“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

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

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

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

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

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

2) running/jogging,

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

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

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

6) prolonged sitting (>6 hours),

7) prolonged standing (>6 hours)

8) physical therapy (PT) for LBP.

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

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

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

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

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

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

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

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

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

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

So where am I going with this?

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

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