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 (see , et al Research alone is not sufficient to prevent sports injury ) 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 (almost 15 years now), we are still looked upon as something of a rogue and not validated due to a lack of medical qualifications. Recently the Google core update on the internet reflects the information on our website in exactly the same way and moved us down the rankings in internet searches that we had previously ranked very well with. Google has a hard time understanding how a particular injury can relate to so many things. It wants 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.
Science in Sports
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 revolutionised the tactics and training regimes used in the sport to great success.
Science has also combined with other sports like NBA basketball and cricket to introduce player load management to reduce the chances of injury from fatigue. 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 & Injury
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.
This does not sit well with science and in particular the community who want to have an absolute answer to health problems. 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 currently using. Manual practice had proven faults within the findings.
The information in their course is often out of date for it to be included it must have had a study completed, analysed 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. The study was not useless as it lay the groundwork to find the better methods and solutions, but the key is that it is just the foundation and not the only way.
Studies That Contradict Each Other
The next major problem with relying on studies is which one do you use? For every study you find supporting your idea, you will undoubtedly find one supporting the opposite, and probably another one again with a completely different angle.
In our recent article looking at the role of using unstable balance equipment we found this exact scenario. There was compelling facts and information supporting balance training and just as compelling facts to debunk it as a reliable training model. Below is the links to the research.
My question to you is which one do you believe is best to use?
Most people will use the information that suits the model they want to use. I prefer to test them first before making a decision and in most cases I will find arguments to use both. It all depends on the person in front of me if it is relevant to them. Again it will come back to field testing to find the best way to use this information.
Take for example the endless number of 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 the wall squat is a terrible choice and the second video that explains why isolating the VMO is a waste of time.
How can the research be wrong?
The big problem with most research is that it specialises 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
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.
Read the article – Why you cannot blame a single muscle for a movement problem
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.
Who Completed the Research & Why?
A big thing that many people never even consider when reading the results of studies is where the research comes from? Who does 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.
The guys at Precision Nutrition wrote an amazing article about this I suggest to check out 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 and our over reliance on it 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.”
A great book and I highly suggest reading this as it will open your mind to the problems we see today and why our science is making us worse not better.
This is important to recognise, 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! Watch the two videos below that explain the reasons behind ACL injuries in sports.
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 stabilise 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.
Surgery DOES NOT Address the Cause
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 - "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.
Here is a great story of a young client I met who had surgery for her back and was in more pain than before the surgery. When I met her she was getting pain counselling to deal with her pain for they told her there was nothing more they could do. None of them bothered to look at how she moved and teach her movement strategies that would prevent her from beating up her spine.
Back Pain Success Story after surgery ruined her
"For the past 10 years pain has been a constant in my life. I ended up having 2 surgeries for a bulged disk in 2006 and have never really recovered. The surgeon referred me to a physio who I saw twice a week and they also had me doing one-on-one Feldenkrais to learn how to move correctly again. I did EVERYTHING they told me to. After a year I was still in a lot of pain so I went back to the surgeon. He did another scan and confirmed there was no longer a bulge, and said ‘give it another year’. Easy for him to say!
Over the following 8 years, across different countries, I’ve seen at least 10 different physios, ~2 osteos, ~5 remedial massage therapists, ~2 myotherapists, ~3 acupuncturists, ~2 personal trainers, an exercise physiologists, one-one-one clinical Pilates with multiple physios, a swim trainer and 2 podiatrists. Well that’s what I remember - I could have paid off my house by now! Last year I decided my twice weekly Pilates wasn’t building my strength, and it was also aggravating my shoulder and wrists. I knew it was related to bad habits picked up from ‘protecting’ my back, but no one could really diagnose it. Late last year I saw a new sports doctor, who after finding out I was recently pregnant told me that he ‘couldn’t really help since I couldn’t have an injection, so I should plan to leave work early as I was highly likely to struggle, and well good luck with the feeding because that’s going to be tough’. After working so hard for so long I felt like I had failed. As it turned out I had a miscarriage, so I decided to suck it up and go back for the injection – my last resort. The scans and injection cost close to $2k, and it didn’t work at all. He didn’t have much to say to me, so I demanded he refer me to a pain clinic – if they couldn’t fix it, I was going to need a better way to cope with it – enough was enough. Instead he referred me to a rheumatologist, who suggested I immediately cease all Pilates, go back to Feldenkrais and learn meditation. He suggested my problems stemmed from being super tight and ‘strengthening’ just made me tighter. I felt much better initially, but 4 months later I felt worse than I had with the Pilates, I’d lost any strength and momentum I did have, and was just another patient they had forgotten about.
Upon hearing this recent update, a friend who had been seeing Nick for a while recommended I give No Regrets a go so I reluctantly met with Nick one lunchtime. I thought his approach sounded great as it seemed to pull together so many of the various things I’d learnt over the years, and I was keen to give it a go, however I was completely reluctant to commit as I had been through this so many times in the past 8 years – throwing a lot of money into a different approaches – only to be the one who gets screwed in the long run when the trainer/physio/specialist etc. get very little results and basically gives up, but continues to take my money until I eventually get handed over to someone new, and the cycle continues…
But I did really like that Nick took learnings from so many different approaches and I felt that maybe he would just pull all the different bits from all the different therapies and put them into something that worked precisely for ME. I am only 33, and I simply felt like I shouldn’t have to settle for where I was at – yes I was ‘functional’ and working full time again, but every decision and plan in my life was made with pain management in mind.
I’ve now been seeing Nick twice a week for three months. Right from the start he has identified poor movements patterns that I’ve always felt weren’t right but no-one ever listened or taught me HOW to correct it. He is great at explaining why we do movements or exercises a certain way and identifying the specific trouble spots that I have, allowing me to be much more aware of how I move both in and out of the gym. Particularly the way he structures workouts around the relationship between stretching and strengthening makes so much sense. Much of what he says is bits and pieces of what I’ve heard before but finally packaged into a training session that works for ME and doesn’t aggravate my various complaints. He’s also very flexible and will change his workout plan to suit how I’m feeling that day which means I never feel pressured. I’ve learned that I still hold a lot of fear with my movements but I know I can be honest with Nick and he makes sure I feel supported physically and emotionally. Whilst I get the muscle soreness that you get from a good workout, my body has quickly adapted and I’m yet to have any major ‘set backs’ like I’ve always encountered with other therapies/trainers.
My employer recently offered me a job closer to home, a dream given driving aggravates my sciatica. After much thought I accepted the position on the condition that I could continue to work from Nunawading once a week so I could continue my training. That’s how committed I now am to working with Nick! I never thought it would be an overnight cure, and Nick is very honest and upfront about the work you need to do and time it takes to make permanent corrections, but I have genuinely seen more improvement in the past 3 months than I have in the past 6 years! Obviously it’s still early days, but for the first time in a long time I feel like I’m making consistent improvements and am on absolutely the right track." - Georgie McIntosh
Below is a picture of her completing a single leg deadlift with weights. When I first met her she could hardly tie up her shoes.
The programs we used with Georgie were all based on many tests. I had to be very careful not to hurt her and we were really flying blind so I was constantly looking up research to find things to support my reasoning for using exercises. Again, I had to be very flexible and open to new ways and not follow a rigid plan because a scientific study tells you to. Remember science had already let her down before.
Surgery vs Manual Therapy Study for Hip Pain
In our article about Osteoarthritis and knee replacements we showed the results of a study comparing surgery to manual therapy and how the study results are very misleading.
Eighty patients were selected for the study. All patients were diagnosed with hip impingement (FAI). The ages ranged from 18 to 60 years old. They were randomly separated into two groups of 40 patients each.
Group 1: Surgery Group - The surgery options involved one or more of the following:
- Changing the shape of the hip bones. An “abnormal” bone shape is considered a cause of FAI, like cam impingement or pistol grip deformity.
- Hip labral tear surgery.
The final decision on which surgery to perform for each patient was based on the surgeon's clinical judgement. After the surgery, the patients went through a postoperative physical therapy protocol.
Group 2: Rehab group - This group underwent a supervised physical therapy program. The sessions were twice a week and 45 minutes long, with a total of 12 sessions. The techniques included therapeutic exercise, and manual therapy to the hip, lumbar spine, and pelvis. The outcomes of each patient were obtained at six months, one year, and two years. The primary outcome was the Hip Outcome Score (HOS).
Results Of The Study
So how did physical therapy for hip impingement compare to surgery? Is the cost of surgery worth the results?
Let’s take a look at the results:
- Over time, there was no statistically significant difference between both groups. The overall perception was “no improvement”.
- The mean cost of hip-related care over the two year-period was three times greater in the patients who underwent surgery compared to those who didn’t.
- Patients who underwent surgery had more complications, including surgery on the other hip, revision surgery, and a diagnosis of hip osteoarthritis.
Why did the manual therapy not work? The researchers designed the protocol based on the belief that bone shape and/or a hip labral tear caused pain for these patients. So, the femoroacetabular impingement physical therapy treatment addresses it as a bone issue:
- The manual therapy techniques try to “open” the space between the femoral head and the hip to ease the movement of the joint.
- The strengthening exercises aim at hip muscles without regard for proper sequencing or mechanics. More specifically, the quads and adductors are activated far too much in the entire program.
- The stretching routine and tissue release techniques relax the TFL, quadriceps, and the piriformis.
The reason the manual therapy did not work correctly for it assumed every person was the same and applied a model of treating the muscles and not how you coordinate movement. The study ignored finding the reason for the pain which in ALL cases can be traced back to how a person moves. In the case of hip and knee problems movement patterns like bending, squats, and lunges reveal the problem. The reason these movements are faulty differ from person to person. Some people will complete these movements poorly as they may be hyper-mobile, whereas the next person will move poorly due to being extremely stiff and inflexible. Therefor, the treatment for each person will be completely different.
This is why testing is so important so you use the correct treatment method for your body.
Research is Still Important
Now it seems like I am slamming scientific research and telling you to ignore it. This is not wise for there is so much great information you will find and it can be invaluable in providing answers to things that do not make sense. And this is where the the person ignorant to research and bases everything on their own beliefs misses out big time. 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.
You can source some of these assessments and program methods for specific injuries referred to in the article are available to download below by clicking the image of the program you need.
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 14 years’ experience as a qualified Personal Trainer, Level 2 Rehabilitation trainer, CHEK practitioner, and Level 2 Sports conditioning Coach. Based in Melbourne Australia he specialises 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