Pot-Pourri

[marcel]

Squat schallenge:

[thenakedphysio]

After participating in the final 20 miles of a 50 mile trail race without training, (keeping a friend company) the concept of RSI or 'injury' in the absence of trauma is making more sense. And by more sense, I mean, calling it an 'injury' (something Barrett has discussed here before) should be questioned.

I was doing quite well with low grade soreness in the medial aspect of my patella until mile 15. The pain built up to a level where I was incapable of flexing my left knee without laughing. You read that correctly, laughing. As someone that understood there was no trauma or damage to the tissues, I actually found it humorous to experience something so intense, resulting in my walking. I immediately began searching for a movement or position to complete the 20 miles (keeping up with my friend). My running gait must have looked horrible without left knee flexion and scooting along. Just an amazing alarm system performing exactly like it should, to protect me.

I do not or would not see a physician, physical therapist or running 'expert' for this. I was not damage, but I had exceeded my potential and tolerance. My system was simply protecting me. I was able to override for the last 5 miles, but had I not understood it, it would has stopped me for good, most likely resulting in me seeking medical attention for something perfectly normal.

As a result, today I am experiencing allodynia (normal), hyperalgesia (normal) and continuing to hunt for movements that are tolerable (walking with toe out on the left and one stair at a time).

As Kyle alluded to via Jason S, it's important for us to experience these things once in a while.

Been reading your post Johnny and I share your thoughts about pain and manual therapy, However why can't it be used as an active treatment to encourage someone to get moving again. Now I understand there are many implications to the idea of MT use. This is where our clinical reasoning comes in. Can't we use 'hands on' treatment to calm someone down? Perhaps we need to stop thinking so structurally about what we are doing with our hands and think about what we are doing physiologically?

There could be so many different possible reasons for someone to experience pain at any one time. What are your thoughts on the idea that having a better understanding of the processes of the factors that feed into a pain experience may help an individual learn to (as you express) 'cope' better? We as clinicians are not expected to solve peoples problems, we are here to facilitate a persons understanding. This is my opinion of course.

I have always had a major issue with the idea of fixing, repairing, removing, injecting as this gives a false sense of expectation of the human body, that we think our resilience is lower than it actually is, (although this is highly variable depending on genetics, health status etc) hence we feel compelled to handover our locus of control (some are more willing than others and some people need to - heart surgery for example), that we need to break habits and adopt new ones. Human beings are influenced by so many factors, it's extremely confusing for people as well as for clinicians. So people will make decisions based upon numerous amounts of information and if one of those pieces of information (physical, verbal, environmental, interventional) works then that person will have a stronger sense of attraction towards that (if MT is that thing then I don't see a reason not to provide it, however there are implications that I take into account with that too).

As for your 50mile trail race, I too experiences the same knee pain but laterally. Now I could have gone down the whole tissue structure and biomechanics route and gone oh my ITB is tight, I have poor firing hip abductors and I need to strengthen my quads and probably need some orthotics. However I saw it from a physiological resilience perspective. Not trained enough, allostatic load, hydration levels, tissue tolerance. I trained for a year to do a marathon and I still wasn't ready. So expectations also have something to do with this.

I wasn't going to say it but I will, keep your chin up! It's hard work being a health professional and if you really wanted to keep things simple for yourself you could adopt a permanent technical rational viewpoint and stay within the boundaries of your beliefs and biases. You would probably earn a tidy little sum. I suspect though that being on somasimple you have questions like we all do.

Cheers

Paul

[Johnny_Nada]

Well done Adam..

http://bjsm.bmj.com/content/49/6/348.full.pdf

[Barrett Dorko]

Paul,

You did what I have suggested be done in the face of countercultural movement - you laughed.

Not always the most convenient thing to do, but we all suffer at times, and we're all human.

You've understood something said by Butler long ago, "We treat physiology, not anatomy." This involves understanding something invisible to the naked eye, extending our senses and ideas which can be defended - until that defense is defeated.

An excellent job.

[proud]

Well done Adam..

http://bjsm.bmj.com/content/49/6/348.full.pdf

I mean really...that is where the evidence leads us.

To me, this whole dry needling phenomenon can be credited to an over-exuberance on our part to appear "highly skilled".

In my opinion, the irony to that is if you are utilizing it then the key "skill" that is lacking is critical thinking.

We do not know if trigger points exist, if they are clinically relevant or of they respond in any meaningful way to the actual practice of needling them.

It's literally a stab in the dark. So how would one justify performing such an invasive procedure then?

[Johnny_Nada]

Been reading your post Johnny and I share your thoughts about pain and manual therapy, However why can't it be used as an active treatment to encourage someone to get moving again.

I use it that way on a daily basis: handshake, palpation, touch, re-assurance. Simple without the non-sense.

Can't we use 'hands on' treatment to calm someone down?

Yup: handshake, palpation, touch, re-assurance. Simple without the non-sense

Perhaps we need to stop thinking so structurally about what we are doing with our hands and think about what we are doing physiologically?

I hope I didn't suggest I think structurally with regard to using my hands. I'm quite the opposite.

What are your thoughts on the idea that having a better understanding of the processes of the factors that feed into a pain experience may help an individual learn to (as you express) 'cope' better?

I think understanding a painful condition can have a positive impact on one's coping, self management, pain, etc

I wasn't going to say it but I will, keep your chin up! I suspect though that being on somasimple you have questions like we all do.

I question myself daily. Many of those questions I discuss here.

[Johnny_Nada]

Hypothesis:

The more science we have about low back pain, the closer we are to third party payors not paying. People will make money on a boutique-like clinic, giving people what they "want" and not what they "need" or is efficacious.

How many are willing to say we know nothing about low back pain in the way of efficacious "treatment?" At this point it would be hard to disagree.

https://www.painscience.com/microblo...n-mistake.html

http://www.cor-kinetic.com/what-does...for-back-pain/

https://www.painscience.com/articles...ty-empires.php

A business owner I know told me: "If I only sold what people needed, I'd be out of business."

[Mikal Solstad]

I've often asked myself if the removal of professions treating MSK-related pain would result in an increase or decrease in disability across the population.

I know what I think.

[Johnny_Nada]

I know what I think.

And I think its an answer few are comfortable with...

[Barrett Dorko]

What we "think" is speculation. Bolstered by good evidence, trust and defense from the literature (which requires reading and some trust) it runs into what I've heard is "the Conan Doyle fallacy." The author of the Sherlock Holmes mysteries invented a character who said, "...when you have eliminated the impossible, whatever remains, however improbable, must be the truth."

Doyle created a character who seemed to know what was going to happen in the future though he had Holmes complain that he wasn't always infallible. He didn't, after all, write of his exploits himself. This is recounted in numerous books. Doyle, after all, defended the existence of fairies. They probably don't exist - or haven't been shown to exist yet. That hardly stops some from believing in them.

Investigation changes things. Defense is unwelcomed though essential.

[Jo Bowyer]

I've often asked myself if the removal of professions treating MSK-related pain would result in an increase or decrease in disability across the population.

I know what I think.

I used to have my practice at a centre that specialised in the talking therapies and they did very well with MSK-related pain. However there were still some that I was asked to look at for opinion/management

[Johnny_Nada]

I have shoulder pain

Get stronger! Wait, maybe you just move it?

https://www.ncbi.nlm.nih.gov/pubmed/27884499/

Oh, well maybe you need to crack it

http://www.jospt.org/doi/full/10.2519/jospt.2016.6319

Damn! Ummm, stab it???

http://www.jospt.org/doi/abs/10.2519/jospt.2017.6698

On second thought, maybe just stay away from us and do your own thing...

https://www.ncbi.nlm.nih.gov/pubmed/26160149

:teeth::teeth::teeth::teeth:

[Josh]

Johnny,
Excellent quick and easy synopsis of our role per the literature. While this should liberate us all, it really stresses most PTS out. They equate it with being devalued, however I see it as the opposite. If we just take the focus off us and our ego, we can assist patients back to what they want to do. I know its not really what I do, but it's how I do it......and more importantly, in some cases, what I don't do.

[nykinvic]

Chronic workload: callous
Acute workload exceeding chronic workload: blister

I don't know why we can't apply this to non-athletes. Loading is loading. While absolute loading may differ between athletes and non-athletes, relative loading may be similar.

Exceed chronic workloads and blisters may form. Stay near your chronic workload and the callous has a protective effect. If a blister has formed, rest and recovery are indicated. Loading is still allowed but most likely it will be an unloading

Because context. How is a squat less context dependent than a paper cut (thinking of Neil Pearson's presentation where he speaks to a paper cut hurting more at work than the beach)?

I have made this point before but one of the problems for me with the 'just load it' approach is that it is heavily based on data gathered from high performance athletes and firmly entrenched in a sport performance/exercise paradigm. In my opinion, it is based on an assumption that high performance athletes are healthy despite their rates of injury and pain AND their preferential access to medical (physical and psychological) care and nutritional resources. I think this has biased our biomechanical understanding of human movement (versus exercise and sport) and perhaps also, our understanding of movement treatment for pain.

Athletes and nonathletes are not the same - high performance athletes have among other things, acces to resources that the other 97% of us do not.

A 'just load it' treatment approach for an athlete is within a specialized context (their exercise load profile is intimately and directly related to their life's meaning) and they often have access to special resources (trainers, psychologists, coaches, food, drug, etc).

Greg Lehman references this article and this definition of load in his workshop:

"The term ‘load’ can have different definitions. In general, ‘load’ refers to ‘a weight or source of pressure borne by someone or something’. Based on this definition and variation in the sports medicine and exercise physiology literature, the consensus group agreed on a broad definition of ‘load’ as ‘the sport and non-sport burden (single or multiple physiological, psychological or mechanical stressors) as a stimulus that is applied to a human biological system (including subcellular elements, a single cell, tissues, one or multiple organ systems, or the individual)’. Load can be applied to the individual human biological system over varying time periods (seconds, minutes, hours to days, weeks, months and years) and with varying magnitude (ie, duration, frequency and intensity).

http://bjsm.bmj.com/content/50/17/1030.full.pdf+html

Two things stand out for me about this definition.

1) it's great to see non-sport burden being recognized for athletes and

2) in a non-athlete population, what word replaces 'sport' - is it 'work' or 'meaningful activity' or 'exercise' or 'movement' or something else?

[Johnny_Nada]

Hi Christine,

I use "loading" with a context more consistent with Erik Meira's description. Loading is more than just "weight, mass, etc" to me. That being said, I'm still in favor of "loading" the tissues to create adaptation for strength, endurance, capacity, envelope of function, activity tolerance, etc.

http://thesciencept.com/just-load-it/