#14 - A modern approach to low back pain with Dr. Greg Lehman

(soft music) You have a severe bout of low back pain. It cranks up your system, your sympathetic nervous system. You might get sweaty and clammy. And they're like, "Ah-ha, people who have low back pain "are sweatier and clammyer than those that aren't. "Therefore, we need to give everyone towels to dry them off." No one would think that. I just made that up. That was a good one, eh? (soft music) In this episode, we explored using older paradigms, like bracing, stability training, TRA timing, with a more contemporary and updated narrative that fits the BPS lens and a patient-centered approach. Specifically, we covered a back pain and we did this with Dr. Greg Lehmann. Now, Greg is a wonderful person to talk to 'cause he's a physiotherapist, a chiropractor, and a strength and condition specialist. He has a few two-day courses going around the world and a wonderful resource called Reconciling Biomechanics with Pain Science. If you are following Greg, make sure you read up on his material and I hope you enjoyed this episode as much as I did. My name is Michael Risk and this is Physio Explained. Hello, Greg. Thank you for joining us. - Yeah, thanks for having me. - So, how did we get to costability in the first place in TRA? How did we get here? - To be honest, it's been around forever, right? I remember teaching gymnastics almost 30 years ago as a kid and we would talk about a tight body where you brace the everything in your trunk and oscillate between a hollow body. It's like slightly flexed and arched. So, we've been talking about it forever, but then Bergmark would be the seminal paper on stability, which just means like all the muscles work together to stop buckling. Stability just means like if you perturb or do something to a system, you try to shove it, it comes back to its resting state. So, a stable system is one where you shove it, it'll come back to its resting state. So, in North America, it's like Bergmark and then that was followed up by Panjabi who went on to this idea that muscles, legaments and the nervous system worked together to stabilize the spine, meaning you control the motion. It tends to be stiffer, but that would mean the system's more robust. Like a willow tree is stable, it just moves a lot, but it doesn't break. If it broke, then it would be unstable. That's what's really neat. And I always associate that with Paul Hodges and probably that whole group. I think I'm not sure who his supervisor was, maybe like Julie Hyde's and the great Australian researchers. You know what, maybe they were inspired by Vladimir Yanda and Bullock Saxon 'cause that research proceeded the idea that maybe some muscles aren't doing their job. So that was the transverse abdominis idea that, if you perturb the system by lifting your arm up really fast and you measured the transverse abdominis timing, they found that in people with low back pain, it was delayed. So the concept at the time was that it should be turning on before you move your arm or at least feed forward. Like it's a planning, a motor planning. And then some people with low back pain, it was turning on at a like reacting and it's not supposed to do that. That was the theory at the time. So it was good like observational research. What happened was that they can't kind of ran with the idea of stability and they never measured stability. They just measured muscle timing and then the assumption there is that it was a relevant impairment that if your muscles are delayed, it stops you from getting better. And it may not be, it could be an epiphenomenon. Right? That would mean something like this. Like you have a severe amount of low back pain. And they're like, aha, people who have low back pain are sweatier and clamier than those that aren't. Therefore, we need to give everyone towels to try them off. You know, we treat them. No one would think that. I just made that up. That's, I love that. That's going, that's, that's in the records. You heard it here first. But that's what we did with the transverse abdominis. We said, oh, here's the finding associated with pain. Therefore, we need to fix it to get somebody better. And that's just maybe wiping off their sweat. Yeah. Right? It could be what's called an epiphenomenon. It's parallel to the dysfunction, not actually in series, meaning driving for contributing or mediating the pain. And so because of that, somehow we got to this place where we are bracing and having rigidity and trying to keep those muscles on. So that's what's interesting. It's like the Hodges approach wasn't about bracing. You know, it was about getting the activation, turning it on earlier and changing the motor control dysfunction. The North American model was about finding the optimal amount. So it's unfair to say it's always about bracing. But it would be more probably there's a subset of people who need to brace to stabilize the spine slightly. And it was never about a lot of strength. Even 25 years ago, all the researchers said it's about endurance where you want to stiffen up the entire trunk. In some people, there'd be exceptions to minimize small motions of the spine, which might be aggravating. That's where the bracing came from. It wasn't the tranny idea, the transverse abdominis idea. Although I think in Paul Hodges' earlier stuff, that would be a progression. He'd retrain motor control. Then you'd progress into gentle bracing and then functional activities. So timing, then bracing. And where are we now in relation to that? In 2019, there was a huge special issue of JOSPT talking about this. And they lumped all of this courseability stuff into motor control impairments. And if you read that, we haven't changed anything. It was still written saying, there's dysfunctional movement patterns. You have to correct. Maybe not the transverse abdominis. We have to correct multifitist timing and activation. There's a role for bracing and changing how you move. And so it's still a debate. Too big questions are, does changing the transverse abdominis from multifitist timing or activation? Is it required to get better? And is it really the mediator of recovery? And then the other area, when I view course stability, all I think it is now, it's like, you're just teaching someone to avoid a sensitive movement pattern. That's it. That's why you brace your spine. You don't brace your spine because it's inherently better to be stiff. You brace your spine because you're stiffer. And then you don't move into positions that are sensitive. That's what stability. That's what I see it as what it means in the North America model. And then are we finding that once we do that or pain subsides, that that timing corrects or like other research is it that no, the pain can go and function can return and the timing can still be off? That's what's really interesting. And so the past eight years, like Anne Manion and other researchers, we've had a number of people who have looked at it where it seems that they measure timing and the multifidist or the transverse abdominis and it doesn't seem to have to change to get out of pain. So you can be in pain and have normal timing. You can be in pain, have different timing. You can get out of pain and your timing doesn't change. But to be fair, like that's the same as other things. It's the same with fear of boydance and catastrophizing. You can have these traits and they're not always strong mediators either. I'm a catastrophizer and I'm often out of pain. I'm sometimes in pain. We should be consistent if we're going to not chastise but be super critical of the course stability idea here. - And with all that said and with this knowledge, we still use TRA or timing and then maybe even progressed to bracing or a version of a bird dog. So is it okay to use these older paradigms, older treatment models with an updated narrative? How do you approach that? - I would simplify. I would say I don't do it but you could certainly still have someone be aware of their spine and try to work on transverse abdominis timing or multifidus timing because that does have like clinical efficacy. It just may be for another reason. And I think if you're honest with yourself, you can do it. You just wouldn't say that we're changing your faulty firing patterns. It could certainly work because it's a start to loading and to get uncomfortable with your back again. And if you're fearful of movement, you start doing these exercises. You start paying attention to your spine again. It could be just related to the awareness of your spine. Right. So I don't want to denigrate anyone who still does it because I would recognize that they are helping people. I think like everything, you can just have an update on what you might be trying to achieve. Just like a bird dog. I still give bird dogs to people with low back pain. I think stressing the spine is good for it. So I just don't think my goal is to make it stiffer. And that's what's mediating recover. I think I want to load it up and work their ass also at the same time. Why not? - What would be your narrative to a patient? So if I was to go slightly old school and say, oh, this will stiffen you up. We're getting these muscles nice and strong and stiff. And that's going to protect your spine. What would be a more updated narrative? when you give a bird dog? - Yeah, so I mean, I've been banging this drum for 15 years. I'm a simpleton here. It just comes back to that simple idea. Like, you're spying, are you are sensitive to certain movements? Avoidance has its role sometimes, but at some point in time, avoidance isn't helpful. It's like being in a dark cave your whole life. And as soon as you go out into the sunlight, like coming out of a COVID lockdown, you're not gonna tolerate that light. And spending more time in that cave isn't gonna prepare you for it. So I can use a bird dog by saying, we wanna get your spine a little bit less sensitive. Especially if someone's done the exercises in the past and they're safe and they feel confident with them. And they're like, why don't we start with this? And then we'll go to squats. And then we'll do something else. And this is weird. In my course, we do this. We bastardize the bird dog. And everyone, for some people are not gonna like it. But if someone's sensitive to spine extension, I'll do the bird dog with a shit ton of spine extension, just to get them comfortable with that, or a lot of flexion. So you progress from neutral to flex, to extended, to twisted, to all these things. So it's just like anything else. It's just building up a tolerance to something. - What I sometimes struggle with along that path is some of the older systems like extension, right? Like extension helps you so we're gonna do it. When I learned that it was attached to an older narrative, I still struggle with that sometimes as to, yeah, this is just a way where you can feel less pain. How do I separate that old narrative for them? Are they gonna walk away and then just go, no, I need to stay in extension because that's what my physio told me. - Yeah, so that's funny. I actually meant it as the opposite, is you go into extension because it's kind of sensitive. - Yeah, so you're poking into it. - Poke, yeah, poke the bear. - I always find that a fascinating question in rehab. When do you expose into a sensitive movement and when do you avoid and protect? It's just the thing that I have the most trouble with. So bird dogs, a nice one. So let's say they're sensitive to extension. We would start not, but just loading it up and say, it seems like we keep flairing you up and we go into extension. Let's avoid it for a bit, but now it's a goal. We're slowly over time, you're gonna get us. Maybe when you do this bird dog, imagine that you're going into extension, right? And imagine the stress and worry that you're feeling and now get comfortable with those feelings as well. And then we start doing it physically. So that's how I take it. Something really, really simple is that. - Do you have any key questions you ask patients when they're exploring that pain? - Yeah, so I definitely ask, like why do you think this is helpful? What do you think's going on when we do this or are you concerned about this at all? - Does structure ever come up? I often find at that point, the lean on structure, like I have a disc bulge. - Yeah, you know what? I'm a true biopsychosocialist. I don't get into the academic arguments about it. And when I mean biopsychosocial, I just mean everything in the Cosmere. So a Cosmere is a brand in Santerson, the universe. I don't think Cosmere is a real word. Anyway, it means just like everything can influence your pain. And I say, there could be something in your spine that's sensitive. It could be the disc, it could be a facet, it could be a ligament. I don't know, in Nord is anyone else. It could be all these things in your life. So we're gonna choose an approach that can kind of work on all of them. So I don't know how much of it is a disc, but I do know that movement and stress is good for tissue. So if the tissue is involved, great, this is good for it. The tissue's not involved, it doesn't matter because the exercises and activity and all the other things we're doing help your nervous system, or help how you respond to sensitivity. So I never feel like I parse it and I don't feel like I ever have to have arguments with my patients about where the pain's coming from 'cause it doesn't really matter. (laughs) - Yeah, yeah, that's good. Do patients ever feel like you're disregarding their MRI or scan? - No, 'cause I'll acknowledge that it can be part of it. You know, that's why it's the cup analogy where all these potential contributors to pain or mediators are in your cup. You can never be sure. Let's treat with a big net. There's lots of different things that we can do. - I like that. That's a really nonsensible approach. I feel like it's very easy to see someone doing a bird dog or a manual therapy or start with a basic exercise and make some judgments. I think you're communicating often with the patients. I wanted to ask, how often do you see someone like in an example like that? They're pushing into extension. Are you feeling like you need to see them often? Do you call them a lot? Do you email check in? - Yeah, it's a lot. It's the email. I always stress to my patients. Like don't hesitate to email me anytime and I'll get right back to you. So anytime a patient is pushing into discomfort, I'm like, let's just see how this goes. Let's evaluate it over a couple of weeks. 'Cause that old adage, like it took you a long time to get into this. It wouldn't be weird to take a long time to get out of it. But, then I'm always optimistic. But amazingly, you could feel dramatically better in a week. I have no idea. - Right. I was sad those expectations, very broad. - They're broad, but they can get in touch. Do you find people do get in touch often at the start of that journey? - Yeah. Then if it's too much to do through a one sentence email, then we do follow-ups of course and all of that. It reminds me, I need to send out an email today. - Greg, we've actually already gone the time limit. But thank you so much. I've really enjoyed this chat. We'll have to do a part two. - Sure. Thank you. - Thank you so much, mate.