“If we studied normal gait now, we’d have to revise everything.”

Posted on February 13, 2014

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From an upcoming, much longer post, detailing my second visit to The Washington University in St. Louis. Where I took a course by Shirley Sahrmann and the physical therapy department. You can read about my first visit here

Robert Sapolsky has a great lecture series called Being Human: Life Lessons from the Frontiers of Science. He tells the story of treating Sudden Infant Death Syndrome (SIDS).

For a long time SIDS had no understandable cause. Eventually, in the early 1900s, we delved into this disease and examined a bunch of SIDS cadavers. This was a great opportunity as cadavers represent one of our best diagnostic tools, especially a hundred years ago. We can look inside the body and go, “This group, who died of this disease, seems to have this commonality.”

Upon opening the SIDS cadavers we found an obvious congruity. All the SIDS babies had enlarged thymus glands. Understanding their death became easy: Too enlarged of a thymus gland could asphyxiate the infant, causing quick death.

We immediately formed a solution: Irradiate the thymus gland, causing it to atrophy, and boom, no risk of suffocation.

The result? Ten thousand people were killed, and many more harmed.

“Wait, what?”

To understand this you need to consider what cadavers were looked at, and their relationship to what we considered “normal” bodies at the time.

In human history, through a myriad of mechanisms, the majority of cadavers have been from poor people. Executed criminals -who are usually poor- often had their bodies donated to medicine. Bodies were even stolen from graves and sold to medical schools. What bodies were easiest to dig up? What bodies were least likely to have solid coffins? Poor people’s.

So, we’re at the early 1900s, and nearly all the cadavers we’ve studied at this point are from the poor.

We, especially in the United States, often assume more money is always better. In more recent history, one of the revelations when it comes to the relationship between financial well being and physical well being, is a plethora of money doesn’t lead to a plethora of health. But a deficiency in money can lead to a deficiency in health. Being rich isn’t healthier than being middle class, but being middle class is way better than being poor.

In the States the median household income is about $50,000. The median household isn’t going to add much to its health by striving for more income. It can hurt its health by not staying at this level though. As Sapolsky states, some of the best health advice is, “Don’t be poor.”

One of the obvious health issues with being poor is the strain that accompanies trying to make ends meat. The constant stress hurts the immune system. What’s a gland with a big role in immune function? The thymus. When you’re chronically stressed the immune system never gets to work like it should. What happens when something in the body doesn’t get to work like it should? It atrophies.

Poor people => Chronically stressed => Atrophied thymus gland.

So, we’re at the early 1900s, and nearly all the cadavers we’ve studied are from the poor with atrophied thymus glands.

By the definition of SIDS, the death is sudden and unexpected. In order for a death to be such, the infant must have been healthy beforehand. What infants are most likely to be healthy? Certainly not the poor.

What happens when you get a bunch of SIDS cadavers? You get a bunch of cadavers who are not similar to what’s been studied so far.

Cadavers of poor infants => More likely to have atrophied thymus glands.

Cadavers of SIDS infants => More likely to have regular sized thymus glands.

But, when you’re idea of normal is smaller than it should be, what do the SIDS thymus glands appear as? Too big. Doctors studying the SIDS cadavers go, “Ah ha! These thymus glands are all too large. If we can make them smaller, we can prevent SIDS!”

Doctors began irradiating normal thymus glands thinking they were all bigger than they should be. Their idea of normal was skewed. When you irradiate a bunch of regular thymus glands and the organs around it, you end up predisposing the person for cancer. Which these doctors did, thus killing at least ten thousand otherwise healthy people. [1]

(By the way, this type of stuff -disproportionate amount of poor people being studied- is still going on.)

“If we studied normal gait now, we’d have to revise everything.”

While she didn’t go into it much, this is the genesis of what Shirley was saying. People move so horrendously now due to the nature of what society has become, if we studied what normal movement is now we’d be completely off.

low shoulder is something I’ve covered. I’ve seen others talk about this and state, “Don’t worry about a low shoulder. You’ll see something like this all the time. It’s normal.”

When these guys are saying “normal,” I think it’s safe to say we all take that as it’s nothing to worry about. It’s typical for the body to be this way. Like it’s a natural form of being human. Akin to having 10 toes.

To which I say, no, it isn’t. Just because you see it all the time doesn’t mean it’s “normal.” It’s like saying being overweight or sitting 15 hours a day is “normal.” It may be a regular occurrence, but in terms of the health of the body, it’s not normal, it is something to focus on, it is an aberrant condition of an unadulterated body, it is an issue. How the body moves is a reflection of what you regularly do with it. If you have a low shoulder, that’s a reflection of what you regularly do with the arm. (You keep it low.) [2]

We have to be very careful what we consider normal and ok. I’m going to go over this more with the hip later on, but suffice to say, this is not easy. I have no doubt the SIDS doctors were brilliant people with the best intentions…who still killed seven thousand more people than the September 11th attacks…which should scare the excrement out of you.

For a long time we would excise people’s ENTIRE meniscus when they had knee pain. “That tear is not normal.” The result? We destroyed people’s knees by taking whatever good meniscus they had out. Now we try to repair the tear, and if we can’t, we’ll cut a part of the meniscus off. This has by no means been shown as the best approach. We’re finding, in many cases, it may be best to leave the knee alone. (Surgically; not exercise wise.)

Why? Because it’s plausible having some tears here and there is part of being alive for a long time. Not to mention the relationship between chronic pain and structural damage is dubious.

Shirley referenced a guy who had a knee issue for years. Eventually, doctors looked inside his knee, saw how worn out it was, and decided he was a prime candidate for a knee replacement. It was only later, when his knee was still bothering him and Shirley got to work with him, she realized he never had a knee problem; he had a lower back problem. His pain was radiating to his knee, but it wasn’t starting there.

How on earth could a surgeon miss this? Well, remember, when they looked inside his knee; it was really worn out and didn’t look “normal.” But their frame of reference isn’t a 60 year old knee that’s been around the block. Their frame of reference is a perfectly good looking knee. What we need to figure out is, maybe a “worn out” joint is a perfectly good looking knee for a 60 year old. Maybe it’s just like having scars and wrinkles on your skin.

One of the gold standards of research is using a control group as a reference point. How many atypical control groups have we used to deduce what a proper reference frame is? How many imaginary diseases have we concocted? How many futile surgeries are we doing? The scary answer: We have no idea.

Treating chronic problems is a new phenomenon in society. We’ve never had as many people living as many years, and we’re learning on the fly how to deal with this. Alzheimer’s, many forms of cancer, chronic joint issues, these are novel issues for humans. It’s only recently we’ve begun living long enough to have great numbers of people dealing with these things. Up until now we died from infectious disease, malnutrition, violence, all before we had the opportunity to encounter the chronic side of things.

At the same token, it’s not long ago we became such a sedentary society, where physicality is not a major part of our lives.

Let’s take lower back pain as an example. We know 80% of people will have a chronic lower back issue in their lifetime.

How long have we’ve been studying lower back pain? According to Google Scholar, I don’t see a paper referencing something related to “lower back pain” until 1915. And we start to study it more rigorously around the 1920s. We’re less than a century into studying the most common reason people go to the doctor. We’re centuries upon centuries into having a spine though.

Many believe, doctors included, due the prevalence and difficulty in treating lower back issues, it’s a normal part of being human. I’ve seen some state it’s part of the deal for being bipedal. Implying you can’t do anything about it.

How do we know it’s normal? Were 80% of people before the 1900s suffering from lower back pain? What about in the 1500s? Are 80% of people in third world, non-sedentary countries getting lower back pain? Or, is it common (not normal) for a sedentary, long-living population to acquire lower back issues through their lifetime?

In training many different age ranges, I’ve noticed women who are roughly 50 years old and up bend their knees differently than the current generation. You often see women bring their knees together when sitting because of wearing things like dresses and skirts. However, you see this way more often in the older generations.

It didn’t take long for me to repeatedly hear, “That’s just how I was brought up. In my time you never, ever, opened your legs while sitting.” After telling some older women to open their legs when getting up and down to take some stress off their knees, I’ve even heard, “I feel like a prostitute. I don’t think I’ve ever gotten out of a chair like that.”

How easy could it be to study women brought up in this manner, and even nowadays, and conclude squatting with the knees coming in is “normal” for women? Yet, knowing how the Romans and such treated females, I wouldn’t be surprised if there was a time women were ordered to keep their legs spread at all moments. Or, if just before dresses and skirts were invented, women never had to worry about such a thing.

Again, is it normal for women to bend their knees with them caving inwards? Or, is it common for women of the last 100 years to acquire such a pattern?

This is a crucial distinction. Normal, like having 10 toes, well, there’s not much we can, or would want to do about that. Something which is acquired, like lung cancer from smoking, there’s almost always something we can do about that.

In some areas, this type of stuff is obvious. No one says being overweight is normal because two-thirds of population is.  In some instances, it’s not that big of a deal either. Exercise someone in the wrong manner and at least they’re still exercising. But, in other areas, it’s extremely difficult to figure out a proper reference frame, and the costs for getting the wrong starting point can be exorbitant.

[1] Perhaps the greatest irony of the SIDS story is the well off were the ones who had a lot to do with poor people’s bodies being donated to medicine. They went so far as to have laws if you couldn’t afford a proper burial, the body was automatically donated to medicine. Who was most likely to experience these irradiation therapies? Those who could afford it, i.e. the well off.

Maybe karma does come back around.

[2] It’s typical in the research world to hear how outdated some research might be. While older research may be crude, the fact it’s older and may have studied a different population could prove fruitful. If Florence Kendall were to conduct her work now, who knows how different -and potentially wrong- it would be. She could have thought a low shoulder was normal herself.

Take a look at some common postures and movements modern society has fallen into, and how to get out of them. 

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Posted in: Miscellaneous, Pain