Take Care of Your Feet!


       If you are a runner and you are serious about avoiding injury, then there 3 things you need to be sure to do for sure!

– Look after your Feet

– Look after your Hips

– Manage your training load

Of course,  there are many other things that will help avoid injury but these 3 areas sure are important.

Over the next few updates I will break each of these elements down with a few pointers to get your heading in the right direction to bullet proof your body!

Starting with the Feet…

On average, the each foot strikes the ground between 80-100 times per minute when running. With each strike equal to approx. 3 times the person’s bodyweight.

The feet are responsible for absorbing that impact and transmitting the forces up through the body efficiently & effectively.

The better shape the feet are in, the better they are at dealing with these forces without a) becoming injured and b) placing more strain upon joints further along the chain (i.e. knee, hip) due to their inability to move well and absorb.

…So let’s look at what we can do to prime our feet.


Running is very repetitive, with the feet pounding the pavement in the same movement pattern for a long time. Coupled with the fact the majority of recreational runners may also spend 5 days a week confined to restrictive work shoes, spending some time each week to keep the feet mobile and free will be extremely beneficial.

Here of some example of things that you can try:

Hockey Ball Roll
Soft Tissue Therapy Planter Fasciitis

After a long week of pounding the pavement, help to ease all of that built up tension in the bottom of the foot by spending a few minutes applying pressure through a hockey/tennis ball.

Fingers between Toes
Toe Stretch

Just as we like to stretch and move all other areas of our body, our feet and toes are no different. There are many small but very important muscles in the foot that can benefit greatly from a couple of minutes of separating the toes and rotating in small circular motions.

Knee to wall
Knee to Wall

This can be used as an assessment to compare range of movement of the ankle. It can also be used simply as a way of working through a full range of movement of the ankle by spending a minute or two slowly moving in and out of that end range position.

Massage / Joint Mobilisations

Your feet carry you through all of those long miles, so it makes sense to treat them to regular treatment in order to keep them working optimally for you. Massage is a great way to ease off sensitivity in the area. The major joints of the feet will benefit from mobilisations to ensure free movement to allow the them to efficiently absorb the forces placed upon them.


An inadequate range of movement around the foot/ankle can cause a number of issues with running. If there is not enough free movement for the forces of impact to be dealt with at the ankle, then these forces will travel upwards and end up being placed upon the knee and hip. Over time this kind of faulty loading pattern can contribute to the onset of pain.

Below are some suggestions of stretches that can be used to ensure full movement of the foot & ankle: –

Calf Stretch
Leaning against a wall, straighten the back leg and drive your heel into the ground.

Soleus Stretch
Leaning against the wall, bring the back foot in slightly and sit back towards the heel. This will put a good stretch on the soleus.

Achilles Stretch
Wearing running shoes, bring your front foot towards the wall and places the toes up against it. Bend the knee towards the wall, this will produce a stretch that puts emphasis on the achilles tendon.

Plantar Fascia
Plantar Fascia Stretch
Without shoes on, place your toes up against the wall and bend your knee into the wall. Stretching in this manor will hit the achilles but also targets the plantar fascia of the sole of the foot.

Toe Separators
Toe Separators

We keep our feet locked up and restricted in shoes for very long periods of time. This can have a compressive effect on our feet – if you compare an average adults foot to that of a baby, you will see the difference between the foot as nature created, and the foot that has spent 30 years in narrow shoes! Try wearing toe separators in the evening to stretch the intrinsic muscles of the foot and regain your natural foot position.


This is the biggie! Running places great load through the feet. The most effective way to manage this is to ensure that the relevant tissues are strong enough to tolerate these loads. There is an old myth that strength training for running should be light weight and high repetitions. This is in fact not true. Muscle endurance for running is built by running itself. The supplementary strength training must be designed to increase total strength capacity. The more we can lift, the better. Of course, it must be progressive, and we should build up the load gradually in order to not overload our body and cause injury.

Below are some introductory exercises for the feet/ankle. All of which can be loaded more either by performing whilst holding weights, or using heavier bands.

Calf Raises Straight/Bent Knee

Calf Rasies                      Calf Raises
These exercises through the calf, ankle and foot. The Straight leg variation will target the gastrocnemius, while the bent leg version targets the soleus. Progression of this exercise would see you perform single leg raises / load the exercise by holding weights whilst performing.

Resistance Band Eversion/Inversion/Dorsiflexion

Ankle band strength              Dorsiflexion
You can really start to strengthen and stabilise the foot and ankle by incorporating resistance band exercises that load through the ranges of movement that the ankle produces. This is a great way to increase your body’s tolerance of the demands of running.

Tip Toe Walks / Heel Walks

Toe Walks        Heel Walks
Great exercises to build up endurance in the lower leg/foot. They are good drills to use to build up movement patterns/strength for good running technique.

Pogo jumps

Pogo jumps are a great way of starting to utilise plyometric drills in your training. These jumps will help develop the elastic strength in the achilles that is so important to run well. Focus is on pulling the toes tight towards the knee when jumping and actively planting on the landing.

Lateral Hops

Lateral Hops
This exercise is another way to utilise plyometric training. It also develops the stability of the ankle and it’s ability to deal with the forces acting on it when running. Two areas are created alongside each other and the drill is to hop from one side to the other repeatedly. Focus is on ensuring that the landing is strong and controlled.


This is by no means a complete nor exhaustive guide, just a few ideas of ways you can look to optimise the health of your feet. If you can incorporate even just a couple of drills from each section you will be positively impacting on the capacity of your feet to tolerate the demands of your running training.

Please feel free to get in touch to discuss any methods of improving your running performance further!

I have a 12 week running performance package that utilises strength training to improve your running – email me if you would like details.

Experiment & Enjoy.

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Knowledge Is Power – What I Need People With Back Pain To Know

Back Pain
Check out this fantastic compilation of information that is presented by Ben at Cor-Kinetic!

A great bit of free information to help people who have/are experiencing back pain to learn and gain a little better understanding.

*IMPORTANT – This document does not replace professional medical advice and is only intended for information purposes.*



• Back pain is normal. Up to 20% of people are likely to get some each year and a whopping 80% of us will get some back pain in our lifetime, in fact it would abnormal not to get back pain.

• Back pain can last up to 6 weeks – this maybe longer than you anticipated. So if it has been going on for a bit there is no need to unduly worry. Lots of pains only last a number of days but it is still normal for it to last longer.

• Although we all know someone who has had long term persisting back pain that has caused lots of problems it is actually somewhere between 10% and 25% of people with back pain that lasts longer than normal. So you have good odds it won’t last longer than 6 weeks.

• Back pain is no different to any other pain in our bodies such as shoulder, ankle or knee pain although people do tend to worry more about it.

• Pain itself is normal and nothing to be scared of. It is a protective mechanism that has evolved help us out. You would not want to live without it!

• Pain is not a good at reflecting the physical state of our back or any body part. We can have lots of pain without  significant damage. Think about getting a paper cut or a bee sting. They can hurt like hell but don’t really damage us.


Diagnosis can often be challenging with back pain although I know that people often want an answer. We don’t always need a definitive answer to help you. Here is what we do know:
• The vast majority of back pain is not serious, in fact around 99%. The 1% is mostly fractures, can include cancer, but these a pretty rare occurrences.
• Around 10% can be pinned down to a specific tissue diagnosis such as a disc or a nerve.
• These statistics mean that it is unlikely to be a ‘slipped disc’ or a nerve problem and people often throw these terms around as causes without really knowing this for sure. This can often be unhelpful.
• Therapists have some tests to tell if the problem is in that 10%. These include clinical tests for the nerves and nerve roots as well as muscle strength, sensation and reflex tests.
• It is very difficult to make a diagnosis from a MRI alone. Lots of MRI findings also exist in people without pain, hence the need for a clinical exam to accompany a scan.
• MRI’s are not able to show us pain.
• We often can’t pin it down to a specific tissue or pathology around 9 out of 10 times. There are lots of different tissues in a small space and if it is irritated or inflamed then it may affect more than one of the tissues.
• Inflammation is a good thing. It means the body is working well and doing its repair jobs.
• From a medical perspective this type of back pain is often termed ‘non-specific’ and we should see this as a positive diagnosis as it means nothing serious is wrong. It could still hurt a whole lot though.
• The term ‘non-specific’ means the tissue, not non-specific to you or has no origin. YOUR PAIN IS ALWAYS REAL AND SPECIFIC.
• Non-specific pain often responds well to moving and although we cannot give an exact label does not mean we cannot give some ideas to help or an a basic explanation about why you might have back pain.


• Lots of different factors (many which you may have not considered) can affect your back pain.

• This can mean that you feel your back pain has a life of its own but it maybe that you have not been informed about or considered all of the potential contributing factors.

• These other factors can include abnormal sleep, lots of life stressors including work and family, feeling that the pain will never go and negative beliefs about your back and performing daily activities.

• Its probably not your spinal posture, your pelvic tilt, a teeny weeny muscle not firing or something needing to be put back into place causing your back pain. How do we know? We have studied this stuff to death.

• If you have been told this before it could mean your therapist is not up to date with the latest research in this area. You may have been given lots of opinions previously and it can often be confusing for you and hence the need to be aware of the scientific data in this area.


• There are NO magic treatments for back pain that work for everybody unfortunately.
• It might not be one singular problem but a few different things happening together. A minor pain might be exacerbated by other things that are making you a bit more sensitive.
• Your therapist should be able to give you some basic advice or point you in the direction of others who can if it needs more specialist help.
• Lots of different treatments can help in the short term, such as a few hours or days, but don’t simply put your recovery in someone else’s hands. This has been shown to often be worse in the long term.
• You may have to avoid aggravating activities in the short term but make sure you go back to doing them. Nothing should be off limits in the long term. Don’t let anyone tell you otherwise.
• People who feel they need to protect their backs can also have worse outcomes.
• Learning more about what helps you and what makes you worse is important to help you manage your back pain. Your therapists should help you do this.
• Movement and exercise might help.
• Unfortunately here are no magic exercises for back pain. Find what you enjoy and just do it. This could be Pilates, strength training, sport with friends or simply going for a walk in the park.
• Don’t feel you have to really push yourself to get stronger or fitter but it is good once in awhile to exert yourself. This gets your body used to doing it.
• Moving and exercising can help us build confidence in our bodies and this might be key to recovery rather than fixing a physical problem.


• The common term for persisting pain is chronic pain, The term chronic does not mean ‘worse’ it is actually just a general term for pain that has gone on for longer than 3 months.
• How we respond to back pain might play a role in how long it lasts. If you change what you do in terms of activity such as avoiding things or think very negatively about your pain and your recovery.
• We could see persisting back pain as our protective systems, in this case pain, doing its job too well.
• Although pain is normal and a good thing, we could see it a lot like red wine. A little bit is great, but sometimes we can have too much of a good thing and it leaves us with a hangover.
• Persisting pain is currently seen as problem of the protective system itself rather than simply reflective of the state of your body.
• The more we work the mechanisms that contribute to pain the stronger they can get. It’s a bit like working your bicep in the gym. Just like your muscles the protective system can adapt and get better at protecting you.
• Unfortunately this means that the things that did not used to cause you pain now can do and may explain why you can be very sensitive to things that used to be normal.
• All of this does not mean you can’t get better but it is not as simple as finding an ‘off’ switch.


This is some advice from some fantastic and experienced therapists from around the world who have kindly contributed to this document.

• Sheren Gaulbert – Stay connected with people who matter in your life/engage in activities you value.

• Karen Litzy – Don’t consider yourself broken or damaged goods.

• Ash James – Its often better to be at work than at home. You will move more, rest less and get back to normal stuff sooner.

• Kjartan Vibe Fersum – Important to have a shared plan (with your therapist) to move forward with.

• Tom Goom – It’s good to experiment with movement, relax into it and see what helps pain and stiffness. Movement is medicine, and like medicine it has a dosage, experimentation is needed to find the right dose for you.

• Claire Higgins – Your back is designed to be strong. It can so easily be visualised by patients to be a stack of blocks which could be “crushed” or “topple” at any moment. Education on how our backs are super strong and to trust in them is important.

• Claire Higgins – Focus on the things which turn your pain down, restoring balance e.g. exercise, meeting friends for coffee, being in the great outdoors.
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Degenerative Disc Disease Correlation To Pain Doesn’t Matter As Much As You Think

Read this great, and informative post by Jamie Johnston at The Massage Therapist Development Centre. They are many more great articles to be found at his website : https://themtdc.com

Degenerative Disc Disease Correlation To Pain Doesn’t Matter As Much As You Think

He came in with a look that resembled someone in grief.

I asked if he was okay and his response was a bit surprising.

“I was just told I have a disease which is causing my back pain, as a result, the pain may never go away.”

As I inquired more he told me the diagnosis was degenerative disc disease, which was causing his spine to shrink and as a result, it was causing the low back pain he was experiencing and would now have to seek treatment on a weekly basis just to deal with it.

This once active person (in his 50’s) was now disheveled because of this MRI diagnosis he had been given by another practitioner, he felt hopeless.

Why MRI Is Just One Tool That Should Be Used

Stories like this happen all too often with our patients.

They experience some sort of low back pain, (which usually they have never experienced before) and their doctor or other healthcare practitioner orders an x-ray or MRI and the results seem catastrophic. They are diagnosed with a “disease” or “syndrome” of some sort but aren’t given any really good information surrounding their condition.

While there is a possibility that disc degeneration (DDD) could be a contributing factor to their pain, it’s not as simple as just looking at some medical imaging to get a proper diagnosis.

There are several contributing factors including environmental factors, genetics, and associations with heavy physical work, lifting, truck-driving, obesity and smoking (smoking has been found as a risk factor for pain and DDD) found to be the major risk factors. However, these do not point to a clear pattern between degeneration and clinical symptoms.

Something that doesn’t get mentioned as often, is how this is also simply a part of normal aging. One systematic review points out some interesting facts to show just how much this happens. When looking at 3110 images of asymptomatic people the review showed:

  • Prevalence of disc degeneration in people at 20 years old was 37% which increased to 96% in 80-year-olds.
  • Disc bulges occurred in 30% of people at 20 years old and 84% in those at 80 years of age.
  • Disc protrusions were 29% of 20-years-old and 43% of 80-years-old.

And all of these individuals weren’t experiencing any pain!!

Another study showed changes in the disc at multiple levels were more common in the elderly (in this case above 60 years) as well as other degenerative changes around the facet joints, ligamentum flavum, and disc bulges.

Even though degeneration has been seen in the younger population as well, there is little correlation between radiological findings and pain. Quite often people whose imaging shows major issues have no pain and those who present with minor signs experience severe pain.

Unfortunately, many of these people are referred for surgery (usually a spinal fusion) which eliminates motion and can lead to degeneration of adjacent parts of the spine. Another part of the problem here is this only addresses a symptom, not the cause and the surgical outcomes are not great. It is also important to note that 70-80% of people who have surgical indications for back pain or disc herniation recover whether they have surgery or not.

These surgical referrals usually happen because imaging has been used as a diagnosis, rather than just a tool used in the process. This isn’t to say imaging shouldn’t be used, but it should not be the only thing used. Overall we see the association between MRI findings and DDD are unreliable, so the importance remains on our clinical reasoning and of course, patient history as well as looking for any neurological deficits.

The Role Of Depression

Now that we understand DDD risk factors, it’s age-related changes, and correlation with pain there is another factor we need to look at.


In a three year study looking at veterans who were asymptomatic with low back pain, they were given repeated MRI’s over this three-year span. The researchers made a point of not telling the participants the results of what they saw as they didn’t want the patients to alter their symptoms by becoming sensitized to trivial issues or amplifying their symptoms.

Imaging findings varied, some discs were less severe, or even normal, and some became worse. The study concluded that central stenosis, nerve root contact, and disc extrusion were the most important imaging findings that may be risk factors for future back pain, however, protrusions were not a risk factor.

But, the strongest predictor for low back pain was depression. 

Of those who self-identified (and were being medically treated for it) as having depression, their pain scores were greater at EVERY follow-up, whereas the progression of disc changes was only occasionally associated with new pain. Some of the participants also pointed out their activities were limited because of their depression.

As we know (when reviewing the clinical guidelines of low back pain) bed rest used to be one of the main recommendations for those dealing with acute low back pain, but now exercise and movement is the far better recommendation. When we look at discs exercise does not affect them adversely and they respond well to long term loading strategies. 

So, think about that patient who comes in and is catastrophizing about the diagnosis they have just received. We know part of what we have to do is provide reassurance, in fact, this is a MAJOR part of what we have to do. Looking at all the information we have just discussed, letting them know that disc degeneration is a part of normal aging, there is little correlation between their diagnosis and pain (unless there are neurological symptoms) and quite often the issue resolves itself without surgery. Could we actually reverse their catastrophizing? Could we also assist this by encouraging them to exercise, even by getting them moving on your table to show that movement is safe? We know that exercise has great results in helping with depression and now we know it also helps with disc health, so aren’t these the things we should pay more attention to rather than focusing on MRI results? I’d say yes…and the research agrees. 


Read this blog and many more great posts at his website!

Degenerative Disc Disease Correlation To Pain Doesn’t Matter As Much As You Think

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Big Time Boxing is Back in Nottingham

Leigh Wood set to defend his Commonwealth Title at Nottingham Motorpoint Arena.
leigh wood

Big boxing cards are back in Nottingham, as Commonwealth Featherweight Champion, Leigh Wood, is back in action defending his title at the Motorpoint Arena on 10.05.19.

Part of an action packed Matchroom Boxing bill featuring WBA International Featherweight Champion Jordan Gill, Central Sports Massage sponsored athlete Leigh Wood is sure to draw his home town fans in to pack the arena. A great match up against Ryan Doyle is set to create a great night of boxing!

Get on board and show your support to Nottingham’s rising talent. Tickets will be on sale soon, ranging from £40 – 120. They can be purchased from BluePrint Nottingham.


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MTDC Articles of the Week

Here is the latest newsletter from Jamie Johnson at the Massage Therapy Development Centre with a selection of great articles from the last week!

Some extremely interesting, progressive pieces to help keep you up to date with current understanding and practice.

Follow the links below to be directed to the full articles….

Articles Of The Week January 20, 2019


Coming out of college, everything seemed so straightforward! You’ve got a toolbox of techniques and you may even look to specialize in one of them, all the while helping as many patients as you can. Well, things aren’t so straightforward, and the times they are a changing. With it usually taking 17 years for new research to be applied in practice, we need to stay on top of the new and evolving research, along with a strong alliance with those patients.

“Manual Therapists: Have You Lost That Loving Feeling?” – Paul E. Mintken, Jason Rodeghero & Joshua A. Cleland

Patient centred care means different things to different people. Because it has different meanings for different people, there may also be ethical dilemmas surrounding the topic as well. This article delves into some of these topics, while also having you reflect on what this topic means to you.

“‘Patient-Centred’ – What Does It Mean And How Achievable Is It?” – Andreas Laupacis & Jennifer Gibson

Using unstable surfaces for strength training and rehab has been a popular practice for quite some time. However, does it really work? Well, it depends on the patients goals, your scope of practice, and just plain sticking to the basic principles of exercise program design.

“Is Unstable Surface Training A Waste Of Time?” – Nick Ng

He has been at the forefront of pain research over the past number of years and Peter O’Sullivan is always worth listening to. No different with this article, where it shows how he and his team are using ‘Cognitive Functional Therapy’ to treat back pain.

“The ‘Mythbusters’ Of Back Pain Believe They Can Treat It – With Words” – Liam Mannix

We published a post earlier this week about when NOT to treat a patients thoracic pain, but when you can, this is a good post. Dean goes through a few different drills and exercises to help increase thoracic rotation, most of which you can do right in your treatment room.

“Cleaning Up Thoracic Rotation” – Dean Somerset

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How Can Strength Training Help Runners? – Mike James

How Can Strength Training Help Runners?

Sports Injury Fix’s resident running expert Mike James recently wrote his top tips on injury free running and follows this up by expanding his thoughts on the hot topic of strength training for runners. 

Original Article:

Barbell for strength training
Benefits of Strength Training 
The injury incidence among runners varies between 11–85%, or 2.5 to 38 injuries per 1000 hours of running.1,2 Research suggests that the top 3 benefits of strength training are:

1. Reduce overuse injuries
2. Improve running economy
3. Improve performance

Strength training has been shown to reduce overuse injuries by up to 50% and improve performance.3,4 A recent review found that strength training improved running economy by 2-8% and time trial performance by 2-5%. It also dispelled many common misconceptions relating to strength training being detrimental to endurance activity as maximum oxygen uptake, blood lactate and body composition all appeared unaffected.

Get strong and stay strong, coupled with appropriate management of training load and recovery appear to be the biggest factors we can actively affect in reducing injury risk and improving performance.

Despite such obvious benefits a large proportion of runners do not undertake regular strength training.  In fact, a study of 2008 US Olympic marathon triallists found that roughly half did not do any whatsoever.6 This statistic is anecdotally supported whenever I question runners in clinic, at race events or during the courses and workshops that I present.
Kettle bell on the floor with person about to pick it up
Misconceptions of Strength Training 
I believe many age old, long held misconceptions exist regarding within the established running community. The top six misconceptions on strength training are:

1. Fear that it will negatively impact endurance performance
2. Increases in body mass
3. Be detrimental to their training
4. Are not ‘functional’ for running
5. Are less important for injury reduction than stretching
6. That it is complicated to master and needs instruction from an expert

When these are combined with time constraints, work and family commitments, the belief that it needs to be undertaken in a gym, and a failure to appreciate the potential positive benefits then it is understandable why it hasn’t become a staple part of the runners training regime.

Making the Most of Strength Training 
When I do come across runners who perform some degree of strength training, then they often do so with the outdated belief that as an endurance athlete they should perform high reps/low resistance workouts to target endurance capacity. Whilst this may be more beneficial than performing zero strength training, it may fail to maximise the benefit available. Eventually, when skill acquisition and confidence of the low load exercises is achieved, low repetition, high load appears more beneficial to the runner than remaining at high repetition and low load. Building a greater capacity to tolerate forces and generate power will ultimately provide a greater stimulus for the system to perform and reduce injury risk. The current evidence appears to support the notion of performing concurrent strength and endurance training for maximum benefit that includes increased movement economy 7, reduced / delayed fatigue 8, increased maximal speed and enhanced capacity anaerobically. 9 As with all training regimes though, compliance is key.

In summary I believe strength training has the potential to produce a more robust, economical runner with a reduced likelihood of injury when coupled with appropriate training and recovery schedules. Happy athlete with hands in the air
How to Start Strength Training?
So, we’ve established that strength training is worthwhile but how and where do you start? Do you have to join a gym? The key is to keep it simple and then progress as you feel comfortable and see benefit. We know that a large proportion of people fail to adhere to exercise, even when part of a rehabilitation plan, and a major factor in this is unclear instructions 10. For that reason I believe that  the top two tips when starting are:

1. Do it at home
2. Use Bodyweight exercises

The guide below gives a simple regime of 6 exercises that can be completed 2-3 times a week and less than 20 minutes a session.

A beginner’s guide to strength training for runners at home: 
As with all training regimes, compliance is key, and I have designed a simple regime of home, bodyweight-based exercises for the runner to try. Blagrove et al 5 states that the most effective type of training prescription is difficult to identify at present but suggests an optimal dosage may be 2-3 x week for 6-14 weeks (longer is better!) and when run training increases in the lead up to a race, then once weekly may be sufficient to maintain gains.

On a practical level, try to allow 3 hrs after high intensity running before performing strength training, and allow at least 24 hrs recovery afterwards before completing high intensity running.

Aim to complete 4 sets of 8-12 repetitions of each exercise. This can be performed as a circuit or one exercise at a time. Allow around 30-60 seconds rest between sets as required.

Should the exercises become easy, or you are already performing bodyweight exercises, then adding some resistance as shown below is advised. Simple equipment such as water bottles, sand bags, rucksacks filled with books will add extra resistance, however, if you have access to simple fitness equipment such as dumbbells, kettlebells and resistance band, then they work well also. Again, aiming for 8-12 repetitions per set, 3-4 times.

This is by no means an exhaustive list of exercises for the runner. They are simply an introduction to strength training at home. Exercise dosages are simply a starting point for the general runner and should the runner wish for further progression and/or to develop specific components of strength, such as power or plyometric ability, then guidance should be sought from an expert.

Exercise 1 – Squat
Squatting is a common daily task that is common place in many strength training regimes.  When we look for “most bang for your buck” type exercises, then it’s no surprise the squat is at the top of the list. By nature of its multi joint strength and control demands encompassing many types of muscle contraction, then it becomes a fundamental exercise for the runner.

squat exercise start and finish mike james

Air squat – feet shoulder width apart, stay tall and strong, lower with control to a depth you can control and then drive through the legs to return to the start position.
goblet squat start and finish mike james
Progression – add resistance – this variation is called the goblet squat and adds both resistance to the lower limb and trunk control. Wearing a ruck sack converts the exercise to a traditional back squat type movement.  Try to avoid excessive forward lean, knees tracking over the toes and the knees collapsing inwards at the bottom of the squat. Try to keep the chest up as if to show off your favourite race T-shirt to someone in front of you. Progression through to heavier resistance and / or a single leg squat variation would be appropriate.

Exercise 2 – Deadlift 
Another fantastic multi joint movement with excellent emphasis on the posterior chain. Whereas the squat is a knee driven exercise, the deadlift is a hip driven movement, meaning, most movement is a pivot / hinge at the hip whilst keeping an upright strong trunk. The knees will need to bend when you feel the hamstrings pull. Only lower as far as you feel you can control, then drive back to start.

deadlift BW Start and finish mike james
The deadlift can be a difficult exercise to master and may require practise of a simple hip hitch movement before developing into the full technique. A simple technique is to stand a few inches from the wall, try to touch your buttocks against the wall without bending the trunk or knees.


deadlift with weights start and finish mike james

If performing well, add resistance as above, or try a single leg version (below). Running involves significant amounts of single leg support and control and this is an excellent exercise for targeting this. It is an advanced technique and takes time to master.

singe leg deadlift start and finish mike james

For each deadlift variation, aim to keep your hips higher than your knees, your buttocks moving back rather than down, and your trunk and upper limbs square and facing forward. Add resistance again as tolerated.

Exercise 3 – Calf Raise 
An essential exercise for runners. The calf complex and Achilles tendon transmit and absorb massive forces and increased capacity in these tissues will almost definitely benefit the runner. Begin with a finger tip supported drill if required, potential strength gains and loading should not be affected by limitations in balance and coordination. Always concentrate on full range movement right up onto tip toes and with control. Time under tension is crucial for these muscles.

calf raise straight leg start and finish mike james


calf raise bent leg start and finish mike james
Perform with both straight leg (Gastrocnemius biased) and bent leg (Soleus biased) variations to maximise effect. The key cue is to always move in a vertical direction with the ball of your foot in contact with the floor.

Performing on single leg is an effective progression (straight leg shown only but remember to perform with bent leg also.

single leg calf raise start and finish mike james
Finally, performing both types over a step / stair will allow you to take the heel “below the level of the floor” and increase the range the muscles can work through. An effective strategy for increasing resistance safely is to use a rucksack with weight in it. This will allow you to maintain your hands in a free position should fingertip support be required. These progressions are merely options and do not all necessarily need to be performed to progress. Simply adding load and / or more time under tension (taking longer to perform the repetition) may be appropriate.

step calf raise options finish only mike james
Exercise 4 – Bridge 
Another fantastic posterior chain activity, easily performed at home without the need for expensive, complicated equipment. Begin with the double leg variation. Raise your buttocks/trunk off the floor, aiming to achieve an imaginary straight line running through your knees, hips and shoulders, variations include a very slow and controlled raise/lower or a faster raise and lower with a small pause at the top position.

basic hip bridge start and finish

Key errors to avoid are overarching of the lower back, failure to raise to the top position and holding the breath throughout the movement. Play around with foot positions to bias certain muscle groups more or less than others. Bringing the heels closer will increase Gluteal work, whilst moving them further away will increase hamstring activity – be careful they don’t cramp!

bridge variations finish only mike james

To progress either move onto a single leg variation or add resistance across the pelvis as illustrated below.
The resistance band can also be performed on the single leg variation as required.

Exercise 5 – Step Up
Another great fundamental exercise that demands stability and control throughout the single leg as per the actions required for every stride when running.  Be cautious when selecting the height of the step to be used. Don’t get too ambitious too soon if new to this exercise. Key coaching cues include driving up through the weight bearing foot/leg and maintain control throughout. Many runners perform this exercise based on the momentum generated from the movement and this should be avoided.  Remember the resistance level used shouldn’t compromise the control on the down phase whilst returning to the floor.

step up start and finish mike james

Adding an upper limb movement that replicates a running pattern whilst progressing to a high knee step up variation is an effective technique for runners to develop. Once mastered, adding resistance to the step up (again, a loaded rucksack is often sufficient) can be effective. Other techniques to increase resistance include the following. Give them a go and see which ones you find the most beneficial.

step up options
Exercise 6 – Core
The topic of core strengthening is much debated and controversial. Many exercises such as the plank have been advocated as effective exercises for runners. Personally, I feel core work needs to include two aspects: controlled rotation and an anti-rotation element to encompass the demands of running. Here are two variations that focus on these aspects.

6a. Anti-Rotation via Pallof press 
I find resistance band is perfect for this drill. A resistance band can be found in many high street shops and/or online. It is manufactured in different grades of resistance differentiated by colour.
For this exercise – position yourself so that there is enough tension on the band to make you feel like your trunk wants to rotate towards the band. Whilst resisting the rotation, drive /push your arms forward, this will increase lever length and increase the effort needed to resist rotation towards the band. Perform with the band pulling from both sides of your body. It can be performed in kneeling or standing depending on level of ability. I particularly like the single leg standing variation as a high-level drill, but as with all the exercises, this requires time and patience to master and progress to.

kneeling pallof start and finish mike james

standing pallof start and finish mike james
6b.  Rotations 

For this exercise the intention is to do the exact opposite of the Pallof press. We are aiming to rotate against the band whilst maintaining control throughout. Focus on trying to rotate through the trunk and not by simply turning the hips and pelvis. Again, perform in kneeling, standing or eventually on single leg, progressing only when control is effectively maintained. It is important to maintain control on the return to the start; a common mistake is to use a resistance that is too heavy, and the return phase becomes a recoil as opposed to a controlled movement.
kneeling rotation start and finish mike james

standing rotation start and finish mike james
Hopefully you may find these helpful and effective at improving your running and reducing injury risk. We’re really excited to hear how you get on so please let us know via social media Twitter and/or Facebook

If you have any queries, please seek the assistance and advice of a running specialist via sportsinjuryfix.com

Bottom of trainer

1.Buist I, Bredeweg SW, Bessem B, et al. (2010) Incidence and risk factors of running-related Injuries during preparation for a 4-mile recreational running event. Br J Sports Med.  44(8), 598-604.
2.van Gent R, Siem D, Van Middelkoop M, et al. (2007) Incidence and determinants of lower extremity running injuries in long distance runners: A systematic review. Br J Sports Med. 41(8):469–480.
3.Bredeweg S, Zijlstra S, Bessem B, et al. (2012). The effectiveness of a preconditioning programme on preventing running-related injuries in novice runners: a randomised controlled trial. Br J Sports Med.46:865-870.
4.Lauersen J, et al. (2014). The effectiveness of exercise interventions to prevent sports injuries: a systematic review and meta-analysis of randomised controlled trials. Br J Sports Med.  48:871–877.
5.Blagrove R, Howatson G, Hayes P. (2018) Effects of strength training on the physiological determinants of middle- and long- distance running performance: A systematic review. Sports Med 48:1117-1149.
6.Karp J. (2007) Training characteristics of qualifiers for the U.S. Olympic Marathon Trials. Int J Sports Physiol Perform. 2:72-92.
7.Storen O, Helgerud J, Stoa E. et al (2008) Maximal strength training improves running economy in distance runners. Med Sci Sports Exerc 40:1087-1092.
8.Aagaard P. (2003) Training-induced changes in neural function. Exerc Sport Sci Rev 31(2):61-67.
9.Mikkola J, Rusko H, Nummela A. et al. (2007) Concurrent endurance ad explosive type training improves neuromuscular and anaerobic characteristics in young distance runners. Int J Sports Med 28(7):602-11.
10. Sluijs, E, Kok, G, & van der Zee, J. (1993) Correlates of exercise compliance in physical therapy. Physical Therapy, 73(11), 771-782.

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Lous Gifford and his legacy – 50 top quotes!

Louis Gifford and his legacy


I have for some years now, been reading articles by the legendary physiotherapists Louis Gifford. Some of these quotes are from articles and some from scientific papers. Louis Gifford is one of the lesser known pain experts, but in my opinion he deserves a lot more attention, for the great legacy he leaves behind after his death. His pioneering teaching about pain science and pain management has influenced a generation of physiotherapists and continues to do so.

Louis Gifford was a clinician for over 30 years, and a lecturer and writer about pain and physiotherapy. From the early 1990’s through to 2007 he spent a great deal of time lecturing about pain biology, pain management and treatment. In the late 1990’s and early 2000’s there was a massive pain science revolution in physiotherapy, that Louis was very much involved in.

His book series on pain science called Aches and Pains, are highly recommend, and so are all his articles, and scientific papers. He was also the editor of the “Topical Issues in Pain” (1-5) series, that marked a milestone for the understanding of pain and physiotherapy.

Without further ado, here are 50 quotes from legendary physiotherapists Louis Gifford:

“Pain is multidimensional, and so should management be, that is what we are grappling with and it is not at all easy at present, but it will be before long. Important changes take time to integrate and get right. Things are changing for the better and the physiotherapy profession in this country stands to gain a great deal of respect for the way in which it is taking on this material. Patients and society should also benefit, and as Gordon Waddell (1998) powerfully points out, if medicine can create a low back pain disability epidemic, then it can also reverse it.” Louis Gifford

“If your therapist only does a ‘treatment’ to you and misses out the ‘get it moving/rehab/ graded recovery/functional recovery process – then its my opinion that your therapist is a complete waste of time” Louis Gifford

“Integrating psychological and social issues into practice is not an easy matter for professions that are linked historically to tissue/injury/pathology-based explanations and treatments for all pains. Overcoming a natural antipathy to integrate ‘other’ issues, concepts and explanations is a major step towards effective practice change.” Louis Gifford

“Most of us tend to think of pain as an unpleasant, distressing sensation that originates in traumatized tissues and courses its way along neural pathways to the brain and consciousness. Thus, the amount of pain perceived fits with the amount of damage done and the pain happily recedes in direct relation to the pace of healing.

The problem is that our clinics and departments are full of patients who have ongoing pain with no clear trauma or disease process, or who have suffered trauma but the pain continues on long after a reasonable healing period.” Louis Gifford

“A significant problem for physiotherapy is that it is by nature a physical therapy, and that while the inclusion of psychological and sociological factors are acknowledged in training, many see them as being outside the remit of our profession or of relevance only in some complex chronic pain states. Because increasing research into low back pain demonstrates that outcome is determined by psychosocial factors as much or more than by physical factors, this omission can no longer be justified” Louis Gifford

“It is also about our relationships with our patients, and their’s with their pain and their families. With changes in practice there is a necessary extension of traditional thinking into new territories and new skills to be taken on. We need to encourage those who are involved in the early treatment and management of pain to take on new information and new assessment and treatment approaches; the burden of responsibility for chronic pain prevention is with them.” Louis Gifford

“The biopsychosocial model proposed by Waddell (1987) draws attention to the impact of the patient’s response to their situation, and the impact of their work and social environment, as well as the impact of any tissue abnormality, the pain, and relevant biomedical factors on their progression through the problem and eventual outcome. Psychosocial factors are now acknowledged to predict low back pain outcome far better than do the available physical and biomedical findings” Louis Gifford

“Shifting therapist and patient thinking, from a largely unidimensional biomedical model based approach, to incorporating a multifaceted and multidimensional model, is the great philosophical and practical challenge confronting clinicians.”  Louis Gifford

“Pain is distressing and high levels of distress do not help recovery, are likely to maintain tissue unhealthy behaviors, and may ultimately play a part in maintaining a low or weak physiological profile that inhibits reasonable recovery and normal coping mechanisms. The science of psychoneuroimmunology testifies to the importance of psychological well-being to recovery and fitness of the immune system, for example” Louis Gifford

“Physiotherapists must confront the problem of ‘if you look you will find’ when assessing tissues in on-going pain states. This means that clinicians will always find something wrong in the tissues, but it may not be relevant to the patient’s problem and focusing on it may divorce the patient from the full extent of the problem.” Louis Gifford

“Without doubt, ongoing unrelenting pain that escapes an adequate explanation and diagnosis and whose legitimacy is challenged is distressing, disabling and the cause of much suffering. The mature literature on chronic pain states, powerfully avoids using psychological status as a tool to use in order to blame the patient for their condition. However, psychological status and health beliefs strongly contribute to the level of physical disability” Louis Gifford

“Patients in chronic pain states also suffer from an excessive pain ampli®cation response and spread of pain to physical movements/activities and testing procedures. The pain response often increases with repetitions of a movement or test (the windup phenomenon) and it often continues for many hours or days afterwards.” Louis Gifford

“Acute adaptive pain signals threat. Its major purpose, in parallel with the biologically linked emotional reactions like fear and anger, is to motivate and bring about an alteration in our behaviour in order to further our chances of recovery and survival” Louis Gifford

“The weakness of the tissue based model for diagnosing and treating on-going pain has been highlighted because there is powerful evidence that it does not help and that it may actually be making matters worse”  Louis Gifford

“Recent revelations about the capacity of axons to become pathophysiologically sensitised and active self-generators of impulses, goes a long way to help explain the way in which pain behaves clinically. Injured or degenerate/regenerating axons within nerve trunks or nerve roots can become sites demonstrating enhanced sensitivity as well as sources of ongoing and self-sustaining barrages of impulses that have the potential to cause long lasting and high intensity pains” Louis Gifford

“It is not surprising that in our attempts to help our patients, legitimise their pain and find something for them, that we have plunged into greater and greater depths of skilled tissue testing and focused analyses of the behaviour of pain. A fundamental reasoning error may be made by labelling a tissue as faulty on the basis that passive manual testing can reproduce the patient’s pain. The reasoning error is to assume that a sensitive tissue evoking pain on mechanical testing is responsible for the pain rather than a reflection of the sensitised state of the nervous system.

The strength of the tissue basis of pain construct can be further reinforced by the application of apparently successful techniques and interven- tions to the ‘blameworthy’tissues. For example, successfully relieving pain by mobilising, manip- ulating or injecting the cervical zygapophyseal joints of a patient who complains of neck and arm pains can be seen as validating the targeted joint as being the source of the problem. This logical application of reasoning unfortunately omits a broad understanding of the effects of factors” Louis Gifford

“Physiotherapists are pulling ahead and some, are way ahead. These are those who base their day to day work practices around a multidimensional and biopsychosocial model of pain. Those who read, understand, feel at ease with and implement the kind of material found in the Topical Issues in Pain series! No arguments, no political manoeuvring, no in-fighting, but sound and well reasoned agreement around a very sound model secured by outstanding and continually growing scientific support – it’s powerful, it fits, it works – but will it endure?” Louis Gifford

“Clinicians involved in the diagnosis and management of all benign pain states have two major problems. First, evidence of pathological changes in tissues underlying the painful area and in tissues which can refer pain to the area is often lacking. Secondly, there is a large body of evidence demonstrating tissue pathology in the absence of pain”  Louis Gifford

“Unfortunately physiotherapists have rarely questioned this paradox and have persevered with highly skilled physical tissue analyses aimed at validating the tissues and peripheral nerve trunks and roots as definitive sources of ongoing pain in the great majority of patient presentations. This is hardly surprising, considering that the only alternative status for on-going pain states that medicine cannot fit within a tissue abnormality/disease based construct, is the unsavoury and unproductive ‘psychogenic pain’ label. So often the implied message for the patient is that if nothing can be found, nothing can be wrong and the patient is therefore to blame” Louis Gifford

“The powerful links between the neuroendocrine and sympathetic systems and the immune system are also well recognised. The important clinical implication is that if we can positively change the way people feel emotionally, by for instance changing their knowledge and beliefs about their problems or situations, we can beneficially change activity in the output systems”  Louis Gifford

“Even though tissue damage and subsequent nociceptor activity can be seen as a dominant mechanism in acute pain it should be appreciated that psycho- social factors have a powerful role in determining and modifying the implicit physiological outputs and explicit behavioural patterns that are such an important part in recovery.

In the chronic pain situation, similar sampling- scrutinising-output analysis applies, it is just that the pathobiological pain mechanism focus shifts from the tissue and nociceptor mechanisms in the periphery to focus more on maladaptive and widespread reactivity and sensitivity of the whole sampling-scrutinising-output systems.” Louis Gifford

“Evolution of practice is unstoppable; there are always changes going on and there always will be. New material is often integrated inappropriately, and occasionally dangerously, and failures will always occur, especially in the untrained and unwise. Good therapy and management skills endure, like good inventions. Some changes are for the better, some are not, and many are fads that come and go.

It is the same in medicine as it is in physiotherapy. Fads are based on beliefs, anecdote and charismatic individuals. We have all been seduced. As followers we tend to believe that revered and published therapists are highly effective with all patients. Yet when we try to emulate them we often struggle and get frustrated. I do not know of any outcome studies with long-term follow-up using multiple measures that have included a ‘guru’ in the therapist population.” Louis Gifford

“I have always believed that every patient who goes to see their doctor wants to know the following:

  • – Doctor, what’s wrong with me?
  • – Doctor, how long is it going to take to get better?
  • – Doctor, is there anything that I can do to help it get better?
  • – Doctor, is there anything that you can do or give me to help it?

The order of importance to each individual may alter slightly, but for most, a reassuring answer to the first question is always somewhere near the top. Implicit here is a simple desire to know whether there is something seriously wrong. It is often the most important starting point for a successful treatment outcome.

Perhaps clinicians need to think about this more, because without a thorough understanding and without reassurance, the patient’s progress is likely to be hampered by feelings of uncertainty and insecurity.” Louis Gifford

“The therapist can then use the knowledge to provide the patient with a well-reasoned explanation. For example, where maladaptive central mechanisms are operating, the pain is likely to be mysterious and worrying, and often been given inadequate explanations from previous medical encounters. These patients are often grateful to receive a well-supported and rational explanation for their pain. An explanation that reconceptualizes the problem away from the notion of tissue weakness and harm is often the point from which patients start to be able to move on towards a productive recover}” pathway.”  Louis Gifford

“Physiotherapy is attempting to move away from a largely inefficient unidimensional focus on pain relief pain response towards function and normal movement in parallel with appropriate pain relief modalities, medications, and pain management. Movement undertaken with fear and trepidation is likely to result in a great deal of tension or guarding as well as increased attention to pain. Conversely, appropriately guided goal-oriented movement, in which the patient feels in control, is approached in the context of no or little fear can provide a wonderful starting point and focus for recovery. This takes a great deal of skill and the integration of cognitive-behavioural principles.”  Louis Gifford

“Integration takes time, mistakes are made and those critics who seem unwilling to learn, listen and change in the face of the growing body of sound findings are likely to be in a minority in the future.” Louis Gifford

“At last year’s CSP Annual Congress, Nick Kendall, one of the primary authors of the yellow flag assessment tool, indicated that those unwilling to change may well be forced to do so, and that peer pressure may be the key factor in seeing to it. This sounds like bullying, but like it or not, the pressures are on. Do not moan about them, get out and find out more — but be careful who you listen to before you make your judgements.” Louis Gifford

“The overwhelming message coming from respected researchers, clinicians and writers on the way forward with ‘pain’ is for patient empowerment via education and active rehabilitation of function rather than over-reliance on passive therapies”  Louis Gifford

“The literature also recommends that this approach should be augmented with the recognition, assessment and adequate therapeutic focus on psychosocial factors that have been repeatedly shown to have great predictive value for chronicity and therapeutic outcome”  Louis Gifford

“To identify patients who are at risk of developing chronic pain and associated disability problems, physiotherapists are being encouraged to actively screen for, identify, and then appropriately manage relevant psychosocial components” Louis Gifford

“I believe that physiotherapists in outpatient settings are working in one of the most difficult and most stressful areas in medicine – musculoskeletal pain and particularly chronic pain and disability. Day in and day out well-meaning physiotherapists do their utmost to try and help incredibly complex pain problems. Pain patients cause many physiotherapists to burn out — we often blame ourselves for the failure, and patient overload with severe time constraints is a big problem.” Louis Gifford

“Education about pain that includes the modification of commonly held ‘abnormal structure/ mechanics’ related beliefs about pain is seen as vital to successful rehabilitation and outcome. On-going pain states are best explained to patients in terms of an altered sensitivity state as a result of altered information processing throughout the system, and not solely a result of damaged and degenerating tissues. This helps patients accept the notion that hurt does not necessarily equate with harm – which leads on to the positive message that carefully graded increases in physical activity mean stronger and healthier tissues. This is reinforced when patients achieve improved physical function. By contrast, continued focus on a tissue as the pain source reinforces fear of movement and activity, the need to be constantly vigilant for pain and the desire for increasingly expensive passive therapeutic interventions that are yet to demonstrate convincing efficacy.”  Louis Gifford

“Patients with intense acute nerve root pains rarely find consistent positions of relief and if they do it is only for a brief period of time. A key feature is that the patient becomes physically restless with the pain and greatly appreciates an understanding of this problem. ‘The doctor told me to take paracetomol and lie down and rest for 10 days’. . . ‘The last physiotherapist insisted I sat up straight and kept my neck in perfect posture. I’m sorry I just can’t keep it up, at first its better for a short time then I have to move and get relief by bending my neck forward’ – are frequent comments from patients.” Louis Gifford

“Graded exposure tackles activities and physical tasks that are feared and/or avoided because of pain or the belief that they will cause further pain and damage. The process helps the patient to restore physical confidence via agreed graded progressions and pathways. For example, a patient with back pain who fears bending may agree with confidence to begin gentle pelvic rocking or flexing exercises lying and progress to bending while sitting before making attempts standing. As confidence and skills are improved, the later stages may include increased loading and more functional tasks, as well as performing the tasks faster.”  Louis Gifford

“The clinical significance of this is that many tissues that produce pain when physically tested by manual techniques using physiological movements, static muscle tests or palpatory pressures may be relatively normal. Thus, the central consequences of tissue/ peripheral nerve injury may easily result in ‘false’ positive findings in examined peripheral muscles, nerves, joints, skin and any other soft tissues in areas segmentally related to the nerve, and in extreme/severe cases, tissues well beyond normal segmental limits.” Louis Gifford

“Pain science is now amassing experimental evidence to support the organic basis of chronic pain, regardless of whether signs of physical impairment are thought to fit or not fit with the `evident’ tissue injury. While the original lesions for a whiplash patient may be in the tissues of the neck, the legacy and the central focus of ongoing pain pathobiology in the literature, is on altered central nervous system excitability and altered central nervous system processing of normal inputs” Louis Gifford

“Thus, the mechanisms that produce the pain change and move with time – and for those that develop marked and severe chronic pain states the pain is said to be `maladaptive’ in nature. This means that it serves no productive purpose in protecting the tissues concerned, which have long since done their best to heal anyway. Its most powerful impact is on the life and happiness of the patient ± causing much distress, loss of physical confidence, loss of self-esteem, often powerful feelings of guilt and a sense of hopelessness and despair. Many chronic pain patients become clinically depressed, or demonstrate signs of clinical depression” Louis Gifford

“It should be clear from the above discussion that past injuries and past pain states predispose the individual to vulnerability to future problems. This needs to be looked at in two ways. Firstly, if previous injuries have occurred, tissue weaknesses are likely to remain and degeneration has the potential to be faster than normal ± the tissues themselves are therefore vulnerable. Secondly, long-term neural sensitivity changes or `memory’ throughout the whole nervous system, may remain after the recovery of an injury. As such this means that further injury may easily re-kindle past neural representations and past neural activity of pain and symptoms related to the same, or closely related, tissues.” Louis Gifford

“In other words, if the pain and posture are adaptive, what right do we have to get rid of them?  have to get rid of them?  If we do deem such a posture and pain to be adaptive, evolutionary reasoning would predict that too early a resolution of the pain, or too rapid a correction of the posture might not be a good thing, may prolong recovery and lead to more episodes later on. This is a very useful type of research question that is challenging to several physiotherapy method – and which needs answering. Clearly, whenever we examine a patient it is important to reason whether what we observe can be viewed as adaptive, maladaptive, or an imperfection/defect.” Louis Gifford

“The biomedical, or ‘disease’ model of pain is a single level construct which may be fine where a problem’s cause can be established and which has a remedy available for it. The biomedical model assumes that an individual’s complaints should result from a specific disease state represented by a focus of disordered biology, the diagnosis of which is confirmed by data from objective tests of physical damage and impairment.” Louis Gifford

“Intervention is directed specifically toward correcting the organic dysfunction or the pathology and if this doesn’t work the patient, rather than our inadequate understanding, is frequently blamed. Thus, the traditional medical approach adopts a simple dichotomous view: symptoms are either somatogenic (real and potentially fixable) or psychogenic (not real and hence of little or no interest).  Although variations of this view still pervade, supporting evidence is lacking. If we really want to explain and understand pain, pain disability and pain response and prevent them from continuing to be major health care problems, we need to adopt a much more open minded multidimensional approach. We need new broader based models to help us understand chronic pain and incapacity and its development. This is what many in the vanguard of pain management and disability prevention are suggesting.” Louis Gifford

“Waddell’s writing is pithy, smart, and makes intuitive sense. The messages are sound, evidence based, clear, and easy to follow. Like many others, he argues that the biomedical approach to back pain has not solved the problem and may even be adding to it via inappropriate intervention. He advocates passionately that we should all adopt a biopsychosocial framework. “ Louis Gifford

“The physiotherapy and medical professions involved in pain diagnosis and management are facing major challenges.  These are exciting times that should reap the rewards of the mature and well controlled research that is now available.  Our professional profile can only benefit if we start to show that we are acting on the knowledge and messages coming from this high quality work.  In a very timely editorial to the journal ‘Pain’ Steven Linton (1998) persuasively argues the case for the instigation of early preventative programmes in the management of acute low back pain: …..“we found that a secondary prevention program in primary care, for first time sufferers, significantly reduced disability and reduced the risk of becoming chronic by 8-fold as compared to ‘treatment as usual’. “ Louis Gifford

“The sensation of acute pain is the conscious signal of a physical threat whose major purpose, in parallel with producing the biologically linked emotional reaction of fear and/or anger, is to motivate and bring about an alteration in our behaviour in order to further our chances of recovery and survival”  Louis Gifford

“Most therapeutic approaches usually consider pain in a single sensory dimension i.e., the perception of where the pain is located, the quality and type of pain, its intensity and the way it behaves over time. However, pain has been considered in terms of three dimensions for quite along time i.e., the sensory dimension as described; the cognitive dimension, which recognises that pain alters our thoughts; and the affective dimension recognising that for every pain we have there is some kind of emotional reaction.”  Louis Gifford

“The following two examples demonstrate how basic science developments have’ changed and directed thinking and practice in physiotherapy. First, knowledge that changes within the central nervous system can contribute to pain states. These central changes may amplify modest incoming nociceptor traffic, and can modulate sensory impulse traffic from normal tissues so that it leads to pain. Even more malignly, it may itself generate nociceptive impulse traffic. Clearly, these central changes have implications for treatment. Traditionally, a flaring pain response was linked to worsening of the tissues, whereas ‘ in fact it may simply reflect maladaptive central sensory processing.

A second research finding to have great impact for physiotherapy is that some of the central changes share a similar biology to synaptic events associated with memory, involving early short- and later long- term potentiation. One implication is that, once established, these central changes may become permanent, just as a long-term memory becomes fixed”  Louis Gifford

“‘Biopsychosocial’ is one of the latest physiotherapy buzz words. Along with ‘EBM’(‘evidence based practice), it is being perceived as threatening to our established and much loved methods and practices. This is unfortunate, because change and challenges in practice are some of the things that makes physiotherapy so exciting. Therapists and therapies need to evolve in parallel with new knowledge and rapidly changing values and culture. The position held here is that integrating the biopsychosocial model into our practice will actually empower some of our practices and methods if we interpret it and use it in the right way.”  Louis Gifford

“The source of a patient’s pain changes over time. This is fundamental to enhancing the general understanding and confidence about pain and its meaning. For the long term pain sufferer it is a great help to start to appreciate that hurt does not equate with harm, and that there is such a thing as maladaptive pain.  The longer pain goes on the more widespread and diffuse become its sources – hence the problems with therapy approaches that over-focus on finding a specific ‘source’ of pain, this is fine for fixing a car but not for fixing complex human pain states. “ Louis Gifford

“When tissues are injured the nociceptive cells innervating that tissue begin to increase their sensitivity and start to fire more easily, some may even fire spontaneously. Increased sensitivity and spontaneous firing is a product of the availability of active ion channels and receptors and their relative numbers”  Louis Gifford

“They may have a point, but the complexity of factors that play a role in precipitating chronic pain and chronic disability are such that some at risk patients require thoughtful and time consuming assessment and management in the early days of their problem. This is the key time. Linton’s (1998, 1999) work, has shown that identifying and addressing the known risk factors in early management of back pain can reduce chronic disability by 8 fold over ‘treatment as usual’. The interventions Linton (1998) used involved understanding and dealing with the anxieties and fears patients have about causing pain and causing structural damage with movement and activity, plus other psychosocial issues” Louis Gifford


Article taken from:

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Tendinopathy – Rehab Progression

So I have linked to a very interested blog post on the topic of tendinopathy rehab.

This article is quite technical, so a good knowledge of anatomy and physiology will help! But a lot of the runners out there may find it an interesting read!

Please follow the link below to access the post:

Tendinopathy – rehab progression – part 1


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Foam Rolling Science

Foam Rolling

Foam Rolling

A great infographic from Yann Le Meur looking at the evidence behind Foam Rolling.

Have a quick read and learn how to best utilise foam rolling in your program!

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Nocturnal Cramping: What is it? Who Gets it? And How To Get Rid of it?

Nocturnal Cramping.

One question that I often get asked by my clients at my sports massage clinic is, ‘Why do I keep getting cramps at night?’

Nocturnal leg cramps are pains that people experience at night. They are most frequently experienced in the calves but may also occur in the feet or thighs. Many people often wake up in a state of cramp with the sensation of their muscles contracting and ‘knotting’.

An episode of cramps can last anywhere from a few seconds up to a few minutes. Due to the intense level of muscle contraction involved, nocturnal cramping can leave muscular soreness in the affected area for several days after the event.

The people who tend to experience more common bouts of cramping are the over 50’s, but younger people will also experience it at various times.
Nocturnal Cramps

What Causes Nocturnal Cramping.

There are many theories on what may cause the cramping.

The NHS states that cramping can sometimes be caused by the following:
– Ageing
– Exercise
– Pregnancy
– Not drinking enough fluids
– Liver Disease
– Medication to lower cholesterol, or high blood pressure

Other possible causes include:
– Alcoholism
– Parkinson’s Disease
– Neuromuscular Disorders
– Arthritis
– Respiratory Disease

Some researchers have theorised that our modern day lifestyle may contribute to cramping. They link the enhanced tissue health from the time our ancestors spent resting in the squat position (stretching & strengthening the soft tissues), to the modern day where our need to squat has all but been removed.

It has also been theorised that when we lay in bed, our feet are generally kept in a ‘plantar-flexed’ position. This meaning that our toes are pointed. In this position the tissues of the calf are in a shortened state. After being in this shortened position for long periods of time, even a slight movement could trigger cramping.

There is some evidence, the strength of which is questionable, that Magnesium and Calcium deficiencies play a part in these cramps. There is also research to show that people who stand up for long periods of time during the day are more likely to suffer than those who do not.


How Can Nocturnal Cramps be Prevented?

There is some evidence that stretching before bedtime, targeting the hamstrings and calves, could reduce the frequency of cramps by nearly 60%. However, there are also studies which show no correlation!

Increasing the intake of magnesium may have positive effects, as many people do not consume adequate amounts within their diet.

Consuming a larger intake of liquid throughout they day may also be beneficial. The standard recommended amount of water to consume per day is 2 litres. Although, I am not sure how much of that advice is solid evidence based. Either way, as long as you drink when you are thirsty, maintain a pale, straw like urine colour and increase your fluid intake when physically active, you will be fine!

In essence – there is no rock solid reliable approach to getting rid of nocturnal cramps as it is not fully understood yet exactly what may be causing them. So, the best approach would be somewhat trail and error. Making changes based on what could potentially work and seeing how the body responds.
Cramp Massage

If cramping has been experienced then stretching and sports massage therapy can be very effective in reducing the muscular soreness experienced. I treat many people at my Nottingham sports massage clinic who have experienced bad cramps and the combination of soft tissue massage, advanced stretching techniques and dry needling can be very effective.

Thanks for reading,

https://jamanetwork.com/journals/jama/article-abstract/372582?redirect=true http://cochranelibrary-wiley.com/doi/10.1002/14651858.CD009402/full https://www.ncbi.nlm.nih.gov/pubmed/21846281 https://www.sciencedirect.com/science/article/pii/S1836955312700681

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