McGill

I had the pleasure of spending a weekend in Saco, ME listening to Stuart McGill.  As you may know, Dr. McGill is a wealth of knowledge, info, research, and clinical insights.  So I don’t become one more in the long line of people to misquote Stu on the web, I’ll let his work speak for itself, you can read his books, review his research, or watch his DVDs to get his opinions and I’ll simply offer a few things I took away from this weekend.  Here’s a few reminders, tips, tricks, concepts, or soundbites I took away from the seminar. 

  • Always look at both sides of an issue.  Make an argument for it and against it.  Almost all tools/methods/systems have strengths and weaknesses.  You need to know this!  I was surprised to see how many exercises, methods, experts Dr. McGill began with I love (Insert method/technique here) it’s great at (insert desirable outcome here), but we’ve also shown that (insert negative impact or side effect).  My translation:  Use all of these great tools, just understand when to use them and when to apply other strategies.
  • Smiling is wonderful, but you can’t lift hard, train hard, or be powerful while you do it.   Concentrate and maintain complete focus until you’ve nailed some quality reps.  Smile after you reach your goal.  
  • Train the nervous system.  The evidence is overwhelming, this is what makes the best athletes.
  • Know the physical demands of the person you’re working with.  Assess their current capacities and then design a program to fill this gap.  For athletes review tape of their competition and break down the movements.  From a fundamental standpoint, what movements are you seeing?  How often? How many times? What duration?  In what combinations?  Write it down and be specific.  Train these fundamental movements.
  • Dissociate.  Proximal stability gives distal mobility and power.  If you can’t separate ball and socket movement from spine movement, stop, peel back and try again.  This is an essential skill.  (Side note great, descriptions in Osar’s book. Osar’s Movement lecture here.)
  • While movement quality  is essential, the fact that speed and load change these unpredictably cannot be ignored.  McGill’s research demonstrated that individual’s patterns changed, in both directions (from ideal to compensated and from compensated to ideal), under load.  Make sure your assessment includes something that matches your patient/athlete’s demands.  Also realize that even though someone passes an initial screen this does not mean the get the ‘green light’ to do anything.  They may have a green light to train, but you need to constantly monitor and assess for quality movement.  Patterns change with speed and load.  (This leads us into the next point.)
  • Assess, assess, assess. Constant assessment and reassessment is performed to titrate the exercise to work at the edge of the patient’s abilities.  It is also necessary to evaluate progress or impact of the intervention.  Assess, reassess, repeat if desired.  (Feel like I’ve seen this pattern somewhere before.)
  • Small things make a huge difference.  As with so many things the difference of good and great, or great and world class are little things.  Don’t overlook the little things that can take your patient to the next level.
  • You need to respect someone’s congenital limitations.  Hip shape is not uniform.  Squat depth and peak abilities will be affected.  Also simple exercise like tolerance for the elliptical trainer, can be dependent on having enough hip motion to spare the spine.  Assess the movement of the ball and sockets. Scour (perhaps daily according to Dr. Cubos).
  • Exercise selection is a risk vs. reward decision.  Stated this way I doubt many will disagree, but when presented more scientifically such as EMG activation vs. joint load, my guess is many will choose to remain in their comfort zone and stick with the exercises ‘that have worked before’.  While EMG studies have their limitations, remember risk vs. reward and that any training capacity you can spare, can be used later.  In those who are injured or at risk, choose exercises judiciously.

Other McGill resources:
Cubos notes from similar course. 

McGill resources from Liebenson

Backfitpro resources

McGill Movement Lecture

Prior post with links to McGill NY times video and article.  Hate sit ups?

 

Addition by subtraction

I had a new patient enter the office recently who had been under the care of another chiropractor.  This was an interesting visit as often times when a patient comes from another health care provider there is a reason.  Perhaps they are in some way dissatisfied, not improving as fast as they would like, have a new condition, recently moved, etc.  This one was different.  The patient was thrilled with their current health care provider.  You may be thinking the same thing as I was, “why make a change when you’re extremely satisfied?”.  Here’s the answer I was given (paraphrased):  “I love my current doctor, but cannot drive all the way to see him more than 1x/week due to gas prices and time.  I’ve had these symptoms for 3 months, I lived with it for 8 weeks and then have been receiving treatment 1x/week for the past 4 weeks.  I am gradually getting better, but if I could be seen more often, I would get better faster.”   Sounds logical, if some is good, more must be better.

Patient history includes back pain and left sided leg symptoms (S1 sensory changes).   No signs of ominous pathology.
Prior treatment: weekly instrument assisted manipulative therapy with mild improvement each week.  Patient was also stretching at home.

So at this point the question is what to do.  First, I’ll say that  when I take over care for a patient who believes their current treatment regimen is working, I rarely change it initially unless I have significant concerns.  I instead work with it and make gradual changes in most cases.  I believe that what the patient thinks will make them better often does.  Their confidence in their treatment is an important part of the puzzle. (Is this approach right or wrong?  Feel free to weigh in.) 
Next issue is what to change in the treatment to make it more effective… the frequent debate is with whether to mobilize or stabilize first.  From Boyle’s Joint by Joint approach we have some general guidance as to what tends to need to be mobilized and what areas tend to need stability.  From FMS/SFMA (& others) we have the general concept that mobility is necessary before stability.  While I agree that mobility is often needed first, this is not a rule as much as it is a guideline.  Frequently, I’ve seen that providing stability where needed allows the nervous system to reduce the ‘tightness’ of other areas.  As stability is restored, the nervous system stops drawing upon ‘prime movers’ to act as stabilizers and mobility is restored.  To determine what type of treatment is most likely to benefit an individual patient, I follow this model, as outlined by Dr. Craig Liebenson.  Its brilliant simplicity is applying a McKenzie (MDT) concept to active care, including mobility & stability exercise.  While the mobility vs. stability debate will continue on, there is a more important first step that is at times overlooked. So let’s go back to this patient I saw and the case at hand.  I did provide instrument assisted manipulative therapy, similar to what the patient had previously received.  The patient was satisfied with this portion of care.  I also reviewed the patient’s current stretches.

After realizing that the patient was performing positions that involve common back injury mechanism (repeated or prolonged end-range loading, in this case lumbar flexion), I simply asked that she stop doing 2 of the 4 stretches the patient was doing on her own each day to try and remedy her condition.  (Picture on right was #1, a seated version with legs spread was #2.)

The outcome:  Patient returned 2 days later and was 50+% improved.  After 3 months of symptoms, I consider that a positive outcome.  Please realize, this is not a post about me, how good a job I did, or the quality of care I strive to provide.  It is also not a post to say, look at what someone  else was doing wrong.  (I hate these types of blog posts and FB posts.  We’re all on the same team.)  In fact, if you reread this you’ll see that I actually did very little.  I simply duplicated someone’s treatment.  The only thing that was changed is I followed the advice of one of the Prague school pioneers.Karel Lewit

“The first treatment is to teach the patient to avoid what harms him.”  Karel Lewit, MD

Patients who are not well informed as to what harms them are unlikely to respond favorably. Removing offending movements, positions, and activities is essential.  Sparing advice trumps mobility, stability, balance, etc.  (In reality it often includes bits and pieces of all of them.)  At times patients have a hard time understanding how important and powerful this part of treatment is.  I’ve heard and use the following story, “If you came here with thumb pain, I could treat your thumb any way imaginable, but if it hurt because you were hitting it over and over again with a hammer, wouldn’t you agree that teaching you to swing the hammer differently is most important?”  Change hammer & thumb to anything that resonates with the person in front of you and I think you’ll have a productive first interaction.

Don’t skip step 1:  “Teach the patient to avoid what harms.”  (Added note: Don’t let step 1, become ‘avoid activity’, be specific.)

Sparing strategies:

A) For repeated movements: ergonomic advice, teach/train better quality movement, and improve joint centration. 

B) For prolonged loads: microbreaks.  If you stand, sit. If you sit, stand.  Examples:  Brugger’s postural relief position.  McGill’s overhead reach.  McGill's overhead reach

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