All human beings should be able to perform basic maintenance on themselves-- Kelly Starrett
Kelly Starrett's (@MobilityWOD) recent appearance on the
Therapy Insiders Podcast a few weeks ago generated ever so slight a buzz in the PT world on social media particularly over the topics of movement, mobility, performance, and pain. Reverberations from the interview and the ensuing discussions are still going on now. It's an important conversation to be had, and while much was debated, I'm not sure that anything was yet resolved, nor will it likely be anytime soon. However, such discourse is vital as we adapt to the changing healthcare landscape and the evolving scope of our profession.
I, for one, was grateful for the discussion because the relationship between movement quality and pain and function is one that I've had an internal struggle with for several years. My manual therapy training through the Ola Grimsby Institute was heavily inundated with biomechanics and pathoanatomy, but fortunately there was still a healthy dose of neurophysiology through emphasis on some of the proposed mechanisms of manual therapy (see work by Bialosky et al), central sensitization, and segmental facilitation.
Before going any further, let me also say that I am a fan of Kelly Starrett's work. This does not mean that I agree with everything he says or promotes, and I think I made that clear on social media during the aftermath of the podcast. However, I love his passion and commitment to promoting movement awareness, strength, and self-efficacy. Do I agree that "dysfunctional" movement automatically leads to pain? No, I don't. Do I acknowledge that "better" movement is possible? Yes, I do. Do I own a "supple leopard" t-shirt? You know it. It's the most comfortable t-shirt I've ever owned.
Kelly's work has had a positive influence on me, both personally and professionally. As some of you may know, I am more than fifteen years post lumbar fusion (L4/5) for spondylolishesis, and have been managing inconsistent but ongoing low back pain/tightness since. Several hip joint and soft tissue mobilization techniques that I discovered from Kelly's work became immediate "game changers" for my own rehab/mobility and symptomatic improvements, and I began incorporating them regularly into patient care,
From a big picture perspective, I think Kelly is taking a look at problems that we can all acknowledge are plaguing our society today-- obesity, heart disease, cancer, stress, diabetes, and chronic pain-- and seeing that even with advances in modern medicine, the incidence of most of these conditions is RISING, not declining. Lifestyle choices can arguably have a profound impact on some, if not all of these issues. One of the things that directly affects lifestyle and health is lack of physical activity, and I think this is where Kelly believes he can gain access to people to try to influence change.
There appeared to be two general groups on social media following Kelly's appearance on Therapy Insiders. (I'm painting with a broad brush here). On one side there was a very movement-centric group with the viewpoint of "good" vs. "bad" movement. This community appeared to primarily consist of strength coaches and the hybrid PT-strength coaches. The other group was much more skeptical, (to put it mildly) regarding the distinction between good and bad movement. They had particular objection with the assertion of the association with "dysfunctional" movement and positions with pain.
Everyone is right with their thinking, except everyone's thinking is based on a particular set of assumptions-- Katy Bowman
I'm in the camp of trying to keep an open mind and figure this shit out. While I am a much stronger advocate of the biopsychosocial model, I don't think we can discount movement, lack of movement, or quality of movement as not being an issue. After all, it is part of the "bio" in the BPS model (Greg, I had this last sentence in there even prior to our conversation on Twitter).
Because we also acknowledge that pain and tissue damage are unrelated, can we then say that abnormal movements or stresses can cause joint/tissue damage without us having the perception of it? Without the perception of pain does that mean everything is fine and shouldn't be addressed? I have a hard time wrapping my head around that one as well.
Yet, at the same time, I don't think we can also say there is an ideal way to move. Although there are range of motion standards at each joint, quality of movement can be relative to each individual and for a particular activity. For the average person, movement variability is probably more important than moving in an "ideal" form. From my perspective, I think the discrepancy lies in the type of person that the opposing groups are seeing. Movement specifics may be more important in more active, athletic, and performance-oriented populations that appear to make up the bulk of the patient/client population of Kelly's as well as other hybrid S&C/PTs, as opposed to pain-dominant and less active individuals. In these cases, more frequent movement, in my opinion, trumps "optimal" movement.
Not only are the structural explanations for pain generally unsupported by any scientific evidence, the last 25 years of research results mostly undermines them, often impressively-- Paul Ingraham
For example, I work in a general outpatient ortho private practice. On Thursday, I eval'd a 15 y/o female runner with recurrent "shin splints" with more of an SFMA-type approach. An hour later I had a follow-up with a 57 y/o retired gentleman with a long smoking history and type II diabetes. He had presented with sub-acute LBP several weeks earlier after helping his daughter move furniture and was highly guarded with all movements. He needed to have his fear reduced and his confidence in movement increased. In his own words, he is significantly better now, but to look at him from a movement standpoint, there is still much to be desired. But his goals are different. His baseline is different. Ultimately, he still needs to move and move often.
My main concern is the nocebo effect that comes from pointing out "flaws" within someone's movement. With so much individual variability, can we really know for sure? Highlighting "problems," especially in the rehab arena, may only serve to drive fear, something that as clinicians I think we should constantly strive to avoid.
Here are some questions I've considered followed by my current responses, based on some of the issues that were discussed. To borrow a phrase from Greg Lehman, I reserve the right to change my opinion at any time:
Do biomechanics matter?--(yes-in certain situations, positions, under loads, and with some people but not all)
Does pain change movement?-- (yes)
Can changing how someone moves affect their perception of pain? (yes)
Can someone have full functional movement and still have pain? (yes)
Can someone have less than optimal movement and be pain-free and have full function? (yes)
Does level of function matter to each individual? (yes)
Can movement affect function/performance at a high level (probably)
Does load matter? (yes)
Is load relative to each individual? (yes)
Is knee valgus bad? (sometimes, but not always. Just ask an ice hockey goalie)
Is it safe to lift things with a flexed spine (yes, for some people. It also may depend on the load, frequency, tissue status, previous training level, etc).
Should I pick up 400 lbs with a flexed spine? (I wouldn't)
Does pain mean tissue damage? (No)
Can you have tissue damage without pain? (Yes)
Can you predict that "better" movement will reduce risk for injury? (Much of the research doesn't seem to think so but I think this is still the big unknown)
Now, maybe I'm being naive, but after reading two of Kelly's books, listening to almost every podcast interview he's done, and watching many, many of his daily m/wod videos, I think Kelly has a better understanding of pain and its relationship with movement beyond what he lets on with his public persona. Likewise, I believe that Robin McKenzie knew there was more to treating low back pain than just press-ups. (And yes, before you start yelling at your computer, I know the MDT method is more than just press-ups. I'm just trying to illustrate a point).
Pessimists are usually right and optimists are usually wrong, but all the great changes have been accomplished by optimists-- Thomas Friedman
One thing we can agree on is that Kelly is a very effective communicator. He knows his audience. And guess what? I don't think his primary audience is us. By us I mean physios in the classic sense. His audience expands beyond to strength & conditioning and Crossfit coaches, athletes, military operators, and those that desire to be part of those communities. It's like Simon Sinek's mantra in Start With Why, "people don't buy WHAT you do, they buy WHY you do it."
I think Kelly's "WHY" is pretty clear. I think he sincerely believes that most people are capable of doing more and being better than what they believe for themselves. He also takes interventions beyond the traditional rehab- to training, sleep quality, and nutrition. He is trying to stop problems before they start, which is an admirable quality.
So, why is this an important concept to understand? Well, what's one of the biggest issues we face in physical therapy? The average person doesn't really understand "WHAT" we do! Gene Shirokobrod highlighted this fact several months ago on an episode of Therapy Insiders during a "man on the street" segment outside of the private practice conference. I imagine if we asked ten physios the same question, we would also get a variety of responses.
If we're honest with ourselves, we will admit that most people don't like to have to think too much. They respond much better to messages that affect their emotions. In the 1980s, an ad for Steve Jobs' brand new Apple computer "Lisa" was 9 pages of technical jargon placed in the New York Times. It bombed. Jobs was let go. At Pixar, he learned the art of simplicity. When he was brought back to Apple, the first ad that was run consisted of just two words: "Think Different." The rest is history.
As Sinek explains, the logical, language part of our brain, the neocortex, is not where decision making resides. Decision making resides lower down, in the reptilian limbic brain; the one that responds to emotions. Kelly uses words like "release," "smash", and "gristle." Many clinicians dislike the use of these words because of the relative inaccuracy of the descriptions to what is actually taking place within the tissues or with the top-down effects from the stimulus. But these words can create a visceral reaction. This gets people's attention. Jerry Durham discusses this same concept when it comes to PT marketing and customer experience. It's about how the customer feels about your clinic--the location, the look, the smell, the sight, the general ambiance.
We very emotionally and animatedly, remain static. If you're going to be emotional and engaged, do it while moving forward-- Jeff Moore
Instead of the incessant squabbling, can we find a middle ground? There is no absolute "right" or "wrong" that has yet to be demonstrated. It's important for every clinician to extrapolate and distill information and concepts and determine how they might best apply to the person sitting in front of them.
Healthcare is evolving. How people consume healthcare will hopefully not be too far behind. Our profession needs to evolve as well. Change starts with a movement (see what I did there?). Some movement can lead to more movement. More movement may lead to "better" movement. I think we can all agree that there is a "better" out there that is capable of being achieved.
Thanks for reading,
-Andrew
Interested in live cases where I apply this approach and integrate it with pain science, manual therapy, repeated motions, IASTM, with emphasis on patient education? Check out Modern Manual Therapy!
Keeping it Eclectic...
