Archives For December 2013

courtesy of encyclopaedia.wikia.com

courtesy of encyclopaedia.wikia.com

I recently wrote a post which was in response to a review of “Becoming A Supple Leopard” by Kelly Starrett. The reviewer took issue with both the lack of reference to scientific studies within the book, and Starrett’s failure to refer to current pain science (by looking only at postural/structural/biomechanical causes of pain). The same theme cropped up in an article called “Back Pain Myths: Posture, Core Strength, Bulging Discs” from the website ‘Better Movement‘.

“Back Pain Myths” states that the majority of physical therapy and corrective exercise done in the USA is based on incorrect assumptions, and concludes a consideration of the evidence for each ‘myth’ as follows: “..there is little evidence to support the idea that we can explain pain in reference to posture or that we can cure pain by trying to change posture..”; “…if a large percentage of pain free people have bulging discs, then how likely is it that a bulging disc is the cause of your back pain?”; and “..the current evidence states that there is nothing magic about core strength as means to prevent or reduce back pain…”. It is not surprising that some might take this as an attack on their practice.

There is no doubt that pain is a very complex subject, and that, especially in the case of chronic pain, the sensation of pain may not be caused by an injury, postural fault, or structural defect. It seems to be clear too that there are many people who have a disc bulge (or several disc bulges), without any symptoms at all. If nothing else this would seem to be good grounds not to rush into a surgical procedure if you are diagnosed with a disc problem. I can’t argue that Todd Hargrove (the author at Better Movement) doesn’t make some legitimate points – it is always good to have our beliefs and assumptions challenged – and we shouldn’t fall into the trap of letting popular wisdom become dogma.

A typical example of the ‘Back Pain Myths’ content is reference to various studies that fail to show any link between poor posture and pain (and it is interesting to read that other studies show a stronger correlation between back pain and stress levels, job satisfaction, exercise etc). Hargrove does refer to a study that seems to suggest a link between poor posture and pain, but hastens to remind us that: “it is important to remember the rule that correlation does not equal causation“. I like this mantra and am inclined to repeat it quite often myself. However, it is perhaps also worth mentioning that non-correlation does not equal non-causation – if a study fails to find a link between one thing and another it does not mean that there is none (I think that this idea is more normally expressed as: absence of evidence does not equal evidence of absence).

Again, we’d be foolish to pretend that someone’s pain isn’t an intricate tapestry, but I’m not inclined to feel that the foundation of the way that I work is being critically undermined by articles such as this. Dysfunction, poor movement patterns and stabilising strategies may not cause someone pain now, but they may cause tissue damage that could result in pain at a later date, or have a knock-on effect on a nearby structure that may become the cause of pain. I know, there’s a lot of ‘may’s in that last sentence, and I believe that’s partly because it’s very difficult to conduct meaningful studies on humans. That is to say, it is probably impossible to account for every variable between study subjects (even if we were to be able to treat humans as we treat beagles, chimps etc.), so we cannot expect any studies of pain triggers, or potential treatments to do better than show some correlation – and we know the rule about that.

I believe that the majority of studies that have been conducted would seem to indicate that exercise of nearly any kind (shall we just say ‘movement’?) is helpful for back pain sufferers, and one kind of movement doesn’t seem to be better than another. I don’t think it matters that we cannot prove the efficacy of a movement discipline, if the result is that people increase their awareness of their own bodies and thereby move and position themselves in a ‘better’ way than they were previously able to. Another thing that would be very hard to study is how the sense of empowerment from a movement practice might impact someone emotionally or psychologically, and thereby have an effect on pain sensation. Failure to prove these things does not make us charlatans.

To return to ‘Back Pain Myths’, I have to acknowledge that Hargrove’s article finishes with questions: “why do these approaches seem to work; how can so many people be wrong; and if these aren’t the true sources of pain, then what is?” So, despite the lack of science, he acknowledges that ‘these approaches’ (from the article we must assume that he refers to making postural improvements, surgery, and core stability training) seem to work. Interesting… Reading further, Hargrove turns out to be a fan of Eyal Lederman, who wrote a famous/infamous article entitled “The Myth of Core Stability” which, for me, speaks volumes about his outlook. You can easily find “The Myth of Core Stability” with a search of the internet if you wish (I tried to include a link but each time I tried to open a page I got an automatic download and, trust me, I’ve more copies of this article than I need). Lederman does an, apparently, able job of rubbishing the notion that there is such a thing as core stability, provided you accept that he fails to actually define what ‘core stability’ is, and doesn’t include an explanatory quote from any of the practitioners whose work/theories he questions. (I’m no lover of the term ‘core stability’, and I suspect this is true of most Pilates teachers. At the same time, I can’t fault anyone for trying to understand and explain how our brain controls our muscles and movement. I’m inclined to think that they are engaged in trying to find explanations for things that Joseph Pilates, for example, recognised as being true without the need or equipment to figure out why.) Lederman’s article is full of scholarly references, and he undermines the theories of those he calls ‘CS practitioners’ by means of those references to conflicting evidence. That SCIENCE trump card again. (One of those studies, at least, involved methods of testing trunk stability hilariously far removed from a ‘real-life’ situation).

Hargrove is a Rolfer and Feldenkrais practitioner. Lederman is an Osteopath. I do not wish to disparage any of these practices, but/and I’ve found it very difficult to track down any proof for their efficacy, or superiority to other practices, on PubMed, or any other websites. Yes, pain is undoubtedly a complex subject, and it is a very good idea for anyone working with people in acute or chronic pain to be aware of current theory. We cannot overlook the psychological/emotional component to, particularly, chronic pain. A very recent experience of mine (anecdotal, sorry) seemed to show that helping someone to understand how to effectively stabilise their midline (core, if you wish) had a positive impact on their confidence, and sense of self-worth, which had been seriously undermined by back pain. Yes, it only ‘seemed’ to help – I cannot prove it, and I don’t suppose the person in question would feel the need to have proof.

If people may be being routinely harmed by a practice then there is clear reason to question it. Does this mean that an unproven movement practice should be avoided, or that it is invalid? Er, NO.

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Prove it!

December 1, 2013 — 1 Comment

X YI recently came across “Back Pain Myths” via pilatestree.com, from a website called ‘Better Movement’, and a review of Kelly Starrett’s book ‘Becoming a Supple Leopard’ from a website called ‘Exercise Biology’, that both use science, or the absence of it, to question, or indeed attack, the beliefs and practices of many practitioners working within the sphere of exercise and rehabilitation. Somehow it feels as though this is a popular subject at the moment.

To paraphrase outrageously, the thrust of these is that if scientific studies cannot be found to support an idea, the idea must be wrong. “Back Pain Myths: Posture, Core Strength, Bulging Discs” (to give it its full title) sets out to show that anyone who has suggested that poor posture, lack of core strength, or bulging discs are a likely cause of someone’s back pain has not kept up with the science, and is barking up the wrong tree. (More about ‘Back Pain Myths’ in a post to follow). Our man at Exercise Biology levels the same accusation at Starrett: “He is literally taking your hand and walking you back to the dark ages of physical therapy of the 1950’s, when we used to believe pain comes from joint, tissues, bad posture and movement.” (Good thing that the OED had revised the definition of ‘literally’ to include ‘metaphorically’ as one of its meanings). To be fair, the book’s subtitle: ‘The Ultimate Guide to Resolving Pain, Preventing Injury, and Optimizing Athletic Performance’, leaves Starrett open to this kind of critique (if you are deliberately obtuse and overlook the fact that the book is manifestly about all three things combined, and not just resolving pain).

I don’t suppose that it will be news to many of us in the Pilates world that the causes and manifestation of pain are complex areas, and that there is strong evidence that people can have, for example, multiple disc bulges and no pain. Many of us may be familiar with the work of Butler and Moseley, who wrote the excellent ‘Explain Pain‘, and will know that (oversimplified) pain is a sensation produced by our brain, based on information it has received from somewhere in the body, that it has filtered through near enough every sensory input (physical experience, anecdotes heard, films watched etc) it’s ever received. Small wonder that experience of pain seems so highly individualised.

The International Association for the Study of Pain defines pain as: “An unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage.” So, the role of pain is to alert us to the likely need to change our behaviour, which seems pretty straightforward, and supports the idea that a poor position could indeed trigger a pain response. Of course, it is complicated, especially in the realm of chronic pain, and when someone experiences pain with no identifiable symptoms. Whilst I am familiar with, at least some (Butler/Moseley), current pain theory, I’m not ready to dismiss the possibility that how someone moves and holds themselves may have a bearing on the inputs that their brain receives. According to Anoop Balachandran (Mr Exercsie Biology), who is a fan of the ‘biopsychosocial’ model of pain, the biomechanics (usually termed PSB: postural-structural-biomechanical) model of pain “is now outdated, unscientific and incomplete..” Incomplete it may be, but if someone has pain that is clearly mechanically derived, and resolves the pain by changing their mechanics, that can’t be dismissed. (Nor would it somehow serve to disprove the idea that there is a valid biopsychosocial model of pain).

I don’t want to give into what may be flawed logic, but I’m sure that many of us will have seen the positive outcomes achieved by helping people to understand and change poor posture or movement patterns. I have no studies to fall back on to prove it, and accept the fact that we cannot prove that Pilates, for example, works. A solution that appears simple can still be a solution. Balachandran writes: “I wrote an article back in 2005 about the myth of posture and pain and ended the article saying Now close your eyes, take a deep breath, slowly slump – and savor the freedom of movement”.” He ‘knows’ that this is a sound thing to be saying, because no-one has yet conducted a study that can show conclusively that there is a relationship between posture and pain. I ‘know’ that it’s a ridiculous statement, because I’ve never seen anyone moving well, or freely, from a slumped position. I know that I went from being a chronic pain sufferer, to being pain-free because I learned better movement patterns, and better positioning strategies. I know that my joints fitting together as well as possible, and the surrounding soft tissues being supple and elastic will help me to avoid dysfunction – and I’m positive that, pain or no pain, that’s a good thing. To quote him again: “The more you talk about biomechanics, joints and movements, the more you are raising the threat level in the brain and making the pain chronic. This is exact reason why current pain science involves educational sessions to change people’s belief about the role of their muscles and joint in pain. Just changing the beliefs about pain has been now shown to lower pain, disability score and improve ROM and movement.” It may be that my beliefs about pain were changed during the first year or so that I took Pilates classes, I’ve no way of knowing that. It may be that counselling would have had a similar result, but we cannot prove it either way. A movement practice, and the changes in habit that followed, in my experience, resolved my back problem. I don’t need to prove whether it was a mental or physical change – it’s not provable – and it doesn’t matter. The practice was empowering to me in some way, maybe many ways, and that’s all that matters.

Ironically, Balachandran refers his readers to this interview, which is fascinating, and also includes the affirmation that Balachandran’s beloved BPS (bio-psycho-social) model of pain actually incorporates the PSB model of pain that he derides, as we saw above, as “unscientific” and “outdated”. His scathing review of ‘Becoming a Supple Leopard’ hinges on it being unscientific – given that Starrett doesn’t mention BPS, and that there is “no single scientific reference...” included. Ah, SCIENCE, the trump card. Balachandran makes it clear on his blog that he favours an ‘evidence-based’ approach to fitness. I believe that the only evidence that can be considered to prove anything comes from a randomised, double-blind study. I’m given to wonder what exercise we can undertake whose efficacy has been proven by studying groups of people, chosen at random, some of whom are undertaking the exercise without being aware of it, and supervised by people who don’t know who’s exercising and who isn’t. Thus, if he’s not basing his exercise on anecdote or observation, he is probably not exercising very much.

I’m not seeking to defend Starrett particularly (though I do think that BASL is a very useful resource), but a superficial reading makes it clear that the primary subject is pain that can be related to movement dysfunction, and that the evidence that he bases his work on is the success that it appears to have over his years of practice as a coach and physio. Isn’t it the case, in the realm of fitness (movement), that anecdote and observation are as reliable evidence of the value of a practice as any other kind?

Efforts to increase our understanding of how the human body works must be helpful, and science doubtless has much still to teach us. Particularly if we are working with people who have long-term chronic pain (especially that which doesn’t appear to have any biomechanics cause), it is helpful to have some understanding of the complexities of the biology of pain. That should not equal throwing the baby out with the bath water.

Starrett’s tagline for his work, attached to all the free material that he published to the internet long before the book, is “All human beings should be able to perform basic maintenance on themselves”. Listening to him it’s easy to believe, financial rewards aside, that he is motivated to try to make a positive difference to people’s lives – to make the world a better place. Perhaps those of us in the Pilates teaching profession all share that same desire.

Is the motivation to write a review of this book (which carries an implicit critique of any of us who’s work is often centred on the PSB model of pain) the desire to educate, to advance debate, or the desire to build a reputation?