Archives for February 2012

Wellness & Nocebo Paradox

What do wellness and the nocebo have to do with one another?  Very little.  But an odd paradox arose today, which prompted me to sit down and write a little rant.  My hope is that we all begin to think more about what we’re doing and how it impacts the end result, rather than just continuing our current routines.

Recently I had a patient whose case looked like one I’ve seen hundreds (perhaps thousands) of times before.  The classic case every practitioner who treats back pain knows so well.  Patient reported with low back and buttock pain with no true radicular symptoms following a series of repetitive flexion activities.  A common condition, from a common cause.  A common solution was found and was successful after reassessment.  But there’s more to the story.

As worked with this patient I was aware that she had been to another chiropractor and was dissatisfied, prompting her to seek my care.  I didn’t ask much about what was done previously.  After I was done treating her, the patient showed me a written report from the previous chiropractor.  The written list included a multitude of ‘abnormal’ exam findings from range of motion limitations to pelvic unleveling and torque. It also included imaging findings of disc space narrowing and spinal decay (diagnosed by x-ray), numerous subluxations, areas of trigger points and spasm, abnormal spinal curvatures, and likely others I’m forgetting.  While I acknowledge these findings are likely accurate (and commonly reported by many chiropractors), I question 2 things.  1) There importance considering until a week ago the patient was smiling, happy, & healthy.  2) The way they are presented.  We are seeing more & more that presenting people the idea that something is wrong can be very disabling.  This is called the nocebo effect.  If you tell someone something is wrong, it often becomes a self-fulfilling prophecy.

“For each ailment that doctors cure, they introduce ten others in healthy individuals by inoculating them with a pathogenic agent, thousands of times more virulent than any microbe- the idea that they are ill.”  – Marcel Proust, The Guermantes Way
This is not to say that we don’t need to tell patients of their exam findings, just that we need to be mindful about how we do it and why we do it.  To use a cliche, you are presenting patients with a glass of water, you can choose to tell them it’s half full and this is how we fill it up more, or that it’s half empty and this is dangerous because it will eventually be even more empty.
For those who know this is a common occurrence, here’s what made me write about this today.  There is a complete paradox here that often goes unspoken and is rarely discussed.   The same chiropractor who imparted all of these ‘ills’ upon the patient, is a chiropractor who promotes ‘wellness’.  The disparity between telling someone they have a multitude of maladies and then trying to sell them wellness care is enormous and frankly doesn’t make sense.  Perhaps this is the break them down and build them up strategy we see in military training and coaching?  But I don’t believe it has a place in health care recommendations.  Using what equate to scare tactics creates a nocebo effect.  While fear is a good motivator, hope and opportunity are much better.  Fear gets people to do ‘just enough’.  Hope and opportunity will foster an environment where someone becomes self-empowered to work beyond the bare minimum.  If we want people to strive for ‘wellness’ our first move can’t be convincing them they’re ill.  (Feel free to reread Proust’s quote above)

Wellness defined:  Wellness is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity. – World Health Organization

Before you give examination or test results, think about the effects of how you present the information.

Nocebo defined:  a harmless substance that when taken by a patient is associated with harmful effects due to negative expectations or the psychological condition of the patient.

  • Keep in mind that ideas and perception are the driving force behind the nocebo effect.  Giving someone the idea that they are not well, or may not be well in the future is what creates symptoms, not the sugar pill or saline injection.  Thoughts, ideas, and poorly delivered diagnoses or reviews of findings can create disability and illness.

This has been common knowledge for some time, but has not been put into clinical practice.  It has been studied and written about in the general media. The nocebo is real. “in double-blind clinical trials of antidepressants, even those participants receiving a sugar pill report side effects like gastrointestinal discomfort if investigators have warned them at the outset that those effects are likely.”from The Nocebo Effect Time Magazine in 2009.  Also in the Huffington Post, read about pessimism and the nocebo.

Funny video with Dr. Ben Goldacre. (Warning: contains crude language.)



A few studies for those who are curious.

Crossfit Controversy

The background is that the viral video in question circulated FB and the web and was first sent to me from the west coast by Phil Snell (of fame).  Speaks volumes to tipping points that can be created with the internet when it was filmed less than a mile from one of my offices.

Below, a short clip, featuring yours truly, from our local news.  I think they did a nice job presenting a balanced approach.  I find it funny what they chose to use out of a 45 minute interview, but I agree with their conclusion that Crossfit should likely entered into with caution like training for a marathon rather than as a general exercise program.

A nice piece by Katherine Underwood: Crossfit Controversy

Points I wish made the video:

  • We have a sedentary, obese society that needs to sit less and move more.  By motivating people to get moving in some ways Crossfit has it right.  They have also done well removing seated exercise machines and motivating people to perform a variety of more functional activities.
  • Crossfit can be extremely fun, motivating and exciting.  (This is one of their great achievements but it can also compromise judgment.)
  • One of the main flaws in training is the value of quantity over quality.
  • Big picture goals should be as follows: For athletes: Long Term Athletic Development.  For adults: Long Term Athletic Participation.
  • It is very easy to make exercise hard.  Do more reps, add more weight, do it faster.  It is very hard to make exercise challenging. This is where the exercise remains under control, but just on the edge of someone’s capabilities.  The difference is HUGE.  Challenge leads to adaptation and improvement.  Exercising hard leads to injury and failure.
  • Health care providers have a duty to at least “DO NO HARM”.  Fitness trainers should adhere to this same concept.  
  • Professor Stuart McGill reminds us that, “There is no good or bad exercise” only ones that are inappropriately applied.  Group exercise classes do not allow individualization which creates problems.  In other forms of group training there are also problems, yoga, pilates, etc… however with these other forms of group training there is more of an environment that it is acceptable that an exercise or activity may not be for you and an encouragement to ‘listen to your body’.  Crossfit adopts a mantra closer to ‘no pain, no gain’.
  • Each person should be screened pre-participation.  Screening should include cardiovascular assessment, but also a movement based assessment such as the FMS looking for movement limitations & common injury mechanisms.  It is also essential that screening is implemented using corrective exercise and modification of the routine.

Some blog reviews: of Crossfit:

Original video for those who haven’t seen it:

Faulty Movement Patterns – Functional Assessment & Training in Phoenix, AZ.

Faulty Movement Patterns – Functional Assessment & Training with Dr. Craig Liebenson.  Phoenix, AZ. March 10-11, 2012 in Phoenix, AZ.  I just booked my flight out there.  Looking forward to a weekend of workshopping with Craig.  There are always some new clinical nuggets to pick up and bring home.

I was excited before, but found out from some Facebook friends that there is a water slide and some fun to be had at the resort.  Resort fun is a distant second, but a nice perk to what will be a fantastic seminar.

Seminar Flyer


Assessment/Training of Faulty Movement Patterns bridges the gap from acute care to injury prevention to skills training. This program is ideal for any musculoskeletal practitioner who works with patients or clients that want to enhance their results. Learn the art of functional assessment of the kinetic chain and how this relates to sports function as well as injury rehab. Particular emphasis will be on the groundbreaking work of Professors Janda & McGill, Gray Cook, Michael Boyle and other leaders in the athletic development.

Some of the Topics Covered:
• Subcortical Reprogramming of Movement Patterns
• The Frontal Plane and Knee Instability
• The Transverse Plane & Upper Quarter Syndromes
• Kolar-McGill: biomechanics & neuro-development
• Cortical Plasticity & the Neuro Matrix

Human Locomotion by Tom Michaud

Dr. Tom Michaud - Human Locomotion BookI had the pleasure of meeting Dr. Tom Michaud at Dr. Craig Liebenson’s Modern Spine Care seminar in Albany several years ago.  A few questions to Tom during one of the breaks turned into a miniature gait seminar, which was fabulous.  His depth of knowledge was quickly apparent as was his appreciation for how it could be applied clinically.  Further, it was apparent to me from Tom’s attendance at the seminar that he understood that we needed to be looking at the ‘whole picture’ even when focused on a foot or lower extremity issue.  This concept is evident in his new text as well, beginning with the title, Human Locomotion.

For those who haven’t purchase the book yet (available on the Newton Biomechanics website), read this paragraph from the preface.  Tom, “had me at hello”.

“Using the latest technologies, modern researchers are proving what practitioners experienced in conservative interventions have known for decades: hands-on manual therapy, orthotics, and rehabilitative exercises provide inexpensive, effective, long-term solutions for the majority of gait-related injuries.”

The book begins with a fascinating history of the evolution of bipedal walking and gait.  Laced with details that I’d never considered, it’s a fascinating read.  For example, “An extreme important by product of Homo rudolfensis’s habitual bipedality is that it decoupled the process of breathing from locomotion.  As noted by Carrier, running quadrupeds time their respiration with their strides…. the coupled patterns locks the breathing cycle during quadrupedal locomotion to the stride rate.”  I guess I haven’t spent enough time analyzing my dogs breathing pattern while he’s running.   This evolutionary detail reminded me of the common conversation of timing breathing with exercise. Considering the essential nature of respiration in spine stability, with the diaphragm serving as the dynamic lid of our pressurized canister, we must always have controlled breathing to have adequate spine stability.  The argument is often when to inhale and exhale during exercise and I think this point in Dr. Michaud’s book lends itself to what I’ve always believed the answer to be.  One of our evolutionary advantages is that we can inhale and exhale whenever we like, completely separate from gait or physical activity.  This evolutionary advance is something we should not give back by training specific inhale or specific exhales during exercise.  (exceptions for extreme performance such as Olympic power lifting are acknowledged)

This text continues with analysis of biomechanics, evaluation of gait cycle (ideal & abnormal), exams, orthotics, shoes, and ends with treatment protocols.  It includes a very insightful discussion of the risks and benefits of the barefoot running trend.   I enjoyed this particularly as a part-time, rational, minimalist runner.  For those interested in this specific topic see also Barefoot in Boston by Art Horne.

I’ve found myself using the book as a reference for lower quarter problems that I’ve been treating and taking some pearls away from Dr. Michaud’s text to add to my clinical toolbox.   This is a great read that shouldn’t be missed.  For other info and reviews of the book, see below:

AUDIO INTERVIEW @ SPORTSREHABEXPERT.COM (view the sample articles if you’re not a member)

During the interview Dr. Michaud covers a variety of topics.  One is the growing body of research that pre-competition stretching does not change injury rates.  He recalls a story of Rob De Castella in his clinic after winning the Boston Marathon and notes that he had a 4″ ASLR raise.  In discussion Rob explained, “when I run that’s as far forward as my leg goes so that’s as far as I want it to go”.  Dr. Michaud discusses the athletic value of ‘tightness’ and the clinical presentations which warrant stretching.  He also discusses barefoot running, treatment of plantar fasciitis, the role of hip stability and proprioception, reasons for recurrent hamstring strains in runners, and shows his ownership of the research which is so evident in his book.   To listen to the audio interview with Dr. Michaud go to (membership to the site may be necessary): Dr. Tom Michaud audio interview

Still not convinced…. Read a great review and blog post by Patrick Ward about Human Locomotion.

Dr. Tom Michaud, author Human Locomotion

Dr. Tom Michaud, author Human Locomotion

To see the actual work, read some samples from the text and see the Table of Contents @