Part 2/3 - Philosophical Principles of Performance Therapy
In part one of this three part series, I made a case for the importance of a principle-driven approach to rehabilitation and sport performance. In today’s article, I will be exploring the philosophical principles that drive my decision-making process. I am comfortable admitting that these ideas are partial truths at best, since they attempt to describe the ever-moving target known as ‘complete understanding’. I am flexible to evolve my thinking in light of a better perspective.
All things considered, here are the philosophical principles that guide my practice as a clinician and coach.
All models are wrong, but some are useful. No approach is complete on its own, and it’s unlikely that we will ever fully understand the human system.
All models are simplified versions of the truth; therefore they cannot represent what is actually going on in reality. In an ever-complex world, we need models in order to make sense of what we are observing. Following this logic, if we were to integrate as many coherent models as possible, we can effectively fill the gaps in our thinking.
My goal is to continually upgrade my thought-process and expand my knowledge-base without dogma or exclusion. This requires radical openness – good ideas are good ideas regardless of who or where they come from. Our best chance of having a holistic view is to detach ourselves from any one paradigm.
The whole is greater than the sum of its parts.
This principle is relevant across multiple scales. As clinicians and coaches, we should consider the whole musculoskeletal system (i.e. regional interdependence), human organism (i.e. subsystems of the body) and body-mind-soul (ex. monism and metaphysics). For example, regional interdependence leads us to consider the body as an integrated system made for movement, rather than a reductionist view of isolated muscles and joints.
If we want to understand something, we may need to pull apart its components; however, we must reassemble the pieces to gain an appreciation of the whole. For this reason, there are no boundaries around the human system. We have created divisions for the purpose of clarity and discussion in academic circles. The organization, names and filters we look through are constructed in attempt to make sense of the whole. These boundaries can lead to problems if we overlook the fact that we’ve artificially created them. If we don’t broaden our view to include the entire system, we will have an incomplete picture.
The human system can self-regulate through natural physiological processes.
We have the innate ability to heal ourselves if the main tenants of health are accounted for. This does not contradict the utility of Western Medicine; instead, it provides a broader view that is inclusive of complimentary therapies. When considering total system health, the leverage points of movement, sleep, nutrition, stress-management and human connection will give us our biggest return on investment. The esoteric but equally important pillars of emotional regulation and spiritual fulfillment will also support wellness and vitality.
Each patient should be treated as an individual with their own needs, anatomy, physiology and psychology in mind.
A truly homogenous population is impossible to encounter; this is why protocols fail to serve all subjects within a group. Clinical trials are built upon averages, but not all patients respond in a way that is consistent with research norms because there is no average individual. Instead, we should treat each patient encounter as an A-B-A single subject experimental design. Take objective data points that are meaningful to the patient, apply an intervention, then observe how the data points change. Repeat this process until a desired result is achieved. This test-retest approach allows us to integrate the best available evidence with clinical expertise and patient values. If an intervention is effective and makes sense in terms of the fundamental sciences, we should encourage its use despite the lack of research on the methods in question.
Belief drives reality. A healthy mindset and knowledge surrounding pain is essential as it empowers individuals to take control of their experience.
The main goal with this type of education is for patients to understand their pain better so that they can no longer fear it. These educational and soft-skill practices are important, but they should not be used as a treatment strategy on their own. Rather, they should be used in combination with all other interventions to enhance treatment outcomes.
In order to build buy-in, we need to understand the patient’s beliefs behind their injury and our treatment. If an unhealthy thought-pattern exists, a patient’s beliefs must take precedence over the intervention. This doesn’t mean that we can haphazardly apply treatment strategies; it means that we must invest in developing the patient’s confidence in our therapeutic skills and their ability to recover. By creating a dialogue where the patient is heard and understood, we create an opportunity to cater our reasoning and treatment to best suit the individual. If we don’t provide the container for a patient to achieve their goals, it will be much harder for them to do so.
If you are interested in learning more, David Butler, Lorimer Moseley and Adriaan Louw have some fantastic resources for patient-friendly information on pain.
Flow should be sought after in performance and rehabilitation.
Flow is defined as a state of effortless concentration and immersion leading to optimal performance outcomes. By paying close attention to what we are experiencing, nothing else seems to exist. Our default mode network stands in opposition to flow as it is defined by cortical activation patterns linked with mind-wandering and a lack of presence. This state of consciousness is closely related to emotional reactivity and detachment, two characteristics that are counterproductive for pain management and performance. Finding flow has the ability to disrupt these default settings both during our experience and in the rest of our waking hours. In other words, flow and the default mode network are inversely activated during tasks. The focus that athletes find in competition is what we should aim to achieve in rehabilitation in order to maximize treatment outcomes.
Research has blended eastern wisdom with western science by investigating the pain experience in meditators versus non-meditators. Findings suggest a functional decoupling of cognitive-evaluative and pain-related cortices in those who practiced meditation. The result was that meditators were more tuned to noxious stimuli, but derived less suffering from it due to the absence of psychosomatic influences. These patients were able to objectively feel sensory data without coupling it to a dialogue of what the sensation means. The non-meditators exhibited more activity of the default mode network and showed a greater linkage of sensory and emotional centers. This suggests that we can intervene at a psychosocial-emotional level in order to promote better self-regulation of pain. It also supports the notion of practicing mindful movement during physical therapy. (1)
Instead of having the goal of removing pathology and pain, rehabilitation should focus on exceeding movement norms in order to build a robust, functional system.
Our focus should be health, not the absence of disease. We should aim to improve total system properties like resiliency, variability, adaptability, longevity and resistance to stress. Developing resiliency is a focus in my practice and is expressed by our homeostatic response to ‘right’ the system when it is perturbed in some way. Resilient systems have more room for error and are able to deviate from their norm without consequence. In contrast, someone who shows system rigidity has a much smaller buffer zone to operate on.
Building resiliency is essential when rehabilitating an injury because it better prepares the individual to respond to the demands of a task or environment. This is particularly relevant for those who live an active lifestyle, but is also inclusive of a broad spectrum of function, from sedentary to world class athletes. Movement principles should be scalable across one’s lifespan and function. Principles should not be confused with methods, which will differ depending on the patient and their goals.
We can increase our health through two main mechanisms: increasing system ‘deposits’ or decreasing system ‘withdrawals’.
A system deposit can be defined as something that is beneficial for our health. For example, appropriate exercise, nutritious food and quality sleep can improve the total system properties that were discussed in the previous section. A system withdrawal is something that diminishes our health. We often neglect system withdrawals, especially if we don’t ask the right questions in our subjective interview.
As part of our training and treatment plan, it is important to remove the negatives before introducing any positives (2). For instance, removing inappropriate movement patterns, training volumes or inflammatory foods may cause a decrease in pain and an increase in performance. If these “leaks” are ignored, we will be fighting an uphill battle when applying positive interventions.
The SAID principle is the key driver of growth and should be applied with graded exposure and progressive overload in mind.
The body will adapt in response to the specific demands that are placed on it. The SAID principle has applications in many scenarios, such as mechanotransduction and tissue remodeling, motor learning of skill-based tasks and cognitive reframing. Like most processes, growth operates on a parabolic curve – we need the right amount of stimulus, stress, motivation, arousal and effort to yield the best results. Anything less or more will negatively affect one’s return.
Graded exposure operates on a continuum upwards towards progressive overload. Graded exposure deals with a patient’s tolerance whereas progressive overload deals with a patient’s capacity. This principle should be leveraged in order to allow for supercompensation to occur based on the context and the patient’s goals.
In part three of this three part article series, I will be exploring the movement principles that guide my practice as a clinician and coach. What are your philosophical principles? Post in the comments below!
References:
Grant J, Courtemanche J, Rainville P. A non-elaborative mental stance and decoupling of executive and pain-related cortices predicts low pain sensitivity in Zen meditators. Pain. 2011;152(1):150-156.
Cook G, Burton L, Kiesel K, Bryant M, Torine J. Movement. Aptos, CA: On Target Publications; 2010.