Kat Stene's Physiotherapy Blog

Tri it out:

Triathlon is one of the fastest growing sports in the world.  The usual format is a swim followed by a bike & then a run.  My favourite thing about triathlon? It’s in the name, ‘try’.  Very few people lining up on the start line will be there with the sole intention of being the first to cross the finish line, most will be there to give it a go and just get there.  Yes of course winning would be nice but to the majority it’s to beat a personal goal or, believe it or not, for fun! I certainly never thought I would actually win.  I was never ‘sporty’ at school, B-team at best. I studied music and liked horses.  I took up triathlon because I had an inkling I’d like to give it a go.  I bought a road bike and started social riding- cake and coffee rides with my local cycling club, then a triathlon club and really it grew from there.   

Before you even get to the start it’s the training that’s the tough bit.  It helps if you enjoy swimming, cycling and running!  Throwing in a Pilates or yoga class is a good idea to give you a nice rounded routine and body conditioning that helps avoid injury.  Training with a club gives some structure, helps you get fitter, faster and make friends.

On race day the bikes get lined up ready to receive the swimmers.  In every transition zone there will be a delicious array of expensive carbon bikes and futuristic aero helmets, but they’ll be hung next to a slightly creaky mountain bike borrowed from the mother-in-law with flat pedals and 3 working gears.  You could be next to an 18 year old or a 70+ year old- who may or may not soon leave you in their dust as you glimpse their surname printed across their GB kitted backside in a blur.

Whatever you feel are your strengths or weaknesses there is a race for you.  There are different distances from super sprint (400m/10km/2.5km) to full ironman (3.8km/180km/42km) and beyond; pool swims or open water; flat or hilly courses. If you don’t feel up to all three grab a couple of friends and do a team relay.  So really there is no excuse, triathlon is for everyone to try.

(And despite the early start times being an effort, you’re usually done in time for a well earned pub lunch!)

Ok, a real basic one.

Start with 5 exercises to do. Eg Squats, Lunges, Calf Raises, Chest Press and Seated Row

Have a go at doing the exercises, get happy with technique and figure out the load/weight you can add so that you can do 12 in a row, keeping good technique. This is your baseline weight.

Start the gym session with a 5-10 minute cardio warm up on the bike, rower, cross-trainer or treadmill.

Do 2-3 sets of 8 repetitions of your 5 exercises, with your baseline weight.

Finish with stretches for the muscles you’ve worked. This is your workout and should take 45 minutes.

Do this routine 4 times (2-3 times a week) to work out the bugs (too hard, too easy, just right).

Advance the program by increasing up to 12 repetitions of the 3 sets over a few weeks. This might look like 12, 11, 9 or 12, 12, 10. When you achieve 12 x 3, congrats! 

Next time you go, increase the weight a little and start again at 3 sets of 8 repetitions at the heavier weight. If you can easily do 12 at the new weight with good form, go a little heavier. 

Summary: Start an exercise 3 x 8, increase to 3 x 12. Increase the weight, drop the reps back to 3 x 8. Build back to 3 x 12 with the new weight. Repeat. 

Change up the exercises you do every 6-12 weeks. Partly from boredom, partly from adaptation. The body works better as a whole until when you keep challenging it in new ways. Get a personal trainer to help with this, that’s their job and they’re great at it!

Once you’ve been in the health game for a while (for me now around 12 years) you start to realise that not everyone gets better - no matter how hard you try. There are some injuries / syndromes which a person needs to live with, to manage, rather than cure. This doesn’t mean the person is destined to have a poor quality of life. Rather they need to learn what their system can tolerate and work within their boundaries to continue to achieve their goals in life. I am an optimist - I believe everyone can achieve amazing things in their lives, its just a matter of figuring out how.

So when it comes to chronic pain, how can a person achieve things if the system keeps throwing them a curveball (i.e. pain) when they try to improve their lot or just get on with the day-today? We don’t really know for sure. 

Pain science is like the wild west - there is so much we don’t understand about the brain and the multitude of connections within the body in heaps of different systems (think hormones, cardiovascular, nerves, gut, skin, fascia, organs, bones etc). There are some amazing groups doing some really cool stuff to figure out why some people get stuck with pain which disables them and others can get the ‘same’ injury and keep going, despite the pain, but we’re a long way off truly figuring out how to fix chronic pain.

My take on it so far (in my dumbed down way):

- Pain is an output of the brain (meaning the brain is the thing that gives pain) based on what signals it receives from the body and other parts of the brain.

- Pain is always pain - doesn’t matter where it comes from (muscle, organ, brain), when we feel pain, it’s there.

- Pain is the brains clever way of telling us that something feels wrong (pain of a broken heart, pain of a 5km run, pain of touching a hot stove); it’s a warning light on the dashboard that lights up when the system is faulty/senses danger in some way.

- Pain can be from tissue damage (touching a hot stove), as a warning signal (this might damage tissue if you keep doing it) or even as a premonition of injury (this hurt before so don’t even try it).

- Pain can become circular. An event takes place that causes tissue damage (rolling your ankle). It hurts so we stop using it (walking, running). The body/brain protects the area (to allow tissue to heal and stop us doing something stupid!) with compensation patterns like muscle tightness or swelling (tight calf, swollen ankle). The compensation pattern causes pain (tight calf causes ankle pain). The body/brain protects against the pain by compensating (not moving the ankle). The compensation pattern causes pain (ankle becomes stiff and sore). The stiff and sore ankle tells the brain to avoid using the area as there is an injury (limping feels sore but not as bad as when I rolled it so I’ll keep limping as it’s safer). The ongoing signals of pain continue to tell the brain that there is still an injury, so the system continues to compensate...and so it goes on. The initial injury can heal (tissues take different times to heal but for argument lets say an ankle ligament is 12 weeks), but the compensation pattern can remain ‘stuck’ so that the pain remains, even though the initial injury has healed.

- The system (body and brain) can become sensitised to normal sensations (that don’t cause tissue damage) and pain can be felt from a previously non-threatening situation.

- Thoughts, beliefs and emotions play a part in what is seen as a threat and therefore what causes pain. 

- Environment and the context of a situation play a part in what is seen as a threat and therefore what causes pain.

- Everyone’s experience of pain is personal and individual so there isn’t a one size fits all solution to pain; it is as unique as different we are.

So with this very clever and complex system which warns us of danger, how do we know, when the light has been lit up for a long time, what is actually damaging us vs what is a remembered injury or a pre-warning signal?

One current approach which is popular is graduated exposure therapy. This is a way in which, over time and with goal setting, a person can gradually increase their exposure and tolerance to situations and stimulations which have caused pain in the past. It works by starting with something that is uncomfortable but achievable, and continuously ‘upping the anti’ and increasing the systems ability to tolerate more and more. This doesn’t necessarily mean the pain goes away; more that the person can become more able to cope with the pain and not let it affect what they want to get out of life. Exercise is important, as is having a tool-kit for managing flare-ups and becoming self-managing of pain. 

This is an update post from my first one on core contraction cues here. 

For people with no pain or injury to the spine or pelvis, the core should work automatically - this means the body has the best strategy for holding and controlling the spine under load - not too much or too little; just right.

For those with an injury this patterning can get confused and either not remember how to come on or too much comes on to protect the body. Both are inefficient and lead to straining and potentially pain. Ever wonder why when you try to get your abs strong and blast sit ups for a few days, thinking you’re doing the right thing, only to feel your back get sore? This is an example of the body not being able to cope with a load and then telling you about it i.e. pain. Learning what the spine should feel like when moving and underlay is key for finding the right level of exercise to begin at so that you don’t over do it, fail, and then give up.

So, thinking of the core like a carry on suitcase, the core extends from the pelvic floor to the base of the head. When holding the spine in a strong neutral position we can’t ignore the upper spine and just focus on the pelvic floor. Often in an exercise class the instructor will talk about pulling your lower belly in (a cue for the transverse abdominus) which is great if the rest of the spine follows suit and aligns itself on top of the pelvis, but what if you’re very rounded in the shoulders or your head sticks far forward from years of computer use? Then this cue isn’t likely to help the area you need to be thinking about; the upper back and neck.

So for a ‘whole body core cue’ I will get people to initially find the pelvic floor and lower belly muscles, get familiar with how they feel, and then advance to a cue that engages the rest of the body, while still bringing on the lower stuff too (remember these should all work together so you shouldn’t have to have multiple cues, just find one that switches the whole system into the right gear for loading or movement).

Number 1. Imagine there is a string pulling the back of your head away from your neck (in sitting or standing this is towards the ceiling, in lying it’s horizontal to the ground). The sensation is the neck gets longer and the spine gets taller.

Number 2. Imagine your head is full of helium and floating 1mm above your body. Works same as number one but stops people from using their shoulders or trying too hard.

Number 3. For neck, shoulder and upper back grippers; Relax shoulders, ribs down at the front. These group do worse if you get them to bring muscles on, they just need to relax the compensations gripping pattern to allow the core to work naturally.

Number 4. Imagine your spine is being stretched at each bone level so that you grow a couple of inches, relax legs, arms, head.

The ‘core’ is now a confusing term. The word is used through different disciplines and for different reasons. In the gym having a ‘strong core’ might mean you can hold a rigid plank position for 5 minutes. In pilates it might mean you can move with pre-activation of the deep spinal and pelvic floor muscles. For real life it means moving with the best strategy to achieve the outcome desired.

An example of this is if you need to lift a tv you’d be best advised to pre-engage your abdominals, breath hold and brace the spine so as to keep a rigid, strong torso for the heavy task. If, however, you need to pick a pen up off the floor, you’d be best advised to relax the muscles of the spine and allow the back to bend smoothly and gently and use minimal effort for the small task.

It’s all a matter of matching load of effort with load of task. The great news is our brain has been working this out with our muscles for years - just watch a baby learn to walk, climb and jump and you see how often they practice to get it just right, or the ultimate extremes of elite athletes performing exquisitely specific and finessed physical efforts with power, speed, load and control - they aren’t thinking ‘what effort do I need to tense my core’, they’re focusing on the specific skill required, and the brain/muscle combo takes care of the rest.

Unfortunately when the system gets its wires crossed - which can happen after injury, with chronic pain and with stress, we can consciously or unconsciously unbalance this perfect control and start over or under-using our core muscles when performing a task.

The core is essentially made up of four muscle groups which, when contracted together strongly, enable the abdomen and torso region to become stiff and rigid or, when contracted gently, to allow controlled and precise flex and bend of the spine. The strong contraction has the wonderful ability to create a stable platform for our legs and arms to pull on, allowing heavy loads to be shifted, lifted and manipulated or preventing movement of the back for a period of time to allow healing if there has been an injury. The lighter contraction allows amazing combinations of movement and timing (think interpretive dance).

These four muscle groups are: the pelvic floor muscles, the deep abdominal muscles, the diaphragm and the deep spinal muscles. Together they form a cylinder-type shape around the abdominal region with a length sticking up the back (think a carry-on suitcase with it’s handle pulled up). When the core muscles are contracted, the spine can withstand huge pressures, however this gain also comes with some cost; the spine is no longer able to bend and flex and twist freely - so rigid strength won at the demise of movement.

So why does it matter if we go through life with bracing our spines if this means we are really strong? The problem is, spines are designed to move. They love moving as it’s through movement that our joints, discs, muscles and connective tissue get their nutrients, stay soft and pliable and normalise pain signals. Take a broken arm; when the plaster comes off after six weeks, the wrist and elbow are very stiff and sore (even though there’s nothing wrong with them), as they haven’t moved for weeks. It takes time for the brain to readjust to normal sensations again, the tissues and muscles take time to stretch out and get stronger again and initially it hurts to do these things. It’s the same with backs. If the back remains rigid for a period of time (in some cases for years!) it takes time for the brain and tissues to accept that the original injury has healed, moving isn’t damaging the tissue, and in fact it’s normal to move and will usually feel better once everything is stretched out again.

When the system becomes too rigid or uncontrolled is when training the core muscles is necessary to return the body back to appropriate levels of contractions or relaxations - resetting the controller so that the spine can get back to doing what it loves to do - move.

Things that matter:

1. Support of a chair to relax into

2. Height of desk, chair, screen so that there isn’t constant strain on something (shoulders, neck, back, eyes etc)

3. Ability to change positions (sitting, standing, slouching)

4. Equipment which supports a ‘neutral spine’ position (chair, desk, screens, laptop raiser, mouse, keyboard, foot stool).

5. Move!!! Don’t stay in the one position for more than 20-40 minutes. Set a timer and change, even if just to sit in a different position. Best practice is to walk away from the desk for a couple of minutes (toilet, tea, water cooler break).

The dificult thing when setting up a work station is that due to the huge number of variables, the options are pretty much endless; so where to start?

Start with a decent chair. One that is adjustable on multiple axis, not just up and down, so that you can set it to a height where the knees are just below the hips, you can relax back into it with good support for the lower and upper back and move the tilt for easing strain on hips.

Then organise a desk where you can stand for times and also sit (as simple as a box on a desk with a second screen or an electric one-press button).

Set up the screen so that you are looking forward at it not down (think laptop raiser) and adjust multiple screens so the main one is central.

Wireless keyboards and mouse(s) are essential for laptop users (and pretty much everyone!) so that you can have the arms gently resting on the desk and not have to reach for typing or mousing.

For short people with standard height desks, foot stools are good as you’ll never get a decent chair/desk height ratio and still be able to touch the floor!

You can install programs which tell you to move and shut down the screen or a simple option is a timer on your phone. No excuses.

Is there a perfect posture? Yes and no. There is an alignment of the spine and a stacking of the bones that puts the least amount of stress on joints, muscles and discs; true. There is no one perfect position to adopt which will prevent back pain; true. So what’s the deal?

Perfect posture is a lie.

Moving regularly from position to position (sitting slouched, sitting upright, standing, sitting with legs crossed, sitting with legs tucked under chair legs, sitting on a foot, standing with a foot on a step...) changes the load on the body parts and prevents the load building to strain and then pain.

Knowing ’neutral’ spine position in sitting, standing & squatting is essential to recognising when the spine is no longer in the optimal position, and thus be able to make choices on whether to move or stay. Neither are wrong - they just have different outcomes.

So...in sitting the neutral spine is when you are sitting on your seatbones (this can be found by sitting on your hands and feeling the bones), not too tall when the weight is on your thighs and not too slouched when the weight is behind the bones. Goldilocks it. The chest should then be stacked on top of the pelvis and the head should be stacked on top of the chest.

The spine will have 3 curves to it at this alignment. Concave in the lower back, convex in th eupper back and concave in the neck. This is a position which the ligaments and discs of the spine are under minimal load. The core muscles will automatically work to hold this position - so it’s tiring to maintain as it requires muscular effort. This cannot be sustained all day (and shouldn’t be!). Standing is the same - stack the pelvis, chest and head to get the 3 curves and you’re there.

A recent article I wrote: Back pain is a normal occurrence; which on average happens once or twice a year. The back, as with any other part of the body, is made up of bones, ligaments and muscles and these structures, from time to time can become injured, sore, strained and sprained and take a few weeks to repair. A classic example is, as Spring approaches, many will be tempted to spend long hours in a sunny garden; bending, reaching, lifting and twisting, and although these are very normal and natural things to do, if the back isn’t used to this form of exercise you can expect to be sore afterwards. So what can we do to prevent or minimise this? Backs love to move. Movement of joints keeps them healthy by improving blood flow, stretching tissues and getting nutrients into joints. By regularly moving the back the tissues, joints, muscles and ligaments become stronger and more able to tolerate the odd burst of enthusiasm that comes with Spring and sunshine. Regularly moving the back as a daily routine is a brilliant way to keep your back in good health. There are many movements that will be suitable and if you haven’t had severe back pain or injury in the past then movements like touching toes, standing side bends and twists and arching backwards can work well. Repeating the movements ten times will warm up the back prior to exercise and cool it down afterwards. So why do some backs stay sore for more than a few weeks and if so what can you do about it? Most persistent back pain is due to discs in the lower back losing height. When young, discs are tall and full of water. Their job is to keep the spine bones apart, give bounce to the spine and help make the back strong. Age, being still for long periods of time (think sitting at a desk) and environmental factors can make the discs lose some of their water. This weakens the discs and can sometimes end in injury and pain. The pain can come from lots of different structures including the discs themselves (these injuries are things like disc bulges, herniations and slipped discs) the joints in the back (called facet joints) or things like muscles, nerves (called sciatica), ligaments and bones. To determine exactly which structures are causing pain is often a mystery that medical science is desperately trying to solve. Discs and nerves can be very painful structures when injured and although it’s normal for discs to wear with age, if they wear quickly or become injured in an accident, they can take 1­2 years to heal. In these cases the back still needs to move but in a more controlled and supported way, using core muscles to prevent flare­ups. This is where a specialised set of exercises, designed specifically for the individual, is necessary to allow the back to heal and become strong again. These exercises are often started in lying and involve bringing on a set of muscles called ‘core muscles’. Core muscles are a combination of deep abdominals, the diaphragm, the pelvic floor and deep spinal muscles. They protect the back from excessive movement and strain. Before starting a program of core strengthening exercises, if you have back pain it is advisable to see a specialist spine physiotherapist to test your movement and strength and have them design the perfect program for returning your back to the healthy strong structure it should be. Other important things to do are relatively easy and form part of a healthy lifestyle ­ eating plenty of Omega 3 fats (found in fish, nuts, seeds) plenty of green vegetables for essential nutrients and minerals, limit sugar and highly processed foods and drink plenty of water. Remember your back is a strong, stable part of your body and if you look after it with plenty of movement it should stay that way. If you need a helping hand to get moving or build the strength of your core, call Physio 1to1 on 01483 424470 to arrange an assessment with one of our amazing team of specialist physiotherapists to get you stronger and moving today.

Short answer = yes

I like treating people when they have pain & making them feel better. I like that they appreciate my skills of manual therapy & come to me for help. I think that when I reduce someone's pain I am helping them. I think that manual therapy in England is getting a bad rap and it's undeserved. Having come from a sports background in Australia, manual therapy has formed a large part of my skill base and is usually an initial part of treatment I provide for my private patients.

I think manual therapy gets such a bad rap because it takes time to do & therefore in a public space like the NHS is relatively expensive and has limited long term outcomes in studies compared to giving an exercise program.