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Hauntological Corrective Exercise: A Critique and the Implications of Physical Therapy

by Max Blochowiak | March 20, 2019

Jacques Derrida saw the present as inexorably tied to the past and future. It’s never simply this moment, but an amalgam of the three. He called this hauntology, a mixture of haunt and ontology. Imagine that at any given point in a symphony, we are hearing only the note(s) being played in that instant. Although, we carry into that instant the prior notes and as that moment dissolves into the past it is used as fodder for the notes that are yet to be played as a projection into the future.

If we didn’t have this innate characteristic of continuous temporal fusion, the conception of music would belong to greater beings. The current moment devoid of the past and future is utterly impossible to imagine because our entire experience of Being is an intermingling of all three phases. Our existence, then, is haunted. The present moment is always partially a ghost of the past that no longer exists and the blurry image of conjecture. How much of our existence is abstraction and how much is real?

This is how I’ve come to view the phenomenon known as pain. If pain is a warning sent down from the brain that does not have to be pinned down with a musculoskeletal abnormality, how much of it is real? Lorimer Moseley PhD experienced no pain when he was bitten by a snake, but months later was brushed on the ankle by a twig and was crippled with pain [1]. Was his pain real if he had not actually been bitten by a snake this second time around?

Perhaps "real" isn’t the best word, since the sensation feels as real as any other. Was Moseley’s pain accurate? Or, at least, how much of it was accurate and what percentage was an apparition projected by his brain? If two people have the same musculoskeletal abnormality and it causes pain in one but not the other, what is that pain? Or, rather, what is the lack of pain in the other? Moreover, if two people have the same musculoskeletal abnormality and the same healing intervention is applied to both but one’s pain goes away and the other’s does not, what is the purpose of that leftover pain? What is its purpose if it is not actually protecting us from danger? Why is it so unreliable? What do we make of pain in a phantom limb, one that has been amputated or lost catastrophically?

The Writer’s (really truly very humble) opinion is that pain is an exceptionally confusing phenomenon that we are only beginning to understand. Adding to the uncertainty, what are we to do with this study of 350 Italian Air Force cadets [2]? They were all 18-22 years old and asymptomatic when they underwent MRIs, but 270 (77 percent) showed spinal pathology. A whopping 30 percent (106/350) of the subjects had at least one disc desiccation (loss of normal moisture content), and at least one bulging disc was found in a staggering 49 percent (176/350) of cadets. How can we interpret the fact that almost half of 350 young adults had bulging discs but not a single one was symptomatic? Can a completely asymptomatic patient be diagnosed with a pathology?

This study [3] took a 63-year-old woman to 10 different testing centers in order to see the variation in diagnoses for her history of low back pain and L5 radicular symptoms. Across all the tests there were a total of 49 findings of distinct pathology. However, not a single one was present in all 10 tests, only one was reported in nine of the tests, and 32.7 percent (16/49) of the pathologies were only found once.

Each Medical Authority Figure knows what ails this woman, but what does their confidence mean about their inaccuracy? Is it a problem of interpretation, or a measurement error in our state-of-the-art tools? A combination of the two? If The Medical Authorities can’t figure out what’s wrong, what’s actually wrong with her?

I’m not saying that there’s nothing wrong with the old bat, and that she’s out of her gourd. I am asking what it means to be diagnosed with a particular ailment given the range of things in these studies that could possibly be the cause. Only one pathology was present in 9 of the 10 tests, and if we are under the impression that pain and radicular symptoms are purely mechanistic phenomena, we would see one or more pathologies show up in all 10 tests with a small margin of error.

The best doctors can be and will be wrong, and they will be wrong with even the best tools we have available. If this is the case, how willingly should we accept the interpretation of the medical majority? Furthermore, what do we do about incompetent medical and health care professionals – especially ones who do not even attempt to use objective criteria, people who are under the impression that they know what they do not know?

I do believe in the abilities of competent medical professionals to accurately diagnose disease and illness in the body, but it always has been and always will be a science-based "art," with a great deal of learning on the fly. The average practice is much improved since the days of bloodletting, lobotomies, and giving crying babies heroin, but it would do the Reader good to foster a skepticism of The Medical Authorities and the mountains of cash they bring in [4].

Let's take a little tour through some areas occupied by The Medical Authorities and investigate a few things about which you should be skeptical.

Exercise: Know Thine Enemy

When it comes to exercise, the various forms of physical and occupational therapists and exercise physiologists – we’ll call them "Occupational Activators" (OAs)– are the folks who can name all 650 muscles of the human body, but don’t understand the Stress/Recovery/Adaptation (SRA) cycle at all [5]. Many trainers who regularly vomit the word "functional" pitch a dumbed-down version of the common Occupational Activator practice as well. We’ll call them "Functional Proselytizers" (FPs). In addition to these folks there are chiropractors, massage therapists, athletic trainers, coaches, athletes, and many more who peddle similar dogma.

Their overarching narrative: Every person is tremendously fragile and we have to make sure the client can perform [bizarre arbitrary test] or display [arbitrary degrees of ROM] in [specific joint] before we can even think about allowing the client to safely perform [any barbell exercise] with an external resistance.

One well-known physio – I won’t name him, but the Reader might know exactly who I’m talking about – popularized the idea that the “big” joints of the body split roughly into stable or mobile categories. The foot needs to be stable, ankle mobile, knee stable, hip mobile, lumbar spine stable, thoracic spine mobile, scapula stable, shoulder mobile, elbow stable, wrist mobile, hand stable. This is a simplified version of his version of simplification, but it’s the meat-and-potatoes of what he preaches. Most OAs explicitly or implicitly follow a methodology like this.

Often an OA will notice the arch of a squatter’s foot is collapsing medially and that’s creating a poor working environment for the ankle, hampering the client’s ability to dorsiflex. Because the ankle is unstable, his knee tends to wobble throughout the movement. This creates a need for his hip to attempt stabilization of his femur at the knee, thus not allowing it to be the mobile working environment it is designed to be. The lumbar spine isn’t as sound and stable as it should be because of the poorly-controlled hip movement. This can continue on up through the chain. This is cause for celebration (found the problems!) and chastisement (the client is the biggest problem).

The OA can inform the client about his joint instability/immobility quagmires and make him terribly aware of how horrific his movement patterns are and at how much risk he’s placing his body throughout his various ranges of motion. Usually, an OA will inform the client that these movement errors will cause this pain or that injury if not addressed, or that they are the cause of the current pain or injury the client has.

Ideally, the client should leave the office able to understand how these profound problems affect every movement during every waking moment of every single day. All he has to do is be completely present in every particle of his physical existence every passing second to ensure that his body is moving optimally. He simply needs to become a Movement Monk. No pressure, buddy, you got this!

In case the Reader is dubious of my description of these OAs, I did not attack a straw man. I promise the Reader can find many examples with a cursory perusal of YouTube, Instagram, or Facebook. They are everywhere: the Internet is crawling with these parasites.

OBJECTION(S), YOUR HONOR

We have been conditioned to hear Physical and Therapy as the demarcation of a particular profession. Alone, "therapy" means the relief or cure of a disorder, and "physical" refers to the material substrate of the Homo sapiens. We can see a problem already: the name of their profession implies the necessary existence of a disorder, without which they are superfluous.

Extremely Very Basic Mechanics

A lot goes on in the squat [6], but every time one squats down and stands back up, all of the same contractions happen. A person squatting his bodyweight is not going to maximally recruit his motor units the way a person squatting a 1RM is going to, but they are still using all the same muscles. This is important to accept because it is terribly common to hear nails-on-the-chalkboard talk of quadriceps dominance or a lack of activation or amnesia in the gluteus medius during the squat which is causing some crippling malady that must be addressed with Physical Therapy.

This is malarkey. Talk of dominance between two muscle groups is a pure conjecture of the feeble-minded. Muscles are not rogue entities talking to one another throughout a movement,with the Lifter merely along for the ride. If one is using “all quad” to stand up in the squat, it’s likely that they are not using any deliberate hip extension [7] out of the bottom position. But they are not using "all quad," because there is no neuromuscular mechanism by which you can ascend from the bottom of a squat without extending the hips, and therefore using the hip extensor muscles in the movement. This is a matter of biomechanics and muscle physiology, not the symptom of some nebulous "muscle imbalance."

Varying degrees of involvement from the muscle groups that constitute the "quads" and the hamstrings and the glutes can be produced by using varying skeletal positions in the squat. Front squats, Olympic squats, and the infamous low-bar squat produce different levels of involvement from the muscle groups that extend the knees and hips, and place different levels of loading on the back. But all these squats use all the muscles, since all the joints are moving. And it's possible to do each variation incorrectly. To fix this, coach the squat correctly and enforce correct technique, even if it takes a ruler across the knuckles.

One would think such a deep knowledge of anatomy would give the OA a strapping foundation for the understanding of biomechanics, but one could not be more wrong. People who actually have trouble activating muscles are usually referred to as "paralyzed" – some form of a lack of communication between the central nervous system and the muscles. If the person stood up, there is no paralysis.

Blowing Knees Out Like Candles

A client’s knee wobbling during the ascent of a squat is the result of a lack of good coaching. If an OA sees repeated clients who have this problem, it is not the clients’ problem. The root cause is the poor coaching ability of the OA. Usually their first solution will include, but may not be limited to, standing/lying/seated hip abductions, banded walking of various flavors, something called a “bird dog,” etc.

Rarely will an OA continue the squatting prescription out of fear that the client’s knee will explode out of the leg and shoot across the room. They back away from compound movements because when, say, hip abduction is monitored in isolation, we see that the gluteus medius is the Prime Mover. This is entirely irrelevant to normal human movement and the large system within which the gluteus medius actually operates.

If a client is truly struggling with wobbling knees, focus all his attention on his knees and do not progress the intensity of the exercise until the knees no longer wobble – this should take a competent coach about 5 minutes. All the OA is doing with "corrective exercises" is having him practice controlling his femurs in isolation while fumbling around with bands and "bird dogs" for three weeks, and when the client returns to the squat his knees still don’t know how to not wobble in the squat. As it turns out, banded walking, hip abductions, and "bird dogs" do not teach the knees what to do in a squat, so they don't correct the problem. And three weeks got tossed into the wood chipper.

Overload Events (Or Lack Thereof)

The most important aspect of the SRA cycle is the overload event. The stress we place on the body in order to cause a positive adaptation needs to be above a threshold that is relative to the individual's current level of adaptation. Much of the activity done in the office of an Occupational Activator or in the gym of an Functional Proselytizer could be classified as maintenance, or even negative stress for a person in even moderate condition, i.e. no positive adaptations are made.

progressive overload and the stress/adaptation/recovery cycle

If a patient was recently bedridden, the stress of walking (or the attempt) would be a positive stimulus because the baseline of such an individual would be extremely low. Furthermore, the baseline will climb quickly until it is in a more “normal” range. Stressors will need to be titrated up toward normal if the patient wants to be normal again. Once we become super-normal, our overload events require such large stressors that they would challenge Thor Odinson.

For a vanishingly small chunk of the population, the aforementioned isolation exercises may constitute an overload event. However, these will probably be an outright waste of time after one or two workouts, because OAs don't understand that the loads must increase. It will become movement for movement’s sake that will not disrupt homeostasis. For the folks who are even remotely trained and sustain an injury, these exercises will be tomfoolery, buffoonery, horseplay, fandango, i.e. silliness.

Where's Waldo’s Pathology?

The notion that any of these movement issues have direct, causal links to certain injuries or pain is interesting, has made a lot of people a lot of money, and has yet to be demonstrated with any level of certainty. Movement inefficiency should obviously be improved for better performance, but the burden of proof is on the OA/FP to show the studies that prove certain movements cause pain and/or musculoskeletal injury.

For example, knee valgus is commonly seen as a disaster-in-the-making. What they’re referring to is a general caving-in of the knee, not the medical assertion that the distal femur is internally rotated, which can be noticed in an individual’s leg from about a mile away. Real valgus makes me queasy, but movement errors as described by OAs/FPs rarely have a concrete causal relationship to pain and injury.

All that has been shown for their faux-valgus is that it increases tension on the ACL when landing, which should be painfully obvious [8, 9, 10] .

If we perform depth jumps off of a box and let our femurs internally rotate, and allow our knees to shake around like the legs of a newborn fawn, we will probably increase our risk of injuring our ligaments and tendons. The simple fix: learn how to absorb force with your hips and knees like somebody who does not suck at movement.

So, here's an important question: why do people like Dmitry Klokov [11] and almost the entirety of the Chinese weightlifting team [12] rarely, if ever, sustain any knee injuries while regularly displaying valgus/varus knee movement that would be considered by the OAs to be an orthopedic death sentence? Hmm?

It’s Not You, It’s Your Rhomboids

We know from this longitudinal study [13] that back pain is not correlated with posture, spinal mobility, or physical activity. One would think this would stop the OAs from worrying about posture, but these spirited folks still put clients through postural rigmarole with labels like Upper-Crossed Syndrome (and Lower-Crossed Syndrome).

UCS is an absurdly complicated phenomenon that essentially means the subject’s head and shoulders are forward. Yet, when Lab Coats attempt to define normal positions v. abnormal positions, they cannot agree because of the natural variation humans display. If we cannot definitively state where one’s shoulders should be, how do we know they are forward, and to what degree? Furthermore, what is the root cause of this non-existent problem?

Why, it’s muscular imbalance, of course. However, all the data shrugs its terribly rounded shoulders when it is asked what exactly is imbalanced and by how much. The Lab Coats have tried to define muscular balance for decades, but they cannot agree on strength standards or ratios, what constitutes a “tight” or “loose” muscle, or possible correlations between muscular strength and weakness and pain or injury.

The gist of Paul Ingraham’s great article [14] on postural science: we cannot define poor posture because of the innate variability of human anthropometry and kinetics. Therefore, diagnoses that address specific symptoms are spurious, and various “treatments” of the symptoms we perceive as poor posture are not effective. It’s quite difficult to fix something if we can’t determine how it should and should not be operating. The good news: posture doesn’t really matter.

A lot of "imbalance" talk is still being devoted to hamstrings/quadriceps strength ratios for preventing ACL injury. This has been futile [15]. Three decades of H/Q strength ratio studies have concluded that stronger hamstrings are better than weaker hamstrings. Imagine my shock. Between the problems of people who do nothing but sit on the couch and the cases of men and women who deadlift hundreds of pounds with a rounded back for decades while rarely experiencing pain worth writing home about, it’s nearly impossible to predict which movements should or should not cause pain or injury.

Diagnosis, Intervention, and the Ether

“If you see fraud and do not say "Fraud," you are a fraud.” – Nassim Taleb

OAs and their minions regularly see arbitrary movement errors and diagnose pathologies that do not exist, or they will tell the patient that their current issue is not yet thoroughly pathological but will definitely cause a particular pain or injury in the future if not addressed immediately. Once the pathology is on the table, they postulate a counterfeit root cause which is obviously bringing about some highly arbitrary amalgam of symptoms and pain, and which must be treated with a variety of corrective exercises. They tell the client to dance around with colorful bands and dumbbells until the pain goes away (almost all pain disappears on its own time), or the client ceases to be terrible at moving and stops hurting himself, which would imply that future pain and injury have been proactively avoided with the OA's help. Both the client and the OA are satisfied with this intervention, and it ends. Perhaps some clients continue because they have lots of money, and they are sick of using $100 bills as kindling and decide they would rather give it to a runner disguised as somebody who understands strength.

It’s also worth noting that we can be classically conditioned – like Dr. Pavlov's dogs – to feel more pain and catastrophize others’ pain if we see a pain signal. We can also be primed to feel or expect to feel pain in specific movements/positions, creating fear avoidance behavior [16, 17, 18].

By definition, OAs must discover an issue to cure or relieve. Truly, they are pulling diagnoses from the ether. Then, they employ corrective exercises to fix the imaginary root causes and actual pain they have created. In a not-so-hilarious twist of cosmic irony, they become the root cause of the inaccurate-yet-real pain the client is experiencing. We now have millions of people walking (limping) among us who are living out the painful experience of a disorder that doesn’t exist, all because they were conditioned to do so by The Medical Authorities.

Every person will experience pain, and organic decay is an unavoidable feature of biology. The question is not how one rids themselves of that which is natural, but how to manage that which is inevitable. Perhaps the Reader is defensive, but this philosophy of diagnosis is liberating. It frees one to be no longer beholden to an affliction, no matter its severity.

The most common disposition of the knowledgeable among us is befuddlement. The more we dig into any one thing the more we unlock its complexity, realizing how much we do not know. There are infinite pieces of information available for any individual to notice at any one time. We see or know a tiny fraction of these data. If we put this into perspective, our accumulated knowledge is closer to absolutely nothing than it is to any significance at all. In this sense, the universe is stupefying and it would behoove us to practice humility. However, as a prophet, I am exempt from discarding my hubris.

Feeling overwhelmed at the necessarily confusing and arbitrary nature of most phenomena that do not seem so at first glance is nothing about which the Reader should feel embarrassed. The ancient Greeks revered this feeling of aporia, which is basically utter puzzlement or reaching a cognitive impasse, and they were smarter than the Reader and me (or at least the Reader).

Men of Military Importance still believe jogging five miles is the epitome of fitness. The Medical Authorities tell patients that squatting is “bad for the knees.” Indeed, this study [19] showed less than 12 percent – as low as only six percent – of doctors polled knew about the ACSMs recent guidelines for strength training and recommended it to their patients. Everyone knows that basketball players who try to lift weights will see that it “throws off their shot.” The foundation of strength is one’s "core."

The majority are devoted to bad ideas, and as Mark Twain said, whenever you find yourself on the side of the majority, it’s time to pause and reflect. Those who know the truth usually claim to know nothing while those who sincerely know nothing portray omniscience.

Go lift some weights.


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