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

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  • #76
    Nathan,

    Have a think about the strength and pain issue. Does having strong muscle/s prevent pain? Do footballers rarely get injured and/or experience pain because they work on strength building and fitness? Same with athletes? Do you not see that pain and muscle strength are not associated? Why doesn't someone with flabby/"weak" muscles be in constant pain?

    My answer is that those with "weak" muscles are like that because they don't move enough - they may spend their days in front of a computer at a desk. So they can develop aches and pains. The solution is to move - do anything physical, not prescribed exercises which are at best, a waste of time. Tell your Hispanic patients to go dancing. Stuff like that.

    People age and as as they do, their musculature weakens; this increases their risk of falling, but they do not necessarily have pain unless they sit all day.

    Hope it doesn't sound like I'm talking down to you, but I would like to help you understand what we are saying.

    Nari

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    • #77
      I think the relationship between strength training and pain is still poorly understood. One perspective is that strength training -> reduced perceived threat ->reduced pain output, another perspective is that strength training ->increased tension/stress in the system ->increased pain output.

      To me it makes sense what others here have suggested in the past. Let's first focus more on helping calm down the system, and if then "Weakness" is found to be an issue for the patient for whatever reason( disuse/atrophy or pre-existing, and now required to improve for work/safety etc) then we can also work on that. It is not wrong in itself to work on strengthening, after all, it is one way of (Self) protecting and maximizing health into the future. The tricky part is identifying when a patient is ready for strengthening, and for how much of it ("gentle" vs. overload/doms) always in the context of "treatment". It is tricky not only because pain can be unpredictable and non linear, but also because a little bit of increase in pain does not always mean that you have chosen the "wrong" approach with the patient. This is relevant discussing "Repeated bout effect" / system adaptations. Also, what Steven George, PT, PhD shares (through Kyle Ridgeway) here .

      I can't help but think that these discussions revolve around the angst that this philosophical question has helped create: should we be moving towards or away from pain?
      -Evan. The postings on this site are my own and do not represent the views or policies of my employer or APTA.
      The reason why an intellectual community is necessary is that it offers the only hope of grasping the whole. -Robert Maynard Hutchins.

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      • #78
        Originally posted by Barrett Dorko View Post
        Nathan says:



        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.
        No I'm guessing you do. I'm not really worried about what you tell other therapists. Your statement that history and evaluation provides a good place to start is "untrue" is something I don't agree with for the reasons I mentioned.

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        • #79
          Originally posted by nari View Post
          Nathan,

          Have a think about the strength and pain issue. Does having strong muscle/s prevent pain? Do footballers rarely get injured and/or experience pain because they work on strength building and fitness? Same with athletes? Do you not see that pain and muscle strength are not associated? Why doesn't someone with flabby/"weak" muscles be in constant pain?

          My answer is that those with "weak" muscles are like that because they don't move enough - they may spend their days in front of a computer at a desk. So they can develop aches and pains. The solution is to move - do anything physical, not prescribed exercises which are at best, a waste of time. Tell your Hispanic patients to go dancing. Stuff like that.

          People age and as as they do, their musculature weakens; this increases their risk of falling, but they do not necessarily have pain unless they sit all day.

          Hope it doesn't sound like I'm talking down to you, but I would like to help you understand what we are saying.



          Nari
          Somewhere along the line somebody got the idea that I am equating strength with being able to bench 350lbs. Does anyone not see me asking repeatedly, how can you separate strength from reconditioning/better patterning? That is what I am trying to look at. Not that somebody needs to do more curls or squats to get out of pain!!!! Jeez.

          If I have become reconditioned due to inhibition secondary to pain and been in that state for years, PT asks me to do a particular exercise(s) or dance (if I'm hispanic). If my ability to perform a once pain-forbidden movement improves, I would say that those muscles became better at performing their jobs and stronger in the process. Stronger = strength.

          I would go further from that last point to say that further strengthening, in the traditional sense, the control of that movement by applying appropriate and varied forces would add more confidence in performing that motion and more complex motions associated with that area. If I am not mistaken, that is what we are trying to do. Improve self-efficiency.

          Finally, saying all this in yet another way so as to distance my point from what others have thought of as MORE bench press, MORE squats, MORE leg extensions, I don't train muscles when I ask someone to perform exercise. I hope to train motor patterns or control of a joint(s). For those that like to jump on me at every chance, I don't NEED the patient to perform ANY particular movement as though that movement would be necessary for the resolution of pain. I ask for movements relative to what that area is supposed to be able to do, see what happens and adjust accordingly. Then microprogress. I am saying any improvement in repetition capacity means the patient is recovering control and thereby able to recondition deconditioned muscles. To me that means strength!

          Nathan

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          • #80
            Nathan, you are talking about neuromotor patterns and muscular function. This is only loosely related to strength.

            Why worry about the concept of "strength"? Endurance strength? One rep strength? High rep strength?


            Furthermore, it is a word with a TON of baggage in rehab.

            Why even use it?
            Muscle function is a nice generic term that does not evoke images and ideas of weakness. After all, that is what strengthening means, isn't it? Getting rid of weakness?
            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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            • #81
              "Should we be moving towards or away from pain?"

              If the goal is to perform an activity that is necessary or important in our lifestyle, I would say towards.

              If the goal is to avoid pain with no desire to move or maintain function, away.

              This question asks a black and white question, but it's root is very gray. Based on the black and white, this is my opinion. It's up to the person in pain to determine their goal, not me. It's my role to help them reach it.
              "The views expressed here are my own and do not reflect the views of my employer."

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              • #82
                Thanks Matt, I really like what you say here:
                It's up to the person in pain to determine their goal, not me. It's my role to help them reach it.
                -Evan. The postings on this site are my own and do not represent the views or policies of my employer or APTA.
                The reason why an intellectual community is necessary is that it offers the only hope of grasping the whole. -Robert Maynard Hutchins.

                Comment


                • #83
                  Originally posted by Jason Silvernail View Post

                  Sometimes I can't even convince people that pain, however we want to define it, is a perception not a sensation.

                  Hi Jason- help me understand this better- sensation (tactile/vibraton/proprio) involve stimulus of large myelinated A alpha/beta, while "pain" *usually-but certainly not always* can involve A delta and C fibers, both sensory stimulus and nocioceptive stimulus travel the SC in somato-organized routes and are modulated by the brain... i understand that unlike regular vibratory sensation, pain is much more complex and influenced by many factors, though my question was after reading that statement was, are both pain and sensation a perception?

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                  • #84
                    I agree tal that a sensation is a subjective experience, and therefore, I think it should be considered a perception.

                    Maybe Jason is referring to the commonly held view that pain is a purely bottom up "sensation", that isn't influenced by any contextual appraisal by the brain.

                    I think the broader problem is the erroneous connotation of the term sensation.

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                    • #85
                      If I have become reconditioned due to inhibition secondary to pain and been in that state for years, PT asks me to do a particular exercise(s) or dance (if I'm hispanic). If my ability to perform a once pain-forbidden movement improves, I would say that those muscles became better at performing their jobs and stronger in the process. Stronger = strength.
                      Hi Nathan,

                      I don't think this is a reasonable chain of thoughts

                      Particular exercise>>>>improved ability to perform a task>>>> muscles better at performing their jobs>>>>>muscles get stronger in the process.

                      I think we need to agree on a definition of strength, or what being stronger means. And then we need to decide if there is a better term to use, because as Bas pointed out, the term strength is loaded with baggage.

                      So first step: how do we define strength?

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                      • #86
                        Patrick,
                        Particular exercise>>>>improved ability to perform a task>>>> muscles better at performing their jobs>>>>>muscles get stronger in the process.
                        I don't think that would be my chain of events. I would be more inclined toward; Movement of an area>>> by the very fact that movement is happening muscles are contracting and lengthening>>> (Let's just go with the notion that movement is improving/increasing to forward this line of thinking)>>> continued practice of the movement shows increased repetition capacity, greater ROM>>> more muscle fibers being recruited,>>>> add new force vectors to the movements>>> ROM and recruitment increase>>> Etc.

                        That sort of seems like strengthening to me.

                        I am happy to work with you to define strength but for now the chain makes sense to me. Perhaps you can be the first to offer some parameters for the work strength, as you are the one who does not agree with my thinking.

                        Nathan

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                        • #87
                          Blaise,
                          Exactly.
                          So...where does that leave us with a whole branch of physiotherapy...is it still young, sap-filled and springy, or old and about to self-prune?
                          Good (rhetorical)question. Depends on one's inclinations and level of doubt, but the self-pruning is not really happening much as far as I can tell from In Motion and the APA journal. Which is sad, given the skills of Moseley, Butler, Gifford and the likes of them.

                          Nari

                          Comment


                          • #88
                            Originally posted by tal.b View Post
                            Hi Jason- help me understand this better- sensation (tactile/vibraton/proprio) involve stimulus of large myelinated A alpha/beta, while "pain" *usually-but certainly not always* can involve A delta and C fibers, both sensory stimulus and nocioceptive stimulus travel the SC in somato-organized routes and are modulated by the brain... i understand that unlike regular vibratory sensation, pain is much more complex and influenced by many factors, though my question was after reading that statement was, are both pain and sensation a perception?
                            Please, if I may: after reading for years about all this, all I can glean is, it depends entirely on what level of "brain" is doing sensing vs. perceiving.

                            All the gnarly problems of consciousness (and what that is) come back up.

                            A robot can be made to sense its environment, by placing sensors on and in it. A motion detector can "sense" a presence entering a window. In fact, when I teach people about pain, I use the example of a motion detector going off inappropriately because it has recalibrated its focal length to be too long, so it has "sensitized" itself. (The way the spinal cord does.)

                            Anyway, it doesn't take much brain power to "sense." Most sensing is done way below any level of awareness.

                            Perception implies that conscious awareness is required to "make sense" out of something that isn't clear to begin with. More computational power is brought to the task of clearing out the noise, to find the signal. The brain "chooses" what is signal to it, and what is just noise.
                            Sometimes it doesn't do that very well. So you can end up with hallucination (if the noise is visual) or pain (if the noise is somatosensory).

                            I'm not sure about any of that (not sure anyone is really sure..) but that's my story for now, and I'm sticking to it.
                            Diane
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                            "Rene Descartes was very very smart, but as it turned out, he was wrong." ~Lorimer Moseley

                            “Comment is free, but the facts are sacred.” ~Charles Prestwich Scott, nephew of founder and editor (1872-1929) of The Guardian , in a 1921 Centenary editorial

                            “If you make people think they're thinking, they'll love you, but if you really make them think, they'll hate you." ~Don Marquis

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                            "Doubt is not a pleasant mental state, but certainty is a ridiculous one."~Voltaire

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                            • #89
                              Very good Diane --reminds me of Todds post here -very clear, concise writing I thought.
                              http://www.bettermovement.org/2013/b...us-perception/

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                              • #90
                                Bas: "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. "

                                I do not agree with this at all; for me it's the foundation of examination and treatment. I'd spend 20-40 minutes on the subjective exam depending on what the problem is. Could I ask you on what "data" you build your diagnostics/treatment on, since you amongst others here, appreciate the lack of reliable and valid clinical tests? Or is it straight to "explaining pain", feldenkrais, skin stretch and the Barrett Dorko stuff whatever the complaint your patients present to you?

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