A few weeks ago I had the pleasure spending the weekend immersed in something that has increasingly become a fascination of mine since I left PT school. It was a course run my a former classmate and friend of mine, Dr. Greg Lehman. Greg has a very unique perspective on the rehab profession at large because of his triple threat training as a researcher (did a masters of biomechanics with Pr.Stu McGill), a chiropractor and a physiotherapist. Coming into and directly out of physio school I must admit that I did not give much thought to the nature of pain. I knew people had it and I thought I would acquire all the tools in the world to fix it. I would mobilize stuck joints, release tight muscles, and give exercises to strengthen peoples cores. I would CURE people! I took courses in manual and manipulative therapy (Canadian System), acupuncture, soft tissue courses etc…all in an effort to get rid of peoples pain. Whenever I helped someone in a single session I thought I had the magic touch…what an idiot I was ;)
In my attempt to keep this prelude brief, I will say that as I moved forward in my practice and kept a skeptical mind about what I was doing and what I was taught, I began to realize that I could do any number of different techniques and people would still get better. I reasoned that it was just as much as what I said to my clients as it was what I did that made all the difference. It was then that I realized I needed to become better at what I said was the cause of peoples pain. I needed a way that didn’t make patients feel dependent on me to align them or make them feel like they’re fragile. I used to do that… a lot. I struggled mightily with this paradigm shift because it’s SO EASY to tell somebody they have a rotated pelvis causing their back pain. It’s tempting because it necessitates more therapy and it’s easy for the patient to understand. It also makes the therapist look like a genius for finding this flaw that can be fixed. The problem for me came when I was forced to realize that twisted pelvis’s, stuck cuboids, or tight muscles were not the sole cause for peoples pain. In fact, they were actually relativity minor players in the pain game. The PhyisoFundamentals course was about talking about the other players in the pain game…namely The biopsychosocial model.
Instead of giving a bullet point list of what was discussed, I think it would be far better to do this as a small case study to demonstrate how the content of this course would change how I handled a patient with good old fashioned knee pain.
Mr. Jones is a 65 y.o male with insidious onset medial knee pain on the right of 4 months duration, He thinks he developed this pain from playing “too much” tennis over that time period and has since stopped playing due to pain and fear of making it worse. He owns a large manufacturing business, which is quite stressful for him to manage. He complains of pain with prolonged sitting >30 minutes and with any pivoting motions. He saw his GP who ordered him an X-ray showing moderate to severe osteoarthritis of the medial compartment, which he now believes is the cause of his pain.
Based on this quick history, we could go several routes in both or physical exam and subsequent explanation of the condition. We could relate his knee pain to his twisted pelvis, creating a leg length issue thus placing more strain on the joint…how cool would that be if it were true?!?! Or we could do the following:
1) Explain that structure does not dictate function and that misalignments in the body have never been shown to cause pain. Our bodies adapt and there are many people out there with all sorts of anatomical peculiarities that don’t have any pain. This provides hope for the patient..he is not doomed to be in pain by his posture or alignment
2) We would NOT assess his pelvic orientation, how his L3 moves on his L4 or his inner unit timing and then relate it to the cause of his pain. What we would do is explain that while certain activities like tennis might make his pain worse, this is more of a neurologically mediated protection response than it is any knee specific problem. The brain interrupts the twisting motion as a threat and thus relays the message of pain to the brain. Slowly building capacity and confidence in the ability to move without pain will allow him to get back to tennis. We do this by manual therapy to desensitise angry nerves, explaining that he is not broken and the robustness of the body, and by graded exercise prescription specific to the tasks he wants to achieve.
3) We would be wary of making any correlation between his knee pain and his imaging findings. In fact, we would explain that he probably has the same amount of degeneration on his other knee and that many people get this and don’t have pain. Explaining how just as we age on the outside with wrinkles and grey hair, we age on the inside with degeneration and arthritis, This is a very important falsehood to correct because we know that if you believe the idea that your body is “degenerating” then you will naturally fall into behaviours that protect you. These “protections” are lack of use, hypervigilance and increased sensitivity to the area in questions…all things that promote the pain response. Giving the patient the power to see past a static diagnostic image is both evidence informed and ethical. Personally, I question any healthcare professional who uses an X-ray finding to keep his/her patient coming back over and over again in the hopes of correcting whatever perceived misalignment or degenerative changes the image shows.
This course was unlike any I have ever taken before. There were no specific techniques taught and it was heavily based on language and evidence as opposed to palpation and guruism that so many other courses endorse. Greg made the strong point that we don’t have to change what we do with our patients on a day to day basis. If you like cracking backs, keep cracking. If you like prescribing the McGill big 3 or “releasing” muscles with an instrument, go nuts! All this course sought to do was re-frame the how and the why behind what we already do so well. And this is something I can get behind.
My personal comment:
This course will be a hard sell for a lot of newer grads because they, like I used to, crave the “fix”. They went into the profession to help people and the promise of instant gratification is a powerful thing. There are many courses that promise quick fix techniques that seem very sure of themselves. The pain science movement doesn’t make itself out to be the panacea that many other courses seem to and this is why it might be hard for newer grads to reconcile. We want to believe we have magic hands and can move the body like a mechanic moves pieces of a car around to get it running perfectly again. This courses challenges those beliefs and might be a hard pill to swallow for some.
Overall I recommend this course to anyone who treats people in pain. We can do better and I think the content this course provides will help. I know it is still a work in progress for me to integrate all of this into my practice, but I will keep trying and make sure to assess my own interactions with each new patient I see.
Have a great week!