Boston Sports Medicine and Performance Group, LLC Blog

Your Body is NOT a Machine, and I am NOT a Mechanic

Posted by Boston Sports Medicine and Performance Group on Wed, Sep 25, 2013 @ 07:09 AM

 

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Your Body is Not a Machine, and I am Not a Mechanic.

(And we clinicians do not “fix” you.)

 

And if I could make the title longer: I do not treat with a “toolbox.” In fact, I’m nearly incompetent with anything more complex than a screwdriver and an Ikea desk, never mind the human body.

 

This idea came to me after a recent exchange with a patient. I had been treating her for about a month and she was frustrated with her continued struggle dealing with her back pain. Feeling debilitated she lamented that she didn’t think she would ever get better, and that she was completely crippled by her symptoms. She told me she couldn’t sleep, sit, or exercise without thinking about her back, and she didn’t understand why she wasn’t fixed and why no one knew “what’s wrong with her” (my quotations). In an email to her, I wrote the following:

 

“Your back will get better if you let it.  Which means listening to it. Not pushing into pain, or getting yourself worked up, but finding things that are calming, and nourishing for your back. Like gentle swimming, variable movements, deep breathing. When it hurts, its a call to action to change whatever you're doing. When what you're doing feels good, its a call to action to do it more. You are in charge of yourself...not me, not an MRI machine, not an MD. Commit to this and see it through!”

 

She seemed to respond positively to this sense of empowerment I was trying to instill, and although it took a month for me to get there, I realized that I needed to start incorporating this language Day 1 of my patient interaction. Too often I get a sense of dependence from my patients. Dependence upon myself, their doctor, their surgeon, their radiograph, etc.  instead of an ownership of their wellbeing. And looking back, I realize that I am probably guilty of fostering this exact dependence that I am trying to get rid of! How many times have I told someone “you need x, and you need to come here 2-3 times a week”. Patients come to us with expectations, and we feel obligated to meet them. Just like when I bring my car to the mechanic, I want to know the problem (diagnosis), solution (treatment), and cost (prognosis), and so do my patients. So we create different assessments and objective measures to figure out the problem and then manual interventions and exercises to “fix it.” But it perpetuates a belief that their body is made up of parts, instead of a whole complex system. And that if we can fix the part, we can fix the system.  But shouldn’t it be the other way around?

 

As my own brain continues change, I have begun focusing my efforts on changing other’s. Movement and pain are both centrally driven, and so we must always start there. And yes, we are purported to be movement experts, so it makes sense to have a strong foundation in motor control. It does seem odd however, that we don’t strive to be known as pain experts as well, since that’s usually what brings people to us in the first place. Adriaan Louw posed a great question at the last BSMPG conference. He asked: Why do people come see us in pain, and leave as experts in biomechanics?  Shouldn’t education, reduction of threat and locus of control be given to the patient during the first evaluation? Perhaps if we placed higher value on these things, we would be less enamored with building up our own toolbox, and focus instead on building one for our patients.

 

 

Chris Joyce is a curiously skeptical physical therapist working in an outpatient clinic in Boston. He can be reached at cjoyce@sportsandpt.com 

 

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Are you doing what you think you are doing?

Posted by Boston Sports Medicine and Performance Group on Tue, Jun 11, 2013 @ 07:06 AM

As the world of physical medicine continues to forge ahead with evidence breakthroughs and paradigm shifts there appears to emerge 3 distinct bodies of clinicians/researchers whom all make very compelling cases why their methodologies are superior for treating patients in pain. Appropriately, a cornerstone of each model is exercise, or better yet, movement.  The three ideas:

 

Biomechanical Model: There is a correct, and incorrect way to move based off of ideal joint alignment and muscle synergies, and once deviations occur improper stresses are placed on nerves, muscles, ligaments and joints, which then cause pain.  For the most part, pain is fixed by improving a person’s strength and/or mobility and taking pressure off of said structures.  Treatment is guided by evidence using mostly biomechanical assessments and EMG studies to target specific muscles.

 


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Neuromuscular Model: There is a correct and incorrect way to move governed by the central nervous system. Motor patterns developed during childhood represent movement in it’s most natural state and thus are our entryway into restoring proper function of our neuromuscular system. Emphasis is placed upon motor control, proper muscle timing and activation or deactivation of certain muscles.  Believes that pain is caused by improper stresses on joints, muscles, nerves and ligaments, but also recognizes the connection between movement and pain in the brain, and changing a person’s movement will change their pain. Treatment utilizes different techniques aimed at restoring proper motor function, with principles grounded in evidence.

                        

 

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Pain Model: There is no perfect way of movement, but rather all movement is good in variability and moderation, and lack of movement is bad. Movement mechanics are largely a construct of westernized medicine and have little relevance to actual pain past the initial insult.  Recognizes that improper stresses on joints, muscles, nerves and ligaments cause acute pain, but that pain is always an output from the brain and thus all treatment must be focused on the neuroplasticity of the brain.  Changing the brain’s perception of movement will change their pain, and changing a patient’s perception of pain, will change their brain.  Treatment is focused on patient education, patient ownership, and the neural tissues of the body.

 

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Why Rehab Works:

 

My goal is not to push people to subscribe one school of thought since it is likely that they all have their place, but rather to introduce the idea that perhaps when you’re prescribing exercise, it may be working for other reasons than you believe. For example:

 

Breathing

I won’t get into the importance about assessing your patient’s respiratory pattern-there’s an overflow of information coming out on this. But here is why breathing works in all three models:

 

Biomechanical: When properly done full exhalation engages the obliques and pulls the ribcage down into the transverse plane, optimizing its position for respiration and stabilization. According to McGill peak stabilization of the abdominal cavity occurs not at full inhalation, but in the first part of exhalation, or during the weird grunting noise you hear people make as they flirt between squeezing out that last rep or having an aneurysm. It is here that muscles responsible for stabilization of the lower back are working synergistically to prevent shear forces on discs and spinal nerves. 

 

 

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Neuromuscular: One of baby’s first skeletal muscles to ever contract post-partum is the diaphragm. Restoring proper breathing is the very first step in reprogramming motor patterns.  Piggybacking the biomechanical model, it is imperative in stabilizing the spine, which becomes the building block for the neurodevelopment of the child. As the child moves through positions in supine, then rolling, then prone etc…the spine stabilizes first in each position before coordinated extremity movements occur. Thus by placing patients into developmental positions and cuing breathing and stabilization, we are bringing motor control back to its most primitive patterns and improving neuromuscular control

 

Pain: Push play on any meditation series and the very first thing the calm soothing voice whispers to you is to draw attention to your breath. 1) it takes your mind off of anything else you may be thinking of (pain!) and 2) slow deep breaths shift your nervous system from sympathetic to parasympathetic, and we all need some of that.  There is a strong positive correlation between anxiety, stress and pain.  If we can decrease a patient’s stress, we can decrease their pain. One of the primary methods used with patients in chronic pain is meditation, and the breath is once again the foundation.    

 

Hip Hinges

 

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Biomechanical Model: Improving hip mobility will decrease lumbar mobility, and thus improve lumbar stability. If we move more with our hips, we move less with our back and avoid unnecessary forces on discs, nerves, muscles and tissues. Hip hinging drives glute activation, decreases lumbar flexion, and improve hip flexion. The joint by joint approach suggests a mobile hip and a stabile lumbar spine is the anatomical function of the lumbopelvic complex.

 

Neuromuscular Model: Have you ever looked at someone’s back and seen two guy-wires running down the sides of their spine, as if they were about to deadlift a car. Only problem is they are just standing.  

 

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(Tone much?)

 

This display of hypertonicity is an indication that there is insufficient activation of the deep stabilizers, and over activation of the global muscles. Likely caused by repetition of movements without proper stabilization, the key to restoring appropriate muscle synergy is to look into motor patterns that are incorrectly recruiting the erectors instead of deep spinal stabilizers. Instructing the patient how to move with their hips as opposed to the lower back avoids perpetuating this faulty motor control, and thus decreases erector activation.

 

Pain Model: Remember this guy?

 

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Well it appears that he plays a major role in pain patterns, especially in those with chronic pain. Living in the sensory and motor cortices the homunculus is a representation of human body in the brain. Areas of the body with greater fine movement and sensation have larger real estate in the brain, such as the thumb and the mouth. In the presence of back pain, the back’s representation can grow and which causes unassociated movements to become lumped in with back pain. Movement therapy focused on painless specific movements will better define the cortical borders of one body part from another, and may help dissociate hip movement from back movement and therefore back pain.

 

There are plenty more examples that would elucidate the concept that exercise/movement “works” on various levels.

 

Bird Dogs:

Biomechanical: Core stabilization training

Neuromuscular: Crawling pattern for baby

Pain: Movement variability is key to changing pain neurotags, and how often during the day do you get down on your hands and knees and crawl like a baby??

 

Squats:

Biomechanical: Bigtime strength and mobility exercise

Neuromuscular: A major neurodevelopmental milestone

Pain: Lots of LE movement mapping

 

So next time you prescribe an exercise think to yourself: Am I doing what I think I’m doing?

 

Chris Joyce is a physical therapist at a sports orthopedic clinic in Boston. He’s currently completing a Sports Residency at Northeastern University, and can be reached at cjoyce@sportsandpt.com.

 

 

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Reflections of a PT: Year one out in the real world.

Posted by Boston Sports Medicine and Performance Group on Thu, Mar 7, 2013 @ 07:03 AM

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by Chris Joyce, DPT

 

Fresh out of school eager to cure everyone and be the best goshdarn PT I can. Ditched the nametag (finally!), and traded in my bookbag for a manbag, my meal plan for a lunchbox, and my MBTA card for a fresh set of wheels. One year later here is what I’ve learned:

 

1) I don’t know anything.

Kidding.  I know some stuff. What I don’t know is whether it’s right or wrong.  The people I learn it from believe it’s right, and my patient’s believe it’s right.  And believe it or not, for some strange reason it usually works. In the back of my mind though, I know the level of uncertainty that exists in physical medicine, and I’m okay with it. It feels good to come clean.  I will continue learning and figuring out. The coursework ended in 2011, but the education will never cease. The more I learn, the more I don’t know.

 

2) Reassessment is kind of important.

In school everything made sense. You evaluate, come up with your correct diagnosis, sneak back to your notes real quick to make sure you’re right, and then follow treatment plan x for diagnosis y.  Unfortunately, arriving at diagnosis y is a lot more complex than a couple powerpoint slides and a 2 hour lab.  Which is what makes assessment, or should I say reassessment, so great. I don’t have to diagnose (except red flags). I keep it simple. You have pain when you do this. Let me try this and that, reassess and see if it worked.  I stopped trying to tell patients “you have y” because the fact is, there’s a lot more going on than just the structures that are involved. I call knee pain, knee pain and try to avoid diagnostic labels choosing instead to focus on the goal at hand: moving without pain. Which brings me to my next

 

3) Pain is a sonofagun. And if you’re not learning about it, you’re not treating it.

Pain neuroscience has made leaps and bounds in the past 10-15 years, but I’m not sure why it isn’t a bigger part of formal education. Very often I need to reassure patients that the information they got from other practitioners, the web, their friends/family, is just outdated. Pain comes from the brain, it doesn’t come from your IT band, or your crappy posture. It originally began because of an aberrant movement, or even a lack of movement, and persists because your brain is trying to tell you that you need to do something different. It’s a warning signal, not a pathology gauge.  It doesn’t tell you how much is wrong, but just that something might be. By reading up on pain neurophysiology I’m much better off treating and educating my patients.

 

4) Variety truly is the spice of life

What do the following have in common: pain, exercise, professional development, diet, clinical care, and personal life? They all worsen in the absence of diversity. When we lack variety pain will persist, workouts become tedious, education seems boring, nutrition declines, clinical care falls routine and we end up just “going through the motions.”  The more non-PT related stuff I read, the more I see how intertwined everything truly is. Too much of one thing, no matter how good it is, impedes growth somewhere else and at worst it perpetuates the dysfunction (talking to you long distance runners).  Take it from a guy who grew up in Boston, went to school in Boston and works in Boston.   

 

Chris Joyce is a physical therapist at a sports orthopedic clinic in Boston. He’s currently completing a Sports Residency at Northeastern University, and can be reached at cjoyce@sportsandpt.com.

 

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