Models Of Pain And Movement

 

There are various models used to understand pain: the neuromatrix model, the biopsychosocial model; Louis Gifford’s Mature Organism Model; the Onion skin model, the biomedical model. And for motor learning and physical training, there is the constraints based model, or dynamic system theory, the various Russian sports science models, non-linear pedagogy, etc.

 

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I often see debate as to the relative merit of these models, which is a good thing. But what I think is not such a good thing is when people argue that because a model has a certain flaw or limitation, it is fatally deficient. Or that using this model will always lead to error. Or that existing problems with current models require a complete and radical revolution in our thinking. These arguments are particularly common in regard to models about the brain because let’s face it, the brain is pretty hard to model.

The way I look at it, all models are necessarily wrong, at least to some extent. But some models are still useful. We need to be aware of how a particular model might lead us astray, but we also need to appreciate how it can provide insight.

Building models is a fundamental part of trying to understand the world in any systematic or organized way. The world has too many details and complexities to be taken in all at once. In order to really understand a particular phenomenon, we need to focus on certain essential details while ignoring others.

For example, to understand the movement of large objects in response to forces, we focus on the mass and velocity of the object and the magnitude and direction of the forces applied to it. But we ignore non-essential but very real details like the color of the object, the shape of the object, or even the effects of friction. The result is a model with simple equations like force equals mass times acceleration.

We can test the accuracy of the model by seeing whether it makes accurate predictions. If it does or leads to better understanding and control over the events we are trying to explain, it is a success. Further progress can be made by noting the limitations of the model, arguing about whether other models are better, making improvements to existing models and so forth.

Although we can improve the accuracy and utility of models, they can never be complete or accurate representations of the world. In order to fully model the world, we would have to build another world! That’s impossible, and it wouldn’t really help anyway. So models are not mirrors of reality, but simplified reflections. They are, therefore, to at least some extent, “wrong.” But again, they can be incredibly useful.

Newtonian mechanics allows us to make amazingly accurate predictions about the movement of large objects like planets. But it fails to describe events accurately when objects are very small or moving near the speed of light. Under these circumstances, we need different models – the theory of general relativity or quantum mechanics. So Newton’s “laws” are not universal, but they remain accurate in the “middle-sized” world that is our usual area of concern.

Here’s a relevant quote from Sean Carroll (a very smart physicist) in his new book The Big Picture:

Our best approach to describing the universe is not a single, unified story but an interconnected series of models appropriate at different levels. Each model has a domain in which it is applicable, and the ideas that appear as essential parts of each story have every right to be thought of as “real.” Our task is to assemble an interlocking set of descriptions, based on some fundamental ideas, that fit together to form a stable planet of belief.. . .

Our fundamental ontology, the best way we have of talking about the world at the deepest level, is extremely sparse. But many concepts that are part of non-fundamental ways we have of talking about the world — useful ideas describing higher-level, macroscopic reality — deserve to be called “real.”

 

The key word there is “useful.” There are certainly non-useful ways of talking about the world. In scientific contexts, we refer to such non-useful ways as “wrong” or “false.” . . . Every scientific theory is a way of talking about the world. The world is what exists and what happens, but we gain enormous insight by talking about it — telling its story — in different ways.

I agree!

The human body is one of the most complex organizations of matter in the known universe. To understand it, we must build models, use metaphors, and deal in abstractions. This necessarily involves ignoring certain details, creating simplified pictures, and relying on metaphors that have the potential to mislead. But we have no choice! Models and metaphors are indispensable thinking tools for understanding the body. Is the brain a computer? The heart a pump? The kidney a filter? The nerves telephone wires? In some ways, yes, and others no.

Each model is a different perspective from which to see the world, with its own unique insights and blind spots. For example, you can look at movement or pain from the perspective of the musculoskeletal system, the nervous system, the metabolic system, the immune system, or the endocrine system. You can take a microscopic view to consider the behavior of individual cells, or zoom out for a big picture of the relationship between larger systems. Some perspectives might be highly informative for a wide variety of purposes, and generally, foster an accurate perception of the viewed object. These perspectives are great. Others may get you looking in completely the wrong direction. These perspectives suck. But there is no one perspective that can offer a complete understanding of a multi-dimensional phenomenon like pain, movement, or any other event in the human body.

Articles Of The Week March 17, 2019

I would say as a profession, we are a compassionate group. However, it turns out compassion can be trained in your brain and can be enhanced with training and practice.

“Brain Can Be Trained In Compassion” – Alison DeShaw Rowe

This is a REALLY good article to share with your patients who are dealing with pain. All too often they are referred for imaging, which only increases pain when patients see the result. However, if we changed things and patients were educated about their pain properly, we would probably have better outcomes.

“Do You Know The Risks And Rewards Of Pain Treatments?” – Kal Fried

Communication matters, however, sometimes communication can be tough and sometimes we are left wondering if our communication was done the right way. If you feel like you’ve been in a situation like this before, you’re not alone, but it is something we can work on. 

“The Enemies Within” – Benjamin Stevens

As business owners, the way we present our business can make a massive difference in our success. This is a great article about what to look for and create when it comes to designing your logo.

“What Makes A Strong Logo For Your Massage Practice (With Examples)” – Michael Reynolds

We have written about imposter syndrome before and as this article shows, it’s not just an issue with people in manual therapy. One of the things that is a little surprising, is those who have imposter syndrome are quite often top performers. While this article is directed towards doctors, it provides some great advice for all of us who may be doubting our skills.

“Understanding And Dealing With Imposter Syndrome” – Jocelyn Lowinger

The Negotiation Of Pressures

 

  • “Using a soft touch which is generally no greater than 5 grams – about the weight of a nickel – practitioners release restrictions in the soft tissues that surround the central nervous system.” (source)
  • “It has been suggested that ischemic compression therapy using either 90 (seconds) low pressure up to the pain threshold or 30 s stronger pressure up to pain tolerance can create immediate pain relief and MTrP sensitivity suppression” (source)
  • “In the past, it was suggested that you hold pressure the trigger point at the individuals’ pain tolerance of a 7-8/10 (10 being excruciating pain).  It is now accepted that even a 7-8/10 may be to high to get a proper release, so authors and researchers suggest holding the trigger point at a level of a 5/10 until the individual experiences a decrease in symptoms, at which point you can either go deeper into the tissue (look for trigger points that are in deeper muscles) or move to another location and search for trigger points” (source)
  • “Pressure during deep-tissue work must be significant but always stays just below the client’s pain threshold.” (source)

Uncertain as to how much pressure to use? Well, the above statements should straighten things out, right?

Regular readers of my blog know my take on pressures, but if you are new:

In manual therapy/massage literature, there is little, if any credible, repeatable peer-reviewed evidence to show one type of pressure being superior to another. But there is also little that shows static pressures/stretch, of the type often used in myofascial release, to be superior to dynamic/movement stretching/massage.

Sure, you will find published studies showing many different styles of pressure having positive outcomes, which mistakenly leads therapists to feel their work has been validated.

Read enough studies and you may realize that just touching may be sufficient to produce potential positive outcomes, though that is a tough sell to most therapists. Having paid my way through a very expensive MFR curriculum a few decades back, I wanted to be taught how slow, light, static engagement is superior to all other forms of manual therapy/massage. The work I was taught and still continue to use/teach was and continues to be quite effective.

But is it better than others? Probably not.

Successful therapeutic outcomes are far more complex than simply the style and amount of pressure that you use and beyond the scope of this post. So how to decide on the proper amount of pressure?

I recently had a patient in my PT manual therapy practice who had a fair amount of experience as a therapist trained in craniosacral therapy. After hearing this I fully expected the patient to request the very light pressures that are typical of that line of training. (Disclaimer: Using and sticking to using only 5 grams of pressure used to drive me crazy!!! I know the craniosacral narrative quite well and what they say happens if you use more than 5 grams, but attempting to use pressures that do not even let me rest my hand on someone drives me frickin’ crazy! Even when I was taking CST classes I cheated and used more. Things seemed to happen in a positive way no matter what sort of pressures I used, which validated my belief that the CST narrative was less than stellar. Now, with a much better understanding of pain science, indirect/contextual factors, and the potential benefit from very light stretching to the skin I can better understand why those 5 grams of pressure may work for some therapists. Back to my story.) But, instead of requesting/expecting light pressures, this patient wanted me to hammer on them, repeatedly asking for a LOT more pressure than I normally use!

Some pretty scary pressures were requested and I had to recalibrate. Understanding that patient expectation often plays a big role in outcomes I found myself in a bit of a negotiation. Even current models of Evidence-Based Practice allow that fully 1/3 of the model is based upon patient values and preferences (link).

My big take on pressures is that whatever I am doing my patient should feel that my pressures are replicating a familiar aspect of their condition. This could mean bring their pain, etc., to their awareness (NOT hurting them, just making them aware that what I am doing is familiar) or reducing the intensity of the symptom. My pressures should feel helpful to them, or at least potentially helpful. They should never leave a patient feeling that the work we are doing may not be good for them.

Logical, but not always a common approach in manual therapy/massage/myofascial release. I do not think enough therapists ask their patients for input/guidance beyond, “Are you OK with this pressure?”.

During recent sessions with this patient, I found myself trying to draw them back from the ledge a bit but equally found myself taking a look over the edge of the ledge a bit. This patient and I negotiated a pressure that they felt was potentially effective while staying within my beliefs as to what pressure was necessary. I am fairly certain that I’ve done this in the past, but never actively being aware of the negotiations that were occurring at the moment.

The concept of negotiating pressures has taken on new meaning to me. As shown at the top of this page, from statements culled from various websites, pressures are taught in somewhat predetermined ways, mostly based on the inherited narrative or a story used to support the type of therapy/modality. It may have been presented in a manner that sounded well researched and even scientific in origin, but digging deep may prove that to be false. But the pressures may have worked well for you. I must admit that my MFR training seemed to give me permission to use a variety of pressures, but words like, “Intuition” were bantered about when trying to figure out how much to use. I still maintain that light to moderate pressures are sufficient to allow awareness and help to elicit change, but now I allow myself to be a bit of a car salesman, negotiating pressures until we both agree.

How do you determine pressures? Do you think that one level of pressure is superior than others? If so, why?

Articles Of The Week March 10, 2019

 

Communication is important…like REALLY important. In fact, a study has found that verbal, eye contact, body language, and listening skills are just as important as our hands-on time with patients.

“Physiotherapy Patient Interaction A Key Ingredient To Pain Reduction Research Says” – University Of Alberta

Are you prepared to work with people who have experienced trauma? Well, first we probably have to understand what trauma is, and what can cause it. Additionally, there are four other things that can help us understand and be better therapists when it comes to trauma.

“These 4 Essential Skills Will Help You Practice Trauma-Informed Massage” – Sage Hayes

We have heard so much over the years about positive thinking. But did you know positive thinking can actually strengthen the connections in your brain, to get rid of negative thoughts and help improve your brain?

“Your Brain Has A Delete Button, Here’s How To Use It” – Judah Pollack & Olivia Fox Cabane

Pain is subjective, so reducing it means different things to different patients. It also depends on each persons interpretation and meaning of pain, so part of the process is navigating what it means to people. So, does reducing pain in one person, mean the same for the next?

“Why Reducing Pain Intensity Doesn’t Always Mean A Better Outcome” – Bronnie Lennox Thompson

We need to stop blaming back pain (or other pain for that matter) because of muscular instability or weakness. This article does a great job of dissecting why we need to stop blaming the transverse abdominus for back pain.

“Why We Need To Stop Blaming Transverse Abdominus For Low Back Pain” – Brendan Mouatt

Self-Efficacy A Well Used Term But Well Understood?

Self-efficacy is a term banded around in therapy quite regularly at the moment especially as more active approaches to rehabilitation are being embraced.

So we have to ask exactly what does it mean, why does it matter and how do we improve it?

In fact, my twitter friend/colleague Jerry Durham asked me this question whilst I was in the process of writing this blog, talk about great timing! It also shows that we often don’t have a well-defined definition for a well-used term.

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Let’s Start With What Does It Mean?

It was a term first coined by Bandura in the 70’s, he described it is the ‘belief of an individual on whether they have the ability to perform behaviours relative to a specific activity’. Self-efficacy has also been described as a ‘resilient self-belief system’.

I like to describe it as a sense that ‘I have got this’ or ‘I can do this”.

This could be self-efficacy in relation to pain, such as the perception of the ability to remain functional and perform activities of daily living whilst you have pain, or it could be treatment-related activities such as a specific activity or exercise.

So let’s say that your kind therapist has suggested that you go to for a walk to help out with your back pain, do you think that you will be capable of doing this?

Maybe you don’t feel motivated?

Perhaps you don’t feel confident that you physically can?

Could be that you feel you can’t fit it into your busy life?

Low self-efficacy may result in challenges, such as changes in behaviour, being seen as threats to be avoided rather than things that can be overcome. Bandura identified a number of psychological processes involved with self-efficacy, these being cognitive, motivational and affective (emotional). Having valued goals and activities appears to be associated with these factors as well and self-efficacy and resilience literature points towards valued activities being an important part of this process HERE.

Bandura also identified four main sources of self-efficacy.

Mastery

Previous mastery of an activity or action influences our future perception of capabilities. We are starting to learn that human beings use prediction based on past experiences to navigate the uncertain nature of the world around them. If we have been successful at something in the past then it is likely we will perceive that we can overcome it again. This is also related to the ease of successes.

If our successes have been easy then we may be quickly dissuaded by obstacles. If the successes have been tough then we may also be used to overcoming any obstacles that come our way.

In line with this view, we see that previous adherence and participation in exercise has been shown to be important in future exercise adherence HERE.

Experiences

The world around us also influences our perception of capabilities. If people surround you that you perceive as similar, who are achieving similar things that you are being required to achieve, then you will also be more likely to see these things as attainable. This could be from the media that we consume to the involvement in social activities or our family circle, this underlines the social aspects of pain that appear to be pretty important.

This is a great recent paper on social factors in pain HERE

Persuasion

Now, this can be both positive and negative, and of course, it is easier to be influenced negatively than positively! But those that are persuaded, both verbally and experientially, that they are capable of achieving a task are more likely to be able to do so especially if we see previous success as a key factor.

Negative Emotions

Strong negative feelings towards an activity or the negative perception around an activity also will influence the level of self-efficacy someone has. Self-doubt is often an emotion that influences behavior negatively.

So We Have To Also Ask, Why Is It Important?

It appears that self-efficacy has been linked in multiple papers to worse outcomes across various measures of pain and disability. Now we cannot suggest it is causative or even that improving it will simply improve outcomes at this moment in time. But if I were to go out on a limb I think it probably would : ), especially if we are promoting more active approaches to therapy.

Certainly exercise as a treatment relies on it being performed and evidence-based medicine falls flat on its face if we cannot apply the treatment to the patient.

Foster, in 2010, found that for people with low back pain, low confidence in their ability to perform normal activities, or low self-efficacy, was predictive of a worse outcome in terms of disability at 6 months, in fact, better than fear avoidance, catastrophizing or depression HERE.

Keedy, 2014, found that those without the ability to engage in pain management related behaviours, pain self-efficacy, is related to the outcomes for back pain rehabilitation HERE.

Greater passive behaviour scores were also found to be associated with worse outcomes at a five year follow up for lower back pain by Chen, 2018 HERE. Passive coping strategies rely on external resources for pain control rather than internal resources such as our belief systems HERE that also influence self-efficacy.

Self-efficacy has also shown to be fundamental to the adherence of exercise interventions. These studies found that low self-efficacy was a predictive factor for poor adherence to a home exercise program HERE & HERE. For all the focus on the nuts and bolts of exercise, it is a pretty redundant process if the person does not feel capable of doing it. Time spent in this area rather than a focus on sets and reps may drastically improve adherence and therefore outcomes.

I call this focusing on the hole rather than the donut (the whole!)Slide2

What Can We Do To Alter It?

Success

The first steps may simply be to create a successful experience!

Previous successful adherence and progress have been associated with increased self-efficacy and this ties in with a Bayesian perspective of human function. So perhaps our aim for those that display low self-efficacy should be to set a low threshold for activity that can lead to easy adoption and fast progress. We often aim for a dosage of activity that leads to some kind of physical overload and adaptation. This could potentially lead to a negative experience for some and limit increased participation, without a positive initial experience they may not achieve longer-term sustainable success. So essentially good for psychology but not so much for physiology in the short term but hopefully leading to greater longer-term physiological impact through sustained participation.

It could be that just making an exercise session fun and not boring could be a very beneficial outcome. We often don’t place much importance on these things within medicine though. Why do people play sports? Maybe because they enjoy other aspects beyond just the physical exertion component.

People are often driven by challenge, fun & competition, how often do you incorporate these aspects into your training?

Some questions I often ask to gauge self-efficacy around exercise & activity are:

“Would you describe your self as confident around moving and exercising?”

“Do you feel you are currently capable of increasing your activity levels if required?”

“Would you describe yourself as motivated with regards to activity and exercise?”

Motivation

Motivation also appears to be a key aspect of self-efficacy. Helping people find something that actually motivates them could also be important and this could be through a goal-setting process that identifies valued activities.  We could then break it down into more perceived manageable chunks that create little wins to help motivate the person.

I call this helping them find their ‘why’.

Lots of exercise programs don’t resonate with people, especially if they have not really participated in one before so exercise in itself is not enough of a ‘why’ for them.

We might ask “what would your perfect day look like with regards to activity?” or “what are some things you love to do that you don’t or can’t?”.

Autonomy is another factor associated with successful exercise, HERE, so also giving choices and options rather than a ‘this is the exercise you have to do’ approach.

Planning

Sitting down and planning with people when they might do things and how much might also have an impact on self-efficacy. Being able to do this for themselves might be a limiting factor and the participation in activity may feel like too great a challenge without some guidance.

What days might be best?

What time of day?

What type?

For how long?

What kind of effort level?

Set a reminder on the smartphone?

How to progress?

Alternative options if you do not succeed?

Takeaways

  • Previous experiences with behaviours are involved with future self-efficacy
  • Social environment and support is important
  • Self-efficacy can make or break an active approach to treatment
  • Self-efficacy is involved in outcomes for pain and disability
  • Self-efficacy is important for exercise adherence
  • Create behavioural wins and good experiences
  • Your input in terms of planning and motivation is vital if self-efficacy is low

Testing, Graded Exposure, And Reassurance For Low Back Pain

 

Over the past couple of weeks, we have been looking at and discussing the clinical guidelines for treating low back pain.

We have covered how important reassuring our patients their tissues are safe is a crucial component in their recovery from pain as well as building our therapeutic relationship with them.

We also discussed how important using graded exposure as part of that reassurance is, along with its importance in getting them moving again. So, this week we’ll cover how you can do some simple and effective graded exposure right in your massage therapy treatment room.

But first, we’ll have a look at the orthopedic test that was commonly recommended throughout those clinical guidelines and how to do it. There is a bit of controversy between papers as to how effective this test is, but it is the one that was most commonly recommended, so we felt it important to review.

Here is how to do an SLR (straight leg raise).

Even though the more common use of an SLR for low back pain is to look for a disc issue if you get a positive it is still important to reassure your patient they are okay. Use terms like “it just shows us the area is sensitized right now, so we just need to calm it down”. Try not to alarm them or instill any fear around there being a damaged disc or tissue.

Quite often when patients with low back pain come in, there will be some movements they are fearful of doing. Commonly forward flexion is the one I’ve seen in practice that most people have an issue with, so we’ll look at how we can do some graded exposure to help with that.

If you have a hydraulic table here are some simple things you can do to not only reassure the patient movement is okay, but also to help build up their trust in you:

If you don’t have a hydraulic table, here’s how you can do the same thing with some of the furniture most of us have in our treatment rooms.

The biggest takeaways:

  • Provide reassurance to the patient that they are not “damaged”.
  • Make them feel safe with the movements.
  • Gradually expose them to an increased range of movement.
  • Encourage, encourage, encourage your patients!