Where the world of Physio is going
These are just a few examples of what I hear every day. More than every day. In fact the majority of patients I see have been told something along these lines or of a similar notion. The notion being that there is something inherently structurally wrong with you. That you’re not right as you are. That your body is failing you. That your body is not robust. That you’re broken. That you need fixing.
Without realising, these beliefs impact us on both a conscious and a sub-conscious level. If we genuinely believe our pelvis is out of alignment or our hips are out of place, we’ll move and load and trust that part of our body in a completely different way. The crux of it is, often without even realising it; we won’t trust that part of our body. We’ll be fearful, we’ll not have the confidence that it’ll be there to support us, we’ll be tentative – whether that’s when simply standing up or doing a 100kg back squat.
This has become a significant part of my job now. Unravelling peoples’ beliefs about why they’re in pain. And it’s quite remarkable what people believe, which often has developed over time and from a variety of sources – family, friends, chiropractors, doctors, physiotherapists, neighbours, massage therapists, osteopaths, social media, newspapers…the list goes on. Some people believe their spine is crumbling because of what their X-ray showed. Some people believe a disc has slipped out (just to clarify – discs don’t slip). Some people believe they have too much curvature of the spine and for that reason should avoid all lifting forevermore (despite having the same curvature (which is inherently ‘normal’) for their whole adult life and only having pain for the last 3 weeks since going overboard on deadlifts…).
Of course, the human feeders of these thoughts and beliefs don’t do this with malice. They don’t deliberately plant a seed that can build and build into a potential life of chronic pain. They don’t do it to trap people into paying for more sessions (I hope). I genuinely believe they’re just a bit oblivious about the impact their language has, but also on the topic of pain physiology – a topic which has expanded dramatically in the last 5 years or so.
Don’t get me wrong, this happens in the world of Physiotherapy as well. I’m not tarnishing all other professionals with this brush. It’s rife everywhere. But what I do know is that as a profession, Physiotherapy is becoming more and more aware of this and is working hard to abolish it as much as possible.
The management of non-traumatic musculoskeletal pain is taking a huge turn in the Physio world. The impact and prevalence of over-diagnosis is well and truly in the spotlight. The recognition that variation is normal between people and, more importantly, between sides of one person’s body, is becoming accepted fact. How your shoulder blade (AKA scapula) moves when you lift your arm, what your natural posture is, how curved your spine is and where your head sits in relation to your spine….these are just a few things that vary hugely between people and, where applicable, between left and right of the same person. These vary in people with pain and without pain. But often, these are the things that are blamed when a person is in pain. Even though they’ve had an ‘increased’ lumbar spine lordosis (AKA curve) their whole life. Their right scapula has moved more than their left, their whole life. Yet all of their pains have occurred within the last month, 6 months, few years and what’s often simply changed is either their tolerance to load and/or the load itself – and this load can be anything in everyday life (not just what weights you’re lifting) and can include both physical and mental load.
It’s this over-diagnosis and subsequent fixation of both the clinician and patient on these biomechanics that changes a patients’ mindset. Don’t get me wrong, how a person moves (or not moves) is huge and can significantly contribute to why a person may be experiencing pain. Technique is vital in CrossFit and, as we all know, if you do a duff lift or squat your body will soon let you know it wasn’t happy doing it that way. Correct your technique and off you go happy as Larry.
However, it’s when technique is spot on and normal variables are wrongly identified as the sole driver of pain that is where things are going wrong. A driver that then becomes the focus of treatment for both the clinician and the patient. This then leads to over-treatment.
Prime example…your scapula rhythm (i.e. how your shoulder blade moves when you lift your arm) is ‘abnormal’ on the right, that’s why you’re getting shoulder pain…let’s treat that to get it back to ‘normal’. That’ll stop your pain. That’ll fix you. 10 sessions of scapula ‘stabilisation’ exercises and hands-on therapy later and the pain has gone. Yet A) studies show that scapula rhythm does not often correlate with shoulder pain (Ratcliffe et al, 2014), B) scapula rhythm can stay the same despite patients reporting reduced pain (Camargo et al, 2016) and C) pain often runs its own natural course and resolves of its own accord…which can be the actual reason why a treatment has ‘worked’. You probably also lowered your snatch and push press weights, maybe avoided pull-ups and really focused on A* tekkers throughout the whole process…coincidentally you may have also had a lot less stress at work and managed to sleep more than 6 hours every night…
Don’t get me wrong (again!), I’d much rather someone gets sent away with some active exercises to do rather than lie down for half an hour and have things ‘realigned’. But it’s still the reasoning behind these active treatments that, without meaning to, will impact a persons’ mindset. They will inevitably believe that there is something wrong with their body, or how their body moves, or how it has been built, or how it has aged or what it is capable of. The actual facts that our bodies are strong and resilient are nowhere to be heard. The locus of control is no longer in their hands but in the hands of another person.
And of course, if any form of hands-on therapy is involved you feel fantastic after! You feel a whole new person. You must have been really out of line then. Your pelvis must have been all over the shop. You probably even had a rib displaced. And don’t get me started on scar tissue….there must have been a tonne. But thankfully everything’s back where it should be and your pain has gone.
Until 1 week later, 3 CrossFit sessions later (one of which included that b**ch Annie), 4 nights of crap sleep, 1 really annoying boss, 2 kids with a sickness bug and a diet largely consisting of chocolate giant cookies and cereal….your pain returns.
Better go and get yourself realigned again then as that must be why your pain has returned…
Thanks for reading my first blog for Heyl CrossFit! My cynicism and rant-ability will unlikely change but I hope to provide you with some insight into the Physio world which in turn, will hopefully help you in some way. (FYI for anyone who doesn’t do CrossFit ‘Annie’ is a workout not an actual human!)
In essence, there are a whole host of factors that contribute to pain and the persistency of pain. Your perception of pain – what’s causing it, what will help it etc – is arguably one of the most important factors and has a huge impact on the pain itself, as well as your recovery and your self-confidence in dealing with it. This perception of pain, however, is easily influenced by external sources – people you see, what you are told and what you hear.
Just remember, at the end of the day, you’re the expert of your own body – a body which is hugely robust and built to last a lifetime!
If you fancy any more reading here’s some of my favourite Physio bloggers:
Until next time, much CFH love
Rosie
Camargo, P.R., Alburquerque-Sendín, F., Avila, M.A., Haik, M.N., Vieira, A., Salvini, T.F. (2016) ‘Effects of Stretching and Strengthening Exercises, With and Without Manual Therapy, on Scapular Kinematics, Function, and Pain in Individuals With Shoulder Impingement: A Randomized Controlled Trial.’, The Journal of Orthopaedics and Sports Physical Therapy, 45 (12), p984-987
Ratcliffe, E., Pickering, S., McLean, S., Lewis, J. (2014) ‘Is there a relationship between subacromial impingement syndrome and scapular orientation? A systematic review.’, British Journal of Sports Medicine, 48 (16), p1251-1256
