Rehab 101: The recovery fundamentals that form the basis for Reconciling Biomechanics with Pain Science

Audience: Therapists and bored patients of mine

I don’t think good rehabilitation has changed dramatically in the past 20 years. I keep hearing people say that if they are doing the same thing 5-10 years from now they have somehow failed as therapists. Poppycock. We’ve known the fundamentals for many years but where we improve as clinicians is how and when we apply them. See this Twitter thread for more details

Reconciling Biomechanics with Pain Science has three main areas:

1. Critical thinking development to improve clinical decision making
2. Deep dives into research to support, refute and FIND treatment fundamentals
3. A loose framework of treatment options that aims to simplify treatment

Let’s take a look at #1 and #3.

Critical Thinking Development and Clinical Decision Making

This is not deconstructing myths for the sake of demolition. It’s easy to blow shit up and mock approaches but I don’t think its helpful. I’m not interested in critiquing without providing an alternative. This is the part of the course where we deconstruct common ideas and approaches to find what is good in those approaches. Where we try to reconcile how two seemingly different treatment approaches might be doing the same thing. It’s deconstruction to find the ACTIVE INGREDIENT in our therapies to help us get better at what we need to do. We ask questions like:

1. Expose versus protect?
2. Why is exercise helpful?
3. When do you need to be specific?
4. What has to change to recover?
5. When are impairments relevant and do we need to “fix” things to get better?

Answering these questions leads us to a general framework of rehabilitation and helps guide the specifics in that framework. That framework can be seen in the picture below.

This framework has 4-5 components which are basically the “how-to” or the practical components of the course. They constitute the “things” you do with your patients. Lets take a look:

1. Cognitive Restructuring - Understanding Pain

I guess this is the “pain science” part of the course but we don’t get into very much detail on pain neuroscience. You don’t need to be a neuroscientist to help people make sense of their pain. Rather, this part of the course is about understanding the Key Messages of Recovery and how we can explain and tailor these messages to our patients. Sure, there is research in here but its really about being practical and providing an explanation for why things hurt that compliments the physical and other interventions. You can see the Key Messages in my book Recovery Strategies.

2. Specific Load - Local and Distant

This would be the exercise prescription part of the course where we discuss exercise prescription for specific pain problems like PFPS, tendinopathy, knee OA, shoulder pain, low back pain etc. What we discuss is the common simple principles behind choosing exercise, how they might influence pain and recovery and ALL of the wonderful options that we have. When you take a deep dive into the literature you see that there are many roads to Rome and we have a lot of options. Specific questions we try to answer are:

when do we back off or expose?

when do we need specific exercises and which ones?

what are the targets or mediators of exercise prescription success?

when are impairments relevant (e.g strength, tendon stiffness, ROM, movement control)?

why movement preparation trumps quality?

choosing and selling exercise prescription to bolster our Key Messages of Recovery

and When Biomechanics Matter.

This is a good example of how after you go through the complexity of the research you come out and see that that the practical applications are really quite simple.

3. Micro Load Modification aka Symptom Modification

This is where we try to find some common threads across treatments. How can Mulligan, McKenzie, CFT, Graded Exposure, Neurodynamic Techniques, the Kinesiopathological Model and manual therapy all fit under the same tent? Well, they can. And this is the part of the course where we discuss a few approaches, try to simplify and again find common threads. There are some specific lectures on Graded Exposure to feared and avoided activities plus a case is made for why Movement Options trump movement ideals. In person, we develop options for treatment and hopefully show you how your current skills can be used in a framework that might be different than what you first taught. No babies get thrown out with bath water.

4. Macro load Management/Get Healthy/Resume Meaningful Activities

Ya ya, I know that’s a bit much for a title. This is a bit of a catch all. It’s more about recognizing that pain is multidimensional and that means a number of factors can be helpful. Hence, the simple idea of “getting healthier” can actually help with pain. But, we want this tailored to the person in front of us so the challenge is how we make this make sense and how we work with our patient.

Local load will often occur with the resumption and progression of meaningful activities (i.e Macro Load Management). In sports rehab its pretty much Rehab 101. A nice review of the blending of local specific load with more general loading (aka sport specific) is seen in the infographic below.

This part of treatment framework recognizes that graded activity/pacing in resuming meaningful activities (e.g return to sport) is a huge part of rehab (I’d argue part of every program where sometimes we can skip local exercise and symptom modification). This means that running (e.g sport specific) can be part of rehab (details here) but so can resuming the things that we are missing or are afraid to do either because of pain or because of the poor advice people have been given. In the sport world this is “sport specific training” but in the persistent pain world this is “life specific training”. Resuming our goal activities is a FUNDAMENTAL of recovery. Both of these realms recognize that we have this amazing ability to adapt to the stressors we put on ourselves but perhaps we need to optimize the individual to best respond to those stressors. And this is where therapeutic alliance, optimism, making sense of pain, self efficacy might all interact with graded activity, pacing and exposure to get an amazing outcome.

Good rehab does work on fundamentals. Find your fundamentals and then figure it what details you need to improve on when applying those fundamentals. People are wrong when they look at the research and say “nothing works”. What that research is really saying is that there are a lot different ways to help people and we should be open to learning new ways to apply those principles