Reconciling Pain Science and Biomechanics

Greg Lehman

It's finally happened. I finally attended a course presented by a Canadian! I also work with a
Canadian Occupational Therapist and from my sample size of n=2, I think it's possible that Canadians are smarter than Americans. Why is it that Canadians seem to know more about American politics than we do? I can only inadequately describe how our government operates and I know absolutely nothing about theirs.  It's like they care about what happens in the world, or something. We should do better, America.

Anyways, since I'm sure you also want to take a course instructed by a Canadian, I'm sure you want to know what course it was? "Reconciling Pain Science and Biomechanics" by Greg Lehman. Greg is a physiotherapist, chiropractor, strength and conditioning specialist, and biomechanist who also teaches a course called Running Resiliency, which is probably excellent if you run or treat runners, which I try to avoid.  (I avoid running.  I don't mind rehabbing runners).  "Reconciling Pain Science and Biomechanics" is a two day course that bridges the gap between the clinicians who focus heavily on pain neuroscience education and the psychological side of the biopsychosocial model versus practitioners who tend to focus primarily on perfection of movement patterns and anatomical tissue structural damage as potential drivers of pain.  If you're working in orthopedics or with pain management you should definitely check this one out.  The course was overall broad with big concepts that ideally could apply in multiple situations.  It also came with an extensive set of resources including his presentation and a huge number of literature papers for consideration.  So much evidence to support the discussions. 

I've previously written about pain here (and several other posts).  Greg defines pain for this course as "When all your loads/stressors exceed your ability to adapt/cope."  Pain is the balance between all the things that are harmful to you and all the things that are good to you. I often like to use the concept of inputs versus outputs with my patients, especially because people often don't recognize that pain is an output. I can't put pain into you. Pain is an output message from your brain in response to stresses that have been applied.  I can apply stresses to you so that a painful output occurs, but instead I try to find the minimum effective dose of stress to input so that your output is positive adaptation, not pain. 

Some examples of inputs: mechanical stress to tissue such as an incision or deep touch or the feeling of your rear end on the chair you're sitting on, chemical stress such as dehydration or improper nutrition, emotional stress such as those from your family or your job, light, sound, and temperature changes.  Inputs are not good or bad, they are just stresses that we have to process in our body.

Some examples of outputs: pain, emotions, sweat (loss of heat), neuromuscular adaptations such as increased strength, seeing your mental health counselor and talking it out, breathing, coping/calming strategies.

So when a person is experiencing pain, anywhere, the options for treatment could include:
1) Can you decrease some of the inputs?  Examples: Turn off the lights, focus on some breathing strategies, go for a walk, change your body position, change the temperature, increase or decrease the amount of touch on the area that hurts. 
2) Can you increase some of the outputs?  These could actually be the same as above because of things like hot versus cold where changing temperature in one way actually accommodates both, but also doing some yoga, exercise, see your therapist, take your regularly prescribed medication if you have diagnosed anxiety or depression that is being medically managed, or spend time with friends.
3) Or can you make it so that you're able to accommodate for more inputs without changing the input or output?  Again, there is overlap here.  But for many people, building up tolerance through strength training or meditation practices or learning ways to desensitize your skin can all have this sort of impact. 

It's important to also consider what is getting in the way of making some of these changes. Is the patient fearful of going for a walk because they have pain in their foot?  Are they catastrophizing or perseverating on horrible possible outcomes by participating in a certain activity so they're unwilling to try?  What are the current beliefs and expectations about their condition?  Knowledge about how the mind and body connect and work together can help decrease these roadblocks to facilitate recovery.

Greg provided some important questions to ask patients to help them return to their favorite things.  For example, "In what ways do you think you could be healthier?"  This open-ended question allows a person with headaches to consider that maybe they could better hydrate, have more nutritious meals, sleep at more optimal times, go for a walk at lunch time, maybe acknowledge some of the recent spikes in stress at their job or school... but it allows them to identify potential sources of their pain, allows them to outline what they believe is happening, and also gives you a chance to better learn about the patient. 

Greg Lehman and Me

He also discussed the importance of asking "What activities are meaningful to you?"  So, for me, I really like to play softball.  When I hurt my knee a few months ago, I was disappointed that I couldn't play for a week or two, but then I was able to return in a modified way.  If I hit well enough, I could hobble my way to first base and get myself a substitute runner for the rest of the bases.  I didn't think I would damage my knee worse by doing this, and I actually didn't have much pain when I tried that.  I spent a little more time in the dugout instead of alternating innings so I could avoid spending so much time in my catcher's squat position.  So, I was able to dose my activity so that I could do some rather than none at all, and this actually built my confidence to return back to my usual level of participation after healing and recovering. 

Which leads perfectly into "Encourage the patient to ask themselves 'Will the activity harm me? and/or 'Will I pay for this later?'"  Like with my softball example, I didn't hurt myself worse by participating and I didn't hurt more after playing. Certainly there are times when doing activities can be harmful. As a physical therapist, it is our job to recognize when that is the case and appropriately guide our patients, but modifications are often possible.  In particular, I really think it's important for our post-surgical patients who can't be playing their sport to spend time around their teammates. Be the team manager!  Learn more about your sport.  Spend that time with your friends.  It's better for mood, learning of the game, growth with teammates (and they'll get better support if they're around and showing their progress over time." 

Best Thanksgiving Food

In another example, this past weekend I attended a delicious Friendsgiving dinner at my friend's home. I've been managing some gut issues lately and had been eliminating several foods to try to identify where the problem was coming from. After a month with no wheat and two weeks without any onions or garlic, I wasn't exactly sure what would happen if I had some stuffing... but I really wanted it!  I actually did use this line of reasoning while I ate.  Will I do any permanent damage to my body by eating this? Not likely, no. Will I pay for it later? When I made the decision, I wasn't entirely sure, but I thought it was possible, which impacted my decision for quantity of stuffing that I took (dose). And yes, I felt like crap from it.  But was it worth it? That's very individual, and up for me to decide, and now I have data. Next week when I'm home for family Thanksgiving, I get to decide if I want to repeat this same thing knowing what the likely outcome will be, or not.  But I'm empowered to determine what I do to my own body, and that's something I think we can teach our patients, too. 

What else can we do as physical therapists to help our patients who are experiencing pain?  We need to help make sense of their pain using their own understanding of what's going on. A person who thinks their "back is out" can't just be told "that isn't really a thing, backs don't ''go out.'"  They'll never buy into your message if they have a belief of what's wrong and you just strong-arm them into an opposing idea.  So instead, we acknowledge their beliefs, educate them on how adaptive the human body is, and we facilitate cognitive restructuring.  An example that was suggested in the class was "I bet someone has told you that your spine is twisted," and by acknowledging their perspective, you can try to bend that belief just a little bit, "but actually your pain could be from something else, so why don't we work on getting you moving in ways you can tolerate."  You create a small hint of doubt into their beliefs and see if the patient gives you an opening and slowly you can chip away at the beliefs over time.  We can facilitate adaptability by using intentional application of specific stressors that induce adaptation for increased resiliency, and this includes with beliefs. We must meet our patients where they are at with the psychological and physical approaches, progressive loading ooth their thoughts and their tissues, which might be a really little bit of loading at the start, but sometimes that's all they can manage. We work hard to encourage their autonomy and self efficacy.  One of Greg's quotes which I really enjoyed: "Requirements for adaptability: 1) Human. 2) Not Dead."  He also made sure to include a statement about how physical therapists don't fix people.  We facilitate them.

Bob Ross

And so physical therapists need to understand barriers to recovery, which could be at the tissue healing level, or could be in the psychosocial realm, or a whole host of areas in between.  And we need to appreciate that what we do is, in fact, an art, while also being a science.  That makes Greg Lehman just like Bob Ross, I think.  He painted this one beautifully. So many happy trees.

And with that, I'll finish with another quote from the course "Limping is a helpful adaptive pattern. It is successful in keeping people moving. It decreases pain. But should we advocate for everyone to start limping?"

Thanks so much, Greg.  I hope you'll come back to the USA soon!