We were honored to have Ben Geierman (@medicinal_movement_rx) attend our PSMMT November course and also spend a day observing the application of the course materials in our clinic at Dynamic Movement and Recovery. Ben has taken a number of courses over the years and has really good insight into the global picture of the Biopsychosocial model across the recovery and training paradigm. He was kind enough to write up his experience of the weekend as well as how it was applied in the clinic. We offer this opportunity to any of our course attendees and we believe it gives the most insight to see the content in action. Without further ado, here were Ben’s thoughts:

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This past weekend I had the unique opportunity to not only take Dynamic Principles Pain Science, Movement, & Manual Therapy (PSMMT) course but also to spend the following day with Leonard & David experiencing first hand how they incorporate the principles taught in the course into the everyday application of treating those in pain.

Overall, the course was a great overview of the current evidence on everything pain, manual therapy, neurodynamics, contextual factors, and critical thinking. However, I found myself most intrigued by the lab component and ‘movement experiments’, particularly with walking and standing.  Initially, these movement experiments seemed quite peculiar as I walked back and forth across the clinic, being mindful of the feelings in my feet, ankles, knees, hips, spine, and so forth all the way up to the head. We performed a similar experiment in standing, playing with various stances and positions at each joint to try to find the greatest position of ease. These were very interesting experiments and quite novel to me, however, I wasn’t quite sure how I would implement them in the clinic or honestly if I could even get patients to take them seriously. However, those concerns were quickly resolved as I spent the next day with Leonard and David watching them put these experiments into action.

Both Leonard and David used the movement experiments quite often during treatment sessions and I was surprised to see how well patients responded to them. Most of the patients we saw that day had persistent pain and previous therapy consisting of more structural interventions and passive modalities without much relief. However, the movement experiment approach was much different and allowed the patients to actively explore their experiences. One patient’s experience in particular stuck with me. She was having hip pain and felt it every time she stood up. By leading her through a movement experiment and some mental visualization techniques, she was able to subtly alter the way she moved all by herself and stand up pain free in less than 5 minutes. Another patient with low back pain participated in a walking experiment and was able to become more mindful of her movement and find a way to decrease her symptoms through finding the movement pattern that provided the most ease. Now most of these patients still had symptoms, but by utilizing these movement experiments, they were able to be more mindful of their movement, experience their symptoms, and discover a new way to move in order to “create space” within their experience to allow for more movement freedom and decreased suffering.

The magic of these experiments further solidified their usefulness as I found myself at the gym in the following days. I had personally been working through some knee pain for the past few weeks while simultaneously completing my powerlifting programming in an attempt to increase the strength of my squat. This was beginning to become quite a frustrating experience, as my knee pain would consistently increase in severity as I added weight to the bar, causing me to have to decrease the weight on the bar during my top sets and subsequently cease the progress I had been making before the knee pain arose. However, after spending the weekend at the PSMMT course, I decided to run a little movement experiment myself. By playing with my stance, squat depth, and bar position, I was quickly able to discover a squat pattern that allowed me to squat without symptoms and even work up to my programmed weights on my top sets essentially symptom free.

Now I pride myself on being a ‘movement optimist’ and finding ways to modify painful movements temporarily while sensitivity decreases, but even in light of that, the pain I experienced in my knee over the past weeks and the associated frustration that came along with the inability to progress my strength as planned, narrowed my perspective to the point where I found myself in a repeating loop of pain and frustration.  This essentially incarnated from coming into the gym feeling fairly well, working up to a decent weight, and like clockwork, experiencing a return of pain in my knee pain again. This experience, as I believe is common with many pain experiences and supported the movement variability research, led to me to pigeonholing my options with various squatting techniques due to my hyper vigilance and yearning to perform the movement as usual without any pain. I think this is such a common occurrence with folks dealing with pain, especially persistent pain, where we get stuck in a rut of doing things the same way over and over again without noticing and continually experiencing the same symptoms, creating a vicious cycle or pain that further fuels itself. However, the beauty of the movement experiments is to allow you to find alternative options on your own to break this cycle by improving your relationship and awareness with your body and movement, all while increasing autonomy and self-efficacy by managing symptoms independently.

Overall, this course was a game changer for me and getting to experience first hand how the material was implemented in the clinic was invaluable. Although I took the most from the movement experiments, there were a ton of other gems in the course and nuggets on new research that I had not been aware of and which will certainly positively affect my future practice. Nonetheless, the magic of the movement experiments will stick with me most, and I loved the acceptance and commitment therapy (ACT) framework presented alongside it for working with people dealing with persistent pain. The whole approach is essentially aimed at accepting the symptoms but committing to engage in meaningful activities despite, in order to decrease suffering and improve function. However, it’s imperative to recognize that acceptance does not mean passivity and by using the movement experiments, patients are able to actively create space by becoming more mindful of their movement, leading to greater flexibility to live meaningfully in spite of pain. I firmly believe this approach will be immensely helpful for my future patients dealing with persistent pain and I highly recommend experiencing Dynamic Principles course first hand for any healthcare provider treating humans in pain.

Ben Geierman DPT, CSCS

There is an epidemic of movement professionals emphasizing outcomes without understanding “why” they are seeing the things they are seeing in human movement. Whether a rehabilitation profession, a strength and conditioning coach, or personal trainer, just because something changes, doesn’t mean that it had anything to do with the specifics of what you did, there are many factors involved in movement behavior change, most more powerful than the direct effects of your prescribed exercise! The “why’s” that are frequently touted tend to be focused on rigid structure, failed understanding of tissue strain curves and plasticity, and a fallacy of some sort of predictable patterns which must be re-organized like a puzzle piece or molded like a piece of putty. There is rarely a basic analysis of the underlying physiology that creates the measurable change that is occurring. Failure to investigate the most studied mechanisms for the changes we see, limits significant potential for improving prescription strategies and may also increase risk of harm of the client for which the plan was made. In fact, the education we use to describe our movement strategies may negatively impact the potential of that movement strategy, or even harm the client’s beliefs about themselves and their potential. Furthermore, a failure to understand how psychology, social factors, and culture are tightly interwoven into the physiology of human movement has long term implications of movement across a lifespan.

Below are 8 examples of strong basic scientific concepts related to movement which are vital to understand for anyone who observes and prescribed movement interventions

  1. Flexibility and Mobility
    • Muscles, tendons, and other soft tissues are not independently operating tissues of the body, they cannot become “tight” or “stiff” on their own, they require a nervous system, immune system, and endocrine system (infact there is growing evidence muscle is a an important endocrine organ!) to be able to do anything including how willing they are to move and be lengthened. To understand flexibility, range of motion, and “mobility” you must understand nociception in contexts other than pain. You must understand that nociception does not equal pain and plays a vital role in many areas of human function. If nociception was pain and if we have “pain fibers” and “pain signals” in the body, then we’d all be screaming in pain as we explore our available range of motion, because how nociception is processed is what predominantly regulates your flexibility and your ability to change it. Your nervous system is the primary driver of how willing your muscles and tendons are to lengthen, if it feels you shouldn’t lengthen that tissue, no amount of stretching will change it unless you can “play with processing” to see if it will behave in another manner. Fundamentally, if the term stretch tolerance is new to you, you missing out on the most basic fundamental science of stretching and mobilization, stretch tolerance the cornerstone physiology of range of motion works in humans.  (here, here, here, here, here to start) Furthermore, by understanding stretch tolerance and knowing that nociception is both peripherally and centrally facilitated and modulated means you need to understand a persons thoughts and emotions are going to regulate how much the muscle will resist lengthening. (see here) The amount of time wasted on stretching and mobility activities emphasizing an area that doesn’t want to move is ridiculous. Odds are very good there is a reason the tissue is behaving the way it is, and efforts to try and change it may counteractive to the functional benefits of it being “tight”, perhaps the behavior could even be protective! We see this very clearly with running, if the gastrocsoleus and achilles tendon complex did not stiffen with increased volume of running, you would lose a tremendous amount of passive tissue energy reserve which reduces strain and effort throughout the body. Yet here thousands of runners waste their time “stretching” their calves, or thinking they are mobilizing their talus with a band, fighting against a very useful and performance enhancing adaptation. Worse yet, and depending on the area emphasizes, this excessive time spent on mobility and flexibility may contribute to unhelpful compulsive behavior and potentially result in tissue injury in the long term. Remember, it doesn’t require a fancy technique or tool to change mobility, just play with context and processing and see what happens, look here for an example.
  2. Strength and Durability of Soft Tissues
    • To fail to understand the high tensile strength, adaptability, resiliency of connective tissues and normal connective tissue changes such as scar tissue, means to not understand the purpose and nature of fascia and to not understand tendon/fascia skeletal muscle interface as related to movement.  (here, here, here, here, here)  Fascia really has two primary purposes, it’s a firewall to protect the spread of infection to deeper tissue, and to conserve energy. Take for example the IT band, which requires over 2,000 lbs of tensile force to lengthen a measly 1% in length, that tensile strength is what helps to make walking gait and running far more efficient, it has to be tense! Let alone the basic science of physics clearly indicate you as a clinician could not lengthen it (or any other piece of fascia) even if you wanted to! Over emphasizing and/or under appreciating these fundamental concepts of soft tissue leads to many common time-wasting strategies, promotion of negative self-beliefs, obsessive behaviors, and possible injury to neurovascular structures. Clinically it is not that uncommon I see athletes who regularly “roll their IT band” end up with significant sensitization of the lateral femoral cutaneous nerve, which can sometimes take a very long time to calm down. The warning signs are common, if you find yourself upgrading from a foam roller, to a bumpy roller, to a PVC roller, to a steel pipe and beyond,  because you can’t get your targeted area to “mobilize” like it used to, you are starting to experience some change in nociceptive processing, you are experiencing less the DNIC effect. (Diffuse Noxious Inhibitory Control) DNIC is part of what gives you the illusion of tissue change but is actually an endogenous modifier of nociception and nocifensive behavior such as tissue guarding (see #1 above). Keep ignoring the growing sensitization and thinking the tissue just needs to be “Beat-up more” to be “mobilized” and the problem could expand into something else.
  3. Regional Emphasis on Mobility
    • This is one my most frustrating things to see on social media and I’m equally guilty for previously propagating this misunderstanding in the past.
      • “Focus on dorsiflexion to improve your squat” – No, you don’t need to, dorsiflexion only influences one aspect of a squat, the ability to go past the toes, which you may want if you want more quad work. It’s based on the idea that there is some form of “good” squat form, there is not, you squat the way your body is built, you don’t force your body into a particular squat. The key is, you can still get a great squat with less dorsiflexion, there are thousands of other ways to squat to and past parallel, and ways to work your quads more, all while meeting the ability of your anatomy safely and appropriately. Squat to your anatomy, not into it, or past it!!
      • “Your hip flexors limit your squat” – No, they don’t, look at the anatomy and follow the osteokinematics with the origin and insertion. No, they don’t, please look at the anatomy. Please stop.
      • “Your psoas is too tight and pulling on your back keeping you out of neutral spine during your squat” – No, it isn’t, no it can’t. See above. And no you can’t keep a neutral spine, see below.
      • “Mobilize those hips to get this very specific angle of hip width/ER/flexion in your squat that you must have to protect your spine” – Your hips can only move in the way your anatomy was built. Human hips have a great deal of femoral acetabular variation, it is common and many factors influence it. (see here) Even a form of the “dreaded”  Femoral Acetabular Impingement (terrible name for a normal variant of the body) exists in some manner in up to 67%  of asymptomatic individuals (here) Odds are if you keep pushing hips into a direction where two bones get really close to each other, your body might start to guard or get angry. See topic 1 above for consideration.
  4. Keeping a Neutral Spine
    • Human bodies cannot keep a neutral spine while squatting, even in highly trained Olympic lifters. No matter what, 40-50 degrees of lumbopelvic flexion always occurs during efforts of “maintaining neutral” while squatting or picking something up (see here). If you are worried about spinal flexion and spinal discs, perhaps it’s best to realize we are all “doomed” and maybe that doesn’t matter. Or perhaps our understanding of the biomechanics of the spinal discs is that in weight bearing flexion is not that of a jelly donut, and might protect the spinal cord and nerve roots in comparison to neutral or extension. (see here)
  5. Stabilization and Muscle Activation Exercises
    • Guilty as charged, I sadly even wrote articles to perpetuate this limited concept without fully questioning many of the authors and clinicians thinking. This is the problem when you expect “leaders in the field” to do the critical thinking for you rather than delving into it yourself to make sure what they are saying makes sense. The fundamental problem is there are no specific “stability” motor control patterns written into the body that can be assessed or that need to be trained, there are a number of very fundamental aspects of humans with spines that are commonly missing from the dialog, in particular, the role of context in posture and movement. Rather than “stability” motor programs in the human body; there is a “keep from tipping over”, “don’t drop that thing”, and “don’t get squashed” contextually derived dynamic postural-righting behavior that is heavily influenced by your emotions and your thinking in real-time. (start here and here) Many of the smaller muscles of the spine are spending a good chunk of their time as sensing organs while other portions of their time fine tuning movement with other larger and smaller muscles, sometimes they’re even allowing the passive structures to do work, and that’s normal and needed for the health of the spine articulations and structure – Gasp!  Any effort to train them is an exercise in futility. Every study that has examined this belief shows there is no change in actual muscular behavior when doing specific exercises; doing those exercises might make a person feel better for a number of other reasons, but nothing changed with how the muscles function. (here, here, here, here, here, here to start) Furthermore, things like specific order of activation of muscles, do not exist, I’ll let Greg Lehman take it from here and here. We can’t program motor behavior with exercise prescription, they’re not programmable, you can condition the muscles but their motor behavior is dynamic, not static, and the amount of factors involved in that dynamic state, let alone the infinite numbers of contexts they are changing in, is impossible to predict and accommodate for with a deliberate exercise. Specific “Stability exercises” are not only a waste of time but may reinforce pain related behaviors by reducing variability of the trunk in response to context, which may be detrimental in the long term by creating a virtual “movement prison” (thanks to Jarod Hall for that term).
  6. Emotions and thoughts in Movement
    • If you fail to recognize the vital importance of emotions and thoughts in the human movement, you fail to understand motor behavior in a meaningful way, motor control and coordination does not exist in a sterile environment, in fact their very development is dependent on emotions and cognition. (here, here, here, here,). Trying to make someone selectively “turn-on” (since when was it off??) or emphasize an muscle when they have significant stress in their life is not just a futile effort, but it’s essentially impossible for them to do in that context of their life in that moment. Their motor circuitry is overloaded by their emotional state which no cognitive cue is going to override. Fear results in massive co-contraction of the TVA, multifidi, IO/EO, rectus, and ES! That corset is already there, the problem is, they don’t know how to do anything BUT brace their core at that moment.
  7. Posture is Biopsychosocialcultural
    • If you fail to understand the psychological, social, and culture roles of how humans hold themselves, you do not understand posture, it is not just a bunch of bones stacked on each other. (see previous post on this here)
  8. Injury Prevention is Non-specific
    • There are many “injury prevention” and “bullet-proofing” programs out there by a number of gurus. Some of those gurus were hired by professional sports organizations, how do you think those teams are doing? (here, here, here to start.). When looking at specific vs. general programs of preventing injury, no specific strength, flexibility, or neuromuscular control strategy stood out amongst the rest (here). Simply doing something different than current sport while participating in your sport seems to help, and the slow burn recognition that the most predictive return to sport after injury are psychosocial factors is slowly making it into daylight.

If these concepts are new to you, please take the time to struggle with them. I started this journey toward understanding movement 21 years ago for my own benefit and then began trying to help others 5 years later and I’m still processing this stuff on a daily basis to make sure I can best take care of myself and my clients. There are a lot of unknowns in movement, but as described above there is a strong scientific basis for shifting the way we look at human movement through a Biopsychosocial lens and not getting caught up in this illusion of a “movement system” that operates like a machine. We are not simple cars, we are so much more than machines.

Your client is here.

You, at a normal pace, hurry to greet them but quickly slow in approach as you watch them rise from their seat with the movement quality of someone 50 years their senior.

The slow rise finishes with qualities of an old machine attempting to shift into a locked position as they intensely brace themselves through the maximal slow strenuous effort to extend their hips and spine to an upright posture.

You start your steps toward the treatment room but by your second step you realize you already passed your client 6 feet ago. You realize, it’s time to be here now.

The journey to your treatment room provides time to review testing findings and discussions both you and the client’s had coordinated with other disciplines. The patients words require significant effort for them to express.

Their words have a defeated and tired air to them but they certainly are giving all their effort.

The travels, the demands of work and the significant struggles in family life, the sheer tenacity and will to keep going in spite of a body that screams for rest. Life must go on after all does it not?

You observe the posturing that looks that of a much frailer representation of the younger client who stand before you. Your mind wants to speak of the antalgic changes in kinetic loading from foot to head and the way the sandals are worn on the feet to allow for some relief but now is not the time. The rigid shoulder and arm posturing, the clenching of the fists, and the strain of the words coming from their mouth.

You arrive at your treatment room, you lower the table. Already all plans for the session have changed four times since you first greeted your client.

Every plan shift reviewed systems, symptoms, behavior, client report, reconsideration of other discipline objectives, the social and work constraints presented by the client. Where is my entry point today, no not there, ah there, no the time is not right, could they progress on that from before, are they ready for this? No not now, let them lead.

You place the chair but the client opts for the table.  They do not know their body, they do not know struggle they themselves are adding the problem, but words do not matter now. Only the bolster and hands on guidance for ease.

The client exhales a sigh of relief for a moment, their eyes change as they seem to indicate that they just learned something in that process, and they thank you for helping them.

You notice the swelling of both ankles are improved since the last session and the client reports they are seeing improvements since the first session with the strategies you had discussed.

You know the relief is short lived and begin planning in the background the next steps and how those steps could be used to further educate and empower the patient to learn know their own needs better. You balance your words in your mind as you find ways to both the dance with the complexity of, dare I label and define it?

Moments later the next wave has arrived and stuns the client into a heightened state once again. They steel themselves and demonstrate an intensive muscular effort of the back and hips that they report provides them momentary relief of both legs but worsens their back.

The session now reveals itself dynamically.

The dance of the dialog and interactions of session now reaches a flow point. You and your client work together to engage the suffering and workability of their struggle with pain.

The dance is certainly technical, from review and progressing of  meaningful understanding and application of the physiology, the cognitive, the emotion, and the social interactions.. To managing the biomechanical outputs through hands on guidance and coaching of positioning relief  to allow them to appreciate value of awareness and exploration of the automatic postural and guarding response of the human body. The larger picture unfolds and the conversation naturally leads to where the client is going to engage in the process.  The artistic beauty of the interaction paints the picture, rather than the technical details.

The client breaths comfortably. The pain is less, but this not important. What is important is that the meaning of the pain has changed. They feel hopeful and they know their role in the process going forward.

The time allotted is now over. Now the journey from the sterility, but subtle safety, of the room to the clients own reality begins. They arise now taller, there is a lightness present in their movement, and there is strength in their words.

“An important role of human body is to protect itself, in particular the health of the nervous system, a somewhat important system that sustains conscious human existence, which has physical, cognitive, and emotional layers attached to it. It is likely not helpful to label these protective behaviors as bad or good, but to recognize in some circumstances that these protective behaviors may begin to limit function. Often, movement and physical behaviors of the body are perceived as part of the musculoskeletal system alone, however cognitive and emotional states, which are intricately bound to social/cultural demands and expectations, also influence body behaviors, including postural and ideomotor tendencies that could manifest as protective strategies of the human body. Some of these protective behaviors may limit movement and movement variability and this could be sensitizing to the peripheral nervous system because nerves might not be experiencing adequate blood/movement/space, chemical irritation might not be dispersed quickly enough, and/or they could be undergoing possible noxious mechanical deformation. While the goal should always be to have the client independently explore variability and quality of movement, sometimes they simply can’t find the area of their body to move, have poor sensorimotor awareness and coordination, and generally have difficulty creating movement variability without some guided tactile input from another person. There is notable evidence in research that somatosensory neuroplastic reorganization is constant and that certain areas of the body are poorly mapped, such as the back/pelvis/hip. Furthermore, a sense of self is more than simply “where are the body parts”, how humans see themselves internally via interoception has been recognized as an important component of their behavioral and emotional states. Lack of movement, movement invariability, and pain experienced with movement may result in changes of these body maps that make sensorimotor awareness and coordination challenging. Tactile input and tactile cues do not necessarily need to be considered “manual therapy”, however, many traditionally taught manual therapy techniques can easily be “re-framed” in ways that could help someone to better “get to know their own body and behaviors”, including influencing somatosensory mapping and sensorimotor behavior through various forms for clinician “manual” input. I would argue that in our continued efforts to improve on the application of a biopsychosocial framework, we move beyond using manual therapy simply for “symptom modification”, but rather helping a person to better understand their body and the behaviors it exhibits, not only in the clinical setting, but in broader biopsychosocial contexts. “ – Leonard Van Gelder

Often as a culture, we have associated lifting heavy things and being in awkward positions as triggers of acute LBP. While these are important factors, the risk of them causing an initial episode of acute LBP is SIGNIFICANTLY increased when combined with psychosocial factors:

“transient exposure to stress and fatigue triples the odds of developing immediate back pain, whereas distraction increases the odds by a factor of 25” – https://www.ncbi.nlm.nih.gov/pubmed/25665074

Regard recurrent cLBP triggers, a recent study  looked at 6 physical factors factors that play a role in a ‘flare-up’ of LBP and compared them with stress and depression. They looked at the following physical factors:

1) lifting a heavy object (≥35 lbs.) between 1-5 times, or >5 times,

2) running/jogging,

3) vigorous, non-contact sports (i.e. tennis,swimming, cycling, etc.),

4) vigorous contact sports (i.e. football, hockey, soccer),

5) physical trauma such as a fall, motor vehicle accident, or other trauma,

6) prolonged sitting (>6 hours),

7) prolonged standing (>6 hours)

8) physical therapy (PT) for LBP.

Rather than heavy loads and intense activities as triggers of LBP ‘flare-ups’, instead they found “prolonged sitting (>6 hours) and stress or depression triggered LBP flare-ups.”. Good news for those of us in rehab, the data supported that “PT was a deterrent of flare-ups. ” – https://www.ncbi.nlm.nih.gov/m/pubmed/28700451/

Research Review Brief

An educational approach based on a non-injury model compared with individual symptom-based physical training in chronic LBP. A pragmatic, randomised trial with a one-year follow-up – Sorensen, et al.

Population

207 patients 18-60 years (52% female)with LBP for at least 4 out of the last 12 months with the last 14 days =/>4/10 on a VAS. If they had leg pain, the back pain had to be a worse complaint. All subjects made it through the study with no drop out in either groups (impressive!)

Treatment Groups

Group 1 (EDUC):  105 Subjects received an educational approach designed to improve confidence in the robustness of the spine and two movements: Seated flexion and rotation
Group 2: 102 Subjects received Symptom Classification Based Treatment – MDT(by certified MDT) Directional preference, Stabilization, or intensive dynamic exercise. IN ADDITION: group 2’s physical therapists could at their own discretion referred for pharmacology, manual therapy, or physician for injection to complement their symptom based plan

Outcome Measures

Pain, Activity Limitation, FABQ, Back Beliefs, physical activity, work ability, quality of life

Results

Primary Outcomes: Non-significant trend towards activity limitation being reduced mostly in the educational group although this could not be determined as clinically relevant.

Secondary outcomes: Improvement in fear-avoidance beliefs was better in the educational  group. All other variables were about equally influenced by the two treatments.

The median number of treatment sessions was 3 for the educational group and 6 for the physical training group.

Conclusion:

“We have demonstrated that, among patients with cLBP, the educational/cognitive intervention with few consultations was at least as effective as an individualized, multidisciplinary physical-training approach. ‘At least’ refers to the observed overall trend of more improvement in activity-limitation with EDUC. ”

“There was a statistically significant difference at 2 months in favor of EDUC in the proportion of people improving by a Minimal Important Change (MIC) in activity-limitation (5 or more points on the LBP Rating Scale).

“Post-hoc regression analysis showed a relationship between improved activity limitation and improvement in FABQ, and FABQ was more improved in the EDUC group at all three follow-ups, on balance these data appear to favour the EDUC approach.”

 

Full article Available Here.

***Please read Finding Ease Part 1 – Making Peace with Posture and Pain prior to reading and watching the video below:

Ah, sitting, Western culture’s perceived demon. Is it really that bad? The alternative of standing all day isn’t fairing well in research or in practice, so perhaps it is time that we reconsider making peace with sitting.

One of the questions I ask about sitting, is how often are most of us really “using a chair as a chair”? Are we resting in a chair, or are we desperately trying to meet the cultural phenomena of “good posture” and not allowing our body to take a rest? We look at the phenomena of lumbar flexion-relaxation in standing during bending behaviors and we see that it is hard to let our lumbar extensors rest when we are in pain. It has also been shown that in some cases, even after pain resolves it is still hard for us to “let the back go”. When we look at sitting behavior of the lumbar extensors in pain-free individuals, there is a nice relaxation of the lumbar extensors during slouched sitting. Coincidentally, much like standing trunk flexion, people experiencing low back pain have decreased flexion relaxation in sitting.

Clinically, I see this every day with my patients who cannot tolerate sitting well. Even when slouched, they struggle to really be at ease in any chair. There is this disconnect between finding comfort and holding their body how they believe they “should” be holding it. They can’t give themselves permission to shift to a more comfortable position, and if they do change, its seems like their only option is a big giant “ants in the pants” change to find momentary relief for their nerves that have been screaming for blood, movement, and space. My early attempts at telling people simply to “relax” were relatively fruitless. People didn’t start getting more comfortable with long bouts of sitting until I transitioned to an experience-based approach to exploring options and introducing variability throughout the body for finding ease in the sitting. All the while combining the experience with pain science education. Thanks again to Joe Witte for inspiring the foundation for this experience, I have definitely am doing a dis-service to the simplicity of his approach.

What is a “good posture”? When  295 physiotherapists across the world were asked this question, they could not agree on what it looks like. If you were to ask more than one person who claims to work on posture this same question, odds are pretty good you will get different answer. Despite a lack of agreement, people still believe that a “good posture” exists. On the other end of a spectrum, a number of scientific research studies have failed to demonstrate that “bad posture” (whatever that means) causes pain; most could not find a connection and those who found a correlation could not separate out cause from effect. For those of you unfamiliar with the literature, please check out Ben Cormack’s Definitive guide to Posture & Pain in 3 minutes flat post for a brief abbreviated overview. Despite these contradictions, the widely held belief that a “perfect posture” and a “bad posture” exists continues to be spread.

As much as I would love to believe we all recognize that the complexity of pain makes something as simple as posture simply a grain of salt in the big picture of the worldwide disabling epidemic of pain, this recognition does not appear to be trending much better, yet…  A slight glimmer of good news occurred as some international news circuits have picked up on a recent study which nicely demonstrates that the fear-mongering “text neck” does not cause pain and the Guardian recently had a great post regarding the myth of sitting posture. If these don’t get you thinking, check out a great video from Greg Lehman titled “Perfect posture doesn’t exist“.

If you think about it, it never really made sense, take a moment to look at life around the world and recognize how what many perceive as “bad postures”, are in fact, a normal variation in the demands of daily living. The body is remarkably resilient and designed to take on the stresses of daily living:

Part of the problem in interpretation of “good” or “bad” posture is the illusion that somehow, we are all keeping certain postures during the day. The truth is, we rarely keep the same posture for long. Dreischarf et al. looked at 208 adults with no current low back pain and monitored their lumbar spinal postures via electronic sensors for 24 hours. They found that the average range of change during the day was 8-33 degrees of lumbar lordosis! What we think of posture is just a tiny snap shot in the motion picture that makes a person’s day:

Another problem is that what we perceive as a “bad posture”, may simply be representative of an unconscious protective behavior. If you introduce a noxious stimuli to someone’s back, IE: inject a high concentration saline in their back, they will change their posture. As shocking as it may sound, our body wants to protect itself, and it will change its behavior with, or without, your input. What the body perceives as threatening is more than simply nociceptive input, your emotions influence your posture as well. Moderate to severe depression is associated with classic “poor postures” and fear of pain reduces lumbar flexion to provide just a few examples. If you combine fear of pain with minor injury such as a workout which produces normal “muscle soreness”, your body may avoid lumbar flexion. Furthermore, if you have an episode of back pain, even if you do not have fear about it, your body will change you trunk musculature to behave in a more protective manner.

So where am I going with this?

I think we are looking at posture too much like a stand alone “thing”. Rather than being a cause, or a victim, it seems posture itself is a biopsychosocial representation of human needs, experience, and expression. It is reflective of a moment in time (or series of moments) and a person’s relationship to posture in that moment. Biologically, our nerves may need blood, movement, and space and posture change may be needed for that to occur. Culture and society may deem certain postures necessary, or conversely, inappropriate, and this may conflict with the needs of the physical body at the time. Emotions could be drivers and/or expressions of posture, ideomotor expression is a fascinating phenomena. Are we at peace with our body, avoidant and ignorant of our needs, or does it appear like it is is constantly on alert for a possible threat? If we are stuck in state of threatened existence, how do we find ease? Is it enough to tell some just to “relax”, do some breathing, move more, or do they need a little more guidance?

Below is the first of a series of “finding ease” guided experiences I wanted to share regarding how I believe we can use physical, cognitive, and emotional strategies to find ease in a posture for a moment. I must give a massive shout out to Joe Witte, a local physical therapist who is also a Feldenkrais practitioner, who cued me into these strategies for laying down, sitting, and standing. However, I will acknowledge I have essentially butchered the original non-verbal guided beauty of how he introduced me to this approach, but this is intentional. My belief is that simple experiences, such as this example of laying down, are ideal opportunities of effective therapeutic neuroscience education that may be helpful to unravel beliefs and open a person to new options for potential change in their life. Combining education, with an experience, body awareness, postural and movement variation, and re-assuring human contact has offered a number of my patients life changing insights into the complexity of their pain and a very real sense of hope that they did not previously have. Many of my patients cannot find comfort in a laying posture, and it is often the easiest place to build awareness and introduce change for other positions and movement, so this is where we start:

 

This post is far more personal/autobiographic in nature than anything I have previously posted. I hope it does not detract too much from my intentions for this blog, but I have found that reading and hearing other clinician growth/life stories has tremendously helped my professional growth. I hope that perhaps this post may be meaningful for someone else.

Preparing for the journey:  Pain and Movement

I was exposed to the experience of persistent complex pain early in life. Shortly after birth, my family started to question why I was in near constant distress. Countless medical care visits later, I received my first pain diagnostic label; chronic cluster migraines, at age 2. This made for a challenging childhood, I missed many typical school age experiences and averaged ~50 days of lost school a year. I know it was a terrible burden on my family, and the physicians didn’t help the problem by telling my family to watch out for possible suicide efforts, as historically, cluster migraine was labeled the “suicide headache”, now that is nocebo!! Imagine as a parent, or a sibling, how that felt to think about? I was thankfully oblivious to this information until later in life. I can relate with the social implications of persistent pain quite closely. I can also relate with my patients on how pain negatively influences your relationship with movement. I wanted to move, I was a kid, I wanted to go out and play and hangout with friends, but the fear of triggering a cycle of pain sometimes prevented you from wanting to try to move. Despite this, I had this intense inner desire to move, and by grace and with the resiliency of youth, I was able to find a movement experience that fit my needs, falling in love with martial arts, and later stunts and movement choreography. With martial arts, I progressively, yet unconsciously, found a balance between intense physical training and rest though a 7-year sedentary career in information technology during the dot.com boom in the 90s. Perhaps this paced rest-to-work ratio was part of what made such a profound dent in in the frequency and intensity my headaches in those years. Likely, these effects were combined with the reduction of social pressures by dropping out of high school at that time… Regardless, all other medical interventions had failed prior to that point to improve my pain.

Another important observation to note about that time was when I instinctively recognized there was something more to human movement than the physical domain. Movement at times would resonate with me emotionally, it stimulated me cognitively, and as I explored different martial arts styles, I found the cultural  variations of essentially the same movements fascinating. Long before I knew the science, or what the words meant, there was this unconscious awareness that movement and pain was bio-psycho-social in nature.

The Journey There

In 2002, I was training and teaching at a kung fu school which decided that they wanted to expand their strength and conditioning offerings for their San Shou (Chinese Kickboxing) program. The school owner invited me to join him in attending a Perform Better seminar that year. I gladly accepted the opportunity because at that time only thing I knew about “Conditioning” was working yourself into the ground combined with traditional “Chinese torture” conditioning methods. There were several great speakers at that seminar, and being blissfully ignorant to the world of performance enhancement, made me feel like a kid’s first experience in a candy shop. I cannot recall all the speakers for the seminar, but I was most influenced by Mark Verstegen and Michael Boyle that day. Michael made a statement during his presentation that finalized my decision to become a physical therapist. It was the early days of the joint-by-joint, correctives, and of course, “core stabilization.” We had previews of the Gray Cook Movement trend to come and looking at the landscape today, it is shocking how little has changed in the last 16 years. I was also introduced to the idea of mobility work with various tools and rollers and this magical “fascia” and phenomena called “Trigger points.” I had dabbled with manual therapy before then, in particular with “trigger points”, having received treatments which had given me some short-term benefits for aches and pains from time to time. It made sense to me that hands on care had some value. If I’m honest, it didn’t take much to sell me on the dream of being a manual therapist to “fix” and train people, I still had aspirations to grow up to be the legendary martial artist and Chinese Medicine “bone-setter” “Wong Fei-hung.”…

I remember the thrill of the experience of being at that seminar clearly to this day. It created that feeling of the days of learning that “secret” technique in martial arts. I was enamored by all of it; I loved the “structural” thinking and the “healing” potential of the concepts of the biomechanical/pathomedical model. Being an IT guy at the time, the idea that there was some sort of “ideal” motor control and motor pattern for all sorts of movements that every person should be adhering to avoid “dysfunction”  seemed so logical, people had to be fixed! This started my first “binge phase” of learning. Before I went back to school to become a physical therapist and athletic trainer, I already had purchased the red tome of Travel and Simons, picked up a copy of Florence Kendal, and memorized Netter’s musculoskeletal pages, excluding the nerves of course, what good were those to fascia?! I bought a treatment table and lined up my “victims” to develop and practice my new-found skills using hands and other modes of manual therapy combined with my growing collection of “correctives”.

Doubts on the Journey

Fast forward through the roller coaster of information and skills I explored between the years of 2002 to 2010. It was a head first dive into a wide variety of manual techniques, Thomas Meyer Anatomy Trains, FMS and SFMA, Vladimir Janda, Stuart McGill, Pavel Tsatsouline, and countless other concepts and “thought leaders” at the time. No questions asked, if the pros were using it, I had to learn it. Besides, there must be evidence for these things somewhere right…? All I knew was, I wanted to be a movement expert and a highly skilled manual therapist, I had no concerns about the tens of thousands of dollars I invested in these resources along the way, or thousands of hours exploring them. But some tiny doubts started to creep up as I started to realize how much of my own training time was used for preparation and mobility work, and it was beginning to cut into skill training. Plus, I started getting frustrated because none of it was really helping any of my body aches and pains, instead, it seemed as though they were starting to become more frequent and persistent…

In 2008, I started to wonder why it was so hard to find research to support all these amazing outcomes we believing we were seeing in the field. So, I did what any other sane person would do, I decided I should start learning how to “science this shit of this” and begin adding to the literature myself. As is classic me, I fumbled my way into learning the scientific method with whatever resources and mentorship was available to get the job done. I chose something simple at that time which was the “hot topic” of dynamic vs. static stretching and chose to look at their roles in agility performance because nothing had been published at the time in that area. You can see the results of that experience here.  There are many things that can be learned in the process of developing, conducting research, writing, peer-review, and publishing a research article. The most important thing I learned was to be very systematic/procedural about literature review and begin to question my biases. By no means am I saying somehow I have succeeded in completely overriding my biases, but it was enough for me to start questioning some of my core beliefs about movement, manual therapy, and pain. The literature review process for stretching also brought me into the world of the nervous system and how it would be impossible for me to truly know about movement if I didn’t understand the nervous system better. Up to this point, my understanding of ROM and mobility was based on traditional biomechanics and the stress strain curve, so this was eye opening to be learn non-mechanical properties had a more profound role in available ROM. It was also when I first time was exposed to the idea that nociception does NOT guarantee pain, nor was pain it’s only role, but that it had other important biologic purposes. Of interest to me at the time, nociception’s role key role in stretch tolerance, the cornerstone of ROM and mobility. I didn’t realize how important that bit of learning would be in my current growth, because I still had my blinders on and had a fairly structuralist based mindset, but my curiosity was increasing.

Fast forward two more efforts to contribute to scientific literature, both of which had their own positives, negatives, and flaws (here and here). After completing these, I decided to take a break from being involved in active research to focus just on clinical practice with my new thinking in place. I have no doubt I will revisit the role of being a researcher again in the future.

Finding Ground

From movement and manual therapy came the opportunity to learn about pain science. I figured a good part of my life I had experienced some form of pain, sometimes finding relief for short periods of time, but I wondered why no treatments or magic trick seemed to have lasting benefits. So naturally, it was time to learn more about pain. Between natural curiosity, expanding available literature, and the “hivemind” that is internet social media (filled with its own opportunity and pitfalls), there was a great deal to learn. The constant feed of people smarter than myself on Blogs, Twitter, Facebook, and sites such as SomasSimple forced me to constantly question my interpretations of literature. There were times I felt my beliefs and interpretations were under constant threat and the ground beneath me was going to give way, but I knew that struggling with these ideas were vital toward my goals. It was a challenging time but my own struggles with pain made me realize the biomedical model was woefully inept at addressing the Complexity of Pain and I finally had to embrace the biopsychosocial framework.

It is hard for me to make a single list of all the people who inspired me and helped me understand pain better and how to implement it into clinical practice, but I must at the very least mention Adriaan Louw, Lorimer Moseley, David Butler, Louis Gifford, Diane Jacobs, Greg Lehman, Peter O’Sullivan, and Todd Hargrove. I owe Adriaan for not only helping me connect some important dots in pain physiology, but for changing my life in a short conversation he had with me about the fears I had about my own pain problems. His approach resonated with me and greatly influence my education style a great deal. I recommend anyone who works with people in pain consider taking part in the Therapeutic Pain Specialist program at the International Spine and Pain Institute.

With my foundation and framework somewhat stable, I began to nearly exclusively treat complex and persistent pain problems. The demand was so high in my community, I could not keep up with the number of referrals myself. To meet these needs, I developed an outpatient pain treatment division for Generation Care. This meant beginning to develop a curriculum and a system to start sharing my ideas with other clinicians. Through 2017, I had 10 clinicians suffer through my attempts to get ideas out of my head and try and making meaningful applications to their clinical practice. I can proudly say we have made a successful team to take on extremely challenging cases in our community and I look forward to new additions joining this year as the demand is not slowly down.

Back again

This brings us to 2018. Before the start of this journey, there was pain and movement. When I started the journey, it was about movement and manual therapy. As the journey continued, I reconceptualized pain and realized understanding pain meant understanding movement and manual therapy better. Now, the realization is there is a person behind all these things, which is an amazing conversation in and of itself. But in the meantime, I have a new-found love for all things movement, manual therapy, and pain.  Having realized how valuable it was for me to take a multitude of perspectives and interpretations of science and clinical experience, I felt it was my turn to give back by sharing my interpretations. This year, I will officially offer my first full course: Pain Science, Movement, and Manual Therapy. This course work is designed for Physical Therapists, Athletic Trainers, Occupational Therapist, Chiropractors, Physical and Occupational Therapist Assistants, Massage Therapists, and physicians who work in rehabilitation settings. The course work is designed both for those new to these topics, but also to offer some twists for those who already have experience, and are familiar, with these topics. These will be offered in 2018 with live classes and by 2019 I will hopefully have the online with live lab hybrid classes ready to go as well. By 2019, I also hope to expand to offering courses dedicated toward my physician colleagues as their needs are truly unique compared to the movement based rehabilitation profession. I am teaming up with a fantastic advisory board to make these products with the goal of improving communication and patient care through shared understanding of pain and science based interventions across multiple disciplines. Every effort will be made to keep the courses current with the evolution of research and changes in my own thinking. Change and improvement is inevitable, this will be reflected in revisions of the course as the years move forward. I look forward to the process and I hope I can be a small part of helping someone else in their journey.

Teaching people about the complexity of pain is extremely challenging, you must meet each person where they are at. It is not cookie cutter, there is no script, what is meaningful for one person may not resonate with another. You can provide too much information and you can provide too little. While we cannot predict what every patient needs to help them take the next step forward, themes and patterns of information that patients are missing that help connect the dots for them do arise. The late Louis Gifford is one of the pioneers who had a knack for this. Louis has made countless contributions to our understanding of pain. His development of the Mature Organism Model (MOM) was an extremely valuable contribution to both our understanding and education of patients regarding pain. Below is an effort to bring the “Complexity” of the MOM to the patient.