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That Grinds My Gears: "You Say Biomechanics Doesn't Matter"

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  • #61
    or feel that their treatment modality inherently covers it all.
    of course,, we all have to do something,,, all theorizing aside,,we might rub, look at internal rots,, we might even continuously mobilize,,, its the "CONTEXT",, ain't it???
    KISS, keep it simple and stupid.

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    • #62
      Well perhaps I should be asking you all! Jason started this thread saying that no one here has said to dismiss biomechanics. Perfect! So maybe it would behoove me to ask what Jason meant.

      Moseley, in explain pain talks of repetitive movement stains and posture as irritative factors in persistent pain states.

      Proud, yes I do think strength plays a large role I persistent pain. Like I said earlier how can you separate strength from fear avoidance reduction?
      Core strength? Willingness to move the spine? How can you separate the effect of an "exercise"?
      Many who have been in pain have become deconditioned. Their system I reliant upon compensatory mechanisms. Asking them to strengthen their low back using skillful application of force- in a very ridiculous example asking someone to swing a kettlebell vs. cats and dog stretch- is what I call biomechanics. Someone who is dealing with a long term inhibition state that never was challenge with judicious application of load could certainly be dealing with repetitive strain issues as joints and tissues take on excessive responsibility for prolonged time. This is also discussed in Explain Pain.
      Nathan

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      • #63
        Originally posted by Barrett Dorko View Post
        What of that "single modality" crack?

        Do you still think strength is necessary for pain relief and fear avoidance?

        Do you think I tell people NOT to strengthen themselves?

        Do you think I'm a personal trainer?
        1) No, I don't think it is a necessary ingredient in pain relief. I also don't think ideomotion is necessary. I think activities that engage joints and tissues that have been damaged and now healed is a magnificent ingredient to encourage, empower and to destress a patient regarding their pain and therefore provide a top-down reason for less pain output, and a bottom-up reduction in inflammatory soup, reduction in repetitive strain.

        2) I don't know. I can't remember any reference in your writing regarding strength training specifically.

        3) No
        Last edited by zendogg; 01-12-2013, 04:59 AM.

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        • #64
          Asking them to strengthen their low back using skillful application of force- in a very ridiculous example asking someone to swing a kettlebell vs. cats and dog stretch- is what I call biomechanics.
          I'm still to sure how you are defining a biomechanical intervention.

          I think there should be strong opposition to a treatment narrative that leaves the patient thinking "I need to strengthen this bit and that, because it will correct my posture/alignment, thus normalizing tissue strain, and thus eliminating my pain.

          I avoid this by providing a narrative that leaves the strength work until "phase 3", after pain has improved/resolved, so that there is less risk of the patient assuming that increased strength = decreased pain.

          Having said that, most of my assessments, but probably nowadays less of my interventions have a biomechanical underpinning. It is the specific story I need to have running in my mind to give some structure to what I'm doing.

          For example, knowledge of arthrokinematics is important for determining, via observation of AROM, which directions of movements the brain is protecting against. Also, if one dares to thumb their nose at the low inter rater reliability of motion palpation, knowledge of arthrokinematics is also important for determining, via feel of movement, which directions of movements the brain is protecting against.

          I also think the location of pain relative, to movement can be used to give a clue about whether the brain is guarding against compressive or tensile mechanical deformation.

          Taken together, I think one can use this info decide how to direct passively applied forces. E.g. If a patient has pain on the right side of neck with extension, right rotation and/or right side flexion, I would be inclined to think that there is a closing/compressive mechanical deformation contributing to the threat processing in the brain.

          If the pain was on the left side for the same movements, I would be inclined to think there is a tensile mechanical deformation contributing to the threat processing in the brain.

          These would direct my first choice of passive interventions. Quite often, however, I need to adjust directions inline with how the patient responds.

          So that's the biomechanical story I have in my mind most of the time. As much as I can, I shield the specifics of this operator narrative from the patient. Instead I'll say something like "let's see if why an find a more comfortable position for you neck. And if we're successful, we can work out a way for you to gAn this comfort on your own. Without this process, it seems like I'm just guessing.

          While I acknowledge that there is no way to differentiate the specific effect of sensory/discrim input from the contextual appraisal of it, the flipside of this is that we can't rule out a specific effect. So I hedge my bets and use a biomechanical assessment of movements and symptoms to reach a hypothesis about the most likely nociceptive source, and then if it is reasonable to do so, apply forces that stand a good chance of reducing mechanical deformation, and/or unloading inflamed structures.

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          • #65
            Nathan says:

            I also don't think ideomotion is necessary (for pain relief).
            I just chose one thing you said. There were others.

            I guess it doesn't matter to you what is said about what ideomotion is or what the research indicates. In addition, it doesn't matter what I say, demonstrate or reveal about its use in and out of the clinic.

            Why are we even having this conversation again?
            Barrett L. Dorko

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            • #66
              Thanks Patrick. My viewpoint is similar to yours. You say you're unclear as to my definition of biomechanics, well I do look at posture and the potential ischemia caused by various positions like long term neck extension, or shoulder position, compression or tension on nerves, etc. I would look arthrokinematically look at knee movements for a runner complaining of knee pain. The list is endless really. I am not saying that poor biomechanics causes all pain, nor that all pain is fixed by restoring biomechanically sound posture or movement. A solid history should give a decent indication of the likelihood of where a good place to start would be. One place could be to provide movement to the shoulders and some biomechanically appropriate strength to the body - I wouldn't be suggesting crunches, bench press to the person who had posture related ischemia in their upper shoulder region.
              What's your definition of strength? Somebody can push more weight? Better joint control? Greater positional awareness? Greater range of motion? I'd all of them.

              Once again, Jason originally stated that bps includes and does not deny the need for biomechanical thought process and intervention when appropriate to decreasing pain.

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              • #67
                Nathan says:

                A solid history should give a decent indication of the likelihood of where a good place to start would be.
                You'd think so, wouldn't you?

                It's untrue.
                Barrett L. Dorko

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                • #68
                  You say you're unclear as to my definition of biomechanics, well I do look at posture and the potential ischemia caused by various positions like long term neck extension, or shoulder position, compression or tension on nerves, etc. I would look arthrokinematically look at knee movements for a runner complaining of knee pain. The list is endless really. I am not saying that poor biomechanics causes all pain, nor that all pain is fixed by restoring biomechanically sound posture or movement.
                  Nathan, take a look at all these issues: posture.
                  You suggest "long term neck extension" as a potential irritation leading to pain.
                  What do we do biomechanically about it? We educate the patient about long held stresses to sensitive tissues, and help them change their immobility.
                  No strength advice.
                  No postural advice.
                  Just educate them how the pain may have originated.

                  Then the knee.
                  You look at arthrokinematics of a painful knee (I assume non-traumatic). Have you ever seen the knee before it hurt?
                  How can you relate the knee pain with what you think you are seeing; how do you measure the influence of all the structural factors, physical habits, running shoes, sleep positions, work positions, stress levels, previous non-conscious nociceptive events, etc etc.?

                  A "good history" will tell us if A) it is an acute trauma or not, B) the level of disability the patient perceives it to be, C) what they think the problem is and D) what aggravates and relieves the complaint.
                  That's all we can get out of it.

                  Focusing on strength in a patient with pain is a slippery road. First of all, because weakness is NOT a precursor of pain - I hope you will agree with that one.
                  Second, because we can almost always consider it a effect of pain.

                  Biomechanics is important because it can explain the physics of movement and stress transfers in the body.
                  But relating it to painful conditions outside of frank trauma or massive overuse, is nigh impossible.

                  And what do we do with frank trauma? Very little, as PTs.

                  What do we do with massive overuse: educate.

                  I have treated 100's of AK and BK amputees in the past, and biomechanics are really screwed up in their gaits, yet they do fine once they have conditioned their required muscular factors and motor patterns.

                  Biomechanical fact:
                  most of the amputees will get increased OA of the affected residual joint after 40+ years of prosthetic use. 40+ years!
                  And we are looking at a 22 year-old with a slight midfoot pronation as a cause of pain? Or a tight hamstring?

                  That is why biomechanics is a small player in the big picture of therapy for pain.
                  We don't see things as they are, we see things as WE are - Anais Nin

                  I suppose it's easier to believe something than it is to understand it.
                  Cmdr. Chris Hadfield on rise of poor / pseudo science

                  Pain is a conscious correlate of the implicit perception of threat to body tissue - Lorimer Moseley

                  We don't need a body to feel a body. Ronald Melzack

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                  • #69
                    Thanks Bas!

                    I don't disagree with anything you've said. At all. You very nicely teased out my points.

                    As far as attributing phrases like "focusing on strength" to what I had said, I think rereading my post will show anything but focus on strength.

                    Some questions:

                    How do you personally differentiate strength from conditioning (your word above)?
                    How do you personally differentiate posture from education about neural compression? If you suggest a position change of the head or shoulders, Foward OR back, you are adjusting someone's posture.

                    Nathan

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                    • #70
                      Originally posted by Barrett Dorko View Post
                      Nathan says:



                      You'd think so, wouldn't you?

                      It's untrue.
                      I know you have suggested that if someone comes in with leg pain that the head would be a reasonable place to start. Well, perhaps, but so is the leg. And while education on what change in ROM or symptoms via manual treatment likely indicates is necessary, the patients mental dissonance potential from starting at the head is as factor. Just as it is likey that starting too close to the painful area could cause trouble.

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                      • #71
                        Nathan, for me the most important thing is: can the patient move A) to correct their painful problem, B) to do what they want and need to do.

                        About posture: using the word "posture" automatically evokes issues of "proper" and "improper", or "good" and "bad". These are firmly rooted in our cultural vocabulary.

                        Posture is the static position of the body. I never worry about what that particular set of alignments is: I worry about the lack of motion in ANY posture.

                        So, I never use the word posture; I never talk about good or bad. I talk about the consequences of absence of motion.
                        We don't see things as they are, we see things as WE are - Anais Nin

                        I suppose it's easier to believe something than it is to understand it.
                        Cmdr. Chris Hadfield on rise of poor / pseudo science

                        Pain is a conscious correlate of the implicit perception of threat to body tissue - Lorimer Moseley

                        We don't need a body to feel a body. Ronald Melzack

                        Comment


                        • #72
                          Bas,

                          How about "strength" vs "conditioning"?

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                          • #73
                            Condition implies the ability to repeatedly perform a required task.
                            That is what my B) above was referring to. It pertained to the neuromotor conditioning - maybe a better word would have been patterning.

                            Muscle strengthening and conditioning (as a fitness factor), is rarely my focus unless we are dealing with post-surgical or post-cast issues.

                            That does not mean that I do not advice people of the value of fitness as an overall goal for self-rehab.
                            But it is never about strengthening this-or-that muscle.
                            We don't see things as they are, we see things as WE are - Anais Nin

                            I suppose it's easier to believe something than it is to understand it.
                            Cmdr. Chris Hadfield on rise of poor / pseudo science

                            Pain is a conscious correlate of the implicit perception of threat to body tissue - Lorimer Moseley

                            We don't need a body to feel a body. Ronald Melzack

                            Comment


                            • #74
                              Nathan says:

                              I know you have suggested that if someone comes in with leg pain that the head would be a reasonable place to start. Well, perhaps, but so is the leg. And while education on what change in ROM or symptoms via manual treatment likely indicates is necessary, the patient's mental dissonance potential from starting at the head is a factor. Just as it is likely that starting too close to the painful area could cause trouble.
                              Do you think I don't know this?

                              Do you think I just do whatever I feel like? I don't tell therapists explicitly what to do because I have a sense that they don't want to be spoken to in that way.
                              Barrett L. Dorko

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                              • #75
                                One more thing.

                                Nathan says:

                                If you suggest a position change of the head or shoulders, Forward OR back, you are adjusting someone's posture.
                                And you think you know the correct path for this?

                                Are you really just trying to make them look better?

                                That's the beautician's job - not ours.
                                Barrett L. Dorko

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