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Bret Contreras on PSB v BPS models of pain

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  • Bret Contreras on PSB v BPS models of pain

    I wanted to draw attention to this post by popular personal trainer cum S&C/biomechanics researcher Bret Contreras.

    [YT]3FVPvonYkZQ[/YT]

    I commend him for addressing the topic in front of an audience that probably has no idea about it (big assumption here on my part), I felt there were a lot of holes in his explanations.

    I left a comment and I will paste that here too, because I am far from sure of what I have said, and would like some feedback and opinions

    My comment:

    Originally posted by Nick Efthimiou
    Hi Bret,

    Firstly, addressing the antibiotics and back pain – there is a large COI. The researchers were on the board that certifies doctors in antibiotic therapy. (http://www.rheumatologyupdate.com.au...o-disclose-coi)

    I haven’t read the study, so I can’t comment, but I just wanted to raise your awareness on this point.

    Regarding the PSB model, I think early in your video you have confused injury and pain.

    Certain biomechanics, particularly under load, can lead to increased likelihood of structural deformation/injury, but this does not always cause pain.

    Conversely, those PTs (and other practitioners) that primarily (or solely) use a BPS model don’t argue that tissue damage from an injury doesn’t cause/contribute to pain, but they are aware of the limitations in blaming the injury solely on pain.

    Anecdotally I have seen this in my clinical practice, where a patient presents with an acute injury and I can treat and alleviate their pain, whilst the injury is still present. This is also the case with medication.

    Your second point, that doing a lot of hyperextensions can cause pain may be valid, but is it applicable to real life. Any very unfamiliar activity, particularly those that can cause tissue damage/deformation (like resistance training) can pose a perceived threat and result in a pain output.

    However, if you gradually built up your tolerance to that workload, would you experience pain? Would the tissues not adapt, as your hypothesised in your article on spinal flexion exercises?

    There may be an increased risk for injury, there may not be. However to definitely say they will cause pain only strengthens the BPS model – your belief system contributes to the brain output, both conscious and unconscious.

    Also, what determines an anterior pelvic tilt? Or posterior? What if that is that persons normal? You have continually mentioned (on your blog) many high level athletes exhibit what would be termed an anterior pelvic tilt – do they have increased risk of injury? Do they experience more or less pain than the average trainee?

    Additionally all the preventative measures you mentioned (stretches, strengthening etc) do work, but by what mechanism? Threatening/noiceptive afferents are decreased, and there might be inhibition of these afferents via descending dorsal columns – this can decrease pain output because the movement is no longer threatening.

    Of course – as I mentioned, tissue damage/injury can contribute to pain, but as I questioned, does the body adapt to ‘bad form’ from a tissue basis?

    This is a great topic to address, and one that needs more discussion both in manual therapy and strength and conditioning, so thank you for bringing it to light.

    Also, please understand, I may be wrong, I am still learning myself, and whilst I have questioned what you have said, I am not attacking you personally, and I am happy to have my understanding clarified.
    Original blog post: http://bretcontreras.com/back-pain-t...ial-bps-model/
    Registered osteopath
    Registered personal trainer
    http://twitter.com/NickEfthimiou

  • #2
    Hi Nick!

    Thanks for taking this on!

    Also, what determines an anterior pelvic tilt? Or posterior? What if that is that persons normal? You have continually mentioned (on your blog) many high level athletes exhibit what would be termed an anterior pelvic tilt – do they have increased risk of injury? Do they experience more or less pain than the average trainee?

    Pelvic tilt is a big concern for PTs and trainers in our area. The idea is that musculoskeletal pain is the result of a chronic shortening of certain muscles which then cause alterations in normal muscle activation patterns.

    For example, I've heard the following line quite often:

    Posture is extremely important. It is the very foundation of the sports machine coaches and trainers are trying to build.

    Pelvic tilt is one thing that is sure to damage the "sports machine"

    Comment


    • #3
      Perhaps this is the time for another daily dose of Mel:

      "It is also important for anyone working at a high level with athletes or offering them rehabilitation to question all theories, look for alternatives, be open to all possibilities and to use criticism to take them further. There is still far too much "hero worship" of certain therapeutic gurus, unsupported beliefs and almost religious fervour in conditioning and
      rehabilitating athletes. Of course, many methods are successful, but often it is the combination of methods, the natural healing process and various mental factors which ensure that the athlete heals, with the result that the most recently applied intervention appears to have been THE cure.


      It really seems as if far too many therapists are trying to make rehabilitation as mystical, academic and complicated as possible, when many injuries often will recover by use of the simplest methods, such as normal daily activities and sporting actions serving as the main foundation for repair, beginning with the simplest, painless and least demanding and
      gradually progressing towards more challenging goals.
      Is the rehabilitation process really meant to sound so complicated and to follow more Commandments than Moses received to help humankind survive, thrive and get along with one another until the end of time? Is it not possible to KISS (Keep it Simple, Sunshine!) and still offer optimal rehabilitation? Or must the therapists really try to emulate the quantum physicists and cosmologists in order to impress and succeed?"

      Comment


      • #4
        If I'm not mistaken, I posted in a discussion on Contreras, web site a couple of years ago and what I said and questioned about the topic was not well-received. In saying that, I'm being kind.

        I'm not surprised that he has conflated pain and injury. This remains a stumbling block many, many never overcome.
        Barrett L. Dorko

        Comment


        • #5
          My advice to Contrares: More brain "curls", less biceps curls.
          John Ware, PT
          Fellow of the American Academy of Orthopedic Manual Physical Therapists
          "Nothing can bring a man peace but the triumph of principles." -R.W. Emerson
          “If names be not correct, language is not in accordance with the truth of things. If language be not in accordance with the truth of things, affairs cannot
          be carried on to success.” -The Analects of Confucius, Book 13, Verse 3

          Comment


          • #6
            Originally posted by John W View Post
            My advice to Contrares: More brain "curls", less biceps curls.
            I think that is unfair.

            As far as fitness professionals go (I have one foot in both the fitness and therapy worlds) he is very (or at least tries to be) evidence based.

            I was hoping to invite him to comment, but those kind of remarks may be taken the wrong way.
            Registered osteopath
            Registered personal trainer
            http://twitter.com/NickEfthimiou

            Comment


            • #7
              Hi John!

              More brain "curls", less biceps curls.
              I appreciate your quick wit...:clap1:

              Comment


              • #8
                I met Bret about 4 years ago when I lived in Phoenix, before he was "famous", before I found SomaSimple. I remember thinking that he had the right kind of attitude towards his profession: he was interested in science and evidence based practices (actually planning to conduct some research), he was excited about it, and most importantly, he was curious. Far too many in his line of work (well, in all lines of work) just play by the established rules and never question anything - Bret didn't seem to have any interest in playing it that way.

                This is the first time I have ever seen anyone well-known in the strength and conditioning community even acknowledge pain science. While it seems that he's got some more learning to do, and his explanation needs a little work, I think it's great that a person with his platform is starting to get some of this information out there to a wider audience. Hopefully the video will plant some more seeds of thought out there.

                It's my experience that when a curious person gets the pain science bug, it doesn't go away. It looks to me like Bret is at the edge of the rabbit hole, trying to get a better view of what's down here. Hopefully he'll fall in like the rest of us did.
                Last edited by Patrick Septon; 20-06-2013, 10:28 PM. Reason: I forgot a few words.
                Patrick Septon, P.T.

                "In the high country of the mind one has to become adjusted to the thinner air of uncertainty..." -Robert M. Pirsig

                Comment


                • #9
                  Originally posted by Patrick Septon View Post
                  I met Bret about 4 years ago when I lived in Phoenix, before he was "famous", before I found SomaSimple. I remember thinking that he had the right kind of attitude towards his profession: he was interested in science and evidence based practices (actually planning to conduct some research), he was excited about it, and most importantly, he was curious. Far too many in his line of work (well, in all lines of work) just play by the established rules and never question anything - Bret didn't seem to have any interest in playing it that way.

                  This is the first time I have ever seen anyone well-known in the strength and conditioning community even acknowledge pain science. While it seems that he's got some more learning to do, and his explanation needs a little work, I think it's great that a person with his platform is starting to get some of this information out there to a wider audience. Hopefully the video will plant some more seeds of thought out there.

                  It's my experience that when a curious person gets the pain science bug, it doesn't go away. It looks to me like Bret is at the edge of the rabbit hole, trying to get a better view of what's down here. Hopefully he'll fall in like the rest of us did.
                  I totally agree - that's why I felt the comment about brain curls was unfair (it might have just been a light hearted joke, I'm not sure, and I'm not sure if that makes it okay).

                  If he started participating here, I think that there would be a lot to be gained by both parties.

                  I would like to sit down and have a coffee with him one day, he knows A LOT about S&C and biomechanics.
                  Registered osteopath
                  Registered personal trainer
                  http://twitter.com/NickEfthimiou

                  Comment


                  • #10
                    Bret's reply to me:

                    Originally posted by Bret Contreras
                    Nick – excellent comment. Appreciate the heads-up on the antibiotics study. The authors seemed cautious in their conclusions and recommended more research, so again, time will tell.

                    Great job clarifying the relationships of load, deformation, injury, and pain.

                    I suppose we can say, “The Biomechanics of Low Back Injury” and examine the physics behind anatomical/structural damage, but not “The Biomechanics of Low Back Pain” as there is no such thing. Pain is a physiological response that isn’t always predictable or related to damage/injury.

                    Good point about tissues adapting, and while they certainly do with bone and muscle, I also think they do with discs (but no research has shown this to a degree that I can say with confidence). However, only to a certain point. Obviously we don’t want to throw caution to the wind and purposely try to induce structural damage to more delicate tissues just because pain isn’t predictable or can be overridden.

                    Great point about the belief system contributing to brain output!

                    And with APT, the research shows that they do not have more pain, but in my experience as a trainer they often require modifications with certain exercises. But I could be biased as I’m aware of no research supporting my claim. The risks of APT are often grossly exaggerated by those who champion the PSB model for sure.

                    I suppose corrective exercise can decrease pain in two ways. First, by improving form which would decrease the deformation on certain structures and prevent the pain alarm. And second, by increasing familiarization/confidence and removing the nociceptive afferents and pain efferents as you stated.

                    I’m still learning too my friend – great critical thinking skills!
                    And my reply, inviting him to comment here (again, please correct any mistakes in my thinking):

                    Originally posted by Nick Efthimiou
                    I totally agree about throwing ‘caution to the wind’ regarding biomechanics – I’m not about to go about doing my deadlifts round backed anytime soon – but I realise that my beliefs as much as my biomechanics play a role in whether I experience pain afterwards (as an aside: I lift KBs, and competitively, the snatch is often performed round backed, with 32 kg for hundreds of reps per week with no ill effects reported anecdotally).

                    I think you are definitely on the right track here, and I’m really happy to see the BPS model get such good exposure in the fitness field, considering how well read you are.

                    Regarding models, as you most likely know (please indulge me here), science can’t prove anything directly, only disprove it. We use models to explain our observations.

                    So when the BPS model can explain things in the PSB model, but the inverse is not true, I would lean toward the BPS model being superior at this point in time, given the current body of knowledge.

                    Just to clarify your point where you stated:

                    “I suppose corrective exercise can decrease pain in two ways. First, by improving form which would decrease the deformation on certain structures and prevent the pain alarm. And second, by increasing familiarization/confidence and removing the nociceptive afferents and pain efferents as you stated.”

                    There is no pain alarm. The deformation would result in change to sensory afferents (if the deformations deformed nerves) – which could lead to a pain output.

                    I see you linked to Soma Simple in your post, I actually posted a thread about this post there, with my comment attached for critique by those more knowledgeable than me. I invite you to come and participate in the thread.
                    Registered osteopath
                    Registered personal trainer
                    http://twitter.com/NickEfthimiou

                    Comment


                    • #11
                      Hi Patrick!

                      This is the first time I have ever seen anyone well-known in the strength and conditioning community even acknowledge pain science. While it seems that he's got some more learning to do, and his explanation needs a little work, I think it's great that a person with his platform is starting to get some of this information out there to a wider audience. Hopefully the video will plant some more seeds of thought out there.
                      Point well taken. Inroads are inroads, and this might in the long run prove to be a good thing. I took John's line as a clever way of framing the brain vs. meat debate, but I can see how others might not appreciate this.

                      Comment


                      • #12
                        Oh, yes. I actually typed that out earlier before I saw John's comment. I guess you could say we have a few "inside jokes" here as SomaSimple. I've been doing heavier and heavier brain curls ever since I found this site.

                        Of course, one could make the argument that all curls are brain curls...
                        Patrick Septon, P.T.

                        "In the high country of the mind one has to become adjusted to the thinner air of uncertainty..." -Robert M. Pirsig

                        Comment


                        • #13
                          I watched Bret's video a couple of days ago and I left feeling that he was "straddling the chasm" rather than fully crossing over.

                          Bret tends to be a big breath of fresh air in the training/S&C community because he strongly advocates research and evidence based practice, and he is not shy about challenging dogma. I think the time will come in the not too distant future when Bret will fully cross the chasm. Understanding pain science doesn't really leave any other options.

                          It's also worth noting that Bret had a guest post on his site about pain science by (SomaSimple member) Anoop Balachandran back in 2011 that he linked at the bottom of his recent video. Even if Bret left things as they were in the video, he's still taken some huge steps in the right direction. I think we all would like things to be as best they can, but if I hadn't learned to accept "better" rather than "best" I think I'd be a very dour person.

                          I had considered leaving a comment myself. I'm glad you did it first, Nick.

                          Comment


                          • #14
                            Conflating pain and injury is a major problem and it does not help when personal trainers try to play "medical" professional and think that reading a few journals and textbooks make them expert enough to video themselves...for the public to consume.

                            I think he should stick with glut exercises seriously.

                            Indeed these kinds of things grind my gears as well...

                            Having stated that, Brett has a well built in excuse for such conflation...he has no medical training.

                            My Physiotherapy colleagues who make the same error...not so much.

                            Comment


                            • #15
                              You know I was surfing the internet this evening and 'voila!'

                              Another video by another person making another claim based on another anectdotal experience suggesting another approach derived by authors (Cook, Janda, Sahrmann, Lego-builder) that all fail to provide any favorable outcome study for low back pain. (please read this posting in a tone consistent with my avatar; Lewis Black).
                              "The views expressed here are my own and do not reflect the views of my employer."

                              Comment

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