Splints and Orthotics of No Benefit for Achilles Tendinopathy

A recent systematic review with meta-analysis (for those non-science folks reading one of the highest quality studies you can have!) looked at a common treatment options for Achilles tendinopathy: exercise, orthotics and splinting.

What they Measured:

Researchers measured function, pain and quality of life for managing Achilles tendinopathy, and analysis 22 studies with over 1100 participants.

What they Found:

Exercise improved pain and function while splinting at night and wearing orthotics provided no benefit to pain, function, or quality of life.

What this Means:

If you’re dealing with Achilles tendinopathy then seek the guidance and assistance of a physiotherapist who can coach you with the best exercises that are appropriate for you and your injury to get you feeling and moving better!

Don’t waste your money or effort on things like orthotics or splints that make no difference in your pain, function, or quality of life !

📖Study Link HERE

Should you exercise during pregnancy? Yes!

Pregnancy is an incredibly exciting time of life, but it can also be a time where you feel unsure about all of the things you should and should not do. A lot of women who have always been active wonder if they can continue to train the way they have previously, while others who have been more sedentary feel they cannot start anything new as their changing body isn’t yet used to it.

It’s time to clear some things up for you!!

Unless you have a high-risk pregnancy exercise is not only a good idea, it is actually so incredibly important for both your health and the health of your baby!!

Due to all of the misconceptions out there on exercising during and after pregnancy, an Expert Committee from the IOC was formed to specifically look at exercise and pregnancy in both recreational and elite athletes. Their recommendations are as follows:

In absences of maternal or fetal contraindications, exercise prescription in pregnancy includes the same principles and elements used for the non-pregnant population.

BUT it is important or remember and work with someone who understands the changes associated with pregnancy, which the IOC committee list as “significant anatomical, hormonal, metabolic, cardiovascular and pulmonary changes/adaptions.”

What does this mean?

That pregnant women should continue to incorporate exercise (or start to exercise)! In fact, the article continues on to state that there is very strong evidence that strength training both in general and of the pelvic floor muscles during this time can both prevent and treat urinary incontinence during pregnancy and after birth. It is also associated with a shorter first stage of labour.

Are there any signs you should slow down?

The IOC Committee explains that women without contraindications should exercise regularly during pregnancy while being regularly assessed. They indicate the following signs to indicate it may be time to stop exercising:

  • Vaginal bleeding
  • Regular painful contractions
  • Amniotic fluid leakage
  • Dyspnoea (shortness of breath) prior to exertion
  • Dizziness/syncope (fainting)
  • Headache
  • Chest pain
  • Muscle weakness
  • Calf pain or swelling

What about Post-Partum?

The birth of your child is a wonderful moment, but it also can very much impact Mom’s musculoskeletal system, with delivery being likened to an acute sports injury. Therefore, deciding when and how to return to exercise can sometimes be more complex and multifactorial. This is why it is important to seek the help of a pelvic health physiotherapist who can guide you based on your needs and your rehabilitation goals.

The IOC committee encourage exercise in the post-partum period should start gradually with a pelvic floor muscle first focus.

Key Take-Aways:

– Exercise before, during and after pregnancy is so important for both the health of you but also for your baby

– In the absence of high-risk pregnancies, exercise is safe and beneficial as long as the anatomical and physiological changes that mom undergoes are considered

– Monitor your body during exercise and be followed/assessed regularly by a skilled coach or practitioner who is experienced in working with pre and post-natal clients.

– Begin exercise post-partum slowly and under the guidance of a professional who can help you take a pelvic floor first approach to strength training

Find this awesome research article, here.

And to find out more about exercise during pregnancy, follow the amazing @coach_vanessagiguere on instagram (she is the one above in the photo, rocking the prowler while in her third trimester!)

Remember, it’s OK to Walk Before You Run.

Today I just wanted to remind you that its okay – in fact not just okay, but necessary – to walk before you run. To slow things down and master the basics before trying to get to the advanced stuff. To recognize that just because you aren’t achieving your end goal at this moment in time, it doesn’t mean you won’t get there. And most importantly to appreciate that its your habits over time that make the biggest impact on your results.

I once had a goal of doing a pull-up. So, in an effort to achieve my goal I would jump on the pull-up bar and try with all my might to do a pull-up. My legs kicked everywhere, my neck got all tense, and I pretty much just shrugged my shoulders instead of using any sort of useful strategy to lift my body upwards. Oh, and then I would always have to let go of the bar because I didn’t actually have the grip, back or core strength to hold on to it for long.

I was trying to run before I walked.

I was trying to perform my end goal before developing the strength and movement patterns needed to successfully execute this goal. And in my effort I ended up just creating a number of compensations that were harder to break later when I focused instead on learning the fundamentals.

Fast forward to today: I still can’t do a pull-up, but I can hang on the bar with all the right muscles engaged and hold myself there in a solid position. If I have a coach around, with their assistance I can pull-up without those wonky strategies I once used – no flailing legs, sore neck or shoulder shrugs. And I know that this puts me at a much better trajectory towards the end goal of a pull-up than if I had just kept trying to “do a pull-up”.

I think we are all guilty of this sometimes. Of wanting to reach our end goal so badly that we skip steps along the way. But most always the process of learning the skill is so important and doing so properly under the guidance of a coach will help you achieve your goal at a much faster rate AND avoid a lot of frustration along the way.

What This Means in Relation to Our Pelvic Health

When it comes to our pelvic health I find a lot of times women start running before they walk. And to be clear, I don’t mean literal running and walking. I mean trying to do advanced versions of their pelvic floor exercises or advanced exercises (with little to no coaching) that they may not yet be ready for.

The progression of what we work on will differ, of course, depending on the individual, the presence of any pelvic floor dysfunction and the activities they are doing. But to give you a few examples of the most common cases of running before walking I see are as follows:

  • Practicing Pelvic Floor Muscle Contractions (PFMC aka Kegels) when you are not ready to do so (either due to incorrect technique or oversight pelvic floor muscles
  • Holding the contractions longer than you are capable of, leading to compensations
  • Doing other exercises with poor form (holding breath, increasing intra abdominal pressure unnecessarily)
  • Doing exercises your pelvic floor is not yet able to tolerate

Sometimes doing these things can lead to further dysfunction (aka worsening symptoms, which no one wants!), or simply putting forth a substantial effort with little to no results from all the hard work. Either way, it can be incredibly frustrating to work towards something without seeing the results you want.

When this happens, we just need to re-adjust and focus on finding out what it is we need to be doing to see continued progress! And I am here to help you do just that

How Do You Know What is Too Much?

Quite simply, you will know by working with a Pelvic Health Physiotherapist who will assess your body (including your pelvic floor) and determine what is best for you.

You see, during an assessment we look at the whole body (posture, alignment, movement, range of motion, coordination, strength, tissue health) including a detailed assessment of the pelvic floor. When speaking of the pelvic floor we assess your ability to voluntarily contract and relax those muscles (in other words, can you do a Kegel properly? Can you relax those same Kegel muscles?), the strength and endurance of the muscles, the coordination of your pelvic floor (does it contract and relax when it is supposed to? Is the timing right?), and how supportive it is to the organs above/is there a prolapse present.

Based on this assessment we will guide you and coach you on how to train the muscles of your pelvic floor to work on any one or combination of the following: strength, endurance, power, and/or coordination. We will coach you on how to move and exercise effectively to both improve your overall fitness and health, but also to both protect and improve your pelvic health.

When your body starts making compensations, or symptoms start occurring (incontinence, pain) we know that we have to adjust what we are doing. Common compensations related to the pelvic floor include holding your breath (which can sometimes lead to more pressure on the pelvic floor) and recruiting other, bigger, muscles or strategies, such as using the abdominal muscles, glute muscles, squeezing your thighs together and tensing your upper body.

What this Blog is NOT Telling You

I want to be clear: I am here to work with to ensure you experience success when it comes to your pelvic floor muscle training and training in general. I will help guide and coach you on how to progress your pelvic floor muscle training, chat with you about all the lifestyle and behavioural strategies we can use, and work with strength coaches to ensure you are incorporating physical fitness.

When I say you have to walk before you run, what I am NOT telling you is this:

  • You can only walk for fitness
  • Running is bad for you
  • You can’t workout and train
  • You can’t do most exercises
  • You are not doing as well as you should be or you are not good enough
  • Something is “wrong” with you
  • You won’t get better
  • You are alone in this

No. All of these are NOT true.

You can workout. You might be able to run. You can do most exercises, though some may just need to be modified slightly.

You see, it isn’t so much about what exercise you do, but how you do it. And luckily I work with some amazing strength coaches who are highly educated and skilled so they can ensure you can have a great workout doing things you love that will not only not negatively affect your pelvic floor, but that will help!

You are good enough. Nothing is wrong with you. You will get better. You are not alone.

So many people think that whatever they are dealing with – be it incontinence, pelvic pain, prolapse, weakness – is just going to be their new normal. That they just have to get “used to it”. This is absolutely not the case! Regardless of what symptoms or things you are experiencing know this: it is common, but there is SO much we can do and you will see change. Because you are not alone in this. So many other women experience these same symptoms, and they, along with us are here with you. We will guide and coach you and ensure that you can be your best you.

Remember: it’s not only okay, but it is also necessary to walk before you run. Allow yourself to go through the process instead of rushing to the finish line. I promise, it will be worth it in the end.

Wearing High Heels Could Make Your Incontinence Worse

Wearing High Heels Could Make Your Incontinence Worse

Our pelvic health is so incredibly important to our overall health and thankfully this fact is starting to get more and more recognition with more resources and research focusing on improving this aspect of women’s health.

Pelvic floor dysfunctions such as incontinence, pelvic organ prolapse, pelvic pain and low back pain are incredibly common among women (both who have had children and who have not), but they are NOT normal. In other words, there is SO much we can do to prevent and treat these dysfunctions so you can feel and move your best!

And I’m not just talking about doing Kegels. In fact, did you know that there is so many more factors to consider when it comes to our pelvic health than just training the muscles of the pelvic floor?

One of these factors is what I want to talk about today – a particular habit that can affect how your pelvic floor functions: wearing high heels.

A recent study just published earlier this year looked at the effect of certain ankle positions on the resting and maximal contraction of the pelvic floor muscles. In other words, they looked to see if there was a difference in pelvic floor muscle activity when someone was in a neutral ankle position (ie flat foot), in a plantar flexed ankle position (ie in high heels) or in a dorsi flexed ankle position (ankle flexed up).

So, let’s dive in to the study and see what the effects of wearing high heels are on your pelvic floor!

The rationale for the study:

When looking at urinary continence it is important to understand that the pelvic floor muscles form a major component of what’s called the uretrhal support system. They provide this urethral support by maintaining the constant muscle tone necessary to support the bladder neck and keep the urethral closure closed both at rest and during episodes of increased pressure (such as during a sneeze).

The Pelvic Floor muscles maintain a constant muscle tone that is necessary to keep you continent.

Previous studies have shown us that the activity of the pelvic floor muscles will change based on different body positions or postures, such as sitting, standing, or in varying degrees of pelvic tilts.

Other studies have shown that wearing high-heels will significantly change your biomechanics, posture and the way you walk, and armed with this information this study sought to determine if there would be a difference in muscle activity wearing high heels (ie plantar flexed ankle position) vs in a neutral or dorsi flexed ankle.

The Results

Authors of the study determined that there is significantly more muscle activity in the pelvic floor at rest when the ankle is in a neutral or dorsi flexed position as compared to a plantar flexed position.

This means that your pelvic floor muscles have a better ability to work and support your bladder and to keep you continent when in these positions, versus when you are wearing high heels.

Authors also determined that women had a maximal pelvic floor contraction (aka Kegel) that was much stronger when they were in the neutral or dorsi flexed positions vs in the plantar (high heel) flexed position. In other words, they were able to better consciously contract their pelvic floor when they weren’t wearing high heels.

Why this is important

The results of this study show us that women who experience pelvic floor symptoms such as stress incontinence could experience worse symptoms when wearing high heels due to the decreased support of the pelvic floor muscles in the urethral support system.

This means that women who experience leaking throughout the day could potentially improve their symptoms by opting for flatter shoe choices.

Just another reason to limit the amount of time you spend in high heels and to visit a pelvic health physiotherapist who can help you to ensure that your pelvic floor muscles are functioning as optimally as possible!

Wearing high heels leads to less activity of the pelvic floor which could mean more leaking.

Check out the study, here.

Prolonged Sitting and Low Physical Activity can Increase Urinary Tract Symptoms

At this point most of us have heard multiple messages talking about the importance of daily physical activity and the importance of avoiding prolonged sitting for our health, but more and more studies are coming out showing us just HOW critical these things are in ALL aspects of our health!

A recent study published just four days ago decided to look at the association of sitting time and physical activity level on the incidence of lower urinary tract symptoms.


Both prolonged sitting time AND low physical activity level were independently associated with lower urinary tract symptoms. In other words, individuals who sat for long periods of time (even if they were physically active otherwise) had increased symptoms, as did individuals who participated in low physical activity (even if they did not sit for long periods of time).

This is just yet ANOTHER reason to ensure you are including movement and exercise in your daily lifestyle!

How do you do this?

If you are someone who works at a desk all day, find a reason to get up frequently! Use a very small water bottle so you have to get up frequently to go fill it. Take every phone call walking around your office instead of sitting in your chair. Change positions frequently throughout the day. Find what works for you, but get up and move to avoid those periods of prolonged sitting.

And otherwise, work with a coach who can help guide you on how to best incorporate physical activity in to your day!

For link to the study, click here!

What to Look for in a Pelvic Health Physiotherapist

Your pelvic health is such a huge part of your overall well-being and quality of life, and I’m so happy to see that this critically important aspect of our health is starting to get some more attention in mainstream media and news as of late.

Women have long since suffered from pelvic floor dysfunctions including pelvic pain, incontinence, pelvic organ prolapse, or pain with sex, usually believing that these symptoms are simply their new ‘normal’.

One thing that us pelvic health physiotherapists have known for years, and what we have worked tireless to educate the world on, however, is that though these symptoms are incredibly common, they are NOT normal. This means though many women experience these things, there is so much that we can do about it to make you feel and move better and to help you rid yourself of these symptoms and feel amazing!

Though North America isn’t quite as advanced as many places in Europe such as France and the Netherlands that include pelvic health physiotherapy as mandatory after women have a baby, our medical professionals and patients alike are learning more and more the importance of having your pelvic floor assessed and treated if any of the above symptoms occur, or after giving birth to a baby.

And though I’m incredibly happy to know that this change is starting and to hear that more and more women are taking charge of their own health by seeking out help with a physiotherapist, I must caution one thing:

Please beware of who you entrust your health to.

Do not pick just anyone, just any practitioner who tells you they treat pelvic floor dysfunctions.

Find someone who you can trust, someone who is highly educated and who treats you as a whole person.

As amazing as it is to me that we are talking more and more about pelvic health in popular media, we must be careful as it is also becoming “trendy” to talk about, which means even those people who are not truly educated and skilled in assessing and treating the pelvic floor are jumping on the pelvic health bandwagon in an effort to not be left behind.

This is why I want you to arm you with some important knowledge before you pick the physiotherapist that you will work with to better your health.

  1. Your physiotherapist should perform an internal examination

I am quite shocked at the number of physiotherapists who claim to treat common pelvic floor dysfunctions who are not trained in, nor perform, an internal examination.

Though I do applaud and think it important that all physiotherapists take continuing education on pelvic health and learn some basic external clues and assessments for dysfunction, it is not appropriate to entrust these same therapists to assess and treat your pelvic floor dysfunctions.

Assessing the pelvic floor without doing an internal exam is like an orthopedic surgeon or physiotherapist assessing the shoulder without ever touching it, or a physician assessing your abdominal pain without lifting up your shirt.

This would (rightly) be thought of as ludicrous and completely unacceptable, yet for some reason has been thought of as ok in the world of pelvic health.

You see, the pelvic floor muscles are on the inside of our body. They surround the opening of the urethra, vagina and rectum and the only way they can truly be assessed is via an internal assessment where a physiotherapist uses a gloved finger in the vagina or rectal canal. In fact, research study after research study has shown that the gold standard recommended first line of defense against most pelvic floor dysfunctions is pelvic floor physiotherapist using internal assessment and treatment techniques.

Though it is important to look at external factors, muscles, and movements during assessment and treatment (as it would be with any injury and to not look at the body in isolation), not addressing the pelvic floor muscles themselves is missing a big part of the picture.

In order to fully test muscle symmetry, strength, length, and tone, there must be an internal exam. In order to look at the presence of trigger points, the irritability of the peripheral nerves, to see if the connective tissue is involved, there must be an internal exam. In order to assess sensitivity, blood flow, myofascial restrictions, and the positions of the coccyx and organ positions, there must be an internal exam.

And in order to properly teach and coach you on what to do – whether it be how to properly contract those muscles to strengthen them or learn to effectively relax those muscles to decrease tone – an internal exam is truly the game changer and the gold standard.

So, when it comes to working with a professional when it comes to your pelvic health, please ask the questions and make sure they are trained and educated in how to properly assess and treat the pelvic floor internally as well as externally and accept nothing less.

  1. Your physiotherapist should also have a strong orthopedic background

Your body, including your pelvic floor, does not work in isolation. Instead it works together as a system, a unit, to create movement. This is why it is important that your pelvic health physiotherapist has a strong background and knowledge in orthopedics as well. That they understand proper movement and exercise. Good alignment, movement, and overall body strength is a huge part of pelvic health as well and should not be overlooked.

Common areas that may be involved in pelvic floor dysfunctions include your spine, SI joint, hips, core, and even your feet! Having a physiotherapist who can effectively assess and treat these areas of your body and how your body moves as a whole is so important in order to best treat you as a whole.

In addition, your physiotherapist should be able to teach you and modify exercises so that you can continue (or start!) to incorporate full body strengthening and fitness into your life as this is such a crucial part to both our overall and specific pelvic health. They should also have a referral network of trusted and skilled strength and conditioning coaches whom they work closely with in order to help you get your best results.

  1. Your physiotherapist should discuss with you behavioural and lifestyle changes that are crucial to your pelvic health

There is so much amazing research out there that shows the huge benefit of pelvic floor muscle training done with a physiotherapist for a number of pelvic floor dysfunctions. However, there is also a ton of amazing research out there that shows the huge benefits of behavioural and lifestyle changes on pelvic floor dysfunctions as well.

This is why it is crucial that your physiotherapist not talk ONLY about the exercises you should do, but also about important strategies and modifications you can make throughout your day to day activities that can make huge and positive changes for your health. These should include, but are not limited to, nutrition and physical activity, bathroom behaviours, managing constipation, and managing fluid intake.

These tips and tricks may oftentimes seem simple, but they are not always common sense and oftentimes need to be discussed to understand their importance. I remember when I was first delving in to my pelvic health education I was shocked at how obviously important these were but something that I had never once previously considered.

  1. Your Physiotherapist is current on new research, evidence, and is using the best methods to help you get results

It is so important that your physiotherapist does not using a cookie-cutter approach to treatment. This means that what works for one person may not work for another, and your therapist needs to be prepared and be able to work with a multitude of different conditions with a variety of different treatment methods to ensure best outcomes.

It is also important that they stay current with research and best practices in the world of pelvic and orthopedic physiotherapy to offer you the best treatment possible.

For example, you may have heard of some therapists using what is called biofeedback while others do not. What’s that all about?

Essentially, biofeedback (in the pelvic health world) uses sensors both internally and externally that measure muscle activity which then give a visual representation of what the muscle are doing on a laptop screen. This gives you the ability to know, in real time, what muscles are doing what by seeing the activity on screen. You will be able to see if your pelvic floor is contracting or relaxing, or if other muscles such as your abdominals or glutes are taking over and compensating. The key with this tool is that you get this feedback in real time and can make immediate adjustments to better learn.

And according to a Cochrane Review (a highly authoritative and reliable research resource) looking at incontinence it was determined that women who received biofeedback in addition to pelvic floor muscle training were significantly more likely to report that their urinary incontinence was cured or improved compared to those who received pelvic floor muscle training alone.

Though there may be times when biofeedback is not necessary, there are also many times when it is highly beneficial, leading to significantly improved outcomes for pelvic floor dysfunctions.

It is therefore important that your therapist is trained and set up to use this important tool in their practice in order to help alleviate and cure your symptoms effectively and efficiently!

In Conclusion:

These are just a few important things to consider when choosing the right health practitioner to work with and I could go on and on adding about 10 other things, but I don’t want to bore you with yet another long read by me, so I will leave you with these, most important points.

Know that it is OK to ask your practitioner questions. Ask them about these things, about their education, about their experience, about how long they have been doing this, about who their colleagues and mentors have been. You have to advocate for your own health and it is OK to want only the best for yourself.


Can’t do a Kegel Properly? We can help with that.

There is incredibly strong scientific evidence that shows Pelvic Floor Muscle Training (PFMT) is a fantastic and effective form of treatment for many pelvic floor dysfunctions, including urinary incontinence or pelvic organ prolapse. However, all of the research that has studied this is performed using participants who are able to correctly and voluntarily contract their pelvic floor. And of course, you need to be able to properly contract the pelvic floor if you want to train it and see positive results!

The problem with this?

Only about 50% of women are able to properly contract their pelvic floor!

In other words, 1 in 2 women cannot perform a proper ‘Kegel’, even with written or verbal instruction, with common errors including contraction of other muscles (abdominals, gluteals, adductors), pelvic movements, breath holding and straining.

So, how can we ensure that these women can effectively train their pelvic floor muscles and reap the enormous benefits associated with PFMT?

Enter Physiotherapy.

A brand new research study is currently in press which looked at three different approaches to best teach how to do a proper pelvic floor muscle contraction in order to then strengthen the muscles.

The study, published here, had four groups:

  1. A control group who received only written and verbal instruction on how to properly perform a contraction
  2. A group that used intravaginal electrical stimulation (where an external electrical impulse creates a muscle contraction)
  3. Vaginal palpation (where a trained physiotherapist facilitated a contraction via hands-on palpation of the muscle)
  4. Vaginal palpation with an added posterior pelvic tilt


What they Looked at:

Researchers looked primarily at the ability of the participants to properly perform a pelvic floor muscle contraction (measured by using what is called the MOS scale – the way physiotherapists measure the strength of a muscle), and then secondarily at whether or not urinary incontinence was improved. Participants were then placed in one of the four above groups for eight weeks.


Though all groups did improve with urinary incontinence, vaginal palpation with or without the posterior pelvic tilt was the most effective intervention for facilitating voluntary PFM contraction in women compared with electrical stimulation or a control group!

What does this mean?

When you have a trained physiotherapist work with you when you aren’t able to properly engage your pelvic floor muscles they can use hands-on techniques – including vaginal palpation – to create a proprioceptive stimulus that makes it much easier to learn how to properly engage the muscles and facilitate a correct contraction of the pelvic floor.

How does this work?

Simply put, the hands on aspect of working with a physiotherapist helps your neuromuscular system to adapt through what is called motor learning. In other words, by having that proprioceptive stimulus together with practice and feedback from your therapist, changes in your central nervous system occur which results in the production of a new motor skill: aka, the ‘Kegel’!

Once these neuromuscular adaptions occur, you can then participate in PFMT to work on the strength, endurance, and coordination of your pelvic floor and benefit from the many positives of doing so!

Moral of the Story?

Physiotherapy is an incredibly important part of women’s and pelvic health. We know pelvic floor dysfunctions can be treated and prevented with proper pelvic floor muscle training, but in order to be able to complete this training it is essential that women are able to properly contract their pelvic floor.

Physio can help.

Article Highlights:

  • Training the pelvic floor muscles is essential for the treatment of pelvic floor dysfunctions

  • However, nearly 50% of women cannot properly perform a pelvic floor muscle contraction, or ‘Kegel’ even with verbal or written instructions

  • Working with a physiotherapist who utilizes hands on vaginal palpation with or without other treatment methods improves learning and facilitates proper pelvic floor muscle contractions

Should you get an X-Ray or Image?

I was driving around town the other day, doing errands, when I saw a sign with a message on it that I see far too often:

“Taking new patients – get your first chiropractic assessment, with full x-rays!”

Now, before I continue on with this article I want you to know that this is not a slam at chiropractors. They just happened to be the one advertising on this particular sign. This article will refer to some, while many others will agree with what I am saying (and what science is saying).

And what I am saying is this:

If you have pain, an injury, or you just want to have a musculoskeletal assessment so you can be in your best health in most cases you do NOT need an x-ray. In fact getting one, or another type of diagnostic image for pain or check-ups, (and I have the research to support this point) almost always NEGATIVELY influences your outcomes.

Why Getting an X-ray or Image SOUNDS Like a Good Idea:

When we have pain it is natural for us to want to know what the cause is so we can fix it. It is this reason that the thought of getting imaging, like an x-ray (or CT scan, or MRI) sounds like music to our ears. Because it will finally show us what is wrong. What is the cause of our suffering.

I’m sorry to break it to you, but this is all one big fallacy. In fact, most often getting these images leads to more harm than good.

You see, the problem with images – especially as a blanket component of a physical and/or health assessment – is three-fold:

  1. Image findings, including x-rays, very VERY poorly correlate with pain and are NOT often clinically significant
  2. There is almost ALWAYS an “abnormal” finding on x-rays, even in perfectly healthy people
  3. Knowing about these “abnormal” findings almost always leads to increased and longer experiences of pain

Oh, and if you want an additional reason, these images waste a whole lot of health care dollars that could have been better spent elsewhere. Like perhaps in the prevention of disease and injury.

Let’s investigate further:

Imaging Findings do not Correlate to Pain and an “Abnormal” Finding is Almost Always Found

There have been numerous studies conducted that look at the presence of what would be considered abnormal findings on x-rays, ultrasounds, and MRIs in perfectly healthy, uninjured and pain-free individuals. Studies looking at each of these imaging forms have consistently found that a very large number of individuals who are completely healthy and pain-free have what is considered abnormal findings, whereas other individuals in substantial pain can have what would be considered normal findings on an image.

Some studies looking at back pain have shown us that over 50% of asymptomatic individuals between the age of 30-39 were found to have disc degeneration, disc height loss and disc bulges, while these same findings were present in over 90% of individuals over the age of 60.

Other studies have shown positive findings on a shoulder ultrasound in 96% of asymptomatic individuals. 96%! That means 96% of people were found to have a thickening of the bursa, osteoarthritis, tendinosis, a partial tear of one of the rotator cuff muscles, or a labral abnormality, while a “normal” finding was by far the anomaly even though no one who had the ultrasound actually had any pain or injury.

The results of these and more studies are clear: these changes are normal, NOT ABNORMAL, and are not causally related to symptoms. In other words, they should not be considered pathological processes and instead just normal findings that are found with aging and un-associated with pain.

And yet, many people still believe that images are the gold standard in diagnosing pain.

Okay, so they are not effective – but what’s the harm?

X-ray and Image Results Can Lead You Down a Path You Don’t Want to Go:

Even the most logical of people can be scared or put-off by reading a radiology report that says that they are broken. That they have moderate-severe degeneration, a torn rotator cuff muscle, a disc herniation. It is hard to not be so, and reading these results reinforces the idea that something is “broken”. EVEN if the results are in no way clinically significant.

An amazing Ted Talk by pain researcher and expert, Lorimer Moseley, gives us a little more insight in to this. He explains:

“Any piece of credible evidence that they are in danger should change their pain… And they are all walking into a hospital department with models like this on the desk: what does your brain say when it sees a disc that’s slipped so far out it’s sitting on it’s own? If you’ve ever seen a disc in a cadaver, you can’t slip the suckers – they’re immobile, you can’t slip a disc – but that’s our language, and it messes with your brain. It cannot not mess with your brain”

So, we know these results can mess with people’s brain. And this can in turn make them feel fragile and broken leading to doing less of what is really necessary: moving, strengthening, and rehabilitating the clinical findings, the clinical reasoning for your pain and discomfort.

What does the American College of Physicians and the American Pain Society Recommend?

When looking at back pain, it is recommended by the American College of Physicians and the American Pain Society that:

  • A thorough, focused history and physical examination be done, including assessment of psychosocial risk factors
  • Clinicians should not routinely obtain imaging or other diagnostic tests
  • Clinicians should only perform diagnostic imaging when severe or progressive neurological deficits are present or when severe underlying conditions are suspected and if patients are candidates for surgery or epidural steroid injection

Put simply, clinicians are advised against advanced imaging unless a serious pathology is suspected with severe neurological symptoms who are likely candidates for surgery.

So, WHY are X-rays being Offered as Part of an Initial Assessment by Some Health Professionals?

With all of the above, compelling research against imaging, why is such an antiquated practice still standard for many practitioners?

Truthfully – I’m not sure.

I truly hope that it is not an intentional form of fear mongering. I remember one of my clients coming to me once with the copy of her x-ray result from a practitioner who highlighted all of the “abnormal” findings and wrote next to the findings that she would require twice weekly visits of 6 months in order to correct them. I also remember that this particular client saw me for about three or four sessions and then felt amazing and no longer needed active treatment.

Because an x-ray cannot tell us what is clinically significant. It cannot tell us how a person will respond to treatment. How they will progress. What their outcome will be. How their pain will change. Yes there is a time and place for images, but it that time and place is far less frequent than you think.

So, remember this when you go to a practitioner who insists that x-rays or images need to be a part of your routine assessment. Ask them why they feel it is necessary and what the general recommendations are. And please, proceed with caution and don’t blindly believe what they tell you.

Because you are NOT broken. You are NOT fragile. Don’t let an image ever make you think you are!

Works Cited:
Brinjikiji, W et al. 2015. Systematic literature review of imagine features of spinal degeneration in asymptomatic populations. American Journal of Neuroradiology, 36(4): 811-816.
Chou R, et al. 2007. Diagnosis and Treatment of Low Back Pain: A Joint Clinical Practice Guideline from the American College of Physicians and the American Pain Society. Annals of Internal Medicine, 147:478–491. doi: 10.7326/0003-4819-147-7-200710020-00006
Girish, G., Lobo, L., Jacobson, J., Morag, J., Miller, B., and Jamadar, D. 2011. Ultrasound of the shoulder: asymptomtic findings in men. American Journal of Roentgenology, 197(4): W713-719.
Jensen, M., Brant-Zawadzki, B., Obuchowski, N., Modic, M., Malkasian, D., Ross, J. 1994. Magnetic Resonance Imaging of the Lumbar Spine in People without Back Pain. New England Journal of Medicine, 331: 69-73.

Epidurals Do NOT Prolong Labor

The newest research provides evidence against the popular belief that it does.

A recent study published in the Journal of Obstetrics and Gynecology looked at the effect of an epidural on length of delivery.

Good News!

A recent study out of the Beth Israel Deaconells Medical Centre shows that having an epidural during the pushing stage of labor does NOT negatively affect the duration of labor.

Previous evidence and common sense from health professionals suggested a link between using an epidural and a longer second stage of labour (the stage where you push). It was therefore thought that there was a link between using an epidural and an increased risk of needing to intervene with an instrumental delivery (such as having to use forceps) or even having to have an emergency caesarean section.

The thought was that due to the numbing effects of the epidural, the pelvic floor muscles would not work optimally to push. Because of this, it has been common for doctors to limit pain meds flowing in an epidural if labour started to progress too slowly, meaning moms-to-be experienced more pain.

Good news is that this new study demonstrates that the epidural did not negatively impact delivery!

Let’s go over the study in more details:

The Study

The study conducted was a double-blind, randomized controlled trial. For those of you who aren’t in the research world, this translates to being a high quality study.

Between March 2015 and September 2015 400 women who had never before had a child completed the study. One group received an epidural during their second stage of labour, while the other group received a placebo epidural during this same stage. Length of vaginal delivery rate, incidence of episiotomy, position of the fetus at birth, as well as other measures of fetal well being were measured.

The Results

Findings of the study demonstrated that the epidural had NO effect on any of the above measures – length of delivery, incidence of episiotomy, position of the fetus at birth, or any other measure of fetal well being.

Not surprisingly, results also showed that the women in the control group (a placebo epidural) had a lot more pain than there control group counter parts.

What it All Means

This study provides some fantastic evidence to show that there is no down side to having an epidural during the second stage of labor. This is important as labor can be an incredibly painful experience, and the decision to have an epidural as a form of pain relief should lie with the patient in collaboration with her physician and/or midwife.

Key Takeaways

  • An epidural is a safe form of pain relief during the pushing stage of labor
  • It does not have an effect on length of delivery, or any measure of fetal well-being
  • The decision to have an epidural should lie with the patient in collaboration with her physican and/or midwife


Read the full study here!

Whole Body Cryotherapy and Ice: Worth the Hype?

Whole Body Cryotherapy seems to be the latest rage, touting amazing benefits for all. But, is it really worth all the hype?

Key Points (for those of you who want the Coles Notes)WBC

  • Whole body cryotherapy is an inferior method to cooling subcutaneous and core body temperatures
  • Placebo is likely largely responsible for the positive effects of cryotherapy
  • Definitive evidence shows that cryotherapy (cold water immersion) does NOT enhance adaptations to exercise training
  • Not only this, but cryotherapy (cold water immersion) has been shown to negatively impact cell proliferation and muscle hypertrophy


Whole Body Cryotherapy is a recent fad that purports to enhance your recovery after exercise, improve mobility, relieve arthritic pain and facilitate rehabilitation post injury.

What exactly is Whole Body Cryotherapy (WBC)? It is a large metal chamber that is filled with nitrogen gas at an ultra-low temperature of less than -100 degrees Celsius (often reaching as low as -150 degrees Celsius). Users walk in to this cold metal chamber and stay there for about 2.5 minutes.

Advocates of Whole Body Cryotherapy preach that this method of cooling is superior due to its extreme temperatures, and sell [decently expensive] sessions to paying clients to help them reap all of these aforementioned benefits.

So, is this really the miracle cure for delayed onset muscle soreness (DOMS – the soreness associated with working out), poor mobility, pain, and/or injury?

It’s time we take a closer look at the evidence, and to do so we are going to focus on TWO specific areas of research:

  1. The effectiveness of Whole Body Cryotherapy versus other simple forms of cryotherapy (such as Cold Water Immersion (a cold bath) and a simple Ice Pack)
  2. The Benefits of Cryotherapy (cold therapy), Period.

Lets jump in.


The Effectiveness of Whole Body Cryotherapy versus other simple forms of cryotherapy (ie cold water immersion and ice pack application).

There is currently no strong evidence that Whole Body Cryotherapy offers any distinct advantage over traditional (read: easy, self-administered and cheap) methods of cryotherapy – such as cold water immersion or ice pack application.

Proponents of Whole Body Cryotherapy claim that because of the extremely low temperatures in the chamber it is a superior method of cooling the body.  However in truth, compared to water and ice, air has significantly lower thermal conductivity at 0.024 K vs 0.58 K (water) and 2.18 K (ice). (1,2)  (Note, K is a measure of thermal conductivity or a materials ability to transfer temperature.)

What this means is that air, as a material to transfer temperature, actually prevents significant subcutaneous and core body cooling compared to the other two methods. (2)

Delving further in to this, studies have found lower surface skin temperatures following a session of Whole Body Cryotherapy vs cold water immersion or a simple application of an ice pack.

One particular randomized controlled study looked at skin temperatures of the knee – a bony area highly susceptible to temperature change.

(Note the relevance of using the knee – Subcutaneous adipose tissue has a very low thermal conductivity, meaning it has an insulating effect on the body. What this means is that certain areas of the body will be more susceptible to a reduction in temperature with application of cryotherapy, with bony regions such as the patella (knee) generally experiencing the largest reduction in tissue temperatures (1,2,3).)

This study found that that 10-60 minutes post treatment surface knee temperatures were lower in the cold water immersion group versus the Whole Body Cryotherapy group.

What that means is that even in areas of the body that have very little adipose tissue and are mostly bony, Whole Body Cryotherapy was an inferior modality 10-60 minutes post treatment.

And these findings weren’t the only ones determining that these chambers were inferior to other methods of cryotherapy.

In a study looking at exercise induced muscle damage, soreness and function after strenuous exercise (4) results showed that greater reductions in blood flow and tissue temperature were observed after cold water immersion in comparison to Whole Body Cryotherapy.

Another study again compared cold water immersion and Whole Body Cryotherapy on recovery kinetics after exercise-induced muscle damage. This study found that again cold water immersion was more effective effective in accelerating recovery kinetics for performance at 72 hours post exercise and demonstrated lower soreness and higher perceived ratings of recovery (5).

 I don’t mean to get to science-y on you, but everything I just said above is a lot of research that shows that the expensive, gimmicky cold chamber is no better (and actually in some cases it is inferior) to other methods of cryotherapy which are mostly easy to self-administer and … well, free.

Key takeaways from this research?

  • Whole Body Cryotherapy is actually inferior to cold water immersion and simple ice pack application when it comes to thermal conductivity, preventing significant subcutaneous and core body cooling.
  • Cold water immersion was found to be superior to Whole Body Cryotherapy in accelerating recovery kinetics as well as levels of soreness and perceived ratings of recovery.

Okay, so cold water and ice packs work the same or better than those huge cold chambers. But, should we even be icing in the first place? This brings us to the second part of this article, or second focus of research:


The Effect of Cryotherapy, Period

Okay, so we now have some evidence demonstrating that Whole Body Cryotherapy isn’t actually superior to other methods of cryotherapy including cold water immersion and ice pack application but that it is actually inferior.

But what about cryotherapy in general. What is the evidence backing its use?

A recent study just published this month looked at the effects of cryotherapy (like the above studies, cold water immersion and Whole Body Cryotherapy was used) vs placebo on markers of recovery following a marathon (6).

Results indicated that either form of cryotherapy was NO MORE EFFECTIVE than placebo at improving function, recovery or perceptions of training stress following a marathon. Not only this, results demonstrated that Whole Body Cryotherapy actually had harmful effects on muscle function compared to cold water immersion post marathon, including a negative impact on muscle function, perceptions of soreness and a number of blood parameters. (6).

Another randomized control study looked at the difference between a placebo and cryotherapy by looking at the recovery of the muscle strength 48 hours after an acute high intensity interval exercise session. Results showed that the recovery placebo was superior in the recovery as compared to cryotherapy (7).

These results lend strong evidence that shows that placebo may be largely responsible for the beneficial effects of cryotherapy.

Another recent paper (8) looked specifically at cold water immersion and the tenet that it enhances post-exercise recovery and resilience, thereby leading to greater adaptations to training. The author of this paper explained how evidence supporting this idea was very much lacking, and outlined two of his studies designed to find out more.

The first study measured muscle mass (using an MRI) and strength in two groups before and after a twice weekly exercise program for three months. One group performed active recovery for ten minutes after each exercise session (low intensity cycling) and the other performed cold water immersion for ten minutes. Results demonstrated that both groups gained muscle mass and strength, but that these gains were significantly smaller in the cold water immersion group compared to the active recovery group. Even more, the cross sectional area of type II (fast twitch) muscle fibres also only increased in the active recovery group.

This is definitive evidence against the idea that regular cold water immersion enhances adaptations to exercise training.

The second study performed looked at men who completed two separate session of resistance exercise on separate days and with separate legs. Researchers analysed blood samples and biopsies before exercise and 2, 24, and 48 hours after.

They found that exercise activated processes in the signalling pathway and stimulated cell proliferation and proteins that regulate muscle hypertrophy. In contrast, these processes were significantly attenuated following cold water immersion.

Inflammatory markers in the blood were also looked at and it was found that there were no significant different between the cold water immersion and active recovery treatments.

This is the first evidence in humans (there has been other evidence in animal studies) that is against the idea that cold water immersion provides anti-inflammatory benefits in muscle after exercise (8).

This shows that not only does cold water immersion not improve inflammation, but it seems to actually negatively effect our bodies ability to adapt to exercise training.

Key Takeaways from this research?

  • Cryotherapy is no better than placebo at improving function, recovery or perceptions of training stress
  • Cryotherapy reduced the amount of cell proliferation and proteins stimulating muscle hypertrophy leading to smaller muscle and strength gains
  • Cryotherapy did not show anti-inflammatory benefits in muscle after exercise


In Conclusion:

When I started writing this article I truthfully did not intend for it to be so long. But when I got in to my research I saw SO many studies – many of them GOOD quality, randomized controlled studies – that simply needed to be discussed!

We have always believed that ice is the way to go for any sort of muscle damage, be it from an injury or from high intensity exercise. The fact that current research shows that it simply is not the best option anymore is one that is hard to swallow for many people, as they have spent their lives recommending or using ice. It is also these beliefs that we’ve held on for so long, that makes the idea of Whole Body Cryotherapy and all it touts to offer seem so appealing.

But, if you sit down and go through the evidence… I think you will see that there are many cheaper, easier, and most important better options out there.



  1. Costello J, McInerney CD, Bleakley CM, Selfe J, Donnelly A. (2012) The use of thermal imaging in assessing skin temperature following cryotherapy: a review. Journal of Thermal Biology, 37:103–110.
  2. Bleakley, C., Bieuzen, F., Davison, G., Costello, J. (2014). Whole-body cryotherapy: empirical evidence and theoretical perspectives. Open Access Journal of Sports Medicine, 5:25-36.
  3. Costello, J., Donnelly, A., Karki, A., Selfie, J. (2014). Effects of whole body cryotherapy and cold water immersion on knee skin temperature. International Journal of Sports Medicine, 35(1): 35-40.
  4. Mawhinney, C., Low, D., Jones, H., Green, D., Costello, J., Gregson, W. (2017). Cold water mediates greater reductions in limb blood flow than Whole Body Cryotherapy. Medicine and Science in Sports and Exercise, 49(6): 1252-1260.
  5. Abaidia, A et al. 2017. Recovery from exercise induced muscle damage: cold-water immersion versus Whole Body Cryotherapy. International Journal of Sports Physiology and Performance, 12(3): 402-409.
  6. Wilson, L et al. 2018. Recovery following a marathon: a comparison of cold water immersion, whole body cryotherapy and a placebo control. European Journal of Applied Physiology, 118(1): 153-163.
  7. Broatch, J., Petersen, A., Bishop, D. 2014. Postexercise cold water immersion benefits are not greater than placebo effect. Medicine and Science in Sports and Exercise, 46(11): 2139-2147.
  8. Peake, J. Cryotherapy: Are we freezing the benefits of exercise? Temperature, 4: 211-213.