Nutshell summary: People in pain have spines that function differently than those not in pain. Many treatments can influence pain. The spine stability model of low back pain does not explain how people have pain and takes an overly mechanical view of the pain experience. No test has ever shown that a spine is unstable or how “increasing stability” would lead to a decrease in pain. Thinking that our spines need more stability or control may be the completely wrong path in explaining how people have pain or how our exercises help them. Our treatment “corrections” occur not via one specific “corrective” mechanism (e.g. improving stability) but rather through global non-specific mechanisms that our better explained by our understanding of pain neuroscience. Making the shift from believing that “stability” is the issue with pain can thus free up to choose completely different exercise programs. Exercise and treatment prescription thus become simpler. We have preliminary evidence to support this view with the clinical studies that show benefits with the various exercise conditioning programs that train different schools of thought on stability or the just as effective programs that completely ignore any concepts of stability.
You can justify strength training for runners via performance enhancement and injury prevention. Surprisingly, the evidence for performance enhancement is much stronger than injury prevention.
Clinical Decision Making in Running Form Interventions
Initially written for Medbridge Education
The purpose of this article is to highlight the clinical decision making process during kinematic running analyses – focusing on evaluating the kinematic risk factors for running injury and not kinetics.
Both predictive and correlational research attempts to identify kinematic variables that are associated with an individual’s future or current injury. Many of those being:
I am helping drum up enrollment for this great course in Toronto June 13-15, 2014. I am a fan of this approach and am looking forward to taking the course and hope to see a lot of people there.
I was one of the lecturers at Runner’s Connect Improving Running Form Course. The other speakers were excellent: Irene Davis, Pete Larson, Brian Heiderscheit, Matt Phillips and Jay Dicharry.
You can see the course at Runner’s Connect
p.s. I am promoting this because I liked the course content. I do not get a fee for this promotion.
Audience: Patients with any type of pain or injury
Purpose: to learn a little about pain and convince you that pain is not in your head even though your brain plays a big role
Why? Understanding pain helps decrease pain and helps us make better choices in the treatment of injury
Some brief pain information tidbits
- you don’t need a leg to feel pain in that leg (e.g. phantom limb pain)
- you always need a Brain to feel pain
- pain can become a habit – and like all habits lots of factors help keep it going
- Changes in how we feel pain can also come from changes in the brain and the nervous system
- tissue damage or degeneration does not have to lead to pain – but it certainly can
Damage does not always equal pain
The idea that lots of pain equals lots of damage is a very difficult concept to shake. It is entrenched in how we think about pain, arthritis, surgery and injuries. When we have pain we want to know what is causing it. We assume there must be something damaged and that causes our pain. The problem with this is that the majority of us are walking around with some degenerative joint disease, disc protrusions, tears in our shoulder rotator cuff and all kinds of things that look like damage YET we have no pain. Conversely, you can have a lot of pain and all the imaging shows that there is no damage. This can be extremely frustrating for someone in pain. Take a look at this rather dry post that details a number of research studies showing the poor relationship between joint damage and pain.
However, sometimes damage certainly does lead to pain. If you break your arm it will hurt. But in a week, that arm will still be broken but you can be out of pain. I also know, that many people with hip degeneration are in a lot of pain, they then get a hip replacement and they are out of pain. This is wonderful.
So why does some damage end up leading to pain and other damage doesn’t?
Several factors can contribute to our experiencing pain. The leading theory on pain is the Neuromatrix Theory. In a crude nutshell, it suggests that the brain ultimately decides how much pain you will feel. The brain takes in all kinds of information and then makes a decision. With a recent injury we think that you feel pain, swelling, weakness, tightness, guarding all because the brain is trying to protect you. The area of the injury will get more sensitive and your brain can get better at producing pain. The brain thinks that pain is a good thing. Unfortunately, pain can persist for a long time after the pain is useful. For whatever reason the brain, your nerves, your muscles, your immune system, your endocrine system all stay sensitized. Its now easier for you to feel pain.
But none of this is all in your head. In fact, this is how athletic excellence works
The brain learns and you become a better athlete/guitar player/knitter
In some ways we can think of pain as habit. Our nerves and brain get better at making pain. Now, I know this sounds like I am saying this is psychological because I’m talking about the brain. But would you ever say its psychological when you get stronger after working out for 6 weeks? Of course not, but after exercise training much of the reason we get stronger or perform better is because the brain and nervous system become better at the task. This is similar to what happens with pain. We get sensitized and better at producing pain.
Pain is neither a barometer or a GPS
The pain we feel gets out of whack with any damage we have. The pain becomes the bigger problem than any wear and tear. Pain is now a poor guage of how much injury there is. Pain is also horrible for telling us where the problem is. Where do people feel pain when they have a heart attack? Their arm, neck, chest and back. There is nothing wrong with their arm. This is how we need to think about pain. It is just an alarm that goes off.
The overly sensitive alarm
If a fire alarm goes off in a building we have no idea if the alarm is due to a large fire, lighter held underneath a sensor, a little bit of smoke or even some problems with the wiring. We can even put of the fire and the fire alarm will still go off. This is how we can think about the pain alarm that goes off in our body. It can stay on long after any damage has healed. You can even think of pain as a cranky toddler. The pain or response of the toddler is often out of proportion to their injury. At an unconscious level this is what can happen with our body. A disconnect between damage and pain and we are left with screaming joints or muscles.
Again, the pain is not in your head
You might ask why I keep talking about cranky nerves and a cranky brain when you know that there are problems with your muscles and your joints. I would probably agree with you. When we have pain for awhile we move differently. We can get weaker, we can get stiffer, muscles can compensate, you might slouch or limp or move poorly. All of these things can either be caused by your pain or can be contributing to it. Addressing them can be helpful but surprisingly it is not often necessary. Often, we can change your pain immediately and you will have immediate change in strength or range of motion.
Treatment is about decreasing the sensitivity of the system
You have threshold to where you feel pain. Treatment is about increasing this threshold. This can be done a number of ways. Good treatment should try to address as many different factors that influence pain.
The significance of everything above means that you can have damage. You can have joint degeneration and certainly can have the normal wear and tear associated with arthritis. Whats great is you can change the amount of pain that you feel without ever changing the amount of arthritis, wear and tear or even damage in different body parts.
Treatment helps turn down the sensitivity of our nervous system.
See here for a description of my treatment approach. But what we need to remember is that since pain is influenced by many factors many things can influence the pain we feel.
Related Pain Links
1. Pain videos
Don’t get me wrong. I
love respect the core. But you can’t open a running book, magazine or blog without hearing how important it is for runner’s to train the core. I agree with this to some extent but for 10 years I have advocated for three points to keep in mind when it comes to runners and core training: (more…)
The piece was part of a companion piece on resistance and “core” training for runners. The thrust of that piece was that general resistance training should come first before gut-blasting 5 session/week plank marathon sessions should occur.
Purpose: core exercises are rampant and extremely hyped. They are much too popular and I think many athletes not working with strength coaches focus on the core and perhaps neglect other body parts. A not at all new thesis is that many simple core exercises can be replaced by compound exercises that have other goals (e.g. train the legs) but still require great core activation.
This brief post has two main points:
Static stretching is not going to kill your performance
Static stretching is not a cure-all
Further, nothing in this post is even remotely new.
Below I have created neurodynamic nerve slider pictures. I use them in handouts for patients and now you can too! They are strongly inspired (ahem, completely based on) David Butler’s work.
share with you and your staff how a decade or so of research is transforming our understanding of how we create a strong sturdy center that anchors all of our movements
As a father of two young girls (5 and 3) I really appreciated your views on healthy sports participation, concerns about body issues and the importance of fun in physical activity. Like you I am also a physiotherapist with a special interest in spine function. I am also a chiropractor, was a spine biomechanics researcher, I completed a MSc in Spine Biomechanics with one of the authors of the references you cited (Stu McGill), I have published a few papers on trunk muscle function (here, here and here) during a variety tasks and was initially very interested in doing research on the lowly and often derided abdominal crunch (here and here). I love talking about spine stability and how much of this actually old research (I don’t think it’s emerging, most has been around since the 90s) is applied to clinic or sport in ways that the research does not actually support. I am also a former recreational gymastics coach and regularly “threw back tucks” after two beers at parties well into my twenties. (more…)
I had a discussion with a Physio friend of mine about a blog he wrote championing performing scapular stability exercises before rotator cuff exercises. Because I am bit of a picky bitch I immediately thought that while I can see the clinical rationale for it I don’t think the muscles actually do this in practice and thus we had a respectable difference of opinion. From some old EMG reviews I knew that some of the best exercises to train the lower traps (with out upper trap activity) were actually lame old rotator cuff exercises. A couple of years ago I made a few graphics that illustrated this (prompted by a similar discussion on Mike Reinold’s blog).