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

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

    You know what really grinds my gears? When people push back against pain science in fitness and rehabilitation by saying: "So You're Saying Biomechanics Doesn't Matter?"
    I am really tired of hearing this ridiculous caricature of a strawman argument.

    I had this interaction with someone on Facebook last week and said the following:

    "I am far from the only one who is annoyed by the " enlightened" pain blogs and chronic pain is based on stats a big issue but saying that biomechanics doesn't matter is foolish or it's only in your head when pain is not an exact science." -Carl Valle

    Now we are getting to the real issue. Every time pain science gets discussed there are always people who push back and it's nearly always, acknowledged or not, the straw man of "biomechanics doesn't matter." No one has said that biomechanics doesn't matter. Mechanical origin pain by its nature is biomechanical and the concepts of neurodynamics are also. The problem is that people have been trained to think things like pelvic tilt and core weakness and short muscles are significant biomechanical problems that must be creating a large nociceptive drive that therefore pain science discussions ignore nociceptive pain. But we need to put biomechanics "in its place" not "out of our mind" when thinking about pain. We need to start to question closely our clinical reasoning processes and realize that not every impairment to movement or function is equally contributing to a pain experience, and many may be irrelevant. We discover which ones are relevant and worth correcting through a systematic assessment and reasoning process - two of the most common and most supported by randomized trials are the McKenzie MDT system and the Maitland manual therapy system.

    What we don't do is assume every kind of positional, movement, muscle length or strength, nerve mobility, or joint accessory movement impairment is contributing nociceptive drive. And that they all need to be addressed and that acknowledging the published research evidence that many of these impairments are normal findings unrelated to the pain experience is somehow 'ignoring biomechanics'. It's a testament to how indoctrinated people are into the biomedical model that their concept of pain begins and ends with their ability to find things to blame and fix in the patients body. I for one won't apologize for trying to move people in the fitness and rehabilitation world away from such a simplistic, practitioner-centered, outdated view to a more complex, patient-centered, and modern view of the pain experience. If people want to say that means ignoring biomechanics we will just have to keep pointing out this strawman argument when we see it - but I am really sick to death of this particular canned response. Nothing personal towards you, Carl.
    Jason Silvernail DPT, DSc, FAAOMPT
    Board-Certified in Orthopedic Physical Therapy
    Fellowship-Trained in Orthopedic Manual Therapy

    Certified Strength and Conditioning Specialist


    The views expressed in this entry are those of the author alone and do not reflect the official policy or position of the Department of the Army, Department of Defense, or the US Government.

  • #2
    I totally agree, Jason... I also hate it when the more 'enlightened' ones acknowledge the value of the 'neuromatrix approach,' but then of course only for the 'chronic patients.'
    Erik Pohlman, PT, DPT

    Comment


    • #3
      Jason,
      I think I have an idea of why this strawman, ignoring biomechanics, keeps rearing it's soft, crunchy head. Here's a quote from someone for whom I have a lot of respect, but it reveals, I think, a deeper nagging discomfort that many of us have with comprehending the vast complexity of the human pain experience:

      This is what i think “corrective exercises” might do. I don’t think they actually correct any “abnormal” posture or kinematics but rather they promote different movements. New movements, that are novel and that might desensitize the nervous system while perhaps changing up some mechanical irritiation on sensitize tissue. However, I know many would argue to ignore nociception altogether in more persistent cases. I’m not sure I can go this far. (bold added) --Greg Lehman
      Isn't that the root of it? That what many of us who promote the neuromatrix model are trying to do is entirely remove the role of nociception from the clinical reasoning process?

      I cannot understand, for the life of me, why it is so hard to accept that we are unable to quantify nociception in the pain experience.

      And that grinds my gears.
      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


      • #4
        Hi Jason!

        Carl V. is an aggressive guy in the speed/stregnth world.

        Comment


        • #5
          Perhaps risking trivialisation but could we extend the oft used maxim beyond nociception to say,

          Biomechanics are neither a necessary nor sufficient factor in the experience of pain. ?

          On another perspective I get the impression that many ppl who use the term biomechanics are often meaning movement but are short handing it. However few, and I think physio are particularly bad at this, really have any idea how movement is generated or controlled but are very quick to offer an opinion. That opinion usually has very little foundation in fact but rather arises from their experience, good, bad or indifferent. So physios and their therapeutic ilk suddenly appear as experts on all sorts of matters in which their actual knowledge is limited at best e.g. running form to pick a current topic

          ANdy
          Last edited by amacs; 08-09-2013, 01:04 PM.
          "Here is Edward Bear coming downstairs now, bump, bump, bump, on the back of his head behind Christopher Robin. It is, as far as he knows, the only way of coming downstairs, but sometimes he feels that there is another way, if only he could stop bumping for a moment and think of it." A.A. Milne

          Comment


          • #6
            This is a wonderful thread.

            Any comment made in response to this complaint should begin: "A straw man is...And this complaint of a our ignorance of biomechanics is a straw man because...

            It seems to me that this would put you not only on the high ground, but it would display your knowledge of the issue.

            As the Boy Scouts say, well, you know.
            Barrett L. Dorko

            Comment


            • #7
              Given how fraught the biomedical model is with dualism, it's no wonder this strawman argument is so prevalent. For some it is, and may always will be, biomechanics versus pain science. In light of this, I particularly enjoyed this quote:

              We need to put biomechanics "in its place" not "out of our mind" when thinking about pain
              It's not biomechanics OR pain science, it's an informed application of both.
              Kenneth Venere PT, DPT
              @kvenere
              Physiological

              Comment


              • #8
                I keep running into people in other forums, one specifically who continues to state "nm vs biomechanics" when talking about physical therapy and treatments. He makes it sound like this is Westside story with the sharks and the jets. We're not gangs fighting for the territory of physical therapy. A good clinician will utilize both into to treatment planning, but know that nociception isn't necessary for pain, and biomechanical "impairments" may have nothing to do with their pain experience, and probably don't.
                Mark Powers, PT, DPT, OCS
                "Language is not neutral. It is not merely a vehicle which carries ideas. It is itself, a shaper of ideas."-Dale Spender

                Comment


                • #9
                  Good TRUE evidence based practice is something we should be fighting for!
                  Mark Powers, PT, DPT, OCS
                  "Language is not neutral. It is not merely a vehicle which carries ideas. It is itself, a shaper of ideas."-Dale Spender

                  Comment


                  • #10
                    Or is it 'be prepared'?

                    Originally posted by Barrett Dorko View Post
                    As the Boy Scouts say, well, you know.
                    No gay people?
                    Jason Silvernail DPT, DSc, FAAOMPT
                    Board-Certified in Orthopedic Physical Therapy
                    Fellowship-Trained in Orthopedic Manual Therapy

                    Certified Strength and Conditioning Specialist


                    The views expressed in this entry are those of the author alone and do not reflect the official policy or position of the Department of the Army, Department of Defense, or the US Government.

                    Comment


                    • #11
                      Hi Jason!

                      I'd be interested in Carl's response.

                      He has his detractors, but who among us doesn't have them?

                      Someone launched a site a while back (http://whodoescarltrain.blogspot.com/)

                      The author notes:

                      "On this blog, we are on the search to find out who Carl trains. Is he really a trainer or just an internet tough guy using fifty cent words who hates himself so much he has to rip on every coach..."

                      To go this far, someonemust be pretty upset.

                      Comment


                      • #12
                        I think there are a lot of things to take into consideration, I'll comment on some of them:

                        1. Implementing science usually takes time
                        2. Science has a "best before period" of a mean 5 yrs.
                        3. Science becomes best available after 5 yrs (more publications get accessable for free, Original articles with great spin-off get more citations and are built upon in more magazines)

                        The first big problem is a cultural problem, derived from the points above. If a implemented state of the art, is well kept alive (also see memen theories: http://en.wikipedia.org/wiki/Meme ) for longer then the science to become outdated, the state of the art becomes tradition. Tradition is better preserved in culture, than new science, especially if it's relativily new (<5 yrs ie, and not fully understood), and good, reliable, clear findings find their way to the clinic, after five years the theory usually is altered, improved, etc. Because it is improved, traditionalists tend to react "well this has served for ... years, and your theory is old and critically discussed already").

                        Now when you look at something like the neuromatrix, there's another problem. They're just logically really hard to "pinpoint". I adressed it before. When you look at it as a theory (or axiom), it is derived from other theories, including biomechanical theories. That might just not be "fair". Biomechanical theories that are reasonabilly well researched, and criticised. Now, what the neuromatrix does, it takes that research and places it in another contruct. Well that's from a logic point of view, tricky. Because:
                        1. There is no distinction between a verification and/or falsification of the Original theory and the neuromatrix (a falsification of one construct, is also a falsification on the other construct, in that way it doesn't fit the demarcation criteria of both logical positivism or Poppers falsification principle).
                        2. There is no distinction between the neuromatrix as a contruct and pain as a construct.
                        Taking point 1 and 2 in consideration, one might ask what the neuromatrix adds, to pain, or to the results of other research propositions included in the neuromatrix. Nothing much would be my awnser. However one important thing is added. Pain isn't a really well described construct. We often think it is, but there is no such thing as 1 kind of pain. Many of those constructs are the constructs from which pain might EMERGE. So using the word "pain" might bring / have brought more confusion, then using "neuromatrix (of pain)". But if Melzack had called it "pain", I wouldn't have mind. That is a practical consideration to bare in mind. As you speak about pain, the patient (or other Healthcare worker) might misinterpret you.
                        I think this is both the risk and on of the reasons for critics to point out that the neuromatrix isn't a typical construct, and that one should see the implications of the constructs which influence the neuromatrix / pain.

                        Besides that, we are typically taught that our evidence based practice has to be scientifical well performed. This means we see ourself in/as a third person. The neuromatrix might however be seen as a first person based framework. I think that is a radical change in the modern medical world, which hopefully will lead us to new ways of reductional research, as wel as reductional testing in physical and psychological exams.
                        In klinimetrics we already start to see a growing amount of research done from a item-response-theory point of view, opposing the more traditional classical-test-theory paradigm. However this takes a lot of complicated mathematics (Crohnbach was a hero, but I couldn't understand him if I tried). And I think we see a change in clinical reasonning as well. I think there is a shift from hypothetic reduction logic (IE much to be diagnosed true / untrue) to a more predicate logic, reductionally tested taking the patients context in consideration and also taking longitudinal processes in consideration. However this is new, also to teachers, medical opinion leaders, experts, clinics, managers, researchers, etc. etc. By the way, which I think most of us already know from intuition, but isnt known from a philosophical / mathematical point of view and more important we haven't got clinical feasible "tools / klinimetrics" for, let alone we can teach and implement the method. We are still learning to use it (as I speak for myself).

                        So it's a whole lot of changes coming at us nowadays, not easy for any one of us to both keep track on, as well as implement. Sometimes it's so hard we reach for specific cases to sketch the context, but then again, this is likely to resut in a changing of the context by the other debater... I think everyone recognises that. I think it shouldn't grind your gears, I think it should remind you that we are probably sometimes trying to make to big of a step, and I honestly think that the future is in a gentle balance on "first-person and third-person" based care. One can lose the balance both ways, and we should Always keep feasibility in clincal practice in our minds. But that's just my view, for what it's worth.

                        Bob
                        The final test of a theory is its capacity to solve the problems which originated it - George Dantzig

                        Comment


                        • #13
                          Thanks Bob.
                          I certainly acknowledge there are conceptual and theoretical problems with the neuromatrix and I find its clinical usefulness to be its strongest advantage. But that's really not the issue in this gear grinding, in my opinion.

                          I wish the things that caused my gears to be ground was that people just aren't incorporating new evidence into practice. It would be easy for me to get over that. What grinds my gears is that people aren't 5 years behind they are more like 20 years behind and they often refuse to acknowledge well-demarcated settled science if it conflicts with their cute cultural story or self-referential conceptual model.

                          Sometimes I can't even convince people that pain, however we want to define it, is a perception not a sensation. That is it modified by emotion, cognition and context. I don't think that's a question of not absorbing cutting edge science or having realistic and defensible theoretical critique of neuromatrix theory. Its a question of being unaware and unwilling to consider, research from the last 30 or so years.
                          Jason Silvernail DPT, DSc, FAAOMPT
                          Board-Certified in Orthopedic Physical Therapy
                          Fellowship-Trained in Orthopedic Manual Therapy

                          Certified Strength and Conditioning Specialist


                          The views expressed in this entry are those of the author alone and do not reflect the official policy or position of the Department of the Army, Department of Defense, or the US Government.

                          Comment


                          • #14
                            Ken-
                            I saw that blog too. I've been interacting with people long enough to know someone could easily make an anti-Silvernail web log, so I'm not that keen to use that link in my discussions with Carl. Truly his entries were late to the game and only illustrated my preexisting issue with this approach so it isn't personal to him.
                            Jason Silvernail DPT, DSc, FAAOMPT
                            Board-Certified in Orthopedic Physical Therapy
                            Fellowship-Trained in Orthopedic Manual Therapy

                            Certified Strength and Conditioning Specialist


                            The views expressed in this entry are those of the author alone and do not reflect the official policy or position of the Department of the Army, Department of Defense, or the US Government.

                            Comment


                            • #15
                              Hi Jason!

                              I've been interacting with people long enough to know someone could easily make an anti-Silvernail web log, so I'm not that keen to use that link in my discussions with Carl.
                              A class approach on your part. Regardless of how much metal gets shaved from your gears, you continue to maintain a high level of colleagial professionalism. I respect that very much.

                              Truly his entries were late to the game and only illustrated my preexisting issue with this approach so it isn't personal to him.
                              Thanks for this clarification.

                              I always look forward to your insights, because you really make an effort to see things from the other guy's point of view. You remain considerate even though frustrated by those who have not considered thirty years worth of compelling research. That's not always easy to do.

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