Your Posture Sucks and You're Out of Alignment

Training Injuries
1

I post these because I’m tired of all the “my posture is poor/pelvis out of alignment/hips retroverted/L leg longer than R/spine pronated when it should be supinating/core is weak…” Even if these are in fact true, they cannot be reliably palpated and their validity is questionable at best. The structure and alignments cannot be changed and have not been demonstrated to occur with manual therapy or improve outcomes. The exercise chosen for back pain does not matter so long as it’s exercise of some sort with a directional preference in mind.

I’m sure this will create some back-lash. If you plan to lash out, do so with research/evidence or science. Opinion and anectdote need not apply. An example of this would be “it worked for me/mom/dad/brother/sister/cousin’s step brother’s dad.”

If this does anything, it may save some folks from spending lots of money.

More later…

2

http://www.cpdo.net/res/page15.html

More about made up issues in the spine

3

Your foam rolling, pushing on tissue or stretching doesn’t change the tissue…

Threlkeld, A. (1992). The effects of manual therapy on connective tissue. Physical therapy.

4

If its all in your head then you should be able to just ‘beleive’ it away and you would never have any troubles.

Summary of articles :

-Todd Hargrove and Paul Ingraham talk sh1t about most health practitioners

-They state that pain is ‘complicated’ and mainly just in your imagination.

-No alternative ideas are offered.

Not very useful IMO.

If he cant offer alternatives whats the point in even opening his mouth ?

5

[quote]olifter1 wrote:
Your foam rolling, pushing on tissue or stretching doesn’t change the tissue…
.[/quote]

Why do you lift weights ? Tissue trauma wont change your tissue or change your posture.

Basically you should be able to sit in a chair with some contorted, flexed posture for 10-12 hours a day and it shouldnt have ANY effect on how you move when performing other activites…

…because pushing on tissue or stretching doesnt change the tissue.

6

This is a very inetersting topic. In fact I’m doing a research dissertation on it at the moment.

From my findings, both the “structuralist” views and the “anti-Structuralist” views are very imbalanced and all or nothing in their approach.

I swing to the side of “anti-structuralist” from what Research I have carried out so far BUT I believe a balance has to be found between the two.

If you are interested in aleternative ways of looking at chronic pain, look up
The fear avoidance model of pain. Also look into CBT.

Now. In my own opinion and personal experience, I have benefited greatly from using a modified version of CBT to treat chronic pain.

Look up “Back Sense” by Ronald D. Siegel

It may come across as quackery, but it is well referenced from reliable studies and research. not just some nutjob saying pain is all your head.

7

Field,

You have taken what is being said in these writings and neuroscience out of context. ‘In your head’ and ‘output from the brain’ are completely different. Pain can be thought of as a ‘multi-system output from the brain’ (Lorimer Moseley). To say it can be ‘imagined’ away is also out of context. We have plenty of research supporting that pain can be reconceptualized leading to better outcomes. Understanding pain is effective for chronic pain. This understanding must be consistent with science and not what many healthcare practitioners think. Most physicians in healthcare utlized a biomedical model suggesting tissue pathology has a positive correlation with pain. This is incorrect. This idea was created in 1664 by Rene Descartes and called ‘specificity.’

How can you explain the reality that is phantom limb pain or studies that can have a subject feel pain in a fake body part?

As far as comparing resistance training to foam rolling for tissue trauma, you are comparing apples to oranges here. One is directly impacting a contractile tissue (lifting weights). The other (foam rolling) is attempting to change a tissue by going through another (skin) thus spreading a force and not showing any change in the tissue. The improvement is neurodynamic.

Stretching has not shown to change muscle structure when performed in typical fashion. To actually increase muscle length you MUST add sarcomeres. This does not happen with normal stretching routines. It would take 6-12 hours of continuous end range stretch to add sarcomeres. After you stop this, the muscle will return to its previous structure. A more likely scenario is improving your neural tissue tolerance to stretch. Please don’t talk about contractures, because this is another apples to oranges comparison. Mr. Field, before you get irritated and flustered, please attempt to provide some form of research to support your rants.

pgtips,

The fear avoidance model is interesting with more and more literature coming out. Dr. Steven George from the University of Florida has some good work as well as Crombez. I agree with the effectiveness of a CBT approach. In the end a biopsychosocial approach can ensure we are approaching patients with pain from all angles.

8

I think this statement relates to the “pain gate theory” correct? As I understand it currently GP’s will perscribe tricyclic anti-depressents to treat this, generally around 25mg.

I’ve posed the question to numerous physicians as to why they don’t consider that the pain could be originating from an un-healed tendon/ligament strain/sprain, in cases of CLBP. The response I’ve always gotten is that after the acute inflammatory phase, which generally lasts about four to six weeks, although it can last longer, the strain/sprain will have healed. After that they consider you to be dealing with “pain gate”.

What I find interesting is that physicians tend to treat acute inflammation with NSAIDS, and injections of cortisone. Quite bizarre really.

olifter, I’m assuming you’re possibly a medical practitioner. Either way you seem to have studied the theories of both modern and alternative medicine. Is what I’m saying in accordance with one of the current methods of dealing with CLBP? What are your opinions on the subject of “pain gate” as it relates to CLBP, if that is what you were reffering to in the above post?

9

VexeN,

No. The gate control theory (Melzack and Wall) was a theory proposed in the 1960’s. It demonstrated that nociception could be modulated from the top down and at the spinal cord. It was the first theory to support the central nervous system’s role in the pain experience. It was the basis for transcutaneous electrical neural stimulation (TENS). By applying a stimulus to the periphery and activating fast transmitting receptors (A-beta), the signal travels to the spinal cord quicker than slow A-delta and C-fiber thus ‘shutting the gate’ to nociception.

In the 1990’s Ronald Melzack proposed a more thorough theory that fulfilled the inability for previous theories to explain the brain mechanisms during the pain experience. It is known as the pain neuromatrix. This takes into account cognitive, sensory, and emotional experiences to create an output response that is pain perception, motor patterns and neuro-immune, neuro-endocrine responses.

So, if the pain gate theory was effective for treating chronic low back pain, TENS would be effective, correct? The same could be said for ice, heat, etc. This is simply not the case. When pain becomes chronic and tissues have healed we can longer rely on the periphery to explain pain. Why? Pain exists as an multi-system output system from the brain. This does not mean ‘it is in your head.’

As far as using NSAIDS, injections and cortison for acute conditions, there is a chemical reaction to acute injury. These interventions are used to relieve the symptoms involved with chemically mediated pain. In some cased, relief is substantial. Using these interventions for chronic pain, not so much.

10

olifter I apologize I honestly didn’t read any of the articles. I’m in fact hesitant to even reply because I’m short on time but I wanted to clarify something.

I’m not sure if I am misunderstanding the point you are trying to get across (which is possible because I didn’t read the articles), or if you’re misunderstanding the point of why many PTs and coaches recommend stretching/foam rolling/correcting body alignment.

I believe a huge purpose of this (in their mind) is to PREVENT injury and therefore prevent chronic pain in the first place. The purpose of these activities as far as I understand it is to increase ROM, decrease fascial tension, and prevent your body from functioning in a disadvantageous position in the first place. Of course, it is then assumed that as any injury heals and gets stronger it is beneficial for the athlete to avoid putting oneself into disadvantageous positions to reduce the potential for re-injury.

There is absolutely a huge neural component to pain, and research would appear to show that this includes chronic pain. I’m really not sure this would come as a surprise to even those who don’t read biomedical literature, because of certain people’s fascination with certain sects of monks for example who are able to completely ignore obvious pain stimuli to their body. Or people who are able to ignore the sensations of cold or heat that would otherwise intensely bother most humans. I’m not sure “ignore” is the correct word here… perhaps “control.” This of course would be getting more into conditioning of the mind and psychosomatic medicine… but alas.

The point I’m attempting to make here is I think it’s silly to dismiss the benefits of techniques structuralists would support just because of phantom limb phenomena and other indications of the role the nervous system plays in pain. Your body doesn’t start off in pain. It gets injured due to various mechanisms (many being due to structural imbalances I would dare say), and the neural aspect becomes a COMPONENT of the problem thereafter. And if you don’t think structural imbalances affect pain in someone’s body please tell that to everyone who benches 24/7, has terrible shoulder pain, then includes lots of pulling movements and their shoulder pain magically goes away. Or tell that to the guy who works a forklift and is constantly cranking his neck around in one direction for his 10hour work shift 4-5days a week and ends up with neck pain 6 months later, or the guy who has shoulder pain after playing competitive tennis for 5 years. Although I am a huge fan of evidenced based medicine and think it is vitally important, I think it too easily provides a bandwagon to jump onto before the other wagons get researched and catch up.

I do however appreciate your knowledge and critical thinking, and agree that the treatment of pain will likely get better as the years progress and we have more research into certain mechanisms such as those you are suggesting.

Best,

DTC

11

[quote]olifter1 wrote:

The structure and alignments cannot be changed and have not been demonstrated to occur with manual therapy or improve outcomes. The exercise chosen for back pain does not matter so long as it’s exercise of some sort with a directional preference in mind.

[/quote]

You’re seriously suggesting structure and alignment can’t be changed?

…Then why do you follow that with “even if it does change, it doesn’t improve outcomes.”

So it can’t be changed, but if refutes your absurd law, it still doesn’t matter? You’re contradicting your own argument.

I just had reconstructive ACL surgery with a hamstring autograft, a medial meniscal repair, a partial lateral menisectomy. Please explain to me how my structure and alignment has not been changed because I see five holes in my leg that declare otherwise.

I just went from sitting against my chair to leaning forward in my chair, I’m pretty sure my alignment changed.

Furthermore, who the hell ever said all you need to do is change your alignment and you’ll be out of pain? The vast majority of the people, at least on this site, suggest correcting how you MOVE along with your alignment. And how you are aligned impacts how you move. I don’t see many people saying, “Yeah your hip is retroverted, you need to change the shape of your bone by doing this exercise which will cause anteversion and bring the hip back into neutral.”

I see very few people say, “Just get cut open, you’ll be all good then.” At least here.

Even one of the links you posted suggested alignment and whatnot IS important. They just said it’s not the only thing you should focus on. Who is arguing against that?

Lastly, don’t exclaim for us to not use anecdotal evidence WHEN YOU POSTED A LINK THAT USES ANECDOTAL EVIDENCE.

12

BReddy,

thanks for joining the discussion.

“who the hell said all you need to do is change your alignment and you’ll be out of pain?”

http://chiromt.com/content/13/1/17

The foundation of this discussion was based on non-surgical/non-invasive procedures such as manual therapy and exercise. If I made any suggestion toward surgical intervention, I apologize. The articles and links provided have citations to back their claims. While written by individuals making suggestions, references were provided. Obviously, performing a surgical procedure can change the structure of tissue. A tibial osteotomy or spinal fusion for a grade 4 spondylolisthesis would be examples. Whether or not they improve outcomes is another story.

“You’re seriously suggesting structure and alignment can’t be changed?”

With non-invasive procedures, yes.

“even if it does change, it doesn’t improve outcomes.”

Let’s look at exercise for chronic low back pain:

PT/DC/DO etc utilizes exercise “A” for back pain “B.” Back pain improves. PT/DC/DO determines A fixed B. This is known as a ‘post hoc ergo propter hoc’ and a logical fallacy.

The same can be said for a spinal manipulation:

PT/DC/DO provided manipulation for back pain. Back pain improves. Manipulation fixed hypermobility/subluxation/ERS/FRS. When we look at research on manipulation and joint position changes, this does not occur.

However, when we look at the VAST research, the underlying theories that are suggested to improve low back pain via exercise (feed-forward, feedback, muscle hypertrophy, strength, endurance, TVA/multifidus muscle thickness, latency periods, etc) do not show a link between physical performance measures and pain. The most plausible explanation is a cognitive-behavioral response.

13

I don’t care what happens for most people I care what happens for me.
Science might (correctly) report that treatment x does not help 99.9% of the population.
Does that mean treatment x will not help me?
No.
Treatment x might in fact help me.
It might be unlikely that it will help.
But certain things might make it more likely
E.g…

I might be fairly different from most people on factors that matter.
I might work a hell of a lot harder in the gym than most people.
I might be eating better than most people.
I might do my rehab exercises more than most people.

And so on…

14

alexus,

thanks for your comments. Throughout this discussion I not have suggested a treatment or intervention may or may not provide a person with relief of symptoms. All I’ve done is bring light to the ‘why’ and the mechanism in which an intervention may take effect.

Have you ever questioned ‘why’ a treatment helped you or ‘why’ you improved? Reading your comments I would expect you to have a better prognosis no matter what you had occur. You demonstrate an active coping style, history of exercise, healthy habits, etc. These all have been demonstrated to improve the prognosis for low back and neck pain, not the intervention provided or exercise utilized. These certain things make it ‘more likely.’

I look forward to your reply…

15

[quote]olifter1 wrote:
Your foam rolling, pushing on tissue or stretching doesn’t change the tissue…

Threlkeld, A. (1992). The effects of manual therapy on connective tissue. Physical therapy.[/quote]

Pressure on tissue doesn’t change it? Will keep this in mind next time I get punched in the kidneys.

16

tyciol,

I’m not sure how this relates to anything in this discussion. This discussion is based on conservative interventions; manual therapy, exercise, foam rolling, massage, ‘tissue release’, foam rolling, S.T.S.I (scraping the skin with instruments) etc routinely used in rehabilitation/healthcare settings.

A punch to the kidney’s is not something I have seen in a therapeutic environment or healthcare in general. Your comment speaks volumes.

To follow up on your comment, the discomfort you may have does not mean plastic changes occurred within the tissues. In most cases, the tissue trauma that results will heal to a similar fashion as before. If you are bound and determined that a tissue change occurred, this change does not result in significant changes that create improvement. An example would be someone that feels it necessary to press an elbow deep into a sore spot or deep pressure massage. No evidence of improved outcomes with increased pressure. No evidence that tissue change did occur.

17

i am a big big fan of placebo response. i think that people are really very unfairly dismissive of it. here are some of the reasons why i like it:

  • it is EFFECTIVE. not any more effective than placebo, obviously, but more effective than not getting a placebo at all. very much so. something like 24% more effective than the absence of placebo. that is pretty fucking good.

  • while there are some nasty side effects associated with placebo they aren’t any worse than the side-effects associated with non-placebo forms of treatment. more than the absence of placebo, but then that isn’t terribly effective, either…

i’m being slightly facetious. but only slightly.

  • does anybody know whether they have tested wether INFORMING a person that they are about to begin a course of (effective) placebo treatment undermines the placebo response? i’m very interested in this with respect to ethical issues around informed consent…
18

alexus,

You are correct about the placebo response. You are also correct about the ethical issues involved with it.

this is a free full text. Written by some very respected fellows in the physical therapy world.

http://www.ingentaconnect.com/content/maney/jmt/2011/00000019/00000001/art00003

19

I have always wondered why some practitioners get caught up in things like leg length differences that are small (>1 cm)

However, if we accept the fact that we can not change tissue length, and that exercise choice not not matter for patients with back pain, what are we as manual practitioners doing that’s helping our patients? Is it one giant placebo effect? We know that exercise will activate the descending pain inhibitory pathway, are you suggesting that the modulation in pain is purely through mechanisms like these, and not the fact (is it a fact?) that the patient for example learned how activate the gluteii and as a result placed less stress on the hamstrings?

Intriguing discussion.

20

I see an osteopath. One of the best things I have ever done.