Course Review – Reconciling Biomechanics with Pain Science

I attended Greg Lehman’s Reconciling Biomechanics with Pain Science course again at the beginning of October and it was a great refresher! The purpose of this post is to summarize my take-away points and discuss how this course has and will continue to benefit me.

Take-away points (in no particular order):

1. The human body is complex. Ironically, understanding this helps our interventions to be simpler.
2. It’s okay to be simple. The reasoning:
   • Why do people find success with all treatment paradigms (e.g. Maitland, Mulligan, Sahrmann, Janda, FMS/SFMA, McKenzie, McGill, CFT) even though they are all based on different and sometimes contradicting principles? How can someone with non-specific LBP do just as well when treated using McGill’s approach vs McKenzie’s approach?
   • Well, let’s look at what they all have in common: listening to the patient, identifying ways to modify symptoms (e.g. via manual therapy, changing context while moving), and loading the body locally and/or globally via exercise
   • So maybe, it’s as simple as doing those above three things and there are less rules to manual therapy and exercise than we think.
3. Pain is more about sensitivity than tissue damage. Therefore, treatment involves (1) calming shit down (CSD), (2) building shit back up (BSBU). In other words, (1) desensitize (symptom modification) to reduce pain sensitivity and (2) load to improve tissue tolerance. And these can be done concurrently.
4. Confront the patient with their strengths using what you found during your assessment and reassure them of their robustness to help desensitize. Calming shit down can be done with your words as much as it can with your hands! This can include telling your patients about red flags you have ruled out.
5. Who decides what movement “ideals” are? Where is the epidemiological research supporting these “ideals”? Maybe rehab should be more about developing comprehensive capacity (i.e. ability to move your body in a variety of ways including “improper alignment” ) and encouraging a variety of postures rather than conforming to arbitrary “ideals”. Maybe “good” posture is more aesthetically appealing…but are patients coming to see us because they want to look poised all the time or so that they can go back to doing what they want to do without pain interfering?

How has this course benefitted me?

1. Increased confidence in the clinic

• It is comforting to know that I don’t need to have extensive manual therapy training or take a bunch of courses to effectively help patients. The manual therapy I learned from school/placement and the exercise prescription I learned through my strength and conditioning background is probably sufficient. It is also nice to know that I don’t need to find the specific “structure” that is the “source” of the person’s pain to help them. Treatment is similar either way! CSD, BSBU.
• I talked with another new grad who attended the course about how the course has impacted him, and he said something similar:
  

  “As a new grad, I found the course very beneficial. It reinforced the idea that pain is complex, but simplified approaches to therapy may have complex effects and a significant impact on patient’s pain. That knowledge boosted my confidence as a new therapist and a confident therapist translates to a comforted patient which in turn sets the foundation for improved therapeutic outcomes. “

• Sure, I will still improve my manual therapy skills in terms of how I am handling patients (am I staying close enough and am I supporting them enough so that they can relax?), and I will still work on my exercise prescription in terms of developing effective cuing and having a large repository of exercises. But this will all come with practice in the clinic. Unlike some recent grads I have talked to, I don’t feel an urge to “do my levels” to become a better therapist (guess this saves me some $$ too)
• I think there are many more skills that I can improve on that would make a much bigger difference for my patients, such as communication and increasing motivation.

2. I can play a bigger role with health promotion by helping patients to reduce their barriers to physical activity and exercise.

• According to the Ministry of Health and Long-term Care, up to 90% of type 2 diabetes cases, 80% of coronary heart disease cases, and 33% of cancers could be avoided by eating well, exercising frequently, and not smoking
• How many people are afraid to exercise because they don’t want to hurt themselves or they keep feeling pain whenever they do try to exercise? Anecdotally, I have had patients tell me “I used to be really active. Then I started getting back/knee/hip pain and my [insert therapist or doctor] told me to stop [walking/running/golfing/whatever activity was actually meaningful for the patient] and I’ve gained 15 lbs since then”. What does the research say? Although it wasn’t the largest barrier, a study in Singapore found that“too much pain” was a barrier to participation in physical activity for 20% of elderly participants (n = 60) and 26.7% of middle-aged participants (n = 60) (1). In a thematic synthesis of qualitative studies investigating older people’s perspectives on participation in physical activity, Franco et al (2) found that
  

  “older people also feel they lack the capacity to engage in physical activity because of their perceived frailty and deem age-related deterioration as being unavoidable and unpreventable” (my bold)
  

  We know that age-related changes are unavoidable but how our nervous system responds to those age-related changes can change via neuroplasticity (does it get protective? is it very sensitive to those changes?).

• If we can (a) simplify how to help people in pain exercise (CSD, BSBU), (b) teach people how much pain is okay when exercising (“poke the bear but don’t shove it”), and (c) communicate with them in a way that tells them that their bodies are robust/adaptable instead of fragile, then that already removes a barrier for them becoming more active.
• Pain education isn’t going to magically make people healthier, nor is pain the biggest barrier to becoming physically active based on the studies mentioned above. However, with a better understanding of pain, I feel that I am free to focus less on unnecessary rules of how people should/should not move (which probably just decrease their self-confidence more) and more on behaviour change skills to actually motivate people to move.

I highly recommend the course as these are concepts you can implement immediately in the clinic. Greg is also very generous with his course materials and will give you access to them (including updates, references, new lectures as he makes them) after the course.

If you have taken this course, what were your big take-aways? Has anything that I said here challenged your thinking? If so, in what way? Please feel free to share your thoughts below or shoot me an email :).

References

(1) Justine M, Azizan A, Hassan V, Salleh Z, Manaf H. Barriers to participation in physical activity and exercise among middle-aged and elderly individuals. Singapore Med J. 2013 Oct;54(10):581–6.

(2) Franco MR, Tong A, Howard K, Sherrington C, Ferreira PH, Pinto RZ, et al. Older people’s perspectives on participation in physical activity: a systematic review and thematic synthesis of qualitative literature. Br J Sports Med. 2015 Oct 1;49(19):1268–76.

PS: Check out some other course reviews by Jesse Awenus and Todd Hargrove

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