Reconciling the 3Rs and physio treatment

A blog from Tim – not meant to be evidence backed, not meant to be science, this is personal experience. It is a blog not a scientific paper.

Background

I’ve had an on- going issue with pain in the area around my Sacroiliac Joint (SIJ) for about a year now. It originally came on in June 2017, stopped me running for pretty much 5 months – and at one point stopped me weight bearing for a short time. Even though I knew that a scan wasn’t going to help, there were a few moments back in August last year where I found myself actively considering getting a scan of my hips…. I *KNOW* that would have made no difference to the outcome, it wouldn’t have shown anything except the fact that I have hips, and yet…. And yet, I found myself contemplating asking for one!

Original rehab

I managed to rehab it myself with a combination of strength

Sunrise on the Ramsay Round.

work and cycling, was back running a bit in November and got to the point where I did a Ramsay Round in May. I haven’t raced much this year, and preparation for specific long races have taken a real back burner, considering that overload was what seemed to bring on the issue in the first place. I’ve upped my training in the last 2 months and, indeed, there have been twinges in the past few months which have very much made me think “uh-oh”. A specific pain which is recognisable as the pain that I had for 5 months.

 

Road Bike Fit and SIJs

Seeing as running wasn’t an option last year I got more into Road biking… a minor issue was the fact that I could only cycle for about an hour before I got a crippling “lactic-like” pain in my right lower back… it went away after a short amount of rest and I was able to cycle reasonable distances, so long as I kept stopping…. In order to sort this out, I saw a cycling specific physio for help with my bike set up, concerned that back pain while cycling was going to stop me from doing the thing that I *could* do even if I couldn’t run. The bike set up was excellent, and although at that point I didn’t have any specific pain in my SIJ, he noted that my Right Hemisphere of my hip was rotated forward when in lying and in standing, and an SIJ provocation test indicated there was potentially something going on in my Right SIJ as well.

Now, having read the articles and the opinion pieces and all the stuff that comes with being a physio with an interest in twitter, I kept my mouth shut about whether or not you can feel if a hip is “in” or “out” and just let him get on with the bike fit.

The bike is now proper comfortable.

Excellent.

However….

A couple of months have gone by since the bikefit and the occasional SIJ pain that I feel – rarely when running, but normally when doing something innocuous – is turning into something a bit more frequent. Something that might start threatening the block of training that I’ve been putting together quite well since the Ramsay. It was suggested at the bikefit that it might need to be something that got looked at in the future…

Hmmm. Maybe it is time to see someone.

There is so much information and misinformation out there on the SIJ and what may or may not be happening to it when you are in pain. Books, websites, courses, blogs, academic papers, opinion pieces….  the amount of cpd workshops is incredible, and there are as many believers as there are detractors in each of the ideas that are taught.

Conference and who to see?

What was interesting about this was that I had just been to the 3R’s conference in Manchester, looking at Reasoning, Responsibility and Reform in Musculoskeletal Physio. Looking to get away from the old way of doing things, away from practices that aren’t evidence based, and much more towards a considered approach which does not draw from the “well it worked for me, so therefore it must work for everyone” approach. There have been a number of spirited debates about electrotherapy, acupuncture, manual therapy etc, their efficacy and just how much they should contribute to modern day MSK physiotherapy, but to be honest, those on each side of the debate just seem to hunker down and ignore what the other side is saying. We know that Exercise and strength work is evidence based, so maybe that is the way forward…?

That being said, I wanted to get someone to look at my hip who knew what they were talking about… finding someone who was going to tell me to strengthen it – as I have done previously, pretty much wasn’t going to work. If a double bodyweight deadlift, a body weight front squat or a bodyweight lunge doesn’t help, then getting those lifts heavier probably isn’t going to help either. Overload is all very well and good, but I felt that I’ve done that… I needed another perspective.

Revenge of the Dinosaur Physio

Ironically, this came from what some at the 3Rs conference would charmingly have called a “dinosaur”. A well respected physio, well known for his work in specific areas, a teacher on a number of university degrees and a consistent deliverer of CPDs, and a consistent physio to some of the biggest sports names in the industry. I was pretty sure I wasn’t going to get talked to about the nature of pain and I was certain we weren’t going to talk about reform in physio… this was going to be, if you will… “old school”.

Let me give you a quick run down….

Dinosaur Physio

Im not sure if my back is supposed to go in *that* direction…

My subjective story was taken down fairly swiftly (to be fair, I’d sat down and gone over it prior to the appointment so that I didn’t miss anything out), then a physical exam – looking at SIJ position, movement and movement with overpressure in various positions. Legs were raised, subjective heaviness noted, and then various pressures to the hips were applied in different places to see if it made any difference to the subjective heaviness. The SIJ itself was proclaimed fine and not a problem in any way. Which was nice. So we went on to trapezius – my whole upper body is apparently semi-rotated to the right, some pretty vigourous PA pressure and glides went on while interferential (!) was put across my QLs. Needles in the origin of upper traps, manipulation of the back, manipulation of the neck (which cracked like a firework), needles in the Quadratus Lumborum, trigger points triggered- which BANG – felt like the pain in the SIJ. It wasn’t quite as wham/bam done as this is suggesting, but we evidently weren’t hanging around.

A short explanation that the pain was coming from the QL – and it was likely overactive as I’m not activating in the core as much as I should be…. I need to keep on top of it with heat, PNF stretching and pressure and that was it.

Off I went.

Wow. I reckon I got a full house on the Adam Meakins Bingo. Thankfully the cupping set stayed in its box.

Funnily enough, I left feeling happy that I didn’t appear to have a symptomatic SIJ. The pain produced by that needle in the QL, and indeed the elbow before that was really an indication of where the pain was coming from.

Now – don’t get me wrong, I know about pain science- nociception, warning signs etc. I know that the clicks don’t really do anything therapeutic, I’m well aware that the person in charge of how well I get is indeed me. However, without someone telling me what the heck was going on, I was almost impotent in making it better – I felt like I was running around in circles looking for the cause and was coming to the metaphorical deadend.

Outcome of the session

Well, having had the benefit of the knowledge of someone who a lot of my contemporaries would consider to be a dinosaur, I feel vastly better, more in control about my symptoms and how to get better because of the consultation. Did the interferential help? Did the manips help? Did the needles help? Was it all witchcraft and a load of gobbledegook? Um… well…. If so, has all that just been placebo? Was it all just waiting for someone to do those things in order to make me understand where the pain is coming from?

Could we have talked a bit more about getting stronger? Offloading my QL? Working a bit on some other running stuff, well, yes, but we can all get better as physios…

How to square the circle?

The funny thing is, I originally started my therapeutic life as a Sports and Rehabilitation Massage Therapist…. If someone came to me with hip pain, I’d have done a number of those things, I’d certainly have been looking for Trigger points in QL, which would have pinpointed the issue pretty damn quick. In the past few years I’ve become more and more bound up with evidence based medicine…. You can’t trust Trigger points – Travell and Simons research was flawed/based on pseudo-science etc, we keep being told that. Yet, yet, yet – that was my experienced pain. How do I now square this circle? There has been talk about Reforming physio to the point of a traffic light system, trying to stop physios using non-evidence based treatments… Green for evidence based, Red for not…. There has been talk about policing physio because if we don’t then someone else will. If that indeed does come to pass, where will these dinosaurs and their knowledge go? Surely physio will be a poorer profession for that lack of knowledge and experience which will effectively be “outlawed”.

I think a lot of people that I met a few weekends ago would have been aghast at what I was presented with in a physio consultation- how it just wasn’t based on Evidence… but… I feel better.

Is that physio? Is it not?

Has it helped me understand where I stand in terms of training/running – yes. Are these things being used at the highest levels of competitive sport – yes. Would physio be a poorer profession without these skills? Well now- that is a conundrum. From the patients perspective, it appears to have it’s place – though from a EBP point of view, it definitely doesn’t. Can this circle be squared? I don’t know. Some will say it’s a circle that shouldn’t be squared.

Or maybe I’m missing something.

Onward.

Onward!

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