The Chronicles of Pain Science with Dr. Greg Lehman, MSc, DC

Pain_ Chronicles2

I have for some time now, been reading articles, papers and viewing lectures by Dr. Greg Lehman, MSc, DC. Some of these quotes are from articles and others are from books, lectures, presentations or debates on social networking sites.

Dr. Greg Lehman, MSc, DC is a physiotherapist and Doctor of Chiropractic. He was an assistant professor at the Canadian Memorial Chiropractic College teaching a graduate level course in Spine Biomechanics and Instrumentation as well as conducting more than 20 research experiments while supervising more than 50 students.

Dr Greg Lehman was fortunate enough to receive a Natural Sciences and Engineering Research Council MSc graduate scholarship that permitted him to train with Professor Stuart McGill in his Occupational Biomechanics Laboratory subsequently publishing more than 20 peer reviewed papers in the manual therapy and exercise biomechanics field.

So without any further ado, here are 30 something quotes from Dr. Greg Lehman:

“The body is more of an Ecosystem and less a car that needs aligning. Our treatment should reflect this.” Dr. Gregory Lehman, DC

“Pain is an alarm. Pain occurs when the brain perceives damage or the threat of damage to the body and wants action. The brain is of the opinion that the body is under threat” Dr. Gregory Lehman, DC

“I wrestle with the relevance of regional interdependence. It seems logical and right, but only if I view the body as a machine or a structure, and not as this complicated ecosystem. I agree that hip movement will change knee movement. I agree that a thoracic kyphosis will change scapular movement and thus affect shoulder flexion. I question its relevance to pain.” Dr. Gregory Lehman, DC

“When dealing with pain, I want to be sure that pain is the primary problem. Pain – secondary to cancer, autoimmune disorders, infections or anything sinister – must be dealt with appropriately.”  Dr. Gregory Lehman, DC

“Patients think they are falling apart. They think they are tight and in need of correcting. I confront those beliefs in my assessment. Patients often believe they have tight hip flexors and weak glutes. I wonder where they got that pernicious and pervasive idea? Often, their hips extend equally on both sides, yet they only have pain on one side. I ask how can this be if their tight hips are the problem. I point out they don’t fall over when they walk or run, so how can their glutes be so weak as to cause problems? If they feel that they have pain because their core is weak, I ask, “How can that be?” A stable core takes less than 10% of maximum contraction of the anterior abs, even during a loaded barbells squat, and most of their pain is in sitting. These confrontations help change how patients view their body.” Dr. Gregory Lehman, DC

“The biopsychosocial model of pain and injury has been argued as superior to the traditional biomedical approach for more than two decades. However, traditional therapy typically relies on explanations and a clinical reasoning model that is predominantly biomechanics based.  Significant research in the pain neurosciences and biomechanics field often appears to undermine the reasoning and justifications for many of the therapeutic approaches and techniques of the physical therapy profession.” Dr. Gregory Lehman, DC

“One reason we avoid having too much pain in rehab is because our system can learn to produce more pain with the same input (Sensitization). Rather than habituating or getting used to it we become more sensitive. “ Dr. Gregory Lehman, DC

“Pain is meant to motivate action to protect the body.” Dr. Gregory Lehman, DC

“Our interventions can be a lot simpler than they typically are. Don’t let gurus make you feel like you don’t know anything. You can help a lot of people with simple, positive advice and simple treatments.” Dr. Gregory Lehman, DC

“Although hurt doesn’t equal harm, sometimes harm equals hurt. I like the biopsychosocial approach to treating pain and injury, as it recognizes the importance of bio. Dealing with a runner who has experienced months of anterior hip and groin pain, I can’t automatically assume that they have chronic pain and a sensitized nervous system. They could have a stress fracture of the femoral neck, a tissue pathology to be addressed. “  Dr. Gregory Lehman, DC

“The paper below shows that a spinal fusion will lead to alterations in joint function at a distance. No surprise there and this leads to abnormal loading and subsequent “wear and tear”. But no increase in pain. That last part is key. No increase in pain.

We too easily scoff at structural problems explaining pain (e.g. everybody knows that degeneration doesn’t equal pain) but then try to suggest that a slight change in ankle/knee/hip/back function will lead to a cascade of problems along this supposedly fragile kinetic change. If actual structural changes in tissue as a result of different loading doesn’t lead to pain why would subtle changes in movement lead to pain?

I would suggest that blaming pain on radiographic findings is catastrophic thinking and leads to more pain but it might just be equivalent to blaming pain on some “movement dysfunction” that we think is not optimal.” Dr. Gregory Lehman, DC

“I think one fear that therapists and trainers have with the idea that people can and should move in a number of different ways is that you have nothing to correct with your clients/patients. If you have nothing to correct than you don’t have any special knowledge to impart to your client about exercise. I mean, what would you do with your hands if you aren’t constantly touching a clients scapula while the perform a press or a raise (I’m kidding, kind of).

But this isn’t true. The therapist/coach still has a role with this movement nihilism. If you think that “faulty” movement is more about people having the same habits of movement or not enough variety then you have a lot of work to do as a therapist or coach. Our job is to identify those habits and be creative to try and give new movement options. People often don’t realize that they move the same way all the time. So rather than correcting, you get to work as a spotlight and provide infinite variety. You still have some work to do.” Dr. Gregory Lehman, DC

“What ends up happening is we ignore basic and good strength and conditioning principles and we try to make things a lot more complicated than they need to be. We treat patients like cars that need correcting and tweaking like an ankle joint is a carburettor – and think that subtle tweaks in one area are necessary for robust changes or healing elsewhere. “ Dr. Gregory Lehman, DC

“Treating pain is about treating the individual. Pain is a perception that is different for everyone.  No one can feel your pain.  Good treatment has to recognize this and tailor a program that is specific to you.  We know that many factors influence how people feel pain thus different approaches should be used in a treatment program.” Dr. Greg Lehman, DC

“A patient may have overloaded or somehow sensitized their supraspinatus tendon. This patient may have always had a slightly anteriorly tilted and protracted scapula. Before it was never painful because the tendon was not sensitive. But now that the tendon is sensitive the normal impingement that the tendon or system was used to is now painful. We can blame normal and pre-existing “faulty” scapula mechanics or we can just say let’s go and help that irritated tendon. “ Dr. Greg Lehman, DC

“The dominant view is that when joints deviate from a neutral position during rest or physical activity, there’s a risk for pain. If a person has an anterior tilted pelvis, hip adduction and weak glutes, the default is to blame this abnormality for their back, knee, foot or shoulder pain. Those movement patterns can be relevant, but I question why they should be the default. If no previous research or ideas existed, would we still hold this view? Consider how common and varied these movements are in the pain-free population, how incredibly robust and adaptable the body is, how pain can contribute to these movements. Should we still default to these patterns as the cause for the pain? Will they become the new structural “damage/degeneration” bogeymen we dismiss on radiographs?” Dr. Greg Lehman, DC

“The pain and tissue damage thresholds are plastic. Meaning they can change and are influenced by a number of factors. Pain does not mean you are weaker or more fragile…just more sensitive” Dr. Greg Lehman, DC

“Pain is not a Damage Indicator, with trauma pain is pretty good at telling us that there is a problem but pain is poor at telling us how bad the problem is. When pain persists the link between damage and pain becomes very weak.” Dr. Greg Lehman, DC

“I know a patient’s pain can freak out because I exceed their ability to tolerate the load. But I also know that this tolerance to activity sometimes has nothing to do with tissue strength but is just a response of their entire ecosystem. There could be fear, lack of self-efficacy, lack of confidence, poor sleep and other stressor in their life. I often teach patients like this that their body is strong but it is also very sensitive. “ Dr. Greg Lehman, DC

“After ruling out the pathologies, I can view the body positively. Regardless of pain levels, I can tell the patient that their tissue is strong and start treating the whole person. I want to change their beliefs about their body and convince them in the above axiom. The human body isn’t a stack of blocks that will fall apart if there’s something slightly off.” Dr. Greg Lehman, DC

“Pain is a Protective Response. Pain motivates an action to help protect us from perceived harm or the threat of harm. When your hand gets near a fire you feel pain before damage occurs.” Dr. Greg Lehman, DC

“I think that posture and dynamic posture (form) have only a small role to play in the development of injury and persistent pain. Or alterations in posture or form are due to the pain. I’ve felt this way for years but biomechanics and its relationship to injury development is one of the areas I read the most on. What I consistently see in the literature is the inconsistent relationship between typical biomechanical variables and pain.” Dr. Greg Lehman, DC

“I believe that treatment is an interaction between the therapist and the patient.  Treatment is not something I “perform” on the patient but rather it is the working together to achieve meaningful goals.” Dr. Gregory Lehman, DC

“If I read less and had a predisposition to believing biomechanics was important in the way that people often think it is (e.g. sit up straight, don’t deviate from neutral, avoid a winging scapula), then it would be pretty easy to selectively filter the research to support my view. But what I see is a mess that confuses correlation with causation and and even research conclusions that really try to support their narrative when the results don’t. “ Dr. Gregory Lehman, DC

“Treatment at its core is about desensitizing and then building back up. We find aggravating variables and modify them (e.g. a squat hurts the knees so we change the biomechanics to unload the knees temporarily) but at the same time, we also build the tolerance to the offending activity. Some patients are so sensitive that we need to resort to imagined movements (Graded Motor Imagery), but then we still increase the load incrementally “ Dr. Gregory Lehman, DC

“I shy away from a lot of the biomechanical models of care that try to draw very strong links between different segments of the body – looking for “dysfunction” everywhere and trying to link to that pain/injury. You know, the big toe causing shoulder pain – such a weak view of the body. To me, it creates a sense of fragility if you tell some housewife that their shoulder pain is because they have an anterior pelvic tilit and therefore their diaphragm is not “properly” aligned and they have a slightly winging scapular and therefore they have pain. That is so defeatist and alarmist to me. It implies that we have this optimal way to move and when we deviate from it we are in trouble. “ Dr. Gregory Lehman, DC

“Pain is multifactorial. The Brain creates pain from many factors. This often why different people have different amounts of pain even with similar injuries” Dr. Gregory Lehman, DC

“Remember, pain is not simply about tissue damage…other factors can help ignite the pain neurotag. This is why danger signals from the body are often not enough to create pain or why other things like fear or stress can contribute to your pain. Memories or beliefs about how strong your back is can also help trigger the activation of a neurotag and give you pain” Dr. Gregory Lehman, DC

“I have been asking this question for 15 years. When does biomechanics matter? Specifically this question relates to pain and injury. I’ve listed below in glorious vagueness when I think biomechanics matters:

1. Acute injuries to protect damaged tissue

Changing biomechanics (both form and loading) is a good idea when you have an acute injury and you want to desensitize or relatively rest an area

2. High load activities

When we are dealing with heavy forces having what the biomechanical and epidemiological literature consider tissue sparing can be justified. But of course, there are exceptions.

3. Interruption of habits associated with pain

Well, we manipulate mechanics to influence a sensitized neurotag or maybe breakup the coupling with some movements and pain. A temporary measure

4.Temporary changes to desensitize the ecosystem

Similar to #1 and and #3.

5. Disconnect between task/sport demands and current function

Can we say that having huge mobility is necessary for all sports? I don’t think so. If someone is starting a sport there a certain physical demands required in it. Changing mechanics to achieve these demands is probably necessary or at least helpful. This statement also respects that huge variability exists and the body is redundant in how it can safely achieve many tasks.

6. Respect for adaptation (MSQ)

When you start a new loading program (e.g. running) it takes time to adapt. You can choose certain technique variations that might make it easier to adapt based on your existing abilities. Another example, is running form changes. If we change your footstrike pattern we can’t do this abruptly. We have to ease into it. I respect biomechanics in this regard.

7. Pragmatic epidemiology

Sometimes are reasoning is flawed and if there is a good evidence that suggests certain movement patterns are linked with pain/injury then we need to respect that good research and adapt.” Dr. Gregory Lehman, DC

“The pain often has little to do with their structure or strength; it’s more of an allergic response by the body. People don’t die because of a bee sting, but because of their allergic reaction to it. Pain is the same way. You can remove the stinger (i.e. heal the tissue) but still be left with the protective responses driving the dysfunction. When you modulate a patient’s pain in 5 minutes and contrast it with the obvious fact that they didn’t heal in 5 minutes, these ideas start to click.” Dr. Gregory Lehman, DC

“I don’t want any patient to fear any movement. BUT, I recognize the possibility for exceptions…If the research makes a strong case that certain movement patterns in certain populations under certain conditions are related to injury (e.g. increased knee abduction moment during landing in females in sports with high ACL prevalence), then I take that research and redecorate my structure. But do I freak out when every girl who runs 2 km twice a week shows up on my treadmill with some knee valgus? No” Dr. Gregory Lehman, DC

“How do you keep up with the literature to guide your practice?” The daily volume of publications can make it difficult. My solution is to regularly refer to my fundamentals of treatment, which stay the same, and occasionally “redecorate” them with new ideas. This way, new research complements my fundamentals and rarely throws me for a loop. For your own practice, I’d recommend writing down what you consider to be your fundamentals of treatment. What do you hope to accomplish within your treatment session? What are your views of the body? What can you do to affect your patient?” Dr. Gregory Lehman, DC

“There are multiple triggers and amplifiers of pain. One trigger is the initial tissue “danger” signals that you felt when you twisted your ankle, sat on a lumpy couch for too long or did too much of something that you weren’t used to. Its normal to feel pain in these situations. But what those complicated neurotags and the neuroscience teaches us is that when you feel pain there are other variables that influence how much pain you feel. Remember your brain is always evaluating the situation and can makes a decision of how much protection you need.” Dr. Gregory Lehman, DC

“I use manual therapy to prove to patients that their pain is about sensitivity. Manual therapy isn’t about correcting anything, although it may help in the short run. It’s about changing what they feel and helping to believe in their adaptive potential. I often fake manual therapy. For example, I might “correct” the scapula with a scapular assistance test and then have the patient lift their arm – and it hurts less.

After 1-2 repetitions, instead of pushing the scapula, I just twist the skin – still less pain. Then, I twist the skin in another direction – still less pain. Then, as they keep lifting, I stop “correcting” completely – still less pain! I explain that there is no way I’ve corrected their scapular motion. Rather, I’ve changed how they feel – their sensitivity. Perhaps they became more confident, less fearful. Perhaps something happened in the brain (likely, but I don’t always get into it). I use that change as a learning tool and then use exercises to reinforce the new perception” Dr. Gregory Lehman, DC

People don’t die because of a bee sting, but because of their allergic reaction to it. Pain is the same way.” Dr. Gregory Lehman, DC