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Abstract

The recent Hollywood blockbuster Jurassic World tells a story of how extinct species have returned to the present only to cause chaos and confusion. Unfortunately, this Hollywood fantasy is a reality within the world of physiotherapy with dinosaurs among us causing chaos and confusion. The dinosaurs I am referring to are the many iconic, influential and idolised clinicians and researchers who, despite a new era in understanding pain and growing evidence of the biopsychosocial model, still stubbornly refuse to change their methods or mind-set, and continue to promote and teach outdated methods of assessment and treatment. The dinosaurs, despite giving occasional lip service to the biopsychosocial paradigm, have no desire to support or promote it. They have vested interests in peddling snake oil treatments, and selling their courses and books that promise simple assessments and quick fixes, from realigning subluxed sacroiliac joints or twisted thoracic rings, to releasing psoas muscles or immobile kidneys. The dinosaurs continue to worship predominantly at the altar of biomechanics and in the normalising of movement. They continue to teach the identification and correction of incomprehensibly subtle joint and muscle imbalances, …
Dinosaurs among us causing chaos
and confusion
Adam Meakins
The recent Hollywood blockbuster Jurassic
World tells a story of how extinct species
have returned to the present only to cause
chaos and confusion. Unfortunately, this
Hollywood fantasy is a reality within the
world of physiotherapy with dinosaurs
among us causing chaos and confusion.
The dinosaurs I am referring to are the
many iconic, inuential and idolised clini-
cians and researchers who, despite a new
era in understanding pain and growing
evidence of the biopsychosocial model,
still stubbornly refuse to change their
methods or mind-set, and continue to
promote and teach outdated methods of
assessment and treatment.
MUCH MORE THAN BIOMECHANICS
The dinosaurs, despite giving occasional
lip service to the biopsychosocial para-
digm, have no desire to support or
promote it. They have vested interests in
peddling snake oil treatments, and selling
their courses and books that promise
simple assessments and quick xes, from
realigning subluxed sacroiliac joints or
twisted thoracic rings, to releasing psoas
muscles or immobile kidneys.
The dinosaurs continue to worship pre-
dominantly at the altar of biomechanics
and in the normalising of movement.
They continue to teach the identication
and correction of incomprehensibly subtle
joint and muscle imbalances, in spite of
any robust evidence of reliability or valid-
ity. They continue to fail to consider the
many other non-mechanical factors that
can, and do, contribute to pain.
The dinosaurs always look to adjust and
x so-called movement aws and believe
this is fundamental in reducing pain in all
they see. They truly believe there is a
correct way for us all to move, they truly
believe they know what this is for every-
one and they truly believe they can, reli-
ably and at all times, identify this.
This prehistoric thinking fails to recog-
nise the growing evidence that many
common pains and pathologies correlate
poorly with biomechanics or so-called
movement aws, and that many other
factors must be recognised.
15
This is not to say biomechanics is unim-
portant. Of course there are times when
biomechanics matter,
6
but just not as
many or as often as the dinosaurs would
have us believe.
CHALLENGING DINOSAURS
Dinosaurs often surround themselves with
loyal and devout followers, and command
authority from positions of almost unques-
tionable status and experience. This makes
any attempts to question or challenge
them daunting, intimidating and socially
awkward, with a fear of being seen as
inferior, or at risk of ridicule from peers.
This is perfectly understandable, as
dinosaurs do often quickly resort to their
authority with anyone who is brave
enough to challenge them. They will soon
state that, as an authority their views and
opinions carry more weight and validity
than do the views and opinions of those
who are not. This, as Carl Sagan tells us,
is baloney.
7
Those in authority have been
wrong and made mistakes in the past, and
will do so again.
In science, there are no authorities,
there are only experts. We need experts,
their role is indispensable, and the work
and effort to become an expert must be
recognised. However, it must also be
recognised that an expert is, by denition,
someone who knows more and more
about less and less.
8
Experts have a tendency to fail to see
the bigger picture. Non-experts, however,
tend to be very good at seeing the wood
for the trees, and as such can be better
placed at recognising the wider perspec-
tives and implications, such as clinical
relevance and practical utility. Being a
non-expert should not discourage the
challenging of an expert.
DISAGREEMENT IS NOT
DISRESPECTFUL
It can be challenging to confront dino-
saurs as they can also be erce and fer-
ocious, roaming in packs, attacking, en
mass, anyone or anything that threatens
their position or status. The most
common tactic used is to change the
point at issue, usually by reporting about
the tone of an opposing argument.
Dinosaurs often claim to have been
offended or insulted by the way a differ-
ing view has been presented or expressed.
They will then continue to focus the rest
of the argument on this rather than the
original point made. It is one of the main
reasons why a strong case presented by a
non-expert can lose its momentum, and
obvious logical aws can be lost in a fog
of related but unnecessary issues.
We all have a choice of whether to be
offended or not; this choice varies from
person to person as to who or what does.
However, in any debate, being affronted
by someones views, opinions or com-
ments is not a counter argument.
END OF AN ERA
Dinosaurs should be extinct. However,
many are thriving because of outdated tra-
ditions that discourage challenges to
authority. Dinosaurs survive because too
many of us have a fear, a reluctance and
an apathy to not confront the old, weary
and obsolete ways.
Let me be clear, I am not saying all our
iconic, inuential and idolised leaders are
dinosaurs. There are many highly experi-
enced leaders in our profession who are
fully open to suggestions, comments and
challenges, who are humble and honest,
and who do not pretend to bring com-
mandments down from on high, and it
seems that these icons do not have an
all-encompassing obsession with biomech-
anical analysis.
It is now time to end the era of the
dinosaur, and to put a stop to the chaos
and confusion they cause with their far-
fetched, poorly supported and improbable
methods. The only way this will occur is
if more of us move beyond fear and
apathy, and are prepared to question and
challenge them regularly, robustly but
respectfully.
Twitter Follow Adam Meakins at @adammeakins
Competing interests None declared.
Provenance and peer review Not commissioned;
internally peer reviewed.
To cite Meakins A. Br J Sports Med Published Online
First: [please include Day Month Year] doi:10.1136/
bjsports-2015-095282
Accepted 14 July 2015
Br J Sports Med 2015;0:12.
doi:10.1136/bjsports-2015-095282
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Department of Physiotherapy, Spire Bushey Hospital,
Herts, UK
Correspondence to Mr Adam Meakins, Department
of Physiotherapy, Spire Bushey Hospital, Heathbourne
Road, Bushey, Herts, UK; adammeakins@hotmail.com
Meakins A. Br J Sports Med Month 2015 Vol 0 No 0 1
Editorial
BJSM Online First, published on August 3, 2015 as 10.1136/bjsports-2015-095282
Copyright Article author (or their employer) 2015. Produced by BMJ Publishing Group Ltd under licence.
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confusion
Dinosaurs among us causing chaos and
Adam Meakins
published online August 3, 2015Br J Sports Med
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... Recently, the mechanical view of human function has come under fire from various commentators within the world of manual therapies (Lederman, 2015(Lederman, , 2011Meakins, 2015). ...
... Many of the critiques of the current system are borne of dissatisfaction, often with war-cries of "out with the old" (Meakins, 2015). Yet, just because pain physiology is becoming better understood, or because neural plasticity is more thoroughly researched e or indeed that studies fail to find statistical correlation between one aspect of biomechanics and pain, doesn't mean that suddenly gravity has vanished; nor that mechanical principles no longer apply to human beings. ...
... For example, a recent editorial in BJSM refers to laggards as 'dinosaurs that should become extinct'. 8 On popular and social media, the draft of the NICE guidelines on low back pain mainly referred to things that 'are not to be done anymore' or 'people should exercise' without any reference to the BPS framework. The recommendation to use the BPS-oriented 'STarT Back screening tool' for risk assessment and stratified care was hardly mentioned. ...
Article
Full-text available
Background Clinicians commonly examine posture and movement in people with the belief that correcting dysfunctional movement may reduce pain. If dysfunctional movement is to be accurately identified, clinicians should know what constitutes normal movement and how this differs in people with low back pain (LBP). This systematic review examined studies that compared biomechanical aspects of lumbo-pelvic movement in people with and without LBP. Methods MEDLINE, Cochrane Central, EMBASE, AMI, CINAHL, Scopus, AMED, ISI Web of Science were searched from inception until January 2014 for relevant studies. Studies had to compare adults with and without LBP using skin surface measurement techniques to measure lumbo-pelvic posture or movement. Two reviewers independently applied inclusion and exclusion criteria, and identified and extracted data. Standardised mean differences and 95% confidence intervals were estimated for group differences between people with and without LBP, and where possible, meta-analyses were performed. Within-group variability in all measurements was also compared. Results The search identified 43 eligible studies. Compared to people without LBP, on average, people with LBP display: (i) no difference in lordosis angle (8 studies), (ii) reduced lumbar ROM (19 studies), (iii) no difference in lumbar relative to hip contribution to end-range flexion (4 studies), (iv) no difference in standing pelvic tilt angle (3 studies), (v) slower movement (8 studies), and (vi) reduced proprioception (17 studies). Movement variability appeared greater for people with LBP for flexion, lateral flexion and rotation ROM, and movement speed, but not for other movement characteristics. Considerable heterogeneity exists between studies, including a lack of detail or standardization between studies on the criteria used to define participants as people with LBP (cases) or without LBP (controls). Conclusions On average, people with LBP have reduced lumbar ROM and proprioception, and move more slowly compared to people without LBP. Whether these deficits exist prior to LBP onset is unknown.
Article
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Identifying risk factors for knee pain and anterior cruciate ligament (ACL) injury can be an important step in the injury prevention cycle. We evaluated two unique prospective cohorts with similar populations and methodologies to compare the incidence rates and risk factors associated with patellofemoral pain (PFP) and ACL injury. The 'PFP cohort' consisted of 240 middle and high school female athletes. They were evaluated by a physician and underwent anthropometric assessment, strength testing and three-dimensional landing biomechanical analyses prior to their basketball season. 145 of these athletes met inclusion for surveillance of incident (new) PFP by certified athletic trainers during their competitive season. The 'ACL cohort' included 205 high school female volleyball, soccer and basketball athletes who underwent the same anthropometric, strength and biomechanical assessment prior to their competitive season and were subsequently followed up for incidence of ACL injury. A one-way analysis of variance was used to evaluate potential group (incident PFP vs ACL injured) differences in anthropometrics, strength and landing biomechanics. Knee abduction moment (KAM) cut-scores that provided the maximal sensitivity and specificity for prediction of PFP or ACL injury risk were also compared between the cohorts. KAM during landing above 15.4 Nm was associated with a 6.8% risk to develop PFP compared to a 2.9% risk if below the PFP risk threshold in our sample. Likewise, a KAM above 25.3 Nm was associated with a 6.8% risk for subsequent ACL injury compared to a 0.4% risk if below the established ACL risk threshold. The ACL-injured athletes initiated landing with a greater knee abduction angle and a reduced hamstrings-to-quadriceps strength ratio relative to the incident PFP group. Also, when comparing across cohorts, the athletes who suffered ACL injury also had lower hamstring/quadriceps ratio than the players in the PFP sample (p<0.05). In adolescent girls aged 13.3 years, >15 Nm of knee abduction load during landing is associated with greater likelihood of developing PFP. Also, in girls aged 16.1 years who land with >25 Nm of knee abduction load during landing are at increased risk for both PFP and ACL injury.
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Alterations in scapular orientation and dynamic control, specifically involving increased anterior tilt and downward rotation, are considered to play a substantial role in contributing to a subacromial impingement syndrome (SIS). Non-surgical intervention aims at restoring normal scapular posture. The research evidence supporting this practice is equivocal. The aim of this study was to systematically review the relevant literature to examine whether a difference exists in scapular orientation between people without shoulder symptoms and those with SIS. MEDLINE, AMED, EMBASE, CINAHL, PEDro and SPORTDiscus databases were searched using relevant search terms up to August 2013. Additional studies were identified by hand-searching the reference lists of pertinent articles. Of the 7445 abstracts identified, 18 were selected for further analysis. Two reviewers independently assessed the studies for inclusion, data extraction and quality, using a modified Downs and Black quality assessment tool. 10 trials were included in the review. Scapular position was determined through two-dimensional radiological measurements, 360° inclinometers and three-dimensional motion and tracking devices. The findings were inconsistent. Some studies reported patterns of reduced upward rotation, increased anterior tilting and medial rotation of the scapula. In contrast, others reported the opposite, and some identified no difference in motion when compared to asymptomatic controls. The underlying aetiology of SIS is still debated. The results of this review demonstrated a lack of consistency of study methodologies and results. Currently, there is insufficient evidence to support a clinical belief that the scapula adopts a common and consistent posture in SIS. This may reflect the complex, multifactorial nature of the syndrome. Additionally, it may be due to the methodological variations and shortfalls in the available research. It also raises the possibility that deviation from a 'normal' scapular position may not be contributory to SIS but part of normal variations. Further research is required to establish whether a common pattern exists in scapular kinematics in SIS patients or whether subgroups of patients with common patterns can be identified to guide management options. Non-surgical treatment involving rehabilitation of the scapula to an idealised normal posture is currently not supported by the available literature.
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The objective of this prospective study is to investigate possible scapular related risk factors for developing shoulder pain. Therefore, a 2-year follow-up study in a general community sports centre setting was conducted. A sample of convenience of 113 recreational overhead athletes (59 women and 54 men) with a mean age of 34 (17-64; SD 12) years were recruited. At baseline, visual observation for scapular dyskinesis, measured scapular protraction, upward scapular rotation and dynamic scapular control were evaluated. 22% (n=25) of all athletes developed shoulder pain during the 24 months following baseline assessment. The Mean Shoulder Disability Questionnaire (SDQ) score for the painful shoulders was 34.8 (6.3-62.5; SD 17.4). None of the scapular characteristics predicted the development of shoulder pain. However, the athletes that developed shoulder pain demonstrated significantly less upward scapular rotation at 45° (p=0.010) and 90° (p=0.016) of shoulder abduction in the frontal plane at baseline in comparison to the athletes that remained pain-free. In conclusion, although these scapular characteristics are not of predictive value for the development of shoulder pain, this study increases our understanding of the importance of a scapular upward rotation assessment among recreational overhead athletes.
Article
Background: It has been suggested that dysfunctional posture of the scapula, thoracic spine, and cervical spine is associated with the development of subacromial impingement syndrome (SIS). Objectives: This paper explores the current literature describing the association between static posture and SIS. Major findings: Thirty-one articles were included in this review. Nine of these articles looked specifically at the resting posture in subjects with SIS. All nine of these studies found no correlation between static posture and SIS. Fifteen articles included subjects without SIS and/or non-self-selected resting posture. Of those, nine provided support for the plausibility of a relationship between SIS and posture. Seven of the studies included in this review examined treatment aimed at posture. Only one looked specifically at the effects of postural correction in subjects with SIS and found that it improved pain-free shoulder range of motion (ROM) but there was no change in pain intensity. Three out of four studies, which examined the ability of stretching and strengthening exercise to change posture, found that exercise can have an effect on posture. Several limitations were present in the articles that reduce the strength of the conclusions. These include the heterogeneity of the SIS diagnosis, limited information on subject variables, complexity of measuring posture, lack of blinding, and limited reporting of power analysis. Conclusion: This review has highlighted the current lack of strong evidence to support an association between posture and SIS. The evidence examining this association is plagued by poorly defined diagnostic criteria, wide sample variation, and poor statistical power. Clinicians should be mindful of the current evidence pointed out in this review when considering using posture as a diagnostic and interventional strategy for patients with SIS.
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The purposes of this study were to (1) determine whether sagittal spinal curves are associated with health in epidemiological studies, (2) estimate the strength of such associations, and (3) consider whether these relations are likely to be causal. A systematic critical literature review of epidemiological (cross-sectional, case-control, cohort) studies published before 2008 including studies identified in the CINAHL, EMBASE, Mantis, and Medline databases was performed using a structured checklist and a quality assessment. Level of evidence analysis was performed as outlined by van Tulder et al (Spine. 2003;28:1290-9), and the strength of associations were determined using the procedure outlined by Hemingway and Marmot (BMJ. 1999;318:1460-7). Quality of the included articles were assessed by our own scoring system based on the STrengthening the Reporting of OBservational studies in Epidemiology checklist. Studies scoring maximum points (4/4 or 3/3) were considered to be of higher quality. Fifty-four original studies were included. We found no strong evidence for any association between sagittal spinal curves and any health outcomes including spinal pain. The included studies were generally of low methodological quality. There is moderate evidence for association between sagittal spinal curves and 4 health outcomes as follows: temporomandibular disorders (no odds ratios [ORs] provided), pelvic organ prolapse (OR, 3.18; 95% confidence interval [CI], 1.46-96.93), daily function (OR range, 1.8-3.7; 95% CI range, 1.1-6.3), and death (OR, 1.40; 95% CI, 1.08-1.91). These associations are however unlikely to be causal. Evidence from epidemiological studies does not support an association between sagittal spinal curves and health including spinal pain. Further research of better methodological quality may affect this conclusion, and causal effects cannot be determined in a systematic review.
Demon-haunted world: science as a candle in the dark
  • C Sagan
Sagan C. Demon-haunted world: science as a candle in the dark. Ballantine Books, 2011.
A specialist is a man who knows more and more about less and less. The Reader's
  • W Mayo
Mayo W. A specialist is a man who knows more and more about less and less. The Reader's Digest 1927;6:406.