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.”

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 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.

First Sleep, then Coffee.

The Newest Research Links Pain and Sleepiness.

coffee-mug

A new research study from Harvard Medical School brought together researchers from a pain and sleep background to look at an area not yet well studied: does sleep, or lack thereof, influence pain?

Researchers from Boston Children’s Hospital and Beth Israel Deaconess Medical Centre determined that decreased sleep increases pain sensitivity, though this isn’t all too surprising. What was surprising, however, was the role of alertness in pain sensitivity.  You see, researchers found that even with sleep loss, the more alert subjects were (for example had they been given caffeine), the less sensitive to pain they were.

In other words, the more sleep subjects had the less sensitive to pain they were; however, if they were deprived of sleep they experienced less sensitivity to pain than their other sleep deprived counterparts if they were given medications that promoted wakefulness, such as caffeine. Not only that, but these medications promoting wakefulness actually worked better than standard pain medications such as ibuprofen and morphine!

Let’s go through in more details:

The Study

Researchers looked at normal sleep cycles using EEG and EMG readings in mice. They then proceeded to deprive the mice of sleep. In a unique methodology, however, they tried to mimic the way most humans would lose sleep: they entertained them!

Essentially what this means is that they kept the mice subjects awake in a non-stressful manner (as opposed to making them run on the treadmill or fall off platforms as other studies frequently have done). Subject mice got to play with toys and do fun activities (similar to how us human counterparts may scroll through facebook, or watch late night TV). During there sleep deprived entertainment, researchers monitored the mice’s sleepiness, their levels of stress hormones (to make sure the mice weren’t stressed out) and tested their response to both painful and non-painful stimuli.

Pain sensitivity was measured by how long it took the subject to move away from a painful stimulus (heat, cold, pressure, or capsaicin – the agent in hot chili peppers), while non painful stimuli included looking at the subjects startle response to loud noises.

The Results

Findings of the study demonstrated that in otherwise healthy mice even just five consecutive days of moderate sleep deprivation significantly exacerbated pain sensitivity. This was specific to pain and common painkillers including ibuprofen and even morphine, a strong painkiller, did not block the pain hypersensitivity that was induced by the sleep loss.

However, researchers did find an interesting result that caffeine and modafinil, drugs that promote wakefulness, successfully blocked the pain hypersensitivity caused by both acute and chronic sleep loss.

What it All Means

This study is a great example of learning more about the sometimes complicated ties of lifestyle to both chronic and acute pain and tells us a lot about some new future areas of study.

Sleep is critical in all areas of our life, including managing our pain. Even acute sleep deprivation can worsen pain and can lead to a vicious cycle of pain and poor sleep quality. Therefore working on your sleep hygiene and ensuring you get sleep and avoid the distractions before bedtime can play an important role in feeling better.

Does this study mean you should go out and pump yourself up with wakefulness promoting drugs, like caffeine? No – remember, so far this study has only been done on mice – but it is an interesting note to think about. Because perhaps it is something we will need to consider in the future, as according to the authors, “This represents a new kind of analgesic that hadn’t been considered before, one that depends on the biological state of the animal…. Such drugs could help disrupt the chronic pain cycle, in which pain disrupts sleep, which then promotes pain, which further disrupts sleep.”

Key Takeaways

  • Acute and chronic sleep deprivation increases pain sensitivity
  • Painkillers such as ibuprofen and morphine may not block this hypersensitivity from sleep loss
  • Caffeine, and other wakefulness promoting agents, did seem to improve pain sensitivity when sleep deprivation had occurred.

Read the full study here, or read a bit more about the importance of sleep on injury and performance with a previous article of mine, here.

Questions, let me know!