The Blessing & Curse of Slow Change Over Time

“The chains of habit are too light to be felt until they are too heavy to be broken”

– Samuel Johnson

Today we are going to talk about two sides of the same coin: change. More specifically, how insidious seemingly small actions or symptoms can build over time to the point where we wonder what and where things went wrong. Yet on the flip-side how we expect everything to revert back to its previous state in the matter of days or weeks.

As you read through this article there is one concept I want to really sink in and that is that the habits and changes that happen slowly and consistently over a long period of time are the ones that stick. These are the changes that we don’t see coming until one day we can no longer deny them.

This is a truly important and empowering concept because it means we have a whole lot more control over our own health than we may think. And the sooner we can understand this, the sooner we can come face-to-face with our own habits, then the sooner we can recognize how they may be influencing our life and make long-lasting, positive change.

Insidious Change Over Time

I am a pelvic health physiotherapist so I will speak often about issues women face when it comes to the pelvic health, but the concepts I’m speaking about today can be true for other aspects of behavioural change.

I’m so fortunate to work with and be able to help incredible, strong, powerful women who come to me for help with a variety of health issues ranging from minor to quite debilitating. In my years of working with these amazing clients one reoccurring story keeps coming up that sounds something like this:

“I don’t remember when it started. There was no one event or one memory I have of leaking/pain/discomfort. But somehow along the way it has become my normal. It has become something I now deal with everyday.”

OR

“If I think back I can remember small incidents of leaking/pain years ago. But I just brushed it off. And then yesterday I completely emptied my bladder unexpectedly while I was at work and I could not stop it. It was so embarrassing and it was the last straw. I’ve waited long enough for help, enough is enough.”

OR

“I skipped going to the gym when I was slammed with work while on deadline for a big project and somehow never got back in to my old habit again. That was seven years ago.”

These statements (or similar versions) may sound familiar to you. The truth is we’ve all likely said something to ourselves along these lines. I think it is almost some sort of invincible fallacy – we simply don’t appreciate how much things will effect us. If we experience something negative (leaking when coughing, pain during sex, or a tweak in your knee) or make a choice to skip something positive (going to the gym, going to sleep at a reasonable hour) we try to logically justify why it happened or why it wouldn’t matter for us, because we’re different! We say things like:

“Oh, my bladder must have been REALLY full just then, and wow, that was one STRONG cough. Anyone would have leaked a bit with that one!”

OR

“I know I shouldn’t really strain hard to lift up this box or really push to have this bowel movement, but I’m in a hurry and it won’t make a difference if I do it just this one time, right?”

OR

“I’m beat. I’m going to skip the gym just this one time. Don’t they say that sleep is more important, anyway?”

It’s logical. It makes sense to us. And it really will be just this one time (or so we tell ourselves). But then after we brush off that one time (that first episode of leaking, that first episode of pain, the first time we go against what we know we should do) then the second time seems easier to justify too. Then the third.

See where I’m going with this?

It’s insidious.

We either do it entirely unintentionally (whether it be because we don’t notice or we don’t think it matters), or we do it intentionally but ignorantly – not realizing just how much of an effect over time these choices can have on our health and wellness habits.

This is the curse of small, slow change over time because we simply don’t recognize how important each individual decision, or each individual warning sign our body is telling us, is. And when we finally realize, when we finally take an objective look at what we are experiencing, what our body is telling us, or how we are feeling, when we finally are ready to do something about it, to improve our health, our habits, that is when we need to take a hard look at the flip-side of the coin.

Positive, Long-Term Change Takes Time Too

Have you ever dropped a behaviour after only a few weeks (or days) because it just wasn’t leading to the results you wanted as quickly as you expected?

I think the truth is we all have. But remember, you didn’t lose your shoulder mobility in a week so it is going to take longer than a week to get it back. You took 9 months to grow your beautiful baby girl so it is going to take longer than 6 weeks to look like your pre-pregnancy self.

The magic pill doesn’t exist. That vibrating chair you sit on for 30 minutes that claims to make your muscles contract to the equivalent of “11,000 Kegels” isn’t going to cure your incontinence. That crazy restrictive diet you’re going on isn’t going to be sustainable. Going so hard at the gym you injure yourself and can’t continue is only going to set you back.

The truth is the magic pill to success really isn’t all that sexy. It’s doing things that are good for your body day in and day out. Making positive choices and working with a coach (like a pelvic health physiotherapist, an orthopaedic physiotherapist, or a fitness and nutrition coach depending on your goals) who can guide you, progress you, and support you as you consistently work towards your goals.

I’m not saying this is easy. It most certainly is not. You may go through periods where you think it isn’t working, where you think that nothing is changing and that all of your hard work has been in vain. But then, one day (just like we talked about earlier), you will realize just how far you’ve come and wonder when exactly it all happened. But this time you won’t be sad and frustrated, but proud and empowered.

Remember the power of small change over time. How negative habits can creep in without us realizing, or how the positive ones can overcome. “The chains of habit are too light to be felt until they are too heavy to be broken.”

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.

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

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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.

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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:

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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

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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.

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References:

  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.