Jason Silvernail is a prominent voice in the world of physiotherapy and pain science, and argues that while biomechanics has some value in terms of understanding pain, that value has been largely overrated. It has now come to our attention that pelvic tilt, core strength, and “postural abnormalities” are perhaps trivialities when understanding a patient’s pain.
“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for trying to move people in the fitness and rehabilitation world away from such a simplistic, practitioner-centered, outdated view to a more complex, patient-centered, and modern view of the pain experience.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. ” Dr. Jason Silvernail, DPT
Brilliant article written by Apply Research: Article.
– “Information asymmetry” is a overlooked problem in health care. Kenneth Arrow, a Noble Prize winner in Economics, described the phenomenon as the severe disadvantages that people face when they know less about a commodity than the seller does.
This holds true in many aspects of life. From banking to housing, from couches to cars. Yet, one of the most frightening displays of competency difference is seen in health care.
The gap between the knowledge of the clinician and most patients´ proficiency to understand health information is so vast, that patients face gruelling odds . An alarming minority of patients is actually able to receive, analyse and interpret information critical for their own health and well-being. In other words, patients are by all accounts totally and unequivocally at the mercy of the clinician in front of them.
This raises some serious dilemmas. Clinicians can recommend care of little or no value because:
- It is financially rewarding
- It is easy and it keeps patients satisfied
- Professional indolence has caused auto-pilot habits
- They genuinely (but incorrectly) believe in the actual service they are providing
For decades health literacy has allowed clinicians to assume a God-like status. Even in cases where evidence is scarce or completely missing, clinicians can quietly build a bubble of self-glorification without protest or scrutiny.
Extreme repetition of a movement pattern, or doing the same movement in the same manner for a long time, might actually cause motor neurons to “burn out”.
“Musician’s dystonia (MD) is a neurological motor disorder characterized by involuntary contractions of those muscles involved in the play of a musical instrument. It is task-specific and initially only impairs the voluntary control of highly practiced musical motor skills.”
Variability of movement is good. And perhaps essential when dealing with chronic pain. This is a brilliant Cor-Kinetic article detailing this concept. The article is rather damning of the FMS (Functional Movement Screen). Ingraham of PainScience has spoken about the problems with FMS: PainScience FMS article
Some of my favourite excerpts from the Cor-Kinetic article:
“Decreased ability to move differently and have other movement options has been associated with the transition from an acute injury to chronicity”.
“Simply altering foot positions in a squat or a lunge will adjust femoral orientation in the acetabulum and provide a different stimulus to both the tissues of the hip and the CNS for a different response – hopefully less pain.”
“In a pain situation the aim may simply be to move with less pain rather than targeting a specific muscle to make it stronger. I would hope we are now moving away from a single muscle weakness as a cause of pain or biomechanical ‘dysfunction’. The more you move in the same way with pain the more you are likely to trigger the same response. The painful movement could look like ‘really good’ movement and ‘really bad’ movement could be pain free. We need to get MORE comfortable with being able to adapt exercises and movements to the person rather than shoehorning them into an ‘ideal’ version of an exercise.”
“Essentially some peoples CNS’s get very good at being in pain! So pain is very easy to trigger and because it is easy to trigger people become both aware and wary of this. We see this with hyper vigilance and fear avoidance. Being able to find pain free movements with these people becomes of huge value far outweighing if it is the ‘right’ exercise performed in the ‘right’ way. If we can also make movement relevant to the person then the psychological value is going to be significant. Fear avoidance is in part is maintained by avoiding perceived pain situations and therefore not getting pain, the relevance of movement and the dosage of how we interact is paramount. Not addressing relevant movement may sustain the problem.”
“Movement also promotes basic fluid dynamics that can take away the nasty stuff and bring in good stuff so not moving is generally not the answer. Movement is also analgesic *HERE* An increase in corticomotor output promoting descending inhibition and an increase in endogenous opioid production have both been discussed as potential mechanisms. The more inhibitory chemicals we have floating around the spinal cord the less sensitive it is likely to be, this includes chemicals such as GABA and endogenous opioids. This top down inhibition can influence what’s happening physiologically within the tissues and even simply having positive associations with movement may have an inhibitory effect on pain.”
Good NPR article suggesting that the best way to ditch back pain is to exercise…any kind of exercise. Start moving, and don’t look “back” !
“While back belts and shoe insoles didn’t seem to offer a benefit, they determined, exercise reduced the risk of repeated low-back pain in the year following an episode between 25 and 40 percent. It didn’t really matter what kind of exercise — core strengthening, aerobic exercise, or flexibility and stretching. Their review was published Monday in JAMA Internal Medicine.
“If there were a pill out there that could reduce your risk of future episodes of back pain by 30 percent, I’d probably be seeing ads on television every night,” says Dr. Tim Carey, an internist at the University of North Carolina in Chapel Hill who wrote an accompanying commentary in the journal.
And yet, he says, health care providers don’t prescribe exercise nearly enough, given its effectiveness. Carey says fewer than half of patients participate in an exercise program, even if they have long-term back pain.
In researching what docs do and don’t prescribe, Carey found that passive treatments were much more common, like ultrasound or traction treatments, back belts and orthotic insoles. “Prescribing ineffective treatments for patients may actually distract them and give them a false sense of security away from treatments that are actually beneficial,” Carey says.
The discrepancy between what’s most effective and what’s most prescribed highlights a bigger problem: The health industry is centered on sellable products, and exercise isn’t one.”
Very interesting study done, published in the Journal of the Neurological Sciences with the title: “Manual therapy as an effective treatment for fibrosis in a rat model of upper extremity overuse injury”. (Study used rats, not human subjects). It is much easier from a human ethics point of view to artificially induce repetitive movement disorders in rats than it is doing so in humans…
Bottom line: results indicate that massage therapy lead to decreases in pain and improved function in repetitive movement disorders.
Abstract: Key clinical features of carpal tunnel syndrome and other types of cumulative trauma disorders of the hand and wrist include pain and functional disabilities. Mechanistic details remain under investigation but may involve tissue inflammation and/or fibrosis. We examined the effectiveness of modeled manual therapy (MMT) as a treatment for sensorimotor behavior declines and increased fibrogenic processes occurring in forearm tissues of rats performing a high repetition high force (HRHF) reaching and grasping task for 12 weeks. Young adult, female rats were examined: food restricted control rats (FRC, n = 12); rats that were trained for 6 weeks before performing the HRHF task for 12 weeks with no treatment (HRHF-CON, n = 11); and HRHF task rats received modeled manual therapy (HRHF-MMT, n = 5) for 5 days/week for the duration of the 12-week of task. Rats receiving the MMT expressed fewer discomfort-related behaviors, and performed progressively better in the HRHF task. Grip strength, while decreased after training, improved following MMT. Fibrotic nerve and connective tissue changes (increased collagen and TGF-β1 deposition) present in 12-week HRHF-CON rats were significantly decreased in 12-week HRHF-MMT rats. These observations support the investigation of manual therapy as a preventative for repetitive motion disorders.
Link to abstract (I have read the full study) – http://www.jns-journal.com/article/S0022-510X(15)30093-9/abstract
“It is important to understand, however, that the human body is remarkably resilient. The liver, kidneys, lungs, and several other organs work around the clock to remove harmful substances and excrete waste products of metabolism. They don’t need any help from pepper-infused lemonade. Moreover, there is evidence that commercial detox supplements are not based on facts. A 2009 investigation found that not a single company behind 15 commercial cleanses could name the toxins targeted by their treatment, agree on the definition of the word ‘detox’, or even supply evidence that their products work.”