Dr. Nathan Kadlecek, PT
Is a physical therapist committed to providing high quality health information, largely focused on lower back pain and the gross overuse of diagnostic imaging, medication, surgery, low quality treatment methods, and the over-diagnosis of pain conditions. He's also a powerlifter, pain nerd, macro-scale thinker, and wants to help you think differently about pain, healthcare, and life.
America needs help. It's suffering from a chronic pain epidemic.
Don’t confuse ‘how you feel’ with ‘why it works.’ Effectiveness does not explain the why.
POP. Sweet relief.
I love getting my back cracked. It feels amazing and causes me to just want to lay there for a few moments and soak it in.
When I was applying to physical therapy programs, my idea of helping and healing people from musculoskeletal issues was that I would be able to diagnose and then treat people based on their specific dysfunction. This could have been a slight positional change in the spine where one segment was rotated more than another, or a pelvis that was rotated too far forward (anterior tilt) or even one of the innominate (hip) bones being rotated more than the other on the sacrum.
I thought I was going to be going to school to fix people and that I, and only I, with my hands could determine what the true dysfunction was.
I was wrong. I had an existential crisis.
**Disclaimer: I am not a manual therapy hater and I use it from time to time.**
Why is this important??
I CAN FIX YOU WITH MY HANDS!
Upon taking my first class in my physical therapy program at Columbia University, I was bright eyed, bushy tailed, and ready to learn exactly how to fix people. This started with in-depth anatomy classes with a lab section for cadaver dissection, physiology to further solidify our undergrad knowledge of each of the bodies internal processes, and various classes specific to neurological conditions, orthopedic conditions (muscle, bone, tendon, ligaments, etc.), pediatrics, geriatrics.
Each of these classes were interesting, however none piqued my curiosity more than the orthopedics courses. These were the courses that would talk about exercise, manual or manipulative therapy, soft tissue mobilization (i.e. massage), and various modalities. In these courses, particularly the spine course, I was fully engaged and soaking all of the information up like a wet sponge.
But, there was a problem. When it came time to start practicing and learning about spinal palpation (feeling spinal segments) and we were asked to perform special tests to determine the difference in rotation of various segments, or the height differences of one innominate bone (hip) from the other, I couldn’t do it. I sucked.
I’ve sucked at things before, I mean, really terrible. I was so bad at field goals my freshman year of high school that I didn’t even get the kicker position (I went on to get a scholarship in college as a punter/kicker). I barely passed neuro in PT school. And wrapping presents… yea it looks like a child did it (although there have been improvements ;) )
This spinal palpation and diagnosis thing though, I couldn’t get it. No matter how much I worked at it or practiced it, I couldn’t feel what the highly experienced professors could feel.
I remember one day I asked, “I really can’t feel the difference, and really, won’t everyone feel something differently, anyways? Isn’t this based on our own perception and confidence?” The response from the instructor was “you just need to practice more and eventually your hands will get more sensitive to the motions.” What’s funny is that I ran into this instructor a few years down the road and found that he doesn’t even believe that, go figure. The educational system is weird.
With the help of some highly skeptical friends, who were older and a bit wiser than I, they helped me build up a healthy set of skepticism towards the palpation of “segmental dysfunction,” and the idea that something was either “out of alignment,” or “mispositioned,” and that it needed to be “corrected,” and that this was somehow the cause of pain. In addition to my skeptical bros, our final ortho class was extremely insightful.
For the entirety of the past two years of PT school I had been under the impression that pain was largely caused by biomechanical faults that could be palpated and corrected by manual therapy. At the beginning of my third year, this paradigm was absolutely crushed and I was left wondering why the hell I even went to school and paid hundreds of thousands of dollars. I was left feeling disillusioned and angry that so much of what we had learned was based on old and outdated evidence. It was exhausting and defeating.
Thankfully, as time went on, and we continued to learn and push through the final third year, things started to look up. I found that instead of feeling disillusioned from my bias being challenged and destroyed, that I now had more freedom and that many of the patients suffering with chronic pain that I had worked with in the past (who didn’t respond to manual therapy at all) might have some hope after all, to suffer less, that it wasn’t about me ‘fixing’ them.
LAW OF THE ARTERY AND LAW OF THE NERVE
I love reading and studying about beliefs, behavior, bias, fallacies, and many other areas of behavioral economics. This has spurred me on to read numerous different books on the topic, one of my favorites being Thinking Fast and Slow by Daneil Kahneman. If you haven’t read this book, you need to, as you’ll realize you aren’t nearly as smart or bias free as you think.
Due to this love of learning about biases, beliefs, and become more skeptical, a curiosity arose. Just like I had wanted to fix people with my hands, many people before me also wanted to do the same; not only Physical Therapists, but Osteopaths and Chiropractors, too. I became curious about how each of these professions started and where in the world did the term “out of alignment,” crop up from. I’d learned and read about the origins before but never as in depth as now.
Before osteopaths, chiropractors, or physical therapists, there were “bone setters”. These bone setters were present in Indonesia, China, Japan, Russia, Hawaii, Nepal, Mexico, and other parts of the world. They performed various techniques of manual manipulation including “adjustments,” “high velocity low amplitude thrusts,” “osteopathic manipulations,” or whatever you’d like to call it. They also reduced actual dislocations of the hip, knee, and shoulders, although they had no formal medical training. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2565620/#B8
The first Osteopathic Medicine college: 1892, in Kirksville Missouri, Andrew Taylor Still the father of Osteopathic Medicine opened the American Osteopathic College.
Founding belief: Law of the Artery: “He based his theories of disease and dysfunction on the “disturbed artery” in which obstructed blood flow could lead to disease or deformity. This would become known in Osteopathy as the Law of the Artery.”
The first Chiropractic College: 1897, in Davenport, Iowa, Palmer opened, The Palmer College of Cure, now known as the Palmer College of Chiropractic.
Founding belief: “...Palmer began to reason that when a vertebra was out of alignment, it caused pressure on nerves. He further reasoned that decreasing nerve impulses would surely affect visceral function leading to disease (the Law of the Nerve).”
The first physical therapy college: 1913, in Otago, New Zealand. The School of Physiotherapy at the University of Otago, NZ.
Founding belief: No particular “founding belief,” as this profession developed organically out of close relationships with orthopedic surgeons. PT’s were originally known as “reconstruction aides,” for injured soldiers during and after World War I (WWI). Mary McMillan was the first and most prominent reconstruction aide, as she was taught by the pre-eminent Sir Robert Jones, a physician in England who co-authored the treatise “Orthopedic Surgery.” Use of massage, corrective exercise, and other modalities were originally utilized.
Prior to the 20th century, much of medicine was still following the motto of “observe and use what helps, avoid what does harm,” which sounds good in theory, but doesn’t always work. This can be evidenced by a procedure to treat fevers back in 1796 and into 1800’s, “bleeding,” using a tool called a lancet (scalpel). It was assumed that if you get rid of the symptom, fever, you solve the problem. So… why not just make people bleed enough to where they become cold. Clearly this wasn’t a great approach and in my mind emphasizes why it’s important to also understand the mechanisms as to why things work so we don’t continue to do incredibly stupid and counterproductive things.
We shouldn’t judge professions based on their beliefs 100 years ago, and we also shouldn’t judge individual people just because they are part of a certain profession. I think this is counterproductive and does not take into account individual beliefs of practitioners and the evolution of professions over time. However we should absolutely hold people accountable when the narratives given to people about pain are incorrect as these can cause serious chronic issues down the road.
FALSE BELIEFS DO CAUSE HARM
“Why should I care about how it works or what they’re telling me, I just want to feel better.” Feeling better at the expense of possibly developing chronic pain down the road is not a healthy trade-off. Like I stated before manual therapy and adjustments/manipulations/mobilizations all have a positive effects for many people, however the ‘why’ behind it working is also important.
Here is where I have some qualms. Over the past three years of practicing as a physical therapist, i’ve had multiple people, nearly every day, tell me either, “my back is out,” or “my hip popped out,” or “my PT said my hips were WAY off,” and I need to go get it adjusted to get it put back into place. I’ve had more people than I can count, get an adjustment to “put it back in place,” and then who are deathly afraid of exercise because it might “pop it out.” These conversations are frustrating for a few reasons. Disclaimer: *This applies to PTs, Chiros, and Osteopaths. I’m not singling one one profession, so don’t get all bent out of shape ;).*
Clearly, we have a problem. The # of individuals suffering with chronic pain continues to increase, and seemingly, the amount of people who still believe outdated information from the 1800’s is HUGE. I will state it again, just because something has been around for 100’s or thousands of years, and has some positive effects, does not explain the WHY.
This “why” is important because it’s now understood that this is a huge contributing component of who will suffer from a chronic musculoskeletal pain condition, and who will not.
SO… IF MY BACK AND HIPS DON’T GO OUT, WHAT’S GOING ON?
There is no doubt that often times our back or hip feels a bit or very ‘off.’ If you really dig deep into your first experience of this feeling and who was the first few people to give you advice on it, it’s likely you’ll remember somebody who said “oh, you need to be careful,” or “you should go get adjusted,” or “wow, your hips are WAY out,” or “your L5 vertebra is way out of place by 2mm.”
Often times we feel and experience pain, and immediately we tap into our memory to see if this is something similar. If it’s not something familiar that we’ve experienced before we’ll go search it up and see if we can figure it out. This is typically when someone will get told that “oh, it’s because your back is out of place,” lemme just pop it back in…
Back pain itself, especially the kind where we feel something is off, that nasty muscle spasm and grabbing feeling, or sciatica, are multifactorial. The irritated structure could be a nerve, muscle, tendon, ligament, disc, or something else, but, there may be a better way to think about this. Rather than trying to find an exact diagnosis (when there typically is not one), what if you thought about pain as what it’s NOT vs. what it is.
If you can rule out that the pain is not due to a fracture, kidney stone, infection, cancer, gall stone, and some other rare conditions, then chances are, with a program to stay moving, and working on your self-efficacy and healthy body beliefs, that things are going to be okay.
Perception is reality, however reality can be warped. If your perception is that your back hurts, therefore your back is out, then your reality that you’ve created is (likely) that everytime your back hurts, it’s because your back is out. When really, this is not happening, for reasons cited above. Our perception of situations and events is usually horribly flawed. We are incredibly irrational actors, and the sooner we can accept that and become a little more skeptical and use a few more sources, the sooner we will be able to make a dent in this massive problem that is chronic and persistent pain.
What do YOU think? As always, please leave your wonderful comments below or respond directly to me via email with your love mail or hate mail :). Email me
AND for a much more in depth review of this topic please visit https://www.painscience.com/articles/structuralism.php -- it's really an epic document! VERY detailed and rational.
A few more references:
1. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2565620/#B8 - A History of Manipulative Therapy
Ergonomics has become a billion dollar industry. And with any billion dollar industry, come many charlatans.
If you work for a large business, particularly one with greater than 500 employees, it’s likely you’ve had the ergonomic or ‘posture people’ come in to do an assessment of the workplace. They probably charged the company $300/hr, took a bunch of measurements, ordered custom equipment, and made claims that “with this equipment, and based on our algorithms, this will reduce workplace injury by 33%.”
This is all well and good, and workplace injuries/pain are important to address, however are these $300/hr consultants actually worth it? Do they actually provide value? As most things go in life, there are some that are worth their weight in gold and should charge more than that, and there are others that should be working for free due to how ineffective and outdated their methods are.
As a physical therapist, I see hundreds of people per year who are dealing with some sort of pain. Some of it is work related, some of it due to recreational activities, and some of it doesn’t have a clear origin. The work related issues are interesting. These issues are almost viewed as something completely different than just a typical course of back and shoulder pain and then elevated to a more severe level due to the current nature of worker’s comp claims. (i’ll write another blog post on the craziness of work comp and temporary/permanent disability).
For the past 25 years, ergonomic consultants have been coming to offices, changing people’s work stations, postures, using cognitive behavioral therapies, giving stretches, and teaching strength training principles. It’s likely that many of these consultants are well intentioned, but, if they are not promoting the number one method to reduce musculoskeletal disorders in the workplace, then they should be fired, as the evidence has evolved over time.
What is that method? Resistance training. Based on the highest levels of evidence that we currently have, resistance training with weights or bodyweight based exercises are the most effective tool we have to combat workplace related pain and injuries. This honestly does not surprise me as this is the same approach I use in the clinic. I use an active approach with people where weight training and controlling bodyweight movements is implemented on day one. To me, there is no difference of helping someone in the workplace vs. helping someone in the clinic. There is literally no difference. Our physiology doesn’t magically change just because we are working. We don’t turn into feeble humans just because we are working. We are still resilient.
Resistance training, aerobic activity such as walking, cycling, or swimming, all have ridiculous positive effects not only on our ‘work life,’ but when we are outside of work. Various studies over the past years have shown that even by getting 30 minutes of physical activity in a day, even if that’s just walking, will provide us with a significant reduction of not only musculoskeletal pain and injury but heart related conditions as well.
Nearly everyone knows what i’ve just written about in the paragraph above. It’s not news to people that if we could just get outside or get to the gym we’d be healthier, happier people. So, I won’t bore you with platitudes of ‘you can do it,’ rather, i’ll provide you with one strategy that you can start implementing today to help with putting exercise back into your routine.
That strategy is, add it to your calendar. If you don’t have a calendar, make one. If you don’t know how to make a calendar, search on google or youtube and i’m sure you can find many different strategies. If you add in “walk 30 mins” to your calendar, even if you don’t succeed with it everyday, you’ll succeed much more than if you don’t add it at all. Physical activity does not need to be a chore, and based on what you want out of life, and what things you want to be able to do later on in life, it’s not an option.
Often times we do not make decisions that will benefit our future self. This is due to an inability to see our future self as ourself. We view our future self as a stranger… and why the hell would we commit so much time to a stranger? Your future self is NOT a stranger and is intricately intertwined to each decision you make today.
In the spirit of not getting too derailed in my thought process in this blog post, here’s a quick recap of what we talked about…
Have you had an ergonomic specialist come into your workplace? What was that experience like? Was it helpful?
Are you looking for someone to help you with pain or injury that you've developed at work or outside of work? Click the link below and setup a completely complimentary consult with us!
Ready for it?? Keep a CALENDAR.
If I asked you this instant to show me your calendar, what would it look like? Would it look completely empty like mine did for the first 23 years of my life, or would it be stacked full and organized?
This has likely been the most effective action i've taken over the past 5 years that has significantly altered how much i'm able to get done and how much I remember to do.
We've all got SO MANY THINGS going on all at once and I find it incredibly important to be able to manage those things with a calendar. I use a task management software too, but all of my time blocks are scheduled out on el calendario.
Do you keep a calendar? Why or why not?
You need to do these, then.
Go to your local hardware store, buy a PVC pipe about 5 ft. in length, put it in plain sight, and be amazed at how much better your mobility will become over a short period of time.
Mobility is something that is attained over time. It takes consistent effort to get there.
It's taken me months to get to this point with a PVC pipe on an overhead squat!
Of course, you can modify these by squatting to a box if you have trouble getting into a deeper squat due to hip, shoulder, or ankle mobility restrictions.
Got any favorite shoulder mobility exercises?