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.

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.