You are not weak.

By Clem | In Physiotherapy | on September 17, 2017

It has been an age since I sat down and put thoughts on tech paper. Lots have changed in the life of Clem since I last wrote. I started a new job working for NHS Lothian in the neuroscience department as a physiotherapist at the start of the summer. I began the summer juggling three jobs working with the NHS, running my own personal training business and trying to work in a physiotherapy clinic at the weekends.

It quickly became clear why I quit my job working in the corporate arena. Working three jobs is bat shit crazy and my body slowly started to fall apart. I’m now happily juggling my NHS job with personal training and getting a tonne of new experiences with a brand new demographic of patients. Every day is most certainly a school day right now.

My message today is a quick one and (my frustration whilst writing made this piece far longer than I intended) borne out of an idea that I hear on a weekly basis not just from clients but from friends and acquaintances I meet socially or in work.

“I get back pain pretty often because I have a sh1t core”


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This grinds my gears ladies and gents. The idea that back pain comes from weakness in your core seems to be as resilient and long lasting as Keith Richards liver. The idea of core stability and its relation to back pain originated in the 1990’s when research into trunk control and pain was explored. Those in pain displayed changes in activation of trunk muscles like the transverse abdominis. It was assumed that back pain would have been caused by weak abdominal muscles and if we strengthen those muscles, we would fix and prevent the pain.

Programs like Pilates were looked at which greatly helped people out of the doldrums of back pain. Everyone rejoiced and was happy that we had solved the dreaded back pain mystery. At least that’s what a lot of physios, osteo’s, chiro’s, etc. would have had you believe.

The trouble is when you look at back pain and exercise interventions like Pilates, it doesnt seem to matter what you do as long as you become more active. This research found that Pilates and general exercise had the same effect on back pain. This study with 1836 subjects reports that regular physical activity helped improve back pain recovery for women. So yes, you could do your pelvic thrusts, pelvic tilts, front planks, etc. BUT why not get outside, get the heart rate going and get busy? Both seem to have the same effect on back pain but one approach ticks a lot more boxes.

The issue I have with research looking into this idea is the following. When we are in pain, our bodies go into a protective mode as a means of survival. This is generally a good thing as if it didn’t, we as a species would not have lasted very long. Our bodies behave very differently in pain vs not. Looking at people in pain and investigating for muscle imbalances, weakness, etc. just gives us an idea as to how we compensate/adapt but most likely not what caused the pain in the first place.

So whats going on then?

Back pain is caused my a number of factors, some physical but a lot of them psychological and social. Pain is bat shit crazy weird and not as simple as “this area is in pain therefore this area is too weak”. Understanding how pain works can be HUGE when it comes to managing to live a better quality of life with it. Pain is greatly influenced by past experiences, knowledge, beliefs, past successful behaviours you have carried out or others have carried out, tiredness, stress, etc. This pretty funny video from the awesome Professor Mosely greatly helps explain how pain works.

The graphic below does a great job of explaining how we come to a conclusion that a location is painful.

taken from the website

The fact that your trans ab is weak has probably very little to do with it. With that in mind, it is important to ask yourself if your time could be better spent doing something your whole body could benefit from rather than lying on the floor working one particular muscle.

So what do we do?

Todd Hargrove really puts it well in his blog where he advises that we  “create noise to block the signal”. Our nervous system receive signals on a constant basis and you are only aware of a fraction of them. If you are sitting on a chair right now, you are likely unaware of the pressure that chair is putting on your bum cheeks, but the signal is going to your brain. The signal is not enough to warrant a painful experience however. Feedback is constantly coming into your brain and this feedback is greatly increased when we are in pain.

When you understand pain, you realise that pain will increase considerably if your attention is drawn to it. Have you ever noticed that once you start talking about your painful back, knee or wrist or a friend or relative it slightly gets a bit worse? Exercise and movement helps focus the body on another task and adds noise to the constant stream of input your nervous system has to deal with. When we move (or when we are being massaged), the nervous system is busy processing this input and has less of an ability to perceive and process signals that would have contributed to pain.

It is also important to work on movement skill. This will allow the body to appreciate that movements similar to those that cause pain but subtly different, can be carried out without the alarm bells going off. This helps build a trust with your internal alarm system and helps decrease the perceived threat and hence pain. This is why interventions like Yoga, Pilates, Zuu, Feldenkrais, Tai Chi and weight training can greatly help decrease pain. You and your alarm system start to trust each other again.

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So I’m not weak?!

Well…you might be, but its probably not whats causing your pain. If weak = pain, then strong = pain free.

Ask any power lifter, crossfit athlete or Olympic weight lifter if that’s the case.

The trouble happens when our industry perpetuates this myth. Our patients believe they are about to fall apart and therefore continue to seek out professional opinion and treatment creating a cycle of never ending care and dependency. This might well work out very profitable for the physio, chiro, osteo or GP but not the person in pain who continues the suffer.

This case study from JP Caneiro does a great job at showing how people can get stuck in this endless cycle of pain and treatment largely driven by their beliefs of being damaged or worn out and driven by fear, anxiety and frustration. The responsible therapist will first guide and reassure that person to a better understanding of their pain and what it might mean. The person might then have the confidence to start moving by choosing whatever movements they a) enjoy doing b) can do regularly and c) are effective.

That could be Pilates, running, cycling, swimming or Prancercising around their back yard. Science believes it doesn’t matter. Any of it is better than lying on your back talking to your trans ab muscle.


from @jpcaneiro

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