Welcome back to the Healing Pain Podcast with Dr. Greg Lehman
If you followed the podcast for the last couple of months, you probably heard a lot about the brain, about the nervous system, about alarms in your head, about pain psychology, your thoughts, and your emotions. At this point you’re probably thinking, “Dr. Joe, what about exercise? Where does that fit in? Where does movement fit in? What about all the information around biomechanics?” Here today to help us reconcile biomechanics into modern day pain science is Dr. Greg Lehman. He is a chiropractor and a physical therapist who has worked in clinical practice as well as conducted research in the field of biomechanics. He now integrates a biopsychosocial model aligned with a biomechanical model.
Reconciling Pain Science With Biomechanics with Dr. Greg Lehman
Dr. Lehman, welcome to the Healing Pain Podcast.
Thanks for having me.
Looking over your bio, it’s pretty interesting because I see you’ve got some cool initials after your name: DC as well as PT. A good place to start is to just tell us your journey on how you came to two degrees that are pivotal in the pain science and obviously the pain world.
I did an undergrad in Canada in Kinesiology, mainly Exercise Physiology and Exercise Biomechanics. I was really lucky to get a scholarship to do a Master’s. I thought I wanted to do chiropractic right away but I still had doubts at the time so I did a Master’s with Stuart McGill in Waterloo just right down the road for me on the Exercise Biomechanics and on the neurophysiology of manual therapy or spine manipulation. I was really lucky at that time as there were two chiropractors who were doing their PhD and they really, and same as you, exposed me to a lot of the myths and a different way to think of manual therapy and exercise and pain. I was introduced to the biopsychosocial model really young. I wrote a paper in 1998 in an ergonomics class supposed to be on how to hold the drill to decrease wrist pain. I was writing about phantom limbs and about central sensitization for an ergonomics class. I was into that stuff from the start. Then I went into chiro school, which in Canada was very evidence-based, very critical, very much trying to understand the biopsychosocial. It’s certainly hard. I don’t know if we had the skills then. I was in practice for five years and researching at the same time. Then I went back to physiotherapy school just to give me more options.
Between the chiropractic training and the physical therapy training, did you find that one included more of biomechanics or one included more of biopsychosocial? Or really were they just both starting to blend at that time?
Both didn’t include enough psychosocial, that’s for sure. The chiro did a better job of the biomechanics just because it was twice as long. Probably two years of that was too much, you didn’t need it. They’re both good training but I found the chiro in Canada more critically thinking-based. That always surprises people.
The PT school in Canada is still two years long, right?
Just two. It was excellent because they just pared it down to what you needed to learn. For chiro, I always describe it’s like learning the map of a city plus the subway system and everything underneath. You don’t really need to know all that. Where physio, they did a good job in saying, “What do we really want our students to learn? Let’s make sure they learn that.” Chiro was more, “I’m going to beat the hell out of you for four years.”
In your clinical practice today, when you’re working with a patient, how do you begin to talk about the biomechanics as well as, let’s say, someone’s emotions? Obviously, we know that someone’s emotions have an impact on their pain, both their intensity and duration. How do you begin to weave that into your practice?
You often let the patient tell you. That’s the point of open-ended questions. I’m not going to generally talk about emotions and their influence on pain if it doesn’t sound like that’s one of the factors. Open-ended questions like, “When do you find your pain is worse? What’s going on in your life?” They might stay in the biomechanical world but often they’ll bring up the other factors. Or, “What’s different? Are there any new or unmanageable stressors?” If I’m working with athletes, they might say, “What do you mean? My running?” I’d say, “Yeah, it could be your running but what’s work like, how’s your sleep?” I start with very non-threatening questions. Sleep and stress: people get an idea that those things influence everything in their life. That opens the door to maybe asking little more personal questions about the emotions and psychology and anxiety and depression and that. I don’t always do it because some things are simple, like it could be a sprained ankle. Some things are just a little crick in the neck and it’s going to go away. I don’t always need to get into those things. It always depends on the patient.
Talking about manual therapy, because as physical therapists, as chiropractors, manual therapy is one of our key treatment approaches. What are some of the pitfalls that a new therapist might fall into as they start to use manual therapy in practice without thinking about the biopsychosocial approach at the same time?
I probably do a lot less manual therapy now than I did when I was a chiro student. The biggest thing is you get worried that if you have a patient who is paying for two years, they’ve probably already seen physios and chiros and done lots of manual therapy. If you think, “I’m going to be the one to do the right manual therapy technique. I’m going to find the right thing to fix,” because that’s what you always do, I don’t think you’re going to be successful. I was never arrogant enough to think, “My hands-on skills are going to be better than all the people down the street.” If that’s the only thing that you have to offer people, then you’re going to be a little bit limited. That’s the issue with manual therapy. If someone’s in pain for a while and you’re delivering manual therapy and you deliver it in such a way where you’re saying, “These are the things that are wrong with you, I’m the one that can fix them,” I’m not saying everyone does this, but you could be setting someone to feel like they’re reliant on you for a fix.
I prefer to do manual therapy. This was my thesis, so it’s more of it’s just a desensitizer. It’s okay to have something that feels good in and of itself. It’s bolstered with exercise and explaining what’s going on. I don’t mind manual therapy like that. There’s value in having a little bit of pain relief for a few days certainly with the things that are less severe and risky for disability, that’s fine. It’s like ice. I don’t think ice ever healed anyone in the long-term. But if you feel better that day having a little bit of ice on your knee and it lets you do a lot of other things, then it’s fine, as long as that ice doesn’t get in the way of your ultimate recovery.
Especially new therapists, when they start looking for manual therapy courses, at times there can be a marketing component to certain education courses where this one technique or this one fix is better than others and it’s going to be the one thing that will improve your practice or improve your skills or improve your patient outcome. Clinician perception as well as eventually the exact carryover to what you’re telling your patient, like you said, they become connected to you almost that they need you to heal.
That’s the issue. We should be partners with our patients. That’s the idea there. Education often sell it by making therapists feel stupid like they don’t know something and they make the techniques seem very esoteric and you have to come take it in the multiple levels and if you’re not, you’re a bad therapist and you don’t care about people. I have a real issue with selling like that. The same people would do the same thing with their patients. “You have to get this treatment. If you’re not, you don’t really care about getting better and you’re not committed.” They put the blame on the patient. That’s the whole classic chiropractic model, “No wonder you didn’t get better with our treatment, I told you to come in three times a week for twelve years. It’s your fault because you missed that one in April when you’re off at someone’s wedding.”
A lot of PTs tell people their pelvis is obsolete, “If you come once a month, we can maintain it so that it doesn’t go out of place.”
Horrible pernicious thoughts.
Shifting from the manual therapy towards the biomechanics. When we start talking to people about exercise, about how their mechanics may be related to their pain, where do physios get into a little bit of a sticky situation? We have a big background in biomechanics. It’s a large foundation of what we do.
To me, when I hear biomechanics, what I’m hearing is that it’s called the kinesiopathological model; meaning someone’s structure or their posture is in the wrong position. They don’t move the way an ideal way to move, like the knees might cave in. The way I see physiobiomechanics is this idea that there’s an ideal way to move, there’s an ideal way to stand, there’s an ideal posture to have. Any deviations from that posture are going to cause people to have pain. That’s something that I consistently rail against. I’m not too concerned if people bend forward and their spine flexes. I’m not worried if they lean over to the side and they’re asymmetrical. I’m not worried if their knees cave in a little bit when they walk. There might be cases when those mechanics are related to injuries, but those instances are fewer than we often think. That’s my big issue with biomechanics. It’s important and we should find out when it’s important instead of having blanket statements.
Some of those blanket statements such as if you pronate when you run, that you’re going to get tendinitis or Patellofemoral Syndrome, let’s say.
That would be a good one. The research is pretty weak on that and it’s not that strong. What you see is a massive variability across people where you can pronate and you can have no pain and you can run 100 miles a week. It’s not that big of a risk factor. It’s actually quite hard to change. That’s what’s interesting as well. Sometimes, the treatment that’s trying to change it, like an orthotic, can be helpful but then it doesn’t even change the pronation but it’s still a helpful tool. People think, “That’s why pronation is so important, we just fixed it,” even though we didn’t. Something else was going on there. We have to look for reasons to bolts our explanations that even if it’s not supported.
It reminds me when I first started practice in 1996. New Balance had the anti-pronation shoe and every patient had the sneaker, whether they were pronators or not because they wanted to prevent pronation from happening, but obviously these are normal motions that your body goes through. Some people pronate a little bit more than other people do just naturally.
It’s such an inconsistent risk factor.
What’s interesting about your work is obviously it speaks well to physios and chiropractors and other biomechanical clinicians. I’ve worked with a lot of Pilates instructors and yoga instructors where they don’t necessarily have the basic science background and they don’t necessarily have the physiology, but they’re being taught things that are being handed down through a method decade by decade. How do you begin to talk to those types of professionals? They’re in between almost. They’re not the layperson and they’re working with people every day. They’re not evaluating them but they really are talking to them about their pain and their function.
I did this a long time ago when I was very biomechanically driven. We can be too hard on them and throw them under the bus. They do a lot of good, yoga and Pilates instructors. I’ve had a lot of yoga and Pilates instructors take my course. I often try to get them talking because I think they have a lot of strategies that can be helpful. They can be fluid in their philosophy behind what they’re doing. They’ll have good skills on getting people moving again, moving differently, moving in a way that doesn’t hurt, moving in a way where maybe they’re bracing and they’re tense and that relates with pain and they teach them differently. There are a lot of good skills in there but they just might have a different philosophy of why someone hurts. Just subtle tweaks. If I work with them, it’s saying to them, “You don’t have to throw out the vast majority of the things that you do. There are just a few subtle tweaks in here that might be a little bit more consistent with our evolving understanding of why people hurt.” That’s less daunting than saying, “You suck.” That’s all wrong. That would be totally unfair. You have to help people allow that they’re still utility in what they do.
I know one of the courses you have is a course on running injuries, how to help people integrate some of the biomechanics with the biopsychosocial. What are some of the ways, especially about aging athletes, about athletes that are getting older and they have ideas and beliefs about their physical body, how they function, how long it should last, how long they can even do particular sports, how do we begin to communicate with athletes? Maybe we should talk about the older athlete in a way that’s not potentially harmful for them and their belief system.
This would be all athletes but certainly older athletes. Runners think that pain means they have to stop, pain means that there’s something wrong and there’s something damaged. We need to normalize the idea that pain can be present and that’s part of being human and that’s healthy. If you’re training hard and you have a race coming up and it’s the highest volume and intensity you’ve ever done, it’s not weird to get up in the morning and your ankles to be a little bit stiff. That’s not a problem. It’s not weird to start a run and have really excruciating knee pain for five to ten minutes. Then you actually find out, you think about it, reflect and run a little differently and keep running and it goes away. We have to normalize pain sometimes, is the idea. You can keep running and that’s what you should be doing. That’s the only way you’re going to stimulate your body and your nervous system and immune system to adapt and to just be better in the future. We’re biological systems and it responds to stress positively. We’re not bridges and structures that fall apart with load. That to me is the shift.
Talk about the concept of relating to stress in a positive way versus thinking of activities that may break the body down. What does that mean to the average patient, because we have patients and practitioners who listen to the podcast? When you talk about reacting to stress positively, what image comes to you about the human body?
Not just the human body, it’s just humans. I like the expression, I don’t know where it’s from, maybe it’s Stephen Covey or something, “If you want to get something done, you give it to a busy person.” This is the idea that we are able to adapt and build up our tolerance and habituate to more and more stress. There are times when there is too much load or stress on us, we have to back off. With the athlete, it’s not just looking at the mechanical stressors in their life but all of the other stressors and seeing how well you’re managing that. Maybe those other stressors, like not sleeping well, stress at work, stress with your kids or any emotional flare-ups that are going on, these are other things you want to look at; not just blaming and getting down on your body and thinking that you’re falling apart. If you think you’re falling apart, the point of pain is to protect you and help you out. If you think you’re fragile and frail, it makes sense that you and your body and your brain would produce pain to help out that belief system, “You better stop. Here’s some pain, take it easy.” It’s self-fulfilling, so we have to change our view of our body and how we respond to load.
I like the word fragile. I haven’t heard so many people say that. People use the word harm a lot. Fragile is a very different word. It gives someone the sense that they can hurt themselves or something can be broken, so to speak. That’s a fantastic word. You also talk about being robust often. One of your goals is to help people to re-confront their thoughts and emotions or their beliefs about how they can be more robust in their life and in their health. Can you talk about that a little bit?
Robustness to me is just tolerance. It means you’re going to have things that try to knock you down and you can cope with them. When you have persistent pain and when you get out of that and you’re recovered, you’re still going to have flare-ups. The definition of stability means there’s a perturbation, you get knocked and you should come back to your original resting state. Robustness means you can tolerate more and more perturbations to your life and come back to that resting state. That’s a stable system. A more robust system means you can tolerate more stressors. That’s what we’re trying to build. That’s the idea of resiliency; the robustness and resiliency. We can’t avoid all of the stressors in our life. That’s what we do when something’s fragile. We put the stamp on the outside of the box, “Fragile. Handle with care.” Instead we should be saying, “You’re not fragile. You don’t have to handle with care. You need to stress it to make it more robust and adaptable and tolerant.” That’s the cool thing. We’re not eggs. I don’t think an eggshell responds to load; that you don’t want to drop. You can drop babies and they can tolerate it. We never freak out when our kids fall. They’re like, “I’m okay.”
Obviously, we know that exercise helps us build resilience back up, to build that immune system back up, to build the things that we need. Does manual therapy do the same things for people?
I don’t know. That’s a huge debate. One of the ways exercises work is mechanotransduction. If you stress tissue, like a tendon, it’s going to get thicker and stiffer and you can put more load on it. That’s mechanotransduction. Some of the theories out there, and I used to say this, is maybe if you rub and put pressure on a tissue with your hands it’ll make it more mechanically robust via mechanotransduction. I don’t know if that’s how we work. That’s just a theory out there. I’m not sure there’s much research. It’s just an idea out there. If load from your hands delivered to tissue can make it adapt via mechanotransduction possibly, but I’m not sure it can in other ways.
How I like to spin manual therapy is you do a short symptom modifier with your hand. If someone lifts their arm up and you put stress to their scapula with your hands or pull their tissue or press somewhere and it feels dramatically better, then you say, “I’m hardly changing anything. I’m just moving it slightly differently here. There’s no way I healed your rotator cuff with that and you felt dramatically better.” That might change the patient’s view point of their body and their opinion of their pain. There might be something there with changing their resilience or their robustness. But it’s a cognitive effect rather than a physical one.
Obviously, you’d have to have your whole body treated multiple times probably throughout the week to get that kind of benefit that you’re talking about.
Some people advocate that. I always say to them, “Go ahead and rub your biceps and make them hypertrophy.” You want to do twenty minutes of bicep rubbing so you can get to the beach in three months. It just doesn’t seem plausible to me.
Continuing along the manual therapy, do you typically work with people in a way that’s softer and gentler and increase the force over time, or is it something that you take on a case by case basis? There are a lot of people that have different approaches to how manual therapy should be applied. If you have chronic pain, let’s say you have fibromyalgia, that you want to start really soft and gentle first and progress, or people should be able to adapt relatively fast.
I’m gentle probably all the time now and, certainly with someone with fibromyalgia. I’m not sure I would really do any manual therapy on someone with fibromyalgia. I’d advocate they get a massage but just as an end in itself, that it’s okay to be touched and say, “This feels good and I like that.” It’s less about fixing. I’m not sure I would do too much manual therapy with any central sensitization or something like that. I would tend to use it in a short-term flare-up of back pain when it stays local and they’ve responded in the past to manipulation. It’s pretty harmless. They have healthy beliefs about their back and there are not a lot of other issues going on.
The question that someone with fibromyalgia would want to ask you right now is, why would you not use manual therapy regularly as part of the treatment plan?
For me, I would rather work on other things. That would be it. I don’t think it’s harmful and I know therapists that do gentle manual therapy work and it fits with their style. It’s just probably not my style. I’d rather work on exercise and their beliefs and what they know about pain and goal setting and pacing and all of that stuff. It’s just a finite amount of time. I would certainly never vilify a therapist that did it. I just don’t think it’s my style.
Exercise-wise, is there a certain approach that in your practice you’re going toward? Are you going toward more something that’s, shall I use the word more functional-based or are there different types of therapeutic exercises that you tend to use more than others?
Again, it depends on what’s going on. I really do believe in heavy load for some things. Sometimes a tissue does need a specific load to make it adapt; like a muscle tear or a tendinopathy, that needs specific load. I tried to treat comprehensively because I can never be sure why it happened. I can never be sure what the factors are. I treat locally and at a distance. If it’s a hamstring tear, I treat the hamstring and the gluts and the back and the hip and the knees and the ankles. I’d load everything. For someone who it’s just exercise more as a general pain relieving or to get them moving again or that’s what they want to do, the exercises I choose are not that specific, it’s up to them. I find that the exercise they want to do and we slowly work to doing them. In that case, it doesn’t really matter what we do as long as it’s something that they’ll do. They want to do Pilates, let’s do Pilates. “What’s your goal? You want to do yoga? Okay.” I had someone in a few months ago and she wanted to do hand stands. I’m like, “All right. This is the loading protocol to get you to tolerate hand stands again. There we go.”
Can you tell everyone where they can find you and some of the great things you have going on?
I’m in Toronto, Canada. My website’s GregLehman.ca. I’m on Twitter @GregLehman and all that stuff. My pain workbook which seems to be well-received is on the website too. I’m a therapist all around, I travel a lot. I’m somewhere.
I want to thank Dr. Greg Lehman for being on the Healing Pain Podcast this week. Make sure to check out his website. He has a great book there you can download for free about how to reconcile biomechanics and everything else around the biopsychosocial aspect of pain. Stay tuned each week and make sure to share this with your friends and family. I’ll see you next week on the Healing Pain Podcast.
About Dr. Greg Lehman
I have been in clinical practice for more than 13 years as both a chiropractor and physiotherapist. Previously and concomitantly I held faculty and research positions conducting biomechanical research into the mechanisms of manual therapy, muscle activation during rehabilitation exercises and sports medicine publishing more than 20 papers in peer reviewed journals. I have lectured at numerous global conferences on biomechanics and the biopsychosocial model, giving more than 6 keynote talks within the past year. I have developed a two day seminar which helps clinicians incorporate best evidence into clinical practice and helps them develop skills to practice in a manner consistent with the biopsychosocial model of care. This course has been taught more than 40 times on 4 different continents.
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