One thing that has been a constant problem for me over the years is explaining to medical practitioners our methods for helping people to overcome serious injuries and regain their life. The very first thing they say is that there is no scientific research to support your findings. There has been several great books and articles that have explored this topic before which I will share in this article but I have posed this question as it relates more specifically to our training studio based in Melbourne Australia. Even though many of our programs and methods are based on research papers and studies, and we have hundreds of testimonials and even case studies that have proven these to work for a long time (over 20 years now), we are still looked upon as something of a rogue and not validated due to a lack of medical qualifications. Even Google rates my articles very poorly even when I can prove it works. Google has a hard time understanding how a particular injury can relate to so many things as they prefer to have an algorithm that gives a specialist answer. And unfortunately it is not just Google who thinks like this as this is the thinking applied by most people and is supported by research that also uses this same reasoning. I must make it clear we use scientific research all the time and most of our programs are based upon this, however, it is through practical application that all of our best solutions have been discovered. This article I wish to explain how we currently use research and the danger we place by relying too much on what science has to say.
Sports & Science
There has been a lot of great advances with the combination of science into sports. Finding better ways to train and get every single bit of energy out of the athlete to perform at their highest potential. We have seen the dramatic impact this has had with many sports and where teams like Sky Racing the British Pro Cycling team, now known as Ineos take science to a whole new level to dominate the sport of cycling for a long time. The use of science revolutionized the tactics and training regimes used in the sport to great success.
Science has also combined with other sports like NBA basketball and international cricket to introduce player load management to reduce the chances of injury from fatigue, however many would argue this has made players more vulnerable to injury instead of preventing it! Along with great technological development there has been a rapid increase in the use of analytics and equipment to improve skills and techniques that have never been seen before.
We have also seen science combine with sports in a bad way such as doping in many sports like cycling and track and field and even supplement controversy as with the Essendon AFL club back in 2011 to 2013.
There is no doubting that science has contributed to some significant improvements for athletic performance. However where science gets a bit foggy and things are not so clear are when it comes to pain and injury.
The Problem With Science & Chronic Pain
Many of the greatest findings with regards to exercise were discovered in the field first and confirmed later via science. I am a huge fan of Dr Stuart McGill (see article Best lessons I Learned from Dr McGill) and if you have seen any of his lectures or read any of his books he will constantly tell you that all of his methods are based on science. I apply many of the methods and approaches he uses for back pain clients and successfully adopt them in our training every week.
He will also tell you the same thing that many of the greatest exercise interventions came from the sports coaches, personal trainers, and physical therapists working in the field with real people. There was no research to back up what they were doing for they had invented something from applying wisdom and creative thinking to solve a complex problem. What he did was use science to prove or debunk if it was successful or not. The science did not come up with the idea for it was too rigid in the thought process and not creative enough to look for other solutions that may not make sense at the time.
This does not sit well with science and in particular the community who want to have an absolute answer to health problems when there is not one. Even when you look at the results of studies that report something like – “in 73% of cases xxx exercise improved strength into xxx muscle reducing pain”.
My question with this is what happens to the other 27%?
University students are taught to rely solely on evidence based practice. That means everything you do should have some sort of evidence to back it up.
I have had several Exercise Physiologists work with us and question many of the things I was using at the time as they were just taught at University to do something the exact opposite. When I explained to them why their method had research backing it up it was out of date and not useful at all. I could prove to them with their own body and also with countless other clients that their method was inferior to what I was using.
The information in their course is out of date for it to be included it must have had a study completed, analyzed and submitted to the University, then text books and written into the course outline which could take several years to do. During this time people like myself using this research with real people in the field find problems and make modifications where required.
Take for example the endless number of isolated VMO exercises and wall squats used for knee pain. This is a common thing I have seen with endless amount of research supporting their use (latest research), but in reality this did nothing and in most cases made the injury worse!
See video below for an explanation of why this exercise is a terrible choice.
How Can The Research Be Wrong?
The big problem with most research is that it specializes so closely on one thing and ignores the fact that the human body is a complex system of systems with many moving parts all interacting with each other. We are all so unique and react to things in different ways making it impossible to apply an absolute one way for every injury or condition. What works for one person will make things worse for the next person.
In the case of the wall squat example it has several key factors that it ignores.
Firstly the reasoning for using it was that it could activate the VMO muscle and quadriceps that studies had found were weak with people suffering knee pain. The VMO is important to maintaining patella alignment and knee stability and is a key factor in addressing knee injury and pain.
While I fully agree that VMO strength is a big part of addressing knee pain I do not agree that it is the main problem and I definitely do not find any VMO isolated exercises to be of any use. Using the wall squat exercise to strengthen it has many significant problems are more likely to make the knee injury worse! This is why.
The research fails to look at the reason the VMO was weak in the first place and simply applies a solution of if it is strengthened the problem will just go away.
It fails to see that the cause of the problem is really to do with 3 key things
•Poor foot stability
•Poor hip stability
•Poor movement patterns and motor control with single leg stance
Watch the video below for an explanation of this.
Firstly the wall squat has no emphasis on any foot stability and completely ignores any emphasis on assessing the mobility of the ankle or ability to create optimal alignment of the lower limb during walking or movement. Even though the injury is at the knee you must understand the role the feet play in creating this problem. Any strength you may have gained in the VMO from the squat will be completely useless to you the minute you move if your feet and ankle are not functioning as they are supposed to.
Secondly the position of the body during the wall squat is horrible for the hips and spine to be placed in, and while it activates the quads heavily, it does this at the expense of many things. The role the posterior chain of the glutes for maintaining optimal alignment and the hamstrings for resisting shear of the tibia is vital in movement.
This exercise again ignores this principle and focuses only on the VMO strength. The position of posterior tilt creates stiff and tight hips which will further inhibit the glutes, creating further alignment problems with the knee in a standing position. But worse than that is the potential risk of a herniated disc in your back by constantly flexing your spine with this movement.
Lastly we have to appreciate that sometimes there is nothing wrong with any of the muscles in terms of strength at all but how the brain coordinates the movement. This is very common in teenagers and people who have developed faulty movement patterns during their life. Many of the beginner clients improve their strength remarkably quick from learning to move better, not from any strength methods.
Again research finds this very difficult to measure for this can vary significantly from one person to the next.
To see how I would strengthen the VMO in line with foot stability and hip function watch the video below.
Who Completed The Research & Why?
A big thing that many people never even consider when reading the results of studies is where does the research come from?
Who completes it?
Who pays for it?
Do they have an interest in finding one result over another?
The food industry is one of the worst for this and there is so many conflicting and confusing arguments about food that it is impossible to work out what is good to eat and what is not. One day we are told red wine will reduce cancer and heart disease with all types of supporting research and the next day we are told it will cause cancer and heart disease with other scientific research backing up its claims. I won’t go down that rabbit hole with this article but I suggest to check out Precision Nutrition who wrote an amazing article about this called food research conflict.
If we were to use knee pain again as an example, let’s say there was a study funded by a company who makes knee sleeves to determine their effectiveness in reducing knee pain. Do you honestly think they are going to find poor results?
However if the study was performed by a medical practitioner who had no monetary gain from using the sleeves or not and was simply looking for a better solution for his patients versus other treatment options the results will be much different.
When dissecting and using scientific research this is where a skilled person whether they are a physical therapist, trainer, or sporting coach can apply this and observe the results and decide when and who to use it with. Very rarely is it a 100% conclusive result.
Surgery & Our Over-reliance To “Fix” Us
The tendency for most people in the community is to attribute cause and effect to injuries. When we are talking about a car accident or something traumatic that was out of our control surgery is amazing and science has saved many lives. But when we talk about an injury that developed from how we move and referred to as chronic pain this approach is not a good solution.
If we have a sore back we instantly think it is something wrong with our back. When in most cases it is nothing to do with the back, it was the effect of a cause somewhere else in the body. The back is just where the pain settled. It is not the reason it is sore.
In the book “Surgery the Ultimate Placebo” by Dr Ian Harris on page 175 he makes an interesting observation.
“At the heart of this question is a reflection of society’s overreliance on surgery as the preferred way of fixing the physical breakdowns that occur in our body. We look at the body like a car in need of a mechanic. And I must admit that it still surprises me when I discover that treating the body like a machine, by removing torn cartilages, repairing torn tendons, unblocking arteries and veins and catching clots in a next, patching holes in the heart, either doesn’t work, or doesn’t work any better than leaving it to the body to sort it out.”
Another great insight from this book is how the media portrays modern science with medicine. Almost everyday on the news you will see some report about some breakthrough in science for treating some type of injury or illness. Rarely do we question these and we place so much faith in this research that it is true.
Again Dr Harris says this best in his book on page 56, “The over representation of good news from medicine is a problem in the scientific literature, but that bias is magnified manifold in the media. I have seen media reports of supposed cures for things as cancer, dementia, and paraplegia. And the more advanced the science seems to be, the more the media love it.”
This is important to recognize for the first things people often think about when they develop an injury is what amazing surgical method can fix you. The media has trained us into thinking that way by constantly providing messages about all the amazing things it can do. Even when surgeries come with risk, high expense and no guarantees many people will still prefer this option than going the long way and trying to restore the problem from the source.
In sports this is usually the worst as sporting athletes look for shortcuts to get back on the field/court as soon as possible.
How often do you we see some sporting star going for surgery to “fix” an injury that was caused by how they moved. With some injuries it is undoubtedly essential such as an ACL tear. A torn ACL will not heal as it has limited blood supply so surgery is the only way to reconnect the ligament. But just because the surgery has reattached the ligament does not mean everything is fine. The football player will need to investigate WHY they injured the knee in the first place.
Over 75% of the ACL injuries are non-contact meaning it has everything to do with HOW THEY MOVE!
It is not bad luck, it is not even a lack of strength as the reason for the injury. For if it was due to lack of strength then how do you explain how some massive American Football players tear their ACL or an Olympic level gymnast with more strength than 99% of the population? The problem is not the muscles but how their brain and nervous system coordinate movement and stabilize joints.
Failure to do this correctly shows that there is a very high chance of injuring the knee again! How many times have you seen sportsmen suffer multiple ACL injuries? In recent years in the AFL in Australia this has happened regularly and the general public and media see this as simply bad luck. It has nothing to do with luck but the ignorance of the player and the team of people around him/her to address faulty movement patterns.
Read the article – Why females are more likely to tear the ACL
Surgery DOES NOT Treat The Cause Of The Problem
All surgery can do is replace or fix a broken part and then hope you know how to use it correctly. It cannot address why it was broken in the first place and does not tell the brain to move differently because there is a new part installed.
Only exercise can do this, but it must be exercise that addresses the multiple reasons behind the poor movement strategies. If the exercise method is stuck in the muscle approach you will have changed nothing. And this brings us to the area that science hates, ambiguity. For it is impossible to have a 100% conclusive reason for every person why their injury occurred and what to do about it. There is just so many factors at to consider that the only answer you can use is – it depends!
Even Dr Stuart McGill who bases all of his training on scientific research states in his most recent book “Back Mechanic” in the chapter Is Surgery For You says,
“Ninety Five Percent of the challenging patients see do NOT need surgery, even thought they were told that was their only cure. My opinion based on three decades of experience, working with patients who have been successful with surgical avoidance and in dealing with the “failed backs” caused by unsuccessful surgery.”
A skilled trainer or therapist who knows what to look for, uses detailed assessments and clever programming specific to the needs of the person will have the answer that provides long term success. Many of these corrective methods and assessments will have come from scientific research but it takes a skilled person to know what ones to use, how to use them, and how to structure a plan accordingly.
Following a rigid plan because a scientific study tells you to, is fraught with danger.
Research Is Important But Must Be Combined With Practical Experience
Now on the other side of this argument is the person ignorant to research and bases everything on their own beliefs.
This is very common to the personal training industry and they will base all their methods on things that support their belief. We still need to use research as many of the studies can provide you with insights to things you would never know. This can be extremely useful in finding great outcomes and a basis for all of your programs.
A great article to read looking at this debate is by Science of Running. They make a very smart comment in their conclusion.
“There’s a reason why pure exercise physiologists are seldom great coaches. There’s also a reason why people who know nothing about the science, like your typical HS football coach turned CC coach, are pretty bad at coaching. The best coaches or practitioners are those who can blend the two.”
I think this is a great way of looking at how science is very important and needs to be integrated into practice.
One area that science is critical to use is with diagnostics. Things like X-ray, MRI and CT scans are invaluable for providing insights as to where the damage actually is. It takes out the guess work and gives you a clearer picture of what you may be dealing with.
However, once again it does not explain HOW the injury or problem occurred. There are some tools and tests you can use to help you in the assessment process that can guide you but it will take a person with experience to know how to put all the information together.
Summary
I hope this article gives you a different perspective on the use of scientific evidence and its use with health and exercise, in particular with injury. There is a definite need to have the science to back things up and provide you with better information to base choices of treatment and exercise corrections around. The value of diagnostic cannot be overstated, however we must be always looking at treating the problem at the source which in most cases will be due to a movement problem.
For many years I have struggled to gain the confidence of many local practitioners for I did not have the letters after my name, even though they acknowledged what we did was working. If I had the qualifications from University and was doing the same stuff I am doing now everything would be fine. I learned all my craft from completing many courses, reading hundreds of books and research papers, watching online video courses and lectures, but most importantly from applying this information with real life people. It was from the real life situations I learned the most and discovered the best programs and solutions that I use today.
I did not invent exercises, I just applied the teachings of many successful experts. I do not have templates or hard and fast rules, instead I use guidelines and logic that can be prescribed based on the person in front of me.
About The Author
Nick Jack is owner of No Regrets Personal Training and has over 20 years’ experience as a qualified Personal Trainer, Level 2 Rehabilitation trainer, CHEK practitioner, and Level 2 Sports conditioning Coach. Based in Melbourne Australia he specializes in providing solutions to injury and health problems for people of all ages using the latest methods of assessing movement and corrective exercise. He has worked with professional athletes in Golf, Tennis, Basketball and Football but is known throughout the local community more for his work with injury prevention and rehabilitation. Having participated at high level in many sports himself and also recovering from several serious injuries he has spent considerable time developing detailed assessments and programs to cater for injury and pain.
References
•Movement – By Gray Cook
•Surgery the Ultimate Placebo – by Dr Ian Harris
•Athletic Body in Balance – by Gray Cook
•New Functional Training for Sports – by Mike Boyle
•Knee Pain Injuries in Athletes – by Sports Injury Bulletin
•Bending the Aging Curve – by Robert Signorile
•Corrective Exercise Solutions – by Evan Osar
•Diagnosis & Treatment Of Movement Impairment Syndromes – By Shirley Sahrman
•Low Back Disorders – by Stuart McGill
•Back Pain Mechanic – by Stuart McGill
•Anatomy Trains – by Thomas Meyers
•Motor Learning and Performance – By Richard A Schmidt and Timothy D Lee
•Assessment & Treatment Of Muscle Imbalance – By Vladimir Janda
•Scientific Core Conditioning Correspondence Course – By Paul Chek
•Advanced Program Design – By Paul Chek
•Scientific Back Training – By Paul Chek