“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.

—-

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:

—-

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

Your client is here.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

The session now reveals itself dynamically.

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

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

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

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

I currently work with a large percentage of patients who experience “complex ” and/or “chronic pain”. Many have multiple surgical intervention histories (most repeat surgeries), every known non-invasive treatment (multiple episodes of PT/chiro/body workers), and every known pharmacological intervention known to man. All of these patients share a similar story, they were all told that “X,Y,Z” would resolve their pain or dysfunction with absolute certainty, everyone told them it was a simple fix. Yet, here they are continuing in pain, or in worse pain, in front of me.

As I sit back and review many of these cases, the most consistent theme I see of why they continue to suffer is that the traditional differential diagnosis has failed them. Many were told they had a specific diagnosis and were given a specific treatment. Differential diagnosis is based in the contemporary utilization of “Occam’s Razor”, which is the principle that “Among competing hypotheses, the one with the fewest assumptions should be selected.” (Side note: Historically it has been argued this  statement is an inaccurate reference to Occam and was created by later philosophers) . Utilization of Occam’s razor is critical to many aspects of healthcare, in particular emergency medicine. However, regarding pain, it is a principle which falls far short. Pain is complex, not simple.

The absolute, “this tissue/disease is the issue”, which is both culturally and healthcare driven, is why we are in a chronic pain epidemic.When it comes to pain and movement, physical medicine and rehabilitation professionals need to come to terms with the complexity of pain. It is never a single factor, even if there is a single predominant source of nociception. This also holds true for acute injury, you must account the environmental factors and the processing, as well as the outputs:

 

Gifford Scrutinise Image

Louis Gifford’s Mature Organism Model – 1998

This understanding makes pain and movement complicated, it makes things a bit gray, there is no absolute. You must make a clinical decision to guide the treatment, you need to be able to identify red flags quickly, you need to identify some important tissue issues, but you also must be able to confidently proceed with fair degree of uncertainty with a great deal of grace and skill.  I call this skill, “Confident Ambiguity”.

Confident ambiguity allows a clinical decision to be made in the absence of an absolute diagnosis, and the absence of absolute certainty. Classically, you would look at it as a list of possible diagnosis, within your differential, but now you are asked to not just identify the possible biomedical diagnosis but also the psycho-social factors and assume for all of them to be present concurrently with a constant dynamic shift, as well as combined presence, in any given moment (Louis Gifford calls it the “Shopping basket”).

Research and clinical prediction rules help, but they need a larger framework to address all the concurrent layers of a biopsychosocial model. Personally, I, as well as many others, have been drawn to Ronald Melzack’s work on the neuromatrix at face value to help with developing a constant confident inventory of inputs/outputs  in the biopsychosocial model. At all times, while interacting, assessing, and treating, in the back of my mind I play the “input/output” game, which at first appears challenging, but over time is very re-assuring both for yourself and your patient based on the dynamic nature of the interaction. This same approach has been beneficial with performance enhancement.

Neuromatrix

Melzack, Ronald and Joel Katz. “Pain in the 21st century: The neuromatrix and beyond.”Psychological knowledge in court. Springer US, 2006, 129-148

Every pain experience and every movement dysfunction cannot simply be broken down to single tissue damage, single disease, length tension relationships, muscular imbalance, tissue restriction, or any other musculoskeletal emphasized diagnosis. You must learn to accept the fact that the tests you delivered ,which you so confidently felt were reproducible to a specific tissue or movement pattern, may at least in part be a “neurotag”, a pain and/or movement memory that is driving everything you see and feel.

Microsoft Word - Figure 5

Furthermore, lumping the patient into a primary “psychosocial” driver of pain is a also problem, one cannot ignore sensory input, regardless of whether it is nociception or any other sensory input perceived as a threat.

Pain is complicated, pain is messy, if we don’t treat it as such, you will be lost and you aren’t give the patient everything they need.