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Quantum blog #3: Reality really is relative

Welcome to the last instalment of this series on Quantum Mechanics, focused on our perception – and therefore our patient’s perception – of reality. This topic is so relevant for any clinician and you may be thinking that, ‘this is A, B, C stuff, so why the hell would I waste 5-10 minutes of my day listening to you ramble about it?’ Well, it’s a good question and hopefully I can answer this in one blunt statement, ‘is it really that simple?’

Do we know all that we need to know to make firm conclusions about this topic? If you have been following the last couple of blogs on Quatum Mechanics, or are scientific in any manner, then the answer should be pretty evident – absolutely not.

But, to be honest, I start from the same biased position as many of you might when entering this topic – it should be very simple, to understand our patient’s perspective. In fact, going further, one might think (and I tend to agree) that we get told this is a core skill as a health professional. After all, allied health professionals are meant to be the experts in empathy right? Seriously, there is data here – we’re supposedly better than doctors AND EVEN TRADITIONAL CHINESE DOCTORS (Ref). So, in my mind, the ability to appreciate and understand your patient’s version of reality should be simple, it should be the mark that separates the good clinicians from the great clinicians. At least, this is what I’ve told myself for the past 10 years (yes I told myself this at university… OK!?).

Once again, though, if we understand anything about the natural world and the make-up of the universe, is that it may not be that simple. And maybe what we do, when we apply our expert analysis of the perception, drivers, intent and behaviours of our patients, isn’t what we really think we are doing… Let me explain.

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Consciousness; is it actually this simple?

Theory of Mind

Theory of Mind is the ability to recognise and attribute mental states – thoughts, perceptions, desires, intentions and feelings – to oneself and others and to understand how these mental states might impact behaviour. (Ref)

We’ve all got it, apparently. Like an X chromosome, it’s an innate trait that we are born with. It develops as we age and interact with other humans – sometimes it can go astray in conditions like autism. It explains why you can delve into your ‘heuristic’ system of thinking – System One thinking – and pretty quickly come up with a map of why your patients may have come into your cubicle or clinic. You attribute intents and desires behind their actions and behaviours, and there you have it, you start with your first question,

“Tell me your story”

I’m not saying that your practice of attributing meanings is wrong, mind you, just that it is not quite as right as you might think. And don’t worry – I still think starting with the above question is absolutely the best way to go in the clinical scenario, because what else do we have if not the patient’s story – a bunch of meaningless tests, amongst meaningless data, which doesn’t correspond to the patient’s phenomonen of pain – useless as tits on a bull. For reals.

To my point; the theory of mind, our practice of this in clinical situations and in general daily life is simply the process of human’s telling stories to themselves. And you can weave a story any way you like, it doesn’t make it real. The theory of mind, believe it or not, is still just a theory; there is not and never will be, any discernible evidence for thoughts or feelings attributed to actions – these are stories we use to understand how other people behave. The issue with people, is that they are unpredictable and their story might not match yours – because after all, you got into this game because you are a rational, reasonable and thoughtful individual – so unlike your patients right!!? So maybe the mountains of data that you diligently get from your patients isn’t the only thing you collect, that is useless..

Let’s get this out of the psychological realm – because I am woefully out of my depth – and bring this into the quantum realm – where.. I am even more woefully out of my depth.

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Perception is reality

You’ve heard of Schrodinger’s Cat. Great little thought experiment – there’s more wacky people doing these – from none other than Edward Schrodinger (get right out of town!), which elegently poses the problem with interpretation of quantum mechanics. That is, that any quantum phenomenon (like atoms, which we are all made up of), can exist in multiple states at once, until observed – or interacted with – by an external system. It is the process of observation that makes the world so, in short the world actually is really what we make of it.

Observation causes the wave function collapses into one definitive state – reality. But it is slightly more complicated – observer and object are then instrinsically linked and coupled – to form our reality. One cannot exist without the other.

It doesn’t take Einstein – or Schrodinger – to figure out where this is going. It is a fundamental fact of the natural world that your patient’s reality is theirs, and only theirs. We know that the pain phenomenon is a subjective experience, but now you can back that up with quantum data! It might only really transmit if your patient is a physicist though.. so probably don’t mention that.

So what?

Ok, so I have rambled for long enough and present my two presuppositions. The theory of mind is just stories we tell ourselves, no more real than any fairy tale you listen to as a child. And the nature of reality is such that it is truly a relative experience that can’t actually be shared by another conscious being. But what’s the takeaway you ask?

If you understand that your patient’s stories may not mean as much as you think they do, then this can be a liberating experience. Once you understand that some stories exist, in our patients minds, not actually in reality, simply to exist and not to impart meaning onto actions – because we may actually simply create that meaning in the first place – you may be left with a sipmle decision. Where do you want their story to go? Who cares where it has been – it doesn’t mean much anyway!

This is another way of saying something I have been saying for years, and maybe what has lead me to progress into the roles I am now in. If we get caught up in being reactive, and ascribing meaning to where there may be none – in a patient’s pain presentation – then there is limited room to change the future path for them. Do we want to manage someone and create no change, or do we want to look to the future for them and help them create that change? Rhetorical question- I think you know my bias there.

So if reality is relative, how to we get their ‘story’ headed in the right direction? Again, a fundamental theory of how the universe works, tells us that we live in an uncertain world that is only made concrete by our conscious perception. But extrapolating this is when things become very interesting; an uncertain universe means that the future is far from certain. Their reality is of their making, and maybe just maybe, they can understand that it can be different if we get this concept across.

Our job is to be teachers and open up more possibilities. Everybody – I mean absolutely everybody – is ultimately limited in their perception of reality, but people who come to us for help are much more limited. Our job is to open the door to other realities.

Teach an understanding of avoiding absolutes and understanding that pain, injury, difficulties are all going to happen – they are a natural part of our existence, in an uncertain, unpredictable universe. There are some simple things to practice to increase your adaptability to this uncertainty, namely being durable, potentially even anti-fragile. But nothing is unavoidable because of our uncertain universe. The beauty of our uncertain universe, however, is that we can choose any path to the future, there is always room for change and nothing is set in stone; it is up to us to demonstrate this possibility to the patient.

Once again, thanks for reading.

A heartfelt apology to my patient

I am writing this to say sorry to you. I’m sorry for a lot of things and through this I hope you understand more about what you need to be expecting from your health professionals and your health system. I am sorry for all of the bad experiences you have had. I’m sorry for all of the people like me that haven’t done the absolute best they could to help you. I want to apologise for them, because if I don’t you’re going to continue to think a certain way about us. When you come to us, you expect a certain level of service, and over time this level of service has probably not met your expectation – or if it has, you may be unaware of some things that could be better, things could be different for you. I promise that some of us are different, some of us think differently, we act differently and the health professionals like me want what is best for you and will do everything we can do to truly help you. I promise that you should be expecting more, you shouldn’t be settling for what you have had in the past.

Before I do that, I want to explain to you why it is difficult for health professionals to give you the experience you deserve. I want to explain why it is hard to manage people in pain and why it is hard to ensure you have a lasting resolution of your pain. You see, when you come to us in pain, you may also be troubled by other things. It isn’t obvious to you, but it is something we know also contributes to your pain and sometimes can be one of the main drivers for it. These other things make treating you more complex, and unfortunately we can alert you to these other things, but we can’t actually do very much about these things. These are things like if you’re having a stressful time at work or you may have had family issues for a while. We can’t change your boss, your colleagues or your family; we know they impact on your pain but we can’t change them. We can, however, let you know about the impact this has. In fact, there is a lot we can teach you and that is where I will, once again, apologise for those who haven’t taught you more. Because although there are some things that make your pain worse, which we can’t change, there are so many more things that we can change. This starts by simply telling you about these things, and I’m sorry for all of those health professionals that haven’t done this. When you come to us in pain, we know the best things you can do is not be afraid of that pain and to understand that you are not fragile or broken. I am so sorry for those people who made you think you were. If you knew more about how wonderfully fascinating your body and brain are, when they work together to form the feelings you associate with your pain, you would be as interested in it as we are! You wouldn’t be afraid of it, you would marvel at the amazing complexity, but awesome simplicity with which you are able to protect yourself. If only you knew more about the things that make your body and brain become overly protective and the things that make you think you are capable of less than you actually are. If only you were taught about these things by all those previous health professionals, instead of those people letting you continue to believe that you are less than what you actually are. I am sorry that you were lead to believe that you are less than capable, I am sorry that you think you are fragile, I am sorry that you have had to deal with health professionals that have never told you otherwise. Because the truth is, you are more durable than you know and capable of so much more than you think.

So it might be difficult to treat you when you come to us in pain, but it isn’t difficult to teach you some simple things that will always help. It is easy to tell you to stay positive about the outcome of your pain, because most things – and I mean most things – do get better whether you come to see us or not. It is easy to tell you to keep moving and to not be afraid of causing more damage, because these things help the most. These things are easy and I’m sorry for those people who don’t make you remember these things above anything else. I’m sorry that you end up confused and think your problem is more complicated than it needs to be. It really can be different, and we are working on it; but we need to be better for you and make you believe in yourself, your health and a better future.

For all of the thoughts, feelings, stories and yarns that you feel and have told yourself about fear and fragility; I’m sorry. Because I know that people like me probably caused a lot of that, and you trusted us to make you better, not worse. I am sorry that we are failing you when your only expectation of us is to help you. We are doing our best to change things, but it is still not enough; we need to be better for you and give you the experience you deserve, not a dim version of the one you’ve come to expect.

I will say, though, when you come to us in pain, sometimes you want to get better so much that you place all of your hard work on our shoulders. I’m sorry about this, because sometimes we are not brave enough to admit how little input we actually had into making your pain better. We largely do very little, and that’s the truth. I’m sorry as well, for all of those practitioners, who let you think it was only them that made your pain better. I’m extra sorry for those practitioners who preyed on you and ensured you returned to them week after week, year after year, whilst never actually giving you any way of helping yourself. I’m sorry that you’ve never been given the skills to help yourself and manage your pain like any other normal thing you have in your life – like getting old or changing jobs. You’re probably pretty well equipped to deal with these things, but somehow you’ve never been shown how to deal with pain in your life – well it’s pretty normal too and I’m sorry that you think we have all the answers. We need to do better, and believe me we are trying, to ensure you know the answers just as well as we do.

Most of us are trying harder than ever to find the answers and tell you, but some of us aren’t. For those professionals that you have seen that don’t pay attention to the up to date information, I am not only sorry, I am angry. And you should be too. We live in a more connected world than ever, with more information available at our fingertips than the entire history of humankind. For those people that don’t pay attention to this information in order to give it to you, there is no excuse for this. If you have come across professionals who do have their head in the sand; they were lazy and it hurt you in the process. You should expect better from us and don’t settle until you find it.

I’m sorry for all of those practitioners who made you think they had the answer, or a quick fix to your pain. I’m sorry for all of those practitioners who told you, ‘I definitely know what’s wrong with you.’ It hasn’t helped you and it’s just made you lose confidence and trust in us. The truth is, there is no miracle cure and sometimes we have to accept that we don’t know the exact cause of your pain. I’m sorry if you still believe there is a quick fix and that you just still haven’t found that one person that can find out the one thing that is wrong. It is understandable that you think that when you come to people like me, because you see it everywhere you go. I will say, it is difficult to do our best in a health system like this, where you see promotions for ‘pills’, ‘fads’ or ‘the latest gadget’ on everything from the TV, internet and social media. You’d be forgiven for thinking that this is, in fact, the best way to go – a nice quick, simple fix. But once again I need to apologise for those people, those companies and those platforms that make you believe this. It isn’t easy to get to a good place with pain, it takes a lot of hard work and time, but because of all of those things this is time you don’t want to spend. It’s not your fault, it’s ours; we need to do better for you. We need to tell you the truth about your pain and what you need to do to improve, for that I am sorry. For you to trust us again, you need honest health professionals and an honest health system, so let me start that off by apologising to you.

Take this as a heartfelt apology about not doing the best we can for you. We will encourage those that aren’t trying to be better for you, we will continue to search for the answers and be honest with you when we don’t know them. Please understand that we are trying and if you have been treated by someone who isn’t trying, then uknow that we’re not all like that – in fact most of us aren’t like that. If you are still being treated by someone who isn’t trying, then go find someone who is; you’ll be better for it and you can thank me later.

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Quantum blog #2: Durability, anti-fragility and … Quantum Mechanics

If you stuck around from the last blog, the first blog in this series related to Quantum Mechanics, then congratulations.. You made it through one of the least topically relevant pieces of absurdity that quite possibly exists in the health blogging atmosphere. If you’re just tuning in, and want to make your eyes bleed, then take a look at the first instalment in this series of blogs linking Quantum Mechanics and health issues here – seriously, it might make more sense to start at the beginning.

Or it might not, because if you learnt anything from a brief introduction to Quantum theory, it’s that not much makes sense. The world is, for all intents and purposes, a non-sensical place.

It is a place where, whether you want to believe this or not, randomness and chaos are the major players in daily happenings. Your daily schedule, which may be planned out to the micro-second (or not, if you know what’s good for you), is a futile attempt to create order in a disorderly universe.

You’ve heard of the Butterfly Effect? Yes, that movie with a verile Ashton Kutcher, which came out wedged around the time he was trying to air the stench of ‘Punk’d’ from his life and just before he got some baby-mama drama with Demi Moore. Well, it’s kind of related – it does a pretty good job! If you’ve seen it, you get the premise; a small change in a system can have drastic (larger and non-linear) effects at some other point in the system. It’s actually best explained with the title of the original article written by Edward Lorenz who presented the theory, ‘Predictability: Does the Flap of a Butterfly’s Wings in Brazil set off a Tornado in Texas?’. To trace this back a step, you may want to understand a little bit about Chaos Theory. Of which, the Butterfly Effect explains one aspect; the sensitivity to initial conditions is just a nice way of saying that when you have a small change somewhere, the divergence and chaos in the natural world ensure that you get a much larger change and effect further down the line. Chaos Theory also states that as you increase the time gap in your predictions, you increase the level of uncertainty about that prediction. But, of most importance, chaotic systems should actually be predictable if you know enough about the initial conditions and variables that impact the system. The problem generally is that, in order to get a full understanding of variables and initial conditions, you need to spend a long time gathering information. There are biological applications to Chaos Theory, but in my opinion, not nearly enough about one of the most important aspects to daily human life – movement.

In order to get more immersed in the field of randomness, then you must also understand a little bit (because that’s as much as I know) about complexity. Watch this quick video explaining the Cynefin framework of determining the best course of action when you are presented with various types of problems. When dealing with a lot of natural phenomenon, we are actually dealing with complex, random systems. So the following discussion is based on two presuppositions:

  1. Human movement is chaotic

  2. Human behaviour is complex

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Now to the juicy part and I want you to tell me; when you are dealing with patients, are you dealing with either of these problems in isolation? Probably not right.. So we need to understand the kinds of problems we are dealing with, and have an appreciation for when dealing with either, there may be different strategies to use. Lastly, what I want to get across, is that, it is our job to instil these kinds of strategies in our patients, and most importantly, we also need to help them understand these strategies for an empowered and functioning existence into the future.

Movement is unpredictable

Some background for you here, there is work into motor control and chaos theory. Mathmatical modelling in human movement is obviously not new, there are many a degree to undertake if you want to understand kinematics better. A read of Glazier & Davids (2009) review on current understanding of ‘self-organizing optimality’ may help you better understand where I’m coming from. The human movement system and performance optimisation may be best understood as a dynamic interplay between external factors impinging upon an individual. This co-ordination is self-organising, always individual, adaptive to all factors and dependent upon conscious and sub-conscious intepretation of all factors.

To put this simply, movement is an output of a chaotic, self-organising system. If you are stuck in the stone age of the ‘top-down’ motor control model, this may be a shock, but that’s a pretty simple take on a really bloody complex problem – movement – and you didn’t think it really was that simple did you!?

Some people may have read Frans Bosch and can resonate well with the idea of a self-organising system. But, he’s actually not just ‘crazy Dutch-man’ making this shit up whilst he smokes a bong and eats a pancake..

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He’s actually basing a lot of his work off some hard science into investigating motor control developement by Newell and colleagues and Kelso and colleagues. Movement – and the enhancement of this movement – should be seen as non-linear, chaotic and another biological system. Not the way it is currently viewed, as linear and mechanical.

Movement and performance is chaotic; it is non-linear, it has the capacity to be modelled, but is ultimately unpredictable.

So what are we doing when we rehabilitate or train?

Why do we squat? Why do we lunge? There is no doubt that there are some common movement patterns that are commonly performed by everyone – whether athlete or not. If you read Frans Bosch, you may think of training these movements as ‘deepening the troughs’ of ‘Attractors’. In other words, making a primary movement pattern easier and more co-ordinated. This sounds pretty neurological right? Well for the most part it is, but we are doing so many other things as well, however, and if aiming for muscular hypertrophy – which in itself is an incredibly vague term – you are creating a physiological response from muscle cells to create more ‘substance’ from which to create force. I think you can tell that this topic, in particular, could go on for a very long time.. Ain’t nobody got time for that and you probably want me to get to the point.. When we train – or rehabilitate – in the typical, common fashion, are we actually achieving much when it comes to the complexities of movement and performance? With a basic understanding of ‘dynamic systems’, heck even quantum theory, do these very predictable and orderly movements actually relate to movement in real-life??

Here’s what I think; I think there are some movements you need to perform well. These are our ‘attractors’; a non-exhaustative list is:

  • A squat pattern
  • A hinge pattern
  • A single leg squat pattern
  • A single leg hinge pattern
  • A horizontal push pattern
  • A horizontal pull pattern
  • A vertical push pattern
  • A vertical pull pattern

These are well established as primary movement patterns and comprise the basics of any comprehensive program. These movements basically just help you load someone up in a movement that someone else has designed an exercise around. It’s easy because unless you wanted to spend hours and hours trying to account for all variables in a skill and create each exercise based on that, these put simply just save time. Allow some physiological adaptation, but aside from that, I think they’re pretty useless. Most of our job needs to be to consider elements of unpredictability as these elements of ‘challenge’ mimic the real world and allows the system to self-organise. I think we need to be more aggresive and early with our ‘real-world’ challenges. It’s a lot to hold in your head, as you do need to understand tissue healing, strength training principles and periodisation but once these basics are fulfilled, there needs to be a real focus on increasing challenge on the system to create a more efficient self-organisation. I don’t think this challenge always has to be load either, I think we need to get creative with exactly how we are adding complexity and randomness to things.

So, do we achieve normal?

What is normal? You can prepare the body into any ‘perfect form’ that you wish, but ultimately what are you ahieving? The perfect biomechanical picture in many cases is not actually predictive of anything much except an projected idea of ‘normal factors’ gained from a ludicrous cherry picking of various aspects of movement that we know about, which have been arbitrarily linked – at best a retrospective causative analysis – in a controlled fashion. The obvious problem here is that retrospective causation does not prove prospective risk, because the future is ultimately undeterminable. This is especially true with something as complex as movement. There are countless example of ‘abnormal’ biomechanics being not only useful, but the most efficient:

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I know what you’re going to say here, ‘but Connor, you’ve railed against that logical fallacy in the past – the absence of evidence is not the evidence of absence- yadda yadda..’ And I would say ahaha! Right you are sir, but I’m not saying that we should all start to teach over-pronation and valgus in our squats, I’m saying that our practice of always avoiding things that we determine as ‘biomechanically incorrect’ is probably really flawed. We use these ‘biomechanical’ markers on a massive scale, with religious vigour, when it should only ever be another element to consider. If someone’s self-organising system has determined the best way for them to perform the action, is achieving ‘normal’ something that we need to spend much time on? Maybe we just need to have the basic pattern there and then start challenging the system (with load for example). In short, are we actually preventing anything if we get someone to do the perfect squat 100 times over? I want to add to this, that I really don’t know here, and think that the answer lies somewhere in the middle of ‘perfect form vs natural form’, but I also think we are a long way from the answer at the moment with our current practices. If we follow the Cynefin framework, we are trying to achieve stability in our interventions in a chaotic problem like movement. We want to force the system to create stability in different ways to avoid large ‘butterfly effects’.

So, do we prevent injuries?

If a system is truly chaotic, there is a limited chance of predictability, and therefore prevention of events. That doesn’t mean there are things we can do to protect ourselves against randomness. Understanding that most stable systems have very nuanced, multi-layered adaptations that have evolved to reduce disorder and create stability is a start. To reduce disorder is what we need to do and implementing things that do this is important like, reducing spikes in load – after all that is a disordered challenge on a stable system. I am particularly interested in taking the ‘prevention’ and reduction of disorder one step further. This is where we bring in the concepts of anti-fragility and durability.

Anti-fragility and durability

If a system is designed with minimal variables, then any change in one will have a catastrophic effect to the output. Movement is no exception, if we keep movement simple, then any change is inherently going to destroy the output that we want. For example if you only ever practice a squat with a box, and are then asked to perform this same movement free-standing with a bar across your back, you will have buckley’s chance of doing it right. This is a simple example, but if you extrapolate this to running and cutting like in a game of football, then you can see the issue. If you always practice with no challenge, then you sure aren’t durable.

So exposing the body – and motor output – to challenge is key to ensure more variables are incorporated to force stability. Once again, I think we need to be more genuine and thoughtful in our approach here. Enough challenge to force stability over time rather then to over-challenge is key. Because we will never approach any kind of worthwhile prediction in a chaotic system, interventions that challenge the system enough to stabilise and reduce the effects of further randomness are king.

In applying this to every day athletes or patients, it probably doesn’t matter how much they can bench press or deadlift after a certain point, what is key to being a more durable person is exposing yourself to a multitude of different movements, forces and situations.

Anti-fragility

Taking durability a bit further is then speaking about being ‘anti-fragile’. The concept comes from some of Ido Portal’s work and Nassim Taleb’s book of the same title. Essentially, in some systems, those that improve with disorder are then more ‘anti-fragile’ and resistant to failure. Common training programs do pretty much the opposite of improving your capacity to deal with disorder – they train you in repeating the same simple movement task over and over.

We need to start to think this way in performance optimisation and rehabilitation. And once again, we want to start thinking this way earlier in the piece to improve our outcomes. Exposing yourself to random movement is a good way to, at least, be prepared for the unexpected future. It is the opposite of ‘chasing normal’ and needs to be practised. But, I do think that once again, the answer lies somewhere in the middle; always practising random movements leaves no room to get genuine physiological adaptations for other key movements. These are our key exercises that we can use to apply basic strength trianing and overload principles. Once we have the basics covered, we need to force stability in other areas.

I do have some bias here, and you can probably tell. But I don’t think it is a bias that prevents the discussion about the reality of human movement and the natural world. We live in an unpredictable, random world and human movement is one chaotic system designed to reduce disorder and create some kind of output. If put in terms like this, I think the only way to produce a better output is to create a more stable system, and being logical the only way to create a more stable system is to force it to reduce disorder, force adaptation and expose it to more randomness. Not less. Our job should be to improve the capacity of individuals to appreciate this and learn to expose themselves to different movement, varied movement and continue a practice of anti-fragility.

Thanks for reading, and you wouldn’t believe it, but there’s more where this came from in the next instalment about quantum mechanics and the complex problem of patient behaviour. The underpinnings of perception – reality or just their reality?

The problem with the ‘Quick Fix’ explained with Quantum Mechanics

You may be thinking, what the hell does Quantum Mechanics have to do with a health blog? Well, I’ll tell you! And if you stick with me, there is some gold at the end of the rainbow. We can actually learn a lot from understanding the make-up of our universe and it can apply to some key principles in clinical practice. I’m going to do a series on Quantum Mechanics, so there’s plenty more where this comes from, and essentially if you don’t like thinking about physics, then you best tune out for a few weeks.. Please don’t.. I’m also most likely going to butcher the science here, so for any quantum physicists reading…..tumbleweed….cough.. OK, so for any of you who know a little bit about this, hopefully this doesn’t hurt the progression of the field too much.

When you think about it and apply some basic principles, the natural world becomes a fascinating, terrifying place of uncertainty and our living experience is a very limited and restrictive phenomenon.

–        The world is complex

–        The world is unpredictable

–        Quantum mechanics means events are fundamentally immeasurable.

–        Quantum mechanics means that when two systems interact, observation is only relative to the person observing it. So reality is, truly, relative.

The uncertainty principle and complexity

If you didn’t already know, pain is one of the most pressing global burdens; come on guys I write this in pretty much every blog post.. Keep up. One of things we see in clinical practice, that in my opinion is a major factor in propagating the trends we see in this global pain burden, is the creation of a dependent patient and financialising of those that suffer from very thing we want to treat, cure and manage. Once natural history, treatment seeking, placebo and other contextual nonspecific effects take hold of any clinical interaction, what is fairly clear is that the actual treatment effect may remain fairly small. Clinicians who are not able (or sometimes – worse still – not willing) to (either cognitively – or again – in conversation with the patient) separate themselves from this myriad of effects are piggy-backing their apparent ‘intervention’ onto these factors, essentially rendering all responsibility of the patient in all of this null and void. But I am aware it is called business, and repeat business is good in allied health clinical practice. Business is booming.. Which can be a good thing, but also leads to some more ‘unsavoury’ elements of competitive practices. One of which is promising a ‘quick fix’ to pain – whether this is manual therapy, exercise therapy, or any other therapy you can think of. The quick fix externalises any form of personal accomplishment from the scenario and places it squarely on the clinician’s shoulders. and I want to argue that from a theoretical standpoint, the very structure of our natural world is at odds with these kinds of claims. The very fabric of our reality does not support the ‘quick fix’ claims.

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The principle that is at the core of Quantum Mechanics states that we can generally only give approximates about the probabilities of ‘reality’. Watch this video and then report back.. Right, what have you learnt? If you are like me, then about 2m30s in you went cross-eyed and are fully able to appreciate my point underlying this. The human brain is inherently very poor at working in the space of uncertainty and really, really bad at understanding probabilities. From probably the number one book I can recommend, Thinking Fast and Slow by Daniel Kahneman, it is pretty clear we are hard wired to actually ignore probabilities and uncertainty. We have very well established – but very efficient – thinking apparatus, which comes to generally pretty accurate intuitive conclusions, but these conclusions completely miss the nuances and complexities of the natural world and one of these is definitely how uncertain everything actually is.

Human beings want absolutes, we want certainty and control, because it is far more palatable than the alternative. We are horribly ill-equipped to deal with all of the uncertainty, and this is especially true about our physical health. There is nothing more absolute than promising to ‘fix’ a complex problem like pain. And so patients are no different, they absolutely eat that s&*! up! Who doesn’t want a good quick fix! Aside from the obvious fact that it is easier than a ‘long, significantly more effortful fix’, it is concrete and is absolute. It has been shown that, in patients with low back pain, they really do have some concrete expectations on a few matters (Ref):

  • Diagnosis
  • Clear instructions on what to do next
  • What the next steps are in the diagnostic process (for example imaging)

It is obviously important that we give consideration to providing these absolutes when warranted by an individual and as health professionals, we do have license to provide these absolutes. But we really don’t have the license to provide anything much more than this.

As health professionals, we are also taught critical thinking and the scientific method. We really don’t know anything is 100% true, even things that have been proven by a bulk of evidence, are fundamentally open to scrutiny and can be disproven at any stage by someone who is willing to ask the question. This is science .. There should always be room for doubt and uncertainty, if there isn’t there is no growth and no one has any chance of improvement. If you look at it this way, uncertainty is actually an amazing positive, because it provides an opportunity for improvement, it allows growth.

So ultimately, the ‘quick fix’ is an empty promise, because you can’t be 100% sure that you did, in fact, cause the reduction in pain that your patient experiences – no one can be 100% sure of anything! It might just be that your intervention’s puny effect size may have added 10% to the general picture of a patient improving; I think being open to this possibility is not only important for our own growth as professionals, but importantly reinforces to the patient how much they did on their own. In a condition that is so inherently complex and uncertain as low back pain, there can be nothing more damaging than providing false absolutes of a quick fix or an easy cure based on your intervention. It creates a false dependence on something you likely have minimal control over. About the only thing that has a high probability in this condition, is that it will likely happen again once you get it and generally most people get it at some point in their lives (Ref). Patients need to understand that they need to be open to the possibility of it happening to them and returning once it does happen – this is the order of the natural world. Low back pain is complex – and like any complex problem – it is emergent without a possible direct prospective link to causation, meaning you may not be able to prevent it 100% of the time. It might just happen – it is a normal product of living in an unpredictable world.

If we absolutely have to get reductive at any point with our patients (which, let’s be honest, we will need to) what do we focus on?

Interventions generally have small to no effect size when all things are taken into account, so it is quite difficult, to pin down any intervention with a high probability of reducing disability and pain once you get it. Most systematic reviews, which pool together all interventions and provide a more representative picture of things that actually move the needle on a population level, come up with underwhelming conclusions for most interventions. Unfortunately, when I concede my own personal bias, even things like movement and advice to stay active are fairly underwhelming in terms of effect size and low back pain (Ref, Ref). So what are we to do?

Be honest and educate our patients that we don’t have the answer might be a start. It might be a start to admit that being reductive isn’t the solution, that there are probably multiple things that they need to begin working on to see any significant change. That is our challenge as professionals, to take the hard road and ensure the patient knows exactly how much they need to do and how little we are doing. And the patient needs to start the journey along the hard road to long-term behaviour change. We need to teach the capacity to not be afraid of the onset of pain (especially low back pain), because in the natural world, it is impossible to predict and if it does happen to our patients, there are probably multiple simple, but hard, things that they can do to reduce their symptoms and have a better life.

What we really need to do is teach and embrace uncertainty with patients. It is the antithesis of a ‘quick fix’, in that there is no guarantee – because there shouldn’t be in an unpredictable world – but that is ultimately a good thing, because it opens the door to improvement and growth. The best thing about teaching to embrace uncertainty is that it gives the power back to the patient – if they have control, they can ultimately change their life! Importantly, we – as clinicians – need to have the confidence to not have certainty about our interactions; a quick fix is nice to say, and sure makes everyone get the warm and fuzzies, but if you’re being really honest with yourself there is no guarantee in your ‘method’. Be scientific and embrace uncertainty, and maybe we will all improve together.

 

‘My physio bill’

Oxfam_11

Whilst on the Oxfam Trailwalker, I heard this phrase a couple of times, ‘my physio bill,’ in various contexts, like ‘mate, if you fart in my face again, I will personally make you responsible for my physio bill,’ or ‘remember that bet we made before we started where you said you would take care of my physio bill. Suck shit, mate’

Now I understand there are nuances to this and multiple levels of complexity, but it got me thinking about how the public perceives physiotherapy as a profession and is this at odds to what most good physiotherapists would want us to be perceived?

What do the public generally think about ‘their physio bill’?

Although some of us may be all too aware that the bill incurred by physiotherapy is nothing close to that of a surgeon or specialist, but it can obviously be enough to make someone bargain, bet or bully their mates with. It can be hefty enough to be something to offload.

Now you may be thinking the Oxfam Trailwalker is an extenuating circumstance; obviously the treatment bill would be ‘overs’ after something like that. I’d say, yes, you may be right, but I am more seeking some level of discussion in the normative case. When the ‘physio bill’ for young athletes becomes something to make mum and dad skip their date night for, when the ‘physio bill’ for the older couple after his second cortisone injection for the year failed causing them to forego the annual holiday to Port Macquarie. These are all too common occurrences, I’m sure you can think of similar situations that you’ve heard of, or embarrassingly – like me – may have even been a part of throughout your career.

So what am I getting at? I want to know why physiotherapists generally feel the need to bleed people dry to get an outcome. Now I don’t think we are as bad as other health professionals in this… you want me to name them don’t you.. well it begins with ch and rhymes with schmiropractor.. But seriously, physios aren’t that bad, but I think some elements of our training and the business model in which we are forced to practice, are really at odds with what the best evidence now tells us and how physiotherapists generally want to deal with things.

When pushed to extreme sleep deprivation and exhaustion the brain does some weird things; for me, as I rounded another bend and hopped over another rock at 5am, I started thinking rather existentially about the meaning the public puts on the physiotherapy service and it struck me as odd that it is pretty at-odds to what your everyday physiotherapist would like to consider her or himself as. I mean, do we want to be known as the professionals that:

a) are anything other than a necessity ? Once we lose the impact of our service, it gets devalued.

b) are providing anything but the maximal value? Once our service is seen to be low-value for money, they understandably bemoan the ‘ongoing treatment’.

Is it the providers?

Bleeding people dry is a strong term, so I may rephrase; why do (some) physiotherapists feel the need to prolong treatment and devalue our service? I have written about something I like to call the payment paradox in another blog here. There is good evidence for a host of barriers that prevent clinicians from adopting best practice and clinical guidelines (Ref). Lack of agreement, self-efficacy and an inability to overcome inertia of previous practice being some common reasons against change. And when you combine these legitimate reasons against changing behaviour with a reliance on low-value, passive modalities, what you get are clinicians who may just feel stuck with no knowledge or confidence to do different things. The shift toward using the things that we know work like advice, education and movement becomes an uphill battle; surely we can all empathise with that – it happens with nearly every patient we come across. Clinicians become very strongly attached to certain low-value treatments and when cognitive dissonance sets in, all of a sudden you have clinicians not just unable, but also unwilling to try anything else.

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How much of this can you actually blame on financial gain? I don’t know where the answer lies, but I know we all enter into this profession for the same thing – to change lives! There is a real shared altruistic bent to all in this profession and no-one really wants to actively hinder, or even harm, a patient for financial gain. Even the most sceptical of ‘Meakin-arians’ can’t believe that surely. Yes, maybe careless with language and lazy with professional development, but not malicious.

Professions like physiotherapy are marked by our relationships with the patient; generally they may end up meaning more to both parties than a good, speedy, efficient and value-filled outcome. It also helps that this relationship generally is rewarded financially, so it gets maintained and nutured so much so, that the break-up never happens. Cognitive dissonance is so strong that you may even end up losing sight of why the patient came into see you in the first place. This is not a bad thing, people – our patients – need crutches, they need a helping hand every once in a while when they are down. I’m not saying it is bad, but I am saying that crutches don’t get paid very well. The surgeon who fixes the leg, so that you don’t need a crutch anymore gets paid well. No, I’m not saying let’s all be surgeons… come on, I’ve got more sense than that.. I’m saying we all have the potential to fix the leg! Or at least make sure the leg doesn’t become dependent upon you. Why don’t we discharge more people!?

Instead of us being the ‘crutch’ who looks at the problem he/she can prop up and lean on – heck even maybe build a business on – we need to be a bit more like the surgeon, who looks at a problem she/he can fix, and discharge (yes, yes, the irony here is potent I know – remember I said, we are not going to all be surgeons),

So, where you may have some seriously unscrupulous practitioners, I think we have to look a little bit harder at the drivers. We have altruistic people, financially driven to look at patients not as people to be fixed, just people to be propped up until the next step in the road. Drivers, it’s about drivers.

So is it the model?

Yes, absolutely yes. If we increased our service fee it:

  • Allows all physiotherapists to provide maximal value at every appointment. This may result in people being seen less, but ultimately improves the perception of value in our service
  • Makes people take our service seriously, like almost to be a necessity – now wouldn’t that be nice!

Again, I know this is a complex issue with a lot of stakeholders, but if I can get a little bit reductive for a moment. The average fee for service has not increased in 30 years.. Why is that? Do we not, now provide a much superior service than we did 30 years ago?

To that end, a changing service fee would have people finishing the Oxfam Trailwalker saying, ‘I’m so glad I prepared the way I did and I don’t need to go to the physio again, it’s just not a luxury you know, it’s something that changed my life last time I went.’

I felt this way when I went to the psychologist and it really did change my life. It was expensive, but worth every cent.

So to conclude a short rant about something irrelevant loosely linked to an existential non-issue in physiotherapy.. Thanks for reading!

 

Strength and Conditioning; a new frontier in Workers Compensation?

I have some frustrations about the Workers Compensation (WC) system, it’s probably not hard to tell. In my team, we have highly qualified strength and conditioning (S&C) coaches working in a WC system and they have developed their own frustrations. We share some of the same frustrations, so this post is as much about them as it is me.

As a physiotherapist and level 2 strength coach, I think I’m fairly well positioned to comment on the matter BUT there are countless of other more highly qualified personnel that could, and no doubt want to, weigh in on this debate. Please do, but please respect my opinion as I respect yours.

For me, my journey in S&C started with an unimpressive rugby union career and like most physiotherapists it was cut short by injury, which promptly brought me to the dreaded long slow distance and triathlons; I got interested in being strong and resilient but obviously just wasn’t doing it well. What I realised after completing my first 3 -4 years of clinical practice was that when it came to prescribing exercise and progressing someone to performance, my university training had me woefully ill-equipped. While physiotherapy, as a profession, is leading the way in the allied health sphere when it comes to neuroscience, I honestly don’t think the same can be said about exercise therapy. S&Cs, increasingly, have to have tertiary level qualifications to begin their career. Generally in Exercise and Sports Science or similar; in fact in my experience, S&Cs sometimes have multiple tertiary qualifications (many gigs, won’t look at you unless you have a PhD) to their name before they really begin their paid career (before that internships are common). So, they are well versed in the basic sciences, just like any other professional.

Exercise Science is a degree (although I didn’t do it), that I think should be a pre-requisite for any profession in the musculoskeletal therapy realm. I would combine it with basic psychological theory and management, but that’s another story. It is a complex science that is should be the keystone of further training in the field. Because this still isn’t the general course for those entering a physiotherapy degree, then I don’t think we can call ourselves experts in exercise therapy. And those in glass houses shouldn’t throw stones. So now that I’ve laid bare my gaping inadequacies (now somewhat improved) in exercise therapy, we can move on to the point.

In musculoskeletal therapy, those people that should be termed experts in exercise therapy are the professionals who do this – and only this – day in and day out. A good analogy might be that you wouldn’t trust your GP to remove your wisdom teeth – on the surface that seems like a pretty simple procedure BUT let’s leave it to someone who does this day in and day out. We don’t expect it from other medical professions, so I think maintaining the same standards in allied health is important. Now I would accept that there are exceptions, as there almost always are. Generally, your sports physiotherapist, who has worked closely with the high-performance staff for years are exempt from this classification, as they have built an intimate knowledge of the complexities in loading and periodisation parameters. But your run of the mill generalist; to get real, targeted exercise therapy from this practitioner in a musculoskeletal condition would be a snowball’s chance in hell. Proper training and experience is needed, not just a side gig, in-between interferential sessions.

Although the Australian Strength and Conditioning Association (ASCA) are far behind in many aspects (we’ll get to that), it has remained true to its most successful element – the fact that to get anywhere in the profession, you need to have some runs on the board. S&C is a profession where the career pathway is experiential and that is important when it comes to exercise therapy. I have a bias and I will certainly admit that, but when it comes to a profession that requires intimate knowledge of exercise theory and concepts, I don’t know if you can trump S&C. In WC cases, exercise therapy is increasingly being preferred as the primary treatment option; so for pure ‘skin in the game’ factor, why wouldn’t S&C be considered?

Whilst there are similarly qualified professionals who deal in solely exercise therapy, namely Exercise Physiologists, they also suffer from lack of specificity. I’m not saying they aren’t going to do the job, and generally better than a physiotherapist, I am saying that in a discussion about specificity of exercise therapy in musculoskeletal populations, there are professionals who I consider of a higher order. And I’m not even saying that EPs shouldn’t have a large stake in Worker’s Compensation, because yet again, they probably create more active individuals than a physiotherapist (who also may have all the best intentions – but this patient is coming to a physio expecting some of those magic hands..), I’m simply saying that if you want to get this beaten up Hyundai and transform it into a Ferrari, I want to use the professional who knows how a Ferrari is made.

So, although there is a place for both professions, the crying shame currently, is that those professionals who have a very high level of knowledge, experience and clout in the S&C world are not even allowed to enter the playing field. I am not espousing that anyone with a level 1 or 2 ASCA should be WorkCover accredited, but I do think experience – ‘skin in the game’ – and level of knowledge in a relevant field (most S&Cs work in musculoskeletal settings with athletes in pain) should be recognised. I certainly think that if performing a role in settings where they do encounter the complexities of workcover should be accepted and further training be offered to upskill where necessary. I think of the training physiotherapists have to do to become workcover accredited – a dinky online test that takes 3 hours, which has nothing about exercise therapy in sight…. To understand the complexities of neurophysiological mechanisms and behavioural drivers of pain is probably not where I’d want my S&C providing primary treatment, but that is where physiotherapists excel and we can fill in the gaps.

Strength and Conditioning is not just for athletes or those wanting ‘high performance’

This is true but oh so poorly understood. Where does a S&C coach perform best? Where there is a close alignment (or sometimes not so close, depending on where you go) of physiotherapists and S&C staff ensuring all variables are accounted for and the desired outcome is achieved. The current model for WorkCover is world’s away from this; once the physiotherapist has butchered the exercise therapy and taken their time with the initial injury, then there is a very well demarcated gap between this and the ‘commencement’ of exercise therapy – performed by the EP. This leads to poor outcomes, frustrated patients and can be done better. More cohesion, more synergy is needed and having a profession that is used to working intimately alongside physiotherapy rather than in a separate silo is important.

The ASCA need to improve their game to get on the playing field

I think part of the ASCA’s lack of ability to set strategic plans in place for the direction of the profession is, in part, because it is such a young profession. Still finding it’s feet after only 50-odd years of mainstream, burgeoning, practice. But it is a worrying trend that there continues to be an explosion of ASCA qualified practitioners, without much checks or measures to what they can or can’t do after they get the ticket. I know the level 1 trained ‘high performance specialist’ who opens a ‘high performance facility’ really grinds the gears of my team and friends. More scrutiny around the pathway already developed is important, alongside firmer adherence to remuneration based on level of experience.

The ASCA are incredibly good at broadening their scope of practice and widening the reach of S&C as a whole. In progressing the profession, this will always be important. But legitimising the profession amongst the biomedical sphere is a weak point; just as the kind of role S&Cs can play is poorly understood – as above – the profession isn’t targeted to areas where it can make a big impact. And for me, this means talking about Workers Compensation. To make SIRA (governing body for Workers Compensation regulation) take notice and approve S&C to provide services, the ASCA need to make a concerted effort to lobby. I think it is a case that is hard to ignore. To allow appropriately experienced (say ASCA Level 2, on the pro-scheme and above) S&Cs, with access to the right training (pain sciences, online WC legislation training) to provide services under Workers Compensation just makes plain old sense in my opinion.

The ‘coach’ element

A key element, that leads to outcomes in my current team, is not just that I am fortunate to work with high performers, it is that our coaches have taken the ‘coach’ element to the next level. Yes, S&C is a science-driven profession (in terms of evidence-based profession, I must concede it is a way behind physiotherapy or even exercise physiology) but there is another gamet of skills the coach must have. The Art of Science of Building Buy-In by Brett Bartholomew is a great example of the emphasis placed on ‘soft skills’ by the profession. Building rapport, building buy-in, the art of the sell; whatever you want to call it, it is a skill that the coach takes pride in. You need to have this in order for the patient in front of you to truly come to a more positive frame in life. The WC system breeds a negative world-view and sometimes needs a ‘coach’ to bring someone through it. The aspect of the profession that guides and directs a patient in what is necessary and important in movement, exercise, attitudes, beliefs and pain is different to EP; less clinical, more connective. I think this works.

So, in the long-run, I think coaches will live prosperously alongside EPs in the WC world. It needs a bit of firming up of the pathway and training by the ASCA, more solid work on lobbying SIRA. But in the end, why deny this valuable skill set a chance to change lives in a very, very broken system?

 

 

 

‘Core Stability’; I call bullshit.

A guest post from Dave Renfrew of Newcastle Performance Physio

Before we get started, just some things to get out there first.

Things I am not saying include the following –

  1. “Core” exercises are bad
  2. Strong trunk muscles are a waste of time.
  3. People who run exercises classes or teach exercises based on the concept of “core stability” are dickheads
  4. Strengthening doesn’t help
  5. Pilates is shit
  6. Pain Science fixes everything

Right, I reckon that covers it. Let’s get started shall we?

Core stability, as a concept, is bullshit.

Ask anyone who is able to process a question and respond with an audible and discernible response and you will get an entirely different answer each time. Especially if that person is a health professional.

Answer it yourself. Now. Go. I’ll give you a few minutes.

…..

….

Right, what was your answer – BULLSHIT!!!! Ha, just joking.

You’ll normally use words like control, stabilise, protect, whatever. All of which give the impression of stiffness, immobility and the lack of variation in movement of which the back is capable, and actually really good at.

Let’s even just pause and remember for a second that there is no core. Where is your core? What is in it? Abdominal cavity? Does it include your back?

I get the idea. It’s in the middle.

Gymnasts and Surfers – bend themselves over into positions the rest of us are regularly told we shouldn’t do. Do they have good “core stability”?

What about if you lack “core stability”, do you have “core instability”? Bad things happen with unstable cores – like nuclear power plant bad. Is this what we are really saying?

So, let’s not say it.

The concept of core stability came out of research in the early 90s by Panjabi and friends here

The concept, while groundbreaking at the time, has since been shown to be oversimplified and based on incorrect assumptions. While it speaks of segmental spinal movement being associated with pain and injury, it also speaks of feedback mechanisms, central control and faulty firing and dampening reactions. This sounds more like non-human science right?

In Engineering, the stability of a system is also pretty complex, but is related to the relative relationship between input and output. An input, within a certain magnitude, results in an output also bound within a certain magnitude. Input and output are consistently linked, ie does it do what you want it to do. A stable system is also one which remains in a constant state unless acted on by an external stimulus, but then returns to that state once that stimulus is removed.

Stability in the spine is exactly the same. It is the consistency of its performance with varying inputs.

It does not mean DON’T MOVE.

Moving and instability aren’t the same thing.

Stability is not the lack of physical instability.

Stability is not about how strongly you can contract your abdominal muscles.

Now, as previously mentioned, I am not saying that doing these exercises is bad, stupid or whatever. There is evidence that learning to use certain muscles is extremely effective – postnatal pelvic floor and abdominal muscle activity for instance.

I am just trying to get you to think about what you are saying, thinking and why. The core stability concept was picked and run off with and hasn’t stopped to think if the game has changed.

A runner or weightlifter doesn’t need to do “core exercise”

People in pain don’t need to improve their “core stability”

Improving your “core” does not help with weight loss, athletic performance or pain relief.

Exercise can help with all of that. But there are lots of exercises that can do that. Exercise needs to be specific for the person and what they want to achieve. They do not need to be upside down on a BOSU ball trying to not move.

My definition is as follows – “Efficient load transmission between the upper and lower limb in the desired and specified direction and nature of your intended task for sufficient duration and at the desired level of intensity”. Try putting that in front of “..x..class” and selling it.

Which brings me to my next ranty point. Money and health. Always linked and not for everyone’s benefit. Now before you get all high and mighty again, i’ll say it first. I get paid for selling health services to people. I’m not saying people should do it for free, just that what they sell shouldn’t stink.

Health and fitness pick up on research, straw man the shit out of it, and sell it to the public on the basis of “if you don’t do this you will be fat”.

Tone your abs, Get core fit, Stability training, whatever they call it is generally boring, easy or a waste of time. I don’t care how many crunches you can do and neither does your back pain.

I am an advocate for exercise. Exercise is magic. We all need it, and harder and for longer than most people think. But misrepresentation of what people need to do and guilting them into doing it by making them feel inherently broken is bullshit. Saying every human needs to do a certain type of exercise is ridiculous.

The most important exercise to do is the one that will get done. There are generally 4 or 5 barriers to exercise

  1. Time
  2. Cost
  3. Access
  4. Enjoyment
  5. Pain/injury/problem

The best exercise to do is the hardest one possible that ticks as many boxes as you can.

I hate swimming. I am terrible at it and it bores me. I can swim to save my life (I think, let’s not test that out) and I can paddle with a board under me. But if you told me that swimming laps everyday would prolong my life from 85 to 105, i’d be smoking a fat cigar on the eve of my 85th birthday with a smile on my face. Not going to happen.

Swimming is patently good for you, cheap or free, relatively time efficient and we live in Newcastle FFS. Still, don’t care.

You do not need to do any exercise in particular. You do need to exercise. Hard.

Crunches may make your abs hurt, planks may make you want to throw up. But that just means you are getting better at ab crunches and planks.

I agree that if someone is not strong enough they can run into problems. But pain and injury are so much more complicated than a lack of “core stability”. It is a bullshit diagnosis.

The thing that most people lack is capacity. Load tolerance and ability to negotiate movement. We are sedentary, more overweight and doing less physically demanding things. That means we get worse at them over time.

Or we are coming back from an event that has decreased our capacity and we need to build some physical resilience.

Current recommendations sit at 300 minutes of moderate or 150 minutes of vigorous exercise a week with 2 resistance training/strengthening sessions. What percentage of the population hit that?

When we decide to get up and get moving things can hurt and get injured. That doesn’t mean that we have a “weak core”. It means that we have gotten crap at things because we are doing them less and our nervous system has decided that if we kept going bad things could happen.

The core stability model is too simplistic, makes people waste time on useless exercise and gives people false hope that because they can plank for a minute they are strong and healthy.

It is also very unhelpful for people that have been in pain for a long time.

Low back pain in particular is associated with an increase in hypervigilance, a process whereby, given the regularity and severity of pain, a person will either consciously or subconsciously “stabilise” or brace muscles in the back, pelvis, everywhere to make sure they are prepared for the upcoming task. But that could be picking up their toothbrush.

The constant overactivity is a big driver of neural signal to the central nervous system and can result in an increase in pain.

Imagine what happens when you tell that person that their core is weak, that they lack stability.

So what next then, Dave? Just whinge about how everyone is wrong??

For non health professionals.

Make exercise a priority. Do more of it, make it harder and continue until you die, or most likely you will die sooner than you need to.

If you are really strong and fit, well done, but stop putting images of your abs on social media. Old people like me think you are a wanker and young people feel they need to look like that.

If you find exercise hard, find what motivates you. For me, I have 3 young kids that are the reason I do anything. They currently think I am the biggest legend on the planet. I know this will change, but I want them to think i’m lame because i’m old and tell bad jokes and embarrass them, not because I can’t run around with them any more. The day i’m not their hero will break my heart and so i’m doing everything I can to make sure that won’t be my fault. Find what will make you do it and if you can’t –  ask for help.

For health and fitness professionals.

Adapt. We treat humans, the most adaptable thing on the planet. We live in a time where the best information is available at your FINGERTIPS. What a time to be alive!!

Get better. Realise that what you say to people has an effect. Learn more about what you do, all the time. No excuses.

Work together. Thinking that you are the only person that can help someone is ridiculous and often dangerous.

Exercise yourself you lazy buggers!!

Advocate for strengthening, exercise, self efficacy and increasing capacity at every possible point. Build Weapons of Mass Function capable of having greater influence on their own health and being role models for their descendants.

Recognise you will have biases towards what you like and what you are good at.

Exercise people however you want but make it about them, not you. Make them fantastic in what they want to do. Make their trunk strong, but make their legs strong, arms strong, make their coordination and speed fantastic. Give them good balance, agility and reactions.

And stop calling it core stability. It’s illogical and it pisses me off. Clearly.

Until next time.

Dave