Is Movement Therapy Rocket Science?

 

Pain and movement are pretty complicated, right? In a sense yes. But in another sense no. Pain and movement are not complicated, they are complex, which is a different animal.

Imagine you are Elon Musk trying to send a rocket ship to the moon. What sort of thinking process, analysis, modelling, research, predictions, and methods of control would help solve this problem? How would that process be different from solving the problem of say, raising a child? 

I’m sure you can think of many ways these tasks are different. For example, raising a kid requires diapers. Wait, does it really? Is that paleo? And here’s another thing: a quick google search tells me that astronauts actually wear something called a “maximum absorbency garment” on takeoff. Let’s face it, that’s basically a diaper.

But I’m getting off track here. Even if the need for diapers is not really a legitimate difference between rocket science and child-rearing, there are still many other differences that actually relate to the subject matter of this post. So here are some similar distinctions that help get to the point:

  • Designing a social media platform versus getting millions of people to use it
  • Building a highway versus reducing traffic congestion
  • Removing a brain tumour versus maintaining general health
  • Winning a war versus keeping the peace

What’s the difference?

According to an idea used by systems theorists, the first set of problems are complicated, while the second set is complex. Although these words sound similar, they describe two different systems that need different approaches to create desired change. Complicated systems are usually built from design, and include cars, computers and buildings. Complex systems were not built but evolved, and include living things, ecologies and economic systems.

Health professionals, including those working with movement and pain, often attempt to address complex problems as if they were merely complicated. As explained below, this is very much like the drunk who loses his keys in the alley but looks for them under the lamppost because the light is better there.

Read on for more information on how to tell the difference between these different systems and why it matters. The basic idea is that most problems with movement and pain are probably more complex than complicated. Surprisingly, recognizing this fact will probably simplify your approach to improving them.

Some Definitions

A system is a set of parts that work together to perform a common function. Both complex and complicated systems have many different parts and subparts that are very interrelated so that the behaviour of one part will affect other parts and the system as a whole. But there are crucial differences.

One is that a complex system does not have any means of central control. The orderly behaviour of the system “emerges” from the interaction of all the subparts. For example, a bee colony can accomplish amazingly sophisticated tasks like building a nest, but there is no single bee that knows how to build it. Instead, each bee is just following its own simple algorithm for behaviour. The intelligence that builds the nest lives in the interactions between the bees  – it is far greater than the sum of its parts. We, therefore, say that the hive’s intelligence is “emergent” or “bottom-up”,  as opposed to centralized or top-down.

Architecture without an architect

By contrast, a highway is a complicated project. Unlike a bee’s nest, it is built according to a central plan.

Everything is designed, predicted and controlled by experts at the top of a chain of command. These experts have the ability to gather all the relevant data about the project and order changes in every relevant variable. If something goes wrong, they can diagnose the reason for the dysfunction, and prescribe an appropriate correction. So the problem of building a highway is solved according to a very precise process, whereby proper analysis of all the parts leads to a complete understanding of the whole. (This is basically reductionism.)

Now imagine there’s traffic congestion and we want to reduce it. Can we follow a similar reductionistic, command and control process to solve the problem? No, because traffic levels depend on many factors that are unmeasurable, unpredictable and uncontrollable by any central planner: weather, accidents, and thousands of decisions by individual drivers, which are all made in relation to the anticipated and actual behaviour of other drivers and events.

Traffic congestion is, therefore, a complex problem not a complicated problem. That doesn’t mean you can’t solve it, but you do need a different approach. You can’t control the behaviour of drivers, but you can encourage it to change, maybe by building public transit, making carpool lanes or creating tolls.

The effects of these measures might be somewhat predictable, but there will always be uncertainty. It’s kind of like dealing with a toddler – some things that work with one kid will totally backfire with another. And you can’t force them to behave, but you can guide them in certain directions through changing incentives and environmental constraints.

So what do you think? Is improving movement performance and reducing pain more like building a highway or reducing traffic? More like rocket science or more like parenting?

Here’s a chart with more distinctions to help you decide.

 

Consider the work you do with your clients in light of these factors.

For example, does it absolutely require many years of training? If you are doing surgery or administering anaesthesia, then yes absolutely. If it’s helping someone lose weight or making someone feel better after a massage, then training certainly helps, but it is not absolutely required (and won’t guarantee success either.)

Here’s another question: Are you able to understand and solve problems by measuring and controlling all the relevant variables? Or, are there many crucial variables that are beyond your knowledge and control?

The Body Is Complex

Most of what happens in biological systems, including the human body is complex. The body is composed of billions of cells, none of which are any smarter than a bacteria. The intelligence which creates motor control, sensation, perception, including the perception of pain, emerges from the relatively idiotic interactions of all these billions of cells. There’s no one in charge. Unlike a car, the system was not built. It grew.

However! Just because the body is complex, that doesn’t mean that all problems related to the body are complex, or even complicated.

For example, a broken bone has a simple cause and a simple solution. Many other complaints that arise quickly in the body might be related to simple or merely complicated problems, such as acute injuries or even repetitive stress injuries. But many other areas of concern for movement therapists are complex.

Biomechanics is complex.

Motor control is complex.

And chronic pain is definitely complex.

Here’s a simple proof: World-class experts in these areas readily confess their ignorance about even the simplest matters:

Given this level of uncertainty, the problems of movement and pain look more like raising a child than rocket science. Expertise is clearly useful, but (given current levels of knowledge) it does not lead to a full understanding and control of the issues, and cannot be expected to significantly outperform good common sense.

That doesn’t mean you can’t make progress reducing chronic pain! Simple common sense interventions work for chronic pain, just as they work to raise a healthy child.

  • Get support from family, friends and healthcare practitioners. Go to a PT. Get a massage.
  • Learn more about pain. Maintain an optimistic outlook and internal sense of control.
  • Experiment or play with different ways to move. Confront your fears.
  • Apply a Goldilocks level of exercise stress to the painful area to encourage adaptation without further injury.
  • Exercise, sleep well, eat well and try to reduce stress.

None of these tactics are the kind of targeted, scalpel-like interventions that make highly predictable changes in complicated systems. They don’t involve the kinds of algorithms, recipes or blueprints sold by movement gurus.

But they work! Especially under the guidance of someone who is skilled in their application. And they are far simpler, cheaper, safer and honest than interventions that treat the body more like a machine than a living thing.

Differences In Graded Exposure And Graded Exercise

Sometimes I get confused.

Okay, actually, I get confused A LOT.

There are lots of terms in our profession, some sound alike, but mean completely different things. As a result, I get some of those terms mixed up and can’t always remember the difference between things like isometric, isotonic, or ginandtonic.

Thus the inspiration for this post. To understand the difference between graded exposure and graded exercise, as they both sound the same, but mean different things.

Then comes the question of how do we apply both of these in practice, and are both actually effective?

Graded Exposure

Quite often we get patients who come in after an injury, or diagnosis and are afraid to move because they’re worried it will make the injury worse.

We used to preach to patients that movement was a bad thing during an acute injury, so would always recommend complete rest and immobilization, which also played into this fear that movement was bad. And of course, we’ve all had those times where a patient has been told by another practitioner things like: “if you move your disc bulge will get worse,” or “your pelvis is out of alignment, so we need to stabilize it and reduce movement.”

All these statements do, is put a fear of moving into the patient. Some of these patients have been hearing the same stories for years from various practitioners, so many of those beliefs are deeply ingrained.

Graded exposure is a way to gradually expose patients to those feared movements.  It is probably used in psychology (as a means to treat anxiety and phobias), way more than it is in manual therapy, but it has become a valuable tool for us to use in practice. In anxiety or phobia situations, they expose a patient to whatever their fear is in small doses until they can gradually control their fear.

For us as manual therapists, we can use this to gradually expose patients to whatever their feared or restricted movement is. Our biggest role, in this case, is education and helping the patient to understand the ramifications of long-term fear avoidance. One case study showed how using graded exposure as part of a biopsychosocial approach helped a patient who was restricted in spinal flexion (due to concern about disc damage) actually overcome that fear, start to exercise, and return to work.

One of the great ways to do this in practice is to get a patient to move in a different plane of movement, or passively move them during treatment. Imagine a patient comes in complaining of low back pain, and when you ask them to touch their toes, they can’t do it. Try putting them in quadruped on the table, and just have them drop back so their gluts touch their heels. Explain to them how this is essentially the same movement, as their spine has gone into flexion, which also demonstrates that they don’t need to be fearful of the movement. Or if a patient comes in with limited shoulder abduction, passively move that shoulder (gradually) into abduction during the treatment, then show the patient how it is possible for their shoulder to move that far. When they see how the movements are possible it gives positive reinforcement, which you can build upon to continue movement and treatment.

These are just simple examples, but it demonstrates how to start using graded exposure in your practice. Todd Hargrove wrote a great piece on how to start implementing graded exposure in your practice which you can read here. If you don’t follow Cory Blickenstaff, check out his blog forwardmotionpt.com where he talks about this kind of stuff a lot and gives some clear direction on how to use it appropriately. 

Graded Exercise

So, this is where I got a bit confused.

Because we can use graded exposure to get a patient moving, isn’t that the same thing as exercise?

Well, the way I read it, graded exposure is more of a method to change belief systems by demonstrating certain movements are possible, thus instilling confidence in the patient. It’s basically a way to get them moving again.

Once you have them moving again, this is where graded exercise comes into play.

If we look at doing any kind of rehab with a patient, exercise and movement should be a fundamental part of getting them back to activity, whether it is an athlete wanting to get back to their sport, or someone who has been in a car accident and needs to get back to work.

Part of my confusion is that graded exposure is actually a part of a graded exercise, as we are going to provide more resistance and load to those feared movements. Graded exercise is where we start the patient moving, then gradually increase it, this could be via increased load or endurance, depending on what is necessary for that patient. 

One study shows that when you compare graded exposure to graded exercise, the exercise is more effective in reducing catastrophizing when it comes to back pain, and also points out that catastrophizing may play a  part in the transition from acute to chronic pain. The same study had patients do group exercise which consisted of cardiovascular, stretching, strengthening, and functional movement and they saw several functional and objective improvements over an 8 week period. The study also went on to say there is no credible evidence that patients with chronic low back pain should avoid exercise, yet activity restriction is consistently recommended.

So lack of movement and exercise can actually contribute to a patient catastrophizing and making their condition worse, yet because of old habits, this is precisely what gets prescribed to patients! 

As Massage Therapists, we could start with some contract-relax stretching/movement while the patient is on the table, then depending on tolerance, increasing load with specific movements after treatment is done. I know prescribing exercise is out of scope for some MT’s, yet it’s okay to do passive and active range of motion. If this is the case for you, start your patients with passive movement on the table, then progress them to active ranges of motion. When they get off the table, just have them do bodyweight movements that load whatever portion of the body they are having difficulty with. You’re not prescribing exercise, you’re just having them move in specific ways, which is part of your treatment. The evidence is mounting on how effective this is, especially when combined with manual therapy, so while you may have to be creative, start incorporating it into every treatment.

Now I have to go do some research on ginandtonic movements.