When should you ask your health care provider about your pain?

Dealing with some sort of musculo-skeletal (msk) pain is a common issue for most people, in fact low back pain alone is one of the most common issues people deal with and upwards of 80% of people will experience it at some point in their lives. That doesn’t even begin to mention some other common aches and pains such as neck, shoulder or knee pain. 

The good news about most msk issues is that they do tend to self-resolve, or just simply get better with some time. Of course that doesn’t happen all the time and pain is still common. Pain can also be unique for each individual, some activities may flare up symptoms and some may not, but the pain will still linger.

So with so many unknowns about pain, how do you know when you should see a provider? That's a great question and one that I get quite often, and in fact I see a lot of patients who have been dealing with a specific injury or pain for a while but were hesitant to go see someone because they were unsure if it was necessary. Although there is no perfect answer for this question, I have come up with a few criteria that should help give some guidance to most folks.

First I’d like to just say that there really isn’t any issue that you can’t ask your provider about, which is my first point. If you are dealing with a pain that concerns you, no matter how long or how intense the pain may be, you are more than welcome to ask your provider about it. Now, keep in mind that when you ask your healthcare provider about your pain they should ask a few follow up questions and maybe do a test or two to reassure you and themselves that what you are dealing with either is something to be discussed further or something you can let self-resolve with time. If you ask your healthcare provider about your pain and you feel as if you weren’t heard or listened to, you should absolutely look for a second opinion. Now that starts to get into other topics which I’ll discuss in other posts but the point is, there isn’t a wrong time to ask about a pain you have and when asking about it you want to make sure the provider listens.

Another criteria that can be helpful is the time you’ve been dealing with the injury. Now there are a few sub-points with this one depending on the injury. If you sustained an acute (recent) injury and there was some immediate pain such as a pop in the shoulder or low back, then I would recommend seeking help from a provider sooner rather than later. In these cases it's best to rule out fractures, tears or other serious injuries that might require more medical care. That is probably pretty obvious but then again, there have been multiple occasions when someone tweaked something and decided to put off getting it looked at for longer than necessary. 

Now a more common scenario that most people encounter is when pain comes on slowly over time maybe from overuse or just possibly out of the blue, in these scenarios I like to tell people that if the pain itself is tolerable they should wait about a week to see if the pain starts to resolve on its own before consulting a provider. More often than not, pain that slowly comes on like this will likely start to fade if given enough time, so being patient and letting your body do its thing might be all you need to do. However if the pain lingers and sticks around for multiple weeks or like previously mentioned you are just concerned about it, I would suggest getting it looked at to see if you can get some answers. 

One of the last criteria is overall function, even if the pain is mild or hasn’t been there long or you just aren’t concerned about it, if you start to lose some ability to do your daily activities I would suggest getting your pain looked at. Again, I’ve seen many patients who have dealt with things like low back pain or shoulder pain for months if not years and then finally came in to get care and had they come in sooner they likely would have either had better outcomes or just had better quality of life from getting a few pointers on how to manage their pain. 

One last point I do want to make which I previously mentioned (and will talk in more detail on soon) is that when you go to your health care provider to ask about your pain you should feel as if they listened to you and did a thorough history and evaluation of your issue. If you felt they were short or didn’t listen to your full story about your pain then I would recommend seeking a second opinion. 

How to correctly use a weightlifting belt

I see people using belts in training all the time. I don’t see this as a bad thing by any means but I don’t know if people fully understand why or how to use the belt. In fact I will often ask people why they are wearing a belt just to see what their response is. Typically they will respond with “it helps keep my low back stable” or something along those lines. This isn’t exactly wrong but when I see the way they use the belt I see that it isn’t exactly true.

Wearing a weight belt

To understand what the belt is for, first you need to understand few other topics:

Intra-abdominal pressure or IAP is what you are striving for. It is what it sounds like, being able to create pressure in your abdomen. This increase in pressure is what helps stabilize the spine. So being able to create increased IAP is the goal when you want to lift maximal loads with a stable midsection. 

So how do you do this? Well creating increased IAP happens when you draw or breathe in air pressing your diaphragm muscle down which presses out against the rest of your abdomen. The more you can draw down the diaphragm the more pressure you can create in the abdomen (see image below).

Intra-abdominal pressure

A very simple analogy that I hear a lot and seems to make sense to people is the comparison of your abdomen to a pop can. Imagine an un-opened aluminum pop can, if you had it sitting in front of you, you could step on it without it bending or cracking. Now if you took that same pop can and opened just the top and stepped on it then it would likely crumble. And again if you took an empty pop can that had a dent in the side and you stepped on that, it would likely crumble even easier. (let’s be clear, your body is much more resilient than a pop can and you won’t “crumble” under minimal loads, this is simply a comparison so you can fully understand IAP).

When you are able to take a big breath of air in and drive your diaphragm down, this increases the IAP and your spine is able to handle much higher loads with less risk of shear forces (like an unopened pop can). Now imagine you could take that same unopened pop can and shrink it down just a little bit but keep the same amount of contents inside. This would increase the pressure inside the can making it harder for it to deform. 

This is the exact mechanism of how the weightlifting belt should be viewed as. When you are ready to lift heavy you should be able to take a big breath in which lowers your diaphragm and presses out on your abdomen increasing the IAP. Then if you used a belt you could sinche down the size of our abdomen even more which increases the IAP (assuming you can get the same amount of breathe in). This is often why you will hear people say “press out on the belt”. In my opinion the way you should put on a belt is this: let as much air as you are comfortable with out of your lungs, then strap the belt tight to your comfort level and then take a big deep breath to allow your belly to be pressing out against the belt. This will give you a higher IAP and like the analogy used earlier a more “stable” spine.

Caveat: I like to develop my ability to create as much IAP without a belt as possible. I typically don’t use a belt until I am very close to maxing out my squats and I rarely (almost never) use a belt for deadlifting. I think there is a time and place for a belt but especially when the athlete knows exactly how to use it. Thanks and I hope you enjoyed it!

Should you be strength training as you get older?

In the Geriatric population, many people agree that physical exercise is a good thing and can be beneficial in increasing longevity and quality of life. However, there doesn’t seem to be a firm consensus of what type of physical activity is best.

Strong Grandma

Again, most people will agree that it is best to do a combination of all of these types of exercise, but it’s my opinion we should shift the focus more on resistance training. I think it is almost more beneficial for this age group to do resistance training than almost any other age category when you consider the benefits that they can get.

Let’s look at some of the reasons this population should be doing some sort of resistance training. First, just staying generally fit with relatively leaner body mass will aid in all sorts of organ and bodily function. This will give us less overall stress on load bearing joints such as the knees, hips, and feet. Being leaner and more fit will make it easier to get up and move around which can be an issue as people age. Second, overall bone density and muscle mass begin to decline as we age and resistance training can be a great way to help fight that. Falls are a big issue with older people and that is often in part to bone density. Sometimes a misstep or trip can cause a hip fracture which then causes a fall. Having strong robust bone structure is essential for this age group.

This brings me to my next point, which is a few points in one but I think it is one of the most important: Falls. Falls are a major risk factor for older people and if a person over the age of 65 has a fall they are almost worse off over the next few years than if they were to have a heart attack and have an increased risk of dying in the next 2 years following a hip fracture. Falls happen for a few reasons including decreased bone density balance, coordination, and overall strength. Even if one's bone density is adequate, they might not have the strength or coordination to prevent a fall. Falls really are a big deal, and some sort of resistance training is a great way to try and prevent that from happening in the first place.

Getting Strong!

Quality of life also improves when you can add resistance training during this phase in your life. If you can physically walk on your own, have balance and coordination to get up and move around without the use of a walker or cane then you are probably going to be able to enjoy life more. You can go for a walk and see nature, you can play with grandkids without worrying if it is too much activity, you can pick things up without worrying about hurting yourself. All these things can be improved by simple resistance exercise a few times per week.

I think part of the reason we don’t see as many older people doing resistance training is because of the mental image we attach to it. If I were to suggest someone needed to do some sort of strength training they would probably imagine a powerlifter with a super heavy barbell and loud heavy metal music. That doesn’t have to be the case at all. Strength training can be many different things and although I think a barbell is a great way to go, you don’t have to use them to get strong. Machines can work just as well and you don’t need to do a 1 rep max to get strong either. As long as you regularly do some sort of resistance training for multiple body parts a few times a week that is all you need to get and maintain strength and bone density. Add in some exercises that incorporate single leg or single arm movements and now you get some added coordination benefits. Another note is we have to remember why you are doing resistance training, your goal is to improve overall strength and stability than the way you workout will be different from a person who has a goal of doing competitive powerlifting.

So if you or someone you know is getting older, please consider doing some sort of regular (2-3x / week) resistance training. It will be beneficial both short and long term and will add quality years to your life.

Choosing a Chiropractor: Where to start

My sister called me the other day to ask if I had any recommendations on a Chiropractor in Texas for her husband, as I was walking her through who I think she should send her husband to I realized that I wish more people had this same knowledge when it comes to selecting a Chiropractor. 

Of course I am biased when it comes to what I think makes a good Chiropractor but I think there are some commonalities when it comes to the few good ones out there. I’ll start with a short list of things I think are important and add my commentary at the end. 

1. If they claim to correct subluxations and clear/free the bodies innate ability to heal itself, I would be very skeptical and steer clear.

2. If the Chiropractor takes X-Rays on every patient they see, I would again be very hesitant to see them.

3. I would encourage people to look for a Sports Chiropractor or DC with a CCSP or DACBSP distinction.

4. Look for a Chiropractor that offers more than simply adjusting the spine, some soft tissue and a focus on active care are equally if not more important.

5. Treatment times in general should be longer than 5-15 minutes.

6. Look for a Chiropractor who is familiar with the things you do.

So in the world of Chiropractors there are two big camps, those who practice what is called “straight” chiropractic and then those who are more “mixed” in the way they practice. What this means is that the “straight” chiros choose to only adjust the spine (some only work on the upper neck region) and the idea is they are realigning the spine, taking pressure off of nerves and allowing the body's innate ability to heal itself to be reestablished. This has somehow been eaten up by the general population of people but unfortunately there are few great scientific studies that support this type of treatment. 

“Mixers” on the other hand tend to look outside of just the spine they will do some soft tissue work and spend time on active care. This is where there is much more backing from scientific evidence, some manual therapy plus active care for best patient outcomes. The “mixers” or “Forward Thinking” group of Chiros tend to look more towards evidence for treatment whereas the “straight” will look towards philosophy of treatment.

The second point I made suggests you shouldn’t see a Chiropractor if they regularly take X-rays of all patients. First, the evidence for imagining being reliable for diagnosing has become very poor. There are multiple studies on shoulders, low backs and even hips, when someone gets an image of these areas we could see actual damaged tissue but the patient could be reporting zero pain. The opposite is true, we could take an image and see nothing wrong yet the patient will report pain, does that mean specific structures aren’t responsible for pain? Not really, it just means that it is very hard to tell just by looking at an image if a structure needs helping or not. Not to mention each X-ray will expose you to a certain amount of radiation (although small) if it can be avoided it probably should. 

Point three is one of my personal biases, I would first look to someone who recognizes themselves as a “Sports” clinician and there are a few distinctions Chiropractors can get to be recognized as such. One of those is a CCSP or Certified Chiropractic Sports Physician, another is a DACBSP or a Diplomate American Chiropractic Board of Sports Physicians. The CCSP is basically the first step to getting the DACBSP and requires extra hours learning more sport specific management of patients or events. I happen to have a Masters degree in sports medicine and that is another thing you could look for in your Chiropractor is to have additional degrees. I want to be clear here though, I know tons of Chiropractors who aren’t CCSP’s or have a Masters degree that are very good clinicians and would be considered some of the best in the profession.

Point four is similar to point one, but I just want to re emphasise that the best evidence for treatment of pain for a patient incorporates more than just passive treatment (simply adjusting or only manual therapy). In fact there has been more research suggesting that exercise is your best bet for treatment and if the Chiropractor doesn’t try and get patients to do some sort of active care then they probably aren’t doing what is best for the patient.

Point five here is again similar to my last point, but if there isn’t some sort of time dedicated to educating the patient on the mechanics of the situation or exercises that could benefit them then I don’t feel that Chiropractor is doing the absolute best care. 

Finally, something that I feel strongly about is if you are going to see a Chiropractor or physical therapist or even your family doctor for that matter, I think there is a lot to be said for being able to understand the sport/activities that the patient does. For example if you do CrossFit or dance or garden or play basketball, wouldn’t you want your practitioner to be familiar with the demands of that thing? Just like there are specializations in the medical field, there are Chiropractors and physical therapists that understand the demands of different activities better than others. So look for that, do they incorporate things in their website or bio that you like and can relate to?

Ultimately the choice is yours, you can see who you want and spend your money where you like. My intention for this is to simply get you to ask why, why do you want to see someone? If you have been dealing with pain or dysfunction in an area don’t you want to best most comprehensive and evidence based approach? This blog isn’t too scientific in itself or the few things I selected to write about but I think if you as the patient are seeking that out these few things to look for will steer you in the right direction. 

Correcting your movement flaws with this simple trick

If you feel like you don’t move well or if you have been told you have specific movement flaws during different activities don’t worry! First, most people have different movement styles and that doesn’t mean that one movement is always better than another. Movement variability (different styles of performing a task) is ok and it even helps us learn new movements. The few times that specific movement really matters is when you are loading it up with higher forces than normal (lifting weights is the best example). 

In these cases, it might be more beneficial to have “good” mechanics but learning those mechanics can sometimes be difficult or take a while to master. Well, there are a few ways in which you can try and become more proficient at moving and this is a technique I really like. 

The technique that you can start to implement to help change your movement flaws is called Reactive Neuromuscular Training or RNT. It sounds fancy and cool but it is really pretty simple. 

Here is my breakdown of the training approach:

Reactive- in response to. 

Neuromuscular -the nerve and muscle system/unit. 

Training- to practice 

So what does this mean? Let’s use a squat as an example since it is the easiest.

If you squat and you see your knees cave in (see picture), most people would say that is a movement flaw. To try and correct this you can put some sort of extra resistance (such as a band) that actually pulls your knees into the fallen or caved in position. Sound a bit backwards? That’s the “reactive” part of the training. 

Knee Valgus with squatting

If I were to try and push you over, your body would reflexively try and push back to keep from falling over. A similar thing happens when we put a band around the knees; your body will reflexively push out against it now that there is some resistance there. 

Banded knee squat

Now that you know an example, you can apply that technique to just about any part of the body. The trick is trying to implement that into a way you can train it. Have you been told your foot falls in when doing different movements? Put a band around your ankle to pull the foot in while performing a single leg deadlift and see if that helps. 

Hips shift right or left when squatting? Try pulling your hips further into the direction you shift to and see if your body naturally fights the resistance to get back to neutral. 

All you are doing with RNT is providing a resistance in the direction of the movement flaw, then train that movement. Over time you should see that you don’t naturally fall into that flaw as often and you can use smaller and smaller cues or resistance to get the same “correction”. 

Again, this is a simple trick that you can apply almost anywhere. If you have any questions about trying to correct your specific movement flaws, reach out to me and I would love to share my thoughts.