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Posture, Babies, And Bathwater

Posture is a controversial topic. It’s relevance for pain has been properly questioned by fans of “pain science,” biomechanically-minded crowd has worried that a baby is getting thrown out with the bathwater. In previous posts I’ve written about the very dirty bathwater that does indeed need to be thrown out. In this post I’ll provide a few thoughts on taking care of the baby (assuming there is one under the dirty water.)

Extensive research shows that objective measures of postural alignment correlate very poorly, if at all, with pain. But this doesn’t mean that posture is irrelevant to health and especially performance. Posture is a fundamental part of coordinated movement, one of the first skills that a baby learns. We need a well-organized trunk and neck to see the world, coordinate movements of the arms and legs, protect vital structures from injury, and maintain balance. We can barely do anything without a minimum level of postural skill, and that skill must elevate to an elite level if we want elite level athletic performance.

In the context of pain, common experience makes clear that posture is sometimes a dominant cause. For example, I have noticed that standing in the same place for long periods of time at a cocktail party or museum will sometimes make my lower back stiff. It feels better almost immediately when I sit for a few minutes. A slumped position works best, and is also my most comfortable way to rest over long periods of sitting. I have clients with literally the exact opposite set of preferences, which is why they use a standing desk at work and lumbar supports while sitting..

Nothing about these anecdotes is inconsistent with the research on posture and pain, which does not imply that people are equally comfortable in all positions, or that they don’t benefit from tinkering around with different options. Adjusting your posture to be more comfortable is not rocket science, and most people will do it unconsciously. But our natural tendency to self-organize can get stuck in a bad groove if we don’t give our bodies the feedback it needs, in the form of variable postural challenges. And we can really get stuck if we decide that certain postures that feel natural are wrong and to be avoided. Consciously trying to mold posture to some assumed ideal is probably a bad idea, as it tends to encourage stiffness..

So how do you get unstuck from a bad postural groove and make progress? One way is to play with the different constraints around which your posture tends to self-organize. I’ll review five: coordination, strength, mobility, social context, environment, and pain.

Coordination

There are many common exercise methods that focus on training postural skills. For example, yoga, Pilates, or tai chi develop are very much about maintaining a specific postural alignment in a variety of functional contexts. Do you need that specific alignment to be functional and healthy? Probably not. But trying to maintain it under variable conditions is a way to build coordination.

Locomotive activities all challenge the ability to coordinate alignment of the spine with movements of the arms and legs. Therefore, improving your performance in activities like crawling, walking, running, climbing and swimming are likely to improve your posture as well.

Postural skill is also about helping to maintain balance, and therefore we might expect it to be improved through activities that challenge balance, like gymnastics, dance or skateboarding.

Strength

It’s hard to hold a safe and functional posture when lifting a heavy weight, running a distance at a brisk pace, or performing a powerful throw. You need strength to resist the forces pulling you out of alignment. Like Yoga or pilates, “good form” in most weight training exercises is usually about maintaining a long spine. Once again, the neutral spinal position is not absolutely necessary for safe and functional lifting, but the effort to maintain it is a challenge that may create beneficial adaptations.

It should be noted that any postural skills built lifting may be specific to context. Fitness and strength are not likely to be limiting factors for organizing posture in everyday activities, which require surprisingly little core strength.

Mobility

Another potential constraint on posture is mobility. For example, you need pretty good range of motion in the hips to sit upright on the ground with the legs extended, or even crossed. If you don’t, the hamstrings or glutei will pull your pelvis into a backwards tilt, and you will therefore need to round your back to keep your head level. If you improved your hip mobility, your sitting posture would immediately reorganize to make your trunk more vertical, perhaps improving comfort and efficiency. But this change would probably be specific to sitting with extended legs and might not affect other postures.

Social Factors

Posture has a psychosocial dimension. Body language sends social signals about mood and confidence. Teenagers may slouch to look cool. Some people suck in their stomachs to flatten their belly, lift the chest to show dominance, or collapse it to be submissive. On vacation, body language might change to reflect a more relaxed and comfortable mind. I have noticed that my back gets tired after a formal social function where I have to wear a coat and tie. Something about the occasion inhibits my natural movement and literally makes me feel stiff.

Environment

Attention and environment regulate posture. One of the reasons you tend to slouch when you look at a computer screen is that it helps you get closer to the object of your attention. If you direct your attention to the wide world around you, to objects both far, near, up, down, left, right and even behind you, your head will naturally move into a more upright position. Next time you are hiking, imagine you are in untamed wilderness, and need to be aware of potential threats coming from 360 degrees. You will notice a spontaneous change in the organization of your trunk and neck.

Pain

Pain can be a major constraint on posture. We instinctively move away from positions that hurt us. Many people who have their backs “go out” will find to their surprise they have spontaneously adopted a very crooked posture. The postural system immediately reorganizes to protect a tender area. Any time you can get something stop hurting, you open up a new set of possibilities for postural alignment.

In summary, anything you can do to improve your general physical function might also improve your postural organization. Not in the sense of looking more vertical, but in the sense of having a body that is a more functional and comfortable place to live.


The preceding was an adapted excerpt from my new book Playing With Movement: How to Explore the Many Dimensions of Performance and Health, now available on Amazon and Barnes and Noble.

Articles of the Week – January 17, 2021

It’s out of scope for many of us in our professions and jurisdictions to recommend medications. However, it’s important to retain knowledge about the effects of drugs, especially extremely common NSAIDs, on musculoskeletal injuries in our clients.

What Every Physiotherapist Needs to Know about NSAIDs and Musculoskeletal Injuries – Claire Knott

 

A physiotherapists documents her experience of witnessing racism in the workplace. This acts as an important reminder to not just avoid passing judgment on our clients but to also be aware of the past experiences they may have had elsewhere due to marginalization.

I Didn’t Say Anything: An Essay on Implicit Bias, Emergency Room PT, and My Biggest Regret – Dr. Yusra Iftikhar

 

As manual practitioners, we all know that physical touch is a beneficial thing to health. It’s great to be able to define what those are.

The sophisticated language of touch  – Timothy Cocks

 

A summary of research that shows some detrimental effects from children’s TV programming that may be emphasizing many unhealthy attitudes and perceptions of pain in our youth. The takeaway from this should be contemplation on what we can do to mitigate this and educate our kids about pain in a healthy way.

Kids’ TV teaching children wrong lessons about pain: new study – Andy Dunne

 

We’re not here to debate about vaccines right now. However, one interesting study was able to directly demonstrate that the simple act of smiling (and to a lesser extent, frowning) helped to reduce the perception of injection pain. A great example of how expression, especially positive expression, can help our health.

Grin and Bear It: Why Smiling Makes Vaccine Shots Less Painful – Pat Anson

Beliefs, Communication, And How This Impacts Our Patients

I’m sure I’m not alone when I say I’ve seen some horrific things in my practice.

Now, when I say this, it’s not in the sense of major catastrophic injuries, or gory blood scenes, or something like that.

What I’m referring to is what I’ve seen and heard from patients as a result of what another well-meaning practitioner said to them. 

A patient comes in, sits down, and starts crying because another therapist told them they will never get better.

Another person who has been dealing with chronic pain for several years comes in and equates the pain they’re feeling in their back to a “rib being out”, or “their S.I. Joint is out again”.

And in the more extreme ranges someone giving up a career they love, in exchange for a job they hate because two people told them they would never be able to do their job again because of the surgery they just went through. In fact, told them if they continued doing the job they loved (and were very successful at), the surgery they just had would pale in comparison to the one they would need.

While I know none of these practitioners would intentionally have someone change their job, believe they won’t get better, or would constantly relate pain many years later to a simple biomechanical diagnosis, the reality is, their words changed people’s lives. 

And not for the better!

So, why then does this happen? Why are these enduring effects of words having such a dramatic impact on patients? And, more importantly, how do we stop this?

When Well-Meaning Beliefs Go Wrong

When we say “well-meaning” practitioners I do believe it’s just that. I doubt there are many out there legitimately trying to say harmful things to their patients (although I do believe there are some who use less than scrupulous language as part of the rebooking process).

So, when we have these well-meaning professionals saying things to patients, part of why they are saying the things they are is because they truly believe it (even if modern research refutes it). Part of the issue is when these belief systems are passed on to our patients it can have a lasting effect in a negative way. 

Unfortunately, many of these belief systems can come from continuing education courses that haven’t been updated in years and are still preaching these outdated belief systems.

A great systematic review (1) looked at several medical and paramedical professions to look at how their belief systems, (including biomedical and biopsychosocial treatment, fear-avoidance beliefs, and attitudes) affected patient behaviours.

There were several things that stood out to me reading through this(1):

  1. High levels of fear-avoidance in practitioners are related to the same fear-avoidance in patients.
  2. Practitioner beliefs are associated with the education they give patients.
  3. Practitioners with a more biomechanical base are more likely to advise acute pain patients to limit work and physical activity.
  4. Those with high fear-avoidance beliefs are more likely to recommend bed rest (which we know is not good for low back pain) and are also more likely to recommend this if seen in a media campaign.

Now I realize it probably sounds like we’re bashing anything related to biomechanical explanations here but honestly we’re not.

As we have said so many times over the years, biomechanics are still important, it’s just one piece of the puzzle. What I’m taking from this review is that if we’re strictly relying on biomechanical explanations we’re more likely to also cling to fear-avoidance beliefs as well, which isn’t doing our patients any good.

Part of the problem here is that if a practitioner has these beliefs, they get passed on to the patients we see. One of the major issues with this (as pointed out in the review)(1) is these beliefs result in persistent disability but not necessarily a change in pain.

So, if these beliefs are held, the patient’s pain won’t always change, but there is an increase in disability. Imagine your patients coming in for care and strictly because of a belief system, not only does their pain not get any better, but they become more limited in the things they can do. 

In light of all this information, I look back and think about early in my career and how I was saying very similar things to my patients. There comes a time when we have to sit back and ask ourselves whether the information we are conveying is correct, but also, is it in their best interest?

This review showed that even though some health care professionals believed in the biopsychosocial framework (it was originally introduced over 40 years ago), they were still operating from a biomedical orientation. In the case of doctors, they understood how important psychosocial factors can be yet, they lack the time to properly integrate this into practice.

So, while I look back on my career and cringe at some of the things I used to say, I look at this information and see how beneficial this is for us as Massage Therapists. If we embrace new research and change our beliefs, we not only have the time to spend with our patients, we have the opportunity to create lasting change for what they are going through. 

Words Matter!

So, now that we understand the influence of both the patient and therapist beliefs, the question remains, where did these beliefs come from?

Quite often these beliefs are because of lived experience, observing others in pain, or things that have been told to them throughout their life. A big influence was just not having a framework or a reference of what they should do when experiencing pain.(2)

All too often we see patients going to Dr. Google for advice, however, while this is usually looked at cautiously, people do place higher importance on the advice of friends and family.(2) While people would often seek out care from a health care professional, they would sometimes reject the advice given as they questioned their competence, and would even keep their own beliefs if it conflicted with the advice of a professional.

Now, this isn’t necessarily a bad thing because there’s nothing wrong with a patient using their own intuition to choose what course of action is best for them. It’s important for patients to feel confident in the information being presented to them, in fact, it’s even possible for their symptoms to be influenced by their interpretation of the education they are given.(2)

However, even if we believe we are giving them a very simple explanation of what is happening, there can be an enduring impact. I can now hear my mother’s voice resonating from my childhood and what she would say every time my brother and I would fight: “it’s not what you say, it’s how you say it!”

This paper has several examples of the lasting effect of what we say, which I think are important to highlight.

When a doctor gave a simple diagnosis of a sprain in an attempt to decrease the seriousness of the injury, the patient understood this to mean they had moved in such a way they had strained the muscle and they would make it worse by continuing to move the same way.

In the case of a person getting help from an orthopedic specialist, the result was well…horrific:

[The orthopedic specialist] looked at my back MRIs for a little while and turned around with a grin on his face and said, “You’re a builder, aren’t you?” and I said, “Yes,” and he said, “You’re [expletive], ha ha ha,” and went back to his computer again…. So, you know, I think that was his rather odd specialist way of breaking the news to me that I wouldn’t be working as a builder for very long…. Every time I felt a little bit wrong [after that], I started to sort of add it up in my head. And then my usual way of thinking, “Oh, that’s fine, that’s nothing, that’ll go away, that’s not major enough to stop me working, I’ll carry on [changed]”…him saying that was definitely the point, because I probably would have just carried on(2)

This person actually ended up changing careers as a result of what was said to them! Sadly as I mentioned, I’ve seen the same result in practice as well.

Another example that stood out to me in the same paper was equally as life-altering:

Basically all I’ve kind of been told to do by physios is to work on my core…I’ve been tested by various different physios, and Pilates, and I’m apparently ridiculously weak…. I had an abortion because I didn’t think I could have a baby. I didn’t think I could handle it…carrying it, and having extra weight on my stomach(2)

Can you imagine what this woman went through dealing with this?

Again, I’m sure these were well-meaning practitioners but when our communication is focused more on the things we can’t do as opposed to the things we should do can have compounding long-term effects. If we shift this line of thinking and encourage movement, provide reassurance, and show people how they are safe to remain active it can (and most likely will) have the reverse effect of the quoted stories we shared.

While many practitioners have a belief in the biopsychosocial model, many are still using biomechanical explanations of tissue damage, etc in an attempt to help their patients. As we have seen this can be detrimental to the patients well being. So it’s important to have a discussion around how to change these beliefs in practitioners. Many of us went through college and learned these things (I know I learned many of these explanations in school) and unfortunately, there are many continuing education courses still offering these kinds of explanations. This becomes our responsibility as a profession to change this, and really it starts with each one of us. It doesn’t even mean you have to spend thousands on new courses, it can mean just reading blogs like this, or a new research paper a week (it doesn’t take that long I promise), because we must change our beliefs in order to have a better impact on the people we are seeing in practice. When our beliefs (and our messaging) start to change we can slowly change our patient’s beliefs for better outcomes. Then, hopefully…hopefully, patients feel safe to return to their careers or have babies, or just return to an activity they love.

 

References

  1. Darlow B, Fullen BM, Dean S, Hurley DA, Baxter GD, Dowell A. The association between health care professional attitudes and beliefs and the attitudes and beliefs, clinical management, and outcomes of patients with low back pain: a systematic review. European Journal of Pain. 2012 Jan;16(1):3-1
  2. Darlow B, Dowell A, Baxter GD, Mathieson F, Perry M, Dean S. The enduring impact of what clinicians say to people with low back pain. The Annals of Family Medicine. 2013 Nov 1;11(6):527-3

Have We Ballsed Up The Biopsychosocial Model?

One of the most widely discussed topics in healthcare and especially in pain circles of late is the Bio Psycho Social model conceived by George Engel.  The BioPsychoSocial (BPS) model was developed in reaction to the dominant biomedical viewpoint that involves reducing medicine to specific diseases or pathologies that can be identified and treated and this model forms the backbone of most western healthcare systems.

Engel felt the biomedical model:

“does not include the patient and his attributes as a person, a human being”

But the question is, have we misinterpreted the BioPsychoSocial model?

Are we simply applying it in the same way as the biomedical model it was trying to replace?

It’s People Not Just Pathology!

We know that people’s experiences of pain and pathology differ. The same painful problem may manifest as huge issue for one person disabling them from work and reducing dramatically their quality of life, whilst another person may remain relatively unaffected. This has to be taken into account both in treating the problem but also how the person is TREATED by their healthcare professional, their family and social network and the wider healthcare system.

We can see below from Engel’s view that it is a bi-directional model that involves the layers in which we exist rather than discreet treatment targets as we now see.

Download 4We could perhaps determine this interaction between layers as the wider impact OF the problem rather than just as impacting ON the problem. Rather than seeing the BPS as a direct treatment model where we dissect the three domains to find new pain ‘drivers’ to treat, the BPS perspective should really be seen as a CLINICAL philosophy and guide that can be used for improved patient care.Here is another interpretation from a recent paper ‘How do physiotherapists solicit and explore patients’ concerns in back pain consultations’

“underpinning the bps model is patient-centred care (pcc) which involves incorporating the patient’s perspective as part of the therapeutic process”

One of the issues that are often encountered in healthcare however is that clinicians AND patients want solutions and treatments rather than philosophies and the conversion into a treatment model conforms to the biomedical perspective that dominates healthcare.

Maybe the BPS asks us, as clinicians to better understand our patients and their subjective experience? And it may be better defined as a model of care rather than a model of treatment. Now, this does not mean we cannot involve a BPS thought process IN specific treatment but remember that this is just not really the major focus of the model, certainly as I understand it anyway.

So it is really treating people and their overall existence, not just treating their painful problems. These differing aspects cannot just be separated and simply targeted without an understanding of the person and the context they exist in, doing that for me is the biopsychosocial model in biomedical clothing.

Other commentators such as Leventhal have looked at concepts such as the disease and the illness *HERE*. The disease being the specific issue and the illness being the wider issues surrounding the problem, in my interpretation, this is similar in concept to the BPS. How is this PERSON individually affected by the problem that may even BECOME the problem itself?

Just Treat The Pain?

I can already hear some readers shouting, “Just treat the pain – then you will not have any more problems”

Well, that is the biomedical view in a nutshell!

Firstly we have been attempting to do this for ages, hence why there has been a call for a different model. Often treatments for pain are not successful and people need help in other ways and we treat pathology but pain persists. Perhaps the interaction with healthcare even makes the problem worse!

Can we treat the person and pain? Yes, I believe so. We should not forget this, just realize our limitations at doing so and also avoid pain being the only focus.

The question is do we often attempt to treat the person AND the pain? I don’t think this happens as much as we would care to admit.  Maybe treating people rather than their pain can lead to reductions in pain? Maybe we cannot have an impact on people’s pain but affect suffering, disability, and quality of life? We may not be able to do this in a pain-focused model and why we end up with repetitive surgeries and the opioid epidemic?

People can still have pain and live a positive life; the BPS model is really well placed to help them do so and does life simply return to normal even after pain has reduced for all? I would hazard a guess that for many people their lives are fundamentally changed even AFTER persistent pain has decreased.

BPS Model Of Pain

A pain-oriented BPS model has emerged more recently and two examples of this can be found *here* and *here*. These interpretations should NOT be confused with Engel’s model I feel, and perhaps misses the essence of what he was reaching for. Maybe an issue with the BPS model is its breadth and how far-ranging it is? It is quite easy to place our interpretation anywhere within it.

The pain focused model looks at how Biological Psychological and Social factors can influence pain.

This diagram is a great example with the arrows pointing solely inwards.

Screen Shot 2019 08 21 At 07.34.26(Figure Fillingim 2017)
The problem here is that it is a return to a biomedical view in which the person is less of a focus and instead the disease (in this case pain) has returned to become the primary focus. Instead of being a comprehensive BI-DIRECTIONAL clinical philosophy, it has in many cases become a unidirectional treatment model.  We also have much more evidence for BPS aspects being associated with pain than we do actual data to support treatment for pain using these BPS aspects.Seeing PsychoSocial factors simply as pain influencing factors is missing the wood for the tree’s I feel. This would be a multifactorial pain treatment model, not the BPS model set out by Engel.This has drawn critique, and rightly so, of the BPS model and its interpretations. A recent paper from Stilwell and Harman can be found here called “An enactive approach – Beyond the BPS model”(Thanks to the authors for the full-text link!). This critique, I feel and highlighted by the authors, is not really of the Engel’s model but instead, the pain focused interpretation that has evolved. We may not need to move beyond the BPS model, more just apply it in its intended way. Let’s try to do that before we think beyond it.Stilwell and Harman go on to say

“Pain is…..a process that emerges or unfolds through a whole person who is inseparable from the world”

but we should also consider the BPS perspective already to consider the whole world and our existence within it and not just its effect on pain!

The very essence of the BPS model was NOT to delve further and further into the microscopic components of biology but instead to also zoom out to encompass the other factors that may be at play in both pain and quality of life.  I have written about this *HERE*. But if we consider most of the discussion, theories, and dominant messages around pain they focus on the reductionist view that Engel was trying to get away from.

As an example please insert any painful problem here ‘XXXXX’. Even the most uni-factorial biological one you can think of… let’s say a fracture.

How does their perception and knowledge, sense-making, around the issue affect them and their behaviors?

How does the injury affect their work and family life?
What are their perceived implications for the future?
How confident are they to return to sport or activity?

How motivated are they to engage in rehab or treatment?

This is considering the PERSON and heir engagement and embodiment in the world not just breaking down pain ‘drivers’ as the trend seems to have become and accusations of people forgetting the bio (eye roll).

Straight Lines & Trichotimies

Some of the criticisms of the BPS pain model focus on the division into three distinct components biological, psychological, and social as well as a perceived linear causality between the associated factors and pain.

My view of Engel’s work is that he objected to a linear causality model. Emergent properties such as pain NEVER have simple linear relationships with causes (whatever they are?). Again this is a misinterpretation and application specifically to pain of the original work. Linear causality is a criticism of previous Cartesian pain models but appears to be alive and well in the BPS.

The term ‘non-linear’ means that small things can give large effects but also large effects in one area may also give rise to no effects in the targeted area.  There are so many interactions occurring that can affect each other that the same treatment may give rise to DIFFERENT positive or NEGATIVE outcomes dependent on the current state of the organism.

We seem to be happier for this to be the case now biomechanically, but less so biopsychosocially. If we are being honest then we have many more associations WITH pain from what is termed BPS factors than actual data from using these factors to treat pain.

The trend of splitting pain into separates categories of Biological, psychological, and social to diagnose and treat is another critique that Stilwell and Hartman highlight in their paper and neatly term a trichotomy. I feel Engel’s point was not that they exist distinctly as pathologies to treat but in their own right but to consider these things within the wider appreciation of the patient’s experience.

Conclusion

  • We should really see the BPS model as a CLINICAL PHILOSOPHY and way of incorporating the patient into healthcare.
  • It is intended to understand patients, their lives, and contexts.
  • The biopsychosocial model COULD be used as a pain treatment model, but this is probably not how it was intended. This may be better termed a multi-dimensional pain treatment model.
  • There is not really much data on outcomes from treatment using a BPS pain model.
  • BPS factors are not simply linear treatment targets.
  • We may need to better apply the BPS model rather than move beyond it.

How Beliefs And Communication Can Influence Pain

I was listening to a podcast today where the host was talking about successful entrepreneurs.

Since we’re all entrepreneurs I couldn’t help but notice how the information applied to us as therapists.

While the host wasn’t directing the information at healthcare professionals, the main point he was talking about was being good coaches. His biggest point was that being a good entrepreneur meant being a good coach and communicator.

This is especially true in our profession.

The way we communicate and “coach” our patients can have a profound effect on the results we get with them. Both in a negative and a positive way.

The words we use can have both a positive and negative effect, which sometimes can last for years, depending on how it’s delivered.

As we have been preaching about the evidence-informed practice and implementation of the BPS framework for some time, we felt it important (and it was also requested) to look at how the words we use affect patient outcomes.

Fortunately, Darlow et al. has done a number of papers on this so we can draw from some of the research that has been done!

For now, we’ll look at how not only our beliefs and communication but also our patient’s beliefs can affect outcomes.

Patient Beliefs About Their Back

When we look at the BPS framework of pain it can sometimes be difficult to separate what the differences are between psychological and social influencers that could be causing a patient’s pain.

This first paper(1) lays it out quite nicely and shows that psychological influencers include; fear-avoidance beliefs, catastrophization, self-efficacy beliefs, depression, emotional stress, and outcome expectations. Now, this can certainly be a lot to take in if it were someone’s first visit to come and see you, so don’t think you have to get it all figured out on the first visit.

When they looked at much of the data collected in this paper, they further broke down the information into five main themes.

  1. The vulnerability of the back
  2. Special nature of back pain
  3. Prognosis of back pain
  4. Activity and back pain
  5. Influences upon beliefs

Vulnerability Of The Back

Not surprisingly most of the people in this study(1) equated their back issues to physical injury, damage, or dysfunction.

While most were not sure what exactly was damaged they also believed it was possible to hurt their back without being aware they were causing any damage, they also believed that an increase in pain meant more damage, while a decrease in pain equaled recovery.

The interesting part is that while most participants didn’t understand what caused the pain or “injury”, they also came to the conclusion that somehow their back was vulnerable, or designed poorly due to a variety of factors that included genetics, previous injury, or misuse.

There was also a belief where activities that included bending, twisting, and sitting were dangerous things that could cause further injury or pain. In reality, how many times a day do we do these things which are quite safe activities!?

In addition to all these beliefs, many of the patients tended to catastrophize about the possible explanations about the cause.

The Special Nature Of Back Pain

This is another area that brought about some surprising results (at least for me).

People believed that pain was a function of the back and in order to protect itself, it was forcing the person to stop any activity. There were even beliefs associated with the back being its own entity that could achieve its own goals which a person had absolutely no control over.

While this hindered simple things like walking, it also became a threat to people’s financial security as they did not think they would be able to work at their secular jobs.

An interesting consideration was that back pain was difficult to understand without personal experience, however, it was acknowledged that their psychological well-being was affected making people feel old, depressed, and irritable even to the point of impacting their relationships with other people.

The Prognosis Of Back Pain

While the previous sections demonstrated getting a prognosis was important to patients there are some things that proved worrisome for patients.

Some things that stood out were the back’s ability to heal, timeframes, and the quality of healing. This was influenced due to thoughts of vulnerability, not sure if the back could heal, and also because of seeing how back pain affected those with chronic back pain. Most thought due to the type of injury they had, or because of not doing the right things their own back was not going to heal.

The paper(1) concentrated on those three topics, but in just looking at the beliefs around that, is it any wonder people end up developing chronic pain when their belief systems are basically telling them there’s no way they can get better?

Client, Clinician, and Community

To continue on the topic of back pain and beliefs Darlow(2) looked at three different entities that influence our beliefs about back pain, the client, clinician, and community.

We know that psychological factors play a role in all pain but do we really understand why? Because if we did, we could more positively change patient’s beliefs and decrease things like catastrophization, for better outcomes.

As mentioned earlier there are different themes which influence how a patient perceives their back pain. Things like genetics, previous injury, and worries about movement reinjuring the area and are seen as dangerous. So a person can weigh out the risk vs. benefit of not only engaging in activity, but also seeking out care.

As pointed out in this paper (2) almost half of those experiencing back pain don’t seek out care, but for those who do, they see more than one healthcare professional. The things that do cause people to seek care are things like high levels of disability, pain, and maladaptive beliefs like catastrophization.

Now, this is where we can play either a positive role…or sadly, a negative one.

This is because the beliefs of the therapist can influence the beliefs of the patient. Remember, those who are seeking care are typically experiencing disability, pain, catastrophization, so they want more information from a trusted source…YOU!

If we are providing a strictly biomechanical explanation, this can seem threatening as most of those explanations involve things like muscle strain, discs out, hip rotated, the rib is out, etc. In turn when these kinds of explanations are given, if the person feels pain in the area weeks, months, or years down the road, they equate the pain to that biomechanical explanation they were previously given. I’m sure we’ve all seen this in practice when someone comes in and automatically equates the pain they’re experiencing to that “same old injury” that has been going on for years.

Since we know it is likely they are seeking care from multiple professionals, if they are getting different explanations, this can result in not only frustration but increased uncertainty about their capacity to get better.

Interestingly, while very well-meaning professionals give instructions on proper lifting or moving techniques, this can be understood as a need to protect the back creating hyper-vigilance about movement.

However (as we have preached so many times on this blog) providing reassurance, validating a patient, showing that movement is safe, can empower a person not only now, but in the future.

When they looked at community in the study (2) some things that stood out were how messages stemming from places like schools, workplaces, media, and the internet had an influence on people’s beliefs. These actually influenced the amount of support given by friends, family members, and even colleagues. As it turns out, a spouse’s beliefs about pain can actually influence the amount of support or care they give to their significant other.

Now, if your beliefs about pain can actually influence the amount of care you give to someone you love, imagine how this is influenced in the workplace!?

In my past life (before becoming an RMT) I was an industrial first aid attendant in a sawmill, I would see this first hand (although I didn’t understand it at the time). When people were injured at work (keep in mind this was a very bravado-filled environment) people were called wimps (and a host of other names I dare not repeat on this blog), or it was commonly believed they were just trying to get an insurance claim.

If a person is facing this in the workplace, and say their spouse isn’t overly supportive, combined with bills piling up due to the added stress of not working, imagine how this influences not only a person’s beliefs around pain but also the amount of pain they’re in.

The spouse can also have a directly negative effect by emphasizing what the injured person can and cannot do. They can become overbearing in trying to do too much for the person, or by doing too little, again, this comes down to their beliefs.

Part of the issue is that so many of these beliefs don’t match what the current evidence says.(2)

A great example of how this can be changed is the pain revolution cycle tour put on by noigroup. Every year they do a cycling tour to different communities in Australia where opioid usage is high. They visit these communities and put on education events about pain and have seen significant reductions in opioid usage through their education and changing people’s beliefs. 

So, imagine what we could do with each of our patients by just providing a little education!?

We’ve heard so many times practitioners saying things like “I don’t need research, my work speaks for itself, I get results”. One small part of the issue with statements like this is that many times a practitioner has been practicing for years and hasn’t updated themselves, or their beliefs, so are still saying things that are way out of date. While they are very well-meaning (and yes probably have some good results) they are still instilling beliefs like “my pelvis is rotated, rib is out, bad back due to genetics etc. etc.” which as we have seen is actually harmful to a person. We have a golden opportunity to provide education to patients that will change this narrative and alter their belief system in a very helpful way. (2) If we can confidently sit in front of someone and provide reassurance that they aren’t broken and concentrate more on education that will be interpreted positively by not only the patient, but their significant others will bring about far more lasting benefit. However, the only way we can gain the confidence to do this, is by reading current research and staying on top of new information and resources like the ones we’ve cited here. Because really, while you owe this to your patients, you also owe it to yourselves.

If you’d like to learn more about how to incorporate these kinds of things in your practice, we have an upcoming course on the low back, hips, and pelvis we are offering via zoom in February where we will be discussing many of these strategies as well as therapeutic exercise that you can check out by clicking HERE

References

  1. Darlow B, Dean S, Perry M, Mathieson F, Baxter GD, Dowell A. Easy to harm, hard to heal: patient views about the back. Spine. 2015 Jun 1;40(11):842-50.
  2. Darlow B. Beliefs about back pain: the confluence of client, clinician and community. International Journal of Osteopathic Medicine. 2016 Jun 1;20:53-61.

 

Tools From My Past, Reflecting On Change

Recognize those objects in the photo? They are pelvic wedges, used by some health professionals for a variety of reasons. Most rationales center around their use to balance the asymmetrical pelvis.

I learned why and how to use them in a myofascial release (MFR) course on the pelvis, somewhere around 1994. The theory was that pelvic asymmetry, or torsions, was due to injury, birth trauma, and other nefarious insults and needed to be corrected for the pain to lessen, gait, and posture to improve, and many more reasons.

I learned a lot in that class, much of it I used for many years. Those pelvic wedges are well-worn, as I balanced the hell out of many pelvises over a long time. And you want to know something? I helped a lot of patients with their back and related pain through the use of those wedges.

Then around 7-8 years ago I noticed that I was using them less often. In the present, they tend to stay unused. Why is that? Don’t I want to help people as I did in the past?

7-8 years ago is when I seriously began questioning all things therapy-related, both from a manual therapy perspective, but also from an exercise/strengthening perspective. I had departed my MFR world in 2006 after being told to conform or leave. (I chose to leave.)

But I stuck with those MFR principles and philosophies for a number of years and applied them in my work, including what I thought was balancing the pelvis. After a few years I began drifting into other worlds; into other ways to describe and define the effects of manual therapy in general, and MFR in specific. At first, I didn’t like what I read and learned, as there was a lot of confusion and uncertainty over just how manual therapy impacts the human being.

As I learned more, I saw the flaws in many of the simplistic explanations therapists use, as well as how the public views and repeats those simple concepts. Exercise, for instance, is often quite helpful, though I now know that those effects had little (if anything) to do with being weak. The common simplistic statement physical therapists tell their patients that being stronger will help you support yourself better, which leads to less pain was simply false. Or, the statement was so weakly true that it made little sense even to say it.

However, patients say things like that all of the time. It was much of what the core stability craze grew from. “Getting strong” is helpful, but the strength itself is not what diminishes pain. It is a complex combination of factors that vary from person to person. Movement is helpful. Motion is lotion.

MFR, and manual therapy in general, suffer from similar simplistic errors. When one reads through some of the latest evidence (Bialosky, 2009, 2010, 2018; Geri, 2019; Kolb, 2020), these papers read very differently from the way I learned MFR. But I can wager that if you underwent advanced training in any of the popular branded modalities in manual therapy, the science that you learned may not align completely with what others see as truth. How do you put all of that together?

Let’s go back to my wedges. As an MFR-based PT, I saw people coming to me for issues of pain in the low back, peels, hip, sacroiliac joint (SIJ), and more. Often, one of the first places I began my evaluation was at their pelvis. “If you don’t balance the pelvis, nothing will stick” was a familiar phrase I was taught in my MFR of training. Along with postural assessment, a pelvic assessment was key to knowing what was at fault and what needed doing (on my part). Pelvis assessment was done by palpating both the ASISs and PSISs (front and back landmarks on either side of the pelvis), as well as looking at possible upslip/downslip of the pelvis, etc. There were some SIJ assessments, to see if one side was stuck, as well as other assessment procedures, mainly postural. After all of this, I would put it all together and tell my patient why they were having pain (what I thought to be the cause) and what needed to be done to correct things. Many times patients simply agreed to what I said was wrong and trusted me to fix them.

That’s when the wedges came in.

I’d place the wedges in precise locations so that when my patient rested on them, with the assistance from my MFR intervention, their pelvis was released back into a better alignment. We might repeat this over the course of a few sessions and I would reach them homework to reinforce the pelvis corrections. And most got better.

Wedges are used by other professions and by other modalities, so we MFR therapists didn’t own the patent. But the way we used them was said to be unique. Other clinicians wasted their time with ineffectual chiropractic adjustments, etc., but none of them had the long-lasting effects as we did. (I spoke like that a lot back then.

So why did I stop using them? Why would I stop using them?

In today’s culture on social media, evidence and research seem to have taken a turn for the dark places.

Many mistrust research, feeling like scientists are always changing their minds and claiming all research is bought and paid for by big industries, etc. Science does self-correct continually, but that is the nature of the scientific method.

During the period when I left my MFR tribe, I began reading studies, many of which seem to refute what I had been taught and what I had witnessed as a clinician. For instance, in 1999 Levangie looked at the relationship between pelvis asymmetry and low back pain. While they found a weak association between the asymmetry of the PSISs and lower back pain, overall, “Pelvic asymmetry was not positively associated with low back pain in any way that seemed clinically meaningful.” One study does not make a believer out of many, and rightly so.

But the more I dove down this and related research rabbit holes, the greater dissonance I found with what I learned and practiced. While I could go on for quite a while on the weakness of the link, suffice to say there is sufficient evidence that made me question just what it was that I WAS doing.

The use of the wedges seemed to correlate in some way to my patient’s lower back pain resolution, but apparently, if I was to believe that dastardly evidence, it wasn’t because I reduced the asymmetry. (And for those of you who fancy yourself as a skilled assessor of pelvic levels, check out this systematic review of the reliability of palpating the PSISs. “Current methods of palpating for PSIS asymmetry do not result in levels of interexaminer reliability supporting clinical utility” (Cooperstein, 2019). Fake news, you say??? Try again. Another study points to the difficulty in accurately assessing pelvic tilts and ASIS/PSIS level due to inherent pelvic variations in pelvic morphology that render each side of the pelvis different from the other side. WE cannot measure what we think we are measuring when the underlying structure is not arranged as we think it is! Link

So what could it have been?

First off, I am not in any way calling anyone who used wedges ineffectual. Not in the least.

But what I am suggesting is that the process of using of wedges with a patient, from introducing the concept that pelvic misalignment may have a good deal to do with pain, to the rituals involved with the measurement of their posture and pelvis symmetry, to the rituals involved both with the precision of wedge placement as well as the exactness in which I proceeded with treatment, is a part of contextual factors that often go underappreciated. Add in neurological input through the patient’s skin/soft tissue which can signal to higher centers that things are happening, leaving the patient able to participate in the process of change (read those initial references I gave you for more on these concepts), as well as potential local reactions from the body, and often the pain is lessened. Does the pelvis change in a meaningful and lasting way? Many insist that it does and they claim to have proof. Maybe they do, but even if the pelvic alignment changes, how can we be certain of the cause? Meaning, was it the wedges? Our input over their skin/tissues, while on the wedges? The nervous system adapting over time to a novel stimulus? Or a wide range of other variables?

Those of you who use and swear by wedge usage, postural deviations as the cause of pain, and other similar narratives, there is a very strong chance you’ve already given up on this story, as there is too much cognitive dissonance occurring for you to remain.

However, as I learned more about how neurological and behavioral influences impact pain and movement quality, I saw that the wedges were simply a tool to access that entire human in front of me. I learned that I could use simpler tools to accomplish the same end, namely conversation and assuring a richly contextual therapeutic relationship, one that my patient played a larger role in creating.

I continue to use manual therapy (I dropped the MFR brand), though coupled with strong suggestions for movement (exercise, strengthening, walking, dancing, etc.) as a means to get them moving. Do I get better results than I did back in my MFR wedging days? That is difficult to accurately and objectively say, as such data is difficult to analyze. My patients seem satisfied, as are the insurance companies that often pay the bill.

Why don’t I use them anymore?

That I cannot completely answer, as I still see them as potentially useful. If other means did not seem to spark the attention of a patient then I may drag them out and put them into action. Should you stop using your wedges? Nope. Just realize, the wedges may have less important that you and I were led to believe. I can tell you in full honesty that it has been many years since I performed a standing postural assessment, pelvic measuring included. It has been that long since I pinned my patient’s pain on their pelvis being out of alignment.

Much of our training is about learning recipes and rituals. We take more training as we believe it will give us more skills, which it might. But additional training allows the educator additional access to your brain, filling it with the jargon and recipes of your modality. By using those recipes you set up a context that seems precise, but in the end, maybe no more helpful than that provided by the next person. I do find irony in the position put out by some modalities, educators, and clinicians who feel that they use no protocols or recipes; every patient is a unique experience. While that should be true, such clinical models often rely on recipes and rituals, such as “find the pain, look elsewhere for the cause (recipe), if you don’t balance the pelvis, nothing will hold (ritual), and many others.

Many argue against what I’ve said thus far by pointing to their experience and successes. Who can argue with all of those satisfied customers? No one, but what I will take issue with what you feel the reason you were able to help. Many modality educators make money off of the uniqueness of their product and love to inflate their outcomes and sense of importance. Surprised? Probably not, after all, one needs a good sales pitch in this world. But why is it that most of use take multiple lines of training and come up with our own unique hybrid approach? We are not following the rules and recipes of each of our mentors, rather, we are making that information our own. That’s life. Wedges are not magic. They are a part of a recipe, one I let go of and still manage to find ways to help my patients, probably just as much as any of you.

Another problem with rituals that involve my so-called skills is the dependency that this can create. If I pin my patient’s pain on their out-of-balance pelvis, restricted fascia, stuck SIJ, or any other tissue or structural-based problem, dependency may be fostered. It is very easy for a patient to sell themselves on needing us, now and if the pain returns, instead of educating them on strategies for them to take ownership. Many manual therapists do foster such independence through self-treatment education, which is better in keeping with what should be ethical standards of care. But how do you come across? Are you selling secret causation to patients? One that no one else knows the truth?

The moral of this story? Use wedges. Or don’t use wedges. Just understand that the experience of treatment is nuanced and multifactorial. Many factors go into why our patient improves, many more than I am listing here, that to reduce it as being caused by the use of wedges, or the use of MFR, or anything else you can think of. Including the things I think are important.

If you enjoyed some of the concepts presented here, or if they left you angry and frustrated, have a listen to a great podcast (not mine!). Dr. Oliver Thomson’s Words Matter podcast is a dive into evidence and approaches to manual therapy, exercise, and a better understanding of the words we use.

Happy wedging. Or not.