Welcome to the PT Nihilism blog...just kidding. I am being melodramatic. It is probably more accurate to say "welcome to an agnostic-PT's-stream-of-consciousness".
In all seriousness, I am mad about knees-over-toes guys and other similar social media accounts. I am not mad at them, just about them. Allow me to elaborate further:
I don't follow him. I haven't critically evaluated much of his stuff (or any other social media stuff for that matter). But quite frankly, I think it's great that a lot of social media accounts are promoting movement. Sure, I bet I could pick a few bones with some of the messaging, but hey, no one is perfect. And the more people moving the better. Just look at the CDC statistics showing increasing rates of chronic, preventable diseases in the USA (chronic disease, obesity rates). Clearly, the USA needs to move more (as well as other targeted interventions to address these complicated issues).
What I am mad about is that none of this information is new. This is stuff the Rehabilitation community (I am lumping PTs/OTs/Chiros/Orthopedic MDs and other providers together) has known for a long time--or should have known. And yet it takes someone without a qualified degree/education to make the information approachable, accessible, and motivating on a social media platform. THAT is PATHETIC. To be clear, I am not putting down knees-over-toes guy. I am putting down "Rehab".
It seems relatively impossible for the orthopedic world to be on the same page about anything. We promote messages that are fear-laden, catastrophizing, pathologizing, plain confusing, and often contradictory. Just go to your favorite browser, image search "knee arthritis" or "disc herniation". And you get terrifying pictures of things that are colored in red, with 10-cent medical jargon plastered all over the website.
These images are scary. And while they accurately describe the pathology/disease, they don't equate well to the illness (the actual symptoms someone feels). And then we wonder why people diagnosed with arthritis are scared to move and become increasingly disabled?
I want to believe that medical providers are well-intentioned. That we have said things to patients that were truly in their best interest. But communication is really important and can have profound effects on people's quality of life if we are not careful. So rather than continuing to rant, I would like to present some general principles & supporting literature to underscore my argument that all movement is good movement.
# 1 Adaptability
The human body is adaptable. The human body is adaptable. THE HUMAN BODY IS ADAPTABLE. Don't believe me? Here are some scientific studies to support this claim.
Rowing paper & Cycling paper: both studies show that when humans either do repetitive bending against a force (rowing) or are in sustained bent postures (cyclists) lumbar discs adapt positively (thicker, more hydrated) when compared to controls.
Massive Lumbar Disc Prolapse paper: verbatim conclusion:
It is safe to adopt a ‘wait-and-watch’ policy for cases of massive disc herniation if there is any early sign of clinical improvement.
Where clinical progress is evident, 83% of cases of massive disc herniation will have sustained improvement.
Only 17% of cases will have recurring crises of back pain and sciatica.
If there is evidence of clinical improvement, massive disc prolapses do not appear to carry a risk of major nerve damage or cauda equina syndrome.
Massive disc herniations usually reduce in volume and by 6 months most are only a third of their original size.
Osteopenia/porosis paper: Older women with bone scans consistent with either osteopenia or osteoporosis completed an 8-month exercise program of HEAVY lifting (>80% on back squat) and some jumping activities to stimulate bone adaptation compared to a low-load program. Those that stressed their bones with heavy weights were able to either significantly slow bone changes or add bone mass.
Non-surgical ACL paper: There is some emerging evidence that some people do quite well after an ACL tear by just managing with conservative care (PT, strengthening) rather than getting surgery immediately. This is definitely emerging evidence, so keep your eyes peeled!
There is similar data for multiple other areas: meniscus tears, rotator cuff tears, and more!
If you're not into reading scientific literature, maybe I can convince you with some real-world examples.
The deadlift record is 501kg (1104.52 pounds). See Hafthor lift it here.
The oldest competitive power lifter is a 100-year-old woman from Florida. She benches 45 lbs & deadlifts 110 lbs.
The current 24 hour running record is...wait for it...192.25 MILES. Y'all, that is a 7:30 min/mile pace. Set in 2021 by Aleksandr Sorokin.
Appropriate progression of stressors, leads to adaptations to those stressors. This is why there is no "wrong way to move", but rather things that are within our stress-tolerance and things that lie outside of our stress tolerance. That is why those real-world examples show humans doing CRAZY things and not instantly exploding into a million pieces. Because they trained really hard, over a long time, to adapt enough to tolerate that activity.
To summarize point #1: the human body is adaptable.
#2 Variability
This one can get tricky to explain without writing a tome. Plus, this area of research is DENSE. The smartest people I know are motor control people. And I definitely don't have a firm grasp on a lot of it. But Dr. Latash lays it out relatively simply in this paper.
Basically: we are designed to solve movement problems. As with all complicated problems, there are multiple ways to solve the problem and arrive at the same answer (called "redundancy"). And really, for the most part, it doesn't matter how you solve the problem so long as you arrive at a satisfactory conclusion. Just what the heck am I talking about? Take Dr. Latash's explanation of swinging a hammer:
The goal of swinging a hammer is to hit a specific target. In the example above, the goal is to the end of a chisel.
The motion of swinging a hammer involves a bunch of muscles and joints (shoulder, elbow, wrist, hand/fingers). Which means there are millions of different combinations to create the goal output: hit the chisel.
If we track how the expert blacksmith swings their hammer, we see 2 main things. 1) They almost always hit the target (and not their thumb). 2) The pattern of swinging is different EVERY TIME.
Okay, so what is point? The human body will self-organize to achieve a movement goal. Everyone's body will do it a different way. AND THAT'S OKAY. In fact, it is amazing. This is why telling someone the "correct" way to move doesn't really make a whole lot of sense. Your PT cannot realistically boil down the insane complexity of self-organizing movement and tell you that you should "always lift with a straight back" because that is "safe". Honestly, it actually constrains your inherent, amazing ability to solve movement problems and makes you less efficient at figuring things out.
Just take a look at Dr. O'Sullivan's work on those suffering from persistent, debilitating low back pain. His work, and other's, show that people suffering from long standing back pain actually demonstrate LESS variability with movement. This decrease in variability has been hypothesized to be part of the reason pain persists longer than expected.
I also love Dr. Meira's discussions about quadriceps strength and ACL rehabilitation. Without going into a bunch of detail (I recommend you read his blog, here) his opinion is that quadricep strength is EXTREMELY important in returning-to-sport post-ACL repair AND reducing risk of re-injury. A common clinical test for readiness to return-to-play is to look at jumping, cutting, and hopping tasks. What I find so fascinating is that people that do not have adequate quadriceps strength often will pass these clinical tests. So what gives?
Because we are designed to solve movement problems, these athletes figure out how to jump/hop/skip/cut as good as anyone else WITHOUT their quadricep working like it should. Of course, this becomes problematic if you need your quads to work during a game situation and they can't (increasing your risk of re-injury). But the point still remains: the human body will figure out how to perform a meaningful goal however it can.
#3 Beliefs Matter
This is where I risk getting the most rant-y...but beliefs about an outcome matter. A lot. Many qualitative studies are showing that patient beliefs (and provider beliefs, for that matter) have important effects on recovery from an injury...and beliefs are often the least addressed aspect of patient care during a medical appointment. Check these out: patient centered care, shared decision making, expectations, beliefs, patient perceptions, patient led goal setting.
And this is where I can turn an (hopefully) informative blog into a very long, boring soapbox-sermon on all-things-movement. So I will try to avoid that now. I think this is our biggest failure as a collective group of providers ("rehab"). Medical interactions, education, testing, diagnosing, etc, etc, etc are not set up well to have open communication with patients. This leads to poor communication. At it's best: confusing communication. At it's worst: a set up to induce fear and create more healthcare spending. Maybe an example will help me with clarity here:
Back pain. The big elephant in the room in medicine. Guess what? It is extremely common--both prevalence and incidence are high across the lifespan. It is almost always benign (citation). In fact, we are so bad at understanding what is causing the average case of back pain, we have come up with a name for it "non-specific low back pain". That means we cannot, and should not, attempt to identify the cause. Multiple international guidelines (see that citation above for an international position statement) state a few general suggestions: screen for scary stuff (cancer, infection, etc), DO NOT take an image if not warranted (i.e. no scary stuff is thought to be present), give people reassurance that most cases improve in 4-6 weeks, and to stay active both at work and in daily life.
Understandably, this is a hard message to communication to patients. And maybe hard to believe as a provider. Often, medical providers hear "how can you know what is going on with my back if you do not take an MRI/X-ray/CT scan?". But really, all we can do is RULE OUT pathology (cancer, infection, etc). And we can do that confidently. Studies are suggesting that the scary stuff happens only 1-5% of the time; and typically these cases stick out. However, many, many things can cause back pain. And most of the things you see on an image do NOT correlate to the symptoms someone feels (citation).
Really great infographic on 10 things everyone should know about back pain:
But what do we actually do in practice? Take images. Poorly communicate those images ("you have the back of an 80 year old", "this is the worst knee I have ever seen"). Overprescribe medication. Overprescribe rest & time away from work. Blame insurance companies for not getting you the care that you "need". And then send you to a rehab professional. This is where it really gets ridiculous. Once you get to that professional's office--you get some form of passive treatment (massage, electrical stimulation, laser therapy). Some low-level exercise program (if you are lucky). You get a bunch more education that isn't supported by evidence or international guidelines (stuff like: don't lift over X pounds, don't bend your back, lift with your legs, your core is weak, your joints are out of alignment, etc). And then you get told to come in 2-3x/week for some indefinite amount of time that completely ignores robust evidence that states the exact opposite.
And here is the kicker...a large majority of people STILL get better. BUT, now a larger percentage of those patients are at risk to develop chronic back pain that is likely iatrogenic. Iatrogenic is fancy medical term for "caused by the medical system". In fact, a study looked at the effect of non-concordant (meaning not aligned with best evidence) medical interactions in relation to development of chronic low back pain. Lo and behold, more bad advice/treatment leads to more bad outcomes.
Allow me to make it crystal clear: most back pain is akin to the common cold. Generally, the medical community doesn't over-treat common colds. People don't end up seeing 4 specialists, get 3 scans, 2 injections, surgery(ies), change jobs, and have their lives completely up-ended by the common cold. And why not? Because the COMMUNICATION, and EXPECTATION, is very clear. You have a benign condition, that most times resolves on its own. We are confident at this time you do not have something more serious. Do some things to manage the symptoms in the meantime, but don't completely shut your life down. If it doesn't improve in the expected timeframe, we will double check a few things.
What if the medical community treated back pain like the common cold (and as most guidelines suggest)? What if we communicated clearly; addressed patient concerns; and supported people with positive reassurance and watchful waiting; all the while providing best care that results in the best possible outcomes for most people? I dare not dream. But maybe, just maybe, we would stop contributing to an increasingly complicated problem.
The summary point for tenant # 3 is: communication and experience inform beliefs. And beliefs play a large role in recovery.
Summary
My initial goal with this first blog post was to dispel some myths and provide digestible explanations for anyone reading this, regardless of education level. I hope I achieved that.
I also hope that this didn't come across as dismissive. Pain and disability are very real, life altering issues. If you or someone you know is suffering from persistent pain, I want you to get the care you need. We want to help and education is only part of the treatment.
There is a ton of nuance to everything I wrote above. And I think this one blog post could go on for hundreds of scrolls dissecting that nuance. But I hope these complicated topics were an easy starting point for you to generate more curiosity and exploration, and perhaps, more faith in medicine.
Lastly, I am jokingly a die-hard pessimist. But in reality, the 3 points of this "movement manifesto" are some of the most optimistic messages I can imagine: 1) the human body can adapt to do incredible things 2) the human body is not constrained by arbitrary rules governing movement that some dude in a white coat told you 3) communication is a vital part of any human interaction, and can have profound effects on wellness.
Stay well and keep moving,
-TW
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