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.