As a physiotherapist and as a patient we have all heard the theories and reasons why an intervention may work. There has been long held beliefs that some of our treatment interventions work by old outdated and false biomechanical narratives that are still being pedaled by the gurus that benefit from them or unintentionally by some student learning their trade from their mentor or tutor. Both may actually believe these narratives. You may hear things like "your pelvis is out of alignment", "you have muscle imbalances", "your ribs are out of place", " you need to move this vertebra on that vertebra"" Your core is too weak" --all theses narratives create a sense of fragility and promote the need that you need fixing before you start doing. Are there times when these narratives are correct sure there are please read on.
My goal is to promote movement optimism and instill confidence in people that they are not fragile but robust and we can adapt to the load placed on our bodies, load is good. Everybody is asymmetrical and human variations are so vast that there is no perfect posture or position. This might change with elite performance lifters and for people trying to be aerodynamic in elite cycling sports for example trying to beat their personal best times but for most everyday people your best posture is your next posture so instead of trying to maintain a perfect posture we should be trying to avoid prolonged postures.
Examples to explain “that load is good “concept --after a hip replacement or knee replacement you are informed by the surgeon to weight/load bear one day after surgery --why because load is good and stimulates new bone growth, you need this stimulus to heal. Therefore, when astronauts are in space, their muscles waste but their bone density also dramatically decreases--why because gravity is not acting on their joints--hence all the exercise they must do while they are in zero gravity.
All the theories and narratives above are just not supported in the literature, and they can create, for some of the population, especially ruminators, a nocebo effect
What is a nocebo effect. The nocebo effect is the opposite of the placebo effect. It describes a situation where a negative outcome occurs due to a belief that the intervention will cause harm. The term nocebo comes from the Latin “to harm”.
So, when well-meaning therapists use the above language and the technique or treatment used has some positive short term pain relief and short-term increased range of motion benefits then the patient believes the narratives that goes with the treatment. The problem here is not the technique used but the narrative used to describe the technique. Some people don’t bat an eyelid when they are told “your pelvis is out of place”, they just go down to their health care provider to get it back in and they go about their business. You could argue this is okay to a certain extent as they are getting some pain relief however, when people become stuck with this harmful explanation, and they become afraid to move due to fear and pain and they believe they must get their pelvis back into alignment before they feel better. This is where I disagree with the terminology and narratives used.
It is my belief, and the research supports this that joints don’t just go out of place unless there is a major trauma, like on a rugby field and someone dislocates their shoulder but having your pelvis out of alignment, rib dislocated from non traumatic events don’t add up for me. Weak core usually after abdominal surgery or post partam would be acceptable times where we must build up our core but so much of lower back pain especially non specific lower back pain has been blamed on a weak core and this is not supported in the literature. Analogies like "your core is like the center mast on a ship"—something I once used to say is not that useful anymore in most cases. We may be blaming the core in error and setting our patient up to fail especially people who do not wish to exercise. We don't always need to get stronger to get out of pain and weakness does not always cause pain--sometimes we are not sure what is mitigating recovery
Some joints can feel like its out of place, but the truth is that you body has become sensitive to certain movements and some therapy intervention can help with reducing pain. The body can sometimes lie in our perception of pain, stiffness and joint placement. Think about a heart attack –some people get pain in their face or in their arm but not all get direct pan and tightness coming from their chest—the body can be both weird and stupid sometimes.
With the narratives from paragraph one people then believe them. Some shrug it off but some catastrophize and feel like they need fixing or that they are broken and fragile. They then stop doing what they love, and this can have heavy consequences on a client’s mental health. All these factors combine can lead to depression, anxiety, and many more mood-altering states—a very slippery slope not to mention the never ending looking to be fixed approach for something that was never driving their pain in the first place ---a never ending cycle—This is not empowering but, I believe harmful to some of the population.
The problem we have here is that old narratives are much stickier than the new science and research findings. Pain is much more about the whole eco system of our bodies rather than just on simple biomechanical abnormality or perceived abnormalities. It can still play a role in the sensitivity, but many factors influence our pain and stiffness and joint stability perceptions .
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