As many of you have realized, a thirst for knowledge renders a habitual search, and a habitual search often reveals a discovery of more questions. So for this post, I seek not combat, but debate and, hopefully, through intelligent discussion, some answers.
Recently I have been on a quest to enhance my understanding about pain and dysfunction and through my endeavours, have come to a “roadblock ” regarding the concept of MOVEMENT. In particular, the relationship between pain, movement and intent.
As an individual who makes a living from helping to improve one’s pain and dysfunction, I have recently been asking myself, what is the true importance of movement?
To demonstrate my thought processes, I have included thoughts from three well respected physical therapists below.
Diane Jacobs writes:
A big implication in PT is that muscles are to blame for pain. Another implication is that somehow imparting motor control will help mop up pain …. movement of any kind will help “prevent” pain, an assertion I think can be supported by the idea of neurodynamics. But motor control? Why get that fancy about it? I don’t think it can prevent pain any better than simply more of regular movement would.
So, why do we think/why are we being asked to believe that we can train individual muscles? It makes no sense. Not from a nervous system standpoint. And let’s face it – without a nervous system a human organism is a motionless cadaver. So I give that system priority over anything anatomic/structural/mesodermal. Muscles are just the puppet strings, not the puppeteer. I want to interact with the puppeteer when I treat, and I don’t mean only cognitive control over movement. I mean, ways to change behaviour patterns that may be contributing factors, and try to directly approach/affect the sensory cortex through handling its outer sensor array – skin, and physically drag about (slightly) various neural structures embedded from below into skin. Learning about cutaneous nerves, their names and locations, shifting the mental focal length up, closer to the surface, helps reframe a lot of this stuff automatically.
So…. coming back to the point about multifidus, seems to me the brain tries to figure out ways to use movement, get the movement goal accomplished, without using the same muscle the same way twice in a row. Why would you not want to frame the multifidus issue (apparent weakness) as a defense (which would mean that it’s just inhibited, probably by pain), rather than as a defect (i.e., a target for some kind of intervention)?
Kyle Kiesel writes:
The response by the CNS to increase muscle activation to the outer core muscles in the presence of pain is known has a High Threshold Strategy (HTS). Increased activation of the outer core musculature is, of course, normal for the system to manage a high load task, but in response to a painful episode or a dysfunctional inner core, it is a compensatory strategy…
The inner core receives ongoing subconscious input from the CNS, which automatically maintains respiration, activates the pelvic floor for continence and segmental stabilization, and activates the TrA and LM for segmental stabilization in anticipation of a spinal perturbation. This is a highly automated, delicate functioning system…
Gray Cook writes:
The first thing you always need to consider is movement. If movement quality is not above a minimum standard, then this is the first problem you need to deal with.
Personally, I have gone well beyond the concept of training muscles. I understand that we have to employ movement. However, when it comes to the utilization of movement as a prophylactic and rehabilitative approach for pain and dysfunction, my personal preference would be to strive to achieve movement that is of ideal quality and not simply compensatory.
So my (vague) question for the masses is:
When it comes to pain and dysfunction, does quality of movement really matter?
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As a strength coach/personal trainer I can say with much certainty that quality of movement under heavy load or high velocity matters very much in terms of preventing injury and pain.
I suppose I’m not like my colleagues. My response – It depends. The question you are asking is way too broad. I’ll need just a tad of patience from you as I try to explain my thoughts…
For someone with an amputation having pain in the non-existent extremity, research is evolving to indicate that using a mirror and moving the existing extremity in a movement pattern that gets rid of the spasm feel/tight feel or abnormal feel of the non-existent extremity is helpful. In other words, the brain self-image has some sort of role in pain.
http://www.ted.com/talks/vilayanur_ramachandran_on_your_mind.html
Last week I met a lady with substantial leg pain. She’s a 74 year old lady. She was using a 3 wheeled rolling walker with brakes. Her seated position of comfort was having her right lower extremity severely flexed up to her trunk. When she ambulated with the rolling walker, she was severely flexed forward at her trunk and her right lower extremity was maintained in hip and knee flexion with her weightbearing pattern going through the ball of her foot because her foot was maintained in a plantar flexed position. Neural mobilization was somewhat helpful – short term. She could sit normally after the short treatment and she reported no pain. The problem won’t be solved by any movement; physical therapy won’t improve her movement/postural dysfunction. I spoke with her referring physician – an oncologist – and the metastasized tumor in her spine did not change after radiation. Definite proof – a space occupying lesion squishing the sciatic nerve creates pain. So, an indication that situations in the periphery of an intact extremity can play a role in pain.
What about someone who is healthy and participates in sports and has a current complaint of pain when performing a specific activity? If the person doesn’t have a significant amount of psychosocial issues (yellow flags), then it is relevant to understand the training schedule, activities performed, how they are performed. The situation could have a neural irritation component (most often does because the brain determined/interpreted the situation as painful) – is the neural irritation due to chemical irritation or a biomechanical issue that is creating a nerve to talk because it is being squished or stretched? First, get rid of the chemical irritation… then look at biomechanics. Alter the biomechanics by addressing the nerve that is sending messages and often the complaint goes away.
What about the situation of chronic pain? Pain that has been occurring long after the healing process should be complete. Movement isn’t the first answer, in my book. I’m beginning to learn, the most important piece is sitting down and talking. Understanding the patient’s perceptions of the situation is key. Just talking about perceptions, expectations and educating on pain creates change… change in the brain. fMRI has enlightened us to realize that someone with chronic back pain can think about picking up a box on the floor and the areas of the brain that are activated are different than someone without back pain. The same person, after being educated on pain, can think about picking up the box on the floor and the areas in the brain activated are more normalized. (Believe it or not, I have had patients report an exacerbation of their main complaint just by thinking about doing a particular activity and not even moving!) I tend to believe that is some strong evidence that what a person is thinking is highly relevant in understanding pain. When I read research has been done on people in pretend strengthening and I see data supporting that the person just thinking and pretending to do an exercise to strengthen finger muscles really does get stronger, that is an amazing feat. (It means the brain can become more efficient in creating motor pathways to create a movement pattern – a movement pattern specific to not just the movement but the quality of the movement and the strength of the movement without even performing the movement.) AND when I see research on playing a piano and learning something in particular on the piano and a comparison between a group who physically practiced on the piano and a group who did mental imagery and the mental imagery group showed improvement and then with 1 hour of physical practice were comparable to the group using the piano for practice… amazing!
The first question I ask.. why? What does the patient think is going on? I address that… I educate on pain… we talk. With regard to movement… initially, sometimes it doesn’t matter the movement – the goal initially isn’t to have some perfect movement pattern. The goal, initially, is to decrease fear and anxiety and to learn the body can move and to learn the body isn’t being harmed… and then graded exposure to components of a movement pattern or activity that is generally painful… and then to tackle the quality of movement.
~Snippets
Great ruminations here Jeff and thanks for the succinct summaries of others.
At grave risk for creating even more (and harder) questions, you might want to shift perspectives/paradigms as the above all reflects a rather mechanistic perspective.
What if we start from assumptions about humans that includes they are a meaning-making species and that action (movement with intention) reflects a number of initiators of “movement” within a “soup” or matrix. We know the influence of work injury/recovery and job satisfaction/meaningful participation in the work place. While the anatomical brain will be firing in both pre frontal cortex and the various portions of the limbic system depending on job context (they need me, I’m letting them down vs boss sucks, colleague harasses, noise levels keep them in CNS hypervigilance, etc). Whatever the outcome of this interplay drives the ANS chemical soup which produces the biomechanical reality of a breathing pattern (800times/hour) which is way more than they will ever “think” or “stabilize” consciously at the work site to fire multifidi/rotatores/gamellus inferior, you name it.
So this other perspective in summary is if we don’t “cap” the leaking well of meaninglessness which leads mindlessness/lack of awareness to move rightly, we can spray the dispersant we want in the form of manual intervention and ther ex of your favorite flavor, in the end the organism moves in congruence with their meaning narrative (conscious and unconscious). The good news is we in rehab also have the tools to help them discover and then edit the story through breath, posture and attention.
thx for the post
Matt
http://www.drofmovement.com
Attention… that’s another interesting topic. In the world of psychology, brain research seems to indicate the more attention a person gives to X… the more automatic and consistent X becomes. To put a physical therapist perspective on this using chronic pain as an example… the patient is in a rut. Way back before the problem was chronic, the person was paying a lot of attention to whatever problem and consciously or subconsciously, for lack of a better word, adapting or compensating. I don’t necessarily believe it is all movement patterns involved with the adaptation, but there could be issues of gaining personal attention, getting out of certain duties, I don’t know exactly, but environmental/social factors might be involved too. Was it pain that started the compensation… was it fear that perpetuated it? I have no idea… but X becomes automatic. Some folks will continue with the narrow focus – think of patients that can give you a run down, detailed chart of their symptoms of when the symptoms occur, how they occur, what they are doing (you know the ones – they hand you a scribbled notebook so you can see how much of a problem they have). In psychology, it seems if Y can be substituted for X… over time X disappears and Y becomes more predominant. The pathway in the brain changes (due to neuroplasticity) and the more attention Y is given, the “use it or lose it” philosophy occurs. X is no longer dominant and Y is. With physical therapy, I do think some physical therapists do change the focus and help with changing attention which then helps reduce the frequency of the complaint from occurring.
Pain is complex and complicated, isn’t it?
~Snippets
Bret, Matthew and Snips:
Thank you all for your input and responses.
I am starting to get a grasp on the neurophysiological approach of manual therapy, however, I still question this approach when dealing with acutely injured individuals, especially those in sport.
In athletics, while certainly not the rule, many coaches and strength professionals advocate for optimal mechanics to both minimize the risk of injury and maximize power output. As such, should an individual become acutely injured, my question is, aside from removing chemical irritants, shall we strive for optimal movement quality in consideration of the responses mentioned above.
For arguments sake, this individual has minimal yellow flags and is eager to return to competition.
Neurophysiological responses to manual intervention probably aren’t the key. Converge the neurophysiological response with the biopsychosocial model and you’ve got gold. The biopsychosocial model might be more relevant in the acutely injured. The aspects to snag from the biopsychosocial model are communication and education. (Whether acute or chronic, it’s probably important to remember that model.) As a professional treating anyone, I believe it is highly relevant to understand the perspective of the person experiencing pain. This means more than just analyzing the movement pattern. Address fears, anxieties, secondary gain (whatever yellow flags may be present – psychosocial issues)… don’t contribute to yellow flags OR create yellow flags (think diagnostic testing (like MRI) for pain situations when the presenting signs and symptoms don’t necessitate it)… educate on pain … educate on the normal healing process… educate on the normal timeline for healing… educate on expectations and progress… mutually agree upon goals (realistic goals)… then begin the process of yes, movement – initially after a recent injury it probably won’t be full movement or normal movement, but if movement is indicated versus stabilization and waiting for healing and safe movement, get the person moving. Then yes, striving for quality in movement by breaking down that movement into more simple components to focus on the deficits.
At the same time… the whole event around the injury situation also needs to be analyzed. The training program… the footwear… past performance…
I guess, from my perspective, when someone experiences pain, my most immediate reaction isn’t to jump in and focus on obtaining optimal movement – that can be a goal, yes… but I always have a ton of other questions in my head to piece together, analyze and sometimes address as part of the experience in physical therapy. Even when the athletes choose me for services, it’s like I need a better grasp of the situation than foot pain or knee pain or back pain or hip pain… Over the years, I have learned that I learn the most from the patient and then piece what I learn from the patient into the objective measurements and observations of movement.
Is that what you are asking? I’m not sure what you are thinking…
~Snippets
Interesting post, Jeff.
I think a lot of this may depend on the population you work with. A highly motivated athlete who wants to get back int he game (and is even willing to play through pain and injury) will be a different animal than a geriatric patient.
One thing I question about Diane’s quote is, how is movement re-patterning (or whatever you chose to call it) not dealing with the brain? How is it not dealiing with the “puppeteer”? The brain has to be involved in order to understand the way you are teaching the individual to move, how does that not make changes to behaviour patterns that may be contributing factors?
Yes, without the nervous system the body is a motionelss cadaver. However, we shouldn’t accept that to mean that when the nervous system is present it is the only thing that matters! The body consists of several systems that are all integrated and all have to work together. Anything that addresses any one of those systems will adress the nervous system in one way or another. There are several entry ways to the same room, does it matter which one you choose to walk through if you end up inside the room?
Patrick
one of the problems with research on any subject regarding manual therapy, physical therapy, psychosocial behaviour etc is the application of the research to real world populations. you see this all the time when attempting to apply “the findings” of a nutritional study into terms the general population can use. many studies have shown a high correlation between high fiber intake in the diet and decreased incidence of various cancers. as such, a high fiber diet was recommended as a prevention for cancer. made sense. however, when other studies were performed that noted that diets that lacked animal protein without a high intake of fiber also correlated highly with lowered cancer rates the idea of high fiber as a defintie preventor of cancer was questionned. was it the high fiber or merely the fact people who consumed a large quantity of veggies simply ate less animal protein that resulted in the correlation? should the recommendation be high fiber or decreased animal protein?
with respect to pain and the reduction or removal of pain in patients it is very difficult to utilize puplished research to determine practical application. for example, if a right handed golfer is complaining of right sided low back pain what information do you require to determione how to best work with this pateint?
obviously how long they had the pain and what they perceived as being the main contributor to the pain are important. but what else?
on the average professional golfer you will notice a significant asymmetry in the musculature of both the local and global spinal muscular systems. is that a result of improper activation on the “atrophied” side or an excessive hypertrophy on the opposite? Does the golfer have a reduction in their ability to actively or passively internally rotate their target side hip, are they creating their rotation predominantly through their lumbar spine or through the hips and thoracic spine, is their posterior fascial chain or lower limb neural length compromised, what is going on with their psoas, glute med, etc. is their pain a result of their prolonged slumped posture due to prolonged putting and short game practice? do they have an upper trap dominant pull pattern at the onset of their downswing resulting in a shift of their body weight onto their back foot and compression of their right side lumbar spine under highly compressive load while rotating?
there are many other reasons for a golfer potentially having low back pain and i havent even mentionned the potential psychological possibilities or contributions from non-golf situations (like carrying children, etc)
if you focused only on the area of pain in the lower back without considering the biomechanics of the full movemnt there are very few instances that the golfer will ever get better long term. and there must be a consideration of the age, load, periodization, diet, specific tissue damage, psychological conditioning, etc of the athlete that could be contributing factors.
this is the same problem many pitchers who have Tommy JOhn surgery. they fix the ligament damage with minimal consideration to the remainder of the players body and why the elbow was overloaded to begin with. should you be training specific pattern inthe shoulder complex or core or should you be looking at any number of other factors?
with so many variables with respect to the agent creating pain how can you possibly implicate any “best method” for dealing with the removal of pain in any general sense? no one person will ever understand how the body works. to claim to know the absolute best way of approaching pain management would truly show how little we know about the source of pain.
Great question with great debate. Cheers Jeff.