Have you ever been frustrated by the explanations for pain that you have been given?
Maybe you felt like you have failed in some way because you did all you were asked, yet the pain remained.
Maybe you felt broken as I talked about here. Thinking you were weak, lacking, or not enough.
I admit I am really heartbroken at hearing so many of these explanations repeated by professionals when we have mountains of evidence saying these stories, and explanations are no longer appropriate. These reasons have been tested and found to be lacking in evidence, especially in connection to pain.
Important reminder for us as to what’s out there.
“Many physical therapists seem not to follow evidence-based guidelines when managing musculoskeletal conditions.”
“Across all musculoskeletal conditions, 54% of physical therapists chose recommended treatments, 43% chose treatments that were not recommended and 81% chose treatments that have no recommendation (based on surveys completed by physical therapists).”
Wait…. What…
81% of physical therapists chose treatments that are NOT recommended for pain.
Well, no wonder we aren’t getting better! It is reasonable to assume the reason 81% of therapists choose treatments that are not recommended, is because they are following explanations that are outdated as well.
So many seem to have not moved forward.
In order for US to move forward, we need to cast off these stories that we have woven into what we think the reason for our pain is.
Let’s walk through some of those stories now.
Core strength:
The story:
Your core is weak and because your core is weak your back is hurting. You simply need to get stronger to end the pain. When your core is strong enough the back pain goes away, or the SIJ stays in place.
Where the story came from:
In the mid to late 1990’s Paul Hodges and some other researchers compared people with and without low back pain (LBP) to see how fast their core muscles activate in response to various arm and leg movements. What they found was that the transverse abdominis (TVA) and multifidus (MF) were slower to activate in people with LBP compared to people without LBP. No other muscles were activated differently between groups during these movements.
So it came to be believed that TVA and MF issues cause LBP, that everyone with LBP needs core stability exercises and that the inner core muscles are the most important muscles in spinal stability and low back health. Wham! Core stability for you and you and you and you! EVERYONE GETS CORE STABILITY EXERCISES!!!!!!!! ( said in my best Oprah voice.)
The problems with the story:
Well, the average delay in muscle activation was 20-50 ms across studies which is negligible. We can’t tell if core muscle delays are a cause or consequence of pain. There are questions if the sensors used to measure the multifidus were also picking up signals from other muscles in the back.
So what about all the core exercises:
Studies in 2012 and 2014 have shown that core stability exercises were not any better or more effective than general exercise in improving back or si pain. One important thing to note is that the general exercise protocols in many studies often included general core exercises (ie planks, birddogs etc).
What does that mean? it means movement is better than no movement and figuring out how to contract that TA or MF is not really useful in getting rid of back pain, but those movements are better than no moving at all.
Muscle Imbalances:
The Story:
It’s interesting how these theories develop. This one comes from a man that studied himself and others post-polio – he developed the theory of upper and lower cross syndrome. The main gig is your hips are too tight and your bum is too weak and so that is causing your pain. The imbalance between the muscles.
Where the story came from:
Dr. Janda was a curious man and I like reading his works. It’s one of those common-sense kinds of explanations that seems like it could be true and easily fixable. I bought his book before I even became a PTA student and devoured it, marked it up, and memorized portions. I mean, I was going to cure the world of SI and low back pain after all!
The problem with the story:
Sadly, the deeper I looked, the more I looked for evidence that muscle imbalance or lower cross syndrome was related to pain it turned out that no one could really define what an imbalance was. or what the correct balance is, no way to measure it, no norms, and none of the suppositions were able to be verified.
So the idea that your hip flexors are too tight and your glutes are too weak just doesn’t hold up. Plus, by what mechanism would that be causing pain? There is no reason a weak muscle would be sending out danger signals.
So what about all the stretching and glute exercises?
Well… .stretching can feel good, it’s gentle movements, and it can help stretch nerves and tissues. Again, movement of the general variety is good! So the prescription for lower cross syndrome can be helpful even if the reasoning is wrong.
Kinda fun isn’t it? That the logic behind these stories can be wrong, but the treatments developed for them can be helpful. So as you keep reading, keep that in mind.
I do think clinicians with this belief help get us moving a lot earlier than other beliefs. They tend to rely on movement and exercise for treatment – which we in the medical community do know – is the best way to treat pain.
Get people moving in the right amount with the right weight for the right amount of time.
Hypermobility:
The story:
You are bendy and being bendy or flexible means you have pain.
Where the story came from:
Ok. I admit defeat on this one, I can’t find the history for why we think this. but it is out there. The solution is to get strong so the joints don’t slip. ( and in the case of EDS is the right thing to do. but again we are equating pain with mobility – so why doesn’t every gymnast, contortionist, and springboard diver hurt?
The problem with the story:
Research has been conducted and there seems to be no association between hypermobility and joint pain in Europeans. There does seem to be an association among Afro-Asians; however, there was a high heterogeneity. It is unclear whether this is due to differences in ethnicity, nourishment, climate, or study design.
So once again, we have a story about WHY we have pain, but not every bendy person has pain, so why is that what we blame it on?
So what about strengthening:
Once again we see exercise as the solution to the problem, and as we learned in the first myth, movement of any kind is the thing that helps low back pain. So yes, the treatment helps, but we don’t have to believe the reason for the pain. Seeing a trend here?
Posture:
The Problem:
You have too much curve in your spine, be it scoliosis. or too much lordosis. or a military back. You put too much weight on one leg. You bump your hip out. The idea is these positions are “bad” or abnormal and are therefore causing your pain.
Where the story came from:
Posture is a social and cultural construct, more than anything else. Different cultures have different postures that are “acceptable” or “normal”
The belief that “poor” posture leads to pain is mostly based upon personal opinion, in that people theorize before they have any solid data, and they become subjectively and emotionally attached to the idea of “perfect” posture.
Posture and movement are highly individual and to some degree random. Posture is like a fingerprint, unique to each person and individualized.
The problem with the story:
The story of poor posture is based on our culture and educational traditions. They assume a perfect nonpainful posture that is ideal. Over and over again research informs us that posture is not related to pain. Yet clinicians continue to try to fix what isn’t broken.
So what about being mindful of my posture:
Posture is specific to what you do, if you are running it’s very upright but if you want to maximize cognitive abilities, it’s often slumped, and if you are resting and saving energy it’s in a resting “Energy saving” mode. The important part is changing postures. Even if you achieve the “perfect posture” if you don’t change position it’s going to hurt. We need movement variability to feel good. Have all the postures and enjoy a slouch now and then.
Leg Length:
The Problem:
You are told one leg is longer/ shorter than the other and this is the reason for your pain. You have to fix the rotation that is causing the “functional leg length issues ( see muscle imbalance theory). Or you need to put a lift in your shoe to even things out.
Where the story came from:
The problem with the story:
“A recent research study from The Ohio State University that was published in Gait & Posture in June 2014 found a rather surprising prevalence of hip and knee joint moment asymmetry among healthy subjects with no pain. Among 182 “healthy, pain-free subjects,” over half of them had more than 10 percent asymmetry in hip and knee flexion and adduction moments during a walk test.”
The variation of structure and alignment is pretty diverse among individuals.
Once again, we have a story that doesn’t hold up to equating to pain.
So what about the lift:
Current research and evidence on human gait patterns suggest that some leg and hip asymmetry may not need to be “corrected.” So if it helps, great, if it doesn’t toss it out.
So what do we take away from all this?
These stories do not tend to help us move. They do not ground us into a reality that can help us move out of our pain and back into a life we love and recognize.
I point out these myths that continue to be perpetuated because any story that creates co -dependence only amplifies the feeling of loss and self-control.
I want you to have the power to reduce your fear and learn how to move through it and past it. So you can have control back. You deserve that.
As always, I invite you to join my Facebook support group and share comments, questions, and concerns there.
More reading:
The fall of the postural–structural–biomechanical model in manual and physical therapies: Exemplified by lower back pain Eyal Lederman
https://www.cpdo.net/Lederman_The_fall_of_the_postural-structural-biomechanical_model.pdf
I put together a series of blog posts summarizing the literature I have come across on manual therapy and what I see as its implications for practice. – Adam Fehr
Part 1: What we are -NOT- doing – http://www.afehrpt.com/…/manual-therapy-part-1-3-what-we-a…/
Part 2: What we -ARE- doing – http://www.afehrpt.com/…/manual-therapy-part-2-3-what-we-a…/
Part 3: Treating Under Contemporary Manual Framework — http://www.afehrpt.com/…/manual-therapy-part-3-3-treating-…/
https://bmjopen.bmj.com/content/9/10/e032329\
http://guardianlv.com/…/does-leg-and-hip-asymmetry…/
