The realm of pain and patient care is a very diverse landscape. Physical medicine and rehabilitation science have progressed to the extent in which we can take some blood, isolate all the stuff that helps you heal faster and then just inject all of those healing bits at a higher density. We can 3D print-grafts and joints; we’ve got lasers and sound waves and hot tubs and cryo chambers.
We have expensive gizmos and specialized clinics and entire rehabilitation teams all at beck and call for the purpose of healing injuries and relieving pain. But that stuff is for athletes. We aren’t athletes; so we don’t really have easy (if any) access to the coolest of the cool stuff.
They get the best care and we don’t get access to real, existing technologies. All because of money. It doesn’t seem fair, does it? Its a shame.
But, I mean… Is it though? You aren’t an elite athlete and admitting that fact is not an insult. But I don’t want to be misunderstood; I don’t want you to think this is a sardonic post about ego checks. Its not and in order to keep my point clear I’m just going to dive right into this one.
I believe that treating every patient as if they are an elite athlete can lead to worse outcomes for pain and function. There, I came out with it. No jabs, no sarcasm, no insults. See?
So let’s all start by taking a gander at the big ol’ elephant in our training room. Classically this idea of an “athletic” approach to pain therapy usually relies on an examination which assesses the “quality” of specific movements and general posture. The problem with this is that movement quality turns out to be just a small but perhaps even irrelevant consideration to the pain relief process.
In other words the “bad” movement or posture remains as a constant, unchanged even after the pain is gone. The “wrong” scapular movement wasn’t fixed. The patient is still “asymmetrical” in one way or another. The gluteal muscles still fire in the wrong “sequence.” None of these things change. At all. But, then again, does it even matter if the pain is gone anyway?
Tell me why, old man, we have to get off your lawn? ...
The problem with this is that if you tell someone that their pain depends on altering some unalterable “thing” then the perceived ‘problem’ is never solved. Even if the pain and disability are both technically gone! Remember that pain is simply behavior modification away from the “less safe” choice. Well this diagnostic approach sets up a way of life that can never feel “safe.”
Plus, let’s take an example of 62 year old Betty who likes to swim laps at the local Y. One day she gets herself into an acute situation with some stress, consequently poor sleep, impaired recovery, and as a result, too high of an exercise volume. She decides to see a professional and is told “your shoulder is all goofy or whatever.” Now this tends to go hand in hand with some weird kind of ‘movement audit’ where the care provider is listening, ears perked, for some kind of “errant” movement he or she can pounce on.
“Swimming!!! Granny mentioned swimming!” So they’ll have her reach for the ceiling and when she inevitably proves unable to put them straight up and into the air the “diagnosis” is revealed. Betty has “tight lats” from swimming without doing her mobility work.
And just like that, activity that once kept an older woman healthy and active has just been labeled as somehow bad or at the very least incompatible with a pain-free lifestyle. Its simply unnecessary. If someone is going to take someone away from you they better be damn sure that it is actually related and that there is no way to help you if you keep doing it.
And I am not trying to set up a straw-man here. I understand that the goal is to enhance Betty’s ability to swim. It’s to get her swimming in a way that will make her feel even better than before. Hell, maybe the therapist didn’t even tell Betty to stop swimming. But the message was sent all the same. An idea was implanted. The therapist has unknowingly created a little grey cloud over the thing that Betty loves to do.
Remember that when it comes to pain relief enjoyability is the only important variable. The key question is “do you dig it?” If the answer is yes then you’ve found the most appropriate “exercise.” But now, because of this biomechanical deep dive Betty has a reason to be anxious about swimming. Like a lactose intolerant ice cream man, Betty may love it but it just doesn’t love her back.
In the effort to avoid the straw-man argument let’s even take it a step further. Let’s think about a young, healthy 20 year old who “enjoys” playing soccer. He didn’t really have an immediate answer to the question of “what’s your sport.” He had to think about it. Soccer is fun…. That’s it. Its just fun.
This time let’s take a pain presentation that is more mysterious, more persistent and harder to treat. He presents with patellofemoral pain syndrome. The thing about patellofemoral pain syndrome is that its really just a medical term for “I don’t know why you have pain and I don’t know how to make it go away.” Unlike lower back pain it isn’t self limiting. Its not just going to go away on its own. However, just like lower back pain it doesn’t show any association with altered biomechanics or postural presentations. The way to helpfully impact patellofemoral pain syndrome seems to be to load it gradually and appropriately so that we decrease the sensitivity and increase the knee’s ability to support impact and bodyweight.
But let’s now inject, into this treatment plan, an ideal concept of biomechanical functioning and the effort to ‘correct foot posture” or stretching the hamstrings. These simply aren’t the interventions that this guy needs. He’s just never going to realize the benefit from any of this biomechanical work. We’re installing computer parts that are so optimized that they aren’t compatible with the motherboard. We’re putting an engine into a car that is just too powerful for the transmission. This is exactly what we are doing when we try to train Johnny, the realtor who “sort of enjoys soccer” by instilling highly scrutinized, highly specific movement patterns.
Ultimately, taking the high detail microscope to the biomechanical habits and postural presentation of every patient that walks through the door simply doesn’t yield any better care. But is there any situation where the biomechanical ‘white glove test’ is helpful? We’re going to get into that in Part 2