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Changing Movement Patterns: not for the sake of correcting them, but for the sake of lessening inputs to all-ready sensitized tissue while continuing to load the body.

Its a long title but the gist of what I would like to talk on today- with some fresh thoughts recently conceived at Greg Lehman’s course "reconciling biomechanics with pain science" for more info see: http://www.greglehman.ca/.

Greg's course is refreshing in the sense that it is not about another technique, or series of techniques that need to be mastered and applied based on specific impairments, but an overall context of treatment that envelopes the benefits of all those "special" techniques without boxing you in, and exposes the commonalities of different treatment philosophies and paradigms, shedding light on mechanisms that are actually more SIMPLE within all these treatment styles, without the guru bs.

We need not throw the baby out with the bath water, in light of pain science. As Greg notes, it is the bio-mechanics research that refutes the bio-mechanics. We just do not have consistency in research for implementing specific movement patterns as "bad" (for the most part), especially relating to PAIN at low loads and normal sport/activity. Research is all over the map, regarding effort to correlate specific kinematic movements with pain, such as hip adduction, hip internal rotation, and pronation. This is also true for correlations between shoulder pain and scapular position, such as scapular tilt, scapular rotation, etc. For high loads, in concern for actual tissue failure, biomechanical implications may apply (for instance, regarding ACL integrity and high impact landing as seen in Myer 2015 research http://www.ncbi.nlm.nih.gov/pubmed/24687011) but for normal low loading activity such as running or typical sports, correlations of pain and position/movement strategy are weak! Furthermore, our assessment of a painful limb is inherently altered- because the person is in pain and we are only assessing how their body moves under the influence of pain!

 In my opinion, certain concepts become sexy, and are difficult to divorce- and we can become fixated on trying to correct something that:

A) wont maintain corrected subconsciously in game play
B) will return, and maintain, as the person has no pain complaint
C) may not be factor at all in the pain complaint in the first place!

BUT there is a caveat! Assessment of movement can tell us a lot. It can tell us how variable or consistently a person is stressing their tissues. Stressing tissues is not inherently bad (we are always stressing tissues!), and is totally normal. Stressing sensitized tissues can cause pain. We don’t need to FIX the entire architecture of movement (as many movement/postural/guru philosophies may attempt) we need to get the tissues to a state where this normal stress is tolerable, and un-noteworthy, and un-noticed.

 We can use our biomechanical knowledge to offer foundation to TEMPORARILY change inputs on sensitized tissue, and change the output of pain (the output which is bringing the person in to see us in the first place).  This gives us a window where tissue can be less stressed, while the body stays active and strong, IF we can use our creativity to let our patients allow this- which is one reason I recommend Greg’s course, as well as the course offed by guest speaker Cory Blickenstaff from http://blog.forwardmotionpt.com/ and it may not need to be a long window (we KNOW loading is GOOD for tissue, and creates physiological meaningful changes). Then we again apply biomechanics to figure ways to load the offending tissue in either a different context, as well as in a way to apply a graded exposure of more loading, more stimulus, to the area, and its surroundings. All this, while addressing psychological factors such as the patient’s views of their condition, as well as external factors that can be influencing protective behavior.

I think a lot of therapists struggle with the conflicting messages of biomechanical research, the simple and extremely complex messages from pain science (that is often thrown at a patient in poor context and poor taste), and the endless manual and muscle based "approaches" to patient treatment.

This is sort of a crossroad for therapists, I think, to which they have a few options:

1) Continue pressing some sexy concept of revolutionizing the way the patient moves, or corrective technique who’s only merit is "it works because it works", all while feeling a little lost inside (or with perfunctory confidence).
2) Become super frustrated, in light of biomechanical research not quite lining up to what we would think or have been taught, lessons from pain science being difficult to realistically transfer into a meaningful cognitive processes FOR THE PATIENT, or patient presentation not aligning to specific rules of thought…and sort of give up in a nihilistic fluster
3) OR look at PAIN presentations in terms of sensitive tissue that needs to learn to adapt, and is begging to be utilized and stressed and strained in a way that lies outside of the habitual painful movements/postures.

The 3rd view offers an approach that doesn't at all compromise our knowledge of the body and movement, but may compromise some of our well-engrained beliefs. It involves a treatment that promotes “comprehensive capacity” of ALL the joints surrounding the painful ones, changes loading when necessary, with the goals of graded exposure to eventually increase loading tolerance to the target area once AS the tissue allows- and there are a lot of ways to manipulate the experience of a painful joint towards allowing stress without causing pain!

I discussed a few simple concepts of obtaining movement in a difference context in last month’s blog regarding "Fear of Movement":


Gaining movement in novel ways is on only one part of desensitization- a major part comes with loading the tissue! Using visual feedback with movement is ONE way to encourage movement and loading in a creative way, and may be beneficial in the following ways:

1) Allowing a patient to view how habitual their movements are, and practice changing this, simply for the sake of "load changing."
2) Allow patients to view their motor control capacity in ALL ranges of motion (as a robust system we should strive for strength and control OUTSIDE of habitual patterns of movement! This may be important especially in injury prevention!)
3) Allow patients to visually identify zones of movement that are associated with pain (we should strive to return to these once the tissue has adapted to handle the stress!

4) Change the internal focus of movement with an EXTERNAL cue- which may play with processing in a favorable way! (ie the patient is not focused on their painful limb, they are focused on the tracking task provided by the visual feedback.)

5) It can definitely load and challenge the body especially in terms of eccentric control, plus its fun!

-Tal Blair, DPT

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Example of using external cues for advanced single leg proprioceptive and motor control training