Play Involves Risk

[The following is an adapted excerpt from my new book Playing With Movement.]

Play often involves risk. When kids play, they learn how fast they can run without falling, how hard they can fight without getting hurt, and how much they can bother Mom before she gets mad. They learn where the lines are by crossing them repeatedly. There’s risk in stepping too far, but also risk in not stepping far enough, and failing to discover the limits of potential. As we age, we start with games that are very safe, and then progress to games with more risk. Many people graduate to doing things that are truly stupid. If they survive, they learn some very valuable lessons (hopefully).

But in the beginning, playful exploration presents little risk. When babies are learning to roll over and crawl, there is no way to get hurt if something goes wrong. Without fear of injury, it’s easy to engage in many trials and many errors, and to learn a ton about how to get coordinated. But they are learning nothing about how to protect themselves. As soon as babies stand up and start walking, their education in the potential risks of movement begins. 

Toddlers taking their first steps will fall many times a day. This is unlikely to cause injury because they are close to the ground and have a nice layer of protective fat over their butts. But falling creates nociception, which is the sensory signaling that can result in pain. This puts the nervous system to work in reading evidence about physical threat and deciding whether pain is necessary for protection. Has the butt been injured? Is this a dangerous situation?

There are other important questions raised by falling. Is backward better than forward? Is it a good idea to cry to get Mom’s attention? Should we give up on walking for now and return to crawling? Confronting these questions is a form of training in weighing the risks and rewards of various kinds of movement. 

As kids get older, they start playing with movements that can cause minor injuries. Jumping off couches or benches, running on sidewalks, or going down slides will frequently bruise knees and scrape hands. Each fall is a learning opportunity — did I get injured, how long will it hurt, will I need a band-aid? If I cry enough, will I get ice cream?

Kids who fall after running often don’t know exactly what to think or feel. They were running along without a care in the world, and now they are face down in the dirt. They usually look around for the face of a parent. If Mom is looking panicked and sprinting over, the kid will probably start crying. And if Mom plays it cool, gives a bit of a shrug and smile, the kid usually gets back up and continues to play. Pain always has a social dimension, and kids start learning about it through play.

After getting some significant experience with scraped knees and bruised elbows, kids will start to refine their movement strategies related to self-protection. Some will become cautious, avoiding climbing, contact sports and roughhousing. Better safe than sorry. Other kids take the opposite path: no guts, no glory. They make several trips to the ER before their 6th birthday, but are rewarded by superior skills in skateboarding. 

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I recently did some soccer coaching for eight-year-old girls, most of them novices. I watched something interesting happen on at least three occasions. A girl got hit with the ball unexpectedly in the thigh, or trunk, or arm. She would look startled, confused, and then start crying about 10 seconds later. She would leave the game, settle down, and then return to the game feeling fine. I think what happened was that she experienced a completely novel and surprising feeling and didn’t know what it meant. Eventually she learned that it was not really a problem — the body is pretty tolerant to getting smacked with a soccer ball, and this isn’t something that should cause pain.

As kids (especially boys) approach the teenage years, they may start playing with some seriously risky stuff, like fighting, extreme skiing, and football. Some of these “games” may be more in the nature of contests intended to establish dominance hierarchies. Either way, there are important lessons for the players. First, there are many occasions to differentiate between minor and more serious injuries, and this can increase body awareness and refine a sense of threat perception. Scrapes and bruises are very different from sprains and breaks. The former should be pretty much ignored, and the latter requires a trip to the doc. With this sense of perspective in place, minor injuries become more tolerable, and may not even be noticed. Another lesson from risky activities relates to fear management. For example, proper skiing technique (much like asking someone for a date) requires that you lean forward with confidence. You may fall flat on your face, but you need to forget about that for the time being. In many situations, worrying about a bad outcome will make it more likely. Fear is the enemy, and playing with risk is a way to learn to master it. Further, handling a risky situation builds confidence, and a sense of self-efficacy. These qualities are protective against chronic pain and disability.

Peter Gray argues that young mammals have an instinct to “dose” themselves with risky situations as a way to inoculate themselves against the disease of anxiety:

In their motor play and rough-and-tumble play, juvenile mammals appear to put themselves deliberately into awkward, moderately frightening situations. . . . When they leap, for example, they twist and turn in ways that make it difficult to land. They seem to be dosing themselves with moderate degrees of fear, as if deliberately learning how to deal with both the physical and emotional challenges of the moderately dangerous conditions they generate.

Kids have less chance to do this in the modern world. Gone are the days when parents let kids play unsupervised for hours at a time near trees, fields, streets, or large groups of multi-age kids. These activities are now considered dangerous unless parents are constantly supervising, monitoring, encouraging, discouraging, coaching, hydrating, child-proofing and doing almost everything short of bubble-wrapping their kids. If the parents weren’t there, heaven forbid that a child might fall down, get hurt, be exposed to germs, or suffer a temporary drop in self-esteem. Many experts believe this approach actually makes kids less safe, and more fragile, sensitive and anxious. Helicopter parenting pushes kids toward safe spaces like couches, and away from uncontrolled spaces where they might actually engage in some playful activities like climbing a tree, riding a bike or even playing a game of tag. This prevents them for learning that they can control risk, and some argue this is a cause for rising rates of teen anxiety. It is certainly not a good idea to be reckless and irresponsible, but it can be just as destructive to fear and avoid movement that makes you healthy and robust.

All the above points have implications for adults. Perception of threat is at the root of many undesirable conditions in the body. Pain, fatigue, inflammation, anxiety, stiffness, and weakness are all caused, at least in part, by the unconscious perception that the body is weak, under attack, incapable, broken, fragile, damaged, vulnerable to threats. Playing with risky movement is one way to build a self-image that is far more robust, strong and capable. So is disregarding the well-intended but counterproductive advice of many helicoptering personal trainers and physical therapists, who would seek to prevent us from sitting, standing, running, or drawing even a single breath without the correct form. 

To learn more about the value of play for movement skill and health, check out my book Playing With Movement

 

Articles Of The Week March 21, 2021

Richard always does a great job compiling resources for us all to learn from. Here’s his list of the best podcasts for Massage Therapists and we’re honoured to be mentioned.

Best Podcasts For Massage Therapists – Richard Lebert

This is a condition I have only seen a few times in practice, so it’s great to listen in on those with a bit more experience. Listen in to learn more about Thoracic Outlet Syndrome.

Thoracic Outlet Syndrome: What You Didn’t Know – Whitney Lowe & Til Luchau

Setting goals and having them come to fruition can sometimes be difficult. That’s where having a playbook might be helpful. Check out how a playbook in life can be a thorough plan of action to achieve your intentions.

Building Your Playbook! – Scott Livingston

A great chat looking at pain from a different approach (at least for us manual therapists). Rachel Zoffness is a pain psychologist, so very interesting to listen to how a psychologist helps people with pain.

Healing Our Pandemic – Dr. Zubin Damania & Rachell Zoffness

Okay for once I’m putting myself in the articles of the week. Had a great chat with Matt Phillips about staying evidence informed. It doesn’t have to be expensive or time consuming, but it is necessary!

How To Stay Evidence Informed – Matt Phillips & ME!

Don’t Fall For The “Ultimate Modality” Hoax

 

A couple of weeks ago, we looked at a Bialosky paper on the mechanisms of manual therapy. 

I liked several things about the paper; for one, it showed us how all techniques we use result in neurophysiological responses in both the peripheral and CNS to help with pain inhibition. 

Secondly, part of the paper’s reason was to try and find a construct that could be used for future research since we now know there are more than just techniques that influence our clinical outcomes. 

With that, we have developed a framework any of us can use to have better clinical outcomes, so here it is. 

The All-New Modality Framework To GUARANTEE Successful Treatments 

As we all know, every good treatment technique in our industry comes with a good acronym. 

When I think back to college, there was MRF, CST, MET, MLD, and probably a host of other ones I’m forgetting. 

I still use some of these techniques in practice today, essentially because they feel good and my patients like them. 

However, with our new treatment framework, we’ve come up with a four-level system that will get you and your patients the results we’re all so desperately looking for. 

This four-level system has four acronyms: EPN, TPN, MPN, and SFN. 

Let’s take a look at how to implement this in practice. Because 60% of the time, this works every time!

EPN – Educate People Nicely

This is an essential factor to start any treatment. Quite often, people come in with certain expectations for what they want and expect from their visit. 

Sometimes they have been to other practitioners who are still using old narratives, leading to specific belief systems around the pain they are experiencing. They may even believe their pain is a result of their hip or rib being “out”. 

Perhaps they’ve been told a specific muscle needs to be “released”, or a ligament on their liver is twisted (yes, I’ve been told this). 

Whatever thing it is, we have a responsibility to educate the person on what is going on and start changing their belief system around those narratives. 

However, those beliefs are often deep-seated, and attempting to blow it out of the water on the first visit may not lead to a solid therapeutic relationship. 

So there are a couple of ways we can handle this. 

Just giving little bits of information with each session and gradually changing their beliefs is one way. As pointed out to me by some colleagues, another is to ask them: “how can I support you”? 

Once you have offered support and helped them, they may ask you for advice or what you think is going on. This opens the door to deliver some education and gives them control over this framework. The more control they have helps in building their resilience, which we should be shooting for. 

Now that we have provided a bit of education, next comes the treatment part.

TPN – Touch People Nicely

I have to give Eric Purves credit on this one.

Give people what they like. 

One of the great things about many of those techniques we learned in school is how great they felt. Since we know that every technique is just a neurophysiological input that helps create change let’s figure out how to touch people in a way that feels best to THEM. 

For some people, a nice light touch feels great; for others, they like a firmer or deeper treatment. 

It’s essential to ask them if they like this because of how it feels or because they think deep is necessary for the treatment to work? 

If it’s the latter, we may have to go back to EPN and demonstrate that a deeper painful treatment isn’t necessary and gradually show them how we can make a difference by doing something else that just feels really good. 

If it’s because a deeper treatment feels excellent to them, this is TPN for them, so continue on. 

MPN – Move People Nicely

I’m a huge fan of movement and graded exposure. 

As my career goes on, I’ve come to my own realization that most orthopedic tests are simply a version of graded exposure. You get a person to move their shoulder a certain way, then get them to do it again right away or after treatment, and sure enough, that body part goes a bit farther. 

Whether you do this before, during, or after treatment and the person can now move a bit farther, it feels nicer; this helps build confidence in that movement. 

The more encouragement we can give them that movement is safe and actually helps their pain experience, this will contribute to MPN and a better outcome. 

SFN – So F@!*ing Nice

So now that we’ve done EPN, TPN, and MPN and we know what feels really good for the person on your table, next comes SFN. 

This happens when we’re using the patient’s favourite technique (and they are quite possibly drooling while facedown), and all you hear is the patient say, “that feels sooo f@!*ing nice”!

This is quite possibly the pinnacle of our new framework for a couple of reasons. Patients love it when things feel SFN, and I like swearing. 

The Truth About This Framework

So this post was done a little tongue in cheek, and obviously a fair bit of sarcasm. 

I have no issue with courses that have a great acronym; many of them are great courses. However, the narratives behind them have to change and be brought up to date with manual therapy’s actual mechanisms. 

It would help if you also didn’t have to pay for specific modalities, “five to seven levels of mastery,” to become certified as a “provider.” 

Another issue is that since we know all techniques work the same, we need to stop seeing things like “we guarantee this will get your patients better, faster!” There are so many factors to a treatment that to make this statement is quite simply false, the technique itself will not do this and to advertise it as such is just plain unethical.

What we need to do is look at each patient as an individual. Talk to them about their expectations, what they like, demonstrate how movement is safe, and help them get to the point where they feel SFN in their own body. 

This can take time and a lot of practice to accomplish. 

Still, if we look at each treatment as an opportunity to learn more about the person in front of us, rather than how a new shiny modality can change our practice, we’d probably be a lot better off. I know our patients would be as well. 

Let’s focus on EPN, TPN, MPN, and SFN so we can help people build resilience and confidence in their own bodies. And I promise we’ll never come up with a new modality with seven tiers to change your practice. Just do what feels nice to people and do what feels good to THEM. 

Articles Of The Week March 14, 2021

The one muscle that seems to consistently create great debate and excitement amongst the MSK professions is the psoas and we really need to start asking why? For some reason, it gets a lot of attention and a lot of the blame for so many problems. However, we really need to start looking at why one muscle could get blamed for so many things.

Psoas Obsession – Eric Purves

I haven’t seen much of this in my practice, so it’s definitely a topic I need to learn more about. Thankfully we have some great people putting content together so we can understand Hypermobility and how to help patients better.

Understanding Hypermobility – Matt Phillips & Bonnie Southgate

For some reason, we are always looking to ‘blame’ a certain thing for a person’s pain. While it’s true that patients like getting a diagnosis, it’s also important for us to realize there are many more factors that contribute to a successful treatment. We need to look past the biomechanical and also try taking a collaborative approach.

Joint Pain Treatment: Beyond the ‘Bio’ and ‘Silo’ – Nick Ng

This is just a REALLY creative and entertaining review of the organ systems in the human body, I applaud their creativity.

How To Learn The Organ Systems In Under Five Minutes – Fundamental Raps

There is many pseudoscience interventions being peddled within musculoskeletal therapy. Now, it’s even being used with animals! If you didn’t see it a zoo used kinesiology tape on an elephant, I’ll let you guess what the outcome was.

Nonsense For Elephants: The Houston Zoo Promotes Kinesiology Tape – Clay Jones