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Homeopathy- the truth behind it!!

It´s one of the fastest alternative therapies that exist out there. Annual sales  in the United States only are $300 million (1)!! But, is homeopathy really effective and if so how does it work?

The funny thing about homeopathy is that people really don´t know what it is or how it came about. So, let´s explain that a little bit.

Homeopathy was invented by a Geman named Samuel Hahnemann at the end of the 18th century. One day when he was healthy he decided to experiment with a drug called Cinchona, which is derived from the bark of a Peruvian tree. Cinchona contains quinine and was being used to treat malaria. When he took this drug, his health deteriorated to the point at which he developed the sort of symptoms usually associated with malaria. He experimented with other drugs that were being used for other diseases and obtained the same results, meaning he would always get sick. So by ¨logic¨ he came to the following conclusion: ¨that which can produce a set of symptoms in a healthy individual, can treat a sick individual who is manifesting a similar set of symptoms(1)¨. But, on top of that, he added that diluting the substance would produce greater effects in curing a person, while reducing its potential to cause side effects. !!Voila!!! There you have it,  the ¨science¨ behind homeopathy…..but it gets better ;). How do they dilutate the substance, you ask? Well let´s go ahead and explain that with an example.

They put a plant in a sealed jar with water or alcohol, which dissolves some of the plant´s molecules. After several weeks the plant or solid material is removed, the remaining water with its dissolved ingredients is called mother tincture. The mother tincture is then diluted to such an extent that there will be NO molecules of the original substance left in the dose you get.  The typical homeopathic dilution is 30C: this means that the original substance has been diluted by one drop in a hundred, thirty times over. This means that less than one part per million of the original solution is in the final product. But this is not important to homeopaths because (this is the best thing) they say that ¨water has memory¨. Ah, I almost forgot: it´s also very important to vigorously shake the homeopathic remedy at each dilution(1-2).

With all this said, you can imagine that all the serious(3-5) trials that have been done have shown that homeopathy is no better than placebo (homeopaths will defend themselves mentioning some poor quality trial). Even after explaining all this to some people, I will still get the typical homeopathy fan that says to me ¨All I know is, I feel better when I take it¨. So how do you answer that statement? Well, you could simply explain to them about placebo and the effect it causes. Or about ¨regression to the mean¨ (, which basically means that all things have a natural cycle, meaning  you will have good days and bad days. It´s like with a cold. It´s going to get better after a few days, but at the moment you feel the worst, that´s when you will do dramatic things to try to get better, like taking a homeopathic remedy. Then, when you get better ( as you surely will from a cold), you will naturally assume that the homeopathic remedy must be the reason for your recovery.

Here are couple of videos that talk about homeopathy. The first video is a MUST SEE!!! It explains what homeopathy is and how scientific trials work.

Until next time!       It´s called Homeopathy: The Test (BBC Documentary Films)


  1. Goldacre B. Bad Science. Fourth Estate. London.2009.
  2. Singh S, Ernst E. Trick or Treatment? Alternative medicine on trial. Transworld Publishers.2009
  3. Shang A, Huwiler-Müntener K, Nartey L, Jüni P, Dörig S, Sterne JA, Pewsner D, Egger M. Are the clinical effect of homeopathy placebo effects? Comparative study of placebo-controlled trials of homoepathy and allopathy. Lancet.2005
  4. Ernst E. Homeopathy: what does the ¨best¨evidence tell us? Med J Aust. 2010 Apr 19;192(8):458-60.
  5. Wilson P. Analysis of a re-analysus of a meta-analysis: in defence of Shang et al. Homeopathy,2009 Apr;98(2):127-8.


Why do ¨alternative¨ therapies seem to work?

Whenever we feel sick, or have pain, we tend to go to the doctor or to a therapist of some kind. The thing is that most of us usually don´t  like going to the doctor or therapist and we wait a long time before we finally decide to go. And then when we finally decided to go, the symptoms usually improve. This makes us think that the doctor we decided to go to or the therapy we decided to do worked. I mean it´s quite simple, A leads to B, or doesn´t it? Let´s take a closer look at that.

When we think that just because two things happen together,  then one must have been the cause of the other is called a LOGICAL FALLACY and this is something we do a lot.

Let me give you an example: When the rooster crows, the sun rises.  Therefore, the rooster causes the sun to rise.

We do this more than we can imagine, and especially in my field (physical therapy) I see it a lot, I have also done it. Patients would come to me, I would treat them and they would get better, so I would naturally think ¨I´m the best¨ and ¨he got better because of me and my new wonderful technique that I applied on him¨ . We tend to base clinical convictions on personal experience and this, my friends, is a mistake. We have to base our treatments on randomized, placebo-controlled trials.  Any treatment that doesn´t base itself on that is ¨bogus¨. This is the foundation of modern healthcare.

And which treatments usually don´t base themselves on that……¨alternative medicine¨( But sometimes ¨alternative medicine¨ works, why is that? Well, here are just a couple of reasons why sometimes it ¨works¨.

  1. The natural history of a disease- Many diseases are self-limiting. If the condition is not chronic or fatal, the body´s own recuperative processes usually restores the sufferer to health.
  2. Regression to the mean- Many diseases are cyclical, meaning they get worse or better temporarily, but always move back to an average severity(1). Back pain, arthritis, allergies, and multiple sclerosis are cyclical, meaning sometimes they get worse and sometimes they get better. Usually, we go to the therapist or doctor when we have the most pain, so it´s bound to get better no matter what the therapist does to you.
  3. Placebo effect – ineffective treatment that can nevertheless be consoling. But the placebo effect is not restricted only to fake treatments, it also plays a role in the impact of real medicine. For example, although a patient will derive benefit from taking aspirin largely due to the pill´s biochemical effects, there can also be an added bonus as a result of the patient´s confidence in the aspirin itself or in the doctor who prescribes it (2). That is why sometimes the doctor´s reputation, the cost of the treatment, its novelty, a gentle touch, a nurse´s smile, a diploma-covered wall, could all increase the placebo effect(3-5).
  4. Confirmation bias- We desire treatment success because illness is unpleasant. Recently there was a study (6 ) that measured objectively and subjectively the effectiveness of active albuterol against placebo (the patients were given a fake active albuterol), sham acupuncture or no intervention.  Active albuterol is used for those who have asthma, it’s a bronchodilator. Subjectively ALL experienced an improvement (they used a visual analog from 0 to 10, in which 0 means no improvement and 10 means complete resolution). With albuterol the subjective improvement was of  50%,  with placebo it was 45%, sham acupuncture 46% and the no-intervention control group getting a 21%. So, all improved subjectively but there was a big difference between placebo-sham acupuncture and the no intervention group, even though all 3 were INEFFECTIVE for the disease, crazy right?! Well, objectively (which means we can measure it), they made each of the 4 groups blow to measure lung function. And not surprisingly, the albuterol group improved the best, in fact, the real albuterol did 3 times better than all the other three groups. But, what was amazing is that all 3 ¨fake¨ groups improved a little, even thought NOTHING was being done to them. And also, objectively there was a HUGE difference between the real treatment and the fake treatment although subjectively there was barely any difference!!!! I hope you all understood the importance of this.

Alternative medicine is called alternative because it really doesn´t work. If it worked it would be called MEDICINE. Physical therapists out there reading this, let´s try to base our treatments on randomized, placebo-controlled trials and not on our own clinical or personal experience.

Here is a nice video that talks about alternative medicine. It´s 45 minutes but very interesting.


  1. Streiner DL. Regression toward the mean: Its etiology, diagnosis, and treatment. Can J Psychiatry. 2001;46:72–76
  2. Ernst E, Simon S. Trick or Treatment ? Alternative medicine on trial. Transworld Publishers.London,UK.2008
  3. Benedetti F, Mayberg HS, Wager TD, Stohler CS, Zubieta JK. Neurobiological mechanisms of the placebo effect. J Neurosci. 2005;25:10390–10402.
  4. Ernst E, Resch KL. Concept of true and perceived placebo effects. BMJ . 1995;311:551–553.
  5. Evans D.  Placebo: Mind over matter in modern medicine. Oxford University Press; 2004
  6. Michael E. Wechsler, John M. Kelley, Ingrid O.E. Boyd, Stefanie Dutile, Gautham Marigowda, Irving Kirsch, Elliot Israel, Ted J. Kaptchuk. Active Albuterol or Placebo, Sham Acupuncture, or No Intervention in AsthmaN Engl J Med. Author manuscript; available in PMC 2012 January 14.Published in final edited form as: N Engl J Med. 2011 July 14; 365(2): 119–126

Massage- what does it really do?

Everyone always wants a damn massage, and they always ask me, especially my family. Even though I studied physical therapy and massage is only a tiny little piece of what we do, everyone associates physical therapy with massage. So, of course, I get asked all the time for a massage. The worst thing about it is that no one ever gives me a massage, so I don´t even know what it feels like anymore, but I do know the benefits of a massage. So what does a massage really do? Lets find out.

Massage reduces depression and massage reduces anxiety, and it does this because it is relaxing (1-2). It is also said to reduce blood pressure (3) and help people to sleep, even when under stress. Massage also helps patients with sub-acute or chronic lower back pain, but not with acute back pain!(5). And that´s about it, folks. Scientifically, those are the only things that massage has been proven to do, nothing else! (It may help with other diseases but it´s usually due to one of these factors I just mentioned) But, what about all those other things we always hear massage is good for? Like, for example, it helps with circulation, it detoxifies and so on. Well, they are basically myths!! So let´s start talking about those myths.

Circulation – massage helps with circulation but very, very, very, VERY little!! If you want to improve your circulation go for a walk, it´s cheaper and MUCH more effective in increasing circulation (6-7,10).

Detoxifies or gets lactic acid out – Massage doesn´t do either of these, in fact it could do the opposite! When we give a massage we produce a mildly toxic state know as rhadomyolysis(8-10).

Massage helps with muscle soreness – Like I stated in my last post (, almost nothing helps with muscle soreness and that includes massage.

Massage helps you recover after an exercise – Actually it doesn´t!! This may surprise more than one (including me), but the evidence says that ¨massage significantly impairs lactic acid and hydrogen ion removal from muscles after strenuous exercise by mechanically impeding blood flow¨(9-10).

Massage releases ¨fascia¨-  First let me explain what fascia is. Fascia is the connective tissue that wraps around all of our muscles and is heavily interconnected with muscular function. Fascia is also very, very, strong. In a study done in 2008, Chauldhry found that forces outside the physiological range would be required to produce just 1% compression and 1% shear of the fascia lata and plantar fascia. In another study done in 2012, Simmons and Martinez found that the relatively low level of forces used by manual therapists is not enough to cause significant deformation of collagen in the fascia. In other words, massage does not release or change fascia, fascia is too tough for that to happen! What may happen, and this is still a hypothesis, is that myofascial release is thought to stimulate intra-fascial mechanoreceptors, which cause alterations in the afferent imput to the central nervous system, leading to a reduction in the activation of specific groups of motor units. So, in plain English what this means is that whenever we touch a patient we are giving information to the central nervous system, and how the central nervous system perceives this information will affect the fascia.

And the last myth about massage is when the therapist giving you the massage tells you ¨You are really tight¨. I have also done this lots of times, but research tells me I was wrong. First, tissue texture correlates poorly with pain(11)  and second we, therapists, are bad at detecting the painful side just by feel (12). So, next time you get a therapist and he tells you how tight you are…..just play along with it…..because we all do it 🙂

In conclusion: a massage is GREAT and probably helps us with a lot of our physical problems, including stress, anxiety and may even help with pain.  There are also things that massage doesn´t do and that I mentioned in this blog, but the good thing with a massage is that you can almost never go wrong. Even if the therapist tells you that he will ¨detoxify¨ you (which he won´t), you probably will come out feeling great!! So go out and get yourself a massage but please don´t ask me 😉

  1. Hernandez-Reif et al. High blood pressure and associated symptoms were reduced by massage therapy. Journal of Bodywokr & Movement Therapies.199
  2. Cady et al. Massage therapy as a work place intervention for reduction of stress.Perceptual & Motor Skills 1997.
  3. Shulman et al. The effectiveness of massage therapy intervention on reducing anxiety in the work place. Journal of Applied Behavioral Science.1996
  4. Moyer. Affective massage therapy.. Int J Ther Massage Bodywork 2008.
  5. Furlan et al. Massage for low-back pain. Cochrane Database of Systematic Reviews.2008
  6. Hovind et al. Effect of massage on blood flow in skeletal muscle.  Scandinavian Journal of Rehabilitation Medicine 1974.
  7. Ramos-González et al. Comparative study on the effectiveness of myofascial release manual therapy and physical therapy for venous insufficiency in postmenopausal women.  Complementary Therapies in Medicine,2012.
  8. Wiltshire et al. Massage Impairs Post Exercise Muscle Blood Flow and “Lactic Acid” Removal. Medicine & Science in Sports & Exercise.2009
  9. Cheung K, Hume P, Maxwell L. Delayed onset muscle soreness: treatment strategies and performance factors Sports Med. 2003;33(2):145-64.
  11. Andersen et al. Increased trapezius pain sensitivity is not associated with increased tissue hardness. Journal of Pain 2010. PubMed     
  12. Maigen et al. Lower back pain and neck pain: is it possible to identify the painful side by palpation only? Ann Phys Rehabil Med.2012

Stretching – is it useful?

Anyone who has ever played any sports has probably heard, or knows, that stretching is good for you. That you have to stretch before a game to warm-up to prevent injuries and to perform better. And we also have to stretch after the game to try to avoid the muscle soreness. It´s something everyone has done, it´s sacred and it works……….. or doesn´t it?

Well, I hate having to do this again but stretching has not been proven to do ANY of these!! Stretching before a game does not prevent injuries, does not warm you up, does not make you perform better (it actually does the opposite) and it does not avoid muscle soreness (1-12)!!

Researchers have discovered in recent years, that static stretching can lessen jumpers heights and sprinters speeds without reducing people´s chances of hurting themselves. They also found that static stretching reduces strength in the stretched muscles by almost 5.5 percent(5-6)!! So, for all those that lift weights and want to lift and train harder, you may want to stop stretching before a lift from now on.

But, what about stretching after the activity, that helps for sure? You have to stretch after an intense work-out, if not, you are not going to be able to move the day after. But, that is not true!! Evidence suggests that stretching is completely useless for  preventing muscle soreness (8,9). In fact, studies show that almost nothing can prevent muscle soreness (8-10).

So what the hell is stretching good for? Well, it makes you more flexible but, remember, more flexible doesn´t mean anything in the sense of preventing injuries(11-13). And it feels great! Also, stretching could affect the peripheral and central nervous system. Meaning, the novel stimulation (stretching) may help the brain downregulate the perceived threat of current stimuli and thus decrease the muscle tension that may be causing you pain.

Ok, then what should we do before we engage in a physical activity? Warm-up, by trying to imitate the activity that you are going to perform but a lower level. For example, if I´m going for a light run, walking can be a good warm-up. Do mobility drills, move  the extremities you are going to use for that physical activity, for example if I´m going to play tennis, I would do mobility drills for the shoulder and arm area. In simple words: warm-up dynamically by moving the muscles that will be called upon in your workout.

In conclusion, stretching feels great and improves flexibility, and if those are your goals then you should be stretching. But if you are stretching because you think you are going to warm-up, prevent injuries, perform better and prevent muscle soreness, then you are mistaken.

Hoped you enjoyed it. Until next time.

  1. Shrier.Stretching before exercise does not reduce the risk of local muscle injury: a critical review of the clinical and basic science literature. Clinical Journal of Sports Medicine.1999
  2. Herbert et al. Effects of stretching before and after exercising on muscle soreness and risk of injury: systematic review. British Medical Journal. 2002
  3.  Lauersen JB, Bertelsen DM, Andersen LB. The effectiveness of exercise interventions to prevent sports injuries: a systematic review and mata-analysis of randomised controlled trials. Br J SPorts Med 2013.
  4. Costa PB, Ryan Ed, Herda TJ, Walter AA, Defreitas JM, Stout JR, Cramer JT. Acute effects of static stretching on peak torque and the hamstrings-to-quadriceps conventional and functional ratios. Scand J.Med Sci Sports, 2013 Feb;23(1):38-45.
  5. Pope et al. A randomized trial of preercise stretching for the prevention of lower-limb injury. Medicine Science in Sports Exercise.2000.
  6. Kay et al. Effect of Acute Static Stretch on Maximal Muscle Performance: A Systematic Review. Medicine & Science in Sports & Exercise.2011.
  7. Gergley JC. Acute effect of passive static stretching on lower-body strength in moderately trained men. J Strength Cond Res. 2013 Apr;27(4):973-7.
  8. Lund et al. The effect of passive stretching on delayed onset muscle soreness, and other detrimental effects following eccentric exercise.Scandinavian Journal of Medicine & Science in Sports 1998.
  9. Cheung et al. Delayed onset muscle soreness: treatment strategies and performance factors.Sports Medicine 2003 .
  10. Weber et al. The Effects of Three Modalities on Delayed Onset Muscle Soreness.  Journal of Orthopaedic & Sports Physical Therapy 1994.
  11. Hart. Effect of stretching on sport injury risk: a review. Clinical Journal of Sports Medicine. 2005
  12. Beckett et al. Effects of Static Stretching on Repeated Sprint and Change of Direction Performance. Medicine & Science in Sports & Exercise. 2009
  13. Sandler R, Sui X, Church T, Fritz S, Beattie P, Blair S. Are flexibility and muscle-strengthening activities associated with a higher risk of developing low back pain. Journal of Science and Medicine in Sport: April 2013.

Yoga, is it really that good for you?

As I write this blog I am trembling with fear, as I am afraid that all those yoga lovers will hunt me down for even questioning if yoga is really that good for us. Because, as we have all heard or even been taught, yoga is amazing. Yoga improves flexibility, yoga improves sex, yoga improves balance, yoga reduces stress, yoga helps menopausal women, yoga lowers the risk of heart disease, yoga reduces anxiety, yoga, yoga, yoga(1-4). Whatever your problem is, yoga will have a solution. I am surprised there is not a yoga phone line to help us in the need of an emergency.

But all kidding aside, yoga is good for us, as is any other physical activity. And if someone ever asked me if they should do yoga, I will 90% of the time say yes, the same as if anyone asked me if they should start walking, or if they should sign up to the gym, or if they should do dancing, or if they should do pilates. Exercise is great and it produces a great benefit to anyone who practices it (, so if that exercise is called yoga then great, go for it, but as with any other activity it has risks, especially more in men.

Yoga plays around with different postures and in some of them you need a lot of flexibility. So yoga enhances flexibility, but we must not forget that more flexibility doesn´t mean a lower risk of getting an injury, sometimes even the opposite is true, the more flexible you are the greater chance of getting injured (5).

We all know that women are more flexible than men and this is where yoga poses some threat to men. Some of the postures that you have to do in yoga are almost impossible for some men (and even women), because of their lack of flexibility and also because of their bone structure. That bone structure will suffer if forced into a position that anatomically is not possible for them. And according to William J .Broad, ¨men will sometimes use their muscle to get into these challenging poses and this is where they get hurt and why men get injured more often than women and suffer damage that is far worse, including fractures, dislocations and shattered backs¨( 6).

But women also suffer, especially in the hip area, due to the mechanical limitations of the joint. Extreme leg motions could cause the hip bones to repeatedly strike each other, leading over time to damaged cartilage, inflammation, pain and crippling arthritis (7). This is called Femoroacetabular Impingement, and is often found in middle-aged women who do yoga ( it also happens a lot to dancers). Yoga has also been associated with a higher risk of meniscus injury compared to badminton, jogging and climbing hills (8). So you see, yoga also has its risks as with any other physical activity.

The last thing I want to touch upon before I leave is the ¨back topic¨. I always hear people say that ¨yoga is wonderful for the back and anyone who has back pain should do yoga¨, and this is not true. Exercise and movement are great for the back and those are two things you do with yoga. But with yoga you also do a lot of bending.When you bend forward, or when you move any joint for that matter, ligaments really aren’t on tension until you get to the end range, so they aren’t loaded. What this means is that when you bend forward or round your low back, you don’t really put strain on the ligaments so long as your muscles are keeping you from end range . This seems fine, right? Well, there is this thing called the flexion-relaxation phenomenon that happens when people round their lower back: the muscles relax and people end up hanging on their ligaments and discs. And this is not a good thing. As I  mentioned in one of my previous blogs (, it is almost impossible to herniate yourself without being in full flexion. Well, guess what? In yoga you are doing a lot of flexion and in some cases even full flexion. Now this doesn´t mean that you should stop doing yoga, or that yoga is going to cause you a herniation. It probably won´t and I will say it again, YOGA IS GOOD, but if you have back problems, depending on your problem yoga can do more harm than good.

The good thing about yoga compared to other physical activities is that it promotes a healthy lifestyle effect like non-smoking, reduced alcohol consumption, increased exercise, vegetarianism and reduced stress, this could all be factors that lead people to say that yoga is amazing and that it does wonders. If we all changed our way of life, did more sports, ate better and reduced our stress, we would all feel much better.


  1. Li AW, Goldsmith CA. The effects of yoga on anxiety and stress. Altern Med Rev; 2012 Mar;17(1):21-35.
  2. Ross A, Thomas S. The health benefits of yoga and exercise: a review of comparison studies. J Altern Complement Med.2010 Jan;16(1):3-12
  3. Innes Ke, Vincent HK. The influence of yoga-based progams on risk profiles in adults with type 2 diabetes mellitus: a systematic review. Evid Based Complement Alternat Med 2007 Dec;4(4):469-86.
  4. Oken Bs, Zajedl D, Kishiyama S, Elegal K, Dehen C, Hass M, Kraemer DF, Lawrence J, Leyva J. Randomized, controlled, six-month trial of yoga in healthy seniors: effects on cognition and quality of life. Altern Ther Health Med 2006 Jan-Feb;12(1):40-7.
  5. Battie MC, Bigos SJ, Fisher LD, Spengler DM, Hansson TH, Nachemson AL, Wortley MD. The role of spinal flexibility in back pain complaints within industry: A prospective study. Spine 1.
  6. William J. Broad.
  7. Ganz R, Leunig M, Leuing-Ganz K, Harris  W. The Etiology of Osteoarthritis of the Hip.Clin Orthop Relat Res 2008 February;466(2):264-272.
  8. Zhuj JK, Wu LD, Zheng RZ, Lan SH. Yoga is found hazardous to the meniscus for Chinese women. Chin J Traumatol 2012 Jun1;15(3):148-51.
 Snook SH, Webster BS, McGorry RW, Fogleman MT, McCann KB. The reduction of chronic nonspecific low back pain through the control of early morning lumbar flexion. Spine 1998, 23: 2601-07.
Kelsey JL. An Epidemiological Study of Acute Herniated Lumbar Intervertebral Disc. Int J. Epidemiol:4;197-204

Osteopaths-Chiropractors: Cracking of the bones

This is a complicated subject since there is a lot of controversy surrounding manipulations. When we think of manipulation, we think of cracks, and those cracks to ¨us¨ means that our bone just went back into its place. I think we have all had someone in our life ¨crack¨, our back, and usually afterwards we all felt better. But, what is that cracking sound, is it really our bones? Or is it something else?

Well, it´s not the bone, sorry to tell you. When you manipulate a vertebrae (bones in your back) you forcefully separate the joint surfaces, the resultant vacuum pulls in nitrogen gas to fill the space, producing a ¨POP¨(1). Once the joint pops, it may take a few hours before the gas is absorbed and the joint surfaces settle back(1). So the popping sound is really just liquid and not the bone. Most people don´t know that the vertebrae are so fixed together that you coudn´t even separate them even with a crowbar(1)!! , and that´s a good thing. So why does it feel so good when they ¨crack¨ our back and is it really safe to let someone ¨manipulate¨ your back?

The scientific community has done different trials on manipulations and they have seen that manipulating is ineffective in treating different disorders as neck pain, headache, non-spinal  primary and secondary dysmenorrhea, infantile colic, asthma  allergy, cervicogenic dizziness, just to name a few(2). They only found out that spinal manipulation was considered superior to sham manipulation but not better than conventional treatments in dealing with acute low back pain.  So their conclusion, which was published in the ¨Journal of the Royal Society of Medicine¨, stated that ¨Collectively these data do not demonstrate that spinal manipulation is an effective intervention for any condition(2). Given the possibility of adverse effects, this review does not suggest that spinal manipulation is a recommendable treatment¨. So, how come sometimes it feels so good when someone ¨cracks¨ your back? Well, it could be simply the placebo effect, the ¨pop¨ can do magical things to people´s head, ( or to the body´s production of endorphins. It is well known, for example, that spinal manipulation, acupuncture, massage, and other forms of physical treatment can stimulate the body´s production of endorphins to relieve pain.

It could also be that manipulation works, but not for the reason most people think it works. When you go to a chiropractic or osteopath they usually assess you through motion palpation test, positional faults assessments, clinical postural assessments or some other test, the funny thing is that these test usually have, at best, poor to fair reliability (5-13). What I mean by this is that, if you first go to one osteopath and then you go to another, they probably wouldn´t agree on what you have. One would say you have too much mobility, while they other one would say something else. The intertester reliability is horrible and if you don´t believe me look at the studies (5-13). So how come sometimes it works? Well, it could be because when someone manipulates you, he is in fact affecting the peripheral and central nervous system. Meaning, the novel stimulation (manipulation) may help the brain downregulate the perceived threat of current stimuli and thus decrease the pain.(

But what I can tell you for sure, and it has been demonstrated, is that your bone is not out of place, there is no such thing as a ¨subluxation¨(1-3). So next time you go to a physical therapist, chiropractic, osteopath or whatever, and that person tells you that you have a ¨subluxation¨and that he is going to put that bone in its place, get up and walk away. Manipulations can have some serious effects. In 2001, a systematic review of 5 studies revealed that roughly half of all chiropractic patients experience temporary adverse effects, such as pain, numbness, stiffness, dizziness and headaches(3,4).  But the greatest risk comes from manipulating the cervical area (neck). This region is hugely vulnerable as it carries all the lifelines between the head and the body. In particular 2 vertebral arteries which are very close to the cervical vertebrae. Cervical manipulation has not been shown to be more effective than a massage in dealing with acute neck pain or chronic neckpain. But they are more dangerous. So my recommendation is not to let anyone manipulate your cervical area (neck).

To summarize, and not bore people to death, I will make a list of what the scientific community says with respect to when manipulation by a professional is in order and when they should NOT be manipulating you.


  • A manipulation could  be beneficial in acute non specific lower back pain. In their own words ¨Manipulation is often more effective than physical therapy in relieving the symptoms of simple, uncomplicated back pain. But such treatment should be discontinued after one month if no improvement results¨.


  • Herniated disk, as suggested by sciatica (pain radiating dow on leg below the knee)
  • Spinal stenosis (narrowing of the spinal canal)
  • Ankylosing spondylitis
  • Cauda equina syndrome
  • Cancer or Infection, which might be suggested by history of cancer, unexplained weight loss, immunosuppression, urinary infection, fever, back pain not improved with rest, and age of patient over 50.
  • Spinal or compression fracture.

Hope you enjoyed it!!


  1. Homola S. Inside Chiropractic.Prometheus Books 1999. Amherst, New York.
  2. Ernst E, Canter P H. A systematic review of systematic reviews of spinal manipulation. Journal of the Royal Society of Medicine 2006 April 99 (4): 192-96.
  3. Ernst E, Singh S. Trick or Treatment? Alternative Medicine on trial.Transworld Publishers 2009, London, UK.
  4. Hall H. Update: Chiropractic Neck Manipulation and Stroke.
  5. Berneck J G, Kulig K, Landel F. R, Powers . The Relationship Between Lumbar Segmental Motion and Pain Response Produced by a Posterior-to Anterior Force in Persons With Nonspecific Low Back Pain, J Orthop Sports Phys Ther Vol 2005: 35;4.
  6. Cornwall J. Lubar Zygapophysial Joint Palpation. NZ Journal of Physiotherapy Nov 2004: 32;3.
  7. Zegarra-Parodi R, Rickards L, Renard E-O. Cranial Palpation Pressures Used by Osteopathy Student: Effect of Standardized Protocol Training. JAQA Vol 109 No 2 Feb 2009 79
  8. Simpson R, Gemmell H. Accuracy of spinal orthopaedic tests: a systematic review, Chiropractic & Osteopathy 2006, 14:26.
  9. Landel R, Kulig K, Fredericson M, Li B, Powers M C. Intertester Reliability and Validity of Motion Assessments During Lumbar Spine Accessory Motion Testing. Physical Therapy, Jan 2008. Vol 88 Number 1.
  10. Kmita A, Lucas N. Reliability of physical examination to assess asymmetry of anatomical landmarks indicative of pelvic somatic dysfunction in subjects with and without low back pain. Internationl Journal of Osteopathic Medicine in press(2208) 1 e10.
  11. Huijbregts P. Spinal Motion Palpation: A review of reliability Studies. The Journal of Manual & Manipulative Therapy Vol. 10 No. 1( 2002) 24-39.
  12. Hughes P, Taylor N, Green R. Most clinical test cannot accurately diagnose rotator cuff pathology: a systematic review. Australian Journal of Physiotherapy 2008 Vol 54.
  13. Tullberg T, Blomberg S, Branth B, Johnson R. Manipulation does not alter the position of the sacroiliac joint: a roentgen stereophotogrammetric analysis. Spine 1998, 23(10):1124-29.

Lower back pain part 3: Prevention

Ok, so in part 2 of lower back pain I explained a little about what a herniation is, now I want to start talking about how to prevent a herniation. First, let me go into a little more detail about what a disc is. ( read and )

A disc is the substance between the vertebrates. It has a nucleus and a annulus. The annulus surrounds the nucleus and prevents it from coming out. The nucleus is a gel like substance, and a herniation is when the annulus breaks and the nucleus comes out ( more or less). The disc varies in size depending on the time of day. In the morning the discs are usually bigger than at night, because we have been laying down for hours and the discs have absorbed liquids. That is why in the morning we are usually taller than at night and a reason why we shouldn´t be doing flexion activities in the morning. The bigger the disc, the more stress you put on it and on your ligaments. A study estimated that disc-bending stresses were increased by 300% and ligament stresses by 80% in the morning compared to the evening (1). In another study it was demonstrated that simply avoiding full lumbar flexion in the morning reduced back symptoms (2). So first factor in preventing herniation and lower back pain, don´t do flexion activity in the morning, wait at least 30 minutes to an hour, that is usually what it takes for the disc to return to normal size.

Spine has memory. The function of the spine is modulated by certain previous activity. This occurs because the loading history determines disc hydration, which in turn modulates ligament rest length, joint mobility, stiffness and, load distribution. In simple words, when we are sitting down, we are in flexion. This means that the nucleus of the disc has moved posteriorly, and we have ¨stretched¨ the posterior ligament (3). So it would be unwise to lift things after a bout of prolonged flexion, like for example when we are sitting for a long time . Then, a second factor in preventing herniation and lower back pain, don´t lift things up after being in flexion for a long time. Meaning if you have sat down the whole day, don´t go right away and try to pick up something heavy, the changes of hurting yourself are going to increase. All you have to do is stand up, wait 5 minutes, and your changes of getting hurt will greatly diminish. This can also be said to all those that play sports like for example, basketball. When you are on the bench sitting down, you are in flexion. So it would be much wiser, if you know that you are going to go into the game, to stand up, or to try sit in a way that your back isn´t in flexion.

Too much of anything is usually bad. In a study done in 1975 (4-5) , it proved that seated work posture creates an increase in lower back pain (LBP).  Another one  in 1996 (6)  also suggested that people who sit for long periods of time have a greater risk of low back troubles (8%), but what was even more interesting is that active workers, meaning people who worked moving around or standing up, reduced their probability of getting back pain by 14% if they would sit once in a while. This suggest that variable work, and not too much of any single activity is the best thing. In other words, if your job consist of sitting down the whole day, it would make sense to get up and move around once in a while. And if your job consist of being active the whole day, it would be clever to do the opposite. So any business man out there thinking of creating their own business or ones who already have one, make your workers do VARIABLE WORK, and you will save up money in the long run.

I already said how easily it is to hurt yourself from flexing your back, how you shouldn´t pick up heavy things after prolonged bouts of flexion, how the best thing to do to prevent LBP is to do variable work, but the number one thing you should really try to avoid is FREQUENT BENDING AND TWISTING (gardening is an example of frequent bending and twisting). The U.S. Department of Labor (1982) and many more studies noted the increased risk of lower back pain from frequent bending and twisting (7-8). In this report vibration was also included, especially seated vibration. So all those power plates fanatics carefull with the vibration (7,9).

80 % of us will probably get back pain at one point or another, that´s a lot! But I´m pretty sure that if we try to avoid things I have mentioned in this blog the chances of us getting hurt will greatly diminish.

Hope you enjoyed it


  1. Adamas M, Dolan P. Diurnal variations in the stresses on the lumbar spine. Spine 1987,12(2):130.
  2. Snook SH, Webster BS, McGorry RW, Fogleman MT, McCann KB. The reduction of chronic nonspecific low back pain through the control of early morning lumbar flexion. Spine 1998, 23: 2601-07.
  3. Mcgill S. Low Back Disorders Evidence Based Prenvention and Rehabilitation 2nd. Human Kinetics 2007.
  4. Kelsey JL. An Epidemiological Study of Acute Herniated Lumbar Intervertebral Disc. Rheumatol Rehabil 1975:14;144-5.
  5. Kelsey JL. An Epidemiological Study of Acute Herniated Lumbar Intervertebral Disc. Int J. Epidemiol:4;197-204.
  6. Liira JP, Shannon HS, Chambers LW, Haines TA. Long-term back problems and physical work exposures in the 1990 Ontario Health Survey. Am J Public Health. 1996;86:382–387.
  7. The U.S Department of Labor Report (1982)
  8. Marras WS, Lavender SA, Leurgans SE, Fathallah FA, Ferguson SA, Allread WG, Rajulu SL. Biomechanical risk factors for occupationally related low back disorders. Ergnomics 1995 Feb:38(2):377-410.
  9. Seroussi RE, Wilder DG, Pope MH. Trunk muscle electromyography and whole body vibration. J Biomech 1989:22(3):219-29.

Lower back pain part 2: Herniation

In one of my  previews blogs I already talked a little about herniation (, but this one is going to be entirely about it.

People are afraid of  a herniation and whenever they hurt their back they automatically think they have a herniation. So, what they do when they hurt their back is go straight to the doctor. The doctor (hopefully) will do a couple of test on you to see that you don´t have any ¨red flags¨, meaning serious injuries, and he might do an X-ray or an MRI on you. Hopefully, if he is a good doctor and has seen that you don´t have any red flags, he will just reassure you that you don´t have anything serious, tell you to try to keep active, and maybe give you something for the pain. I say ¨keep active¨ because different studies have seen that bed rest worsens the condition. At most, and if the pain is really bad, you could do bed rest for 1 or 2 days but never more than 2 days (1). However, if he is not such a good doctor he will send you to have an X-ray or MRI. Patients with simple back pain and no red flags do not need any diagnostic investigations in the first month of symptoms (2). Now, you may ask yourself why this is bad. This is bad because, as I´ve mentioned before in other blogs, 70% of us possible have a disc herniation, disc degeneration, or some other structural abnormality and are asymptomatic, meaning we have no pain (3). So if we have back pain and the doctor sends us to have an MRI he will probably find something wrong with us, but this is probably not the cause of our pain. So, now we will be mislabeled and potentially be receiving unnecessary treatments, but even worse, now we will think ourself as being ¨sick or having something wrong with us¨. And this will probably lead us to having more pain, more absenteeism (sick leave, time off work), decreased productivity while at work, loss of earning, and having a poorer health status (4) . But anyway, this is beyond the scope of this blog. So let us get back to herniation and how we can prevent it.

In one of my previous blogs, I mentioned that it is almost impossible to herniate yourself without being in full flexion and having a compressive force act over the vertebrae (5). A compressive force can be produced by an external weight, like for example a backpack, or by our own muscle. Every time a muscle contracts it produces a compressive force somewhere in the body, so you don´t even have to be picking up something heavy to herniate yourself. Now this is where I´m going to surprise more than one, when you are sitting down you are basically in flexion, your lower back is bend, this causes the nucleus inside the disc (the disc is made of an annulus and a nucleus, the nucleus is gel-like substance and is surrounded by the annulus) to deform posteriorly. This is why sitting down for a long time is bad, because it stresses the tissues. Human beings were not made to perform repetitive work that emphasizes only a few tissues. Nor were humans designed not to be stressed. Research has established that tissues adapt and remodel in response to load (6-8). Too little activity can be as problematic as too much(9) .So let me give an example for you guys to understand what I have just said:

  • In the 1960s, in a power plant in the USA, operators had to respond to a vigilance buzzer on their desk that went off every 10 minutes. At each buzzer interval they would stand and walk around the control panel making adjustments. There was no history of back trouble. As technology got better, they changed the plant so that workers did not have to get up anymore from their desk every 10 minutes. These workers worked 12 hour shifts but now most of the time they were seating down. Well guess what, back problems increased and they had to hire a consultant to help them with their problem.

So, what I basically want you guys to understand is that too much of anything is bad and sitting down for long periods of time is horrible. So all you have to do is get up once in a while.  I always recommend my clients that at least once an hour they have to stand up. And if you have a boss that won´t let you get up, just tell him, first and foremost to read my blog and second that you are saving him money!!

This was only part 1 of herniation, in part 2 I will talk about things you can do to prevent a herniation.


  1. Deyo RA, Diehl Ak, Rosenthal M. How many days of bed rest for acute low back pain? New England Journal of Medicine 1986;315:1064
  2. Liebenson Craig. Rehabilitation of the Spine. A practicioner´s manual. Lippicott Williams & Wilkins 2007. pg 131.
  3. Kim S, Lee Hoo T, Lim Mee S. Prevalence of Disc Degeneration in Asymptomatic Korean Subjects. Part 1: Lumbar Spine. Journal of Korean Neutrosurgical Society 2013 January;53(1): 31-8.
  4. Kendrick D, Fielding K, Bentler E, Kerslake R, Miller P, Pringle M. Radiography of the lumbar spine in primary care patients with low back pain: Randomized controlled trial. BMJ 2001;322:400-05.
  5. McGil S. Low Back Disorders 2nd Edition. Human Kinetics 2007 pg 45.
  6. Carter DR. Biomechanics of bone. In: Nahum HM, Melvin J. Biomechanics of trauma. Norwalk, CT: Appleton Century Crofts.
  7. Porter RW. Is hard work good for the back? The relationship between hard work and low back pain-related disorders. International Journal of Industrial Egonomics 1992;9:157-60.
  8. Woo Y, Gomez MA, Akeson WH. Mechanical behaviors of soft tissues: Measurements, modifications, injuries, and treatment. In: Nahum HM, Melvin J. Biomechanics of trauma (pg 109-33). Norwalk, CT:Appleton Century Crofts.
  9. McGill S. Low Back Disorders 2nd Edition. Human Kinetics 2007 pg 153.

Lower back pain

I don´t want to sound negative or anything, but most of you who will read this blog will, or already have had, an episode of lower back pain. To be exact and according to different studies, low back pain affects 80% of the population at one time or another in their life. Just so that you get a sense of how big lower back pain is I will mention some statistics:

  1. It is the 2nd most common reason for seeing a physician/doctor.
  2. It is the 2nd most common reason for disability, 100 million lost work days a year (1)!!
  3. It is also tremendously expensive, 100 billion dollars are spent each year treating this problem (2-3)!

So seeing its importance, I think we should talk about it a bit and try to dismantle some myths about it. First, I want people to understand that lower back pain can usually be classified into 3 different groups:

  • First red flags: These are caused by serious disease such as a tumor, infection or a fracture. Less than 2% of the people who have lower back pain, have it because of ¨red flags¨(4-6).
  • Second-Nerve compression: This affects less than 10% of the people who get back pain. An example of this could be sciatica.
  • Third Non specific mechanical factors: This basically means we have no IDEA why your back hurts and around 85-90% of the cases fall into this third class (4-6).

So, if you take into account what I just told you, less than 15% of the patients who have lower back pain (LBP) can be given a precise pathoanatomical diagnosis!! The other 85% are sometimes labeled with general terms such as sprain/strain or ¨non-specific¨, in other words they don´t know why your back hurts. The ¨good¨ thing about lower back pain is that it usually has a favorable natural history, meaning that only 5% of the patients with lower back pain will go on to have chronic lower back pain while the rest will (more or less) recover.

Ok, now that we know a bit about what lower back pain is and how it is classified, let´s start talking about some of the myths that exist out there on LBP.

  1. First myth and probably one that you have all heard at one point or another. Strengthen muscles in torso (back) or abdomen to prevent LBP. Until today there has been NO study that has demonstrated this. What has been demonstrated is that ENDURANCE and not strength is a key factor in preventing LBP (7).
  2. Second myth: performing sit-ups or crunches will increase back health. I already talked about this in my blog (here is a link to where you can read it, but just to summarize: no one should be performing sit-ups (8).
  3. Third myth: Tight hamstrings lead to back trouble. This is false, there is no study that demonstrates this. What can lead to back trouble is asymmetry, meaning if you have more flexibility in one leg compared to another (7-10). Also, some studies have shown that the more flexibility one has in the back, the greater the risk of having future back troubles, at least in ¨normal people¨. This doesn´t mean that people should not stretch, mobility is important and so is flexibility but too much can maybe lead to back trouble.
  4. Fourth myth: If you sit straight or on a Pilates ball you will prevent back troubles. First I want people to understand that there is no such thing as an IDEAL sitting posture. Tissue loads must be migrated from tissue to tissue to decrease the risk of any single tissue´s accumulating microtrauma. This is accomplished by changing posture. Even the ideal posture, where they tell you to adjust the chair so that the hips and knees are bent 90 degrees and the torso is upright, is only ideal for about 10 minutes. After 10 minutes tissues deform and the best thing to do is change posture again. So let me repeat this again, THERE IS NO SUCH THING AS AN IDEAL SITTING POSTURE, the best thing is to change posture every 10 minutes (11).
  5. Fifth myth: To avoid back injury when lifting, bend the knees not the back. This is partly right but also partly wrong, because to bend your knees or your back depends on a lot of things. Like the dimensions and properties of the load, the characteristics of the lifter, the number of times the lift is to be repeated, and so forth, and there may in fact be safer techniques altogether. Let´s use an example of a golfer, imagine every time he has to pick up a golf ball he has to squat, meaning bend his knees. Ok, maybe his back wouldn´t get hurt but his knees are sure going to hurt after 18 holes of play. So, to keep a straight back would be ideal but in most cases this is not REALISTIC. What you should always avoid when picking things up is a fully flexed spine.

I could go on with more myths but I think those are the most important. So it´s time to move and start talking about factors that we can do to prevent low back pain, but before this I will first talk about herniation. What exactly is a herniation? Is it really that bad, and how do we avoid herniation. This and more in my next blog. Until then.


  1. Biering-Soerense F. A prospective study of low back pain in a general population. Occurence, recurrence, and etiology. Scand S Rehabilitation Med 1983;19:71.
  2. Cats-Banil WL, Frymoyer JW. Demographic factors associated with the prevalence of disability in the general population. Analysis of the NHANER I data base. Spine 1991;16:671-71.
  3. Hashemi L, Webster BS, Clancy EA, Volinn E. Length of disability and cost of workers compensation on low back pain claims. J Occup Environ Med 1998:40:261-66.
  4. Agency for HEalth Care Policy and Research (AHCPR). Acute low back problems in adults. Clinical Practice Guideline Number 19. Washington DC, US. Government Printing. 1994.
  5. Danish Health Technology Assessment (DIMTA). Manniche C, et al. Low back pain. Frequency Managemente and Prevention from an HAD. Perspective. 1991.
  6. Royal College of General Practioners (ACGP). Clinical Guideline for the management of Acute Low Back Pain. London Royal College of General Practicioner.1999.
  7. Biering-Sorense F. Physical measurements as risk indicators for low-back trouble over a one-year period. Spine, 1984: 9:106-19.
  8. Battie MC, Bigos SJ, Fisher LD, Spengler DM, Hansson TH, Nachemson AL, Wortley MD. The role of spinal flexibility in back pain complaints within industry: A prospective study. Spine 1.
  9. Axler CT, Mcgill SM. Choosing the best abdominal exercises based on knowledge of tissue loads. Medicine and Science in Sports and Exercise. 1997: 29:804-11.
  10. Hellsing AL. Tightness of hamstring and psoas major muscles. Upsala Journal of Medical Science 1988. 93:267-76.
  11. Callaghan J, McGill S. Low back joint loading and kinematic during standing and unsopported sitting. Ergonomic 2001 :44(3):280-94.

Pain part 3

So we have talked already about how pain is produced in the brain, how posture really doesn´t affect pain and how pain can be divided into acute and chronic pain. Acute pain being pain that last 3 to 6 moths and chronic pain, pain that last more than 6 months. So how do you treat the different kinds of pain?

With acute pain it is usually quite easy, the pain is associated with the tissue injury that has been produced and, in many cases, pain medications do work reasonably well. For example, NSAIDs (Nosteroidal anti-inflammatory drugs) have been shown to be effective for injuries (like ankle sprain), and after surgery. But for chronic pain, medications are only slightly effective and this is due to the fact that pain can change your nervous system (1,2).

It has always been said that the brain and the nervous system couldn´t change. But since a decade ago we know that the brain is plastic and can indeed change, it´s called NEUROPLASTICITY. Scientists have seen from imaging and animal studies that persistent pain or pain which last for months and years can change the pain pathway, in other words we become more sensitive. This hypersensitivity causes the brain to interpret anything related to those tissues to be highly threatening. So basically the nervous system and the brain have become more efficient in producing and maintaining pain (3-5). You could say that in chronic pain, the pain has moved up to the nervous system and now has very little to do with the initial damage to the tissues that caused the pain.

Let´s try to clear this up and make it easier to understand with an example: John, age 45, has had lower back pain for the last 2 years. Everytime he bends down to pick up something he experiences pain, so he stops doing that. We know that tissues or bones usually heal in between 3 to 6 moths, so there is really nothing wrong with him from a anatomical point of view. And everytime he bends down it doesn´t mean that he got hurt again or that he re-injured himself. It is just that Johns brain and nervous system have become so good at constructing pain that the slightest of triggers – even those that don´t cause damage, cause pain. So how do we deal with this?

The most important thing would be to educate John about pain, to teach him the role of the brain in pain, and to explain to him that pain doesn´t always equal to damage. When education about pain physiology is included into physiotherapy treatment of patients with chronic pain, pain and disability are reduced (6,7). After this, the next thing would be to gradually expose John to the feared activity (bending down) without causing pain and thereby lowering the threat level in the brain. So we would teach him first how to bend down correctly and to only bend till the point before the pain starts. This process would start to decentralize his pain and eventually make his pain disappear.

To finish I want to hopefully think that people now understand a little bit more of how pain acts and how to deal with pain. These last 3 articles have been difficult and maybe hard to understand but I would be satisfied if people took at least these 3 points home:

  1. Damage does not equal pain; not all damage leads to pain, and not all pain is caused by damage. Example: a study in the journal Arthritis & Rheumatism looked at the relationship between knee osteoarthritis and pain (8). They found out that some people had little arthritis and high pain, and some people had severe arthritis but low pain. The researchers concluded that the level of knee pain was due to central sensitization, rather than the level of osteoarthritis. In other words, the level of pain had more to do with changes in their nervous system, not changes in their knee structure.
  2. You can have a bulged disc or degenerated spine, maybe even impinging on one of your nerves, and still not have pain. Or you could have none of these problems, and still have persistent pain (9-12).
  3. The International Association for the Study of Pain defines pain as an emotion. That is, pain is a perception rather than a sensation. Unless and until the brain senses danger or threat, nothing can cause pain.

To finish I will post 2 links.

In one of them Lorimer Moseley describes how to explain pain to patients and in the second one, which is quite long (44 minutes), he talks about the whole process of pain. Enjoy

In my next blog we will change the topic drastically and talk about food. Is food a drug?? Can you get addicted to food? We will see and explain in my next blog. See you then.


1. Ekman EF, Ruoff G, Kuehl K, Ralph L, Hombrey P, Fiechtner J, Berger MF. THe COX-2 sècific inhibitor Valdecoxib versus tramadol in acute ankle sprain: a multicenter randomized, controlled trial. Am J Sports Med. 2006 JUn;34(6):945-55. Epub 2006 Feb 13. PubMed PMID: 16476920

2. Buvanendaran A, Kroin JS, Tuman KJ, Lubenow TR, Elmofty D, Moric M, Rosenberg AG. Effects of perioperative administration of a selective cyclooxygenase 2 inhibitor on pain management and recovery of cuntion after knee replacement a randomized controlled trial. JAMA. 2003 Nov 12,290(18):2411-8. PubMEd PMID: 14612477.

3.Flor H, Nikolajse Li, Stachelin Jensen T. Phantom limb pain: a case of maladaptive CNS plasticity.

Nat Rev Neuroscience 2006 Nov;7(11):873-81.

4. Flor H, Braum C, Elber T, BIlbaumer N. Extensive reorganization of primary somatosensory cortex in chronic back pain patients. Neuroscience 1997: March 7.224(1)5-8.

5. Ren K, Dubner R. Central nervous system plasticity and persistent pain. J Orofac. Pain.1999.Summer.13(3):155-63.

6.Moseley GL, Nicholas MK, Hodges PW. A randomized controlled trial of intensive neurophysiology education in chronic low back pain. Clin J pain 2004. Sept 20(5): 324-30.

7. Moseley GL. Widespread brain activity during an abdominal task markedly reduced after pain physiology education: fMRI evaluation of a single patient with chronic low back pain. Aust J Physiotherapy 2005: 31(1):49-52.

8.Dallinga JM, Benjaminse A, Lemmink KA. Which screening tools can predict injury to the lower extremities in team sports?: a systematic review. Sports Med. 2012 Sep 1;42(9):791-815.

9. Johnson C. Modernized Chiropractic reconsidered: beyond foot-on-hose and bones-out-of-place. J Manipulative Physiol Ther. 2006 May;29(4):253-4. PubMed PMID:

10. Ernst E. Chiropractic: a critical evaluation. J Pain Symptom Manage. 2008 May;35(5):544-62. Epub 2008 Feb 14. Review.

11. Homola S. Chiropractic: history and overview of theories and methods. Clin Orthop Relat Res. 2006 Mar;444:236-42.

12. Good CJ. The great subluxation debate: a centrist’s perspective. J Chiropr Humanit. 2010 Dec;17(1):33-9. Epub 2010 Sep 21.

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