When it comes to the science of pain, I would say that I remain agnostic about many of the interventions employed in rehab. Social media often displays a dichotomous view where people are either for or against certain interventions, however, when I post content, I only challenge the thought processes we have behind those interventions rather than the intervention itself.

Many researchers and publications have been saying for years that the context and complexity involved with what we call the human experience is far too ambiguous to be able to predict with high precision that we know the solution to one’s problem. This definitely creates uncertainty.

To become comfortable with uncertainty means embracing the fact that you will never be fully capable of comprehending the totality of evidence that has been compiling over the past millennia. This feat is so far outside of our current scope of knowledge that we can’t even begin to imagine the type of information we don’t know we don’t know.

In turn, there appears to be this pervasive nature of individuals opting for reductionist models and lines of thinking to help make sense of their thoughts. To find comfort with our reasoning, we then cling to others who share similar views seeking confirmation that our theories are most certainly true.

Problems exist in this mode of knowledge because when it comes to complexity, it’s hard to reconcile what is actually true. Circling back to the interventions we perform, one thing that seems to be ubiquitous is that most people get somewhat better or will regress back to their average over time. What is difficult to understand and is why some people are able to improve far more significantly than others despite similar courses of treatment.

Again, we can theorize all we want, but for there to be any validation to the theories we create, it must have adequate scope, depth, and precision remaining consistent over time. For example, if we use the theory that the body is like a machine, this is based on a mechanistic worldview. For this to be true, we will have to see a linear progression of tissue degeneration with more active people showing significantly more degeneration. However, that doesn’t appear to be the case. As our knowledge improves and we find that active people have better looking joints than their sedentary counterparts, it pokes holes in the original theory, and one cannot adequately explain why that may occur. This becomes an incoherent way of thinking as the theory says one thing, yet what is observed appears to be different.

Since medicine has been derived from a mechanistic worldview stemming from Descartes theories of dualism, most theories formulated today hold similar mechanistic perspectives. This draws us back to the belief that our bodies are like a machine creating the idiom commonly referred to as ‘wear and tear’. Mechanistically speaking, it makes no sense to describe our bodies like a machine that will only break down when there is solid evidence of one’s ability to adapt based on the context surrounding their unique history. Without context, it’s hard to understand whether someone’s tissues will degenerate to the point they become problematic.

As research continually evolves, pain science enthusiasts have recognized the many flaws in these theories, so they decided to create new ones. Although this sounds good in theory (pun intended), the new theories that are replacing the old theories are still viewed in a mechanistic worldview. Instead of thinking of our bodies like a machine, we moved into the neurocentric idealism that our brains are the machines that can be controlled. Replacing one reductionist model based on a mechanistic perspective with another reductionist model based on another mechanistic perspective is like the definition of insanity. We keep doing the same things repeatedly thinking we are going to get different results. Our failure to become aware of and understand where our beliefs are rooted only hurt the forward progression of where medicine needs to transition.

So where do we go from here? Existing models have been proposed over the past few decades calling for such change, but many people become lost in translation with how they interpret those models. Opinion pieces and different perspectives continue to get published criticizing the nature of how we interpret these models with suggestions to move forward towards newer philosophies that give clinicians a different model to understand the complexities of dealing with pain. But we don’t need another model. We don’t even need another philosophy to show us a better way to understand and explain pain.

What we need is to take a HUGE step backwards. So far back that we explore what worldview we are living in and where our beliefs are rooted. As mentioned earlier, medicine was founded within a mechanistic worldview believing the body was a machine. We have made some progress in the 21st century recognizing and acknowledging the limitations that exist with mind-body dualistic perspectives, yet we replaced all these old theories with the neurocentric belief that the brain is a machine that can control everything. We didn’t actually change our root worldview, we just shifted from one perspective to another with a very similar reductionist thought process.

Now before I go on criticizing the mechanistic worldview, I would be remiss to acknowledge all the benefits that have occurred because of it. It was because of this worldview and its associated beliefs that the field of medicine now has the capabilities to prescribe certain pharmaceuticals and perform surgeries that are lifesaving. If you are a surgeon removing a cancerous tumor from the spinal cord or a physician prescribing the appropriate life-altering medication, you may not care as much about the context involved in the situation and instead do what is necessary to fix the mechanistic problem the individual is dealing with. But that doesn’t mean this worldview applies to everything in medicine. When it comes to pain, it is time we recognize that we can’t live in a mechanistic worldview and adequately treat it.

Stay tuned for Part II where we discuss the importance of shifting worldviews to better understand and apply interventions associated with pain.

How can one tell the difference between fairytale/snake oil science and good human science? This question is as relevant today as when Nikolaas (Niko) Tinbergen first proposed the need for critical questions determining the plausibility of biologic behavior. We are living in a world rampant with pseudoscientific explanations and interventions regarding the human organism that is be spread at an unprecedented level by way of the internet. Unfortunately, much of this pseudoscience also makes its way through peer-reviewed processes to be published in both low and highly referred journals. It doesn’t matter whether we blame it on the many cognitive biases that are associated with these explanations or the pressure on these authors that one should publish positive or perish, there doesn’t seem to be any consistent system is in place to stop this from happening. Therefore, the ability to read and determine the value of an article falls upon the reader.

Fundamentally, for something to be scientifically plausible there needs to be a basic scientific understanding of how we define said biologic behaviors. For human sciences, the most empirically sound evidence is based in evolutionary science. For a biologic behavior to have any form of plausibility, it cannot conflict with the empirical evidence of evolutionary science.

To identify a conflict with evolutionary science, Niko proposed 4 basic questions regarding the evolutionary plausibility of a biologic behavior. These questions are simple and should be kept handy whenever we read a study. When you identify the proposed biologic behavior for a theory, intervention, etc. that is presented in the article, you simply need to ask the following questions about the plausibility regarding the biologic behavior:

  • What is the evolutionary history (phylogeny) of the behavior in a human organism?
  • What are the developmental explanations (ontogeny) of the behavior in a human organism?
  • What is the function (adaptive value) of the behavior in a human organism?
  • What is the mechanism(s) (causation) underlying the behavior in a human organism?

The inability of a proposed biologic behavior to provide answers for all four of these basic evolutionary questions means the underlying theories are not scientifically valid and have not passed basic scientific standards that qualify them for use of any kind. Let’s see how well you can do with the following proposed biologic behaviors:

  • Myofascial restrictions
  • Heart rate variability
  • Nociception
  • Trigger points
  • Motor behavior variability
  • Meridians
  • Davis’ Law of soft tissue adaptation
  • Dry needling
  • Wolf’s Law
  • Core stability
  • Hypothalamic pituitary adrenal (HPA) axis

Provide your thoughts on the above proposed biologic behaviors using Niko’s 4 questions in the comments below or via any of the shared social media posts:

There are thousands of ways to reach up into a cabinet to grab a cup. Each action is made up of a complex interaction of intention, attention, multisystem rules and behaviors, context, execution, feedback and response across multiple joints throughout the body that ultimately yields an outcome. Human movement allows for countless numbers of ways to do things that are wonderfully adaptable to accomplish things that we want to get accomplished. At the same time, there are ways in which human movement can start to develop rules that are not as helpful as others and progress to a point of being unworkable.

When a person shows up for rehabilitation for a specific movement problem of reaching into a cabinet to grab a cup, particularly a problem involving pain. Something strange happens. Movement rehabilitation professionals suddenly get distracted with things they were taught rather than paying attention to person in front of them. It’s literally like someone superimposed an abstract black and white cartoon over a living colorful and vibrant picture. Rather than addressing movement problem directly, we start breaking it down into mechanical parts and dehumanizing the movement. Their problem is suddenly dumbed down to a collection of so called “dysfunctions” in one very specific area, or randomly in some other area without a clear understanding on how to define how they are related. These “dysfunctions” require specific protocols to “fix”.

So, once again, we put on our protocol-clown suits, where a massively inadequate evaluation strips away all of the reality (and humanity) of the problem and instead offers it’s take of the problem via reductionistic model called ‘differential diagnosis’. This model forces the clinician to commit to one single diagnosis (probably the mythical “subacromial impingement syndrome” in this example) by which we are supposed to do our protocol dance from. The dance has all  always found a way to sneak in a “stabilization exercise”, if not for the “Core”, we had to find one for the shoulder. But to “stabilize” and lock down the shoulder what you are functionally moves away from your body to an object has absolutely no functional of protective benefit! Why would you want to lock the glenohumeral and scapula to the trunk with “down and back” cues when you are reach upward and forward toward a cup?!? The amount of unnecessary and potentially aggravating forces yielded on the tissues make no biomechanical sense when you just pause for a moment to look at it, but we do what we’re “trained” to follow this protocol regardless! After a lengthy dance in protocol land, the person meets some arbitrary “objective measure” of strength, ROM, or whatever isolated measure. At this point, they are now considered better, perhaps “Fixed”, and perhaps the client even reports they are better. Everyone is happy, a bell is rung on the wall, celebrate! Off they go until 6 months later the problem comes back, worsens, or turns into a new movement problem with symptoms around the same area. On goes the protocol hat, perhaps with a new diagnosis! Only the problem is this time it doesn’t improve.

Soon they may end up in the surgeon’s office (if they weren’t already coming from there before) and this time, perhaps based on the almighty differential diagnosis, incidental structural changes, or sadly perhaps even for financial reasons, now a surgery is performed. Back to rehab, back to possibly feeling better, only for the problem to come back or change again. Now the surgeon doesn’t have anything to offer other than to refer them to “pain medicine” for injection or pharmacology. All the while, the rehab team (likely by now the client is on their 3rd or 4th rehab clinician) is poking, popping, zapping, and doing all they to offer. The client is sent to multiple more disciplines, all looking through the same protocol-based lens. It must be in their head, send them to the counselor, they’ll fix them. Still not improving, let’s see the alternative and eastern medicines providers, who still follow protocols, just like everyone else. All the while, the client increasingly becomes isolated from work, life, and social engagement with worsening or unchanging symptoms and swimming in thoughts and emotions of hopelessness, anger, and fear.

Sadly, this is the point at which many of these individuals present to us at our clinical practice, still unable to do that simple movement (which has now grown to countless number of movement and symptom problems) of reaching up in the cabinet for their cup…

What happened here? How did we lose contact with the original problem? Why are we not paying attention to the simple actions people are doing on a daily basis and starting there before we create new artificial stories for which to distract ourselves? Let’s take the simple action of reaching the cup in the cupboard:

What’s happening during the action of the fingertips reaching toward the small inanimate object is dependent on a history and the context of that moment. Historically, what has happened to that person’s upper quadrant in the past? How have genetics, use, disease or injury, influenced the anatomical structural and behavioral ways it functions now? Tissues change and adapt to our use over time, it’s different now in countless structural ways then when they were a small child. There are millions of actions that had been learned from, adapted to millions of different contexts, and socially and culturally groomed for appropriateness. What physical, psychological, emotional, or social traumas have involved that area of the body? This history creates multiple flexible rules by which that person can use that dominant arm to interact in their environment. What if those rules become inflexible? What if they are only inflexible in specific situations? What if the rules expand and change other areas, or to other situations, even in the absence of having learned those rules from direct exposure? Instead of just rushing to a physical exam without context, wouldn’t you want to get to know a little about their story to see what may relate with what you are seeing in the clinic that contributes to the way they move? What if by following the protocols you always use, started to reinforce motor behavioral rules that have become more and more rigid and less and less adaptable to the anatomical and tissue loading capacity of that shoulder? What if the education someone provides is making them fearful of doing something wrong which further reinforces the motor behavioral rules contributing to tissue overload? If you told me the stove was hot, I’d reach for it in a far different movement manner than if you told me it was cold. Why aren’t we paying attention to real human movements???

We’re tired of asking these questions and we’re going to provide a real workable way forward. We have developed a framework that works with real humans. Our process-based framework was design to comprehensively evaluate, dynamically monitor prognostic variables, and create functional and contextually relevant interventions. All the while giving you the ability to make fast and efficient clinical decisions that scale up and scale down to the real-world complexity of movement and pain problems! We call this approach the Human Rehabilitation Framework (HRF) and it is the world’s first biopsychosocially-oriented process-based approach to rehabilitation.

To start your journey into a process-based approach to rehabilitation, sign-up now for your free HRF sample e-book and join our mailing list as we share this new approach with the world!

Rehabilitation, and much of healthcare, has reached a point of reckoning. We are stuck in a world where we operate in “protocol-driven clown suits”, putting on an entertaining simplified show for the world to watch. These suits ultimately relegate us to the future of becoming replaceable technicians (hello AI & robotics) that worship the idol of a “specific diagnosis” leading to some sort of step-by-step cookbook approach to intervention. We see this growing daily as all around us as “evidence-based” healthcare providers are scraping, bruising, and poking needles into people like pins into pin cushions based on false “specific diagnostics” and a poor understanding of neurophysiology. While many of these providers are well meaning and attempting to help the person in front of them, ultimately, whether consciously, or unconsciously, they are entering into a theatrical show that sells a false value of their shiny interventions. The show continues to grow in popularity despite access to the evidence that consistently demonstrating no additional value from their new treatment addictions. This show goes by the name “XYZ might just be the thing that finally works!” even when it doesn’t, because we haven’t even defined what “working” is and what it is “working” for. This show is not just about our hands on interventions, but it also speaks to our exercise interventions where we randomly throw exercise based on such false diagnoses as an “instability” of some imaginary sort, without knowing what the exercise actually does for that individual, in what context under what instruction. The show can also sometimes sell this idea that exercise alone is this holy grail. Exercise is medicine, right? …But do they really need medicine right now? Are we medicalizing something that does not need to be medicalized? There also is this lingering belief, often from academics, that we can save the day by protocol-based clinical reasoning. Graduate education, post grad courses, certification, residencies, and fellowships promise clinical reasoning and critical thinking but all they’re doing recycling the same inadequate protocol driven drivel that has very little to do with the person in front of us.

Like our psychology colleagues before us, the time is here for a complete paradigm shift in the way we look at the problems of the people who come to see us. The person before us comes with an individual history, a story, and that story in large part determines how that person and their body is operating now. The way the biopsychosocial processes function in this moment was built on years of interconnecting biomechanical, physiological, psychological, and social behavioral relationships and networks unique to that individual in that moment and time. No diagnosis or protocol for syndrome can possibly meaningfully, or practically, be useful in the context of past and present behavior. When someone comes with a report of knee pain, but then also notes significant impairments associated with shoulder pain, and that they have a history of chronic back pain, not to mention they struggle with anxiety and depression, how many diagnoses do we assign them? How many tests do we need to do, how many interventions, how many referrals need to be made, and how many healthcare providers need to be involved only to ultimately not communicate with each other in any meaningful way? Even a single pain complaint is far more layered if we actually ask more closely about the nature of their complaint. Why does lifting their 20-pound child not hurt their shoulder but a sandbag roughly the size and weight of the child in the same manner cause excruciating pain? Why does that shoulder only hurt on Saturdays when doing the same movement as they would on Tuesday at work does not? History and context are key! Even if you are looking simply at sensorimotor and loading capacity variables, what preceded and what is present in the environment and inside of that individual person changes everything! This is the core of a process-based approach to evaluation, intervention, and prognostication, a science-based, critical clinical reasoning approach rooted in learning how to see where people get stuck across of a lifetime and how to help them get themselves unstuck. No more collecting diagnostic labels, no more piles of homework for the client, and no more handing fish to a hungry client when you can teach them how to fish for themselves!

At Dynamic Principles, we are committed to a future of educating clinicians in a process-based approach. We are excited about what this means for humanity in the future of helping people and we hope you’ll join us in this journey!

“Learn it in one, derive it in two, put it in networks, change what you do” – Steven Hayes summarizing 30 years of his work related to Relational Frame Theory.

 

***Please note new content was added at end of post as of 4/15/2020

Inherently, Relational Frame Theory (RFT) is an extremely complex theory to explain in a short form. Hayes himself struggles with it and even the best written introduction to RFT from Niklas Törneke has proven difficult to consolidate in a single post. At its most basic level, RFT is the most empirically studied theory of human language and cognition. While it may be overwhelming at first, I encourage reading my previous post here, to learn about contextualism prior to, or after you read this post. Furthermore, I encourage readers to learn the importance of RFT being built on a functional contextualistic perspective, the basis of ACT and other therapies, and that this is fundamentally different than descriptive contextualism, the basis of narrative medicine (please read more here). Törneke does an impressive job of condensing this into 237 pages that are quite easy to read, even for someone who does not have a formal background in behavioral psychology. I would encourage ANY healthcare provider to purchase and read Learning RFT, as all of us are fumbling through our language, all of us have to speak, all of us have to educate, and all of us have to work with behavior. However, I believe there is far more to RFT than language and cognition, and there are notable implications for those of us in movement and rehabilitation as well. In an effort to limit how large this post gets I have consolidated my objective to asking two questions:

    1. Why is RFT so important for those of us who work with pain? 
    2. Why may RFT be important to understand movement, in particular motor behavior?

Why is RFT so important for those of us who work with pain? 

As previously discussed in the Coherence post series [Here], many of us in the movement and rehabilitation field have come to realize that we are ultimately working in the field of behavior change. However, our efforts are haphazard, we lack solid ground for which to stand on, dabbling in cognitive behavior (CBT) strategies and conceptual change strategies, motivational interviewing, and others in combination with a curriculum of Therapeutic Neuroscience Education and Biopsychosocial concepts. All of these concepts involve engaging in language and cognition. These strategies assume that the “cognitive” part of humans is somehow open for change, “bad thoughts” can be challenged or deleted, and certain content can be swapped for other information. Unfortunately, by experience, it is quickly learned that any effort to “change clients minds” about deeply held beliefs is far more challenging than it would seem. Surely a more scientific explanation will change their mind, maybe they just need the right piece of knowledge, or if we argue with them on logic, logic will win out, right? By now you know this is not possible. It turns out that researchers who work primarily with cognitive behavior therapies have also started to realize that emphasis on changing thinking and the content of the mind do not appear to explain why cognitive behavior therapies work, nor are they necessary for behavior change to occur (See here). 

What does this mean? It turns out we have very little control over our thoughts, our mind is constantly generating new thought and creating relationships between new and old thoughts. We might have a thought questioned, reframed, or challenged, but eventually the mind will use old relationships and networks to return to what it believes most supports the known content of self. This is exceedingly beneficial from a survival perspective as it means our brains are expert troubleshooters, always trying to create new connections based on old and new information in an attempt to keep us alive. While beneficial, this is also problematic. In particular during times in which no immediate danger is present, this troubleshooter does not stop generating thoughts, making new relationships, or building and connecting larger networks. As Törneke describes it, this is the dark side of human language, and worse yet, social factors both support and promote the rigidity of these relationships and networks. Think of our nocebic language in culture, “I have a bad back because my mom’s got a bad back,” “sit up straight or you’ll hurt your back,” “pain is bad, you should be pain free all the time,” “My pain will get worse as I get older, my spine will crumble,” these are reinforced through self and society. Our best efforts to address this by providing updated evidence rooted in science as “education” are quickly squashed the moment their mind starts to sort through its existing networks yearning for coherence after they leave our space, or even more challenging, speak with a 3rd party human who does not share this new knowledge. Upon presenting the new “knowledge” to the 3rd party human, now that 3rd party human’s beliefs are also questioned with the new knowledge introduced to 1st party human (our client) which activates their efforts to maintain a coherent story in their mind (and the broadly accepted societal narrative) and not wanting to have a disconnect with the friend human’s new knowledge, 3rd party human immediately challenges 1st party human in an effort to defend the coherence  of the content in their mind, and in the end old networks are reinforced for both humans that the content in their mind reassures them that in fact, they still broken and hopeless. However, what RFT shows us is that we don’t even need other people to mess with the new knowledge. To give an example I took from Hayes that I like to use in my courses and with clients: 

If I wanted to stop eating donuts as a method of losing weight and I thought to myself, I’m going to associate donuts with dirty hats! That’ll work, except, as we’ve learned through the development of RFT, that relationship immediately derives itself two ways. So now lets say I see a donut and I think of hats, what they look, smell and taste like. Awesome, success right? Except now, the next time I see a hat, what do I think of?… Crap, donuts… mmmmm.

Research on RFT has seen the same with positive thoughts: at the tail end of every positive thought and everything positive line of thinking you make in your life, is also the negative thought you were avoiding. Efforts to suppress or “delete” negative thoughts results in worsening negative thoughts and feelings. The human mind does not have a delete button. You can’t get rid of the other end of the spectrum. It will always be there. In my own experience as a patient, having seen my own MRIs, X-rays, and  reports, I cannot delete those images and thoughts from my mind, no matter how much I have read and understand the evidence that those spinal changes are normal. I will never be able to “un-see” them, and I still hold relationships of those images with fear, uncertainty, and pain. This means for the rest of my life, I will still have to work with those thoughts and memories and the numerous contexts in which they will arise. These are now parts of my “self-as-process” and “self-as-story” which are parts of a very important area in which RFT has shed light: the experience of self.

Self

In RFT, the experience of self is divided into an umbrella of two parts, self-as-perspective (observing mind, transcendent mind, among many other names) and “content of self”. The content of self is further divided into self-as-process and self-as-story. Self-as-process is the “ongoing, observable process of ourselves”, such as memories, emotions, bodily sensations, and thoughts. It only exists here and now and as a result, is open for change. This dynamic nature of self-as-process is important because this means memories are not always thought of or remembered in the same way, nor does sensation always feel the same, and our emotional state and how we interpret emotions is also variable. Self-as-story is the “who I am”, identity part built on our history, and it is important that this story is coherent and a connected whole. The self-as-perspective, or observing self, is difficult to describe. As Hayes describes it, “it’s borders are fuzzy”, we cannot observe it and it is devoid of content, it is the lens through which we look that is not influenced by what it sees. The observing self is also a powerful process to engage in from a therapeutic perspective, classically emphasized in mindfulness strategies but explicitly engaged with Acceptance and Commitment Therapy.  While there are numerous directions (in particular “I/you”, “here/there”, “now/then” relationships!) for which I could take this and future posts, I will for now leave these for specific courses on these approaches and end on the note that the experience of self, as defined by RFT, provides a clinical framework for understanding the difficulty of addressing beliefs, memories, relationships with emotions and sensations, and sustainable behavior change. As professionals who help clients who struggle with pain, we owe it to ourselves to better understand these layers and respect the challenges of engaging in human language and thought processes.

 

Why may RFT be important to understand movement, in particular motor behavior?

With this question I am moving beyond much of what RFT was developed for and studied. Despite the initial intentions of RFT, what it has done with expanding on Skinners work with operant conditioning and verbal behavior, also has profound implications for movement. Examining motor control and movement from a behavior perspective is clearly not new (see here, here, here, here for some introduction) but what seems to be forgotten is that it behavior in context is the fundamental underpinning of movement. However, it seems that popular beliefs and traditions of movement have fallen back into the idea of fixed motor patterns and programs despite an abundance of evidence that these ideas miss the basic principles of motor control. I suspect it’s the overwhelming nature of the idea of context and what behavior means to so many rehabilitation professionals, and they do not know what to do with that information clinically. 

In this vein, I believe RFT is a way forward to help movement and rehabilitation professionals understand that they are always observing behavior in context. Understanding the worldview lenses for which we could perform research or create practical (pragmatic) applications allows us to confident in the coherency of what we are doing. Specifically transitioning from a mechanistic or organicism viewpoint to a functional contextualistic viewpoint which underpins RFT means we can practically work with complexity, rather than being overwhelmed with the mechanistic nuances. Understanding relationships can be formed between a sensory (in particular to us, sensorimotor), cognitive, or emotional experience (which serve as stimuli), and these relationships can be derived to form into networks, and how these networks interact change the way we move, provides a practical way to assess and interact with movement behavior. This substantially expands and improves on, or perhaps corrects, what I previously called “Post-Antalgic Patterning.” Through the RFT lens, these patterns are simply behaviors and do not necessarily even imply “guarding” or “protecting”, they are simply motor behaviors built on relationships and networks. Using the example of an acute ankle sprain, given the sensory stimuli from the acute injury, a relationship may be formed with the respective nocifensive behavior that results in a limp. Any part of the motor behavior that manifests as a limp could be related with any stimuli, and the resulting networks could also be associated with other movement networks. Furthermore, that ankle sprain occurred in a human, therefore it did not occur without thoughts or emotions. Were catastrophic thoughts related to the degree of tissue injury present? What is the history of those thoughts, have they been associated with other networks that include movement behavior pairing? What implications do those thoughts have with future behavior? Could new movement behavior develop in the absence of a paired non-motor stimuli simply by establishing relationships between movement behaviors? Could emotions such as fear, anger, or uncertainty be paired with these movement behaviors and could they also coordinate with other networks? As relationships grow in two way relationships, so do network relationships. 

The bottom line is the opportunity for old and new relationships to present now or in the future is limitless, and our current exercise prescriptive models do not account for these infinite relationships. We do not know, nor can we 100% predict what it is about an exercise that results in the behavior change we feel is necessary for progress. There are generalizations, but as a whole, we’re taking part in a process. The widely accepted mechanistic viewpoint in our movement and rehabilitation tradition cannot support the contextual nature of movement behavior, and we would propose shifting to a functional contextualist perspective to practically work with movement in a meaningful way. This requires a shift to a process-based framework and approach for movement and pain, and we would like to provide a suggestion for such a framework  in the next post.

Visualization of RFT related to Movement & Pain – Added 4/15/2020

Below is a gross visualization of the near infinite number of relationships between various forms of stimuli and behaviors that could be attached to a simple acute ankle sprain:

 

 

COHERENCE (PART 4 OF 4): BRINGING WORLDVIEWS INTO PRACTICE

Part 1 is available [here],part 2 [here], and part 3 [here].

By now a good chunk of you are wondering, where does this fit in the movement and pain science realm? I will attempt to explain the importance of the above groundwork by drawing a comparison of a mechanistic viewpoint of psychology for mental health presented by Russ Harris in ACT Made Simple, to that of rehabilitation professionals utilizing a mechanistic viewpoint for physical health. Mind you, I’ve taken some liberty in how I recreated his text and this is not word for word from the book:

Psychology mechanistic models for ‘mental’  health

Many clients approach psychological therapy with mechanistic ideas. They believe they are faulty, damaged, or flawed and therefore need to be “fixed” – how many times have you heard a patient/client use the term “I am damaged goods”?

They believe they have “faulty parts” – negative thoughts, anxiety, or painful memories that need to removed.

Many psychology MECHANISTIC models readily reinforce the notions through two processes:

    1. Often terms such as “dysfunctional”, “maladaptive”, “irrational”, etc. which imply we have faulty or damaged components to our minds
    2. A variety of tools/techniques used to directly reduce, replace, or remove unwanted thoughts and feelings are provided with the assumption this is essential to stepping forward in improving quality of life

Rehabilitation mechanistic models for ‘physical’  health

Many clients approach rehabilitation with mechanistic ideas. They believe they are faulty, damaged, or flawed and therefore need to be “fixed” – how many times have you heard a patient/client use the term “I am damaged goods”?

They believe they have “faulty parts” – bad parts, tight muscles, trigger points, maligned/stuck joints, or painful areas that need to removed.

Many rehabilitation MECHANISTIC models readily reinforce the notions through two processes:

    1. Often terms such as “dysfunctional”, “maladaptive”, “irrational”, etc. which imply we have faulty or damaged components to our bodies.
    2. A variety of tools/techniques used to directly reduce, replace, or remove unwanted ‘physical’ symptoms are provided with the assumption this is essential to stepping forward in improving quality of life

 

This comparison was drawn because what I commonly see are cobbling together of concepts from pain science, biopsychosocial principles, and movement principles with all sorts of ecclectic tools but sometimes the underlying viewpoint from which a “tool” is drawn from does not match the root viewpoint of the other “tool” they are paired with. Take for example, if you wished to combine classic “Directional preference” (MDT) with ACT principles you would be attempting to pair a mechanistic viewpoint (MDT) with a contextualistic viewpoint (ACT). At face value, this seems unimportant, but when the mechanistic basis of symptom modifying from MDT is combined with the contextual acceptance/expansion fundamental basis of ACT, there will be inconsistencies which may arise for the client over time through their experience of the combination, such as why is there such an emphasis on symptom modification in MDT but a greater emphasis on not modifying symptoms in ACT? Likewise, the clinician may struggle with deciding on a clinical direction between symptom modifying and function oriented objectives. Similarly, if you combine classic Cognitive Behavior Therapy (CBT) with a contextual movement exploration exercise, you are again inevitably going to run into coherence issues in practical application with clients over time due to some of the mechanistic cognitive reframing aspects of CBT working in opposite of the contextual flexibility processes introduced in contextual movement exploration. Examples of organicism worldviews as the foundation of their development include NDT and DNS with their emphasis on developmental phases. Dry needling, trigger points, myofascial, craniosacral, specific postural/breathing methods, and much of our professional trends are examples of work rooted in mechanistic viewpoints. Both organicism and mechanistic rooted “tools” are often paired with contextual dialog when attempting to “educate” patients about their pain and the role of biopsychosocial factors. This is not to say that these approaches are not useful interventions, but rather that the interventions may need to be reconceptualized from the ground up before they are deployed in clinical practice to reduce coherence problems for the client and the clinician. The biopsychosocial model could be seen as being developed from organicism viewpoint if looked at simply as an interaction of multiple systems in a scientific descriptive manner but I would argue clinical application is nearly impossible for the BPS model without viewing it from a contextualist viewpoint.

The importance of understanding your viewpoint can also be seen in your attempts to create behavior change via education.  When you try and provide therapeutic neuroscience education from the lens of classic CBT to “change beliefs”, or “conceptual change”, as defined by NOI for Explain Pain. These approaches were originally built on mechanistic perspectives, and a limitation of this viewpoint is that it cannot account for why “Successful” education is nullified when the client leaves the clinic, next time they arrive, they may be even more rigid in their thinking than the first time! However, looking at behavior change implications from an educational perspective through Relational Frame Theory (contextualism), accounts for these complications, and while nothing can guarantee change, at least provides a working understanding of why this occurs and how to work with the darkside of human language opens up opportunity for meaningful action with a functional understanding.

By drawing these comparisons I hope to start to clarify the importance of clinicians learning to look at viewpoints more critically and in doing so,  “develop the adequacy of one’s own position, to analyze other positions from within, or simply to illuminate the nature of the philosophical disagreement.”(Hayes, et al. 1988) 

Furthermore, in consideration of the complexity of pain and movement, consider exploring a viewpoint of contextualism as the foundation of developing practical frameworks for clinical practice, a task which we will attempt to undertake on future posts.

COHERENCE (Part 3 of 4): DRAWING LINES IN THE SAND

Part 1 is available [here] and part 2 [here].

…Disclaimer: The depth and scale of Stephen Peppers work is in many ways an understanding of philosophy that is beyond my pay-grade and will likely take some time for me to fully appreciate. In what little I have been able to process, he has provided some significant insight into the coherence issues we are seeing in healthcare related to the topics of pain and movement in particular. For a more educated review, please see Hayes, Hayes, and Reeses book review of Pepper’s World Hypothesis work to explore this topic prior to my butchering and overly simplifying these worldviews [here].

Steven Peppers proposed the idea that the philosophical worldviews (Pepper describes these are world hypothesis) each of us hold can be looked upon like objects in our world. That these viewpoints can be described and compared to each other, and that through viewing them critically it is even possible to determine “relatively adequacy” in their scope and precision. A “Relatively adequate Hypothesis” is built on a root metaphor, which serves as a conceptualization which balances common sense with “refined knowledge”. An adequate world perspective should be “..unlimited (in) scope and is so precise that it permits one and only one interpretation of every event” (Hayes, et al. 1988), but as reviewed by Peppers, rarely do these viewpoints completely succeed and therefore, the “best” can only be considered “relatively adequate”. 

Peppers discusses several principles at the core of his world hypothesis and I could easily get distracted by describing all of them. However, his “Maxim number 3”, states that “eclecticism is confusing”, and this once again rang true for me in my own “yearning for coherence”. In this principle, Pepper states an adequate root metaphor (therefore world view) is autonomous, which means they are mutually exclusive, and to attempt to mix them with other viewpoints can only become confusing. Now, with that stated, Steven Hayes describes a powerful implementation of contextualism to incorporate other viewpoints but avoids the costs of conceptual confusion which we will discuss later.

Here is a A VERY Brief Summary of the ”Relatively Adequate” World Views

Formism

Commonly Called: Realism

Root Metaphor: Similarity

Formists like to organize and categorize things, they label the quality of things and relationships between things. Fruits are often sweet and can be organized relative to the type of fruit and trees or plants they come from. Principles of operation, such gravity/force, etc, are not important, only how things relate to each other in form matters.

Mechanism

Commonly Called: Naturalism, Materialism, and sometimes also Realism

Root Metaphor: The machine

Mechanists look at the entire universe as a machine. Parts and pieces have distinct roles which are systematically related in the machine and alter its function. Mechanism is similar to formism but discreet relationships between parts do allow operations to produce predictable outcomes. Emphasis on outcomes is a key component of this worldview as mechanism is essentially the root philosophical viewpoint of the biomedical model.

Organicism

Commonly Called: Absolute Idealism

Root Metaphor: Process of organic development and organic systems

Organicists look at the “Whole” as being the basic foundation, the whole is not made of parts or a synthesis, rather, they are meaningless except for when they are part of the process of the whole. An acorn is going to become a tree, unless of course the acorn is eaten by pig and then becomes a part of the pig. 

Contextualism

Commonly Called: Pragmatism

Root Metaphor: Ongoing act in context

Contextualists essentially look at “truths” varying within the context of which they are made, including the historical context.  Hayes describes the most powerful application of contextualism is that it “allows the strategic use of categorical concepts from other worldviews subordinated to contextualistic criteria”. What this means is that other viewpoints such as mechanism can be use toward a specific end. The machine metaphor can then be used toward “successful working” of the contextualists agenda if the context is defined. Similar to Steven Hayes’s perspective that contextualism is the most important viewpoint for which to look at behaviorism, we at Dynamic Principles see contextualism as the most practical lens in which to look at movement and pain. After all, when it comes to movement and pain, context is king.

So what now? Read next week’s blog post conclusion: “Coherence: Bringing worldviews into practice.”

COHERENCE (Part 2 of 4): SOMETHING ISN’T RIGHT!

Part 1 is available [here].

Something deep in me (and many of you) has driven a pursuit of knowledge, yet with every new thing I learn, there is this underlying feeling, urge, that recognizes the available pieces do not fit together in a meaningful way and that simply pursuing more knowledge mindlessly is, to some extent, a dead-end road. Given enough time, anyone who has extensively explored movement and pain science would also start to feel the urge to look for new knowledge to serve as another patch and to provide another fix toward our insatiable addiction to gain more and more knowledge that might once again temporarily satisfy us. Unfortunately, this process can lead to endlessly spinning of cognitive wheels in new territories with little reward of fulfillment after spending enough time there. Some just give up and call it “good enough”, make do with their knowledge base and do what they can with it and feel their clients will either get what they’re giving them or not. Many others, particularly those early in their careers will continue to be unsatisfied. While working through an ACT Intensive course led the creator of Acceptance and Commitment Therapy (ACT), Steven Hayes, we were introduced to several “core yearnings” which form some of the functional basis of ACT. One of these yearnings I believe best describes the urge for things to make sense, and that is the “yearning for coherence”. In the course, this yearning was a introduction to Relational Frame Theory (RFT), which is a working model of language and behavior (we will discuss this further and it’s valuable role for working with movement behavior in subsequent posts), but for the purpose of this first series, we are stepping back further and looking at  “yearning for coherence” as our entry point addressing a bigger picture of our desire for things to make sense. This recognition of my own yearning for coherence required me to follow Hayes advice to look at Stephen Pepper’s work on “World Hypotheses”, or world viewpoints, as a place to begin to make steps toward a sense of coherence.  In this process, it is important to note that coherence in a literal sense is not achievable, but coherence in a functional sense is sustainable, workable, and “liveable”. To recognize, understand, and firmly place your feet in one world viewpoint is necessary to develop a sense of coherence, yet most of us have no idea where we stand. In observation of this in myself, past and current colleagues and clients, it has become very clear that most of us are not fully aware of our current world viewpoint, and if we believe we have one, it is likely an incomplete awareness at best. This makes our current working viewpoint unstable ground to begin with, and our efforts to create a new viewpoint out of two distinctly different world views, let alone inadequately developed viewpoints, is further broken when creating “something in the middle” of two perspectives. Creating yet another cobbled together viewpoint which will fail to withstand minimal scrutiny. We then keep throwing knowledge on top of this shaky ground hoping somehow things will fall into place and finally “make sense” , but instead we get further convolution, poor translation, and of course, arguments that are based more on the viewpoint, than on the  content of the argument. Content based on language, which as we will discuss later, lends to it’s own complications, but for now I best leave this post with the following:

“Hold language lightly even the things called facts because they are built only on one part of your interactions..” Stephen Hayes

 

How can we even define this for ourselves and our patients? Read next week’s blog post: “Coherence: Drawing Lines in the Sand.”

This is a long overdue follow-up series on a post on “Confident Ambiguity” from 2016.

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Most of you reading this post will have some background in the biopsychosocial model, pain science, and movement science. Based on this premise, my assumption is what I am about to say rings true with many of you:

Despite all the knowledge we have gained, the data we have scoured and synthesized, little of what we have learned  “makes sustainable sense” when you throw it all together in effort to make it workable. With increasing knowledge, more gaps are inevitable and gaps in knowledge are never ending. Somewhat haphazardly, we patch the gaps as quickly as we can but the patches we use to bring them together are often mismatched. 

If knowledge feels patched together to you, what does it feel like for our clients/patients?

 

Think about it. We’ve got this biopsychosocial model (framework!), the neuromatrix, the needless distraction of predictive processing, the sensation versus perception arguments, and all these other cool neuroscience things. But what about consciousness, what is it??? There are also aspects of contemporary biomechanics and loading capacity that need to be understood and incorporated. Then we’re dabbling with psychology, we’ve got expectancy violations, graded exposure, fear avoidance, yellow flags, resilience…. But wait, what about social and cultural implications? How can we be so cruel as to expect someone in the worst socioeconomic status to be anything other than trapped, they could never develop resilience and be another self-help success story because nothing of their environment supports it! Then there are arguments of logical fallacies, continuing battles of epistemology and ontology, and, wait is there a value to philosophy? But what about the person in front of us? Their story, their narrative! Surely we shouldn’t forget the person! But what about the new graduate navigating the whizz bang shiny objects excited that by finding that “dysfunction”, poking, scraping, corrective exercising, or constricting the circulation of their client into oblivion hoping for that magical, “that feels better!” verbal response to be provided. What about our patients’ autonomy? And our science! What about our science? Outcomes measure outcomes not interventions, the limitations of the peer review process, the poorly (sometimes fraudulently) performed systematic and meta-analysis, the lack of disclosure of conflict of interest, poor blinding and lack of bias observation in much of everything that is available. Oh. and don’t forget, what about our own self care? Don’t look now, there’s the next social media post and the next article to argue about, wait what are we arguing about? Are we arguing?

            ….If you are reading this paragraph several times, you may wonder, like I have, how most clinicians who fell into this curse of wanting to learn more and do better have not all gone mad. It is no wonder the transference of this information has been poor and slow to take on culturally, it’s like we don’t even have ground. We’re taking on all this information but we have no idea where we stand, how to make sense of it, and not just how to apply it, but how do we meaningfully share it with others?

 

No matter where you are in your career, do you feel that inner turmoil? Read Part 2 of this blog post next week: “Coherence: Something Isn’t Right!”

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