cases you’ll be craving a re-do before long (which makes for a lovely business model for chiropractors).

The pattern is that of being “relieved” instead of “fixed.” Over many years of thinking about pain and therapy, it has been a stubborn mystery to me why these things can feel so good — really, really good — without making any large or lasting difference to most painful problems, most of the time.

Feeling good without working all that well causes no end of confusion and trouble. The wonderful sensations are largely responsible for an endless epidemic of excessive optimismabout their healing powers. It’s completely understandable that we would expect something that feels that good to work well, but a lot of testing has shown over and over again that stretching, massage and chiropractic are not exactly saving the world from its aches and pains.”

Monica Noy – Recognizing Changes in Pain Science

Cognitive dissonance in osteopathy explained by Osteopath Monica Noy.  Very well written.  Note what she concludes at the end.  Modesty and honesty needed.

“For instance, a patient comes to see an osteopathic manual therapist who has only rudimentary knowledge of psychology and neuroscience. The primary complaint is low back pain that has no known mechanism of injury and for which there are no findings on either MRI or x-ray. The patient receives assessment and treatment according to whatever protocol the therapist has been trained to apply. The patient leaves the treatment session with no perception of back pain. The therapist is asked to provide an explanation for what happened and does so by revealing their interpretation of what they felt under their hands – a temporal bone in external rotation, a compacted SBS, a sacrum with little to no vitality that is in torsion, an internally rotated small intestine – then describes their treatment and normalization of the lesioned structures. The therapist believes that along with pain relief, the patient has also undergone anatomical and physiological changes that in turn liberate “an area of the body, whose release then provides a cascading effect of other releases throughout the body.”

Unknown to both patient and therapist their interaction is observed by a psychologist who knows nothing of osteopathic therapy. She observes the patient is lying down comfortably and appears relaxed, the room is dim and quiet. She observes the therapist first talk to and then touch the patient in various places; the head, the abdomen, the pelvis. The patient appears to be relaxed by the touch. At the head, the abdomen and the pelvis the touch is slow and sustained and gentle. Other motions applied to the patient are rhythmic and oscillatory. The psychologist offers a possible explanation of the outcome with relation to the psychosocial interpretation of belief, touch and caring that the patient is receiving.

Unknown to both patient and therapist their interaction is observed by a neuroscientist who knows nothing of osteopathic therapy. The neuroscientist offers a possible explanation of the outcome with relation to the patient’s neurological sensors in skin, muscle and joints that are activated by touch and motion and provide a sensory stimulation to the brain that may help to down-regulate the prior neurological input that may have resulted in the perception of pain.

Three different interpretations exist at the same and there are undoubtedly more. With just these examples the question is not which interpretation is correct, but which type of interpretation is likely to be less wrong.

You have an osteopathic explanation that relies on improbable levels of palpation interpretation without being able to establish reliability even with a not-insignificant amount of research, versus explanations that are science-based. Though these explanations may not have specific manual research studies behind them, they are supported by known science that can help to explain how neurophysiological or psychosocial factors may play a part in decreasing pain perception related to touch and context.

These less wrong explanations do not make osteopathic treatment or outcome cease to exist, but they do insist it start to tell a different story, one that makes it more modest, more honest and more flexible.”

Historical Perspective on Posture

Excellent piece regarding the history of posture by Matthew Danzinger: Historical Perspective on Posture

“Those with traditional values sought to counteract the growing trend toward relaxed postures in the late 1800’s, citing ramifications on health and morals as cause for concerns. Doctors and etiquette manuals blamed modern civilization, the need to sit in schools, and social habits for the decline of strict postural habits, and gave detailed instructions for proper behavior in sitting and standing. These guidelines were prominently featured in manuals for raising children, where exercise and postural education was heavily stressed.

Many in the medical establishment warned parents about the consequences of poor posture in children, incorrectly believing that relaxed posture would lead to spinal deformities and the organs to move or become compressed against each other thus impeding function. Many doctors also warned about the nebulous concept of the moral consequences posture would have on the body.

Perhaps because doctors through much of the 19th century were quick to blame the extended periods children spent seated in schools, school physical education programs developed around postural education and training around the same time. Physical education teachers developed a wide variety of tests and treatments for postural problems, including enforcement of habits, exercises, and new furniture designs. These programs were chiefly focused on posture as a reflection of moral character, physical fitness, and even personality. Students would be graded according to these standards and would be shamed if they were found to fall outside the preconceived ideals.

While postural training programs were present in many school settings, they were the most rigorous in the Ivy League universities and similar schools that were generally regarded as the more elite and exclusive institutions. From the late 1800’s to as far as the 1960’s, a great deal of these schools took photographs of each student in varying states of undress upon their admission. Some of these schools would go as far as to reject students if they found their posture (or any other element of their physical condition) lacking. Training programs varied from specific exercises to more general fitness and awareness campaigns, which generally focused on women over men.”

Preventative Health: Multifactorial

Health Promotion: the process of enabling people to increase control over, and to improve their health.

Disease prevention: covers measures not only to prevent the occurrence of disease, such as risk factor reduction, but also to arrest its progress and reduce its consequences once established.

Determinants of health: Personal, Social, Economic, Environmental.

Factors in Pain Regulation

“If your hand hurts, and you look at it through a magnifying glass, it hurts more… It’s a ‘pain’ equivalent of an optical illusion.  A strange experience that demonstrates that the brain is constantly tinkering with our painful sensations” – Paul Ingraham

Taken from an interview @:

Practical Ways to Turn Down Pain Sensitisation

Posture: Not that Important

It has been posited that the shoulder forward position (as demonstrated in the far-right image), is implicated in subacromial impingement, however new evidence suggests that perhaps this is not the case.

sway back

Nxt Gen PT Evidence: While it has been suggested that dysfunctional posture of the scapula, thoracic spine, and cervical spine is associated with the development of subacromial impingement syndrome (SIS), what does the evidence tell us? Well a recent narrative review performed by Nxt Gen Adjunct Faculty, Dr. Adam Rufa, found a lack of strong evidence to support an association between posture and SIS. The evidence examining this association is plagued by poorly defined diagnostic criteria, wide sample variation, and poor statistical power.

Clinical Implications: While many of us focus on assessment and correction of posture in patients with SIS, evidence for a relationship is quite poor. Focusing on reducing pain, and progressing with movements important to that patient, is potentially a more plausible progression of treatment.

Better Your Practice: You can probably focus less on posture when treating patients with confirmed SIS. That stated, there are many things we can do such as understanding that patients symptoms, and how they move, and intervene accordingly.

Rufa A. Subacromial Impingement and Posture. Phys Therapy Reviews. 2014; 19: 338-351.

Core Strength – A Popular Myth

Pain Science is evolving.  The belief in the importance of core strength for reducing back pain is mainstream, and it will probably take 15 years or more for these new and more correct ideas to become mainstream.

“The popularity of core stability training is based on the following assumptions (taken directly from Lederman 1):

  • That certain muscles are more important for stabilisation of the spine, in particular transverses abdominis (TrA).
  • That weak abdominal muscles lead to back pain.
  • That strengthening abdominal or trunk muscles can reduce back pain.
  • That there is a unique group of “core” muscles working independently of other 
trunk muscles.
  • That a strong core will prevent injury.
  • That there is a relationship between stability and back pain.

Admittedly, these assumptions pass the “it sounds right” test for someone who isn’t up to date with the pain literature. But “it sounds right” is far from a scientific basis and as a proponent of evidence based practice, I prefer to make clinical decisions based on the best available evidence. In the case of low back pain and core stability, we have a good deal of scientific evidence that we can consult for answers. The literature suggests the following (taken directly from Lederman 1):

  • Weak trunk muscles, weak abdominals and imbalances between trunk muscles groups are not pathological, just a normal variation.
  • The division of the trunk into core and global muscle system is a reductionist fantasy, which serves only to promote CS.
  • Weak or dysfunctional abdominal muscles will not lead to back pain.
  • Tensing the trunk muscles is unlikely to provide any protection against back pain or reduce the recurrence of back pain.
  • Core stability exercises are no more effective than, and will not prevent injury more than, any other forms of exercise.
  • Core stability exercises are no better than other forms of exercise in reducing chronic lower back pain.
  • Any therapeutic influence is related to the exercise effects rather than CS issues.
  • There may be potential danger of damaging the spine with continuous tensing of the trunk muscles during daily and sports activities.
  • Patients who have been trained to use complex abdominal hollowing and bracing maneuvers should be discouraged from using them.

In short, the assumptions that core stability reasoning are built upon are no longer tenable. The evidence clearly demonstrates that core stability as a single solution to low back pain is no more than a reductionist fantasy. If a thorough review of the literature on the topic is desired, the reader is encouraged to read Lederman’s well referenced paper The Myth of Core Stability 1.”


Pain and Inflammation

Inflammation is the natural response to damage.  When tissue is damaged, like when you’re breaking down muscle in a workout, you’ll get the “cardinal signs of inflammation” or S.H.A.R.P. (swelling, heat, altered function, redness and pain).  This is totally natural.  In fact, the body must undergo inflammatory processes in order to repair and get stronger.

Scenario A: Let’s say we do some exercises like dumbbell rows, ring rows etc. that break down some of your back muscles.  You’ll get an immediate inflammatory response after the workout, in those muscles, which might include pain.  Will icing the lats+rhomboids reduce inflammation?  Yes, it will, but we actually want inflammation at this point, for repair purposes.  Scenario B: It’s 2 or 3 days after our workout, and your back muscles are still sore.  The muscles have not fully healed.  The inflammatory and repair processes have not been adequate (or still need more time due to a large amount of tissue insult), due to any number of factors (age, nutrition, sleep, overtraining etc.).  Heat is what you would want in this situation, to actually promote blood flow to the muscles, thereby promoting healing + accelerating inflammation.  Cold/ice will actually suppress blood flow, and thereby slow the healing process.

So, when should ice/cold be used?  A. For acute pain, when you want relief from pain that comes along with inflammation.  B.  There is something referred to as “flushing” in which one will apply cold for a short duration, following by heat for a short duration, for multiple cycles – the theory being that it causes a net increase or “flushing” of blood within the area.  Otherwise, cold on it’s OWN, will simply reduce inflammation and blood flow.