Low back pain & ecological dynamics

Uncategorized May 06, 2024

Have you ever seen or heard the word ‘ecological’ and not really known what it means when it comes to pain or rehab? If yes, then this is blog for you as I will aim to describe what it is in 10 minutes! The linked articles / chapters are hugely valuable so be sure to check them out!

 Ecological psychology is the branch of science looking cognition with a heavy component on the link between perception and action. And when it comes to people with pain, perception matters… a lot! It is a well-supported theory that the brain is actually a predictive processor, constantly generating hypotheses and expectations based on past experiences to anticipate and interpret incoming sensory information. Within an ecological-enactive approach to pain, pain does not only exist in the tissues (brain, joints, soft tissues e.t.c) but emerges through dynamic interactions between a person and their environment (and not just the physical one).

 Could it be that a part of the...

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Spinal Red Flags

Uncategorized Mar 18, 2024

Spinal Red Flags

Sinister pathologies of the spine, aka red flags. Now, if reading that sentence sent shivers up your back like uttering the word ‘Lord Voldemort’ in a HPaz film, this blog might be for you. Fortunately, red flags account for <1% of all low back pain (LBP) (1) so for the vast majority we can apply the maxim of Dr Theodore Woodward, “when you hear hoofbeats, think of horses, not zebras”. However, this potentially means 1/100 LBP cases could be a sinister pathology and with LBP being the leading cause of disability worldwide to which patients seek healthcare advice, clinicians should take the trouble to learn about these red flags (or zebras) (2,3). 


For the purpose of this blog, I will discuss four sinister pathologies associated with LBP. But before that, what exactly is a red flag? Currently, there are 163 signs and symptoms designed to raise our ‘suspicion’. Although, when considered in isolation, they lack any...

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Top tips for shallow hips (Part 3 - Dysplasia) - Management!

Uncategorized Feb 28, 2024

Let’s tally up what information we have so far.

Caucasian female with a 5 year history of buttock, groin and anterior thigh pain. Reports being hypermobile. Unable to recall if breech birth or clicky hips, no matter. Not currently sporty or loading enough to be susceptible to a reactive tendinopathy and unlikely to have persistent tendinopathy given her history. No inflammatory sounding night pain, early morning stiffness or personal/first degree family history of inflammatory conditions.

Not responded to any rehabilitation efforts or medications so far. Frustrated. Questioning if things will ever change. Is it all in her head if the X-Ray says there is nothing wrong?

Clinically appears hypermobile on Beightons score, we know that has positive associations with DDH. Excessive rotation profile at the hip. Symptoms are reproduced on hip joint testing.

At this point I would be thinking there is enough evidence to suspect DDH. If we hadn’t of had an X-Ray then maybe the best...

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Top tips for shallow hips (Part 2 - Dysplasia) - The clinical assessment!

Uncategorized Feb 20, 2024

Welcome back – be sure to read the first instalment of this blog before cracking on! READ HERE

Right then, clinical exam time. We are fully equipped with our differential diagnoses and index of suspicion that for Jade is a little higher for DDH than others. What are the things we need to look out for on our exam that will raise it further or nip this thought train in the bud? This is how I would approach it.

  • Before I get Jade on the plinth – lets have a look at her Beighton’s score. She is skeletally mature and well into her 20’s so we’re definitely looking for more than a 5 or 6 out of 9 to be suspicious of global soft tissue laxity (there is no universal agreement on cut off). Jade scores a 7, it’s just her elbows that let her down from an A*/100%!
  • Usual functional tasks e.g. squatting, bending. I’m not bothered about technique because I’m an ecologically informed therapist and know this doesn’t matter (don’t @...
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Top tips to not miss shallow hips (HIP DYSPLASIA) Part 1

Uncategorized Feb 05, 2024

“I am 39 now in constant pain... my hip often gives way without warning.... I feel like an old lady... What does the future now hold for me?”

 The above is a quote taken directly from a paper that interviewed people living with Developmental Dysplasia of the Hip (DDH) and I think is a great way to start this blog as it illustrates the impact this condition has on the individuals living with it and is a reminder that we should be able to make positive impacts. From the off, I would really recommend reading THIS paper which provides an insight into just how much symptoms related to DDH can affect the social aspect of life from pre-post op. The guys at the BCP have correctly given me a word count for this blog as I can go on a bit, so I won’t go too much further into the lived experience side of things, but as I said… READ THESE PAPERS! (Edit: )

 I would argue that as physiotherapists, patients with DDH are coming through our doors frequently, but...

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PATELLOFEMORAL PAIN: All you need to know! (part 3)

Uncategorized Mar 25, 2023


In the previous blogs (read here and here) we talked about the multi factorial etiology of PFP and the need to focus on getting our differential right. Education is key in the management along with communication and addressing the psychosocial factors. It is mind boggling to know that up to 500 factors can contribute to development and sustaining PFP (ref). Therefore, it is recommended that, when it comes to the management of PFP, it should be a combination of more than one treatment approach focusing on strength and managing load, addressing flexibility issues and central sensitization and retraining gait mechanics and control. (ref). Demonstrating the integrated approach of interventions with proven efficacy (Lack et al, 2018)



Patient education remains the cornerstone for the management of patellofemoral pain including providing information and reassurance. It should include proper explanation of the potential contributing factors and the...

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PATELLOFEMORAL PAIN: All you need to know! (part 2)

Uncategorized Feb 15, 2023


As if the above factors were not enough, we got some more factors which are considered to be risk factors in contributing to the onset of this condition. These are structural causes which are divided into distal, local and proximal deficits. These include foot posture while running (ref) , reduced Quad strength (ref), delayed VMO activation (ref), weakness in eccentric hip abduction and hip external rotation (ref). It is seen that someone with PFP will show a combination of these local, proximal and distal factors making looking for the cause of pain that much more complex.


There seems to be no consensus at the moment on what causes PFP. Most likely, it is a combination of many factors, both structural and psychosocial. It has been shown that PFP seems to get better without any change in the alignment of structures which were initially thought as misaligned and evidently the cause of pain. (ref) The concept...

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PATELLOFEMORAL PAIN: All you need to know! (part 1)

Uncategorized Jan 25, 2023

By Ashish Dev

It makes me feel quite ‘stupid’ telling a patient about the diagnosis as it makes me feel like they are thinking ‘he doesn't know what's wrong’. And then especially if it is someone who is already fairly active, strong etc I often don't know what to do treatment wise as there is no obvious target.” - BCP member (practicing clinician)

Very few conditions confuse the hell out of patients and clinicians alike more than patellofemoral pain syndrome. Right from the source of symptoms, identifying the contributing factors, modifying, and managing load, designing a rehab plan to providing the patient with a timeline for getting better is all but murky to say the least. The aim of this two-part blog is to explore this condition and I hope by the time you are done reading this you will be able to tackle this condition better as a clinician and as a patient.


 Patellofemoral pain is a fancy way of saying...

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Does diagnosis matter?

Uncategorized Jan 16, 2023

Too often the question of diagnosis is split into a binary of “does it or does it not matter”. This creates a dichotomy & polarity between groups. Maybe the concept of granularity is a better perspective than a binary one.

Granularity, in it’s essence, looks at how much detail do we need to go into in a given situation.

 Let’s take back pain. Everyone would agree that obvious signs & symptoms of serious pathology should be investigated with less granularity required for onward referral. Further granularity maybe applied (such as imaging) further down the line by other HCPs.

Most I suspect would also agree that differentiating between more specific Dx’s would also be important & require granularity too. So being granular regarding neurogenic claudication & radicular pain is likely to be of benefit.

This would likely change the prognosis, explanation & treatment around the Dx, therefore giving the level of granularity a benefit...

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Non specific lower back pain - Understand it better!

Uncategorized Dec 19, 2022

Non specific lower back pain (NSLBP) is the most common MSK problem world-wide. It is also an often-misunderstood problem! This  will help to de mystify what NSLBP is & is not & hopefully provide positive information to pass on to those suffering with NSLBP

What is it? “pathoanatomical cause of the pain cannot be determined” - Maher

“For nearly all people presenting with low back pain, the SPECIFIC nociceptive source cannot be identified” - - Foster

“Presumed MSK origin of LBP. No tests available to specify SOURCE reliably” – Bardin



So NSLBP is actually a pretty broad label, even though it is one of exclusion NSLBP could be muscular, tendinous, ligamentous, joint related or discogenic & these cannot differentiated via clinical testing It could also be contributed to by many things across the BPS spectrum

Its not something specific! 1% is...

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