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

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  • 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.

  • John W
    replied
    It's a good question tal. In my opinion we know- or should know- enough about pain now to be doing things a lot differently than we currently are.

    At the moment, I'm not convinced that knowing more about the potential drivers of peripheral nociception in low back pain is the question that we, as therapists, need to be asking right now. What I suspect will be found as imaging becomes more refined are ever more subtle ways that the organism uses to defend itself against threat and how this manifests itself in the periphery. Unfortunately, many will use this as an excuse to tweak some peripherally-directed interventions. I can just see the next study proclaiming: "Spinal Manipulation Alters Modic type 1 Changes on High Resolution Stutter MRI".

    I'm reminded of the mad pursuit that the pharmaceutical industry has made towards pharmacologically interfering with various steps in the complex process of cholesterol metabolism to prevent heart attacks. They've made a helluva lot of money, but are people who take this stuff really healthier?

    Leave a comment:


  • tal.b
    replied
    "First, current imaging technologies may simply lack the resolution necessary to detect important damage or defects. - See more at: http://www.medbridgeeducation.com/blog/tony-ingram-lbp-imaging/#sthash.Ihzz0CIa.rnNRtGuT.dpuf"

    if we could ask anything of an MRI, in that it be specific enough to detect important damage or defect- what potential highlighted defects would we as therapists find beneficial in the treatment of our patients? if we could gain more information of the physiology of a person in pain, what knowledge would be helpful to our treatment (red flags aside)?

    Leave a comment:


  • Keith
    replied
    Originally posted by Jason Silvernail View Post
    Great conversation on Facebook about not forgetting the back in back pain by Tony Ingram:
    https://m.facebook.com/jon.fass/posts/10151951180846451
    Worthy of a Sunday morning bump.

    Respectfully,
    Keith

    Leave a comment:


  • Jason Silvernail
    replied
    Great conversation on Facebook about not forgetting the back in back pain by Tony Ingram:
    https://m.facebook.com/jon.fass/posts/10151951180846451

    Leave a comment:


  • gilbert
    replied
    ...also, I would NEVER say "your pain could be a mirage"

    I tend to say "We know there is more going on than just physical tissue damage when you have persisting pain." And then I go on to talk about that fascinating study on neck pain in Demolition Derby drivers...and the fact that if you hold your arm out for 1 minute it will hurt...and that helps get patients thinking in the right direction.

    Leave a comment:


  • Mark Hollis
    replied
    Nate,
    If we choose to speak of the possibility of mangled tissue that has had 1-3-6-10 years of healing and the "likelihood" of diminished relationship of pain and damage..... MAN you better be right! To me if you spin that story and the joint or whatever is actually F#¥@'d up... Despite your best manual tests, I'd say the attempt at a cultural change has been lost!
    Round 2. I've noticed this in one of your previous posts a few months ago and wanted to address it then! So thanks for reminding me.

    Let's talk about whatever is actually F#¥@'d up (note the past tense)





    So what you're trying to say is that there are 3 types of pathology.
    1. The PATHOLOGY the patient experiences (which is a subjective comparison somehow constructed by nervey stuff processing what it expects to what it's currently getting and being 'alarmed' by the difference (whether it be stiffness or pain or discoloration or etc)
    2. The PATHOLOGY the therapist imagines (which is based on subjective Hx clues and feedback derived from therapist assisted movement (mob/manip/palpate/muscle test) and observation relative to some assigned norm of the client)
    3. The PATHOLOGY the radiologist observes or the surgeon observes (which is based on tissue performing differently or producing ECM differently dependant upon either external environmental demands or internal genetic commands)
    And sometimes the patient goes to a therapist and they make a clinical judgement based on their examination and then that judgement of pathology is compared to radiology/biopsy and
    • sometimes the judgement and the radiology/biopsy coincide and
    • sometimes they don't and
    • when they don't and if the radiology/biopsy shows altered cellular response then ...
    Question 1: When pathology definition 2 (clinical results) and pathology definition 3 (radiology/surgical results) don't coincide what hidden criteria (pathology definition 4?) do you compare them to to determine which one is most appropriate correlative reason for the pathology definition 1 (client's expereince)?

    Question 2: Okay so the problem is identified (the tissue is pathologised) then what is the next step - excise (surgical) said tissue because it's not functioning and/or artificially induce altered chemical milleau (injection/medication) to alter it's environmental demands and/or ... Say to the client's Let's talk about whatever is actually F#¥@ing up (note the current tense) and under your current control - thoughts, actions, decisions, movements, lifestyle approach and come up with some strategies for these alterable contributing processes (which is a way of cognitively creating different environmental demands)?

    I'm not a woo-woo guy. I think some things are best treated by one approach and others by another. You come in with a massively sprained ankle I'm the first to find the crutches.

    However I also think that

    If a painful experience is an outcome of the brain (not output because of it's dualism connotation) then surely a analgesia-ful experience is an outcome of the brain too

    and to not speak is a disservice.


    Tissue pathology identification is one part of science, how and where that tissue fits into the client's experience is another part of science.

    Identifying a problem is one process, identifying a solution is another.

    In reality there are no antonyms.
    Last edited by Mark Hollis; 05-12-2013, 06:53 AM.

    Leave a comment:


  • Ken Jakalski
    replied
    Hi Diane!

    What I've come to realize is that parents of high school athletes who have a painful condition after a practice session will send their kids to either a chiro or PT for treatment--basically to reduce the injury "down time."

    The irony is that some of the questionable treatments do not seem to reduce the athlete's time away from training or competing an faster than if the athlete simply took time off to heal.

    However, the belief that the "right" therapists have the expertise and technology to repair quickly is deep rooted.

    Leave a comment:


  • Diane
    replied
    Originally posted by Armandos View Post
    Was having some log in problems but I will respond more later. So yes we can read about BPS all you want but applied information is something I asked for. Instead of people's own words I was seeing links to studies. That's like someone asking Ken J about his track program for 400m athletes and he posts Peter Weyand. Great to see what one believes, better to see what they do.

    "Opinions vary as to what constitutes a true biopsychosocial approach (Jull & Sterling, 2009; Weiner, 2008) and it could be argued that the list would vary, depending on each athlete and his/ her specific injury."

    Enough about straw man arguments as I ironically see a trend towards this claim when the discussion turns to application. When I ask what people do this isn't an attack or debate, a request to survey what people do and it seems we have three types of people. One that shares, one that argues, and one that tells me what they know but never what they do. A lot of smart people are on this forum and my simple request is to see what they do with simple case studies so we can get examples of verbal communication and so on. My world is a mechanical strain failure rate, those that see it too much or fail to accelerate the functional outcomes get fired. I am not a medical professional but a part time track coach and need to provide quality medical care if something goes wrong. So far I have received some great case studies so I know at least my communication is attacking the right people, I just think chronic pain and chronic injury are different as damage to tissue may trigger an athlete to complain of pain and listening isn't foolish.
    I found this today, posted by Pain-Ed. How we communicate with patients experiencing chronic pain could be as important as what we do.
    If you want actual papers, look up these guys - they've published.

    Why develop Pain-Ed?
    • The costs of treating pain have massively increased.
    • The disability, chronicity and impact of pain is getting worse.
    • Some say that current practice is making the problem worse.

    Leave a comment:


  • Diane
    replied
    Originally posted by Armandos View Post
    My comments are not about pain research, as I have spent a lot of time reading the suggested authors and respect what they do. My focus is how does one use this information in a clinical setting when athletes are injured. So far, for about three months most of the responses have been citations of pain theory. Good reading and I appreciate how things work and going to Amazon is not hard or even OPTP for reading isn't hard. Only 5% of the posts is clinical in nature, meaning if I had to refer an athlete to someone who is in sports medicine I just wanted a light case study or explanation of what a person would do with an achilles problem that had referred pain. To things happened that are very high profile. An athlete had degeneration of the achilles tendon and was told the pain was in his head. A week or two later it tore. Some told that the trend was there after a few medical imaging sessions some said it was random and pain was not a warning. So I am at a point that I see coaches not suggesting medical help when pain exists, and if the athlete goes on their own they are suggested self-talk audio files from websites without physical evaluation or looking at movement. Guidance of what is normal would be a big help.

    -Carl
    1. take history, watch patient
    2. provide basic pain education
    3. rule out red flags
    4. rule out yellow flags
    5. assess
    6. treat, bearing in mind that less is more. (Less pressure, less speed, less force)

    If there are red flags, refer out.
    If there are yellow flags, address them as treatment relationship proceeds, and if need be, refer out.
    Above all, do not nocicept the patient.

    Is that better?

    Please introduce yourself on a new thread in our welcome forum. :angel:

    Leave a comment:


  • Diane
    replied
    Originally posted by Armandos View Post
    Was having some log in problems but I will respond more later. So yes we can read about BPS all you want but applied information is something I asked for. Instead of people's own words I was seeing links to studies. That's like someone asking Ken J about his track program for 400m athletes and he posts Peter Weyand. Great to see what one believes, better to see what they do.

    "Opinions vary as to what constitutes a true biopsychosocial approach (Jull & Sterling, 2009; Weiner, 2008) and it could be argued that the list would vary, depending on each athlete and his/ her specific injury."

    Enough about straw man arguments as I ironically see a trend towards this claim when the discussion turns to application. When I ask what people do this isn't an attack or debate, a request to survey what people do and it seems we have three types of people. One that shares, one that argues, and one that tells me what they know but never what they do. A lot of smart people are on this forum and my simple request is to see what they do with simple case studies so we can get examples of verbal communication and so on. My world is a mechanical strain failure rate, those that see it too much or fail to accelerate the functional outcomes get fired. I am not a medical professional but a part time track coach and need to provide quality medical care if something goes wrong. So far I have received some great case studies so I know at least my communication is attacking the right people, I just think chronic pain and chronic injury are different as damage to tissue may trigger an athlete to complain of pain and listening isn't foolish.
    Hi Armandos,
    So yes we can read about BPS all you want but applied information is something I asked for.
    This is more a discussion forum than it is an online store for consumers... :sad:

    Not that we don't have items for consumption, and not that there aren't many more items for consumption out there in the literature. :angel:

    Leave a comment:


  • Armandos
    replied
    Was having some log in problems but I will respond more later. So yes we can read about BPS all you want but applied information is something I asked for. Instead of people's own words I was seeing links to studies. That's like someone asking Ken J about his track program for 400m athletes and he posts Peter Weyand. Great to see what one believes, better to see what they do.

    "Opinions vary as to what constitutes a true biopsychosocial approach (Jull & Sterling, 2009; Weiner, 2008) and it could be argued that the list would vary, depending on each athlete and his/ her specific injury."

    Enough about straw man arguments as I ironically see a trend towards this claim when the discussion turns to application. When I ask what people do this isn't an attack or debate, a request to survey what people do and it seems we have three types of people. One that shares, one that argues, and one that tells me what they know but never what they do. A lot of smart people are on this forum and my simple request is to see what they do with simple case studies so we can get examples of verbal communication and so on. My world is a mechanical strain failure rate, those that see it too much or fail to accelerate the functional outcomes get fired. I am not a medical professional but a part time track coach and need to provide quality medical care if something goes wrong. So far I have received some great case studies so I know at least my communication is attacking the right people, I just think chronic pain and chronic injury are different as damage to tissue may trigger an athlete to complain of pain and listening isn't foolish.
    Last edited by Armandos; 04-12-2013, 12:23 PM.

    Leave a comment:


  • Mark Hollis
    replied
    Nate,

    First we are always context of others, I of you, you of me. If the other choses to allow us in as a content then that's upto them and what 'content of what we express to them' they choose to focus on is also up to them.

    While the amazing discovery that ground beef body parts does not always have an outcome of pain.... I would like to be clear, especially in this very thread, that we better be extraordinarily clear, unambiguously righteous in saying that your pain could be a mirage!
    I take a person's subjective Hx very seriously because to them it's serious enough that their background brain has focussed foreground attention on it and created a set of relationships that may or may not coincide with the physical world relationships and also they may be reporting a series of cognitised relationships that are different to my limited cognitive relating to the world and I want to be clear on meaning of words and relationships with them. I also want to focus on the placeboic notions (when they coincide with reality) and maybe explain why I don't focus on noceboic notions (when they don't coincide with reality)

    I'm not engaging or educating them, I'm clarifying and categorising for myself. They're in the room for one reason, I'm there for another and part of that is doing my job and letting them choose how to do theirs. I also do manual tests to aid with that clarification and categorisation and to see whether I'm appropriate to exclude or include my self professionally. If it falls in a certain category I send them for scans or GPs or surgeons or ambulance etc. Somedays i get it right, my categorisation and scans or tissue pathology co-incide with my thoughts; Somedays i get it wrong, pathology gets missed. However I don't beat myself up about it. Not because I believe to be human is fallible but because I doubt I am a god.

    Lack of beating up self = I am a god (doubt).
    Honing professional skills (of which thinking is a subset) = I am a fallible human (belief).

    Pain is never ever ever a mirage. I'm very professionally anti-psychological. I believe psychology does exist and I also believe it's not a physical therapist's domain or right for that particular form of interaction. (Change the word psychology for sexuality or religion or any other form of cultural expression) The psychological/storying aspect of the interaction is their domain. My job is to present facts as I best know them and link them to their story, whether it embeds in their story or not is once again their domain. I'm very pro-physiological. Outside the clinical setting I'm pro-psychology, i'm no longer a therapist therapising and can just be physical therapist.

    Pain is always a mirage. Mirages need a person to experience them and a physical reality to experience it from.

    And Nate, lots of I statements in there because it's my interpretation of science. I've read a small smidgen of all the information out there and in a lifetime won't be able to read all of it so I base what I do and how I do it on what I know now and as new information comes to light will change. I don't own the information, I own the belief doubt in it, mine to hold or discard depending.

    Life is not belief, it is the activity of orienting your self to them (or for the more philosophical - the activity of orienting to a belief is the construction of an identity that emerges as self).
    Last edited by Mark Hollis; 04-12-2013, 07:23 AM.

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  • Bas Asselbergs
    replied
    Nate, I think the complaint is the key element. The history is what the patient adds to that complaint, and can be fraught with perceptual errors.

    For some reason you disagree with my
    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.
    BTW, my post #95 is full of poorly fleshed out thoughts, sorry.

    Leave a comment:


  • Evanthis Raftopoulos
    replied
    Originally posted by zendogg View Post
    I would disagree!

    A death angel and an innocuous mushroom look a lot alike. Eat the wrong one and it will kill you.
    Red flags can be cleared in less than 30 seconds. And maybe I should have clarified: I know the MOI, relevant medical hx, medications,work status, past visits, imaging studies etc etc at least a day prior the patient's arrival. Moreover, I don't manipulate or start with an intervention that necessitates (for safety reasons) prolonged testing prior its application.

    Leave a comment:

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