Therapeutic analogies

Analogies are a great tool to explain a difficult, complex, or unfamiliar topics.  Much of what we try to communicate to our patients took years of foundational education, scientific inquiry, and clinical training.  Somehow we’re supposed to relay all this information to a patient within a short visit, and we’re attempting to do so with varying levels of background knowledge.  In short, clinical communication is a challenge, and something I’m always trying to improve.  Quality communication improves efficiency and outcomes.  Poor communication creates confusion, nocebo effect, and fosters disability and dependency (see last paragraph, but read the whole post).

I will try to remember to share more of the analogies I use, in hopes others will post theirs as well.  All analogies inherently have flaws, but if we can communicate concepts quickly and efficiently our patients and athlete’s will benefit.

Today’s therapeutic analogy:

“Your leg is the scoreboard and your back is the crowd noise.  We need to stay focused on the score, as this is a game we can win.”

After this analogy, the patient’s facial expression revealed immediate comprehension and understanding.  The path to victory was clear.  Other times I’ve spent longer than I care to admit struggling to communicate this idea.

Trying to explain centralization phenomenon to a patient can be a challenge.  Particularly when local pain gets worse and tinging/numbness in the extremity improves (ex.  back pain intensifies, but leg numbness resolves).  Numerous times patients tell me they can live with the numbness they just need the pain to go away.  Our pain centric ideas often get this one backward.  The extremity symptoms need to be resolved — a concept well taught in MDT (McKenzie) training.

Focus on what is important.

Ignore the distractions.

Premature Celebration

To err is human…

When I look back at my own education and experience I often learned the most from my failures, mistakes, and complete embarrassments.  These struggles drive future success.  In the interest of admitting my mistake and hopefully someone else learning from it… here is my latest folly.

Premature Celebration

Bolt celebrates before the line in the 100m finals in Bejing.

Sometimes you get away with celebrating before the finish line (as Usain Bolt did in the Olympic 100m finals), but on occasion it shows you to be a classic fool.

As an avid sports fan I’ve witnessed others suffer from premature celebration with both excitement and ridicule.  Yesterday it was my turn.

I vividly remember Steve Tasker, (perhaps the greatest special teams player of his era, and perhaps the most impactful non-kicker or returner special teams player ever) chase down Leon Lett at the goal line in Super Bowl XXVII.  As a Buffalo Bills fan, I recall the devastation of the fumble, followed by the elation and finger-pointing  as Leon Lett carelessly celebrated from the 10 yard line to the 1 yard line where he was caught from behind and stripped by Tasker.  Premature Celebration = Failure(There was also the Thanksgiving Day slide for Mr. Lett, but that’s another story)

Again 2008 premature celebration struck. The promising young Philadelphia Eagles star DeSean Jackson catches a deep ball, runs ahead of the defense towards the goal line, and releases the ball in celebration at the 1 yard line, failing to score.  A spectacular 61 yard touch down reception and 6 points, erased by hubris.  I remember shaking my head, chalking this up to a rookie mistake, and hoping for a better future for #10.

In both cases, the excitement of the moment, the palpable sense of accomplishment, and certainty of success clouded judgement and action… resulting in heartbreaking and public failure.  Premature celebration is hazardous to your outcomes.

Yesterday I found out that I was Leon & DeSean, only the camera wasn’t on.  Admitting our own failures is humbling, but it is also where the best learning comes from.

I had a patient/recreational athlete who initial reported with a right shoulder injury, post swimming that had persisted for 10 weeks.  This was a chronic, recurrent problem in a very active adult.  We set out to resolve this and modified but didn’t limit activity level and were successful.  As the shoulder resolved, the patient explained she’d had 8-10 years worth of daily back pain and wondered if that too could improve.  While taking a deeper look we uncovered layer upon layer of dysfunction, compensation, and guarding that had protected her and allowed her to continue life and training for years.  With some guidance, her diligence and determination chipped away at these layers (and her shoulder remained functional and pain free).  We rebuilt her ability to breathe from the ground up, we rebalanced her orchestra of core muscles, we improved freedom at the ball & socket joints, and we challenged these things in progressively higher positions, with endurance, load, and speed.  In the end we had a human who was pain and injury free,  who could feel movements, muscles, and body positions that were previously unknown to her.  She was to attempt self-care and had a discharge exam scheduled  month later where we would see how she was doing.  At that follow up it was clear we had someone who had been training for 4 weeks with no issues doing things that were previously painful and some that were unimaginable.  In short, we started with little, had come a long way, and felt like we were in the end zone; but we weren’t.  At her discharge exam we assessed her progress and then spoke about what came next.  Her movements looked coordinated and strong, functional assessment was relatively clean, and her endurance was beyond good.  There was excitement in the room, there was optimism in our tone and words, and there was a sense that the world could now be conquered.  We spoke about the future, new goals, and further achievements.  We were both proud of her journey.

It took me a day or two to reflect and realize that perhaps the emotion of accomplishment was driving us a bit too far.  I remember a feeling of concern as I reflected, “too much too soon” was my fear.  In my detailed assessment of physical measures (movement, muscle activation/tone, joint ROM, functional abilities, etc) I had failed to realize that this biomechanical model was insufficient.  I was dealing with a human; emotion, psychology, and other psychosocial factors play a role — and in this case an important role.  There are two types of patients; those who need prodding and motivation, and those who need restraint and guidelines.  My patient fell into the later category.  I knew this about her, but failed to address it at her discharge.  My excitement for her and pride in how far we’d come caused me to overlook discussion of graded exposure, pacing, and appropriate advances in training loads.  I sat thinking about this possibility but I didn’t act.

Then it hit me like a ton of bricks.  A week after discharge I was getting an urgent visit call from this patient.  We took the ball to the one yard line, but failed at the last moment.  Our beautiful play had turned into a tragic recurrence.  We will pick up the pieces and try to win the game (as they Eagles did after DeSean’s performance), but this bitter pill will serve as a reminder.  Knowing your patients, understanding their mindset, and preparing them for the future is just as important as assessing their function.


Nocebo strikes again

Once again the nocebo has struck.  If I was a better web programmer, I would have some ominous and sinister background music playing as you read this.  Since I’m a novice, please play something fitting in your head as you read this.

nefariousninjaThe nocebo sneaks up on us like a nefarious ninja.  Quietly the words we hear sneak into our minds.  Scientific sounding, but often misguided labels infect our thoughts, become our fears, and disable us.  Most don’t see it coming and some don’t even know it happened, but before you know it… the damage has been done.

For those who have read this blog before you’ll recall that I have a fascination with the effects of the nocebo.  In short, the nocebo is a negative reaction to harmless stimulus, the opposite of the placebo.  Quite often in healthcare this is the idea that something is wrong.  The thought that we are broken/damaged/unstable/deranged/etc can be disabling.  Thoughts are a powerful thing and some of us are either naive to this fact or are exploiting it for personal gain.

As one of the main ethical obligations for health care providers is to ‘do no harm’ (Primum non nocere).  I will begin by stating I think planting a nocebo is harmful.   If we can agree that ideas and images can be infectious, (the current buzzword  for this is fittingly ‘viral’), then we should acknowledge that we need to carefully monitor how we communicate with our patients and athletes.

I tell this story today due to a recent case I had.  Generalities will be used to protect the innocent (& guilty) parties, but also to make the point that this could happen to just about anyone and all too often does.

Background:  A teenager reports with a chief complaint of unilateral low back pain (L2/3 level) focused an inch or so from mid-line of several weeks duration. No prior back injuries or episodes.  Back pain was of non-traumatic onset.    Intermittent symptoms are reported, but there is pain every day.  Onset is after prolonged activity, such as sitting and moreso with standing.  No extremity symptoms or nerve tension upon testing.  Full pain free ranges of motion at time of exam.

For those using your clinical acumen, you have a picture in your mind of the possibilities.  At first glance to me this appears to fall into the McKenzie classification of postural syndrome.  To put it in other terms, it’s clearly an accumulation of load or lack of endurance phenomenon.  The question is does this person have an underlying movement flaw, a lack of capacity/endurance, or just a bad habit?  What I suspected was an underlying movement/postural flaw that they couldn’t control that when repeated put straws on the camels back until it broke.  As I explained this to the patient, they looked at me as if I said something they couldn’t believe. At first, I wondered why…..

I was butting up against an existing diagnosis as they had seen another health care provider 2 days ago.

Previous diagnosis: scar tissue/adhesion of the disc based on physical exam and x-ray.  The nocebo had been planted (and was growing). If you can make sense of that diagnosis in this case, please explain it to me.  Perhaps I’ve missed something in the literature or in my clinical training.

I now understood why this was scheduled as an urgent visit and the patient thought we were going to be seeing each other frequently and for a long time.  With diligent self-management, I doubt either of these will turn out to be true.

Listen to Yoda.

As doctors, coaches, healthcare providers, or trainers we are seen as leaders to our patients, clients, and athletes.  We must respect this relationship.

Leaders can lead through love or fear.  Fear is a shortcut to loyalty and compliance, but it will always create a half-hearted bond and an oppressive relationship.  Leading from a place of trust, openness and passion requires more of us as healthcare providers, but it can also create loyalty and compliance.  Also when achieved it will foster positivity, drive, and a nurturing relationship where great things, perhaps beyond expectation can happen.  In both chronic pain patients and elite performers, I see this lead to great things.

“Men are driven by two two principal impulses, either by love or by fear.”
― Niccolò Machiavelli, The Discourses


“Since love and fear can hardly exist together, if we must choose between them, it is far safer to be feared than loved”
― Niccolò Machiavelli

Is Machiavelli correct?  Here he notes it’s safer to be feared.  He does not state that it is more productive, better in the long term, or the most ethical way, just that it is safer.

“It is best to be both feared and loved; however, if one cannot be both it is better to be feared than loved.”
― Niccolò Machiavelli, The Prince

Let’s just say, I disagree.  In the terms of healthcare providers, coaches, and fitness trainers the current state of affairs warrants us dropping the fear based, nocebo inducing model.  For an interesting discussion of this and to learn about motivation 2.0, see Drive by Daniel Pink.  The carrot and the stick have changed.

More about the nocebo…

Motivating through fear may work in the short term to get people to do something, but over the long run I believe personal pride is a much greater motivator.  It produces far better results that last for a much longer time.  -John Wooden

How do you lift your weights???

While attending a seminar hosted at Peak Performance in NYC, I was impressed by the high level of training offered by Joe Dowdell and his staff.  [visit Peak Performance on facebook] Even as Joe and his staff joined us in the Functional Assessment seminar, workouts continued in the gym with excellent instruction.  The hallmark of quality training is making an exercise ‘challenging’ while maintaining good form, simply making an exercise ‘hard’ (adding weight, doing it faster, performing more reps or sets) is easy to do, but doesn’t produce quality results.  The ‘hard’ way is the hallmark of lesser trainers.  I was impressed by high caliber and ‘challenging’ exercises I saw while at Peak, and I think the contrast with what I saw next is what made it so apparent.

After watching an exceptional set of plank rolls, the athlete stood up, his trainer went to prepare the next exercise, and I watched the athlete bend into complete lumbar flexion with no hip hinge to pick up his water bottle.  Great form and core control in exercise should translate to the same in everyday activities, it clearly did not here.

I saw a similar episode after watching some well done box jumps.  The exercise was performed with quickness, balance, control of a neutral spine, and stability at the hip evident by no medial collapse at the knee or trendelenburg’s sign at the hip.  Upon completing the set, the trainer began to put the box away and the athlete bent over to retie her shoes.  Something like this:

Note extreme lumbar flexion, failure to hinge at the hip. This is not a spine sparing or load sharing strategy.

I was surprised both times this happened. It was clear to me that the athlete understood proper form from the way they performed the exercise. It was clear the trainer understood quality ‘challenging’ exercise from the standard they set for the athlete.  However, there was no translation into activities of daily living.

After thinking about this, I realized that this happens in my office as well.  I spend time training patients in the hip-hinge, proper lunge mechanics, and other spine-sparing strategies so they can continue functioning without aggravating their condition.  In addition to teaching this I explain disc loading (see chart below) and try to follow the teachings of manual medicine pioneer Karl Lewit, MD, “The first treatment is to teach the patient to avoid what harms them.”  However, on occasion that same patient at the end of their visit reaches down to put on their shoes, pick up there purse, or collect their wallet and cell phone and performs the exact movement we just trained with improper form.  I take the opportunity to remind them, they often have a surprised expression, and together we work to repeat the activity with a more spine sparing strategy.

Are you loading your back unnecessarily?

The challenge for the clinicians and the trainers out there… first recognizing improper movement strategies and training good form; second getting good form incorporated into activities of daily living, work duties, and recreational activities through functional training and repetition.  We need our patients and athletes to understand this connection and then we need to work on repetition to myelinate these quality pathways. That which we wish to do with ease, we must first do with frequency.

  1. Teach correct movement patterns. (choose spine sparing, painless, dysfunctional patterns to correct)
  2. Repeat and groove these patterns.
  3. Make movement patterns more complex and add functional challenges.
  4. Add stability.
  5. Build endurance.
  6. Add speed, power, or stability training.

The common thread here is that it is not what we can do it’s what we actually do that determines injury risk.  Much like Professor Stuart McGill’s critique of FMS or similar screens. A simple but brilliant comment. A great analogy is diet and nutrition.  If someone can demonstrate that they can make a healthy, balance, nutritious meal, but they instead choose to eat fried fast food, what is their health risk?

To be truly effective, an athlete or patient’s ability to perform quality movement in the office and/or gym must translate into proper movements during daily activity.

Liebenson’s Clinical Audit Process (CAP)

Craig Liebenson, DC wrote a landmark text in the world of rehab, Rehabilitation of the Spine, which is now in it’s second edition, parts of what is described below can be found in chapter 32.  In his seminars Dr. Liebenson often describes the Clinical Audit Process (CAP).  I suspect many leave the seminar with an appreciation for how powerful this process is, and some understanding of how it works, but my guess is that they would also benefit from time to sit back, read about it, and appreciate it’s simplicity. This is analogous to people’s initial understanding of McKenzie (MDT).  Those who have a cursory understanding think McKenzie is extension exercises.  Those who possess a sophomoric understanding believe it is about directional preference.  Those who actually understand it realize it’s about patient participation and the audit (test-retest) process and using centralization and peripheralization as markers of progress.

To say the CAP is simple does not mean it’s easy. Liebenson’s CAP is a synthesis of some great concepts, ideas, and techniques that were previously distant and are now bundled into one package and process.  Here is my understanding, a simplified but hopefully complete version for those who it may be new to.  Also there is some dovetail with the work of Gray Cook and the scoring systems of FMS and SFMA systems, for those familiar with those concepts they will be incorporated below.

After taking the Lumbar McKenzie course years ago, I realized the link Dr. Liebenson had often spoke of.  The foundation of the CAP is in McKenzie, only it has been expanded to incorporate functional assessment and corrective exercise, such as the work of the Prague School, as well as to address patients who do not have a clear mechanical sensitivity.  What I value most about the Audit Process is that it can be applied to any technique, any type of treatment, and holds us accountable for our choices.  I am the type of provider who likes to collect tools, I enjoy having a multitude of ways to treat a patient’s condition from soft tissue techniques, ergonomic sparing advice, mobilization or manipulation, stretching, movement pattern training, or stabilization exercise.

Training movement patterns with lunges

The CAP allows any of them to be used and simply directs us to which is most beneficial for the particular patient.  As a clinician, I need to have an assortment of great tools at my disposal and my job is to pick the right one.  I let the Audit Process determine which tool I use, it makes my job simple. (Side note: It is human nature to occasionally fall in love with a particular tool, and while I am guilty of that to some extent, the CAP forces me to reassess what I’m doing and why I’m doing it.)

Side plank exercise for stabilization

Dying Bug exercise on foam roller for combined core stabilization and movement pattern training.

Steps to the Clinical Audit Process:
Steps before the audit process:
A) Rule out Red Flags.

B) Mutual goal setting with the patient.
C) Identify/recognize yellow flags (comorbidities, psychosocial factors, and other complications).
1. Identify the Activity Intolerance (AI).
What activity is bothersome or limited due to the patient’s condition. This often becomes part of the process of mutual goal setting.  Remember to help keep the goal reasonable and attainable.
2. Identify the Mechanical Sensitivity (MS).  What motion or position increases the patient’s symptoms?  For those familiar with FMS scoring this is a 0 score. In SMFA scoring this could be a FP (or DP, but FP is much preferred).  I typically do not want this to just be ‘uncomfortable’ but to truly reproduce the patient’s primary complaint.  In McKenzie this would be ‘increased’ and likely ‘worse’. (In some cases you may not find a clear MS, see below for how to handle this.)
3. Identify Abnormal Motor Control (AMC).  What movement patterns/exercises does the patient have significant flaws in? What movements are they unable to perform? Or perform with unacceptable levels of compensation?  FMS scoring of 1, asymmetries (left right scores that differ), or possibly heavily compensated 2.  SFMA score of DN.  This part of the process is not considered in McKenzie (Mechanical Diagnosis and Treatment) and is one of the brilliant aspects of Liebenson’s CAP.

SFMA movement abbreviations: FN= Functional Non-Painful FP=Functional painful DN= Dysfunctional Non-Painful DP= Dysfunctional Painful

If there is an identifiable MS, we will use that as our benchmark.  If there is not a clear MS, we will use the most pertinent AMC as our benchmark.

Once your bench mark is identified it is time to begin treatment.   Choosing from your clinical toolbox, select a corrective exercise, movement, or treatment you suspect will help clear up your benchmark.  Have thSupported Functional Reache patient perform the activity or provide the treatment you determine and retest the benchmark.  Does it improve?  Does it improve significantly?  When you have made the right selection the benchmark will change readily and rapidly, it should be obvious to you and likely to the patient.  If you did not find this, choose a different tool and try again.  When you’ve found the right tool it will be obvious.  When watching those who have mastered the Audit Process, the greed for change is obvious.  As I started this process any improvement was a good sign to me.  As this process is refined you learn to look for the ‘best’ or ‘biggest’ change.  Find the exercise or treatment that gives you the biggest bang for your buck.

This process can be frustrating and daunting at first.  There are so many treatments that ‘should’ work according to protocol based care, prior experience, or clinical prediction rules.  However, we must remember and respect that each patient and each situation is different.  The Clinical Audit Process forces us to be scientific in our approach where we are continually performing clinical trials where N=1.  Nobel prize winner Rene Dubos said, ‘the measurable drives out the useful‘, do not rely solely on quantitative analysis, be sure to look at the quality of movements.  To put this another way, Bruce Lee would say, “What works in a movie doesn’t work in the street. What works in the street doesn’t work in a movie.”  While it may work in a controlled clinical trial, we need to also be sure it will work in the clinic for this particular patient.

As you become fluent with the process you will find it more and more rewarding to have your choices justified or challenged and debunked.  This process holds your care to the high standard that we all strive to achieve.  Most importantly the CAP reminds us that each patient and each case is unique and we must choose our treatments accordingly, this is truly a patient centered model.

“The CAP allows clinicians to adjudicate within-session what treatments are most efficacious.”, Craig Liebenson, Dynamic Chiropractic Article.  This is important because Hahne et al explains that, within-session reassessment was shown to predict between-session improvement.  If post-treatment audit of the Mechanical Sensitivity (MS) showed improvement those patients were at least 3.5X more likely to have between session improvement. – Hahne A, Keating JL, Wilson S. Australian Journal of Physiotherapy 2004;50:17-23.

To see this in action, make sure you make it to one of Dr. Liebenson’s seminars often with discounts for ISCRS members.