Thursday, August 18, 2011

Get In and Drive

I recently wrote about the balanced diet of movement and how important the movement repertoire can be. But I want to be clear that just having options isn’t enough. After all, just having a car and map doesn’t get you to the grocery store. You’ve got to get in and drive.

If a broad movement repertoire were all you needed then gymnasts, dancers and contortionists would all be pain free. But, alas, they hurt like the rest of us.

Let’s try an experiment . Place a cup upside down on the table in front of you. Now, turn it upright with one hand. Which way did you grab it? Did you grab it with your thumb pointing down or up? Most people will grab it with the thumb down so that they end up with the thumb up. You reached in a way so that you would end up in the most comfortable position versus starting out that way.

This is demonstrates the end state comfort effect.

subjects usually grabbed objects to be moved from one location to another in a way that afforded a comfortable final posture rather than a comfortable initial posture (the end-state comfort effect)

All things being equal, it appears that we tend to automatically move in ways to end up in a comfortable position.

An automatic mechanism for comfort has some interesting implications for therapy. Why is getting comfortable often so hard if it is supposed to happen automatically?

Now let’s try a thought experiment. Let’s say that your neck and shoulder were hurting and all you had to do to find relief was to stick your arm straight up in the air. Easy enough, right? Well, you are also sitting front row in a class. Not only that, but the class is filled with people that may hire you next week for a job you really want. Would you stick your arm straight up in the air to make your shoulder feel better? Or, would you be too worried about looking goofy?

Fear, expectation, and social taboo all could easily get in the way of letting this mechanism take place. This is the power of context. Competing desires can be derailing. Instead of getting comfortable we may act on the desire to not look silly. We may act on an expectation, like “sit up straight” or “don’t fidget.” In short, it is quite easy to get in our own way especially with a culture obsessed with appearance like ours.

An expanded repertoire might be enough when all that is holding you back is tendency, but otherwise I can’t think that it’s enough. Similarly, I’ve written that novelty is not enough. Both need a context or circumstance that is conducive to comfort.

Quote taken from:
Rosenbaum D.A., Van Heugten C.M., Caldwell G.E.
From cognition to biomechanics and back: The end-state comfort effect and the middle-is-faster effect
(1996) Acta Psychologica, 94 (1), pp. 59-85.

Friday, August 12, 2011

The Movement Diet

Ever heard of the Irish Potato Famine?

The Irish had found the perfect food. The potato was energy dense and plentiful and for reasons that are easy to understand, it became a staple. Eventually as much as 30% of the population took it beyond the status of staple and became totally dependent on the potato. And then it happened. Disease destroyed the potato crop. Without a viable substitute, widespread famine, starvation, and death resulted.

Pain with movement is often similar to this. Well, except for the starvation and death part.

We all have our staple movements that we use regularly. We tend to be confronted with similar scenarios from day to day and of course must always approach them with the same body and so, not surprisingly, we develop tendencies and habits. This option of autopilot usually serves us well since they free up attention for other things.

Sometimes, however, a level of entrenchment is reached in which the option of autopilot becomes the only choice. Now the habit has become a dependency. This is the dark side of habit because if that dependent movement happens to become a problem and we can’t access it anymore, we have no other options.

As the Irish made clear, dependency only works out if the crop is available. If we are dependent on a movement that becomes painful and we lose access to it, what will we do?

As an example, I routinely see people who perform literally every movement from a flexed position of the low back. If asked to move otherwise, they can’t. They’ve lost this ability because flexion has become so entrenched. This serves them fine until the day that the flexed position of the low back becomes painful. Now they’ve got a problem because they can’t find their way out of the uncomfortable position. They don’t know how to not be flexed. The potato famine has struck.

Luckily in the case of painful movement you won’t starve to death.

My advice is give yourself a varied movement diet so that you don’t become dependent on any particular movement or way of moving. This gives you options for finding the way to comfort.

This was the third in a three post series. The other two were:
The Ticking Time Bomb
When Pain Appears Everything Changes

When Pain Appears Everything Changes

In this previous post I argued that the Ticking Time Bomb theory of body mechanics is problematic. Now this is clearly blasphemy since “sound” body mechanics is seen as a pillar of my own profession of physical therapy. Am I ready to denounce my own profession as well as many others? No. Body mechanics clearly plays a role and many of us use movement every day to help people with pain. So what gives? Am I talking out of both sides of my mouth?

No. I’m saying that when pain appears, everything changes.

Body mechanics is not useful as a pain predictor but can be a useful solution to a problem that is already present.

Regardless of how we move we will all hurt from time to time (a robust foundation of research supports this statement) and the pain will correspond to certain movements. Perhaps it will hurt to bend forward and sit or maybe instead standing up straight and walking will be the nemesis.

Neuroscientist VS Ramachandran said that “pain is an opinion.” Painful movement means that our body is acting on the opinion that we are under threat and should therefore be protected. So, how can we change this opinion?

Movement patterns and postures are often tendencies or habits of moving. They develop over time and therefore give us a glimpse at someone’s typical movement diet. If we give them something new, something outside of their normal diet, we give them something to form a new opinion about. We are channeling their inner food critic!

If we are presented with this something new in a non-threatening context, a context of safety, a context of expansion, we are not likely to come to an opinion of pain.

Pain reduction occurring through body mechanics and postural change is, in my view, yet another example of the power of novelty. It has nothing to do with attaining some idea of perfection and likely little to do with strain reduction and everything to do with non-threatening change.

The Ticking Time Bomb

People worry that imperfect movements create patterns of strain that make them a ticking time bomb to be struck down with pain at any moment. But will they?

I have 3 questions:

1) Why don’t people with cerebral palsy hurt constantly at every joint?
*Cerebral palsy is a condition where movements are difficult to control and where movement and postural asymmetry are common

How do you explain why so many people display these imperfect and asymmetrical movement patterns but have no pain?

But maybe they are all just ticking time bombs whose time has not yet come. But if that’s true…

2) Why are so many of us walking around with herniated discs, meniscus tears, rotator cuff tears, and/or arthritis without knowing it?

Strain has resulted in actual tissue damage in these people and yet they don’t hurt. The research documenting all of these findings in people without pain is robust.

And lastly…

3) How’s that sit with phantom limb pain? More specifically, how’s that sit with congenital phantom limb pain?

Lorimer Moseley, pain researcher and blogger Body in Mind blog, posed this excellent question during a lecture I attended. These folks have no limb to move incorrectly and in the congenital cases, never have. Yet they hurt. How can faulty mechanics explain their pain?

Now you are asking (if not yelling), “Oh sure, Mr. Smarty Pants. Then why do I have countless stories of how I’ve cured pain by changing mechanics and posture? ”

Because when pain appears, everything changes. --> Please read this companion post.

I’m not saying that mechanics are not important or useful (as you’ll see in the other article). But, I do argue that we are not doing our patients, clients, nor ourselves any favors when we convince them that their body mechanics make them ticking time bombs. This is clearly not the case.