356. Are contraindications actually real?

:: 00:05

Welcome to Pilates Elephants, I'm Raphael Bender.

:: 00:09

Are contraindications obsolete? Well, in Pilates specifically and exercise more

:: 00:15

broadly, I'm going to argue that most of the ones that you're probably taught

:: 00:19

and that they're commonly agreed to be contraindications are not.

:: 00:25

There are a few situations where there are genuine contraindications to specific

:: 00:30

conditions and I want to go through a couple of those examples.

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I'm going to talk about what a contraindication is and what it's not,

:: 00:36

and how to differentiate. And I want to talk through the reasoning.

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And I think there's a misunderstanding here that is super common in the Pilates

:: 00:47

and fitness worlds about the nature of injury and pain and physical rehab.

:: 00:54

And this whole episode was prompted by a really thoughtful comment.

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I'm not going to mention the name of the person who commented,

:: 01:01

even though it was very respectfully put and whatever.

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But basically, this is a comment to a post I did on Instagram recently about

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this topic saying, you know, within the ACSM guidelines, here are some things

:: 01:17

that are not contraindicated that people commonly think are.

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One of the things I quoted was, you know, flexion is not contraindicated for people with disc bulge.

:: 01:25

And I'm just going to read out the comment here.

:: 01:28

Ever tried to do side sit-ups on the reformer box or swan dive on the mat or

:: 01:33

very deep Russian squats and come out feeling great with a hip FAI and two lumbar bulging discs.

:: 01:39

I really appreciate the ethos as I've pulled myself back from being an overly

:: 01:42

cautious teacher, but there are obviously aggravating exercises for certain conditions.

:: 01:46

There are a hell of a lot of things that I wouldn't do with a frozen shoulder, for example.

:: 01:50

I realize you're talking big picture and I'm happy to embrace the gist of it.

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I recently learned to be more optimistic about lots of shapes from Dr.

:: 01:56

Kelly Starrett. He says Pilates is the safest system there is.

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All right. So like I said, this is absolutely not to have a go at this person.

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That comment was absolutely fair enough question.

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And I want to do my best to answer that question here in an equally respectful

:: 02:11

way and to give it the depth that I think it deserves because I think there's

:: 02:15

a lot of depth behind this question.

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All right. So essentially, what a contraindication is, is something that you

:: 02:23

shouldn't do if you have a specific condition or injury.

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And contra comes from the Latin means against or opposite to.

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And we say that also in contralateral, meaning the opposite side.

:: 02:38

And indication is something that you should do for a condition.

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So for example, you should put a cast on a broken arm.

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So a cast is indicated for a broken arm. So a contraindication is something

:: 02:49

that you shouldn't do for a specific condition. Now,

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What a contraindication is not is just if you have pain when you do a specific

:: 03:00

position, if you have a specific condition.

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So for example, if you have a disc bulge and when you flex your spine,

:: 03:06

it hurts, that doesn't mean that spinal flexion is contraindicated for people with disc bulge.

:: 03:12

Now let me unpack this a little bit, please, because I think this is where a

:: 03:17

lot of people go wrong in their reasoning.

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And this is the old correlation does not equal causation or Mozart is a table

:: 03:26

and I'll explain what I mean by those in a second.

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So just say you have two disc bulges like the person commenting on that post

:: 03:35

said and you do deep lumbar flexion and it hurts your back.

:: 03:41

Well does that mean that deep lumbar flexion is contraindicated for people with disc bulge?

:: 03:45

Well maybe but what about all of the people who have two bulging discs who don't

:: 03:53

have pain when they flex?

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And what about the people who don't have disc bulges who do have pain when they flex?

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And what about the people who have disc bulges and are alleviated by flexion

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but feel pain when they extend?

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So just because one person has a particular symptom or even a group of people

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have a particular symptom and have a condition doesn't mean that that symptom

:: 04:22

indicates a contraindication for that condition.

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A contraindication is really something, think about it as something that if

:: 04:32

you did it, it will either worsen the condition or it's dangerous if you have the condition.

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And so there is a list, a short list of actual contraindications from the American

:: 04:44

College of Sports Medicine and various other guidelines that I'll share some of with you.

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But just having pain when you do a certain thing and having a condition doesn't

:: 04:54

make that movement or activity contraindicated.

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We know within, and there are probably two main reasons that I'm aware of for this.

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Well, probably three actually, three categories of reasons.

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The first one is that the relationship between pain and physiological findings,

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whether it's MRI findings, x-ray findings, CAT scan, etc.

:: 05:31

The relationship between pain and musculoskeletal findings,

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whether we're talking about disc bulge or FAI, femoroacetabular impingement,

:: 05:40

hip impingement, or whether we're talking about arthritis or whether we're talking

:: 05:45

about stenosis or spondylolisthesis.

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There are lots of different frozen shoulder, tendinopathy, tendinitis.

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There are lots of conditions that we can diagnose on a scan where the relationship

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between that condition and pain is unclear.

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And for example, in disc bulge, we know that disc bulge is very common in people

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without pain. So something like, there was a study by Brynjikji et al.

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In 2015, in fact, there were two systematic reviews by this group in 2015,

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and one of them found that disc bulge is essentially,

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prevalent in something like 20% of pain-free 20-year-olds, and then it goes

:: 06:39

up by roughly 10% a decade.

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So 30% of pain-free 30-year-olds, 40% of pain-free 40-year-olds, et cetera.

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And so if you're a 50 year old with no back pain there's a pretty there's a

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more than even chance that you've got a disc bulge and so you,

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Disc bulge is probably a better thought of as part of the normal aging process

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rather than a pathology or an injury.

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Now, the second Brynjikji study from 2015 did find that disc bulge is more common

:: 07:12

in people with back pain than people without back pain, but only slightly.

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So I can't remember the exact stats in front of me. You can just look it up.

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Brynjikji, B-R-I-N-J-I-N-K-I. K-J-I, I think, at L, 2015.

:: 07:31

And so there is a relationship between disc bulge and back pain because people

:: 07:39

with disc bulge have a higher rate of having back pain.

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So out of 100 people with disc bulge, 100 people without disc bulge, of age-matched people,

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there will be a substantial portion of the people with no back pain who have

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disc bulge if we MRI them, but a slightly higher number of people with back

:: 07:59

pain will find disc bulge.

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And so, you know, does disc bulge cause back pain? No, well,

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it obviously doesn't cause back pain because otherwise you wouldn't have 50%

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of pain-free 50-year-olds with disc bulge.

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If it caused back pain, those people would have back pain.

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Can it contribute to back pain? Yes, it very likely, almost certainly,

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does contribute to back pain.

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And so a better way of thinking about the relationship between these radiological

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findings, you know, disc bulge, spondylolisthesis, osteoarthritis, stenosis,

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scoliosis, many of these common findings that we think of as being sort of quote contraindications.

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And I'm going to put, with an asterisk, I'm going to put FAI in this basket as well.

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Is that the metaphor of the cup of resilience, and I can't remember where I

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got this from, it's a brilliant metaphor, I didn't make it up.

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And so what this basically, this metaphor is, I think it's a very useful metaphor

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for understanding how pain works and how it works specifically in musculoskeletal

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pain, so the conditions that I'm mentioning here.

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And that is that pain is not caused by any one single thing.

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And that we have a number of factors

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that we put in as stressors that will combine and will result in pain.

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So think of a cup being your, it's called the cup of resilience,

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and it's basically your ability to tolerate stress.

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And a stressor is anything that threatens your equilibrium, your homeostasis.

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So we pour in something into that cup of resilience. Maybe we pour in some tissue

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changes in your lumbar disc. you know, the disc wall is desiccated,

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there's a bulge out the back.

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Okay. So that's a stressor that we pour into that cup. And then we pour in some

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other, but that doesn't overflow the cup.

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And so you don't have pain. But then if we pour in some, you know,

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systemic inflammation and some obesity and some low physical activity and some

:: 10:02

poor sleep and some financial stress and some worry and some catastrophization about your back pain,

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well, then if we add up all of those things and that exceeds the volume of the cup.

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We pour in so much stressors that it overflows the cup and the overflow is pain. And so...

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Thinking about this metaphor allows us to reconceptualize pain as an output

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of the system when the system is overwhelmed with too much stress that it can't tolerate.

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And so in that situation, what can we do to help that person?

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Well, there are lots of modifiable things there. We can help them improve their

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sleep, their diet, their weight, their systemic inflammation,

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their exercise, their catastrophization.

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Can we do anything about the disc bulge? Well, we can address it with surgery,

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but we can probably get rid of their pain for most people or certainly minimize

:: 11:03

their pain by addressing most of those other factors.

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And if you think about this, if you've got an injury, you know,

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if you've got something that you've been thinking of as an injury,

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like a disc bulge or a tendonitis or a tendinopathy or arthritis or some other itis or osteopathy.

:: 11:20

Does it hurt exactly the same amount 24 hours a day?

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Almost certainly it doesn't. Most of these things overwhelmingly follow a pattern of.

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Regression to the mean, essentially. Pain's worse on some days, better on other days.

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And it tends to average out over a certain time. Or sometimes you have an episodic back pain.

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So, you might have back pain for a week or three or five, and then it goes away

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for months, and it comes back again at some later date.

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So, what happens there? If you have back pain that is episodic,

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do you bulge your disc and then it takes three to five weeks to heal,

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and then it's fine for six months and then you bulge it again.

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No, that's not how disc bulges work.

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A disc bulge doesn't heal in three to five weeks. So why does the pain go away

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in three to five weeks? Well, what happens?

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Yeah, probably just your body, whatever acute combination of stressors was overwhelming

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your system, you probably just get a bit better sleep.

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You start looking after yourself, all of those things.

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And over time, it just settles down and then you're fine for a while.

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And then next time you're not looking after yourself a bit, it kind of flares up again.

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And so that is a better model for understanding pain.

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So that means like if you, so then if we think about that and then think about

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the person who has disc bulges and has pain when they flex their spine,

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well, that doesn't mean that the disc bulge is causing the pain.

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And even more, even if the disc bulge was causing the pain, it doesn't mean

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that the pain indicates damage and that you are hurting the disc and making the condition worse.

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And in fact, we have zero evidence in live humans that flexing the spine worsens disc bulge.

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Now, we could say the same for FAI, femoroacetabular impingement,

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which correlates to two different kinds of findings in the hip.

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So we have what's called a cam deformity and what's called a pincer deformity.

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And a cam deformity just means the head of the femur, so the ball of the ball

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and socket, has a little kind of bump on it.

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And that bump, as the hip moves through the socket, that little bump can contact

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the lip of cartilage around the edge of the socket, the labrum,

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and can cause pain and damage to the cartilage.

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And then we also have a pincer deformity, and that is where the socket,

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the lip of the socket grows deeper and kind of forms like a pincer shape.

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And so the neck or the head of the femur contacts the lip of cartilage around

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the socket when it moves.

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So you'd think that if somebody had a pincer deformity where the socket is super

:: 14:08

deep and actually, you know, pokes out further beyond,

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you know, the edge of the socket, that lip of bone grows up really deep around

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the edge of the socket, that that would result in a lot more hip pain.

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Well, actually, paradoxically, we see there are quite a few studies now that

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have found looking where they do x-rays of people's hips and then they ask them

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about hip pain. And what they find is people with pincer deformity have less

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hip pain than people without pincer deformity.

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Now, how does that make sense? I don't know, but that is what we see.

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So now people with cam deformity have more hip pain than people without cam deformity.

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And people with what's called mixed morphology, which is pincer plus cam,

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also have less hip pain than people with no changes to the, you know, no cam and no pincer.

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So, for people with cam morphology, a little bump on the femoral head,

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femoral neck, that is correlated with higher amounts of pain.

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Now, there are lots of people with cam morphology who have no pain,

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and lots of people who have pain who have no cam morphology.

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So, does cam morphology cause pain?

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Probably not, but can it contribute to pain? Almost certainly, yes.

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But just because somebody has hip pain and has some kind of change to their

:: 15:25

non-typical structure of their hip doesn't mean the one causes the other.

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And also, even further, doesn't mean that the pain indicates you're doing damage to the hip.

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There are a couple of tests that are commonly used in the clinic to identify

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femorisotabular impingement. And this is, typically one is called the FADIR test, F-A-D-D-I-R.

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And that stands for flexion,

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adduction, and internal rotation. So basically, you lie on your back on the

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massage table, the treatment table.

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The physical therapist flexes your hip and knee and pushes your hip into flexion

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and internal rotation and adduction.

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And if that kind of creates a pinching sensation deep in your hip,

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then that is a positive Fadier test, which is said to indicate femoral acetabular impingement.

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But the problem is that this has a very high false positive rate.

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So what that means is basically everybody feels pain when you do that.

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So even if you don't have any change to your hip structure and you've got a

:: 16:36

completely normal standard hip structure with no cam, no pincer,

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it still hurts a lot of people to do that.

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So just the fact that that hurts doesn't mean that you have anything wrong with your hip.

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So, a lot of people are diagnosed, I think,

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with FAI by physical therapists and don't necessarily have a scan,

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but they're diagnosed with a Fadier test where it's just a false positive because

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basically everyone has pain there.

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Now, even if you do have diagnosed FAI with a CAT scan or an MRI or an x-ray,

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does that mean you should avoid hip adduction, internal rotation,

:: 17:16

flexion, which is the aggravating position for people with FAI?

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Well, yes, but it's not a contraindication. So what should, which brings us

:: 17:29

to, you know, what should you do for people with pain and injury?

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So to say something that's a contraindication we said before means it's,

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you shouldn't do it for people, for anybody who has a condition.

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So for everybody with this condition, we shouldn't do this thing.

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And the reason for that is for people with the condition, the contraindication

:: 17:55

will either worsen the condition or it is dangerous for people with that condition.

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Deep hip flexion doesn't worsen FAI and it's not dangerous for people with FAI.

:: 18:08

Now, is it painful for some people with FAI? Yes, it is.

:: 18:12

Deep spinal flexion doesn't worsen disc bulge and is not dangerous for people with disc bulge.

:: 18:19

Is it painful for some people with disc bulge? Yes, it is.

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And we could go on with a list of these things.

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We could say, for example, with frozen shoulder, external rotation and abduction.

:: 18:31

Doesn't worsen frozen shoulder and is not dangerous for people with frozen shoulder.

:: 18:35

In fact, the most effective evidence-based treatment for frozen shoulder is

:: 18:39

manipulation under anesthetics where you get a general anesthetic and the surgeon.

:: 18:45

That manipulates your shoulder into abduction external rotation forcefully.

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It's like almost dislocating the shoulder and that frees it up and it's quite

:: 18:53

an effective treatment.

:: 18:54

So far from being dangerous or making it worse, it actually makes it better.

:: 19:00

But is it painful? Yes, it is for a lot of people.

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So saying that something is painful is not the same as saying it's a contraindication.

:: 19:08

Now, it can be painful for a lot of people. It can also be not painful for a

:: 19:11

lot of people. A lot of people with disc bulge don't have a problem with flexion.

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A lot people with FAI, with pincer deformity, don't have a problem with hip

:: 19:18

adduction, internal rotation, flexion.

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So what's the distinction there? Well, we should, for all of these conditions,

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and I'm talking now about chronic pain conditions or chronic injuries,

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you know, out of the acute inflammatory phase, essentially,

:: 19:35

pain during exercise does not mean that you're damaging anything.

:: 19:39

So the general and we found uh there's there's a couple of really good studies from 2016,

:: 19:45

uh which i'll see if i can dig up and put in the show notes uh finding that

:: 19:49

painful exercise in the rehabilitation of chronic conditions is not more dangerous

:: 19:56

or less effective than non-painful exercise in fact in the short term painful

:: 20:00

exercise is actually more effective but in the long term it's no more or less effective.

:: 20:06

So just the fact that you feel pain when doing an exercise, if you have a chronic

:: 20:09

condition or, you know, chronic post-surgery or post-injury,

:: 20:14

doesn't mean that that movement's contraindication.

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So what we need to do then is base our...

:: 20:20

Our exercise choice on pain tolerance, right? Which just means like,

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does the client want, are they okay to put up with the pain, right?

:: 20:30

I mean, and that's going to depend on the person and what their goals are.

:: 20:33

And so if the person's, if the pain's really bad and the person doesn't want

:: 20:37

to have that sensation, well just, sure, avoid deep inflection.

:: 20:41

If somebody has pain when they deeply flex their hip or deeply flex their spine

:: 20:46

or abduct their shoulder or whatever, like, fine, don't, don't do that thing.

:: 20:51

But that would be the case regardless of what their diagnosis was.

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So if someone came in and they had no diagnosis of hip FAI and they had severe

:: 21:02

pain on hip flexion, adduction, internal rotation, I mean, it's just common

:: 21:06

sense that you wouldn't do that movement.

:: 21:08

Not because you're worried about damaging them, but just because like,

:: 21:11

if, you know, like if it really hurts when you poke yourself with a pin,

:: 21:15

it's like, well, don't poke yourself with a pin then. It's just kind of common sense.

:: 21:22

But if they are happy to put up with the pain, for example, an athlete who's

:: 21:26

training for an event or whatever, their motivation to do the movement is more

:: 21:30

powerful than their motivation to avoid the pain.

:: 21:32

Well, there's no danger in doing painful exercise in a chronic condition.

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This is assuming it's not an acute injury.

:: 21:41

Now, there is a slight caveat to that, that if you push into the pain a lot

:: 21:47

over an extended period of time and if it reacts by becoming inflamed or more

:: 21:55

painful after training for like more than 24 hours, it doesn't settle,

:: 21:59

then you should take a break for a day or two and then just go a little bit easier next time.

:: 22:04

So that's called the 24-hour rule and that comes from tendon,

:: 22:06

tendinopathy rehab. Okay.

:: 22:10

And when something is in the acute inflammatory phase, so essentially when it's

:: 22:14

red, hot and swollen, you know, within the first few weeks post-injury,

:: 22:20

post-traumatic injury or post-surgery, we should not push into pain in those situations.

:: 22:25

But aside from that, it's generally perfectly safe to push into pain.

:: 22:31

And that painful exercise does not indicate, it's contraindicated.

:: 22:36

Now, there are a few situations where there are contraindications.

:: 22:42

And it's a very short list. In the ACSM guidelines, for example,

:: 22:48

for people with osteoporosis, so low bone mineral density in their spine,

:: 22:54

end-range bouncing and loaded spinal flexion extension rotation is contraindicated.

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For pregnant women, contact sports are contraindicated because of the risk of

:: 23:06

blunt trauma to the abdomen.

:: 23:08

There's a very, very short list of things that are in fact contraindicated,

:: 23:12

both of those because they're thought to be done. Now, the blunt trauma obviously is dangerous.

:: 23:16

But in osteoporosis, actually, interestingly, that contraindication is not based

:: 23:21

on any evidence that we have. It's just based on expert opinion.

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But no one's going to get ethical approval to do that study of let's flex a

:: 23:28

bunch of people with osteoporosis and see if they get wedge fractures.

:: 23:32

So we just avoid loaded flexion for those people because we think it's probably dangerous.

:: 23:40

But that list is very, very short. And almost all of the conditions that you

:: 23:44

were probably taught in Pilates school or on Instagram to avoid certain movements

:: 23:49

for, like disc bulge, spondylolisthesis, arthritis,

:: 23:55

FAI, tendinopathy, rotator cuff tears, frozen shoulder,

:: 24:02

sacroiliac joint, quote, dysfunction, which is just a made-up condition, um, and.

:: 24:10

Patellofemoral pain syndrome. And if you think about any condition that's to

:: 24:15

do with muscles not working how they should, that's definitely a made-up condition

:: 24:18

unless we're talking about a genuine paralysis of muscles.

:: 24:22

All of these, even things like sciatica, radicular pain in the arm,

:: 24:27

in the leg, all of these things fall under the category of non-specific pain.

:: 24:33

And there are no specific contraindications for non-specific pain.

:: 24:39

The guideline is to remain as active as possible and to be guided by symptoms.

:: 24:45

So basically within pain tolerance, what the client is prepared to put up with,

:: 24:50

depending on what their goals and psychological makeup are, but that we should

:: 24:55

avoid the use of alarming diagnostic labels based on pathoanatomical terminology. technology.

:: 25:03

So rather than labeling them as you have a disc bulge, just say,

:: 25:06

okay, you've got some back pain. It hurts when you flex, so let's avoid flexion for now. Okay.

:: 25:11

And the best practice in rehab is to let it calm down by avoiding the painful

:: 25:21

stimulus for a little bit, and then gradually reintroduce that painful stimulus

:: 25:24

and build up a tolerance to it.

:: 25:26

You can in fact build up the tolerance to spinal flexion or hip flexion or knee flexion.

:: 25:30

Now, if you've got severe osteoarthritis in your knee, you're probably never

:: 25:34

going to regain your full deep

:: 25:35

knee flexion, right? Because there are physiological changes in the joint.

:: 25:40

But if you're avoiding a position because of pain, you probably can increase

:: 25:47

your range into that movement,

:: 25:50

maybe not back to the full original range that you had if there are pathological

:: 25:53

changes within the joint, but you can reduce the pain inhibition of that movement

:: 25:59

and the pain avoidance of that movement probably over time.

:: 26:02

And that typically flows into how we think about rehab anyway.

:: 26:05

So if you actually have an acute injury after the acute phase,

:: 26:10

when the inflammation starts to subside,

:: 26:13

essentially in the initial phase, during the inflammation, you want to avoid

:: 26:16

the position or the movement that caused the injury because you're very vulnerable

:: 26:20

to that position. That's what injured you.

:: 26:22

But then over the course of rehab, you need to gradually reintroduce that position

:: 26:28

or movement and start to load it increasingly and move it through larger range

:: 26:31

and higher speed because the whole, what rehab is, is rebuilding your capacity

:: 26:36

and tolerance to that position.

:: 26:38

And if you can't tolerate that position, if you have to avoid that position

:: 26:41

for the rest of your life, or you haven't been rehabbed.

:: 26:44

So the poison is the medicine in rehab.

:: 26:48

It's not, if you injure your back flexing it, the answer is not to avoid flexion

:: 26:54

for the rest of your life.

:: 26:55

The answer is to avoid flexion whilst in the acute inflammatory phase,

:: 26:58

and then gradually, gently reintroduce small range unloaded flexion and gradually

:: 27:02

increase the load in the range over time to build up a tolerance to flexion,

:: 27:06

strengthen the muscles, the ligaments, the tendons, the tissues involved,

:: 27:10

calm down the nervous system, reduce the threat level until you can tolerate

:: 27:14

high levels of flexion without pain or injury.

:: 27:16

And the way you do that is you gradually, progressively expose that body part

:: 27:20

in the system to the stressor.

:: 27:22

And that is what rehab is, increasingly

:: 27:29

loaded exposure to the original stressor that caused the injury.

:: 27:36

All right, dear listener, I hope that helps. I hope you find that interesting.

:: 27:41

To summarize, 99% of the contraindications you were probably taught in Pilates school are not.

:: 27:49

A contraindication is something that you should avoid for all people with a

:: 27:54

condition because it either worsens the condition or is dangerous for people with that condition.

:: 27:58

Just the fact that someone has pain with a certain thing when they have a condition

:: 28:02

doesn't mean it's a contraindication.

:: 28:04

But it doesn't mean that you have to push into the pain. You can just work with

:: 28:07

the person and say, okay, do you want to keep going?

:: 28:10

Are you prepared to put up with that pain or do you want to switch to a different move?

:: 28:13

And depending on their goals, and if you de-threaten it for them,

:: 28:19

say, hey, look, this is not causing damage.

:: 28:21

It's totally safe, but pain's not fun. So do you want to keep doing this move

:: 28:25

or do you want to switch to a different move?

:: 28:28

And just the fact that they have pain doesn't mean that that's a contraindication

:: 28:32

because there might be another person with the exact same diagnosis who doesn't

:: 28:35

have pain with that movement, or there might be another person with no diagnosis

:: 28:39

who has a very similar symptom.

:: 28:41

So that is an individual thing and we have to do on a case-by-case basis.

:: 28:45

So if someone has pain with a certain movement, you negotiate with that person

:: 28:48

about whether they want to keep doing that movement or switch to a different

:: 28:50

version, but that doesn't mean it's contraindicated.

:: 28:54

Okay, dear listener, thank you very much, much love, and I will see you in the next one.