Pain Science, Movement Based, Pathoanatomical?….OH MY!
Pathoanatomical/structural based, Pain science guru, movement based medical provider, such different approaches…………or are they?
With the advent of pain science education I have seen previously loyal followers of Prof. McGill, shift to a pain science model, and suddenly become Stu McGill apologists. Oh well you see, what Stu meant to say was, “blah, blah, blah, blippety, blah”. He didn’t “mean” to say anything. His message hasn’t changed, and it doesn’t have to. It fits very neatly in to both the pain science and the functional model. Don’t shortchange the exam. Have a thorough idea about where the pain is originating from and the directional preference associated with the pain. This will bring clarity and empowerment to a patient that believed that they had some sort of random, nonspecific low back pain. Understand the threshold to aggravation. Is it 20 minutes of sitting? Is it one hour of walking? Modify behavior to remain under the threshold, allowing for desensitization. Start building a robust stability system in safe ranges of motion, adding more and more functional exercise. Eventually building tolerance to previously painful activities or positions. How is that different from what pain science has taught us? It ain’t.
So from McGill we get the tools to perform an effective and thorough examination. From the Gray Cook’s and Gary Gray’s of the world we learned to stretch that exam globally and look at overall joint function and health. Is this different than McGill’s teaching? Not really. The difference is really where the patient falls on the treatment spectrum. In the chronic pain population that McGill sees and treats the onion must be peeled way back. He has to have a very thorough working knowledge of the patients pain provokers, and he has to begin the desensitization process quickly, while working in very safe ranges of motion. He has to start defining the patient’s pain, and building confidence in the robustness of the patients spine. These patients are too sensitized to throw a Brettzel at them, and attempt to get better full body function. He would agree that in a certain population of patient, it is possible and likely very beneficial to accomplish both the goals of desensitization and robustness, while working on contributing dysfunction elsewhere in the body (ex. hip mobility). The tools given to us as medical providers from the brilliance of Gray Cook, is really in being able to take that same patient, and lead them further down the functional scale, effectively bridging rehab and performance. He’s given us the ability to assess function better, improve movement quicker, and take patients further. It’s that simple.
“The test of a first-rate intelligence is the ability to hold two opposed ideas in mind at the same time and still retain the ability to function.” – F. Scott Fitzgerald
What a fitting quote for today’s medical providers. Want to be a medical provider of first rate intelligence? You better be able to do just what the good author says, “hold two opposed ideas in the mind at the same time and still retain the ability to function” We have the brilliance of Butler and Moseley to thank for that. Pain science has gifted us with the seemingly contradictory ideas that biomechanics don’t matter, but yet movement somehow does. Hard to make sense of that statement at the surface level. Microscopically assessing biomechanics as an injury predictor is probably a poor strategy for a provider. However, movement plays a rather obvious role in sensitizing tissue and in accumulation of load in tissue. Movement variability has been shown to positively influence the variable of accumulated load, and thus reduce injury risk. Is that biomechanics? I guess yes and no is the correct answer.
From pain science we are learning how to better communicate with the patient, how to internally conceptualize in our own heads exactly what it is that we are doing, the behavior of pain, how it spreads to other movements and other parts of the body, how thoughts and beliefs influence pain, and much more. Admittedly, the work being done by Moseley, Butler, Lehman, and so on, has certainly added another dimension to our treatment. It has given us new tools and taken away others (quit IASTMing patients until they have internal bleeding, haha).
However, is it in conflict with the McGill approach or the Gray Cook approach? No. It’s an addition to their approach, and more importantly perhaps it should be utilized as a THROUGH LINE that should affect the subtleties of your treatment from day one to discharge. It should not be a proverbial throwing out of the baby with the bath water. It’s a tweak for sure, plus a few more tools that must be added to the ole repertoire.
The fact remains, whether it’s a neurotag or an inflamed disc, if a patient reproduces his or her pain with lumbar flexion then we have to treat it the same. We have to avoid the reproduction of pain, scale back, and begin rebuilding back to pain free function. Hell, maybe you can build them up to a body weight Jefferson curl in the end, but in the beginning you’ve got to stop poking the bear. Call it a hot disc, call it a pain neurotag (you’ll sound smarter to yourself, yet somehow dumber to the patient, haha) call it whatever you want, but flexion intolerance still works fine.
In summary, want to be the best medical provider you can possibly be? You better get busy learning everything you can from all of the above approaches.
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Are you a clinician looking for a comprehensive reading list to improve your skill set? Here is a great reading list that I ran across from physical therapist, Dr. Jarod Hall.