Course Review and My Thoughts: Greg Lehman Reconciling Biomechanics with Pain Science

I will post this week’s regular blog on Sunday, but wanted to write a course review for Greg Lehman’s course I took this past weekend a long with some thoughts on what was discussed. For those that don’t know Greg Lehman is both a physiotherapist and a chiropractor who has a presence on social media for presenting research based on pain science and biomechanics.

I remember in physiotherapy school I first started reading Greg’s blogs and thought he was fairly crazy to be honest. He challenges a lot of common thoughts that practitioners hold dear to their heart and can often make people feel uncomfortable with their reasoning behind common clinical thought patterns. In fact, at this course, one practitioner left after 1/4 of the way through the course I guess because he couldn’t handle his clinical structure being challenged. That was sad to hear about and it was actually the part of the course I enjoyed. I enjoyed having my thought process behind things challenged and Greg makes it tough to argue as many practitioners attempted to over the weekend. Too often, I find at courses lately it all to be too much of the same stuff, mobilize this, stability that. Considering that is the basis of our practices I think that’s totally legit, but it was nice to have a different type of weekend where I felt challenged to think differently.

Before we get into the meat and potatoes, I want to mention that Greg was an excellent presenter. He was hilarious, well thought out, articulate, open to conversation during breaks, and had a well put together presentation as well. For this, and the challenging of common thoughts regarding rehab protocols, I think it is worth every practitioner to take his course and hear him speak.

So what did he talk about? Lots was discussed over the weekend, but in summary he believes that common biomechanical flaws that we as practitioners may point out during a rehab process like lower crossed syndrome, valgus knee, poor scap mechanics etc. may have very little to do with the pain the patient is experiencing. He believes that often pain experienced by patients is not based on actual tissue injury (unless tissue injury actually occurs i.e. acute hamstring tear etc), but more so a sensitivity of the tissue’s tolerance to load. So for example, if someone comes in with knee pain and they have a valgus collapse, is that valgus collapse actually the reason for their pain, or is it more likely that their surrounding knee tissue couldn’t tolerate the new loads of spring running that patient upped after sitting on the couch all winter? Does fixing the collapse actually matter? Or would resting the knee for a bit, followed by a gradual generalized progressive strengthening program and return to running protocol be more than enough to get those tissues ready for the loads needed to run? The phrase he uses to describe this process and essentially the basis of what he thinks most rehab comes down to is “calm shit down, and build shit back up.”

He highlighted a lot of different videos and photos of athletes going into certain positions that would normally make most clinicians cringe, but are common positions for athletes to enter. Is a snowboarder truly going to land with a neutral spine after a big jump? Is a basketball player not going to have some level of knee valgus during a cross over? Is a track athlete not going to go into lumbar hyperextension to maximize their sprinting/jumping? “The guy below doesn’t appear to have his diaphragm stacked on top of his pelvic floor and is doing just fine. ”

broad jump

The thing with a lot of what Greg was saying all weekend is that he is right…..he is not wrong, because pretty much everything he says is based off of research. Technically he is right that tight hip flexors does not mean you are doomed to have back pain, that having a rounded upper back and forward head posture will lead to neck/shoulder pain, or that a stiff ankle means you have to have knee pain. If you look at research in any topic like this you will find that symptomatic individuals may not necessarily have such predisposing issues. You will also see that in asymptomatic individuals that people will have these issues, but experiencing no pain. So why does John have pain, but Joey doesn’t when they both have crazy tight hip flexors and similar activity levels? Maybe John’s lumbar spine had not readily adapted to the loads he placed on it, but Joey has over the years has built a strong and resilient lumbar spine that can handle the loads both put their back through. John’s back is now in pain and sensitized so lets calm that shit down and build it back up so it can tolerate the loads so he can continue working out with Joey.

Looking back on the course I actually agree with Greg about the majority of topics:

  1. Imaging/damage reports correlate poorly with actual pain experience. Not news here for any clinician I hope, but having a rotator cuff tear and disc bulge is not an immediate sign up for surgery. Chances are most people out there have issues like the above if you imaged them.
  2. As mentioned above, he is technically right that biomechanical “faults” does not correlate directly to pain. He does believe that they are an important of the rehab puzzle though. Probably not as much as every other practitioner in the room thought this weekend, but he did mention a few cases where he would still work on biomechanical “faults” to help with reducing pain. For example, if someone is going into excessive lumbar extension and having pain during a basic prone single leg extension he would for sure see the benefit in doing some manual therapy/exercise cuing to help the patient reduce the lumbar extension that is causing pain and move better through the hip. This will help desensitize the area of injury that could be potentially constantly aggravated and not allowed to calm down if the biomechanical stress is not off loaded.
  3. I feel earlier in my career I was much more trying to off load injured structures and re-pattern individuals to take the stress off of the injured tissues. Someone comes in with knee pain, hip exercises galore, ankle mobilizing, but nothing to directly load the knee. Can’t even give the individual an ounce of quad dominance! I’ve switched much more to trying to get individuals to slowly load injured areas to get the tissues use to accepting load again. I was explaining to a patient earlier today I often see 2 mistakes by most patients during their rehab. One, they try to do too much either in the sense that they just continue to aggravate the area and never let it calm down, but also sometimes as soon as they start feeling somewhat better will go back to their initial loads immediately. If you were bench pressing 225 pre-injury and after a few weeks of laying low your shoulder is finally starting to feel functional again and you try to get under the bar to do 225, you are asking to re-aggravate.  Maybe starting at 135 the first time back would make more sense, but let me get back to you on that though bro. The second mistake I see that some people will just lay off their injury completely and not begin the process of re-loading their tissues. It’s like they are waiting for the sea to part so their shoulder will magically start feeling better. After a month of chilling out, its still not perfect so how could I start using it??? Start slow and build tissue tolerance. The re-patterning and working on biomechanics errors is still important, but something has to be said for treating the area of injury directly with progressive loads.
  4. I’ve actually become a bigger and bigger believer that alignment issues are not very important when rehabbing someone from an injury. I know that might seem hypocritical since I have had some posts to do with tibial alignment, but I believe that alignment issues seen in individuals are more so to do with functional imbalances or are genetic and likely can’t be altered. That externally rotated tibia is driven by ankle/hip mechanics and a result of tibial mechanics not being able to be maintained. An anteriorly rotated pelvis on the left that I may have used to try to “correct” is more so likely just a shitty performing hip and core so lets get those working a bit better and the rotated pelvis will take care of itself. Random spine alignment issues are likely not a big deal in the grand scheme of things as we see with pain free scoliosis patients. Greg would maybe go as far as to say that if you had a completely locked up right hip and were having right sided low back pain that the right hip probably doesn’t even need to be addressed. I would disagree with that and will dive into that a bit later.
  5. Though biomechanics may not matter in terms of actual presence of pain and when an athlete may be performing their sport they will be in unideal postures (e.g. cycling, most team sports), it is likely good to train with proper biomechanics to avoid adding extra stress to the body in poor postures that would occur with poor training. An athlete isn’t going to run around the field in neutral spine, but it would be good to do the majority of off field training there to decrease excessive spinal loads compared to if one was to train with lots of spinal flexion/rotation.
  6. There is so much more to pain than just tissue injury/damage. Pain can be amplified by stress, nutrition, lack of sleep etc and this can often result in a damaging cycle of pain = stress = pain. These factors should be addressed when looking at the rehab picture as well.
  7. Certain wording and rehab styles can promote fear in patients that results in them becoming dependant on treatment or feeling like their bodies are incapable of performing until they are fixed. Patients should be motivated and convinced that they are robust and that their injury should often not have to limit their life and that they will get back to their old selves with progressive loading (and I would say movement re-training).

Overall I think Greg comes off fairly controversial, but if you look at the basics of what he is saying he is really just trying to simplify rehab for us all and I couldn’t agree more with that. I think complex systems to rehab are fairly over-rated and in the end it comes down to moving better, being stronger, tolerating loads, and being confident with your body.

Though Greg does believe biomechanics are still important (despite all he says) I did get the sense all weekend that I would still consider them much more important than he does for a few reasons.

  1. Biomechanical “fixing” through manual therapy/exercise is important to help off load structures that are being constantly aggravated that they don’t get a chance to calm down. With constant aggravation it is hard to calm an area down to then build up if it never calms down. Also, if something is re-occuring (i.e. knee tweaks, shoulder tweaks) I think that biomechanical faults can’t be ignored.
  2. I deal with a fairly active population and often times pain is associated with feeling dysfunctional. Even when I had knee pain a few years ago, my frustration was less about my actual knee pain, but more so with the feeling of a dysfunctional leg. I felt I had no glutes no matter how much activation/strengthening I did and no matter what ankle mobilizing I did that wouldn’t loosen either. I think working on the biomechanical faults in my foot/ankle/tibiofemoral/hip were vital in my rehab. I don’t think my knee tissues would have adapted without working specifically on the above. Greg did agree that biomechanics are likely very important when it comes to performance and I think a lot of what I am trying to do with my patients who are active is try to get them to perform better in a pain free matter. So manual therapy and “corrective exercise” are very important tools to achieve increased performance.

Overall, it was a great course that I would recommend to anyone. My practice won’t drastically change, but I feel I picked up a lot of useful tools to help with patient education as to why they may be experiencing their pain and to motivate them through out their rehab process. If you have any questions on the course please let me know!

Dave Leyland

 

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