What's in a diagnosis?

Recently, a medical student asked me if he diagnoses a patient with rotator cuff tendinopathy, can I recommend a youtube video of exercises that he could then recommend to his patient.  We had a lengthy discussion about this.  As his question and, in general, this type of a question comes up frequently in our everyday practice as physiotherapists, I thought it would be worth exploring this.

Here are some examples of the type of questions we encounter:

“I have sciatica...do you treat sciatica?” 

“My friend/aunt/cousin/neighbour also had disc problems/tennis elbow etc and they improved faster/slower than me...why is that?”

“What do you do for a rotator cuff tear?”

A very quick but thoroughly unsatisfactory answer to these questions is that “it depends”.  Yes, people hate to hear it and we hate to say it. 

In the medical world a diagnosis can be very specific.  In a few words, the physician can describe the exact cause of the problem (especially with infections) and they can prescribe the right medication for that specific issue. 

In a lot of the cases physiotherapists would see,  a diagnosis is just basically naming the area that hurts.  So if you have rotator cuff tendinopathy, it basically means that one or more of your rotator cuff tendons is inflamed/irritated.  That is important information.  We can treat that in all sorts of ways to decrease the inflammation.

However, the more important question is why did it become irritated in the first place?  Some people end up with rotator cuff tendinopathy simply because of overuse of those tendons.  In that case, just decreasing the inflammation will often do the trick.  However, that’s not the only reason to have rotator cuff problems.  It is possible that due to poor posture you have had changes in the mechanics of your shoulder.  That is, your entire shoulder is moving in a different, non optimal way.  If we just treat your tendons to decrease the inflammation, but not work on all the other issues, you will have rotator cuff tendon problems over and over again. 

The same reasoning applies for sciatica.  Do you have sciatica because your nerve root is pinched at the spine due to degenerative changes or because one of your muscles along the path of the nerve is compressing it, causing irritation? 

Just like there are a thousand reasons why your car may be making that “clicking” sound, there can also be many different reasons for your leg pain.

This is why your situation will be different from another person’s sciatica or tennis elbow or rotator cuff strain.  This is why I would not generally recommend a youtube video of exercises for everyone with rotator cuff tendinopathy.

And...this is why if you ask a physiotherapist about your “pain”, the only way that he/she can give you a satisfactory answer is after a thorough history taking and physical examination.



How to Choose the Right Physio for You

In a recent seminar with medical students, they asked me how to find “good” physios for their patients.  This is an important question not just for future GP’s but for everyone looking to find that “perfect fit” for their rehabilitation needs.

Here are a few suggestions:

Step 1: Ask your doctor

If your GP has been practicing in the area for a while, he/she will have had experience with the different physio clinics and physios in the area.  Even with your GP’s recommendation, ask why this particular clinic or physio comes highly recommended. 

Step 2. Ask your friends/co-workers/neighbors/personal trainer/dog walker....

You will want to attend a clinic that is conveniently located either close to work or home.  There are many reasons for this:

1. You will be more likely to attend regularly and get the most out of your treatment sessions if you don’t have to drive an hour out of your way.

2. A local physio will be able to direct you to local resources whether it’s a program at your local pool or a suitable beginner’s running route in your neighbourhood or another experienced professional such as a personal trainer or orthotist.

Your neighbors or co-workers may have already tried a clinic “just down the street” and could give you a recommendation but again, ask why they liked their experience.

Step 3: Association Website

If you still haven’t found what you are looking for, check out the provincial association’s website.  In BC, that’s the Physiotherapy Association of BC (PABC) and their website is www.bcphysio.org They have a “Find a physio” section where you can look for physios by location, specialization or even what language(s) they speak. 

Step 4 : Do your research

Once you’ve narrowed down your search, check out the clinics’ websites.  This is an easy and quick way to find out about their rates and hours.  You can also learn about the physios’ backgrounds and credentials.  They may have more detailed information on their website about what you can expect during your visit or how long you can expect to spend with your physio.  This is actually an important but overlooked piece of information.  When you look at rates, you may find that different clinics charge different rates for their appointments.  Why is this?  Well, maybe it’s because of the varying levels of experience and credentials of the physios but it could also be that the physios at the clinic with the higher fees will spend more one on one time with you during your visit.  If this is important to you, you won’t mind paying a little extra. Like with everything “you get what you pay for”. 

Step 5: Do more research

If you don’t get all your answers from the website, call the clinic.  The receptionists will be able to answer your questions.  If you have a clinical question and you are wondering whether physiotherapy treatment would help, you can, most of the time, contact the physio directly via email.  Please remember, physios, just like doctors, are not going to diagnose you or give you exercises over the phone or email.  They need to assess you and prescribe the right treatment and exercises that are specific to your particular issue.  They cannot do this without assessing you in person but if you just want confirmation that physiotherapy is the appropriate treatment for your condition prior to booking, email is a good way to make contact.

Some other things to consider:

Treatment approach:

Two physiotherapists could have similar credentials and yet have different treatment approaches.  Some therapists will focus on manual therapy and some more on active rehabilitation.  At some clinics you may spend up to an hour doing exercises in addition to the one on one time with the physio while at others you will be given the exercises to perform on your own time.  It isn’t that one is wrong and one is right but it has to be right for you.  If you can’t spend a few hours at the clinic every time you go but you know that you will take the time during your day to do your exercises then you may be happy to just be instructed in what you need to do on your own.  It is important that the physiotherapist discusses their approach with you at your first session so that you understand what to expect and you can ask about options on how you and your physiotherapist can best work together.


We are all different and your 20 year old nephew may love his physio but that physio’s personality or approach may not be the right one for you.  Again, looking at the bios on the website may help you with this.  You may find that you have something in common with your physio (e.g. you are both runners or cyclists) that will help him/her understand your physical goals.  Or knowing that this person has worked with the elderly will give you more confidence that he/she will be able to help your mom with her arthritic knee.

Clinic Space:

Some clinics are set up with an open concept.  There are treatment beds in a row and a big gym space with little privacy.  This set up works very well for some, especially in athletic therapy.  However, if you are coming in because you have stiffness in your arm after a mastectomy, you will more likely prefer a space that’s more private so you can discuss your medical history.  A clinic that has private, separate cubicles may be more suitable in that case. 

Choosing the right practitioner is a very personal process.  Hope these few points will be able to help guide you in the right direction.


Tips for an injury free spring

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Apres ski yoga poses

This has been a phenomenal ski season here on the West Coast, especially after the disappointment of last winter.  Judging by the line ups and stories of parking issues on the news, there are definitely more of us spending time on the mountains.  Many of Whistler's yoga studios offer apres ski yoga sessions to stretch out our sore muscles after a day of skiing.  However, if you don't have time for a whole yoga class, here are my 5 favourite poses after a day on the slopes.  

I have written this for those who already have some basic knowledge of yoga poses and therefore have not spent much time describing each pose.  I feel that those who have not done yoga with an instructor before should spend some time in a class with a teacher learning to understand how take the shape of basic yoga poses safely for their own bodies.

First off, to understand why these poses work so well, you have to think about the position your body is in while skiing.  Most of the time you are skiing, the major joints of your body (hips, knees, ankles even shoulders) are all flexed to maintain the ski stance.  The following poses help lengthen the muscles that have to work hard to keep you in that position all day long:

1. Low lunge (Anjaneyasana)

This pose helps open the front of the hips to stretch the hip flexors as well as allowing you to gently extend your low back.  Make sure you add padding under your back knee if your kneecap is sensitive to pressure and don't let your front knee push over your toes.  You can get a great stretch from this with your hands on your hips or overhead.  You can add a chest opener by clasping your hands behind you and rolling your shoulders back but be careful that this does not cause too much extension in the low back.  Hold for 5-8 breaths and repeat on the other side.

2. Reverse Triangle (Trikonasana)

This is a beautiful and powerful pose that allows you to stretch your hamstrings and open your side body.  With your front foot facing forwards, take a long step back and rotate your foot out to 45 degrees with the heels aligned just like in Warrior 2 pose.  Your hips should open to the side.  Allow your back hand to gently slide down your back thigh as you reach your front hand up and back.  Hold for 5-8 breaths and repeat on the other side.

3. Cobra (Bhujangasana)

This pose offers a nice, gentle back extension and chest opening.  Lie on your tummy and stretch your legs back about hip width apart.  Firm your legs, engage your abdominals slightly and press your pubic bone into the mat as you use your hands right underneath your shoulders to pull your upper body forwards and up.  Make sure you don't extend too much in your neck.  Hold for 3-8 breaths depending on how comfortable you are in backbends.  

If you like backbends and can tolerate a bit more intensity, bow pose (dhanurasana) will essentially place you in the exact opposite shape you take while skiing thereby stretching most of the muscles you used repetitively over the course of the day.

Start on your tummy with your legs stretches behind you and your arms along your torso.  Bend both knees and bring your heels as close as you can to your buttocks.  Reach back with your hands and clasp your ankles.  As you inhale, start straightening the knees and this will lift your head and chest off the ground.  Remember not to extend your neck too much and pay attention to how far your low back will allow you to take this pose.  Hold 3-5 breaths.

And now the "aaahh" poses:

4. Reclined Twist

This is a twist that feels amazing on your low back, legs and shoulders.  On your back, bend your knees and place your feet on the mat.  Take your arms out into a T shape.  Push into your feet and lift and place your hips slightly to the right.  Engage your core muscles and lift your legs and gently lower them to the left.  Legs can be bent or straight depending on the amount of stretch you need.  You can also use a bolster or a folded blanket if your legs can't quite reach the ground.  Once you've found the most comfortable position for your lower body and if you have the range in your neck, turn your head to the right.  Hold for 8 breaths and repeat on the other side.

5. Supine chest opener with bound angle

This pose is often used in Yin and restorative classes as it is very soothing and allows the body to take a shape that is quite opposite from the flexed positions we are in most of the day.  This pose extends the low back, opens the chest and externally rotates the hips.  Note that the hips and sacrum are not on the bolster and this may cause too much extension in the low back for some people.  If you need extra support, use a folded up blanket/towel under your sacrum.  Hold for 8-10 breaths.

These poses are quite easy to do anywhere within 15 minutes depending on how long you hold them for.  I hope that, like me, you will find them relieving and relaxing after a day on the slopes.

Post Run Yoga Sequence

Happy New Year everyone!  It's the time of year when people are starting to run again after the holidays or maybe are starting to run for the very first time.  Either way, I wanted to offer you a short (13min) yoga sequence that will target the large muscle groups you use when running and will keep you limber as you increase your miles.

A few things to keep in mind:

1. This is a sequence meant to be done right after your run and therefore it is assumed that your body is already warmed up.  Do not do this sequence without a proper warm up.

2. Do not push into positions that cause sharp pain or strain.  All these poses are meant to give you a pleasant stretch.  If that's not the case, please modify the position to make it more gentle.

3. I'll remind you on the video but you will find this more enjoyable if you keep breathing:)  You don't have to follow my instructions to breathe in or out with a certain movement but at least keep a gentle breath and avoid holding your breath.


The Paradox of Our time

This essay was first published in 1995 in a collection of works by Dr. Bob Moorehead.  Written over 20 years ago, it is, unfortunately, even more true today than ever.

" The paradox of our time in history is that we have taller buildings but shorter tempers, wider Freeways, but narrower viewpoints. We spend more, but have less, we buy more, but enjoy less. We have bigger houses and smaller families, more conveniences, but less time. We have more degrees but less sense, more knowledge, but less judgment, more experts, yet more problems, more medicine, but less wellness. 

We drink too much, smoke too much, spend too recklessly, laugh too little, drive too fast, get too angry, stay up too late, get up too tired, read too little, watch TV too much, and pray too seldom. 

We have multiplied our possessions, but reduced our values. We talk too much, love too seldom, and hate too often.

We've learned how to make a living, but not a life. We've added years to life not life to years. We've been all the way to the moon and back, but have trouble crossing the street to meet a new neighbor. We conquered outer space but not inner space. We've done larger things, but not better things. 

We've cleaned up the air, but polluted the soul. We've conquered the atom, but not our prejudice. We write more, but learn less. We plan more, but accomplish less. We've learned to rush, but not to wait. We build more computers to hold more information, to produce more copies than ever, but we communicate less and less.

These are the times of fast foods and slow digestion, big men and small character, steep profits and shallow relationships. These are the days of two incomes but more divorce, fancier houses, but broken homes. These are days of quick trips, disposable diapers, throwaway morality, one night stands, overweight bodies, and pills that do everything from cheer, to quiet, to kill. It is a time when there is much in the showroom window and nothing in the stockroom. A time when technology can bring this letter to you, and a time when you can choose either to share this insight, or to just hit delete. 

Remember to spend some time with your loved ones, because they are not going to be around forever.

Remember, say a kind word to someone who looks up to you in awe, because that little person soon will grow up and leave your side. 

Remember, to give a warm hug to the one next to you, because that is the only treasure you can give with your heart and it doesn't cost a cent.

Remember, to say, 'I love you' to your partner and your loved ones, but most of all mean it. A kiss and an embrace will mend hurt when it comes from deep inside of you. 

Remember to hold hands and cherish the moment for someday that person will not be there again.

Give time to love, give time to speak! And give time to share the precious thoughts in your mind.

And always remember, life is not measured by the number of breaths we take, but by those moments that take our breath away."


Meditation for kids

I know what you are thinking...kids always seem to be running around and to even imagine them sitting still and quiet by choice is next to impossible.  However, we seem to be hearing more about stress and anxiety disorders in children.  Is it really more prevalent or just more recognized and diagnosed?  The jury is out on that question.  What does seem to be a fact is that our lives are increasingly hectic and busy.  And so are our kids' lives.  We all need to slow down and maybe introducing meditation to our children could have far reaching benefits for their well being and their future as well adjusted adults.  

Here are a few tips to get started:

1. "Be the change you want to see in the world" - if you meditate, the kids will be curious to try and will want to join you.  

2. Start short - some experts recommend 1 min of meditation per year of age to start.

3. Try guided meditation first - meditation can be very challenging at first and is much easier and more fun for the little ones to be able to listen to guided sessions.

4. Add breathing exercises - if you are familiar with ujayii breath, alternate nostril breathing or belly breathing from yoga, introduce the kids to these breathing exercises.  They are fun and very relaxing.

Here's a list of websites and apps to help get started:

Annaka Harris

Christiane Kerr  

Sleep App by Chrstiane Kerr

Sitting still (An app for teens)

Running in the heat

Get out the kiddie pools and umbrellas!  Summer has definitely arrived in Vancouver.  We have had a couple of glorious weeks and everyone is in a better mood for it.  I have to admit, although I do enjoy the sunshine, the heat has sure slowed my running down.  Here are a few tips to keep cool while running during the summer months.

  1. Head out earlier or later.  It's not pleasant having to get up at 5:30 to get your run in but you will feel better afterwards.  And you will definitely be thankful that you did when you are boiling just walking down the street in the middle of the day and couldn't even fathom doing anything strenuous.
  2. Wear light coloured, water wicking clothing.  Dark colours will absorb heat.
  3. Run in the shade.  Change your route so you run on the trails in the parks rather than on exposed streets.  
  4. Keep hydrated.  Drink before and after your run but unless you are going for a longer than 60min run, you probably don't need to take water with you.  There has been a lot of research debunking the myths that lead us to over drink during running and activities in the last decade (see Waterlogged by Dr. Tim Noakes)  Personally, I never carry water with me unless I am running over 12K in the summer.  Even then, I would rather  plan my route so that I go by some water fountains than carry a water bottle.  
  5. Adjust your expectations.  Allow your effort to determine your pace.  You may just not be able to go as hard or as fast as you would in cooler temperatures.

Sometimes, running will just not happen for me in heat like this.  Alternatively, I will run on a treadmill or work out indoors (pool running is another great option) to keep my endurance up until I feel more comfortable heading outdoors again.  Everyone is different, some people love running in heat, that's why they have ultra marathons in Death Valley.  I am not one of those people and I start to wilt when the thermometer hits 20 degrees Celsius.  If you are like me, be sure to take care when running in the heat.  If you would like more information, here's an article that has more details on the risks of running in heat and how to avoid them.

Spring training and injuries

Aaah, spring...the sun is shining, the birds are chirping..what a wonderful time of the year. It’s a time for new beginnings and oh yes, running injuries. BMO Vancouver Marathon is just over 4 weeks away and it is usually the first big event of the season for many recreational runners. As you can imagine, this is a busy time for physios as runners are increasing their distances and find that those niggling little problems they have been ignoring are getting out of control. They only have a few weeks left so they need their physio to “fix” them so they can achieve their goals. Sound familiar?

The bad news is that in most cases we can’t “fix” you this close to an event or race. You would need more time and changes in your training schedule that, honestly, most runners are not willing to make.

But there is good news: you don’t necessarily have to stop running and give up on your goals in order to deal with your injury. Sure, we will have more time to spend on really addressing the underlying problems after your event but there are so many things we can do to help while you are still training. With some acute injuries where there is still inflammation and swelling, you may need some rest but soon after you are past that stage of healing you can run again with some modifications.

Here are some things to consider as you are continuing to train while rehabilitating from an injury:

1. Cadence - to minimize impact and improve your efficiency and mechanics, you should be running at 170-190 steps/minute. This requires some time to get used to but it makes a tremendous difference in the stress your body has to withstand especially during long runs.

2. Foot strike - more and more research shows that mid to forefoot strike while running is more efficient and reduces the amount impact on our bodies.

3. Shoes - just before a race or event may not be the right time to change shoes however, slowly transitioning to more minimal (less cushioning) running shoes may be something to consider depending on your injury and your performance goals.

4. Surface - adding variety to your runs will allow your body to adapt to different forces, venture off onto some trails to challenge your body in a different way. This is a great way to prevent injuries in the first place. If you already have an injury, please remember that your body will respond more favourably depending on your injury and the surface so please check with your physiotherapist first.

5. Frequency - some runners decrease their frequency of running as they have more symptoms, however, if you decrease your frequency your body will never adapt to the loads you will eventually expect it to withstand. You should change your training program (see below) but not necessarily the frequency of your training sessions.

6. Cross Training - whether you are injured or not, cross training is a great way prepare your body for race day. Again depending on your injury and your physio’s recommendations consider water exercises, water running, swimming, strength training, cycling even plyometrics.

7. Run/Walk - there is no shame in doing a run/walk program...in fact, you will be more likely to be successful in achieving your performance goals if you do a walk/run program than if you try to just run through your injuries.

8. Other changes to your training program - there are many other things you can change if you are injured to decrease your chances of further injury and promote healing. Depending on your injury you may need to run more frequently but reduce the total distance/week or you may need to take out hill runs or speed work. For example: Achilles Tendonopathy is usually present due to load that was increased too quickly. Therefore, you may do well with taking out the plyometrics/jumping exercises, uphills and speed work from your training program while keeping the volume with some run/walk intervals.

These are just a few ideas to consider regardless of whether you have an injury or not. The best thing you can do is to have your running program (and your body) assessed by your coach/trainer/physio to figure out what is going to work best for you. I would highly recommend using The Running Clinic website as a resource. This is an organization led by experts in running who are continually gathering and analyzing the latest research on the subject. Click here for their “10 Golden Rules of Running” and see you at the finish line. 

The challenges of meditation

At the end of February, I attended the first of 6 modules of the yoga teacher training at Kushala Yoga Studio in Port Moody.  It was a great weekend of learning new things, challenging my body and meeting lots of interesting people.  The most challenging aspect of the course so far has been the meditation.  

I know I am not alone in this.  Meditation is especially difficult in our fast paced world and I have a very hard time sitting still.  When I do, I usually spend it making lists and planning for what I am going to do next.  To actually try and calm the mind and not think of anything is almost anxiety inducing for me.  

One part of our homework before the next module is to meditate 10 minutes/day.  I didn't think this was possible and to be honest, I certainly have not been able to meet this goal.  However, I started with a couple of minutes of breathing techniques we learned in class, which I found very calming.    Then I moved on to guided imagery which allows you to focus on something and therefore is a nice transition to being able to "let it all go".  And after 4 weeks, I am now doing the first 10 minute module (10 sessions) on headspace.com

So, I am working on it.  It has it's ups and downs and to be honest, sometimes meditation is still more anxiety inducing than relaxing but it is starting to get easier.  It definitely feels like it's something that should be a regular part of my routine as I (and probably, most people) could certainly use more quiet moments in my life.  And in order to experience more calm, I am going to have work on bringing it to me and not just waiting for it to happen.  So I'll keep at it.

Running with kids

So this year, for many different reasons (or excuses), I did not sign up for any races in the spring.  I won't get into it...it will really just sound like I'm making excuses.  Turned out, it wasn't a bad decision as I just had to take 3 weeks off running due to an injury anyway.  

In the meantime, as I was feeling sorry for myself, my kids have been asking about running together.  My girls are 5 and 8 years old and to be honest, I haven't considered running with them before.  I believe that kids their age should be running for fun as they are playing.  However, since there seemed to be interest...I ended up signing them up for the Shaw Mini Sun Run. This was a big decision for me, I am not a fan of the Sun Run.  Don't get me wrong, anything to get people out there moving is great, however, I would not normally choose to run with 50,000 other people.  

So we have started our "training".  I use the term loosely, of course.  Basically, we just started getting out there, running together for longer periods than just the sprints involved in soccer or tag.  These are just a few observations I have made along the way:

1. You need to be patient.  You will literally be stopping to smell the roses or look at slugs or read signs.  Let it go.  This is time well spent with your kids.

2. Go gradually.  I don't necessarily think you need a training program to build up to a 2.5K run but if you need one you'll find one here.  You need to walk/run initially just like you would if you were a beginner runner and increase your distance gradually.

3. Make it interesting.  Add some sprint or interval training but call it tag or a race.  Make your destination a fun one, like the playground.

4. Set goals (mini ones) and include long and short term goals like trying to run to the next stop sign or "hey, next time we could try to run all the way to grandma's house". 

5. Get your kids some light and flexible shoes.  Shoes make such a huge difference and the kids can feel it too.  I'll never forget the first time I bought my older daughter a pair of Nike free 5's and she was literally sprinting around all day because the shoes felt so great.  There lots of great quality shoes out there for kids.  You'll find some good recommendations here.

Anyway, I hope you are getting out there in the beautiful Vancouver sunshine with your kids whether to run or just to play.  See you at the Sun Run.

5 tips for running in rain

The weather this weekend in Vancouver is a perfect excuse to skip your run.  Heavy rainfall warnings in the lower mainland send us all looking for indoor activities.  Seasoned runners (especially those who live in the Pacific Northwest) don't let a little rain keep them from running but for novice runners, this kind of weather just makes it that much tougher to get out there.  Here are 5 tips that help me brave this weather:

1. Wear a hat with a brim - very simply, it will keep the sideways rain from your eyes and face.  The brim also diverts the water that's soaked into your hair and hat and it will drip from the brim rather than down into your face.

2. Photochromic glasses - I bought these for cycling but I actually find them very useful for running.  Photochromic lenses adjust to the light so they darken in the sun and lighten in the dark.  So they protect you from the sun's rays on brighter days but keep the rain and wind out of your eyes when it's stormy.

3. Dress in layers - rain does not always mean cold.  In fact, in Vancouver, we've had unusually mild weather this winter.  Make sure you wear moisture wicking fabrics.  

4. Be visible - you can wear a reflective jacket or if you don't like running in a jacket, then get some reflective straps you can put on your ankles or wrists.  More and more you can find caps, running wear and even some footwear with reflective strips.  Some others like my new Skora shoes are completely reflective.  

5. Protect your electronics - most of us use our iPods or phones for entertainment on our runs.  If you do, make sure that you put it in a waterproof bag or pouch to prevent water damage.

One more thing, don't use wet shoes as an excuse not to run the day after a wet run.  Just put some crumpled up newspaper in your shoes.  You (and they) will be ready to go the next day.