Critical Thinking

The Lack of Meaning in “The Movement System”

I recently watched this interview of Shirley Sahrmann where she describes the future of physical therapy.  Immediately, and predictably of course she launched into her ideas of “developing a diagnostic framework,” “creating labels and using them,” and “identifying a physiologic system and treating that system specifically.” Of course that system is the movement system.  No surprise here she has been preaching this stuff for the last 20 or so years.

What’s wrong with that?  That seems like all pretty harmless stuff—after all we do deal with movement.  To a point this is all true and we have been focused on all this since our profession’s inception.  Despite not borrowing much from basic physiology or motor control research we are still creating impractical theories that have poor correlations to the basic science that should at least underpin them.  Going back to Sahrmann, I asked her during a course she taught, “How she could explain rapid changes in pain and movement via sarcomeres in series (as she speculated) when they are not likely to be impacted during such a short response time (< 4 weeks)?”  To paraphrase, she relayed that she used the concept solely for explanatory purposes and that she had a hard enough time explaining the sarcomere story to physical therapists let alone the more complex concepts of motor control (that would argue against her theory).

  This weekend I also opened up PT In Motion as I was curious about the lead article “APTA’s Vision to Transform Society.” Bold right?  Well surprise, surprise, the goal is, “Transforming society by optimizing movement to improve human experience.”  The article goes into how great and specific this goal is.  Yes, this is VERY specific—heavy sarcasm is to be implied.  Moving on, under the topic of identity the article goes on to elaborate that “the importance of validating the movement system along with other body systems and affirming physical therapy profession’s responsibility to define it, promote it, and evaluate and manage it in patients and clients.” Shirley Sahrmann all over again, same as it never was.

Again, you’re probably asking, “geeze Eric what is your problem?”  Well here is my problem, when I was in PT school I was as much into the movement system as everyone else and I even did some basic science in motor control. Then I started treating patient’s and things got a little sticky—actually real sticky.  Despite taking all of Sahrmann’s courses, patients never really presented themselves in the neat little packages as claimed by Sahrmann or anyone else.  I realized that while movement was part of the treatment it was often not the least common denominator of my treatments.

The term movement system implies an agnostic stance with respect to what causes movements and to what movements belong.  What do I mean? First movements are produced by intentions: a mix of ideas, emotion and motivation.  Second, they are carried out as part of behaviors—which are coordinated with environments in ways to produce effects on environments.  Motor control and the physiological adaptations that occur due to movement occur at this narrow junction that binds intentions to behavior.   When we approach the problems of humanity from the narrow stance of the movement system we are admitting we either don’t know or don’t care about the other parts.  This is the agnostic position that is implied via the treatment of the movement system.

We have been there, done that, tried that, and it has gotten us nowhere.  In fact there is a fairly robust literature in biology, motor control, and muscle physiology about how the nervous system optimizes itself WITHOUT a physical therapist ever being involved.  In fact one could easily ask, why would evolution require a physical therapist for such optimization—probably a very important topic to be tackled later given the broad claims by the APTA.

I am advocating that it is time as therapists we ditch this agnostic position and put some real skin in the game and start dealing with concepts of intentions and behavior.  Whoa, those terms again, those sound like psychological terms one might rejoinder.  When does a movement dysfunction become a behavior and when is that behavior guided by an intention?  These are the hard questions that our profession faces and it does so with a poverty of language and experience in such fields.  Movement unbounded from behavior and intention is essentially meaningless.  Last time I checked human behavior is hallmarked by meaning.

When patients visit us in pain, their movements are parts of broader expressions of behavior.  These behaviors are guided by intentions.  We understand that when a child falls and skins their knee and then looks to mom as means to understand the onslaught of novel sensations flooding their body: they are intending to understand through social referencing.  If the mom expresses attention that conveys alarm through her behaviors, the child’s defense system is ramped up and crying commences.  If mom express equanimity and acknowledges but does not alarm, the child’s distress resolves quickly and without consequence.  The coupling of these seemingly automatic aspects of social referencing occurs without question in children and carries much meaning.

When we divorce our profession of meaning by focusing on “optimizing the movement system” we are inadvertently extricating ourselves from the very fabric of what it means to be human.   We create agnostic classification systems that compartmentalize simple acts that our patient’s carry out when they experience novel and perceptually threatening experiences.  It is time we grow up as profession and to stop thinking that it is going to be taxonomy of movements or interventions that is going to create a diagnostic panacea in our patient populations.

Eric Kruger, DPT @Kintegrate

About these ads

Categories: Critical Thinking

Tagged as: ,

49 replies »

  1. Eric,
    Well thought and well said. I’ll start by saying I’m a big fan of Dr. Sahrmann. Not for the absolute nature of the classification systems she presents but for the observations she shares in each one. It is really inspiring to imagine them at their inception all that time ago. I agree we have progressed greatly in our understanding of movement and motor control and there is now more to consider/master if we want to deliver a holistic approach to restoring function. I came from a Movement Systems focused practice where I practiced a lot of manual therapy. These are two of the tools we talk about a lot in our profession but I agree it is our ability as therapist to steer a patients behaviors and BELIEFS about their body that plays a major role in a patient’s ability to return to function. We offer the promise that by restoring a convincing set of systems into balance that they can in fact recover from their issue. We empower them to “move”, by using our ability clinical reasoning skills to give them the ability to succeed with movement. This further encourages activation of the patient. We create a road map from a basic TA/pelvic floor contraction to tossing their bike on top of their car through structured purposeful exercise. They believe this will help because of our branding as a profession, what they’ve heard and experienced. We relieve the burden of the potential consequences of movement through sharing our knowledge of the healing process, empowering the patient by taking the time to help them understand where they are and what is appropriate based on their phase of healing or ability to handle load through their system. We also know when it is time to crack the whip and get real with a patient about what it takes to recover. It’s the belief that they can get better, that they will get better, and that they have the help of someone who knows what is going on with them. I love where you’re headed with this conversation. You’ve put your money where your mouth is and I can’t wait to see what tools you’ll cook up for us clinician. In the end the APTA isn’t too far off with the whole movement pitch. It’ll just take them time to catch up with innovators like yourself in their branding. Good luck in your post grad program.

    Mitch Owens MsPT, CMPT

  2. Thank you for this writing. I have noted this void in the profession of Physical Therapy as well, and a few years ago decided to start practicing in a way that will touch on a persons deeper needs, desires, fears etc- all either barriers to healing or a driving force to heal. We are nothing without addressing the whole.

  3. Mitch,
    I’m afraid that if the PT profession goes in the direction that Shirley Sahrmann recently recommended, which includes performing regular annual movement exams to identify “damage” in the movement system, then we’re in deep trouble. And the reason we’re in trouble is cogently described by Eric in his comment above. Dr. Sahrmann’s “kinesiopathology” premise flies square in the face of the current neuroscience relevant to pain and its impact on movement and motor control. The assumption that there’s a causal relationship between clusters of movement and alignment “impairments” and pain has not held up to scientific scrutiny. The evidence is in, and there’s no evidence to show for the decades of development of the kinesiopathology model of movement. It has no predictive power at all. It’s dead in the water, and it should be discarded. However, PTs continue to attend MSI courses in droves to learn the latest permutation of this tragically flawed classification system.

    The MSI approach offers two things that PTs just love: a false sense of certainty and results. Yes, teaching patients to perform very specific movements in a graded and thoughtful- dare I say novel- way can help to bring about resolution of a pain problem. However, as a doctoring profession, we are obligated to rely on more than just empiricism in guiding our clinical decision-making. We are obligated to think critically and to move past theories that fail to explain things as they actually are.

    Your comment: “They believe this will help because of our branding as a profession, what they’ve heard and experienced” is all too true. The power of patient expectation and beliefs regarding a biomechanical cause of a pain problem has been roundly reinforced in the medical and therapy community. We really need to stop doing that.

  4. This is nice Eric, your point shows how research is messing up with our minds. Too many information coming out. Exciting and worring at same time.

    I have been seeing and reading lately two sides of the force, the Movement side and the Behavior/Beliefs side. As both were opposites. In my point of view, both sides are right in patients with different priorities. Don’t get me wrong, but we need Sahrmans and O’Sullivans in our world. We need professionals with different focus, looking at different things, so that we can get as many information as possible. Each one will highlight what they see and study. Clinicians may find sometimes in there practice both sides in the same patient, but in different moments. You don’t need a Pilates Studio in your office, but you may not need a divan/couch as well.

    You may not be able to find any movement dysfunction in a lot of patients with acute or chronic pain, simply because they are not moving and/or that’s not there priority in that moment. if those are the only patients you see everyday, well… you may focus your energy studying and learing what your patients need.

    My biggest concern today is that I have been watching many defending one side or the other with all there heart closing there ears and eyes to different ideas. I see this as fanaticism and is not good.

    Yes, we have many looking only at movement, and many times not in the best way. But it doesn’t mean that movement is not important.

    The challenge that we face everyday as Physios relies in our capability to find and understand all of those aspects. We as Physios must understand movement, otherwise a change in profession is something to consider, but yes, all of the beliefs, behavior, sensitisations… must be consider in every second when dealing with patients. We must learn how prioritize one over the other, or when one is simply not in the table.

    But more important, we must learn how to find and fix each one, otherwise we may not be able to judge and make good prioritizations. A good team have individuals with different skills that masters the same game.

    We are in a fantastic moment right now with real good stuff coming out. I suggest everyone to hear everything, question everything and learn, but please don’t throw anything away and don’t say there’s not evidence in movement base practice.

  5. Agree with need for this discussion, but poor choices in focusing on discrediting other professionals. This post will feed your base, but have limited impact on your cause. Also read this looking and waiting for your solution to this problem that is posed to ruin our profession (little dramatic). Could not find that and I assume that will be in next months post. I think more solutions would make for a better post. Anyone can attack others ideas and claim supreme knowledge. So the question is what should we be doing to get better? Specific ideas would be nice. Trashing your profession is not effective.

  6. I found the tone of your blog post to be very concerning. I am a physician who has attended many Washington University courses and my practice is focussed on using my movement impairment education which has proven to be very successful and far succeeds anything else that physiotherapists have offered to our patients and fortunately there are a number of therapist in my area that have the same confidence in changing movement patterns to get rid of people’s pain which is possible without any specific brain therapy. I am excited to see that the APTA has changed their mission statement to encourage their members to take the lead in treating musculoskeletal and neuro disorders. I can tell you from my example that there is a steep learning curve in learning and applying movement system rehab principles but the effort is well worth it. I consider myself to have the best job in the world as I have endless hours of fun putting the pieces of the puzzle together by using a standardized examination and many patients have been given information that has had a significant impact on their lives.
    I know that Dr. Sahrmann is widely respected for her huge contribution to the physiotherapy world and I think all physiotherapy would be wise to pay attention to what she has to say. I also think that a yearly check-up is a fabulous idea!

    • I think yearly check-ups are a terrible idea. We’ve already hurt ourselves as a profession with somehow accepting the idea that pain and tissue/musculoskeletal changes are directly related, when their not. Wouldn’t yearly check ups to make sure everything is “in line” further reinforce terrible concept?

  7. Could I recommend that you remove this blog posting? I had the opportunity to carefully read it and it downright disrespectful and I think likely libellous. You should be ashamed and I promise you I will never return to your website again and I think I will cancel my subscription to Medbridgeeducation as well.

  8. Dr. Stalker,
    I want to first let you know that while ForwardThinkingPT does have an affiliate relationship with MedBridge, which allows us to offer the service at a discounted rate, they are in no way directly connected with this site and the views expressed on this site are not endorsed by MedBridge and are solely those of the author.

    The overall intent of ForwardThinkingPT is to invoke critical thinking amongst Physical Therapists (and other movement based practitioners). To move our practice forward, to a position of being seen as direct, point of entry providers, for movement based problems, we must continuously investigate what we know, and meld that with what we are learning, and determine, “How does this make sense”? Movement is quite an intricate and beautiful thing that we are all attempting to understand (including Dr. Sahrmann). We are very fortunate to be in positions where we can do this regularly.

    While it appears you disagree with Dr. Kruger’s thoughts, I welcome you to write a formal rebuttal article, which I will post to this site. I think this would be important, because it is our duty, as a blog attempting to promote critical thinking, to present ideas to allow the readers to analyze and determine how they may impact their practice. My email is joebrence9@hotmail.com and I sincerely hope you will take me up on this offer.

  9. Robert Stalker, the movement impairment approach is devoid of good scientific principles. I actually find your comments interesting; can you tell me what physiological processes are occurring when you “ged rid of a people’s pain”. Your comments also highlight an ignorance to what the “physiotherapy world” is achieving in developing science-based interventions for individuals with persistent pain. Telling a person a “movement impairment” is the reason for their pain is ridiculous.
    p.s. I’m feeling a tad obtuse, please can you also explain “brain therapy” (not sure what you mean there) and describe the “steep learning curve” associated to promoting novel movement (i.e. behaviour change), sorry I meant “movement system rehab principles”.

  10. Dr. Stalker,

    Thank you for your reply. After consideration, the sentence regarding my opinion as to the content of Dr. Sahrmann’s knowledge of modern motor control have been removed. Thanks to your remarks I realized they were irrelevant and did not assist in the goal of this post. Sometimes passion gets the best of us, my words got out in front of me and I should have been more restrained–poor form on my part. Eric.

  11. I have no interest in writing anything further than to acknowledge that I make a mistake making an assumption that Medbridge Education was a sponsor of your site which is not the case . I personally am a big fan of their website and especially enjoyed Carrie Hall’s program on the hip. The point of my other contributions was to simply say that I use movement impairment principles with great success and have done so over many years. They have made many changes to the material they teach which I see only as a good thing. No one has had a bigger impact on my medical practice of 35 years than Dr. Sahrmann and her colleagues. The other point was to “voice” my displeasure with the rude tone of the blog and there is no place for that. Please show some respect for the giants in your profession whether you agree with them or not.
    I often make judgements using the following quote of Nietzsche – “Convictions are more dangerous enemies of truth than lies”.
    Over AND OUT

  12. Dr. Stalker, please ignore my earlier post, I meant to reply to the entire thread, not directly to you. I agree when you say that we should respect the contributors to our profession, but does that mean we shall not challenge their ideas/beliefs at the same time? Where would we be now if we have not challenged the “big names” of our profession. What if Melzack had not questioned his own theory on pain? We’ve hurt ourself as a profession accepting the fact there is a direct link between musculoskeletal impairments and pain, when their isn’t. I reckon there have been a lot of patients in the past that as a profession that we have failed at helping because of this. I think yearly check ups to make sure everything musculoskeletal wise is “ok” is a really bad idea, as it further contributes to theories that we need to work away from as a profession.

  13. I am interested in the concept of “yearly” examinations, but I am not sure what we could truly conclude from the results, nor what should we focus on during the exam. For those who are proponents of yearly examinations, what do you suspect we should be looking for? Research has indicated that there are likely many contributory variables that result in pain and/or injury. Would the yearly examinations focus solely on movement patterns and biomechanics (indicating that these are directly correlated with injury/pain—which I have not seen to be completely supported in the research) or would we also screen for kinesiophobia, catastrophic thoughts, work environments, depression, etc. which have been more recently shown to be correlated variables. I do see value in obtaining baseline data on individuals (as long as the baseline data looks at the “human”, not simply the meat and bones) but I believe we need to have an open discussion on what would we be examining.

    I am sorry to hear your decline of writing a rebuttle, Dr. Stalker, but will respect your decision. At this site, we discuss ideas that are important to our professional evolution. As our understanding of human neurophysiology improves, we must analyze what we are doing, and unfortunately, question if certain concepts make sense. In doing this, we must assess “ideas”, not individuals, because otherwise, we can easily make a genetic fallacy, known as an ad hominem. I am not impressed by “giants”; I am impressed by”giant ideas”.

  14. Robert Stalker says: “The point of my other contributions was to simply say that I use movement impairment principles with great success and have done so over many years.”

    With all due respect, 1. how do you define “great success” ? 2. Anyone can use this argument to support any construct. For example, an acupuncturist can say I have used the meridian theory principles with great success over many years. Does this validate the meridian theory or support its use? Not really. Does this indicate that the meridian theory was necessary for the perceived success? I don’t think so, any construct that exists in the mind of the therapist could have done as well, and IMO we can say the same for any “movement impairment” construct. Perceived success/usefulness by some does not necessarily support its use.

    Best,

    Evan Raftopoulos,PT

    • Evan, we define success based on the results we achieve with the system we are currently using. Your talking about optimization which is entirely different. In the early 1900′s if you raced Model T’s at top speeds of 45 mph then you were the fastest racer around. With technology just like with education everything progresses. Seems to me this post is more interested in looking “backwards” and discrediting old methods. Which for a group that supports modern neuroscience seems to be a strange argument and stance. As we know you cannot eliminate old pathways, instead you must encourage building of new pathways (ideas). That should be your focus not breaking down Dr Stalkers results based on his system. If forward thinking PT and PT’s in general wish to advance a cause it would be better served to advance the line of thought and promote a practical application of these methods. If this is available I have not heard of it, although I have certainly heard of movement impairment theories and treatments. Again I ask what should we be reading and doing to change our methods and make progress?

  15. @planeperformance

    I disagree. In the context of science based practice:

    If the validity of the old construct is found to be poor, the we can surely eliminate old pathways and create new ones.

    Respectfully,

    Evan Raftopoulos,PT

    • My point is that Treatment decisions are strongly based on habit. In many cases in spite of the science. A little bit if social intelligence can go along way for this cause. Denouncing others methods is a non-starter. We will imitate your methods if we see results (mirror neurons). You cannot simply hide behind the science, ask Dr Semmelweis about that one. He was a pioneer in antiseptic procedures, but physicians would not adopt his hand washing recommendations in spite of the science. This occurred partly because old habits die hard and also because Semmelweis was so arrogant in his theories that he alienated his profession. In that case people actually died, so if MD’s would allow patients to die in spite of science what makes you think that PT’s won’t keep selling movement impairment. They will until someone comes along with a model that works better in the real world. I hope someone in this create is able to create that. Thanks

  16. planeperformance states “so if MD’s would allow patients to die in spite of science what makes you think that PT’s won’t keep seling movement impairment. They will until someone comes along with a model that works better in the real world”

    Isn’t that what we’re trying to do here? The neuromatrix model (don’t really like calling it model as that splits up treatment camps). This model accounts for more variables that contribute to a person’s pain experience than movement impairment models. So don’t we already have a model then that works better in the real world? I don’t think coming up with a better real world model is the issue, the bigger issue is therapists not willing to let their old outdate models go.

    Also “what makes you think PT’s won’t keep selling movement impairment” seems kind of negative. Is this implying that we shouldn’t try. I think the patients deserve for us to find a more comprehensive model that relates to their pain, we owe it to them.

  17. @planeperformance

    I have hard time following your point. Do you agree that we should base our practice on plausible theories that derive from updated knowledge frameworks and logic?

    • Yes I agree with your model Evan, my point is that your model is not mainstream in real world PT practice and if you want it to be then it has to be promoted. Simply denouncing old methods is not effective and turns people off. It’s social intelligence and you have to find a way to mainstream the model. This post started with a PT seemingly more interested in personally attacking old methods than describing a cohesive new message. I have asked 3 time now what I should be reading or learning to better apply these models and no one has answered that question. That’s my point, I am seeking a positive forward direction to take practice as I understand the neuro perspective but not well enough to completely integrate it into practice. Does that make sense?

  18. @planeperformance — Thanks for your contribution, I would respond that sometimes you have to do some demo before you can build anew. Other people keep wanting to build additional floors on the same shaky foundation i.e. annual movement screens, movement that is divorced from intention, belief, emotion, and behavior. You too have the power to answer these questions positively. The person who points out questionable foundations of other people’s ideas is not required to construct; after all, he can leave that to others. But in case your wondering I do have some ideas, but right now I am going to eat dinner. Eric

  19. @PlanePerformance – Thank you for adding to the discussion and giving your insight. As a profession, we are going through a fairly rapid intellectual revolution. This is likely due to the rapid exchange of information through social media and websites, such as this. As we learn more and more about the human condition, we are beginning to unravel the intricacies of its beauty and complexity. Through the science of understanding pain and movement, we are also learning that there are an infinite number of confounding variables, that earlier models (in their best attempts), could not account for (many simply dismissed conflicting findings to statistical regression towards the mean). But in all of this, I do not think earlier models were wrong, or the authors were incorrect in their analyses. I suspect they were instead limited in the available data to analyze. In this post, Eric has analyzed and given some criticism towards a construct which categorizes human movement. He is doing this based upon information that IS widely accepted in modern neuroscientific literature and within many in our profession (even the APTA offered me the ability to author its “Physical Therapist Guide to Understanding Pain”, to present a modern insight on pain to Physical Therapists and Consumers of Physical Therapy. See here: http://www.moveforwardpt.com/SymptomsConditionsDetail.aspx?cid=e6dabed7-c6d5-4362-8260-9ce807427619#.UyEYwU0d_IW).

    A common question is: “Now what do I do? Tell me what to do with this information”. I would answer, “Keep doing what you are doing”. Physical Therapists connect with people. They get them better. I only ask for you to be open to expanding the possibilities of why a patient may have gotten better (an infinite number of variables may have led to the outcome—whatever that may be). Colleagues and myself, have been working on a clinical model of motor control, over the past year and a half, to help PTs, determine how to approach movement. It is succinct and has very few assumptions. It considers three things necessary for helping people move. You can watch me give a short research presentation from the 2013 AAOMPT conference here: http://forwardthinkingpt.com/2013/10/20/the-m-i-p-algorithm-introduced-at-aaompt-2013/

  20. Having practiced in Southeast Michigan for the past 20 years, my background is osteopathic-influenced manual physical therapy. Last year I took quite a turn and completed a Fellowship in Movement Science at Washington University. My current clinical focus is the treatment of chronic pain. I believe pain must be understood as a neuro-endocrine-immune response. I also believe that treatment for chronic pain is most successfully a bio-psycho-social, interdisciplinary approach, which is expensive and not supported by our current health care environment. I follow the work of Barrett Dorko, Dr. Mosely, Dr. Louw, and Dr. Butler. For those of you who are repelled by the Movement System approach because it seems overly simplistic or the research just hasn’t panned out, I have some experience using the Movement Systems examination and treatment that I would like to share.
    Have you ever watched a patient unable to turn his head because of pain and restricted motion suddenly learn that he has full and pain free motion with simple passive elevation of the shoulder girdle? Have you ever watched the strained expression dissolve from the face of a patient who has had constant heaviness and burning pain in her shoulder and arm after a simple change in position? Have you ever had a patient who has been walking for months with great pain suddenly walk without pain by cueing them to squeeze their glute and lift the arch? How about showing a patient that they can reach effortlessly overhead just by facilitating upward scapular rotation or shoulder girdle elevation? These moments have a profound effect as the patient realizes that they have the ability to move without pain. Many times this is the key moment to enlisting them as active participants in their recovery. I have many more of these moments after learning the movement systems approach.
    Of course, Movement Science isn’t the only answer for every patient, but it is definitely worth investigating. Every single patient is unique and some are more complex than others, and it helps to be able to recognize the patterns that Shirley Sahrmann helped to define. It has proven to be efficient at a time when visits are limited. Sometimes I use a Movement Systems approach, sometimes I use manual techniques, sometimes I purposefully avoid putting my hands on the patient altogether and give neuroscience education. Most of the time I use a blend depending on what I think is most appropriate for each patient.
    My two cents is to embrace the tools that that have been fashioned. It is never necessary to chop patients into pieces or use only one lens to view success. Learn from one another’s experience and passion. The solution may never pan out to be this OR that, it might be this AND that. Our practice is a science and an art and our minds work best when curious.

    • Hi Joanie,

      I agree with a lot of what you said but would like to recommend something else. I’m experiencing this right now within my company and with my friends who are physical therapists. When they are unable to help someone improve via “typical” therapy treatments, they refer to me to try some of that “pain science stuff.” I think viewing pain science/neuroscience education as a separate approach is slippery. Anyone in pain, no matter how they present I think would benefit from neuroscience education and teaching them “why they hurt.” I don’t think it should be a fall back approach when other treatments fail, which is what I encounter often. Does that make sense?

  21. planeperformance, thank you for the clarification, do you have a first name btw?

    What worries me more than what you describe is when people blindly accept authoritative statements founded in constructs of questionable validity and reliability. I thought I answered your question in my previous posts. To paraphrase, moving forward we need to set biases aside, stop making unsubstantiated claims, and develop theories related to clinical practice that are founded in modern science and critical thinking. The goal is to help our patients move efficiently towards improved health and functionality.

    Cheers,
    E

  22. I could not let this go by without comment because it resulted in a good chuckle – you imply that movement has nothing to do with pain but your goal is to “help our patients move efficiently”.

    • Who said that movement has nothing to do with pain? Movements often do alter when someone is pain. I suspect the mistake is making the assumption that one happens because of the other. In Ronald Melzack’s Neuromatrix construct, action programming is an independent response/variable by the neuromatrix. In my own algorithm for motor control (M.I.P), myself and colleagues suggest this is likely a means of defense, very similar to pain. What is tough to actualize, is that these two variables may be mutually independent of each other (especially with how we were taught in the past). This is one way to explain finding such as this: (http://forwardthinkingpt.com/2011/05/09/why-do-some-patients-with-low-back-pain-keep-coming-back/).

    • Robert Stalker says:
      “you imply that movement has nothing to do with pain”

      Not really, how did you arrive to this nonsensical conclusion? And in case it was not clear, when I say “help our patients move efficiently” I’m referring to the progress towards resolution, not to being fixated and trying to alter specific movement patterns.

    • Translation: I’m in a bit over my head here so I’ll just drop the mic and walk off stage with a condescending remark. Incidentally I think we have all due respect for Sahrmann’s work. However it’s our duty (if we are serious about the whole “move forward” thing) to provide reasonable criticism of underpinnings which have been shown to be inconsistent and/or inaccurate. There is a long legacy of medical professionals who did great work, but eventually turned out to be partially (or even completely) wrong about their ideas. I’m fairly sure Sahrmann’s legacy is safe within our profession, but when we are done patting her on the back we need to get back to the important work of getting our facts straight. No one is exempt from this.

  23. Yes, Joe the greatest mistake made by therapists interpreting EMG and biomechanics studies is that movement changes that occurred concurrently with pain were the source of pain. Of course some people with pain move differently. Should we expect that this shows up if we zoom in closer and look at the muscles? Yes, and that’s what we find (transverse ab, multifidus and other patterns are just some examples). This is just a more scientific way of describing the same phenomenon that people covary their changes in movement with pain. After all muscles control gross movements and gross movements are part of larger behavioral patterns. Does that mean there is a causal relationship between movement and pain? No. Does research indicate equivocally that movement changes are predicative of pain patterns? No. Does static posture correlate with pain? No. Do we have reliable physiological models that are able to describe causal pathways from movement to pain? No. So looking at movement changes that covary with pain we must ask the question is to why. Why should an organism develop a motor profile that is different to threat? How is this adaptive to the organism? How would have this been adaptive in our pre-historical era which we evolved? All of the above would need to have either a yes or at the very least probable with some robust evidence for us to start making the claim that people need movement screens (annual evaluations), that non-symptomatic people need to perform certain movements to prevent pain or that movement is essential target of physical therapy interventions related to pain.

  24. The proverbial “elephant in the living room” is the theory that MSI is based on, and no one who has expressed displeasure or disagreement with Dr. Kruger’s original post has addressed this critical issue. Dr. Sahrmann premises her MSI approach on kinesiopathology. However, there is no evidence to support this explanatory model. The current neurobiology has informed us that it is flawed.

    I’ll use the clinical example provided by Joanie to explain why. According to the kinesiopathological model promoted by Dr. Sahrmann, elevating the patient’s scapula and then observing an immediate reduction in pain is explained in terms of unloading tissues in the neck in such a way that restores a “normal” axis of rotation of the cervical vertebrae, thereby alleviating nociception from tissues that have been chronically “strained”. Having the patient perform a variety of “corrective” movements to presumably alter motor patterns in such a way that eventually changes muscle length-tension relationships (indeed by adding or removing sarcomeres) alleviates the chronic strain (kinesiopathology), and the patient recovers.

    An alternate explanation based on the current neuroscience relevant to the lived pain experience, however, is much more plausible. Rather than restoring some ideal biomechanical alignment that temporarily unloads damaged tissue, isn’t it more likely that the elevation of the scapula provided a novel input through the skin that also reduced loads on sensitized nervous tissue in the upper quarter region resulting in immediate pain relief? Isn’t this a much more parsimonious explanation? Additionally, don’t we have to consider non-specific effects associated with a caring environment, warm hands and a detailed physical examination all having positive effects on the patient’s expectations of recovery? If this is followed up with specific movements that improve the patients awareness and detached attention to the painful area in ways that do not increase pain, might not this explain the continued improvement in the patient’s condition?

    I really like the fact that Dr. Sahrmann has embraced internal locus of control. This was a lesson that I Iearned from her that prompted me to start asking important questions about the application of manual therapy in my practice. I attended her upper and lower quarter courses in St. Louis where she made appearances at both of them. She’s an excellent communicator and an obviously passionate clinician. However, the theory that she bases her approach on is wrong. It’s nothing personal.

  25. John,

    Thank you for your very eloquent elaboration of the picture I was trying to paint. I must add, though, that without an understanding of the ideal biomechanical environment for movement, I don’t think I could produce the same results.

    I share your concern about appropriate use of manual therapy, and restoring the patient’s locus of control. These are important questions for all therapists. As we move forward into accountable care, empowering patients to take control of their own well-being will be increasingly important. Let’s hope we never lose the ability to provide a compassionate presence for those who need it.

    By the way, did you hear about the 2014 Annual Orthopaedic Section Meeting in St. Louis this May?
    “The Triangle of Treatment: Integrating Movement System Impairments, Manual Therapy and the Biopsychosocial Approach in the Treatment of the Upper Quarter”. The Movement System Impairment, Manual Therapy and Biopsychosocial Approach to Neck Pain: Are Similarities and Differences Complementary or Competitive?
    Presenters: James Elliott, PT, PhD; Shirley Sahrmann, PT, PhD, FAPTA; Patricia M. Zorn, PT, MAppSci (MT), FAAOMPT; and (pre-recorded presentation) Gwendolen Jull, Dip Phty, Grad Dip Manip Ther, M Phty, PhD, FACP.

    Sounds like they may be coming full circle?

  26. This is an interesting opinion article with very good topics and insights discussed in the posts about the profession of Physical Therapy, evidence-based practice and movement based therapy vs. more holistic patient care models. I am not an expert at Shirley Sahrmanns’ theories but know she has made incredible contributions to our basic knowledge base to help people in pain get well. Expanding upon her movement foundation and building a more holistic framework for patient care will certainly be a path for success. Thanks for all your comments everyone and the insight that will help me question my practice with patients today and onward.

  27. Whether you agree or disagree with Dr. Kruger’s article, it has generated a great discussion. Already, I can see how pain science and the movement impairment system can be incorporated together.

  28. Rob,
    I think some concepts about moving in thoughtful and novel ways that have emerged from MSI can be kept and looked at more closely, but this theory- kinesiopathology- is inconsistent with the current pain science. Its origins are based on very entrenched ideas in our profession that causally link weakness or lack of strength to pain. This is what “kinesiopathology” means. This is the garb that MSI is dressed in, and there’s nothing there- the emperor has no clothes. Dr. Sahrmann is definitely on to something with having patients move in ways that reduce threat by moving the painful region thoughtfully, and I’m very keen on patients being empowered towards “self-correction”. However, this theory has got to be chucked in the wastebin along with the Cartesian theory of pain. How long will it take our profession to finally let go of disproven theories?

  29. Joanie,
    Yes, I’ve read about the conference in St. Louis this year; however, I’m concerned that the biopsychosocial model will be clumsily affixed to a system like MSI, which is based on a flawed theory (kinesiopathology) that is diametrically opposed to it on a conceptual level. Lorimer Moseley, a leading PT pain research recently commented “the evidence that structural pathology is neither sufficient nor necessary for pain is so compelling that to stick to old linear, isomorphic paradigms is, well, daft.” I couldn’t agree more with this statement; yet, this is precisely the assumption upon which the kinesiopathology theory that drives the MSI approach is based. In fact, I think this theory gets it exactly backwards. I think what Dr. Sahrmann has very skillfully observed are movement system defenses, not defects. This would explain why there is such variability in levels of pain for those with various observable movement impairments. It would also explain why there are many people with apparent movement impairments (see research by Littleton on shoulder pain/subacromial impingement syndrome) who have no pain. This is why I think it would be a disaster for people to see a PT annually for a movement system “check up” as Dr. Sahrmann recently advocated in an online interview at Physiopedia. There are far too many false positives when it comes to supposed “movement impairments”.

    If we stick with where the science has led us in the earnest and noble quest to treat persistent, non-pathological pain problems, then I think the future will be bright for the profession. However, we need to discard explanatory models that no longer fit. Unfortunately, this means that some of our esteemed colleagues’ lifes’ work may need significant alterations. I think we owe it to our patients to make those kinds of difficult decisions.

    • Hi John,

      I’m intrigued. Can you refer me to research that directly debunks the kinesiopathology model? Don’t you factor in the possibility that multiple mechanisms interplay to produce pain?

      I refer to several proposed models. Articles I refer to include, The Integration of Pain Sciences into Clinical Practice, Gifford and Butler, Mechanism-based classification of pain for physical therapy management in palliative care, Kumar and Sasha.

      Kumar and Sasha propose 5 mechanism based classifications: 1. Central sensitization
      2. Peripheral sensitization 3. Nociceptive/peripheral nociceptive 4. Sympathetically maintained and 5. Cognitive/affective mechanism.

      PT/OT at Rehab Institute of Chicago uses 6 mechanism based classifications for pain 1.Nocioceptive-Inflammatory; chemical to mechanical. 2. Nociceptive-Ischemia. 3. Peripheral Neurogenic. 4. Central sensitization. 5. Affective pain mechanism and. 6. Motor/autonomic pain mechanism. I believe they adapted these classifications from the aforementioned article by Gifford and Butler.

      If you are on to something more current, please do share.

      Thanks again,
      Joanie

  30. I would like Dr. Stalker to elaborate on what he means by too serious. I’m not sure one can be too serious about their profession. Especially when your profession involves helping people in pain. Many of the people we treat have chronic pain and have been unable to get any relief. In extreme cases these people consider suicide. Therefore, I take my profession very seriously. And part of taking your profession seriously is reading and debating the literature regarding our beliefs about pain and treatment options.

    Often times the patients I see have been to other health care providers who have told them all sorts of explanations regarding their pain. Often times these explanations indicate that the source of their pain is in their tissue. They receive many diagnoses involving discs, misaligned joints, leg length discrepancies and muscle imbalances as being the source of their pain. They’ve also usually had many diagnostic tests hunting for the tissue at fault to no avail. Many are led to believe that the source of their pain is in the periphery with no mention at all of the nervous system. None come to see me with the knowledge that pain is an output from the brain and not an input. The last thing they need from me is another story about how their weak or shortened muscles are causing their pain.

    This is why explaining pain is so important. A misconception about the biopsychosocial approach is that it is simply talking to the patient or providing ‘brain therapy’, whatever that is. Lets not forget the ‘bio’ in biopsychosocial. Explaining pain to the patient does not mean we ignore this biological aspect of their pain. Exercise and manual therapy are still an important part of treatment. As a PT I am an expert in movement and exercise prescription. It’s what I do. I provide exercise and recommend movement to everyone. In addition to exercise, I incorporate pain education so that they understand why they hurt and why movement is important. Understanding pain is the foundation of their treatment plan. If the patient believes that their pain is originating in a tight muscle then I have failed them.

    This is why I shared Dr. Kruger’s article. It’s important to begin a discussion about why muscle impairments are not the source of pain. Many of us have these impairments and are pain free. When a patient comes to see me in pain and is guarding the injured area I have no way of knowing what their ‘normal’ alignment should be. I’ve just met them. What is normal alignment by the way? Often times after explaining pain, prescribing movement and performing manual therapy, I see a reduction in guarding. The patient also reports a reduction in pain and demonstrates increased movement. This immediate improvement can’t be explained using a model that indicates a muscle was lengthened or strengthened by my treatment. However, changes in the nervous system and reduced output of pain can explain these changes. Science supports this explanatory model.

    • This entire thread is a fascinating and supports a critical discussion about the change in focus happening in our PT profession. Thank you, Eric, for setting the ball in motion, and thanks to the contributors who have thoughtfully responded to this very big topic. Rob Willcott hit the nail on the head with his observation that “Many are led to believe that the source of their pain is in the periphery with no mention at all of the nervous system. None come to see me with the knowledge that pain is an output from the brain and not an input.” As a clinician who earned her doctorate under the very capable and valuable guidance of Shirley Sahrmann (respect!), I can say confidently that the biomedical approach will fall short for even the biggest giants–despite the giant ideas. I in now way wish to discredit her life’s work, as I do believe she has contributed more to the PT profession than most and she continues to offer relevant insights and thoughts. Let’s talk about why her stuff works so well, for those who have that experience. Is it because of the mechanism proposed? I.e. that the movement impairment is the cause and retraining that movement toward something different is the cure? Is it because of what Paul Hodges has written so much about–this notion that muscle timing is the key to pain? The reason I think Sahrmann’s approach is so successful (and by this I mean that patients who have failed to improve with many other clinicians go to see Shirley or her colleagues and then finally return to functional activities, reduce pain, avoid surgery, etc. after multiple attempts at other clinics. I’ve spoken to these patients and heard many, many case studies presented during the course of my graduate training at Wash U), is that the MSI approach provides PTs with a specific tool to help their patients attend to the painful body part in a positive way (curbing distraction and challenging kinesiophobia), practice of a novel movement (fueling neuroplasticity), foster differentiated movement (which “de-smudges” cortical representations of that painful body part), and track graded progression of movement (triggering the reward center by meeting goals and getting to the next level of difficulty in the exercise series). There are hundreds of approaches that will do the same thing. The problem we face is HOW WE TALK ABOUT WHAT IS HAPPENING.

      I have practiced in sports medicine, geriatrics, acute care and now work in an interdisciplinary chronic pain clinic. I have seen the spectrum of the pain experience and, in my opinion, what’s missing is a discussion about the nervous system. When I work with patients who have been in pain on a daily basis for years, and have tried with other PTs without feeling successful (quite frankly, 80% of my patients tell me that PT “hurt them” by asking them to do exercises that caused more pain), I start off by using new language to explain their problem. I say that “we are going to treat their nervous system”, instead of their back or knee or whatever. I spend a lot of time educating my patients about the complex and comprehensive functions of the human nervous system, and I emphasize the wonderful (and frightful) ability of the system to adapt in response to all sorts of inputs and outputs. This context allows them to better understand the link between their back pain and their GI issues or sleep problems or the fact that their knee hurts more at tax time or why their pain seems to randomly shoot down their leg when that radicular pain used to only happen if they lifted something heavy. Education is absolutely paramount, but I am an advocate of widening the framework of that education. We absolutely do our patients a disservice if we only discuss their body and their pain from a biomechanical and biomedical perspective. To Dr. Stalker, who is calling for a more positive solution rather than just demolition of past ideas, I propose we all (PTs, MDs, DOs, RNs, acupuncturists, etc) start talking about the nervous system at every stage of a pain state, teaching patients that pain is in output, not an input (down with “pain receptors”, please!) and empowering our patients to better understand the complexity–and the simplicity–of pain.

  31. Joanie,
    In science, it is the one proposing the theory who has the responsibility to defend it. I provided a general reference to a line of research on so-called “shoulder impingement syndrome” by Littlewood (not “Littleton”- that was a typo in my last post, sorry about that) that sheds considerable doubt on whether such a diagnosis even exists, much less that we can predict who will experience it based on a musculoskeletal examination. Here’s a recent online review by Chris Littlewood discussing the ubiquity of scapular “dyskinesis” in those with and without shoulder pain: http://thesportsphysio.wordpress.com/2013/10/09/the-myths-of-scapular-stability-a-guest-article-by-chris-littlewood/.

    Lewis et al (2005) compared subjects with and without subacromial impingement syndrome and failed to find a significant difference on the alignment parameters of forward head posture, forward shoulder posture and thoracic kyphosis. In their discussion they reference several other studies that have similarly failed to find a relationship between scapular position deviations and shoulder pain. Based on this literature, it would seem to me that the MSI proponents at Wash U and elsewhere would be interested in publishing validity studies showing that subjects with certain clusters of alignment and movement impairments have a higher incidence of pain in that particular region, and then go about proposing how these impairments are causally linked to the pain by providing some longitudinal data. I’ve seen some research come out of Wash U on the reliability of the categories, and a couple of low level clinical trials, but I’m not seeing a strong defense of the theory from anyone who promotes this approach to care. I challenge anyone to provide any evidence demonstrating that this theory is tenable, much less an explanatory model upon which clinical practice should be based.

    Way back in 1987 Walker et al published a study in PTJ demonstrating that there was no relationship between the degree of lumbar lordosis, pelvic tilt and abdominal muscle performance. It seems that these findings were summarily ignored by our profession, most notably proponents of the “muscle imbalance” concept, who you’d think would be interested in such a finding. I think that was a very unfortunate oversight, and I hope we don’t continue to ignore the growing mound of evidence that tends to contradict some of our most hallowed sacred cows.

  32. Joanie,
    Regarding your example of a patient with neck pain who achieves immediate relief when the therapist elevates the scapula, you responded to my explanation thus: “…without an understanding of the ideal biomechanical environment for movement, I don’t think I could produce the same results.” Why do you think that an understanding of an ideal biomechanical environment informs clinical decision-making for a patient with this presentation? I just referred to research evidence that scapular “dyskinesia” does not predict shoulder pain. Therefore, isn’t the concept of an “ideal biomechanical environment” on shaky theoretical ground? Don’t those who promote MSI need to address all of this contrary evidence to the kinesiopathology theory? I don’t see them doing that. They seem to ignore it. And they seem to have been doing that for nearly three decades now.

    Meanwhile, the theorizing you refer to regarding the complex origins of pain continues to inform us that the lived pain experience is very complex with multiple inputs occurring over time to produce a pain output. MSI proponents seem to give lip-service to cognitive and affective dimensions of the pain experience while hanging their clinical decision-making hat on the unverifiable presence of nociception from “pathological” movement. However, I submit that pain can and does exist in the absence of frank pathology or tissue damage. Dr. Sahrmann references both gross and ultrastructural changes in connnective tissue- particularly muscle- which are based on her observations and very thin laboratory evidence on non-human subjects, respectively. We seem to have a very different definition of what constitutes “pathological” and “damage”. We also significantly depart on the idea that there is such a thing as an “ideal biomechanical environment” within the context of a persistent musculoskeletal pain problem. I think the scientific evidence has shown that movement and alignment variability is the rule rather than the exception. When an MSI practitioner concludes that elevating a “depressed” scapula results in pain relief due to an improvement in biomechanical alignment and therefore reduced nociception to strained tissues, they have, in my opinion, drawn a spurious conclusion that fails to account for too many other variables. Where do cognitive and affective variables factor in to this clinical decision? More importantly, where’s consideration of the physiological properties of the signaling tissue- the nervous system?

Leave a Reply

Fill in your details below or click an icon to log in:

WordPress.com Logo

You are commenting using your WordPress.com account. Log Out / Change )

Twitter picture

You are commenting using your Twitter account. Log Out / Change )

Facebook photo

You are commenting using your Facebook account. Log Out / Change )

Google+ photo

You are commenting using your Google+ account. Log Out / Change )

Connecting to %s