And this time it’s getting serious with a double header.
In anticipation of Greg’s second trip to Exeter we had a quick catch up. This time he will be teaching both his Running Resiliency (8th-9th) & Reconciling Biomechanics with Pain Science (10th – 11th) courses.
BW: Greg, You’re a specialist in biomechanics. The father of spinal biomechanics is of course the legendary Professor Stuart McGill, he came in for some online criticism recently when an old video resurfaced. He was making some widely rejected claims during a patient demonstration. Do you think biomechanics has anything to offer us today in the field of lower back pain? or is it losing relevancy?
GL: Yes, I did see that. I think we can often be a little uncharitable at times in how we interpret things. Sometimes in front of a group you can say things rather quickly that might lose the nuance that you would normally convey. I still think biomechanics has a role and I do believe that even when people take a strong biomechanical approach they aren’t necessarily unaware of the psychosocial factors. They may feel that a mechanical approach can actually help address psychosocial factors. For example, you can teach someone to not bend their spine when they have flexion related low back pain. You might explain that in terms of spine instability etc. Others might challenge the idea that the spine becomes unstable and this is the cause of the pain – meaning we debate the mechanism rather than the clinical effect. The avoidance strategy of not bending might actually be appropriate sometimes. And if you teach that avoidant strategy you might also be able to encourage people in pain to resume activities that are meaningful to them and get them active again. So, its a biomechanical approach, its theoretical underpinning might be debatable, but it could potentially address psychosocial factors. I’m certainly not against a mechanical approach – I just prefer to work a movement based approach into a comprehensive approach that tries to address other variables related to pain and injury.
BW: An element of ironic grandiosity which didn’t quite come across in the clip I think. So if you’re not pronouncing the death of biomechanics just yet, who are the researchers worth following today and what are they looking at?
GL: Depends on the area. I still view Peter O’Sullivan as a biomechanics researcher who has rightly expanded his scope. So, that is a person to start with. Find the biomechanists who try to address the multidimensional nature of pain. Moseley published biomechanical research and Paul Hodges (a biomechanist) publishes research about pain. In terms of younger researchers we are spoiled for choice. Read T Paulson, Vaeghter, S Bohm, A Vigotsky, Debenham, Rio, Mallows. There are so many. Give me a topic area and I might be able to give you 5-6.
BW: Running is a favorite of the biomechanist and ‘Running Resiliency’ is your new course. How do you build on the principals covered in RBPS and what new ground is covered?
GL: The running course is the manifestations of the RBPS course. Sometimes we need to do “specific” things or have “specific” knowledge and that is what the course tries to bring. The fundamentals of care are the same but it gives the practical application of what is taught in RBPS as applies to running.
BW: One of the things that struck me on your last visit was your openness to acknowledge and discuss the utility of symptom modification in practice. You showed some pretty hilarious videos of different approaches, while highlighting significant therapeutic aspects. A year on, and I’m interested to know where do you sit on this topic today?
GL: Pretty much where I always have been. I think it’s a unifying theme across different techniques. That helps me learn from others where I might disagree with their philosophy. But at the same time, I’ve had an accumulation of years of unsuccessfully modifying symptoms yet I still have helped people. So, it’s one of those interventions that I think can be helpful, I’m just not convinced that it is necessary. I’ve always liked poking into pain. Hence, I’ve been quoted as saying “poke the bear, don’t hump the shit out of it”. Symptom modification is thus one option but you certainly don’t have to do it.
BW: I think your openness to this was something that really facilitated debate on the course. How do you rate our profession overall when it comes to debating?
GL: We are all human. We get too emotional and can easily focus on “winning” a debate rather than progressing our knowledge. I think our profession is just as good or bad as anyone.
BW: Winning seems far too civil a term, I think you’ll find it’s all about total annihilation! You’ve got nearly 20 thousand followers on social media. As one of the early adopters of the platform how has it changed over the time you’ve been using it? And where would you like to see its direction go next?
GL: I’m just on Twitter. It’s always been a discussion for me. It’s not changing dramatically but I am avidly against retweeting with comments during a discussion. That’s just shit and ruins the flow. It’s more broadcasting than engaging in helpful discourse. Therefore, no inappropriate retweets with comments.
BW: Oh God, that’s me struck off the Lehman family Christmas card list. Broadcasting proudly to my small but loyal army of random advertising accounts. I understand that you still maintain your own clinical practice, mainly for second opinion consultation. What is the single largest therapeutic practice failing that you are seeing in patients with persistent pain?
GL: I think therapists don’t “give their patients permission” to do the things they love enough. There is still too much of this idea of needing to be fixed before you start doing. That’s why we start our course with the question “Is there ever anything specific that needs fixing to help people in pain”?
BW: No comment, but sometimes yes, if we’re including broken femurs. Do you think that therapists are gaining a new confidence in managing chronic pain with pain science education or psychological interventions? Is there a degree of false confidence that we should be wary of?
GL: Both. But, I think we are also seeing our limits. I have a couple of patients who really understand pain. They know Explain Pain or the Graded Motor Imagery handbook. They aren’t fearful – they recognize the multidimensional nature of pain. But they still have pain – I think their suffering has improved but they certainly aren’t 100% pain free. And I think a lot therapists experience this as well. Or we find that their might be drivers of pain that end up being out of our scope of practice and this can be frustrating.
BW: Pain science and pain education are popular terms now, but what do they actually mean and are they teachable?
GL: We’ve been doing this forever. To me, pain science just means you understand the nature of pain and injury better. You can explain to a patient what is going on and ideally that explanation is associated with a plan that the two of you have worked on together. “Pain Science” just means a better handle on clinical reality. So, yes.
BW: That’s a relief, seeing as you’re clocking up a lot of air miles to teach them here in Exeter! Greg, thanks for sharing your insight and we look forward to having your back for a much more detailed discussion in Exeter this November.
Thanks for reading and for those who would like to attend places are still available via the links below
8th – 9th November – Running Repairs
10th – 11th November – Reconciling Biomechanics with Pain Science