There are many times where we may be pathologizing normative findings in people. There are plenty of examples of this.
There are studies where MRI finding in both shoulders are highly prevalent regardless of pain--https://pubmed.ncbi.nlm.nih.gov/31279721/
Other studies blinded the radiologists and the finding came back with different interpretations of abnormalities or perceived abnormalities. There were also different findings/descriptions between radiologist reports—story for another day.
This tells us that what we see on MRI does not always correlate with pain –In fact it may also prove that these findings, especially as we age are normative---they are like the wrinkles on your face but on the inside. Structural changes do not always mean damage or indeed they may not even be driving pain. Maybe there is a degree of sensitivity, but it gets blown way out of proportion by the words they read on an MRI –things like “Full thickness supraspinatus tear” or “degenerative disc disease”. How anxiety inducing are these diagnosis. We must be very careful with our words and descriptions of people’s pain. Of course, there are definitely times where imaging is very important and necessary but they are far fewer than one might think.
A small case study: ---A person in her 30’s has scoliosis with a low degree Cobb angle— (this is a measurement of the degree of side-to-side spinal curvature). She has been told her pain is because of her spinal curvature and she cannot squat or deadlift---this is utter nonsense---patients need to be monitored when younger as the cobb angle can change with growth and it can sometimes need surgery if the angle is greater than 40 degrees. This person is in her 30's with no other medical conditions other than a low degree cobb angle. There is no reason she cannot complete deadlifts or squats. This person may have pain when doing these activities, but the curvature of the spine is not the driver and you can not change the spine curvature, but you can change pain by changing her belief about her spine and showing her that she can adapt and habituate to load like anyone else. Usain bolt has a major scoliosis, and he is the fastest man in the world.
You do not change her spinal curvature, but you may modulate her pain and instill confidence in her back, empower her that she can move and complete these movements, reinforce that she is not a brittle and fragile creature. Her body just needs load stimulus to adapt. She needs to be given permission to lift. Remember pain sensitivity is not just about biomechanics, it is a lot more got to do with our beliefs and understanding of pain and many factors than cause our pain thresholds to get triggered. This is where the world of exposure therapy comes into play where we discuss old, outdated beliefs, instill confidence by education and perhaps cognitive functional therapy and then load her spine progressively. If she feels pain the idea here would be her system has been thought for many years that she must not move this way or that way or that she must not lift. Our brain works on a system which I will give a crude explanation here. We are in pain –the brain interprets all information about the injury-based on many factors like old injuries, old beliefs, pervious treatments, old narratives and it decides does this injury site need protecting-ie pain or is she safe to move and lift ie—no pain. So, when we feel pain in this case study when she completes a dead lift, we should lean into pain to try and convince her nervous system that she is safe to do so. She is not causing damage in her back but rather her nervous system is super sensitive. This is called habituation and it the opposite of sensitization. It is a bit like playing a guitar, when you fist learn to play, the tops of your finger pads are extremely sore from holding the strings but eventually you get used to it or habituate. This happens both neurologically (in the brain) but also physiologically (calluses on the top of the finger pads/ thicker skin). We are a robust and a resilient species--- we have stood the test of time and we have evolved. Do not knock your patients down build them up.
The traditional way of treating people was to find problems with the patient and then fix said problems. This is known as the kinesiopathological model(KPM) of care where there are normative movement patterns that we must operate in to avoid or mitigate injury or it is believed that some movement patterns, patterns outside the normative ranges predispose to injury.
I propose that we can adapt to almost anything in life, I am a movement optimist, some mechanisms of injury require we go into abnormal movement patterns, if there is such a thing, and maybe we get injured not from the movement pattern but from being underprepared for said movement pattern
Eg: knee valgus, foot pronation –some people require these movements to complete their task like running or rock climbing—maybe we should build up our comprehensive capacity by training into these patterns as opposed to always avoiding them in controlled settings.
Manual handling courses try to mitigate lower back pain by keeping a neutral spine and keeping the load close to COG, this is the most efficient way to move product however the research is scarce on whether this mitigates injury. There are still many workplaces lower back injuries despite companies providing manual handling training to all new employees. How do we explain this? Perhaps we need to prepare for the movements where we must get into unnatural or awkward positions. We sometimes need to do this on a daily basis and perhaps trying to get into neutral spine all the time can sensitize (make worse) somebodies lower back. Getting the load close to COG is great but sometimes we are unbale to do this based on our environment. This is less efficient but sometimes we must be less efficient depending on the task. We can’t avoid these things forever, but we can prepare and try to build our tolerance to it
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