Over the last week or so I’ve seen some interesting discussion and debate on the relationship between posture and pain, and the role that methodologies such as PRI have in correcting/treating them. This discourse has prompted me to reflect quite a bit on my own beliefs on these topics, and I’d like to share some of my thoughts.
While I’m far from an expert on pain science, I do know that the current body of evidence suggests that “poor posture” generally does not cause pain and at best is only weakly correlated to it (note: if you’re interested in pain science, I highly suggest the work of Dr. Lorimer Moseley). Questions of what exactly even defines poor posture aside, we know that pain is a multifaceted and incredibly complex biological phenomenon that rarely, if ever, has solely biomechanical contributors. In almost every case, neurophysiological, psychological, emotional, and social factors combine with biomechanical dysfunction in a complicated and often unpredictable way to cause the symptoms a patient is suffering from. As a result, isolating posture as the sole focus of treatment is, in many cases, inadequate and can yield subpar results or even render treatment ineffective.
Why, then, is considering biomechanics during treatment and using an approach like PRI useful at all? For one, just because biomechanical factors are not the sole contributor to a patient’s symptoms does not mean that they are not contributing at all. Many cases will involve at least some sort of biomechanical dysfunction, even if it is not the main cause. And just because it is not the main cause does not mean that it should be ignored; if the patient is experiencing pain and some sort of pathology does exist, then it should be addressed and treated. As I previously mentioned, pain can be unpredictable and even the most minute of changes or corrections can yield benefits.
Beyond this, however, is the fact that, as I’ve written about extensively in my Intro to PRI series, methodologies such as PRI that may seem to take a biomechanical approach on the surface have a profound effects that extend beyond just the musculoskeletal system. The anatomical patterns that PRI seeks to address are in many ways simply a means to an end: because the patterns are characterized and regulated by specific patterns of Autonomic Nervous System (ANS) activity, treating and training the body in ways that opposes these patterns can influence the balance of ANS activity. Since the ANS and the limbic system–which is a set of cortical, subcortical, and diencephalic structures that are responsible for mood, motivation, emotions, memory, and learning, among other things–are closely linked (primarily via the hypothalamus as well as afferent feedback loops from the ANS to the limbic system), changes in autonomic activity can potentially have a significant impact on negative sensations such as sadness, anger, and even pain. This concept has been demonstrated in the literature time and time again via the observation that manipulation of autonomic functions such as breathing, heart rate, heart rate variability, etc. can induce changes in mood, emotional states, and feelings of wellbeing; Rob discussed a few such studies in his previous post on uncommon recovery strategies. The bottom line is that biomechanical and neurophysiological function are very closely related, and it is impossible to affect one during treatment without influencing the other as well.
Even after taking all of this into account, we must consider the possibility that human social interaction and the sensation of human touch can and often do play a role in treatment as well. Touch and especially words can be immensely powerful when used appropriately, but they can also be extremely harmful if used in a manner that the patient doesn’t like. This is why practitioners must always consider what they say and how they act when dealing with a patient. Displaying unwavering optimism and constantly expressing how much you care are absolutely infectious and can contribute to or even cause positive outcomes, even without actual meaningful biomechanical change.
With all of this in mind, the question then becomes: where do we often go wrong? Where does the system break down, and why do we find ourselves disagreeing over philosophies and methodologies? In my opinion, the problem is that we either are not aware or somehow lose sight of the fact that it is fundamentally difficult not to get lost in a particular way of thinking. It’s hard not to become so deeply enamored in a certain system or a specific approach, and that’s mainly because we see them work so frequently! There are countless practitioners and coaches out there experiencing success using all sorts of different approaches—PRI, ART, FMS, you name it. Many approaches do work for at least some people, and when we see the successes that we’re able to achieve we become convinced that (1) it is the right method or the only method that people should use, and/or (2) everything that we were taught about that method must be true. It is these two assumptions that are so easy to make, especially subconsciously, that are also in violation of one of the most basic principles of the scientific process: question everything, and accept nothing without testing it first. When we make these assumptions and violate these principles, we turn the treatment process from one based on science into one based on dogma.
In order to avoid this mistake, we must always remain grounded in the fact that just because it appears that a treatment has worked doesn’t mean that it necessarily worked in the way that we believe, or that it wasn’t something else entirely that we’re not accounting for that caused the improvement. For example, I can treat a patient with PRI techniques and algorithms, but for all I know it could be the fact that I had a nice, warm conversation with them for an hour and/or the fact that they feel that they’ve made a connection with someone who they can trust and who cares for them and who wants to help them that made them feel better. From the practitioner’s point of view, it’s easy to believe that the 90/90 Hip Lifts and Sidelying Adductor Pullbacks restored function and alleviated pain, because that’s all that we can see–as much as we’d like to, we can’t see inside a patient’s mind. And it very well may be the case that the exercises and manual therapy contributed. But unless we have definitive evidence, usually in the form of controlled research, that states otherwise, we must always consider the possibility that our treatment is not working for the reasons we might perceive or believe. If we do, then we will, in my opinion, avoid much of the unnecessary debate on the superiority of different methodologies and treatment approaches.
This line of thinking raises another question: if it’s not working for the reason we thought or were taught, does this mean that the treatment is bad? Absolutely not. If it works, then it works. Take this example: if a drug designed to treat a disease was found to dramatically reduce symptoms with few to no side effects but we didn’t fully understand the pharmacokinetics, then would we withhold that drug from patients suffering from the disease? Certainly not. What it does mean, however, is that it should not be held up as incontrovertibly true that the treatment works in a specific way, or that it works for everyone. This is what causes science to become dogma, and the scientific and practitioner communities as a whole suffer as a result. While anecdotes and personal experience constitute evidence, they are not considered as strong as scientific research for a reason: they almost never control for external/confounding factors that could be affecting or contributing to the intervention. Keep this in mind as you both formulate your own treatment approach as well as educate others about the treatment process.
To wrap this post up, it’s worth pointing out that these thoughts get at our core principle at Integrative Human Performance: many different treatment and training approaches work for many different reasons, so we believe that taking the things that “work” from the various methods out there and using them as the situation and the individual dictate is the safest and most efficient way to get optimal results, no matter what the goal. There is no one treatment or training approach that is universally true and should be used in isolation, and there likely never will be. Furthermore, using an evidence-based model in constructing your belief system and treatment or training approach is a great approach, but it is important to remember the hierarchy that constitutes the varying strengths of different types of evidence. If we don’t, then we open ourselves up to the possibility of becoming engrossed in certain types of evidence, such as anecdotal clinical success, that may not actually prove what we think it does.
- Gatchel RJ, Peng YB, Peters ML, Fuchs PN, Turk DC. The biopsychosocial approach to chronic pain: scientific advances and future directions. Psychol Bull. 2007 Jul;133(4):581-624.
- Leung L. From ladder to platform: a new concept for pain management. J Prim Health Care. 2012 Sep;4(3):254-8.
- Loeser JD, Melzack R. Pain: an overview. Lancet. 1999 May;353(9164):1607-9.
- Moseley GL. A pain neuromatrix approach to patients with chronic pain. Man Ther. 2003 Aug;8(3):130-40.
- Moseley GL. Pain, brain imaging and physiotherapy–opportunity is knocking. Man Ther. 2008 Dec;13(6):475-7.
- Moseley, GL. Teaching people about pain: why do we keep beating around the bush? Pain Manage. 2012;2(1):1–3.