Posted by: Tyson Bell Comments: 0

In order to stay up to date with the latest evidence and advancements in our fields, most healthcare professionals make a point of participating in continuing education courses every year. The key takeaways from these courses can vary: sometimes one might come away with a new technique for a specific group of patients (a set exercise program for individuals with knee osteoarthritis for example). Rarely, a course prompts reflection upon the framework that one uses to guide their entire practice—Greg Lehman’s course, Reconciling Biomechanics with Pain Science, falls into this seldom encountered category. I was fortunate enough to help host Greg’s course at CPRI’s New Westminster location earlier this month and soak up 30 years of Greg’s painstaking research. Greg prompted those of us attending the course to reflect on the broad ways we might consider treating a patient’s injury or pain and boiled these methods down to leave 2 basic approaches:

  1. Correct & Protect
  2. Expose & Adapt.

    Let’s explore these two options further through some example cases.


Case #1: Sam Sam loves to ski. They love to ski so much that they’ll ski in any conditions, even if there is barely any snow. Unfortunately, on one of these low snow days, Sam skied over a rock, lost balance, fell and tore their ACL. Skip ahead 4 months and Sam is recovering from ACL reconstruction surgery. As a physiotherapist, I have to decide on which treatment approach to take: do I correct and protect or expose and adapt? In this case the answer is fairly clear. Tissue damage occurred when the ACL tore and again as a result of the surgery to repair it. Now, post-operatively, Sam is experiencing a loss of range of motion in their knee and significant loss of leg strength, both of which affect Sam’s ability to walk and move in general. So what are we correcting? We want to start by managing the swelling and stiffness in Sam’s knee with exercises and strategies that promote flexibility. Alongside this, we will build back the muscle strength Sam lost. We will “correct” here by re-establishing strength and flexibility in the leg in order to “protect” the knee joint and the new ACL once Sam returns to skiing and other normal activities. Sam’s case is a physio’s bread and butter and this type of treatment plan is often what comes to mind when folks think of what physiotherapy is.

Case # 2: Taylor Taylor has been dealing with lower back pain for years and has seen multiple physios, been to massage therapists and acupuncturists and received every treatment modality under the sun. Some of these make Taylor feel good for a few hours or even a few days, but the improvements never seem to last. Previous physios have spent countless sessions teaching Taylor how to “activate the core”. Taylor has been diligent with these exercises, spending every evening lying on their yoga mat and feeling for those mysterious core muscles.

When Taylor came in to give physio another try, I tested their muscle strength and found Taylor to be pretty strong already. But when Taylor showed me their forward bend, their back stayed rigid and their face went bright red, straining with the effort. Taylor’s previous MRIs and Xrays revealed no unusual findings. Sure the Radiologist identified some “degenerative changes”, but for someone Taylor’s age, it would be unusual to not have changes in the spine.

All this evidence suggested that the tissues of Taylor’s back were actually pretty healthy and strong but for some reason those same tissues remained stubbornly sensitive to certain movements and pressures. In Taylor’s case, we decided on a combination of correction, exposure and adaptation. Taylor’s habits of keeping the spine rigid and holding the breath while bending forward were likely useful at some point when the back tissues may have been injured. But now they restrict the body’s natural movement patterns and likely raise alarm bells that something dangerous might be happening.

Taylor and I set out on a mission to make bending forward feel good again. Taylor was quite nervous about this. They had spent years thinking that spinal flexion was dangerous. So we took time to discuss the evidence we now have (O’Sullivan et al. 2019 for example) which shows that the spine is meant to bend and is perfectly safe to do so. We started out with Taylor bending their back in positions where gravity’s force is not so high—bringing the knees to the chest while lying on the back and yoga poses like child pose and cat cow. Sometimes Taylor felt sore during the movements or hours afterwards but they reassured themselves that the movements were safe and that pain does not mean damage. Eventually, those initial exercises started to feel easy, so Taylor progressed to bending forwards in a chair and a few weeks later was practising standing forward bends several times per day. Now when Taylor comes into the clinic, they are able to bend forward without their face turning cherry red and their back is flexible, bending the way it is designed so well to do.

Although Taylor corrected some protective habits associated with bending, we did not try to change any properties of the tissues themselves. We broke down a movement that Taylor felt quite nervous about into small, attainable steps. Then with repetition and consistency Taylor provided evidence through movement that bending forward is a safe thing to do. Eventually Taylor’s nervous system got the message and stopped creating pain every time Taylor tied their shoes.

Conclusion:

Greg’s simple framework encourages the practitioner to truly consider whether some quality of the patient’s movement or tissue really needs to be changed or whether the tissues are fine how they are but need to be desensitized. As a society, we often feel dismayed if we find out something cannot be corrected—it always feels more concrete to have a specific body part or posture to blame for our pain. But I would argue that our body’s ability to adapt to nearly any condition is one of the most inspiring things about working in healthcare. Messages like Greg’s remind me to stay humble as it is highly likely that I have given myself credit for “fixing” someone through some clever biomechanical intervention, when in fact the patient’s body probably did 95% of the work.

Notes:
The cases mentioned above do not depict specific individuals but rather are composites of similar patients with fictional names.

For more information about low back pain and the concepts I mentioned above, check out Peter O’Sullivan’s easy to read article, Back to basics: 10 facts every person should know about back pain, which is referenced here:

O’Sullivan PB, Caneiro JP, O’Sullivan K, et al.
Br J Sports Med Epub ahead of print: 16 December 2019. doi:10.1136/bjsports-2019-101611