Stretching the marionette

Many of us, myself included, were raised in a sporting environment that emphasized stretching.  As a distance runner, I was routinely advised to stretch for 1/2 hour or more prior to running every day.  Unfortunately, many continue to repeat what they were taught and never question the status quo. There is a wealth of evidence that suggests static stretching can rob us of performance, although I do acknowledge some degree of tissue extensibility/mobility is necessary.

Liars! Changing the length of my strings makes things harder.

Those who treat runners know motor control (stability) is often an issue, particularly in the frontal and transverse planes.  Recently I saw the most under-controlled runner I’ve seen in a long time.  After an evaluation, corrective strategy, and conversation we reassessed and saw a nice improvement in symptoms and movement quality.  We discussed the future course of care and home exercise prescription and were about to part ways when…. the patient asked me what stretches he should add to the 2 exercises I just taught him.  Maybe I did the world’s worst job communicating what I thought the problem and potential solution were, but I suspect I was just up against an insurmountable preconceived notion.  Stretching is not a panacea solution.  It is also not a necessity for all activities, in particular running.  See NY Times Article: Reasons Not to Stretch.

There is also abundant evidence questioning the value and timing of static stretching.  A random selection, in no particular order:

I understand that handing out copies of the NY Times article or giving patients research citations, abstracts, or even full text articles isn’t a solution to the problem.  Further, in the current healthcare setting time and efficiency is often a key factor in clinical treatment.  So how do we effectively communicate this idea that stretching may impede performance as clearly and succinctly as possible?

Here’s one way I’ve had success.  I recommend you judge your successful communication by the change in facial expression (shocked), demeanor (surprised and curious), and the light bulb appearing above your patient/clients head.   

The way you move is coordinated in the subconscious portion of your brain.  This is done based on feedback regarding length and tension.  Changing your length and tension by stretching just before you run is like changing the length of the strings on a marionette just before the puppeteer takes the stage.  The performance will suffer.

I’m not sure why this analogy works better than all others I’ve tried, but it seems to.  Perhaps it’s the image of the clumsy puppeteer?  Maybe it’s the non-threatening nature of the analogy as it doesn’t directly compete with what so many ‘experts’ have told the athlete before?  Either way, it seems to be a way for people to grasp a complex concept that is often in opposition of their existing beliefs.

 

This conversation often continues into why they feel ‘tight’.  Here’s a nice recap of Professor Janda’s thoughts by Craig Liebenson, DC.

Core, Crunches, & Oversimplification

There is a wealth of information on the core, spinal loads and biomechanics, and appropriate exercise selection. Despite this, there are no perfect, uniform laws of core training. There are some great principles and guidelines, but there are no unbreakable laws. Perhaps in our desire to communicate the ills of repeated, loaded spine flexion some of us have oversimplified this concept.  Such as don’t flex the spine and don’t do crunches.  (I know I may be guilty of this, and in doing so failed to follow one of Einstein’s cautions.  I admit my bias is due to working with a large population of folks with back pain and a great number of athletes/weekend warriors who spend there days in seated flexion during desk work.)  Please note that I am not advocating for or against the crunch, sit up, leg lift, V-up, or any other particular exercise, just a reconsideration of what we know, how we train, and what we say to people about their movements. Perhaps a more complete, reasoned approach is warranted.

Make things as simple as possible, but no simpler.  – Albert Einstein

 

Paraphrasing Stuart McGill, ‘there are no good or bad exercises‘.  We need to find the right exercise for the right person at the right time.  In my opinion this is best done with a constant monitoring: assess, implement training strategy, reassess (within visit and over time).

What does your core training produce? Quality? Capacity? or Both?

I would argue for the novice trainers and clinicians to avoid spine flexion with their patients/clients (particularly loaded or repeated) may be advisable as the yearly and lifetime prevalence of back pain is quite high, 40% and 85% respectively.  However, the more seasoned should take a careful look at the individual, their activities and demands, and then weigh the risks and benefits.  Below are links to an interesting discussion on this, it is 3 parts of a well reasoned, collegial blog conversation.

Side note: I’d like to applaud both authors for stating their points with their own clinical and scientific understanding, reasoned arguments, and interesting perspectives, rather than sinking to the level where some online disagreements tend to go all to quickly..

Side note #2:  The discussion above represent my thoughts and is not intended to summarize the posts below.

Use the links below for a great discussion about appropriate training of youth athletes, the limitations of certain approaches, and finally the multitude of factors that influence appropriate training (particularly in the female athlete). 
Take a moment… read it, think about it, challenge your current understanding…

Post #1: by Julie Wiebe, PT “dear coach”

http://www.juliewiebept.com/alignment/dear-coach/

 

Post #2:  by Greg Lehman BKin, MSc, DC, MScPT  “Dear Julie”

http://www.thebodymechanic.ca/2013/02/14/dear-julie-in-defense-of-the-crunch/

 

Post #3: Response to Lehman’s post by Wiebe “Dear Greg”

http://www.juliewiebept.com/fitness/dear-greg/

 

Things to consider:

  • What factors govern your exercise selection?  Age? Gender? Injury history?  Activity/sport?  Frame size?  Disc shape?  Related mobility (hips/ankles/thoracic)?
  • Are there patients/clients who should avoid spine flexion?
  • Are there folks who should be encouraged to flex?
  • When training flexion how much repetition or load is reasonable?
  • Should training recreate the demands of the sport/activity?
  • Should training prepare someone to resist the loads of their sport/activity?
  • Is core training the same for the male and female athlete?

A bullet list of quality reminders regarding core & pelvic floor.  Once again compliments of Dr. Cubos.

Evidenced Informed Practice Promotion

The previous post (verbosely) discussed evidenced informed practice and how art may influence our science.  Acknowledging that art can influence science, we must also continue to strive to ‘prove’ what we do, why we do it, and how it works.  Best practices involve finding the ideal solution for the patient at hand (each case is a study where N=1), and finding the right solution for the right person is more important than following a particular protocol or treatment method.  Just ask the patient, they’ll agree.

As practitioners we find ourselves working to educate patients as to what we do, how they can better understand their condition, and what they can be doing on their own to improve their own health or wellness.  Below are some great resources for evidence informed practice promotion that may help stimulate conversations within your clinic.

1) Spinecareposters.com  Quality, evidenced-based health care information available for your office wall.  Stimulate meaningful conversation about the topics you know are important to your patients health.  From lifting techniques, to upper & lower crossed syndromes, spinal stabilization, and postural strain.  These eye-catching posters are fully referenced so you can be confident that these posters mirror the excellence and knowledge of your clinical staff.

2)Public Service announcement from the West Hartford Group (WHG).  (disclaimer: I am a member of this group and while I supported this effort I had no hand in the creation of this great video.  I offer many thanks to those who put in the time and effort so this project could see the light of day.)  The WHG encourages you to share, post, or use this video; it was created for the betterment of the chiropractic profession.

ISCRS logo

“Learn the Skills. Master the Art”

3. International Society of Clinical Rehab Specialists (ISCRS).  Membership to this multidisciplinary group includes access to a wide variety of self-help articles for patients as well as member discounts to other resources for further education and patient empowerment.  Visit online @ clinicalrehabspecialists.org.  If you’re up for the challenge, join as a General Member and begin the track to full membership.

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.)

From: http://www.liveleak.com/view?i=9d8_1296516483

 

A few studies for those who are curious.

http://jama.ama-assn.org/content/307/6/567.short

http://jama.ama-assn.org/content/287/5/622.short

http://www.sciencedirect.com/science/article/pii/S0306452207001819

http://ehp.sagepub.com/content/25/4/369.short