Archive for August 2018

The other top 3 mistake people make with their Physio Treatment

The other top 3 mistake people make with their Physio Treatment

I recently wrote and article about the top 3 biggest mistakes I see people make when it comes to approaching their pain and injuries. (you can check it out here)

so I thought I’d add the biggest 3 mistakes that I think people make with their physio treatment.

1. Not having a goal or a plan

Let me give you an example. A few months back I saw a lovely 78 year old lady who her GP had referred to us to help with her low back pain. Now she has had quite advanced arthritis and persistent back pain for 30 years. (not that arthritis always means pain, but in this case it was pretty severe). She said to me at the start of the session:

“I don’t know why I’m even here. You aren’t going to be able to fix my back – nothing is”

No she wasn’t exactly wrong. I can’t change her arthritis. But in many cases I believe that’s not the most important thing. I asked her

“In a perfect world – ideally what would you want to achieve out of your treatment with us? How is this impacting your life that you wish you could change?”

Her answer was “I just wish I could wish the dishes or vacuum the floors without having to stop, or sit down for an hour after because my back was hurting. If I could get to a point where I could do that I would be so happy”

This is a completely different goal, and outcome for her than “curing her back”. Realistically in this case it’s unlikely we will be able to get her completely pain free, but now we had a goal and a plan, and this was ABSOLUTELY achievable for her. We worked out a plan for some hand on treatment and a lot of exercise work to be able to build her up to a point where she could do those things. And you know what? she can vacuum the floors without stopping now. Once we had a goal and a plan we were able to work together towards impvoing her quality of life and getting her where she wanted to be.

2. Expecting Miracles

oh-youve-had-this-problem-for-2-years-tell-me-again-how-it-should-magically-disappear-in-1-session

The unfortunate truth is usually the longer you’ve had a problem, the longer it will likely take to resolve. This is because you get neurophysiological changes, more stiffness, more weakness, protective patterns, altered movement patterns, etc, etc.

(Happily the opposite is true too. A study in hamstring injury came out last year which found that if you start treatment within 48 hours of injury then, on average, you would get back to sport 2 weeks quicker than if you started treatment later).

Some problems can get better very quickly, but by and large it takes time and work.

for some reason people often have two conflicting view points. They are very concerned that their problem will never get better, but then they also expect it to be cured immediately. In most cases neither of these are true.

3. Not following through

Another unfortunate truth is that there is often a big difference between feeling “ok” and being actually 100% better. Pain is a warning system (and a very complex one at that) so it is unreliable to base our management entirely on if you have pain or not.

As a good example – we know that following an ankle sprain you are at 50% risk of re-injuring that ankle within the next 12 months. That’s 1 in 2 ankle injuries that are destined for multiple sprains! That’s a terrible outcome. (How would you feel if you got a new battery for your car but 1 in 2 of them would fail?)

BUT – if we ensure you do at least 6 weeks of neuromuscular retraining (that’s strengthening, balance and stability retraining) after the pain resolves then your chance of re-injury is more like 10%. It is actually irresponsible of us to not ensure that your are not only pain free, but back to 100% strength, movement and function AND ensuring the problem is not going to recur or become ongoing. Anything less is, I believe, poor management.

Now you (the public) don’t know these facts and statistics, so once you start to feel “ok” the motivation to continue doing the work can wear off. This unfortunately leave a large percentage of people who are out there only 70-80% better and likely to have further problems down the track. And it’s true that many health professionals don’t necessarily communicate these facts very well to help you understand WHY you need to keep doing the work (or having further treatment) once you are starting to feel ok.

If you were an athlete, and you suffered a hamstring injury – you wouldn’t stop all management once you could move around without pain and run. you need to be able to sprint from a cold start 100 times in a game, and jump, and stretch, and back that up with training every day or two, and keep that up for 6-9 months without a break. This is the difference between many elite athletes and regular people. Everyday people can end up with dodgy hamstrings (or knees, or ankles, etc) because they never get to fully rehabilitating their problem. Elite athletes do the full amount of work to give them the best chance of 100% long term recovery.

Bonus: Not doing your share of the work

The reality of life is people are busy (and a bit lazy) so we find a lot of people don’t get around to doing their homework. We may see you for something like 1/168th of the week, so that’s a very small impact we can have on your life time wise. That’s why you will often get ‘homework’ from your physio. Things you can do for the other 167/168ths of the week that are going to significantly accelerate your progress and mean optimal recovery and avoiding recurrence.

There was some research done over 15 years ago that showed that about 1 in 10 people completed there home rehab exercises! That means 90% of our clients aren’t getting the fastest or best outcomes because they aren’t holding up their end of the bargain.

Everyone who comes into the clinic just wants to lay down on the treatment couch and have someone else “fix”them. Sometimes there are issues that only require this, but usually there is some work to be done to improve capacity, endurance, mobility, strength, etc.

We help those who help themselves :)

(Actually we’ll try and help you even if you don’t help yourself at all… But it would make our job a bit easier if you do a bit too)

 

Julian Bowen

Julian is the Director and Principal Physiotherapist at EMC Physiotherapy.  He has spent  over a decade working exclusively in private physiotherapy practice, and estimates he would have performed over 40,000 individual treatments in that time. He has worked with everyone from Paralympians, elite athletes, WAFL Footballers, the Defence Forces and weekend warriors; to thousands of everyday people with all manner of issues.  He is passionate about injury prevention and has a special interest in the treatment of headaches, shoulder issues, hypermobility management and exercise rehabilitation for the prevention and treatment of injuries. 

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The Top 3 Mistakes People Make with their Pain and Injury

The Top 3 Mistakes People Make with their Pain and Injury

If there were a few pieces of advice that I would love to give to everybody to help them the most with their pain and injuries – the following would be it. These are big picture things that I end up talking to people about nearly every day.

For the most part these “top 3” mistakes aren’t going to cause anyone any serious harm (unless they miss a bad diagnosis) but these would save a lot of people a lot of time, money and heartache.

So below are the top 3 mistakes I think people make with their pain and injuries:

They don’t do anything at all!

Before I had kids, I would go to parties or gatherings, and nearly every night when people found out I was a physio, someone would ask “hey I’ve been having this pain in my (whatever body part) would you mind having a look at it?” (nowadays it’s more likely to be parents at school)

Normally one of my first questions would be something like “how long have you had it for?” and they would usually say something like “aw like 4 months” (or 2 years!?!)
Then I would say “wow you’ve been putting up with this for quite a while. Have you seen anyone about it?” and they would ALWAYS say “Nope”

And here’s the biggest issue I always see with people and pain. So many people are just walking around in pain and not doing anything about it. Some studies have estimated that 25-30% of people are experiencing musculoskeletal pain at any one point in time! How long do you have to put up with a sore arm before you decide you can’t put up with it anymore? Ow badly does it have to be affecting your quality of life before you get of the couch to do something about it? Or seeing as you’ve had this problem for 2 years it’s now a big, chronic complicated problem when it could have been a quick and easy fix 1 year and 50 weeks ago.

Sure, you don’t have to go running to a health professional with every boo-boo you get, but if it’s negatively affecting your life and not going away (or getting worse) for the love of Odin’s beard go and see someone about it. We usually find that the quicker we get to assess and start correctly managing a problem, the quicker it will get better.

You are making (mostly incorrect) assumptions about it

Now as an example – I’m no mechanic and I only know the basic of maintenance of cars. I can replace a tyre and a battery and that’s about it. If the problem isn’t one of those things I’ve got no idea what to do. What I wouldn’t do is just go along my merry way thinking “it’s just a crank handle sensor (is that a thing in a car?) – it just needs some whatever-I-might-have-read-on-the-internet and it will be fine”. There’s a very good chance my car has a completely different problem and my assumptions are doing nothing to fix it.

But there are so many people we see who have decided they know what their problem is already (and don’t get me wrong a good health IQ and knowledge of your condition is paramount so I think it’s great people nowadays are informed) but if you don’t know what the problem is, how can you do the right thing to fix it.

Regularly people will come in – “I’m pretty sure it’s a pulled muscle, so I’ve been putting heat on it and stretching, but it’s been weeks and it’s not getting better” when once we get down to the actual problem we might find that the heat and stretching weren’t helping because they were actually prolonging the problem. To solve a problem, you first need to

  • Accurately identify what the problem is, then
  • Provide the correct solution for that particular problem.

Pain is a complicated thing (as is the human body). Every week I see someone who has been trying to fix their shoulder pain, when the actual issue was their neck, or their back pain when it was actually a hip issue that was causing all the problems.

I don’t try and fix my car myself, and if your body isn’t progressing how you want it to, maybe you should get more expert help too.

(I’ll record a video soon to tell you the story of my friend Kim who thought for 2 years that she was allergic to chocolate because every tie she ate it she got headaches, only to find after abstaining for two years she had an entirely different problem).

Trusting the internet for everything

Let me tell you a story of a patient I saw many years ago (around the time that Bikram Yoga was just hitting popularity – that’s important for the story).

So this patient (let’s call her Jill) hurt her back. Common story – she bent over and twisted and felt a sudden quite severe pain in her low back on one side. This was really quite sore – she couldn’t straighten up, she was stuck leaning over to one side, the whole deal.

So she limped over to the computer and started googling “what’s good for back pain?”

And she came across a few articles and videos about yoga being good for low back pain.

So she decided (after this expert advice from the internet) to go and book in to a 90 minute Bikram Yoga class (34 degrees and all). Now Jill could hardly move, but she pushed herself through 90 minutes of sweaty smelly pain to try and help her back. After a bit of movement, she did feel a little looser

BUT

The next day she was sooo much worse. She couldn’t get out of bed, and it took quite a few days to just get back to how she was before the yoga session.

Now Yoga certainly can be very helpful for long term and mild low back pain (to improve flexibility, postural endurance and functional capacity) but trying to fold yourself in half is not a good idea when you are in severe pain and can hardly move.

As another example – I looked on WebMD once (out of curiosity) to see what it would say my abdominal strain was. It’s top 2 likely diagnoses were

  1. Pregnant (I’m a guy), or
  2. Ovarian cancer!

The internet is a wonderful place where you can learn just about anything you want. But sometimes it just can’t replace a real person who can think critically, and problem solve according to your specific context.

I estimate that when I see a new client and they say I’ve googled it and I think it’s this – over 80% of the time those people end up being wrong.

One final thing about the internet (and I absolutely understand the irony seeing as you are likely reading this on the internet – unless someone has kindly transcribed the entire blog onto a toilet stall somewhere) is there is no quality control on the internet, and we all tend to assume that all information on the internet is equally valid or accurate. For some reason we as people don’t seem to be very good a critically appraising what we read on the internet.

So what should we do?

If you have a problem and it’s negatively (or severely) impacting your life – please consult a healthcare professional who will be able to tell you

  1. What the problem is, and
  2. What you need to do about it

If you are trying things you think should be helping and they aren’t – go and see someone who can help.

And by all means be informed and aware about your problems, but don’t place the opinion of the internet (or faceless strangers on Facebook who’ve never met you or seen you and your exact problem) above the opinion of highly skilled and trained health professional who literally do this for a living.

And one final (and a little more sobering thought) – very rarely we would see someone who has been putting up with a problem for a long time, or even having other treatments for a long time without benefit, and eventually when we see them we realise something’s not right and it ends up being something more serious (like a kidney infection, or your gall bladder, or sometimes even cancer). This is the worst outcome of trusting the internet and putting up with problems – something that may have been treatable early on becomes something that it’s too late to do anything about.

Now I don’t intend to scare anyone, as this is very very rare, but it never hurts to be mindful of these things (we obviously always have to be).

But just to make sure I finish on a happier note… here a picture of a cat :)
kitten stretching

Happy not-mistake-making

Julian Bowen

Julian is the Director and Principal Physiotherapist at EMC Physiotherapy.  He has spent  over a decade working exclusively in private physiotherapy practice, and estimates he would have performed over 40,000 individual treatments in that time. He has worked with everyone from Paralympians, elite athletes, WAFL Footballers, the Defence Forces and weekend warriors; to thousands of everyday people with all manner of issues.  He is passionate about injury prevention and has a special interest in the treatment of headaches, shoulder issues, hypermobility management and exercise rehabilitation for the prevention and treatment of injuries. 

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The problem with ergonomics

The problem with ergonomics

If you work on a computer at all, chances are you may have experienced some neck or back pain while toiling away at that keyboard. If you work in a large organisation or for the government, you’ve also probably had a workstation assessment done at some point. Occupational pain is a massive problem – studies show about 1/3 of all computer workers experience neck or back pain every year. In Australia alone that’s millions of people suffering because of their computer work!

Companies are trying their best (and rightly so) to look after their employees and this often involves ergonomics assessments of the workstation and appropriate adjustments. The main aim of this is simple – reduce the workload and effort required to do the work, so you reduce the strain the worker’s body is under. Easier work = less pain, right?

BUT, there’s one big problem with this – the evidence that ergonomics interventions work is inconsistent and contradictory. Just as many people DON’T get better with workstation adjustment as those that do. Chances are some of you out there are in this exact situation. You’ve got the perfect chair and the perfect computer and workstation setup, you’re sitting in the perfect position – but you’re STILL getting headaches, or neck pain, or back pain.

And in my opinion, here’s why:

“We spend so much time and money modifying the work environment and task to suit the individual, but we put zero effort into modifying the individual to suit the task.”

Now I’m not saying that ergonomic intervention isn’t important – it definitely is. Providing a safe and appropriate work environment is very important to keep workers safe and reduce the risk of injury. Ergonomic changes reduce the total workload that the worker is under (hopefully). My gripe with ergonomics is that this seems to be the only intervention. The assumption that once we place the worker in a “perfect” position and ensure they don’t deviate from that, then everything should be fine. The problem is it’s not.

Here’s a few other reasons why you might be in pain even if you’ve already had the perfect workstation set-up:

  1. You don’t have adequate physical capacity to perform the tasks.

This is the biggest contributing factor that we see in practice daily. You don’t have the strength, or postural endurance to manage the tasks you are doing all day. As the days wears on, (and the days and weeks) you get more and more fatigued with the workload – which can lead to a whole range of pain issues. This can even include just sitting in one position for long periods of time.

As an experiment try holding your arms out in front of you (like a zombie) and not moving for five minutes. Chances are after 1 minutes you’ll be starting to fatigue, and not many of you out there will last a full five minutes. It’s too tiring and too sore. Now this was only holding one position for 5 minutes. If you’re working on a computer, you’re in the one position for up to 8 hours per day. If you don’t adequate postural endurance for your muscles to hold you in these positions all day, no wonder you’ll be getting sore.

A recent study even showed that strength training was the most effective form of treatment to reduce neck pain in office and computer workers. More effective than adjusting workstation setups, more effective than fancy chairs, even more effective than standing desks! Improving muscle capacity was the best way to reduce pain. By INCREASING the worker’s endurance and strength, their muscles fatigued less and they experienced less pain!

Now I know that if I was working as a roof carpenter (for example), I wouldn’t last one day without back pain. The main reason for this is I’m not conditioned to that type of work. Conditioning for the required tasks is imperative for all physical activities. We know that poor conditioning is a massive risk factor for injuries on the sporting field, and the workplace is no different. You need to have the physical capacity to do the required tasks, for the required duration and to back that up every day.

  1. Your work posture isn’t your biggest risk factor for developing pain.

Studies looking into causes of occupational pain due to computing found the biggest risk factors for pain were:

  • Working more than 7 hours per day at the computer
  • Poor job satisfaction/sense of control
  • Never or infrequent breaks
  • Poor sleep (less than 6 hours per night)

So, what this tells us is how long you do the tasks (in particular how long at one go without a break) is a strong predictor for pain. This also relates back to my first point regarding muscle fatigue. Frequent breaks mean you get a chance to recover and perform different movements and positions, reducing fatigue and sustained postural load. It also tells us (which has also been shown with mountains of research) is that people who are happy/satisfied at work are less likely to experience pain.

Poor sleep means more fatigue. It also increases injury rates across sports and in the workplace. Unfortunately, sleep isn’t a work issue, but a personal one. If you’re struggling with pain at work and you average less than 6-7 hours sleep a night, you should probably get to bed a little earlier.

  1. Changing behaviours is more important than changing workstation setup.

Everybody who works in an office has heard that they should be taking regular breaks, stretching and moving around more to reduce the risk of pain. Unfortunately, the large majority of people just don’t do it. Now I know you’re busy, and it’s annoying to stop what you’re doing in the middle of something. However, it’s a lot more inconvenient to miss work because your headaches are getting too much. In a lot of companies, the culture is to tough it out and work hard – which doesn’t look after employees’ health at all.

Some larger organisations have computer programs that stop the worker every hour to remind them to have a break, but you can over-ride them. Most people I talk to with these programs find them annoying too, and turn them off whenever they can. It’s great to have these tools, but if they are not used properly they are really no good to anyone.

Unfortunately, people do need to take some responsibility for themselves (yes, even when they are at work). If you aren’t following OHS procedures (like pre-start/warm-ups, or regular breaks as prescribed) then maybe this is the place to start with addressing your issues. If you are up all night watching Netflix, and you’re tired and sore at work, then you should probably go to bed earlier. If you don’t have the physical capacity to do your job, then no amount of fancy chairs and keyboards are going to improve that. You need to go out and exercise, or get to the gym, or start doing Pilates, or get some expert advice on what you need to improve to stop your issues.

Take away messages

  • Despite my ranting, ergonomic assessment is a very useful tool and changing workstation setup can go a long way to reducing the load and strain on your body. If you have a shocking workstation, and your posture while working is terrible, then maybe changing the ergonomics of your work setup is a good idea. Just remember that this is only one part of the solution.
  • If your workstation isn’t too bad, you really should look at your behaviours. Are you taking regular breaks? Do you spend more than 7 hours per day stuck in front of the screen? Are you getting enough sleep? Do you do anything else to counteract all that sitting in front of the computer?
  • If you are having problems (particularly is it gets worse as the day progresses) you should really look at implementing some strengthening into your life. 2-3 times a week for 12 weeks will do you a lot of good (focusing on your neck and shoulder of course).
  • If you keep having problems despite proper OHS (and a lot of you are) you probably need to look at improving your physical capacity for your work. If you struggle with maintaining your posture during the day, or you are getting tired or sore, you probably need to start improving your strength, endurance (and maybe mobility). Improving your body’s tolerance to work mean the work you do is easier in comparison. Being stronger is one of the best injury prevention strategies. Being stronger makes life easier.

 

Julian Bowen

Julian is a Director and Senior Physiotherapist at EMC Physiotherapy.  He has spent  over a decade working exclusively in private physiotherapy practice, and estimates he has performed close to 40,000 individual treatments in that time. He has worked with everyone from Paralympians,  elite athletes, WAFL Footballers, the Defence Forces and weekend warriors, to thousands of everyday people with all manner of issues.  He is passionate about injury prevention and has a special interest in the treatment of headaches, shoulder issues, hypermobility management and exercise rehabilitation for the prevention and treatment of injuries. 

References:

  1. Kari Babski-Reeves, Jennifer Stanfield, Laura Hughes, Assessment of video display workstation set up on risk factors associated with the development of low back and neck discomfort, International Journal of Industrial Ergonomics, Volume 35, Issue 7, 2005, Pages 593-604, ISSN 0169-8141.
  2. Brewer, S., Eerd, D.V., Amick III, B.C. et al. J Occup Rehabil (2006) 16: 317. Workplace interventions to prevent musculoskeletal and visual symptoms and disorders among computer users: A systematic review. doi:10.1007/s10926-006-9031-6
  3. Demure, Bernard MD; Luippold, Rose S. MS; Bigelow, Carol PhD; Ali, Danielle RN; Mundt, Kenneth A. PhD; Liese, Bernhard MD. Journal of Occupational & Environmental Medicine: August 2000 – Volume 42 – Issue 8 – pp 783-791 Video Display Terminal Workstation Improvement Program: I. Baseline Associations Between Musculoskeletal Discomfort and Ergonomic Features of Workstations
  4. Xiaoqi Chen, Brooke K Coombes, Gisela Sjøgaard, Deokhoon Jun, Shaun O’Leary, Venerina Johnston; Workplace-Based Interventions for Neck Pain in Office Workers: Systematic Review and Meta-Analysis, Physical Therapy, Volume 98, Issue 1, 1 January 2018, Pages 40–62, https://doi.org/10.1093/ptj/pzx101
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