If you are still with us and are more confused now than before, this is good. Keep in mind, it gets harder before it gets easier. Now that we have discussed some of the limitations with our root beliefs and began the discussion of shifting into a contextualistic worldview, it’s time to see what that really looks like in the clinic. Keep in mind, shifting into the worldview of contextualism isn’t introducing new philosophies, it’s simply showing the ability to adapt your philosophical perspective based on the context associated with the individual you are seeing in the here and now.

To shift into a contextualistic worldview, we must first be willing to accept and embrace uncertainty. Although this seems extremely daunting and uncomfortable, throughout this next blog post I will discuss ways you can improve your confidence by instilling a thing we like to call ‘confident ambiguity.’ It means having the confidence that you know certain directions or paths to head down while still being open to the idea that there are literally thousands more options available. To develop confident ambiguity, it is pertinent that we utilize a process-based framework.

Process-based theory has been discussed heavily by prior experts such as Steven Hayes and Stefan Hofmann. Most of their work can be found in the writings associated with Acceptance and Commitment Therapy, Cognitive Behavioral Therapy, and Relational Frame Theory. Expanding upon their work, Dynamic Principles took it upon themselves to utilize their successes and explore ways it can be applied in physical rehabilitation and pain. Without getting too much into the weeds of how this is accomplished, you can read extensively on how this was performed through many of our prior blog posts as well as our soon to be released whitepapers describing the Human Rehabilitation Framework.

With over a trillion different synapses and millions of different biophysiological mechanisms occurring daily mixed in and interacting with various psychosocial influences, there is no single model that can adequately categorize someone’s pain experience. Nearly all existing frameworks utilize a protocol-based approach that helps identify and categorize an individual into a subset of interventions, but as mentioned above, that almost seems impossible. People don’t fit in boxes and since we are all unique, we don’t do well categorized in a group.

That is why we need a process-based approach. The word “process-based” appears to be sort of a buzz word for many clinicians currently, yet there are very few frameworks that exist that are actually process-based, none of which are in the physical therapy world. Many frameworks such as Mechanical Diagnosis and Therapy (MDT, AKA McKenzie), FAAOMPT frameworks, Applied Functional Science, Certified Movement Links Specialist, Movement System Impairment Syndromes, and many more may claim they utilize a process-based approach, but in actuality are just larger protocol based decision makers. Also, it may be important to note that all these frameworks were built in a mechanistic worldview and despite their willingness to move towards a more BPS model, their theories become too incoherent because they have yet to address where their root beliefs remain. For MDT, it started in the discs, for others, it’s all about the muscles/fascia, and for some it’s all about these dysfunctional movement patterns (whatever that means).

To be truly process-based, we must first move away from reductionism and acknowledge that with every intervention we employ, we are constantly interacting with multiple processes involved in one’s network. There are now over 70,000 different ICD-10 codes and we use these specific diagnostic labels to categorize people and group them into a set of interventions. People don’t fit in boxes, they are all too unique to be reduced down to one or a few specific labels. What happens if someone has more than one specific diagnostic label? If someone is dealing with neck and low back pain, should we reduce the neck down into a tissue dysfunction and the low back into a stability impairment? Many may believe that’s what process-based means, but instead you are merely using two different sets of protocols and adding them together.

With nearly 20% of people experiencing chronic and complex pain, we have to do more. Most of them are feeling broken and have had a thousand different rules created from so many providers. Don’t bend over too much, no twisting, be careful with walking too far, your hips are weak, your upper shoulders are too tense, you have dysfunctional patterns all over you. Algorithms, flow charts, and categorization are just not going to cut it.

In our Human Rehabilitation Framework, we describe processes as the following:

“Processes of therapeutic change are the dynamic functional collection of overlapping and interconnecting mechanisms operating at multiple levels and dimensions that are changeable and interact in an orderly manner accounting for history, time, and the diverse contextual factors involved in a meaningful outcome.”

We have identified nine different processes that are flexible and can allow us to continuously adapt based on the CONTEXT involved with every encounter. This allows us to address multiple body parts, specific individual needs, and create endless opportunities to engage with our clients. Put simply, it’s up to us to learn about each unique experience to figure out what sort of processes they may be stuck with and provide strategies that can potentially get them unstuck. This may very well entail some of the many criticized interventions such as core stabilization or manual therapy, but we aren’t performing them to “stabilize the core” or the “rub out the issue.” We may be performing them to engage with attentional and social relational processes that ties in with the education we are providing that ultimately helps our client build ownership in managing their conditions.

To dive into each of these processes is not within the scope of this blog piece as we have several pieces of coursework that do that. However, my original intent of this series remains the same, which is to help you recognize that most of our current theories are extremely flawed and until we step back to explore what worldview we are living in, we are not going to move forward. Philosophies such as enactivism and dispositionalism sound promising, but if we apply them in a mechanistic worldview, we are only going to make the same mistakes we did for the BPS model where it becomes lost in translation. Having the ability to zoom in and zoom out in a unified and coherent manner while being able to understand the functional context involved with each situation is the path we need to move forward towards, and engaging in process-based therapy helps us do exactly that.

I understand this material can be dense and difficult to comprehend, because it takes a long time to actually shift your beliefs especially when society expects us to live in a mechanistic world. But by being a little more curious and challenging where your root beliefs stand, you may find that through time, it gets a little easier to deal with all this uncertainty. You may even recognize that you are finally developing some confident ambiguity.

 

If this series left you with more questions than answers, good, because there is a lot more to come, so stay tuned…

In Part I of this series, I discussed the limitations that exist with our current beliefs and theories we hold when it comes to dealing with pain. For most of us, this involves having theories rooted in a mechanistic worldview believing that our bodies are like a machine and can be fixed with certain interventions. To understand some of the content in this next part, it’s important you read the first part to process through some of the complex nuances discussed.

Throughout this post, my intent isn’t to give you a new philosophy you need to learn, and it isn’t to suggest which interventions are the best; it’s simply to challenge some of your root beliefs and provide a new worldview that is able to adequately explain with enough scope, depth, and precision why certain interventions work for some people in the right context. By doing so, my hope is that we can move our profession forward through a new worldview that isn’t often discussed or taught in the medical field.

When investigating research surrounding pain, many of the interventions we use have demonstrated some effectiveness, but not necessarily for the same reasons we are led to believe. It wasn’t until the early to mid-2000s when researchers began to challenge some interventions that we idolized with sham-placebo controls. This began to unravel questions as participants seemed to improve equally as well with the intervention compared to the control. Why did people do so well with an intervention that was fake? Surely, if our theory was encapsulated in a mechanistic worldview, it would make no sense; the participant didn’t get the thing that changed the mechanics of the issue, yet they still got better?! This must mean there has to be more to the story. Besides the several thousand differing physiological interactions and processes occurring, there has to be some CONTEXT involved that interacted with the human receiving the intervention.

To work with pain more efficiently, we don’t necessarily need to add any more tools to our toolbox, we just need a better framework that is rooted in a philosophical worldview that can adequately explain with enough scope and precision all the complexity that is involved. Having a mechanistic worldview to explain pain might have been what was needed when Descartes first discussed his theory of mind-body dualism, but now that we are in the 21st century, it’s time to move on to a better worldview that accepts and helps us understand the importance of context involved with every unique situation. This worldview is known as Contextualism, and by embracing the scientific philosophy of pragmatism, the framework we want to implement is called a process-based framework.

Shifting from a mechanistic worldview to contextualism acknowledges the importance of context in every situation. For people with pain, this includes all the unique individual biologic, psychologic, and sociological factors influencing one’s experience. Even though the Biopsychosocial Model (BPS) was proposed in the late 1960s, we still have not had a chance to fully understand its scope because we have forced it into a mechanistic box. However, when you start to view the BPS Model within the worldview of contextualism then the idea of application becomes a little clearer. We can’t just use the model to help explain all the mechanisms involved within each realm. Instead, we must show enough flexibility and willingness to shift our philosophical perspective based on the context that is involved with each realm. This entails having the ability to quickly and efficiently shift between different perspectives based on the CONTEXT involved in one’s unique case.

To help explain this practically, let us think about someone with low back pain. When you take on a contextualistic worldview, your thinking becomes more dispersive allowing you the opportunity think about the back pain mechanistically to rule out any serious red flags, and then can easily transition into a different perspective recognizing all the different dynamic and interacting processes that are involved. Without that ability to zoom in and out in an efficient manner, you either miss the boat completely on red flag issues and risk the ability to help someone receive a necessary life-saving intervention, or you become stuck trying to find a single cause for something that has many different synthetic processes constantly interacting and interconnecting to formulate one’s pain experience.

Failure to become aware of all the differing, complex networks involved often results in a loss of coherence for both the clinician and the patient. This happens often as their beliefs suggest one thing, your words say another, and the intervention you describe doesn’t align with either of them. They may be hearing that their pain is multifactorial, yet you both are in search of the one single cause. (To learn more about coherence within a clinical setting, be sure to read our prior blogs here, here, here, and here.)

So how does viewing pain from a contextualistic worldview change what we are doing in the clinic? Many people have the belief that with a new framework comes a ton of new interventions. That isn’t necessarily the case for this. As mentioned in the very beginning of the first blog of this series, when we think about interventions for pain, it’s better we challenge the thought process behind them rather than the intervention itself.

Let’s take core stabilization for example. Many people have their patients with low back pain perform core stabilization interventions. This idea is often formed from the mechanistic belief and theory that the back is unstable and needs to be fixed or stabilized. The belief becomes stronger when patients who perform these interventions report improvements in their pain experience, which we know happens quite often. Since patients are improving, it must mean that their backs were unstable, right? This all sounds appropriate, however, when you investigate the research and find that people with low back pain are often more tense and guarded around their low back, why would stabilizing an already tense muscle make much of a difference? If people with low back pain show less mobility and coordination then other healthy controls, that doesn’t sound like the back is unstable to me. But why then do some people get better with core stabilization interventions?  There has to be context associated with their unique history, beliefs, expectations, etc, and by performing low graded movements mixed in with increased awareness into the low back is just what someone may need to gain the confidence that they were indeed going to improve over time. It’s hard to truly explain the exact reasons which is why it’s much easier to say it depends on the context and several other thousand interacting, dynamic processes concomitantly occurring for that individual!

Okay, so now that we may have a better rationale for explaining why someone with low back pain benefits with core stabilization, with thousands of interventions already existing, how do we know which one will be the best? This is the path we will take in Part III of this series where we dive deeper into the concepts related to process-based thinking and clinical-decision making.

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.

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!