“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,
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:
This post is far more personal/autobiographic in nature than anything I have previously posted. I hope it does not detract too much from my intentions for this blog, but I have found that reading and hearing other clinician growth/life stories has tremendously helped my professional growth. I hope that perhaps this post may be meaningful for someone else.
Preparing for the journey: Pain and Movement
I was exposed to the experience of persistent complex pain early in life. Shortly after birth, my family started to question why I was in near constant distress. Countless medical care visits later, I received my first pain diagnostic label; chronic cluster migraines, at age 2. This made for a challenging childhood, I missed many typical school age experiences and averaged ~50 days of lost school a year. I know it was a terrible burden on my family, and the physicians didn’t help the problem by telling my family to watch out for possible suicide efforts, as historically, cluster migraine was labeled the “suicide headache”, now that is nocebo!! Imagine as a parent, or a sibling, how that felt to think about? I was thankfully oblivious to this information until later in life. I can relate with the social implications of persistent pain quite closely. I can also relate with my patients on how pain negatively influences your relationship with movement. I wanted to move, I was a kid, I wanted to go out and play and hangout with friends, but the fear of triggering a cycle of pain sometimes prevented you from wanting to try to move. Despite this, I had this intense inner desire to move, and by grace and with the resiliency of youth, I was able to find a movement experience that fit my needs, falling in love with martial arts, and later stunts and movement choreography. With martial arts, I progressively, yet unconsciously, found a balance between intense physical training and rest though a 7-year sedentary career in information technology during the dot.com boom in the 90s. Perhaps this paced rest-to-work ratio was part of what made such a profound dent in in the frequency and intensity my headaches in those years. Likely, these effects were combined with the reduction of social pressures by dropping out of high school at that time… Regardless, all other medical interventions had failed prior to that point to improve my pain.
Another important observation to note about that time was when I instinctively recognized there was something more to human movement than the physical domain. Movement at times would resonate with me emotionally, it stimulated me cognitively, and as I explored different martial arts styles, I found the cultural variations of essentially the same movements fascinating. Long before I knew the science, or what the words meant, there was this unconscious awareness that movement and pain was bio-psycho-social in nature.
The Journey There
In 2002, I was training and teaching at a kung fu school which decided that they wanted to expand their strength and conditioning offerings for their San Shou (Chinese Kickboxing) program. The school owner invited me to join him in attending a Perform Better seminar that year. I gladly accepted the opportunity because at that time only thing I knew about “Conditioning” was working yourself into the ground combined with traditional “Chinese torture” conditioning methods. There were several great speakers at that seminar, and being blissfully ignorant to the world of performance enhancement, made me feel like a kid’s first experience in a candy shop. I cannot recall all the speakers for the seminar, but I was most influenced by Mark Verstegen and Michael Boyle that day. Michael made a statement during his presentation that finalized my decision to become a physical therapist. It was the early days of the joint-by-joint, correctives, and of course, “core stabilization.” We had previews of the Gray Cook Movement trend to come and looking at the landscape today, it is shocking how little has changed in the last 16 years. I was also introduced to the idea of mobility work with various tools and rollers and this magical “fascia” and phenomena called “Trigger points.” I had dabbled with manual therapy before then, in particular with “trigger points”, having received treatments which had given me some short-term benefits for aches and pains from time to time. It made sense to me that hands on care had some value. If I’m honest, it didn’t take much to sell me on the dream of being a manual therapist to “fix” and train people, I still had aspirations to grow up to be the legendary martial artist and Chinese Medicine “bone-setter” “Wong Fei-hung.”…
I remember the thrill of the experience of being at that seminar clearly to this day. It created that feeling of the days of learning that “secret” technique in martial arts. I was enamored by all of it; I loved the “structural” thinking and the “healing” potential of the concepts of the biomechanical/pathomedical model. Being an IT guy at the time, the idea that there was some sort of “ideal” motor control and motor pattern for all sorts of movements that every person should be adhering to avoid “dysfunction” seemed so logical, people had to be fixed! This started my first “binge phase” of learning. Before I went back to school to become a physical therapist and athletic trainer, I already had purchased the red tome of Travel and Simons, picked up a copy of Florence Kendal, and memorized Netter’s musculoskeletal pages, excluding the nerves of course, what good were those to fascia?! I bought a treatment table and lined up my “victims” to develop and practice my new-found skills using hands and other modes of manual therapy combined with my growing collection of “correctives”.
Doubts on the Journey
Fast forward through the roller coaster of information and skills I explored between the years of 2002 to 2010. It was a head first dive into a wide variety of manual techniques, Thomas Meyer Anatomy Trains, FMS and SFMA, Vladimir Janda, Stuart McGill, Pavel Tsatsouline, and countless other concepts and “thought leaders” at the time. No questions asked, if the pros were using it, I had to learn it. Besides, there must be evidence for these things somewhere right…? All I knew was, I wanted to be a movement expert and a highly skilled manual therapist, I had no concerns about the tens of thousands of dollars I invested in these resources along the way, or thousands of hours exploring them. But some tiny doubts started to creep up as I started to realize how much of my own training time was used for preparation and mobility work, and it was beginning to cut into skill training. Plus, I started getting frustrated because none of it was really helping any of my body aches and pains, instead, it seemed as though they were starting to become more frequent and persistent…
In 2008, I started to wonder why it was so hard to find research to support all these amazing outcomes we believing we were seeing in the field. So, I did what any other sane person would do, I decided I should start learning how to “science this shit of this” and begin adding to the literature myself. As is classic me, I fumbled my way into learning the scientific method with whatever resources and mentorship was available to get the job done. I chose something simple at that time which was the “hot topic” of dynamic vs. static stretching and chose to look at their roles in agility performance because nothing had been published at the time in that area. You can see the results of that experience here. There are many things that can be learned in the process of developing, conducting research, writing, peer-review, and publishing a research article. The most important thing I learned was to be very systematic/procedural about literature review and begin to question my biases. By no means am I saying somehow I have succeeded in completely overriding my biases, but it was enough for me to start questioning some of my core beliefs about movement, manual therapy, and pain. The literature review process for stretching also brought me into the world of the nervous system and how it would be impossible for me to truly know about movement if I didn’t understand the nervous system better. Up to this point, my understanding of ROM and mobility was based on traditional biomechanics and the stress strain curve, so this was eye opening to be learn non-mechanical properties had a more profound role in available ROM. It was also when I first time was exposed to the idea that nociception does NOT guarantee pain, nor was pain it’s only role, but that it had other important biologic purposes. Of interest to me at the time, nociception’s role key role in stretch tolerance, the cornerstone of ROM and mobility. I didn’t realize how important that bit of learning would be in my current growth, because I still had my blinders on and had a fairly structuralist based mindset, but my curiosity was increasing.
Fast forward two more efforts to contribute to scientific literature, both of which had their own positives, negatives, and flaws (here and here). After completing these, I decided to take a break from being involved in active research to focus just on clinical practice with my new thinking in place. I have no doubt I will revisit the role of being a researcher again in the future.
From movement and manual therapy came the opportunity to learn about pain science. I figured a good part of my life I had experienced some form of pain, sometimes finding relief for short periods of time, but I wondered why no treatments or magic trick seemed to have lasting benefits. So naturally, it was time to learn more about pain. Between natural curiosity, expanding available literature, and the “hivemind” that is internet social media (filled with its own opportunity and pitfalls), there was a great deal to learn. The constant feed of people smarter than myself on Blogs, Twitter, Facebook, and sites such as SomasSimple forced me to constantly question my interpretations of literature. There were times I felt my beliefs and interpretations were under constant threat and the ground beneath me was going to give way, but I knew that struggling with these ideas were vital toward my goals. It was a challenging time but my own struggles with pain made me realize the biomedical model was woefully inept at addressing the Complexity of Pain and I finally had to embrace the biopsychosocial framework.
It is hard for me to make a single list of all the people who inspired me and helped me understand pain better and how to implement it into clinical practice, but I must at the very least mention Adriaan Louw, Lorimer Moseley, David Butler, Louis Gifford, Diane Jacobs, Greg Lehman, Peter O’Sullivan, and Todd Hargrove. I owe Adriaan for not only helping me connect some important dots in pain physiology, but for changing my life in a short conversation he had with me about the fears I had about my own pain problems. His approach resonated with me and greatly influence my education style a great deal. I recommend anyone who works with people in pain consider taking part in the Therapeutic Pain Specialist program at the International Spine and Pain Institute.
With my foundation and framework somewhat stable, I began to nearly exclusively treat complex and persistent pain problems. The demand was so high in my community, I could not keep up with the number of referrals myself. To meet these needs, I developed an outpatient pain treatment division for Generation Care. This meant beginning to develop a curriculum and a system to start sharing my ideas with other clinicians. Through 2017, I had 10 clinicians suffer through my attempts to get ideas out of my head and try and making meaningful applications to their clinical practice. I can proudly say we have made a successful team to take on extremely challenging cases in our community and I look forward to new additions joining this year as the demand is not slowly down.
This brings us to 2018. Before the start of this journey, there was pain and movement. When I started the journey, it was about movement and manual therapy. As the journey continued, I reconceptualized pain and realized understanding pain meant understanding movement and manual therapy better. Now, the realization is there is a person behind all these things, which is an amazing conversation in and of itself. But in the meantime, I have a new-found love for all things movement, manual therapy, and pain. Having realized how valuable it was for me to take a multitude of perspectives and interpretations of science and clinical experience, I felt it was my turn to give back by sharing my interpretations. This year, I will officially offer my first full course: Pain Science, Movement, and Manual Therapy. This course work is designed for Physical Therapists, Athletic Trainers, Occupational Therapist, Chiropractors, Physical and Occupational Therapist Assistants, Massage Therapists, and physicians who work in rehabilitation settings. The course work is designed both for those new to these topics, but also to offer some twists for those who already have experience, and are familiar, with these topics. These will be offered in 2018 with live classes and by 2019 I will hopefully have the online with live lab hybrid classes ready to go as well. By 2019, I also hope to expand to offering courses dedicated toward my physician colleagues as their needs are truly unique compared to the movement based rehabilitation profession. I am teaming up with a fantastic advisory board to make these products with the goal of improving communication and patient care through shared understanding of pain and science based interventions across multiple disciplines. Every effort will be made to keep the courses current with the evolution of research and changes in my own thinking. Change and improvement is inevitable, this will be reflected in revisions of the course as the years move forward. I look forward to the process and I hope I can be a small part of helping someone else in their journey.
Teaching people about the complexity of pain is extremely challenging, you must meet each person where they are at. It is not cookie cutter, there is no script, what is meaningful for one person may not resonate with another. You can provide too much information and you can provide too little. While we cannot predict what every patient needs to help them take the next step forward, themes and patterns of information that patients are missing that help connect the dots for them do arise. The late Louis Gifford is one of the pioneers who had a knack for this. Louis has made countless contributions to our understanding of pain. His development of the Mature Organism Model (MOM) was an extremely valuable contribution to both our understanding and education of patients regarding pain. Below is an effort to bring the “Complexity” of the MOM to the patient.
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:
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.
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.
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.