Derek Griffin
@DerekGriffin86
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PhD (Pain) | Specialist MSK Physiotherapist | Long Distance Runner | 2'27 marathon | 1'11 half marathon
Tralee, Ireland
Joined April 2012
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10 DOS & DON'TS OF PERSISTENT PAIN
I recently prepared a media piece on "10 dos & don'ts of persistent pain". From today until the 1st of January I will post a summary of each of the 10 points that I have included.
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10k steps per day is often quoted as as a physical activity goal. However for the most sedentary groups, this can seem like a daunting task. It is essential that we are very clear with people that benefits of being active happen well before 10k steps.
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Aerobic exercise reduces all cause mortality to a greater extent than strength training when used as standalone interventions but the greatest benefit may come from combining both!
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I'm thrilled to have run under 2'30 for the first time clocking 2'29'04. It's a proud day for me to finish 71st place in such a big field. Overall very good conditions for racing albeit a bit of wind at times.
@AndrewJamesHobd
and I make a good team. Thanks for all your help.
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Time to bust the myth about a minimally effective dose of 10000 steps/day for health. The health benefits start with the first step. A little activity goes a long way. Pass on the message to all your patients!
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Many times it's not the exercises that help patients; it's the process of "doing" the exercises, realising that their body is capable & the resulting pain/discomfort is only less or more manageable than predicted.
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Simple, progressive exercise for the management of occupational MSK pain. Only 1 set, 5x/wk, completed at work, 67% very much/much improved after 9/52. While bigger studies required, this type of research looking at easy to implement rxs is to be promoted.
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MY TOP 10 PAPERS OF THE YEAR
👉Challenging conventional wisdom.
👉Motivating us to think outside the box.
👉Improving clinical practice.
👉Opening doors to new avenues of research.
Enjoy!
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An amazing data set on 50k people with pain exploring predictors of spreading of pain over 9yrs. The predictors were irrespective of the dx/site of pain.
👉Sleep problems
👉Tiredness
👉Feeling fed-up
👉Depression/anxiety
👉Stressful life events
👉BMI >30
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Many physios argue "I am not a psychologist". That's very true but you are also not a biomechanist or exercise physiologist! Deal with humans? Deal with psychology.
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Sleep loss is:
👉Pro-inflammatory.
👉Contributes to peripheral- & central-sensitization.
👉Impairs descending inhibition.
👉Influences reward systems & dopaminergic transmission.
👉Impairs cognitive & attentional processes.
😴😴😴
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Nice exercise progression framework that we can apply beyond tendons! Work of
@ProfJillCook
et al.
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We keep hearing about neuromuscular exercises. Can anyone give me an example of an exercise not requiring a nervous system and a muscle? More redundant terminology. It's just an exercise!
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Can people please remember that
#Karius
is a human with feelings. Yes, he had an awful game but every athletes regardless of their level of performance has an "off" day. He shouldn't have to apologise for anything.
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✅Top 100
✅PB - 2'28'19
✅Even splits 1'13'49/1'14'30
@bostonmarathon
demands a clever racing strategy given the technical course. I'm delighted with how the race unfolded.
Credit as always to the great coaching from
@AndrewJamesHobd
.
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One look at the anatomy of the rotator cuff complex and it's immediately apparent why you cannot isolate a specific muscle with a "special test".
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Note to all clinicians - with lots of or little experience. Contrary to what it might appear on Twitter, there are no clinicians who achieve excellent outcomes with all patients. Some patients do really well; some don't. We hear more about the former; the latter isn't spoken of.
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1. Lactate levels return to normal with 40-60 mins post intense exercise.
2. DOMS doesn't peak until 48-72hrs post intense exercise.
So post exercise soreness IS NOT caused by lactate!👌
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Osteoarthritis is a systemic problem, not just a "joint" problem. The illustration captures the complexity & multidimensional aetiology very well.
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Tendon adapts to heavy (>85% MVIC) load, not plyometric exercise, which favours muscle.
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People with MSK pain improve in the first six weeks regardless of intervention type (including no treatment) or duration of symptoms. If you want to make a treatment appear good measure short term outcomes!
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Some day physios will stop believing that inner range quads or yellow theraband are effective and start prescribing squats!
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Spinal mobilisation/manipulation no better than a laser machine which was turned off!
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"They are not effective for low back pain, sciatica, spinal stenosis, or episodic migraine, and their off-label use for these conditions is not advised".
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I don't use ice baths or compressiom garments or whatever the latest technology is. I eat and sleep. Don't complicate it and don't fall for the marketing. And just because some elite athlete uses whatever, doesn't mean it does anything.
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For acute LBP only 32% of physios advised patients to stay active; yet 70% have posture advice! 🤔 If we are to change societal beliefs about back pain, we must start with changing our own.
JUST PUBLISHED 📣
New editorial summarising
@JPhysiother
papers on advice and education for spinal pain. Table below summarises what % of physios provide recommended and non-recommend advice and education
@JoP_Editor
@msk_health
#physiotherapy
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We are transiting from an era of misogynistic disbelief of fibromyalgia structural underpinning to a time of innovative research based on well-structured scientific evidence.
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Active range of motion is not a "physical" test. It is a behavioural. It is as much a test of willingness to move as it is a measure of available ROM.
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Symptomatic spinal stenosis is a clinical diagnosis, not a radiological diagnosis....
1) Age > 60 with bilateral leg pain
2) Pain provoked by sustained extension > 30s
3) Pain relieved by leaning forward & sitting or flexing the spine
4) Negative SLR
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MY TOP 10 PAPERS OF 2022
👉Challenging conventional wisdom.
👉Asking the difficult questions.
👉Exploring opportunities for further research.
👉Improving clinical practice.
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Do your patients know that exercise is a potent anti-inflammatory?
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Five step to a successful clinical encounter:
✅(1) take a moment to prepare and focus before greeting a patient);
✅(2) listen intently and completely
✅(3) agree on what matters most
✅(4) connect with the patient’s story
✅(5) explore emotional cues
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"Despite their efficacy, recent studies show that NSAID use in early acute pain can prolong pain and inflammation and delay their resolution."
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Who develops persistent LBP?
😨Psychological distress.
💊Poorer self rated health.
🏋️♀️Low levels of physical activity, smoking, low alcohol intake.
✍️A history of low back pain.
🧰Unemployed.
😐Job dissatisfaction.
🦵Widespread pain, leg pain & reduced ROM
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It's important to reassure patients with radiating pain that:
1. Inflammation can account for nerve sensitivity in the absence of "damage".
2. This inflammatory process has been shown in clinical populations.
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Before you start your run this weekend.
Remember that these elite athletes regularly run >120 miles per week, do tempo runs of 30-40km at pace and run high volumes of 400m-1k intervals.
Before you start your run this weekend.
Remember how slow the world’s best warmup:
The Kenyan Shuffle:
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👉Solues/quads responsible for most of the support forces (peak soleus force = 8.4 to 10.7 x BW!).
👉Gastrocs/hamstrings/glute medius propel the body forwards acting as the "accelerators".
👉Glute max/hamstrings reposition the swing leg in prep for GC.
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How many therapists tell patients with neck pain that their traps are "overactive"? Yet another study showing that upper traps eccentric training reduces measures of pain sensitization in office workers with neck pain.
@LarsLAndersen
@AdamMeakins
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Osteoarthritis is best described as an inflammatory process and the descriptive term of "wear & tear" is both inaccurate and fear-inducing for patients.
#WorldArthritisDay2021
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"Movement in the sacroiliac joint during the single-leg stance is small and almost undetectable by the precise radiostereometric analysis". How many clinicians believe they can assess the SIJ mobility is beyond me!
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Motivational interviewing strategies to facilitate behaviour change:
⭐Express empathy
⭐Avoid argument
⭐Support self-efficacy
⭐Roll with resistance
⭐Develop discrepancy
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An acute exacerbation of pain is a common response to exercise in people with persistent pain. It is important that patients are educated that over time, exercise can reduce pain despite an initial increased pain response.
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Approximately 1 in 3 people have persistent pain following lower limb joint replacement. If "wear and tear" is blamed on the cause of this, then a really good explanation is required to explain why pain persists when the "worn" joint is replaced.
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THREAD-CAN EXERCISE ⬇️ PAIN?
✅Sedentary behaviour = pro-inflammatory
✅Regular exercise = anti-inflammatory
👉Short term ⬆️ in pain can be "normal" with exercise if very sedentary (Counsel pts on this)
👉Change takes time!
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I felt good today but not amazing. I had to work hard today to hold the pace. A solid run but there is potential for more. I didn't fare well with the lack of undulation. Overall happy with another sub 2'30 clocking.
@AndrewJamesHobd
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Physiotherapy has the same problem. Always a "syndrome" or an "itis".....When the most valid diagnosis is "I don't know".
"Doctors failing to diagnose are resented and sometimes punished, while doctors who cause suffering through overdiagnosis and overtreatment are not."
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Well! A nail in the coffin of the "good posture" myth?
i) Slouching improves disc height & IVD hydration
ii) A trend toward increased disc height with more lumbar flexion
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A common belief is that "sure it must work if the elites are doing it"! Unfortunately pseudoscience is common in elite sports too. Great piece by
@NBTiller
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Simple progressive exercise (shrug, front/side raises, reverse flies, wrist extension) performed just 1-2x/week for 20 mins resulted in a clinically relevant reduction in neck pain.
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Note to physios!
"Non specific low back pain" does not mean that peripheral sources of nociception are absent and/or not important. It is a reference to the poor sensitivity/specificity to identify relevant sources of nociception with any certainty.
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The presence or absence of disc herniation or nerve root compresssion on MRI DOES NOT differentiate favorable/unfavorable outcomes in people with "sciatica".
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The degree of nerve root compression or other MRI findings DO NOT correlate with subjective symptoms in people with sciatica.
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There is strong scientific support that much of the "nerve-related pain" that we see is not neuropathic. It is instead inflammatory in nature (not damage). Nerves like movement to facilitate axoplasmic flow, blow flow and minimise prolonged compression.
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Strength training is neuromuscular exercise! It involves a nervous system and muscles! Why do we have all this unnecessary and confusing terminology?
Strength training in addition to neuromuscular exercise and education in individuals with knee osteoarthritis the effects on pain and sensitization
👀👀👇👇
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In a study of elite volleyball players, every MRI scan showed an "abnormality" despite all participants being asymptomatic. MRI doesn't measure pain or function.
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An excellent illustration challenging the common notion that flexion increases a posterior disc bulge. The image clearly shows a reduction in the disc bulge in flexion. Thanks to
@Neurodynamics
for the reference.
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Rather than telling people they have "the back of an 80 year old", maybe they should be told they have "the back of an Olympic athlete"? 👍
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I often speak about the need for clinicians to "biologise" the psychosocial. This is a great example. The relationship between mood & inflammation.
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Key strategies to enhance patient-therapist alliance:
1. Reassure people ✅
2. Encourage people to ask questions ✅
3. Explain the significance of any tests, findings etc ✅
4. Do not judge people ✅
5. Involve people in devising their treatment plan ✅
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This is applicable in the physiotherapy world especially attributing short term change to treatment effectiveness.
Illusion of control: believing that you’re causing an outcome that occurs independently of your behavior.
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It's crazy how people don't realise that if you experience severe anxiety or depression, that's it's not so easy to just go out and exercise.
It’s crazy how people don’t realize that their lack of physical activity/exercise exacerbates their anxiety and depression
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It's a proud day having run the last of the six
@WMMajors
in freezing & wet conditions. I ran 2.37 with even splits. Went through the marathon distance in 2.35 but congestion & no blue line meant I ran a bit over the distance! Next stop London!
@AndrewJamesHobd
#SixStarFinisher
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MUST READ FOR ALL CLINICIANS!
-Move in multiple contexts in multiple ways.
-Explicitly challenge movements deemed threatening.
-Discourage safety behaviours.
-Encourage open discourse/reflection during exposure.
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Before I run I don't do activation exercises, or stretch or use foam rollers. The time taken to do those things is at least work a mile of running!
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No, it isn't just "wear & tear".
👉"OA is no longer considered a 'wear and tear' condition but rather one driven by proteases where chronic low-grade inflammation may play a role in perpetuating proteolytic activity".
@physiojack
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The cortisol response to a psychological stressor is relatively more inhibited in active vs sedentary individuals.
#stress
#resilience
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Maybe because a 20 min walk is exercise! We should encourage all movement and be less judgemental.
Society has become so sedentary that a 20 minute walk is now considered exercise.
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The biggest correlate of fear-avoidance beliefs in people with sub-acute low back pain was the level of fear-avoidance beliefs of their doctor! A fearful clinician creates a fearful patient.
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👉Pain is a stressor.
👉Response to pain is shaped by contextual factors (early life, genetics, previous experiences).
👉A stress response can be adaptive or maladaptive.
👉Maladaptive responses = allostatic load involving multiple body systems.
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The highest ranked goal (91%!) for people with persistent pain, unsurprisingly is pain relief. If we are to be truly patient-centred and listen to patients then the goal of pain relief should be part of the treatment plan.
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Fascinating. This is why doing an AP/PA glide on the femoral head probably isn't doing anything of the sort!
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For all runners: stop stretching your calves; instead develop stiff strong ankles to help your running
#strength
#plyometrics
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Tiger believes that running "destroyed" his body. This doesn't surprise me from the man that also believed his sacrum popped out.
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The Royal College of Physicians' guidelines for the diagnosis of fibromyalgia.
A nice, clinician friendly guide to how to approach this in everyday clinical practice.
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We shouldn't confuse strength & conditioning principles with pain management principles.
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Strength training is the best intervention for......getting stronger. When did it become the best thing for pain? 🤔
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"No smile, monotonous tone of voice, no eye contact, leaning backward from the participant/patient, and no body gestures) contributed to higher reported pain and nocebo effects."
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The training is now complete. I have had a very solid two years of training in the lead up to tomorrow's race. I'm in good shape and ready to race tomorrow. 🏃🏃🏃
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So let me get this right! He postponed sleep for a recovery session! 🤔
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Exercising a non-painful body part is hypoalgesic. Why opt for passive care when there is an equally effective active option? Give people back control.
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@gsingh1902
@MRheumy
@physiojack
@GregLehman
@DrChrisBarton
@jpcaneiro
@ProfDavidHunter
1. Systemic health is important. Think outside the joint.
2. Scans show anatomy, not pain.
3. Physical activity is not harmful for people with OA.
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A stress response is a systemic, whole-body, neuroimmunological response. When we see stress through this perspective (and not something "in your head"), then we can better understand how stress & pain can be linked.
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Everything you need to know about CON vs ECC muscle contractions.
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@Lentini_PT
Three faults:
1. Assuming one will find the fault on a treadmill
2. When one finds a "fault", then assuming this is the cause of injury.
3. Not accounting for the impact on performance of changing these "faults".
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Not all radiating leg pain is "sciatica". The referral pattern of experimentally induced hip pain is extensive with 1 in 5 reporting pain in the lower leg.
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Disc degeneration in the lumbar & cervical spine is largely genetically determined. This was shown after controlling for manual work & exercise. We should stop the "normal wear & tear" narrative.
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How does activity level regulate pain? It's much more complex than many assume! A sophisticated neuroimmune mediated response. This is a nice summary of the evidence.
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There is a trend in physiotherapy to prescribe exercise in line with strength training principles. While I have no doubt this is optimal for function/performance I think is it neither necessary nor sufficient for changes in pain.
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Hopping, which requires < 2.5 minutes per day can improve running economy by approx 2% in recreational runners. No equipment required, minimal time commitment, easily progressed. It's not just resistance training which helps. We need to give ppl options
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Running was not associated with radiographic knee OA progression compared to non-runners. This was a study from 1993. Why does the myth persist in 2020?
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If the patient answers "NO" to two simple Qs (and they have a normal CRP) there is little change that they have axial-SpA (no rheum referral needed).
1. A good response to NSAIDs
2. Morning stiffness > 30 mins
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People with moderate-severe depression often find it very difficult to engage with exercise. We don't need more reviews telling us the benefits. We need more resources/services that actually help people get more active.
🚨What are the effects of exercise on depression, anxiety and distress?🤔
NEW
#BJSMBlog
summarises the
#KeyFindings
from the recently published paper that demonstrated exercise should become the mainstay of treatment, rather than just an alternative🤯
➡️
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Physical inactivity and not physical labor associated with degenerative changes in the thoracic and lumbar spine!
@kieranosull
@PeteOSullivanPT
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An individual's health status is not independent of the world they live in. Excellent overview of the social determinants of health.
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After four month of hard training, the time has finally come. I'm feeling great ahead of the Boston Mararthon on Monday and am ready to race. Hoping to perform to the standard that I expect of myself and that reflects my training. 🏃🏃🏃🏃
@AndrewJamesHobd
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Exercise is very effective for people with persistent neck pain. Two clinical gems:
1. A "recipe" style intervention with a set weight/ no. of reps is equally as effective as an individually tailored "strength" programme.
2. Compliance is essential.
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