Articles Of The Week October 28, 2018

 

You know we love it when people promote evidence-based practice around here! Fortunately, these guys do that a lot and this week bring us the five most effective evidence-based ways to help with concussions.

“5 Most Effective Evidence-Based Treatment Options For Concussions” – Complete Concussion Management

We all know the importance of how we communicate with patients and the difference it can make. What about when negative messages are coming from mainstream media that could affect our patients? Well, they’re taken on with this post and as someone who works in women’s sport, this one is GOOD!

“Dear Runners World, Women’s Health & Amanda McCracken” – Ellie Somers

Super interesting article on how the body deals with and heals trauma. It shows a strong connection with the body and mind connection and the better understanding we have of this the better we can help our patients.

“The Science Of How Our Minds And Our Bodies Converge In The Healing Of Trauma” – Maria Popova

We have had articles and discussions on this blog around the topic of resilience and teaching resilience to patients. But, what is resilience and why is it important? Well, our buddy Ben Cormack has the answer for you and the best part is how many things you can do with your patients to help their resiliency.

“Resilience – What Is It And Why Is It A Big Deal For Recovery?” – Ben Cormack

We are all business owners, whether a clinic owner or a contractor. So, if there are ways to make business life easier, it’s worth taking the time to check it out. Here are 32 tools you can use to help with everything from accounting, to websites, design, and organization.

“32 Mostly Free Tools You Can’t Afford To Run Your Business Without” – Healthinomics

Predictive Coding: Why Expectation Matters For Movement And Pain

 

Predictive coding is a hip new model for perception that I have been studying lately. In some ways, it is very common sense and intuitive, and in others, it is very challenging and mind-expanding. Here’s a post describing what I’ve learned that I find interesting and practical. Before getting into that, let’s review why any of this should be interesting to anyone concerned with movement and pain.

First, good movement requires good perception. The skill of moving your body with coordination is inseparable from the skill of perceiving where your body is in space and how it is moving. We perceive to move and move to perceive, and that is why we often say that great movers have amazing “body sense” or “proprioception.”

Second, pain is in the nature of a perception. It depends on the brain’s interpretation of whether the body is in danger and what needs to be done to protect it. If your foot hurts, that means your brain perceives, rightly or wrongly, that it is damaged. Perceptions about the body (like anything else) can be mistaken, which is why we can have pain in areas that aren’t damaged, and damage in areas that aren’t painful. By learning more about the science of perception, we necessarily learn more about pain and how to treat it. 

The Conventional Model For Perception: Bottoms Up

The conventional model of perception works roughly as follows. We collect sensory information through nerve endings in the eyes, ears, skin, muscles, etc. This information is relayed to the brain, which processes the information, interprets its meaning, and then creates a perception about the cause.

For example, when I see my wife’s face in front of me, this is because light bounced off her face, the pattern of the light was registered by my eyes and sent to my brain, which recognized the pattern as coming from my wife’s face, so it created the perception of her being there (so I would know who to take orders from.)

Or, if someone feels pain in their knee when they take a step, this is because the mechanical force of the step triggered nociception (nerve signals about potential damage), the signals reached the brain, the brain concluded the knee was under threat, and it created pain to encourage protection (maybe by limping). This model is therefore very “bottom-up” or “outside-in.”

It emphasizes the flow of information from the outside world to the periphery of the body, and then from the periphery to the brain. What’s missing from this story? What the model fails to explain very well is the role of past experience in determining how the brain interprets the meaning of the incoming sensory information. 

This is where the predictive coding model adds value – it explains how “top-down” factors modify incoming sensory input.

Predictive Coding: Expectation Matters

According to the predictive coding model, the brain is always building and refining its representations or models of the outside world (and our bodies). Our perceptions depend in large part on these models, not just incoming sensory data.

For example, I have an internal model of my house that includes only one four-legged creature – my dog Levi. So if I walked through the living room in low lighting and glanced at a wolf, I would probably literally see my dog, Levi. In other words, my perception would be determined by more by my expectations than by actual sensory data from my eyes.

Check out the pictures below for some other examples of how expectation can determine perception.

 

In the first two images, you perceived something very different from what your eyes told you, based on your prior assumptions about how words are usually ordered or spelled. In the third picture, you saw two normal looking faces, based on your prior experiences with face parts being arranged in certain ways. (Turn the picture upside down to see a very different arrangement.) 

This happens with many other kinds of sensations. If you think satanic messages are hidden in rock lyrics, you can hear them if you play Stairway to Heaven backwards. If you come up from behind someone and say “hot!” at the same time you put ice on their arm, they will feel heat. The painkilling effect of a placebo is based purely on the expectation that it will reduce pain. And nocebos work the opposite way – expecting pain can cause pain. To some extent, we perceive what we predict.

Comparing Top-Down to Bottom-Up 

The predictive coding model has a great explanation for exactly how expectation affects perception.

The nervous system is arranged in a hierarchical fashion with the brain cortexes at the top and nerve endings at the bottom. Higher levels of the nervous system are constantly predicting the incoming flow of sensory data from lower levels. These predictions create a neural activity that flows downward (top-down) to meet incoming sensory data (bottom-up).

When the meeting occurs, a comparison is made between what has been predicted and what has been sensed and this generates a prediction error. Put another way, top-down “shakes hands” with bottom-up, and disagreements are discussed and compromises are struck. If the error (or disagreement) is relatively small, it is disregarded as being random noise or “close enough.”

Higher levels of the nervous system are not informed of their prediction errors, and the world is perceived exactly as expected. If the error is large, higher levels are notified of their mistake so they can update their model of the world. This creates a subjective feeling that something surprising or important has happened, and attention is automatically shifted to the incoming sensory data so that perception and action can be adjusted accordingly. 

The strength or confidence of the prediction has a big effect on how prediction errors are treated.

If the prediction about incoming sensory data is highly confident, (perhaps based on tons of past experience) even significant errors will get ignored. But if the prediction is not confident (perhaps because the context is novel and errors are anticipated), then bottom-up sensory information has a better chance of ascending to higher levels of the nervous system and causing changes in perception.

Attention also matters for how prediction errors get processed.

If I pay attention to a certain stream of sensory information, it increases the chance that prediction errors will be noticed and not dismissed. The system can, therefore, bias perception in favor of top-down or bottom-up factors based on relative levels of confidence or attention to either one. For example, according to my model of the world, the only black SUV in my garage is my car. If you switched it for another one, I would probably get in without even noticing. My perception would be controlled by expectation, not the information from my eyes. But I wouldn’t suffer the same illusion in a crowded parking lot where my perceptions would be controlled far more by bottom-up sensation than top-down prediction.

Now that we have a basic understanding of how this model works, let’s look at how it explains some common and not so common phenomena related to perception.

Pain

The predictive coding framework helps explain why pain is affected by past experiences, thoughts, expectations, and emotions, and not just tissue damage.

For example, if you have a good deal of experience where flexing your low back causes pain, you will start to build an internal model of your back that predicts it will hurt with flexion. This will strongly bias you to feel pain each time you bend, even if the back isn’t actually producing that much nociception. 

You can reduce the contribution of top-down factors to your pain by updating the model of your back. To do this, you need to cause a prediction error by violating your expectation that bending will hurt.

A good strategy would be to perform low back flexion in some novel way, perhaps in quadruped or supine, while paying attention to how it feels while bending so that any predictions errors are not disregarded. That sounds like a high percentage of movement therapy in a nutshell.

A more aggressive and risky strategy would be to perform some movement where the back muscles have to work very hard to prevent flexion, say a heavy deadlift. Perhaps you do the deadlifts with good form to prevent flexion. It hurts a little, but nowhere near as much as you expected. In fact, you have a visceral feeling of surprise at how strong you feel. This is evidence that you have violated an expectation that your back was too weak and fragile to handle any significant force, and that your map for the back is being updated to account for the prediction error. Good sign!

The bottom line is this – a great deal of what can help with pain in the short term is violating an expectation that something will hurt. There’s probably a lot of ways to do that – massage, deadlifts, cat-cows, stretching, isometric resistance exercise, active or assisted joint mobility exercises. What they all have in common (if they help with pain) is that they don’t hurt as much as you would expect.

Moving Better – Prediction And Action 

According to the predictive coding model, there is a profound connection between perception and movement, because each can help correct a prediction error, and minimizing error is really all the system cares about.

When the system is confronted with a prediction error, it can do one of two things – update models to reflect the new information (change perception) or alter action in a way that gathers sensory information consistent with the prediction (change movement).

For example, let’s say I am squatting to a box with my a barbell on my back. When I squat to a certain depth I expect sensory feedback from my butt indicating touchdown. But there is a prediction error – my butt is silent. I can do one of two things – I can change my perception about the location of the box (oops I forgot to put it in place!) Or I could change my action – move my butt a bit lower or further back until I get the predicted feedback.

So one way or the other, the essential goal is always to reduce prediction error, and it doesn’t really matter whether that is done by changing perception or action. The important thing is that I don’t crash to the ground with a barbell on my back. Either way, good internal models and good predictions are the basis for generating functional perceptions and actions. 

Getting better at movement is therefore very much about improving your internal models for movement and your predictions for what kind of sensory feedback you will get during the movement. This means you need a lot of experience, you need to make mistakes, and you need to pay attention to the right streams of sensory information to identify and correct those mistakes through better perceptions and actions.

Of course, we know most of these things anyway, but I think it’s cool to see that application of the predictive coding framework gets us to the right answers. Here’s some cool stuff that we might learn from predictive coding that we don’t already know and is not easily explained by other models. 

Schizophrenia, Autism And Babies 

Check out this picture of Albert Einstein – is his nose closer to you or further away?

We expect noses to be closer to us, so most people will see this mask as being convex when it is in fact concave.

Interestingly, schizophrenics (and people stoned on marijuana) are actually less likely to make this mistake. This might be because their perceptions are controlled more by bottom-up sensation than top-down models of the world. And maybe this is why they can both tend towards paranoia. Schizophrenia involves delusions where everyday events are regarded as incredibly salient and important.

Imagine sitting in a crowded coffee shop and hearing your name in a nearby conversation. This might get your attention, but it would not probably register in your consciousness as being profoundly surprising.

But if you had a problem whereby the relevance of unpredicted incoming sensory information was massively magnified, then the mention of your name might feel profoundly important, and perhaps contribute to delusions of reference or paranoia. So perhaps paranoid delusions involve assigning too much importance to minor errors in prediction. 

Autism can be also be understood as a condition where bottom-up sensation dominates top-down predictions. Even the smallest prediction errors are considered important.

Thus, all incoming sensory information is regarded as “newsworthy” and people with autism are “slaves to sensation”, constantly distracted or irritated by minor inputs like labels on their clothes, or random noises. Interestingly, people with autism often self-soothe by engaging in repetitive rhythmic movements. These create a stream of sensory information that is highly predictable. Better prediction allows the suppression of sensory information that would otherwise be overwhelming.

Maybe this is why babies like rhythmic movements, or to be carried around all the time, or to be swaddled. Because they don’t have much experience in the world, they have no strong internal models to create confident predictions about their incoming sense data, and they just get blown away by all of the information they are getting about the unpredictable movements of their arms and legs, the variations in the way their back is touching the car seat, and the random noises created by the TV, traffic, etc.

Adults are exposed to all of this information too, but we can easily predict it and therefore ignore it. But for babies without good internal models of the world, everything is a blooming, buzzing confusion. Perhaps they are soothed by getting a nice stream of predictable rhythmic sensory information. Aren’t we all? Lots of interesting food for thought here. Here are some further resources if you want to learn more. 

Good Articles On Predictive Coding

An Aberrant Precision Account of Autism

Prediction error minimization: Implications for Embodied Cognition and the Extended Mind Hypothesis

Active Interoceptive Inference and the Emotional Brain

The Hard Problem of Consciousness is a Distraction From the Real One

It’s Bayes All the Way Up

(Thanks to Derek Griffin and Mick Thacker for linking many of these.)

Articles Of The Week October 21, 2018

Richard is always great at putting educational resources together for our profession and he’s at it again. Here is a long list of educational resources for you to use and share with your network about the benefits of massage therapy.

“Open Educational Resources For Massage Therapists” – Richard Lebert

Review is always a good thing right!? This post was done way back in 2014 but we stumbled across it this week. It’s a great review of a peripheral nerve root, which helps us understand how they work just a little bit better.

“Anatomy Of A Peripheral Nerve Root” – Diane Jacobs.

Ever wondered how much you should increase the load or training demand when doing rehab with a patient? Well, its always a variable, but the 10% rule is a good place to start and this article sums up nicely how to implement that.

“When Progressing Training, Not All Load Is Created Equally” – Tim Gabbett

Sometimes research is done to try and prove what we “think” we are doing, as opposed to trying to prove a theory wrong, or prove what’s “actually” happening. Unfortunately this happens a lot in manual therapy. In this post some bias’ get challenged and research shows what is “actually happening” with some of our treatments.

“Model Issues” – Sam Jarman

This is a VERY important article to share because it could happen to ANY manual therapy profession, and SHOULD happen to every manual therapy profession. The College of Chiropractic here in British Columbia is telling all chiropractors to remove any advertising there is no acceptable evidence to support, or face discipline. Kudos to them for making their practitioners accountable to the public and pushing for evidence based practice.

“Chiropractor Crackdown: College Gives Ultimatum On Misleading Health Claims” – Bethany Lindsay

 

 

Home Care Plans: Instructions Vs. Adherence

I remember going to physiotherapy when I was in high school and having my exercises prescribed to me for my knee pain. I was instructed to do them every day, which I think I may have managed to do for about a week. Past that, they tapered down to as little as once per week only, followed by lies to my physio about doing them regularly.

Was I just a bad client? Maybe.  Let’s fast-forward a decade or so, though.

When I began my career as an Athletic Therapist, I would instruct my patients along the same lines. Do the exercises every single day in order to get better. It’s the standard I wanted and, if nothing else, it would make the clients exercise to some extent.

But my method didn’t work.

Adherence to my instructions was poor and my clients had a difficult time getting better. Truth, maybe there are “bad clients” out there, but at some point, you have to look at the coach rather than the players. Which brings us to the key error so common to many of our practices:

“I tell my clients to do their exercises every single day knowing that they won’t, but at least, then, they’ll do them every other day.”

Does this sound familiar?

As health practitioners, we’re used to working with patients who are only partially or completely non-compliant when it comes to their exercise rehab. As a result, we become accustomed to “tricks” in order to get them to exercise and be able to recover.

However, if you’ve used the above trick in the past, I’m sorry to say that you’re terribly misguided. (As I was.)

Let’s consider that by saying this, we’re raising the expectations for a patient to what is, for all intents and purposes, an unrealistic level. (If it was realistic, then we wouldn’t be assuming failure on the client’s part.) Now ask yourself, have unrealistic expectations ever proven to be a formula for success?

We know this to not work with raising children or dieting, so why in the world do we assume this to be effective when it comes to rehab?

Poor exercise adherence has been shown to be, in large part, due to anxiety regarding the process and an expectation of failure. Think about it; if we’re told that we absolutely need to do 100% to recover, but we know we won’t achieve that 100%, are we going to be motivated to do 50% in hopes that it will be enough? Not likely!

More likely, the guilt of not adhering completely will derail the behaviour change altogether.

So, I’m sorry, there is no easy and effective “trick” such as simply telling a patient to perform a mile while expecting an inch. Instead, actual investment in coaching patients through their exercise barriers is required.

Such coaching techniques include:

  • Helping them understand the starting process and develop a feeling of control
  • Understanding their hesitations regarding exercise
  • Finding exercise and time routines that work with their lifestyles
  • Making small changes at a time
  • Developing relapse expectation and management

So, let’s look into how we can take those points and put them into action with our patients.

Education

As clinical professionals trying to induce behavioural changes, we need to ensure our patients have a thorough understanding of the recovery process and the importance of exercise. With this understanding, clients will develop a feeling of control over their recovery and become motivated by being able to see the direct benefit of their actions.

Exploring Barriers

If a patient has barriers to physical activity, you’re allowed to dig a little bit to understand them for yourself.

Perhaps it’s that anxiety about the process, which education will address. Maybe it’s a time constraint or limited equipment-availability, which signals the need to carefully strategize with their plan. The patient could simply hate the idea of exercising, and so you might have to come up with something that does not necessarily feel like formal exercise.

Discussing these obstacles with your patient will let them know you’re investing time and energy in creating the right plan for them and create trust between the two of you.

Which brings us to…

Individualizing Their Routine

If you have a go-to-patient that is hyped and happy to set aside 30 minutes per day and run through all of their rehab homework daily, then great. For the rest, we need to explore different methods.

For some patients, requesting their rehab exercises to be done every 2-3 days might be the realistic and attainable option. You can also consider programming them as a warm-up before working out, sports, or even just going out to walk, which is great for those with perceived time-restrictions.

Split-routines are an effective method as well, especially when it comes to combatting boredom or monotony. If you have six exercises you want your patient to do, try splitting them into three on one day and three on the other.

Finally, for those who are averse to traditional exercise, in general, you might have to be a bit more creative and find movements that are fun or don’t resemble the “work” of a workout. What I find beneficial is simply reintroducing the activities that patients want to do upon recovery as graded-exposure therapy.

Throughout all this, though, let’s remember to make small changes to lifestyle at a time. As we know, gradual modifications are much more successful in the long-term than massive overhauls.

Develop A Relapse Plan

Finally, it’s crucial we create somewhat of a risk-management plan with our clients.

A lot of things can potentially derail an individual’s adherence to change. Missing a day or two of exercise might demotivate someone from continuing further. A relapse of pain might be the clincher that causes a patient to give up and think they failed. Even simple life events might throw a wedge into the ability for someone to focus on their health.

In these cases, I drive home the point that relapses and derails are likely to happen. By predicting the possibility, we can create methods of coping and moving on. Let a patient know that it’s ok if they miss a day or even a week of exercise and that they’ll continue to reap the benefits as soon as they get back on the horse.

Pain relapses should be normalized as an expected event, and if the patient can use it as a learning opportunity rather than as a sign of a failed recovery. Like with anything we do in life, recovery will involve ups, downs, and plateaus to work around.

In truth, this ability to work with a client to create longer-term habits and adherence is something that many fitness professionals commonly excel at over medical ones. Personal trainers know that it’s an easy way to lose their client by telling them to do cardio six times per week or that they need to work out for three hours per day. Bringing those expectations back down to a realistic level and adjusting their plans as the client changes are the sure-fire way to success. Cookie-cutting a method for motivating that person to exercise is as bad as cookie-cutting the program itself. We have a duty to individualize our patients routine which includes the frequency basis on which it’s performed. And don’t expect failure; aim for success.

Articles Of The Week October 14, 2018

We talk lots about exercise and strengthening around here, but is it always necessary? While I’m a firm believer in movement and loading tissue, sometimes a “mythical dysfunction” comes along and we’re taught very specific exercises to fix said dysfunction. But is it really necessary? Give this article a read to find out.

“Deep Cervical Flexor Training” – Paul Ingraham

Therapists quite often get caught up in “corrective exercises”. In line with these corrective exercises, they’re talking to their patients about how dysfunctional, or weak they are, rather than instilling strength and resilience. When the reality is, just getting stronger is corrective to whatever their treatment goals or issues are.

“Getting Stronger Is Corrective” – Tony Gentilcore

This one has a GREAT infographic along with some great information regarding the biopsychosocial aspects of therapy and how it can be explained to patients.

“Simple Tips To Improve Mental Health” – Keith McCarroll

Knowledge about pain has come a long way in the past few years. However, the teachings around it haven’t kept up the pace quite as well. That’s where some great posts like this one come out and help all of us gain a better understanding of chronic pain.

“A Better Understanding Of Chronic Pain” – Mark Olson

There are just as many misconceptions around exercise as there is about manual therapy. Fortunately, guys like Nick are out there sharing quality information. In this post, he shares lots of information and demonstrations of some lower body exercises (many of which you could perform right in your treatment room with patients) along with the explanations about why they’re important.

“The Missing Lower Body Exercises For Strength” – Nick Tumminello

Qualities Of Muscle And Changes In Sensation

Once in a while, I’ll get called out on something in a blog post.

Fortunately, I don’t take it personally anymore, cause well…we all make mistakes.

In one particular instance, it wasn’t so much a mistake as it was just something I hadn’t remembered learning about, so the post wasn’t as clear and concise as it could or should have been. So in doing some research on the topic, it essentially led to writing this post (but I’ll still need to go back and edit the other one afterwards).

The post was about whether we lengthen a muscle in a treatment and the person said that I didn’t take muscle extensibility into account, so it made the information sound wrong (that’s not what was said verbatim, but it’s the general gist of it).

But there are some other physiological properties of muscle we should take into account as well so that we can always give our patients an accurate description of what is going on with them.

Excitability

Or more accurately, electrical excitability.

Action potentials, or, an impulse travels along a cell’s membrane due to voltage-gated channels. In a muscle, there are autorhythmic signals that come from the muscle itself (think the heart). The other is chemical stimulus like neurotransmitters released by neurons, hormones from the blood, or local changes in pH level.

This quality of excitability is one of the things that generates movement, the muscles respond to these electrical, or chemical stimulus and produce tension or movement via a contraction. 

Contractility

Contractility is the ability of muscles to contract forcefully when stimulated, thus generating tension. If the tension generated is enough to overcome the resistance of an object, the muscle shortens and movement takes place.

As we mentioned with excitability there is an electrical stimulus, when a stimulus is generated it then creates a twitch response (or contraction), one contraction or twitch response occurs for each stimulus. So, contraction begins as an electrical stimulation, which in turn becomes a mechanical response, thus overcoming the resistance of that object you are trying to lift.

This is probably one of the main things we are trying to have an effect on when working through rehab exercises with our patients, making contractility easier, so they can continue on their activities of daily living pain-free (and yes I realize we are having an effect on the other qualities as well). 

Elasticity

Elasticity is the ability for a muscle to return to its original length and shape after a contraction, or extension.

When looking through textbooks most refer to plastic and viscoelastic properties which enable this return to length to occur. However, as you will see when we talk about extensibility below, this may not be the case. 

Extensibility

So, this is where I got called out!

Extensibility is the ability of a muscle to be stretched to a predetermined endpoint of sensation and then return to its original shape when the stretch is removed, without being damaged.

If you remember talking about agonist and antagonist contractions in college, this demonstrates an example of extensibility. As you flex your biceps (agonist), the triceps (antagonist) have to relax and stretch (or lengthen) in order for the contraction to take place.

But in order for a muscle to have extensibility, it also has elasticity, which enables the muscle to return to its original, normal length.

This is where research must come in. There are a number of theories used in trying to explain how muscles can be lengthened, or have extensibility increased. Most of them are trying to say there is a mechanically increased length of the muscle but is this really possible?

There are four of these theories and here are their explanations:

  • Viscoelastic Deformation
    • A decline in resistance to stretch after being held in a stretched position for a period of time.
  • Plastic Deformation Of Connective Tissue
    • Increase in muscle length, immediately after stretching that causes a muscle to remain in a permanently lengthened state.
  • Increased Sarcomeres in Series
    • If muscles are immobilized in fully extended positions, there is an increase in the number of sarcomeres in series.
  • Neuromuscular Relaxation
    • Slowly applied stretch causes neuromuscular reflexes to relax the muscle.

However, most of the above theories have been done as animal tests, could not be performed on humans, provided no evidence of length change according to the description, and provided no lasting change.

Ironically I would have thought neuromuscular relaxation would be the best explanation, however, the studies showed that increased movement after short-term stretching could not be attributed to this. I’m wrong again!

As this review points out, there is a better theory with a better explanation.

The studies reviewed show that increases in extensibility are more likely due to a change in sensation, not an increase in muscle length. It even suggests there is a psychological role in allowing for greater extensibility.

One study showed that an intensive four-week stretch program actually didn’t make a difference in extensibility, but rather increased the subject’s tolerance to uncomfortable stretching sensations and also points out the underlying mechanism may be psychological. The argument was also made in this study, that the four-week stretching program may not have been long enough to make a noticeable change.

This would explain why when I go to a yoga class once in a while, I don’t see any real difference in the amount of movement I can do from one class to the next. My tolerance to the stretch or movements hasn’t increased enough for me to do that damn supta virasana pose (and I don’t think I’ll ever be able to, my body doesn’t bend that way!). However, those folks who go a couple times a week and make a practice of it have a far more increased tolerance to the movement after doing it regularly for an extended period of time. 

For some of you, this may be a simple review and you already know this stuff while some of you may be wondering how or why it’s applicable clinically. Well, we quite often tell our patients we are trying to “lengthen” the muscle when we apply a stretch after treatment. We even use the comparisons of people who do yoga and refer to their “long” muscles.

Well, the reality is there is no length difference in the muscle, but there could be a change in their extensibility. Even as we try to explain to them what extensibility is and the changes we make, we need to be accurate in our description of what’s happening. Just like the when we begin rehab exercises and introduce graded exposure to fearful movements, all we are doing when we provide a stretch is a graded exposure to the stretch sensation. We aren’t even going to make a massive change to extensibility in one treatment, but maybe we can increase a little more tolerance to certain movements. Great, now I have to go back and edit that other post, and we’ll see if I get called out on this one!