Did you miss Movement Debrief live yesterday? Though much more fun live, I have a video of what we discussed below.
This debrief was quite fun, as we had an impromptu viewer q&a. Thank you Alan Luzietti for the awesome questions! If you follow along live on Facebook or Youtube, I will do my best to answer any questions you ask.
Yesterday we discussed the following topics:
Why you should emphasize sagittal plane activities longer than you think
How to coach exercises to maximize client learning and compliance
Why detaching from your client encounters makes you a better clinician
Viewer Q&A – “centering from the chaos” & TFL Inhibition
Lastly, if you want the acute:chronic workload calculator I spoke about, click here.
I shipped off to Boston to attend my first ever BSMPG summer symposium. And it was easily one of the best conferences I’ve ever been to. There was an excellent speaker lineup and so much of my family. Art Horne really put on a fantastic show.
If you haven’t been to BSMPG before, put it on your to-course list. It is one of the few courses that has a perfect combination of learning and socializing. I hope to not miss another.
Instead of my usual this person talked about that, let’s look at some of the big pearls from the weekend.
Why Sapolsky Doesn’t Get Ulcers
In one quote Robert Sapolsky summed up my current foundational premise to rehabilitation and training:
“The stress response returns the body to homeostasis after actual or potential threats.” ~ Robert Sapolsky
Regardless of what your malady is, it can probably be linked back to the stress response gone awry. The specifics become irrelevant because the stress response occurs nonspecifically.
This response works best against acute crises. Guess how we screw it up? Chronic stressors.
Human stressors are quite different from other species’ as we have the capability of inducing this stress response psychosocially. Gazelles on the Serengeti don’t have to worry about student loans.
We can see how chronic stress becomes an issue when you look at what occurs in the stress response:
Glucose travels to the bloodstream to mobilize energy.
Increased cardiovascular tone, heart rate, and blood pressure.
Decrease long-term building projects such as digestion, growth, and reproduction.
Increase immune system activity
Sharpen cognition, alertness, and pleasure
If the stress response perpetuates, other systems fail and break down to continue to support the need to reduce potential threats. We see a shift in the homeostatic set-point toward elevated levels of the above.
Although we all must deal with stress in some way, why is it that some people tolerate chronic stress better than others? It’s all in how one copes. The following is needed to successfully deal with stress:
Aka good training. But how do we build up individuals to continually better tolerate further challenging stressors?
Here is where my man Eric Oetter dominated the conference.
When chronically stressed, the aforementioned stress response takes high priority in all our systems, including nervous. Immune molecules smudge our various homunculi, dopamine floods the system to reward outputs, and myelin solidifies neurological pathways to perpetuate it.
Breaking a chronic stress cycle involves habit alteration.
To be able to effectively create newly favorable habits, movements, or pathways, attention is key. This piece is something we lose in a stressed state; as prefrontal cortex activity decreases. This is why salience is so important.
To return to a favorable homeostatic environment, we enlist Eric’s three P’s:
Prime brain activity via the aerobic system. It boosts brain power, especially if done before an activity.
How: Work between 120-150 bpm for 15-30 minutes prior to motor skill learning. Do something you enjoy so you do not become overly stressed by the activity itself.
Sleep is a big deal. According to one of the speakers, Vincent Walsh, we sleep 37% of our lives. Yet we only work 19% of them. We sleep so damn much that it should probably be taken seriously.
Sleep helps us remember by helping us forget things. The sleep cycle replays our day; keeping the important pieces and discarding the unnecessary.
This discarding is the pruning that Eric referred to, and it occurs by glial cells. Glia is what smooths out new neural connections.
How do we get good sleep?
Respect the chronotype – keep your normal sleep-wake cycles.
Take naps – 26 minute naps are bomb.
Banish blue light – cut out 1-2 hours before bed, as blue light from electronics tells the suprachiastmatic nucleus in the brain that it is light out.
Become a sleep environmentalist – No caffeine after 12, no meals 3 hours before bed, sleep in a cool room, etc.
If you can’t access to the prefrontal cortex, you will never hit the cognitive stage of motor learning.
Chronic stressors inhibit access to the PFC. The PFC is the doorway to variability, which is something unwanted during a stress response. Automaticity is king.
Getting the PFC allows all systems to be freely expressed. How do we do it?
Monitoring (omegawave, bioforce HRV, etc).
Remove the “neurolock” via redirection and respiration (hint hint– PRI)
Energy systems development.
Respect the Thorax
This section will channel my homie’s James Anderson and Allen Gruver. Can’t go a place without getting a PRI fix.
What keeps the spine and sternum oriented right despite the thorax counter-rotating to the left? The answer would be airflow. A hyperinflated left chest wall pushes these areas to the right.
Thoracic movement is determined by this position as well as timing/coordination of gross movement patterns. We can observe how the thorax is driven through what the extremities are doing.
If you look at the baseball throw, we ought to see alternate positioning on each arm. For example, if the right forearm is in supination during a part of the throw, the left arm ought to be in pronation. This reciprocal arm function promote the thorax rotating in one direction. It’s a PNF thing.
If the arms go in the same direction, the thorax must extend or flex. Since sport is usually extension-driven, we can guess which direction one will go.
Vince Walsh gave an excellent talk on the brain. He thinks we miss lots of talent because we look predominately at physical prowess.
Physicality is only one piece of the puzzle. Some individuals may develop excellent decision-making skills later on in their careers that may trounce athleticism.
Your ability to make right choices and avoid wrong ones is necessary for success, and is a trainable skill.
To know how to train it, it is important to understand the three types of decision-making:
Physical – What to do and not do (e.g. gun slinging)
Mental – e.g. poker playing
Temporal – e.g. playing chicken
Vince predominately used computer simulations to train these decisions, but it seems plausible that these tests could be applied to any type of training. Perhaps something like a reactive agility test could help improve physical decision making as an example. You just have to be creative.
A Cautionary Note on Data
Al Smith said some of the most profound words this weekend. He spoke to caution us on data.
Data does not always tell the individual story, as it can lead to less individualized training or rehab. It dehumanizes both our clients and us. This statement made me think quite a bit to those folks who champion evidenced-based everything.
Perhaps instead of measuring everything, one must first ask if there is a problem with what one is thinking of measuring.
Another cool thing Al Smith showed us was the cynefin framework; a sense making model in which acquired data precedes framework.
Depending on what a situation can be categorized in, one would expect to utilize different thought processes.
Simple – predictable relationship between cause and effect (use best practice)
Complicated – predictable relationship between cause and effect that’s not self-evident (use good practice)
Complex – A system without causality (use safe-fail experiments)
Chaotic – A completely unpredictable system (Use novel practice)
Where does training fit? Where does rehab fit? We may be using incorrect methods in particular situations.
You can learn more about the framework here, it’s definitely something I hope to explore more in the future.
“Too much exercise is not normal hominid behavior.”
“This CT scan was not drawn by a commissioned artist.”
“If you think that’s a tight pec you better check pressure in the air.”
“10,000 hours can’t always undo 100 dumb ones.”
“Frank Netter shut down the left AIC.”
“Deny PNF and you are messing with the system.”
“We’re all barking down the same tree. We just like to complain.”
“No plan survives the first contact with the enemy.”
“Changing the answer is evolution; changing the question is revolution.”
“If you live in mediocrity you eventually think it’s good. You don’t know what good is.”
[Note: Most of this article is an amalgamation of the three articles that I cited above and my own thoughts. Rather then cite every sentence AMA-style, I’ll give the credit to these guys above. Read ‘em and figure out how I put this together. For those who are sticklers for proper reference formatting, the type I am using is KMA-style citation.*]
The Pain Neuromatrix Myth
Hate to break it to you, but pain ain’t so special. Here’s why.
If you follow modern pain science, you may often hear the term pain neurosignature or neurotag. This phrase is meant to describe a cluster of brain areas that are active during a pain experience.
Information that can contribute to a pain experience travels to several areas. Some of the big players are the primary and secondary somatosensory cortices (all the talk about the homunculus), the anterior cingulate cortex (ACC), and the insula to name a few. These bad boys are consistently active when pain from a nociceptive stimulus occurs. Hence, these brain areas are considered to be part of the pain neurotag present in us all.
However, this theory has a couple problems. First off, there is no brain area that exclusively responds to nociceptive stimuli. That includes the aforementioned locations.
In fact, these areas have been shown to simultaneously activate by the following sensory inputs: nociceptive, somatosensory, auditory, and visual. This variety can be explained by the vast array of wide-dynamic range neurons; neurons that carry multiple inputs to cortical areas.
The suggestion: the supposed “pain neuromatrix” can respond to a wide variety of sensory inputs. I don’t think the input matters much at all. This fact takes the quote “nociception is neither necessary nor sufficient for a pain experience” to a completely different level. I like this instead:
“Any input is not necessary, but sufficient for a pain experience.”
As if pain wasn’t complex enough.
[Interesting side note: nociceptive specific neurons have been shown to be active when a threatening visual stimulus occurs. How many of you folks who treat pain are asking about vision? Maybe there is something to that PRI after all.]
So how is the pain neuromatrix demolished? Because of the first point I mentioned in this post. We could also see a wide variety of outputs that neurologically appear similar to pain occur. The neurosignature is not always exclusive to pain.
Let’s rephrase our quote again.
“Any input is not necessary, but sufficient for any output.”
What would constitute a change in output that resembles what was once thought as the pain neuromatrix? Here is where salience comes into play.
The Salient Detection System
A salient stimulus is something that stands out relative to the background. The intensity is irrelevant; the key is how different the input is. These inputs can occur within the body or the environment.
An elephant in a room is salient. A room full of elephants is not.
But here is a more scientific example. One study mentioned in the articles used a monotonous nociceptive laser stimuli interspersed with a novel nociceptive stimuli of various physical properties. Larger activity in the “pain matrix” areas occurred when the novel stimulus was applied, regardless of how intense this was.
Deviation from norm is what is necessary for this system to activate. Let’s upgrade our phrase again:
“A salient input is necessary for an altered output.”
Being able to respond to salient inputs helps one adapt to environmental and body changes. This is why nociception can be powerful, as it is a very salient stimulus.
Because there are no brain areas that respond exclusively to nociceptive stimuli, the brain areas typically involved in “the pain matrix” are more likely involved in an all-encompassing salient detection system. The outputs that occur are the brain’s best guess at how to adapt to this new stimulus. As to why one output may occur over another is likely beyond our current knowledge base.
It Comes Down to Threat
If you haven’t read before, I believe that stress/threat that goes beyond our system’s capacity (i.e. is salient) is ultimately what leads to many of the outputs we see clinically.
Let’s see this process in action. Let’s suppose you are exposed to a threatening salient stimulus.
When a severe stressor occurs, the prefrontal cortex (PFC, our decision-making center) decreases its activity and the amygdala takes over. The amygdala likes predictable behaviors, so habitual strategies will run to combat this stressor. This is the stuff you are good at.
If the PFC is active, we consider that top-down control. When exposed to a threatening salient stimulus, bottom-up processing via the amygdala is more dominant.
Stress and inflammatory hormones flooding the system compound this shift, which strengthen the amygdala and weaken the PFC.
Getting Stuck in the Cycle
Let’s suppose you are exposed to a threatening salient stimulus and are fortunate enough to survive. Your brain will ask the following question:
“How do I prevent that from happening again?” ~ Your brain
The major players here are dopamine and norepinephrine.
Whatever output was successful in threat attenuation will be positively reinforced by the amygdala. Our reward neurotransmitter known as dopamine increases its presence when a stressor is applied. Outputs used during that stressful situation will be captured and rewarded for occurring. Over time, this process can contribute to chronic outputting (pain, addiction, PTSD, etc).
If pain fear-avoidance reduces threat, reward. If anxiety keeps you protected, reward. If snorting a mountain of coke keeps you happy-go-lucky, reward.
To me, the above outputs are the same thing. The outputs that become chronic depend on if maintaining chronicity ensures one’s survival.
Norepinephrine, our neurotransmitter that gives us that adrenaline rush, initially drives us sympathetically to combat that threat. However, in chronic stress environments such as those mentioned above, norepinephrine will begin to fire to irrelevant stimuli. These changes can now make inputs that were once nonthreatening threatening.
Going from Vicious to Delicious
So we are stuck in a bottom-up amygdala-happy cycle. How do we get out of it? PFC is the hero we deserve so we can hope to stimulate top-down activity.
We have a problem though. When we have a chronic x, y, or z, working memory over-attends to inputs that perpetuate said output. It takes over our working memory. Individuals stuck in a chronic cycle have a hard time getting out of this state because the output occupies the mind and is rewarded by dopamine.
There’s only one way to break the cycle: Salience.
A new, favorably salient input is necessary to encourage top-down processing. This is how our rehabilitation process begins.
Introducing a favorably salient input is only step one. This piece provides a window of opportunity for learning a new strategy, as the previous threat is reduced.
These examples are the same. All are novel stimuli that divert attention for a brief moment in time.
And they won’t work forever.
[Side note: 2 Batman + 2 Outkast references = best blog yet]
When the system is flipped to top-down, one must introduce variability, capacity, and/or power to better attenuate future threatening inputs. When an individual’s sweet spot of these qualities is found, better stress management occurs. Those salient stimuli that push someone into an unfavorable bottom-up cascade are no longer salient.
The standouts just become part of the noise.
We now have a neurological framework for which we can treat individuals who are under threat, and the common link among all these folks is salience. Recognizing what salient detection means, and creating better body-spatial environments to combat threatening salient inputs, may be a major factor in reducing some of the chronic conditions we see.
Several different thoughts have crept into to my mind sparked by what I have read and conversations I have had. I would like to share these insights with you.
I remember when I was visiting Bill Hartman Dad a few months ago and we were talking about a specific treatment that is quite controversial in therapy today. He said something that really resonated with me:
“Thus, pain can be viewed as a single perceptual component of the stress response whose prime adaptive purpose is to powerfully motivate the organism to alter behavior in order to aid recovery and survive.”
Notice what I bolded there. Pain is a single component of the stress response. Not the stress response. Not a necessary component of the stress response. Just one possibility.
Why do we place so much importance on pain?
Many proponents of modern pain science (myself included) often use this statement against individuals who are over-biomedically inclined:
“Nociception is neither necessary nor sufficient for a pain experience.”
Agreed, pain is not always the occurring output when nociception is present. That said, pain is only one of several outputs that may occur when a tissue is injured. Just because pain is absent does not mean other outputs are also absent.
Many different outputs can occur when an individual is under threat.
Let me propose a new quote to those who focus solely on pain.
“Pain is neither a necessary nor sufficient output of the stress response.”
Why should we limit ourselves to only treating pain? Why should we limit ourselves to only treating outputs? (Spoiler alert, we can’t treat outputs, change them) I have a better idea.
Today, I start treating a human system under threat.
The Threat Matrix
Dad showed me this great editorial here in which Eric Visser expands upon Melzack’s original pain neuromatrix.
Visser calls this idea the threat matrix. To simplify the idea, threatening inputs from the body and the environment enter the system, are scrutinized by the brain, and then the desired output to combat the threat occurs.
Input –> processing –> output
This framework explains how any output, desirable or undesirable, can occur from a stressful input.
Let’s apply this to an example that we have all been through; a breakup with a significant other.
Your significant other decides to leave you, how do you feel?
The answer depends on the individual. Some folks may feel depressed. Some may feel anger.
Some may even experience pain.
These feeling are all outputs that occur as a result from an input (i.e. the breakup) that disrupts homeostatic balance of the human system. The outputs that occur are the ones that the brain determines best aid the individual in recovery and survival.
Let’s now take this thought to the therapy realm. I sustain tissue damage and nociceptive information travels to the brain to be scrutinized. What output(s) could occur? Let’s think of a few possibilities.
Endocrine alterations in gut/reproductive function
Increased/decreased immune activity
Yada yada yada
All of these could occur, some of these could occur, or none of these could occur. The response to the offending input is going to depend on the individual’s brain scrutinizing the situation.
One could argue that a nociceptive event could lead to someone developing anxiety and poor immune function without ever experiencing pain if that is what the system feels best aids in survival.
Nonspecific Effects my Arse
There are many treatments out there that people deem worthless because research demonstrates minimal effects on pain compared to placebo. If someone gets better with this intervention, we deem that nonspecific effects led to the change in pain.
I call bullpoop…sort of.
Nonspecific effects could be a contributing factor to someone benefitting from a particular treatment, but the problem with most pain research is that often pain level is the only thing that is measured.
If pain is only one possible output of a system under threat, how do we know that a treatment didn’t affect a different output?
Answer: We don’t because it wasn’t measured!
Let’s take a controversial treatment for example: dry needling.
Some say it works wonders for pain, some are vehemently opposed, and research is mostly mixed. What do we do?
Perhaps both camps are wrong. Why? Pain is the only output being discussed.
What if this whole time, dry needling worked because it altered inputs coming in from the immune, autonomic, or [what the hell evahhhh] system, which led to changed output from this system primarily with pain output altered secondarily? And here is the kicker; the intervention only works if these systems respond as well as our pain system under a particular threat.
Well we don’t know that because we didn’t look at it. But looking at multiple systems when an intervention is implemented may give us more explanatory power as to why certain treatments help certain individuals. With this information, treatment could be streamlined and implemented.
Making pain our only concern to treat severely limit our capacity to help individuals. If we think of treating the stress response itself, we open up a huge realm of issues our interventions may affect.
If you take a look at the book “Spark” and the corresponding research, we see how exercise can alter many different outputs.
Why can’t rehab folks be a piece of this puzzle? It does not seem unreasonable to me that we could get referrals for anxiety, depression, or whatever output the stress response creates.
Strategically implemented exercise can help alter the stress response. That possibility makes me so hopeful for our professions.
How can one best assess a system under threat?
If clinicians are to assess if an individual is undergoing a chronic stress response, we need to find a reproducible methodology that gives us this information. We must look at the human system from the input/output standpoint.
There are several outputs that can be measured to assess an individual’s homeostatic state:
Other specific medical tests
These are all great tests that can assess the amount of system stress an individual is undertaking. That said, I feel there is an even simpler method of assessing the stress response:
Our physical examination
Assessing the stress response begins with the subjective examination. This piece of the clinician-patient interaction helps us assess potential offending inputs as well as individual processing.
If we come across red or yellow flags, we can easily refer out to providers who can deal with that piece of the stress response. Here is where a psychologist, surgeon, oncologist, other medical professional can come into play. These individuals can alter the offending inputs or help influence processing that therapists and the like may not be able to touch.
Let’s say we get through our subjective and we screen out that the above professionals do not need to be a part of this person’s care. Let us now proceed to our objective examination.
Assessing movement may be the simplest way to assess an individual’s stress status.
If we are to provide the “ideal” physical examination, we need to perform tests and measures that best differentiate a stressed from nonstressed individual.
To undertake this task, we need to have a few assumptions about what a nonstressed individual looks like. Let’s call this individual the “adaptable human.”
The adaptable human will have desirable multi-system variability. That is, human systems can perform as needed under certain situations without being “stuck” in a particular range. For example, blood pressure should stay lower when at rest and rise when performing physical activity. When blood pressure remains high at rest and with physical activity, that individual possesses system rigidity.
The adaptable human will have desirable multi-system capacity. That is, human systems can tolerate prolonged stressors without faltering. For example, a human can perform longer durations of physical activity with blood pressure remaining in levels that would not threaten one’s life.
The adaptable human will have desirable multi-system power. That is, human systems can tolerate intense stressors without faltering. For example, blood pressure can reach a desired level to allow for a particular physical activity to occur.
Our examinations ought to assess these three qualities: variability, capacity, and power.
Of the three, variability is most fundamental because almost every healthy human system functions in the manner. The movement system is no exception to this rule.
Movement variability, the ability to move in three planes, is the simplest reflection of this concept. A nonstressed system will possess movement variability. A stressed system shall become rigid and lose triplanar mobility.
Think to the last time you were stressed. Did your muscles tense or relax? As muscles tone increases, range of motion decreases. Assessing movement variability is an easy way to assess the general tone an individual has, and I speak more of why this notion is favorable here.
To assess variability, our examination must:
Look at the entire individual’s body
Cannot have bias toward one output (e.g. pain)
Must be reproducible and predictable
First, let’s look at popular rehab systems that I feel would not work in this instance and why.
Maitland: Biased toward altering one output (pain); segmental in nature.
McKenzie: Biased toward altering one output (pain); segmental in nature.
SFMA: Not necessarily biased toward one output, but does not look at entirety of human movement. Only two movement planes are assessed. Cannot see if an individual has variability in the frontal plane.
DNS: Wait? Do they even assess?
I shall let my bias now creep in as I suggest the current best model we have for movement variability is PRI.
There are several reasons why I think PRI is currently the best model to assess threat:
It is not biased toward altering one output, as movement rigidity can occur along with several other outputs besides pain.
The entire human movement system is assessed in three planes.
The protective patterns one undergoes in threat are predictable and similar for all individuals.
When one deviates from these patterns, likely pathology had to be created in order to do so.
If an individual can produce nonpathological triplanar movement throughout his or her body, then movement variability is present. A movement system under threat will not have this capacity. A threatened movement system will become rigid.
Establishing movement variability is our primary way to reduce threat-response outputs.
If undesirable outputs remain once movement variability is established, then we know other interventions must be given to address these areas.
If pain is still present, then previously mentioned assessment systems hold value, as does graded exposure.