Thursday, September 28, 2017

Re: Non-specific FX

Re: non-specific FX:
You know how all the literature on manual therapy says, when you read between the lines, is that it's "no better than placebo" ? Well, that's a good thing. It has taken away all the dreams from the dreamers, those who 
imagined their way of doing manual therapy was BETTER than any other way. Mostly this has deflated the orthopaedic manual therapy community, because of all the manual therapies out there, the practitioners (and studiers it must be emphasized) of OMPT were among the most strident about how much better their ways were than other kinds. Mostly though they were riding a wave of confirmation bias that sort of looked as follows:
1. People in pain often have impaired movement. Movement is important.
2. Movement is best measured at joints. Let's study the FX of our work by measuring ROM
3. Move the joints, bring back the movement. Pain should go away.
4. Voila, we have confirmed that pain comes from joints.
It became one of those closed loop ideas, self-referencing and self-confirming.

I never bought it, because in order to do OMPT properly you had to be able to feel joints and joint movement, so you could only do it on thin people, which a) left out all the fat people with pain and movement problems, and b) I knew I could help people of any size with their pain and movement problems without ever having to feel their joints, because I was working on their surfaces, not their depths, in the first place. In other words, I always found OMPT illogical.
In the end I feel vindicated because studies show there is no interrater reliability for palpation or diagnosis (too many type I errors). Good science shot down the myth that had grown that OMPT was superior.

We are straight back to non-specific FX again (of which placebo is just one kind, but not the entire story), which makes me glad. I embrace non-specific FX, because the hunt for specific FX from manual therapy has been futile.

Studies are starting to look like even orthopaedic surgery (for pain) is 'no better than placebo' for a lot of things.
If people are going to do things to other people that are 'no better than placebo', at least be kind! at least don't mess up their body even more!
On the other hand, there are all those studies that show major confirmation bias, like ones for needling and acupuncture showing good results. And just as many that say the results are NOT specific. Again, why be poking through skin with needles when toothpicks work just as well? 

Taking the long view, that all manual therapy is non-specific, and that measuring an outcome does not prove an effect, I am more relaxed about doing this work than I ever was in the preceding 40 years, more willing to sit back and do non-specific things somewhat specifically, and let peoples' nervous systems do all their own heavy lifting to get themselves out of pain.

I'm totally willing to teach other people my set of tricks, that have sufficed for all these many years, plus new ones I have made up more recently, all the while telling students that they need to be adaptable and can make up their own new tricks, they have my blessing. Not that they need it. But they must FIRST sit through a very long lecture about the nervous system, its care and feeding, all the info I have about pain and brain mechanisms that pertain to manual therapy, with all the emphasis on the sensory portion, all the cutaneous nerves, so they will know what they are touching. And that they will be affecting the person, not the person's "body." And that they will accomplish more by doing less, and being kind while doing it, not hurting people more than they already hurt, unloading sore spots, not loading them more.

I'm totally willing to help people but I'm no longer willing to worry hard about trying to fix anybody. I do my best and that's all I need to do. I don't charge for results, I charge for my time. And inside the time people buy from me, I focus 100% on them, try to disconfirm all their noceboic beliefs, touch them very carefully and slowly and lightly where they hurt, load into them quite heavily where they don't hurt, and give their systems enough time to adapt until I can feel responsive changes in their physiology slow down and stop. Then I move on. Until the hour is up. 

My results/outcomes have not been formally measured, but I would lay odds they are just as good as anyone else's.

Old posts about non-specific FX:
Oct 20, 2012
May 15, 2014
May 20, 2014

Friday, September 15, 2017

Three pictures that sum up manual therapy

You cannot be sure that what you think you "feel" in another's body (palpate physically) is really what you feel there. Furthermore, you cannot (objectively) feel another person's pain.
The best you can do is interact empathically with whatever they feel (and are willing to share), and with whatever you feel. With your hands. Without making too many assumptions.
With any luck, whatever they feel will change in the course of a session. For the better. 

Being a manual therapist is not for sissies.


We all have to do this, every day, with every new patient: carefully cross a chasm of understanding, on a rickety footbridge, through fog.
Not knowing how long the bridge is, or how deep the gorge below.
Just putting one foot in front of the other, carefully.
Because people are not objects, like cars. And we must not treat them, or any part of their bodies, as though they were.
Being a manual therapist is not for sissies. 

A "profession" (like PT) starts out as a group of idealistic individuals, who probably imagine that "certainty" is a real thing and that they can count on it to support their adventure through life. However, they can turn the profession into an "industry" over time.
People starting out in a profession feel more comfortable acquiring and using "tools."
Being part of a group that sees itself as an industry can turn the individuals within it into thinking they are car mechanics, if we aren't careful. 
Being a manual therapist with the goal of having good ethics is not for sissies.
Being part of a profession that is madly trying to turn itself into an industry is a bit of a downer, to say the least. 

Thursday, August 10, 2017

The conscious mind/self/conscious awareness

I saw a post today on Facebook that seems a good summary of the conscious mind: 

"Our conscious minds are but one part of our nervous system, and they are not dictators." ~Andrew Jurdan

I reposted it, and added a few more thoughts.

I've always viewed the conscious mind as something that finds itself occupying the top floor of City Hall, as mayor, no clue as to how it got there or what it's there for, supposedly in charge of a city it knows nothing about, has never toured, and doesn't understand the workings of all the other floors or even any names of any other people on those floors.
It prefers to hang out with other mayors and play games.
Yet, it is ultimately the mayor's responsibility if anything in the city goes haywire.
 Here is something I wrote about conscious awareness or self as mayor of a city ages ago, at least 12-13 years ago. 

Saturday, June 10, 2017

Catching up to TV culture


My personal life lately has included binge-watching of TV shows I had heard of but never watched before, like Mr. Robot, Breaking Bad, and Walking Dead.

All of them are bleak, dystopian. The last two were saturated with violence.

I'm currently watching episodes of Handmaid's tale and Vikings.


By far the most disturbing is Walking Dead, on so many levels. And it also seems to be the longest lasting with season 8 coming up. (Maybe this show is a zombie itself.)
Each episode is a waking nightmare of zombies, gore, betrayal, existential crisis, prisoner's dilemma, trolley dilemma.
The protagonist group can't go anywhere or do anything without having to expend energy fighting off/slaying "walkers." Other humans are constantly stealing from them or threatening their existence in multiple ways. They constantly steal and threaten too. Whether they decide to trust others or not seems to depend a lot on whim. As the episodes and seasons have rolled by (99 episodes total so far) the outer threats have become much more about humans in groups than the walkers. The walkers are fairly slow and thoroughly stupid, easily dispatched with a bit of physical force. Killing them requires a stab in the head, through a ridiculously soft skull filled with dilute ketchup. The ketchup budget must be huge in that show.

Here is a short list of things I like:
1. The exploration of ethics and values and how humans behave in groups, how groups treat each other.
2. Women have strong roles, gays are included, racism (apart from the first episode) is a total non-thing. Diversity is valued.
3. It reflects US culture wars.

Here is a short list of things I don't like:
1. Zombies. The premise is stupid, literally. Slightly more plausible metaphorically, perhaps (people who are zombie-like throughout life, mere system-wonks working for/supporting institutions, religions, and political parties that are like un-thinking zombies).
2. The premise of increased environmental stress leading to more egalitarianism, not less, is quite stupid. Humans, especially white male humans still imbued with the value system they have designed and deployed down through generations, do not go from being racist, sexist and gay-phobic to not being any of those things, so instantly, without considerable effort. Especially under the sorts of increased environmental stress posed by having no food/clothing/shelter security, constant vigilance/dependence on others to watch out for all these blood-thirsty mobile walkers, poor nutrition, little sleep, outdoors in the rough, dirty/filthy/no toothpaste, never being able to ever go off to eliminate by yourself (because walkers), and even if you do get hands on some stuff to help you survive, other people will be right there to take it away from you by force.
3. That CGI tiger. 


So, why do I watch these implausible TV shows?
They are immensely popular. I think they are morality plays, disguised, dripping in blood.
I want to catch up to wherever the TV watching culture thinks it is at.
Also, I remind myself that for long long long stretches of time in human evolution and history, life kind of was kind of like that, living rough, minus the zombies of course. Which reminds me to appreciate that I have lived and still live in an era where people like me can lead a comfortable safe private reflective life separated from societal expectations without having to join a monastery. And also that I don't live in the US, although I appreciate how hard its regular people have worked and still work to make it into something, in spite of the current president and his Neganesque amorality, which he seems to be trying to institutionalize.

Vikings is set in the 8th century AD; life is rough, violent, bloodthirsty. Wars are common and mainly fought up close with sharp blades. The premise is valid.

The Handmaid's tale is based on the notion that when push comes to shove, women lose to male-supported institutions. Their default value seems to always end up that they are mere uteruses with arms and legs. The premise is valid.


I have come back in this post to add this: I am also reading these days. Not much in a row, but a few pages or chapters at a time. I've finished Sapiens, by Yuval Noah Harari, and am in early pages of his latest book, Homo Deus. I'm concurrently reading Behave, by Robert Sapolsky.  Here is a nice interview with Sapolsky, You Have No Free Will.

Here is an excerpt of the interview with Robert Sapolsky about the book, and for me, a reflection on The Walking Dead, given that it takes place in the rural US south:

(Q) "What if you're from the rural South?" 
(A) "There's a famous study where student volunteers thought they were involved in a study surrounding their math abilities, but the experiment actually occurred outside in the hallway. Some beefy guy walking the opposite way bumps into a student as he walks past, then says, "Watch it, asshole," before marching away. When the student comes in to take the math test, the researchers take their blood pressure, check their hormones. And if you're from the American South, your blood pressure will be higher, and you'll be more stressed out. This impacts your judgement and how you respond to a given situation.
"This is because, by best evidence, the American South was settled by herders and pastoralists from northern England and Scotland, who had a culture of honor. Centuries later, there's still a residue of that. So this makes culture not such an intangible factor of brain development and behavior. Within minutes of birth, this kind of training starts."

Saturday, June 03, 2017

Ownership and agency in a predictive brain, implications for manual therapy


Recently I stumbled upon a lovely article in The Scientist, Understanding Body Ownership and Agency

It suggests there are several "selves" within each of us that integrate into a singular seamless "self". 
It's easy enough to manipulate the sense of ownership in several ways - research on kinaesthetic body illusions such as mirror therapy, rubber hand, are discussed. Brain interface prosthetics for amputees are mentioned. 

A slide I made using definitions from the article

The article proposes that agency and ownership, while slightly different, are integrated into one another, and are interdependent. 

"...recent research has sought to understand how body ownership might have developed through the sum of agency experiences that we accrue throughout our life. What we perceive as our body is not only what looks like our body, but what we typically have conscious control over. This control is asserted by learned associations between our muscular movements and the sensory feedback we perceive when performing an action—the so-called “action effects.” 

So, agency precedes ownership, sounds like... we learn our arm is part of "us" i.e., "self", by realizing we can control its movement. Bring food to mouth. Etcetera.

The two are slightly separable concepts though: Ehrsson's virtual body part research is mentioned.

In 2012, Ehrsson, along with his then graduate student Andreas Kalckert, designed a rubber-gloved wooden model hand to make finger movements that were either linked by a wooden rod to (and thus synchronous with) movements of the participant’s own hidden hand, or detached and controlled independently by the experimenter.16 Initiation of synchronous movements by the participant elicited a strong sense of ownership and agency over the model hand; linked, synchronous movements initiated by the experimenter (passive movements) abolished the sense of agency, while the sense of ownership remained intact. Conversely, when the experimenters rotated the robotic hand by 180 degrees—putting it in an anatomically implausible position, with the fingers facing toward the body—participants maintained a sense of agency, but not of ownership.

(I'll never forget the drama involved in Ehrsson's set up, where he induced the illusion of ownership of a rubber hand, then attacks the rubber hand with a hammer, or a knife or something, and measured all the autonomic reaction in the subject.)

The paper brings up some definitions:

"Based on theoretical ideas of 19th century physician and physicist Hermann von Helmholtz, German scientists Erich von Holst and Horst Mittelstaedt demonstrated the reafference principle in 1950 to distinguish between self-generated movements and external perturbations. Any time we move, we generate a motor command (efference) to control the muscles. At the same time, we also generate a prediction—based on prior experience of the sensation resulting from the movement—termed the efference copy. The actual movement-related sensory input, which comes from receptors in the muscle and skin, is referred to as reafference. Any difference between the two signals (reafference and efference copy) is the result of environmental input, which is termed exafference. Understanding errors that may occur within this system is probably central to understanding problems in agency and ownership perception."

Hurray! Words!
I wondered how manual therapy might be involved. 

.... And I speculate: 

 May 1, Understanding Body Ownership and Agency,  2017, The Scientist

Friday, April 07, 2017

Spinal cord vs. brain, brain vs. spinal cord - endless struggle for control of the body

I made this meme, but I have people to thank:

Acknowledgements for this meme:

1. Lars Avemarie who posted his thoughts on pain a couple days ago.
I replied to his post with some thoughts on nociception/spinal cord, and pain/brain. I included the dead fish moving video (see below).

2. Nick Ng copied my post, and

3. Lee commented. She still seems to think pain is not a brain thing. It made me think, how can I answer this? I replied.

4. I wrote a longer post this morning, an expansion of my reply to Lee, and included the dead fish moving video again.

5. I tried hard to come up with an image/metaphor that captured the constant struggle going on that has to do with descending modulation. I think shoreline and sea metaphor does it - it shows ceaseless movement. When brain fails to raise the shoreline it can become flooded by input from spinal cord. Then it has a mess to clean up.

The dead fish moving video:

Wednesday, April 05, 2017

Convergence zone


Every day I get up around 6:30, grab some coffee, and sit down to read whatever is on Facebook or in my email or on Feedly.. hoping to be inspired. 

It's always SUCH a pleasure when a mini convergence occurs, when two or three or four things from totally different sources all pile up and make my brain go Whoopee!, this is exciting! 

Here is what has stood out for me in the last few days:

Lisa Feldman Barrett

I first noticed her post to a year ago. She was one of a couple hundred people who answered the Edge question that year, which was "What do you consider the most interesting recent [scientific] news? What makes it important?", and she replied,  "Your brain is predictive, not reactive." It made enough of an impression that I referenced it in my book.
In the last few days her name came up again! I found this paper she co-authored, published in October, 
An active inference theory of allostasis and interoception in depression. Wonderfully juicy. The core part of "self" - and all tied in with brainstem necessities and thermodynamic exigencies. 
If that is too dense to absorb all in one sitting, no worries, here is a video of her, explaining what she means.: Just yesterday I saw this piece from Nautilus magazine, Ingenious: Lisa Feldman Barrett. 
Inside a new theory of emotions that spotlights how the brain works. 
Here is a quick excerpt:

"The way that I like to explain it is, if you think about it from your brain’s perspective, your brain is in a dark, silent box called your skull and it can’t get out and experience the world directly. It can only know the world through the sensory inputs that come through your sensory systems—your ears, your eyes, and so on. It only has effects. It only has wavelengths of light, or changes in air pressure, or concentrations of chemicals and it has to figure out what caused those in those wavelengths of light, or changes in concentration, or air pressure, and so on, so that it knows what to do next. So how does it do that? When there’s a flash of light, how does it figure out what that flash of light means? All it has at its disposal is your past experience, the past experience that it has wired into itself, basically."

Reading her carefully it seems to me that "self" sand "mind" are a bit different from each other. I think self is inherent and mind is changeable. I think self uses mind, directs it around to gather info, but isn't fully overlapped with it. If mind is the movie we see of self, or a mental screen on which we see our life as a cognition of self, self is the projector itself, and also the projector operator, running itself from only the new little bits it lets into itself as fuel, as inspiration, as bits of stress it can also auto-manage.

So, my self sees a lot of new stuff in the course of a morning, sitting, drinking coffee, looking at my computer screen, surveying all the world has to offer up. My self screens out most of it as irrelevant. However it latched onto Lisa, because it found her quite salient. It said "See?? This is important. This links Everything Together." What does it link together? Mind, body, biology, existence, thermodynamics. All that stuff.


I'm not a philosophy geek but I can truly truly appreciate life as an absurdity, so much so since childhood that sometime around age 10, I chose to remove myself from the pool of females who would live to reproduce more humans. This morning this piece by Ralph Ammer, in his blog Personal Growth, linked to by a facebook friend who is very much into personal growth, jumped out at me: Is it worth the trouble? I found it absurdly uplifting. And the gifs are great! We can't deny the unreasonable world. We can't abandon reason. He declares, "One must imagine Sisyphus happy." Imagine!! (This is why the gifs are so great.) He advises:
"1. Permanent revolution: We should constantly revolt against the circumstances of our existence and thus keep the absurd alive. We should never accept defeat, not even death, even though we know it can’t be avoided in the long run. Permanent rebellion is the only way to be present in the world. 
2. Reject eternal freedom: Instead of enslaving ourselves to eternal models we should hold on to reason, but be aware of its limitations and apply it flexibly to the situation at hand — or put simply: we should find freedom here and now, not in eternity.
3. Passion: Most importantly we should always have a passion for life, love everything in it and try not to live as good as possible but as much as possible."

All that is pretty much congruent with my own set of values, and also the ones I learned in PT school. Yup, life can suck bilgewater, but keep at it and keep moving. There is nothing better to do. Be in the "now" and keep going until the end. Try to be a decent person while you're at it.

Finally. It looks as though attention is being paid to peripheral ganglia and their own computational capacities. They do run a bit of stuff that gets sent back and forth. The headline implies that ganglia have just been discovered, but really, they have been there all along, and in fact were there long before brains or central nervous systems even evolved.  

Discovery of 'mini-brains' could change understanding of pain medication

Pretty sure they are what can help make good results from manual therapy good results. In manual therapeutically naive people anyway.  If the therapists know what they're doing. After all there are opioid receptors in peripheral nerves too. And yes, descending modulation and non-specific FX are still the main effectors of a successful intervention no matter what happens peripherally. Never said they weren't.  

Personal convergence
I feel my existence completely supported by these finds.
1. I already knew life was absurd and in retrospect have continued pushing the boulder up the hill anyway, in life as a manual therapist.
2. Lisa Feldman Barrett makes sense, and she's a female who makes sense, so in a man's world this becomes strategically important to me, who is also female. It's confirmation that females are incredibly brainy, inclusive, and that this one has taken everything into account. I absolutely love her wide angle, panoramic even, point of view. I want to be like her when I grow up.
3. It's a fine way to make a living, moving skin around and affecting nervous systems for the better. There is even a lit path that may have to do with stuff going on in peripheral ganglia, before some of that info even reaches the spinal cord.

1. Barrett LF, Quigley KS, Hamilton P. 2016 An active inference theoryof allostasis and interoception in depression. Phil. Trans. R. Soc. B 371.
2. Ralph Ammer, 2017, Is it worth the trouble? Personal Growth blog, Mar 23.
4. Xiaona Du et al, Local GABAergic signaling within sensory ganglia controls peripheral nociceptive transmission, Journal of Clinical Investigation (2017)

Tuesday, March 28, 2017

Enminded body

I was recently entranced by Peter O'Sullivan's deft demonstrations of cognitive functional therapy at this year's San Diego Pain Summit. I wrote about him, here. I also went through his keynote presentation carefully and took screenshots of his slides, adding his comments, posted those to facebook and twitter. One of these days I will gather them all up and make another blogpost.
There were WAY more presenters and speakers than Peter though, and in case you were wondering, I have not stopped examining all the wonderful material from that summit; I'm simply sidetracked by life itself these days, getting ready for the classes coming up in Europe in a few weeks. 


This post is an interlude, a slight diversion about something else:
I see a lot of books and papers to do with embodied mind, and I want to turn it around for those of us who treat people in pain because I think it makes more sense that way. 

Therefore, let's consider the enminded body. 

Here was the impetus:

The host for the class in Rio at the end of June, sent me this today, an open access paper: Reflections on osteopathic fascia treatment in the peripheral nervous system. It is the epitome of a tissue-based reflection on manual treatment that stopped me in my tracks because right inside the paper it refers to clinical practitioners as "operators". 

Which, by inference, means the patient is being regarded as no more than a stretchy, still-warm corpse.
I mean, isn't that what you will have to turn into (hopefully with the help of a good anesthesiologist) if you submit to having an "operation"? On your tissue?
Which is fine if someone has to cut into you to save your life or limb..
But that is not what happens, not what should happen, in therapy settings.

Seeing people as fascia that happens to be animated does them no great service. 

Fascia isn't even alive - it's comprised of materials, strings of extracellular material, that were extruded from living cells.
If living body cells are the smallest units of human life, fascia doesn't even rise to THAT bar. If it's extracellular, by definition it's not really "alive."
What IS alive are neurons, embedded in it..

Anyway, I digress. It was a shock to see something this much against the grain. So physical, not therapist. SO FAR away from what Peter is all about, which is interactivity, intersubjectivity.

Just for convenience sake, here is the published letter that Jason Silvernail and I submitted a few years ago, Therapist as operator or interactor? Moving beyond the technique.
You may remember Jason as the guy associated with the phrase "Crossing the Chasm". 

Here is something I whipped up about that.

A new slide for 2017 presentations

Here is the original I had written earlier: 
What is the operator model? What is the interactor model?

I think a conscious aware person in pain is going to come in to see people like us because they want therapy, perhaps therapy that's a bit physical. 
They will not be anesthetized. 
Our attitude should have evolved by now into not viewing them as some sort of mere assemblage of collagen.

Quite possibly clinicians are trying hard to be completely objective, and think being strictly anatomical in their externalized views will make them appear that way, but c'mon... seriously: there is nothing more variable (probably) than individual anatomy, and as clinicians we have NO way of knowing any individual's anatomy when they come in to see us. 

All we can do is try to help them move toward having less pain and better movement. That's it.
They are enminded bodies, and they are not so happy about it when pain is what has become enminded in their bodies. And they don't know it. They think their bodies are still broken or fragile or deranged somehow, structurally, thanks to well-meaning but misguided and mis-guiding treatment models based on anatomical dissections and imaging studies that show in glaring detail every little bit of frayed whatever going on it there and blaming it for "pain".

I think that the tissue-based biomedical attitudes so well reflected in the osteopathic treatment paper, and so ubiquitous, are likely a cover-up for deep seated insecurities of the operators who are disinclined to treat their patients as fellow humans with pain problems (enminded bodies): instead they prefer to see them as chunks of walking anatomy and tissue (embodied minds?). Feels less messy or threatening to their own sense of self, perhaps. Creates a more comfortable distance between I and thou.

So, it's a subtle thing in terms of manual therapy. 

Do we treat people as embodied minds? 
Or do we treat them as enminded bodies?

I like the latter better than the former. 

If I'm thinking of my patient as an embodied mind I would likely expect them to take care of handling any discomfort my treatment might inflict, either inadvertently or deliberately.

If I take the position that my patient's mind extends all the way to the ends of the neurons in their skin surface (patient as an enminded body, especially someone in pain with a sensitized peripheral nervous system), I'll be more apt to be careful and conscientious in my application of physical forces, more inclined to slow down and be interactive with their nervous system, more open to feel it as it fixes itself, takes down its own unnecessary positive feedback loops, changes its own physiology, permits softening, warming, effortlessness of movement once again. 

Saturday, February 18, 2017

Peter O'Sullivan, Cognitive Functional Therapy. San Diego Pain Summit 2017 blog series #1

This 2017 pain summit was the the third and best so far. If there was an overall theme, it was that to help people in pain, we as caretakers have to dismantle a lot of our own wrong fears and ideas about pain itself. 

Attendees have been asked to write blogposts reviewing the summit, and I plan to do just that. This is the first of several I plan to write. 

You can obtain videos from the summit, here



I had marvelled at videos online of Peter convincing patients with chronic low back pain that it was perfectly safe for them to bend over and do things they had not done in a long time. Here is a youtube video of Peter explaining what's what, about back pain, to someone who has back pain. 

I attended Peter O'Sullivan's two-day pre-conference workshop and marvelled anew. Not only at the vision he presented, but also his skill at handling two actual people very different from each other who both had chronic low back pain. I learned a new word: "disconfirm."

Such a polite word.
So much more neutral than "challenge" or "refute" or "demolish."
"Deconstruct" has been my favourite word up to now. Now I like "disconfirm" better.


Peter started out by admitting he had had to disconfirm his own beliefs first: he participated in a bunch of research that showed the opposite of what he originally believed; core strength was NOT important for pain, back pain was NOT biomechanical, etc., etc. 

His research has disconfirmed the deep-seated biomedical belief that has propelled the entire profession for a long time that tissue damage -> pain, that nociception -> pain. He showed the usual graphs, references, etc. for geeky people. There are a lot of geeky people in my profession.

Here is a short video (11 minutes) about disconfirming the idea of "core stability."

He is brave enough to rest on this disconfirmation completely, let it be the life raft on which he rides in every oceanic encounter with a new patient. Just by interacting with them, he rules out potential red flags. No type one errors for him. 

He also believes that you must not rush that first encounter. He schedules open-ended sessions that leave him relaxed and free to focus entirely on the patient and their story. He says, sometimes his sessions take a good two hours. 

After presenting his research, he went on to demonstrate how he then disconfirms patients' beliefs about their own back pain. 

First he invites them to tell him their story. He listens very hard to their story. 
Then he starts asking questions and they reveal their fears and beliefs about their pain. (See the first video.)

He gives them lots of positive messages about how strong they are and safe their backs are, about how plenty of studies show that a lot of people with no pain have lots of changes on imaging, so imaging by itself is not a very reliable method of determining pain issues.

He finds out what they would like to do, how they would like to move if they had no pain. What activities they would like to pursue in life or get back to if they weren't afraid of injuring themselves. He talks about the difference between a pain event and an injury,  how pain is protective but how sometimes one's own behaviour can prolong a pain event.

He uses short phone videos to show people how they move their backs. He asks them to bend over, in sitting and standing, takes videos of them moving, does a bit of therapy, communicating to them the entire time, asking them questions, explains how if they contract their abs they actually load their spines more, make their back harder to move, create more anxiety in themselves. He uses the analogy of a tire with too much air in it, which makes it too bouncy. Let a bit of the air out. Soften it a little so that the ride is smoother. He points out that gravity is their friend when they bend over, that they can relax into it, that they don't have to have their abs turned on because gravity can pull them over just fine all by itself. He throws a small object on the floor and asks them to bend over and pick it up. Repeatedly. They do. He asks them how they felt doing it the second time with relaxed abs. They say, better. He takes another video of them doing so, easily. Then he shows them the before and after videos to show them they don't need to protect their backs so much.


In Peter's workshop he worked with two actual back pain patients. 

The first was our internet friend Joletta Belton, @MyCuppaJo, blogger about pain at My Cuppa Jo. She is in her thirties (I think), wonderfully open and gracious, frank and honest about the suffering she endured as her life fell apart after onset of acute low back pain that came on after she stepped off a fire truck. 

Yes, that's all she did. Stepped down from a truck, ended up in rehab. She was fit and healthy and strong, lean, trim (still is). She taught fitness to firefighters and paramedics. She was a strength and conditioning professional. She prided herself on being a warrior. 

Then she was consumed by a pain nightmare, including hip surgery, that changed her whole life, and which she continues to emerge from. She loves being outside, snowboarding, hiking, trekking around, taking photos of natural wonders. Recently she had started organizing groundwork for hosting retreats for people with chronic pain. Also recently she had started feeling pain over her non-operated hip. 

In her interaction with Peter she revealed that her biggest fear was that the other hip had started bothering her and that she feared more surgery. Peter pointed out that it was common for pain to start up in times of increased stress, and asked her if she thought she might have been stressing a bit over getting the new organization up and running. She concurred. 

Peter asked her to do single leg squats. Many many many squats. He emphasized repeatedly how strong she was, how competent her body was, how if she had any labrum issues she would never be able to do what she did in front of the class. He disconfirmed her beliefs and fears about her hip in the nicest way I've ever seen anyone disconfirm anything. He praised her for her strength (she snow-boarded!) and bravery. 

He noticed she was in the habit of "checking" her back frequently to see if the pain was still there, by drawing herself erect. He called these pain behaviours "rules" that people employ. He emphasized that behavioural "rules," whether self-imposed or suggested once upon a time by some well-meaning care-giver, generally limited movement variability, and limiting movement variability was counter-productive because that maintained a fear/anxiety/pain cycle. A big one is to bend from the knees, not the back. Every ergonomic class has that idea embedded in it. It is so wrong. 

(I used to teach that myself, doing inservice for hospital employees. I didn't know any better back in those days, in the 70's. Nobody did. Yet apparently that idea still persists.) 

He asked her to let go of her abs long enough to sit in a slumped position. When she did, and he asked her how it felt, she reported feeling less pain. So he gave her that for homework - to slouch instead of check. So simple.


The second patient was a 60-year old man, large, imposing. He had previously had two knee replacements. 

He had gone in for surgery for low back pain a few years ago (I don't remember how many). The aftermath was harrowing: two bouts of MRSA infection that required opening up his entire back and being on IV drip, for months. His low back auto-fused. 

He pulled through. 

He had been an executive, had financial means. He had liked skiing and motorcycling before all this. He couldn't do either activity anymore because of the unpredictability of bounces and bumps and fear of pain or of losing control. He had been on 14 different meds at one point, now he was down to two. He was doing very well, was out and about, engaging in life, but there was a problem. He would get sudden onset pain across his upper back which would stop him in his tracks, and he would have to sit and rest until it passed, about a half-hour to an hour later. 

He wore a back brace when he was out doing things. Peter asked him if he did that because he was worried that perhaps his back was still fragile. Dave answered, yes. Then Peter disconfirmed that his back was fragile by pointing out that his low back was fused, in fact it had auto-fused! So it was protecting itself just fine - he didn't really need the brace, or the belief that his back was fragile.. could it be that the protective behaviour of wearing a brace stemmed from the original issue he had had with his back, more so than any current issue? Dave said that made sense. Peter let that idea hang in the air for awhile. 

Peter asked him about sleeping. It turned out he had to wake up to roll over, about every two hours. And he slept with a pillow between his two replaced knees. 

Peter asked Dave if he would be OK taking off his shirt. He had wide shoulders and a big burley back with a big scar right down the centre, neck to his upper lumbars. I sat there thinking about all those poor severed dorsal cutaneous rami. It turned out his upper back was quite numb, except for when he developed that excruciating pain that would stop him cold. 

Peter examined him for pain behaviour by having him lean forward in sitting, in standing, pick up the water bottle from the floor, etc., made a little video on his phone, then taught him how to let go of his abs to relax his back so he could bend it better, etc., had him pick up several more items using the new strategy, filmed him again, showed him both videos. 

He had him adopt the relaxed slouch posture he would be in if he were on a motorcycle. He asked Dave to go sit on his motorcycle at home, get a picture of it, and send him the picture. 

He had him lie on the plinth at the front of the room and demonstrate how he rolled. He basically log-rolled, protecting his back from any rotation. Peter taught him how to fold his top leg up higher, let it drop so that his pelvis could rotate forward. He taught him how to roll his upper body the other way, leading with his head, let it roll back, follow with the shoulders/ribcage. He had him practice abdominal breathing and relaxing his abs, then perform spinal rotation again. The difference between the first time and the second was astonishing in terms of amount of range he had gained. I could see how it was similar to Feldenkrais' "Spine like a chain" exercise/movement strategy. So effortless. So easy. 

He said he wanted to go skiing with Dave next time he was back in the US.


For both the patients, Peter had not reacted aversely to anything they said. He had stayed in neutral eye contact and had responded empathically, by saying things like, "that must have been hard for you." 

After the session he recapped for them all the ideas, beliefs, fears, anxieties and protective behaviours he had noticed, showed how they were all linked to each other in a positive feedback loop that did nothing but maintain pain. He drew little stick people doing the movements he had suggested, for their homework. He ended each session by reassuring them that they were strong and didn't need to protect their body part anymore, as it was healed completely and doing just fine on its own. 

Peter's summary for one of the workshop patients

I had an opportunity to self-measure. I've been at this work longer than most who were there, 46 years now. I remember way back when we were taught professional assumptions instead of facts that had been elucidated by science from within our own profession. I remember how wrong many of them were. Yet, clinically, I also remember how we had to make do with the simple things, like empathy, reassurance, encouragement. I remember the whole job was about getting people in pain up from bed and persuading them to do exercises after all sorts of surgery that left them with long rows of very uncomfortable stitches up their abdomens, along their knees, over their backs, or hips, or ribs, teaching them to walk on crutches or to deep breathe and cough to prevent post anesthesia pneumonia (now surgery is much kinder, leaving only small puncture wounds and tiny scars).
In a way, it was revisiting an old skill set I already have, this time with a bunch of deorthopaedicalized science to back it (see Peter's references below).

It had to happen. The science I mean. To disconfirm the old beliefs. 

It's not over yet, though, not by a looooooooooong shot. The orthopaedic mindset in my profession was (and still is) very concrete, biomedical, and overwhelming when it comes to pain - pain must have a cause, and the cause must lie in tissue.

This is still current thinking with orthopaedic surgery. Problems in tissue cause pain, can be visualized on MRI, and must be cut out, or fixed so it can't move, because moving creates more pain.

Sometimes surgery helps people, but much of it is completely unnecessary and it can be a true horror show as well. Here is a sad tale about a young woman who died post-op after spinal fusion. The assumption was that her pains and discomforts stemmed from too loose a spine. I wonder what might have happened if instead, first, she had been lucky enough to have a consult with Peter or someone else with his ease and grace, experience and knowledge, to disconfirm ideas that the biomedical approach and mindset had implanted in her?

I stumbled upon a nice paper describing the various pathways in the brain associated with pain that are hooked up to amygdalar function. I want to study it closely as this is my way of being geeky. 

Here is the link:  Jiang Y, Oathes D, Hush J, Darnall B, Charvat M, Mackey S, Etkin A.; Perturbed connectivity of the amygdala and its subregions with the central executive and default mode networks in chronic pain. Pain. 2016 Sep;157(9):1970-8 (FULL TEXT) All in all, I would sit through a class Peter was teaching any number of times. It's like water to a thirsty camel. A huge bouquet to Rajam for reaching out to him and inviting him to speak and teach at the summit, and to Peter for accepting!


Here is a list of linked references Peter used in his talk. 

  1. O’Sullivan P (2012) It’s time for change in the management of non-specific chronic low back pain, British Journal of Sports Medicine, 46:224-227.
  2. Fersum K, O'Sullivan P, Skouen JS, Smith A, Kv√•le A. (2012), Efficacy of classification based 'cognitive functional therapy' in patients with Non Specific Chronic Low Back Pain -  A randomized controlled trial, European Pain Journal. 17 (6) 916-928. (FULL TEXT)
  3.  O’Keefe, M, Cullinane P, O’Sullivan K, Hurley J, O’Sullivan P, Bunzli S, (2015) What Influences Patient-Therapist Interactions in Musculoskeletal Physiotherapy? A Qualitative Systematic Review and Meta-Synthesis, Physical Therapy Journal, Oct 1. [Epub ahead of print] PMID:26427530
  4.  Paananen M, O'Sullivan P, Straker L, Beales D, Karpinnen J, Pennell C, Smith A, (2015) A low cortisol response to stress is associated with musculoskeletal pain combined with increased pain sensitivity in young adults: a longitudinal cohort study, Arthritis Res Ther. 17: 355. (FULL TEXT)
  5.  Bunzli S, Smith A, Shutze R, O’Sullivan P. (2015) Beliefs underlying pain-related fear and how they evolve: a qualitative investigation in people with chronic back pain and high pain-related fear, BMJ open, 5:e008847. (FULL TEXT)
  6.  O’Sullivan P, Dankaerts W, O’Sullivan K, Fersum K (2015) Multidimensional approach for targeted management of low back pain. Modern Manual Therapy, Elsevier. (NOT FOUND)
  7.  Rabey M, Smith A Slater, S; Beales, D, O'Sullivan, P (2016)  Differing psychologically-derived clusters in people with chronic low back pain are associated with different multidimensional profiles, Clin J Pain, accepted 22.1.16.
  8.  Bunzli S, McEvoy S, Dankaerts W, O’Sullivan P, O’Sullivan K, Patient perspectives on participation in Cognitive Functional Therapy for Chronic Low Back Pain: A qualitative study, Physical Therapy Journal, in press 3.2016
  9. Coenen, P; Smith, A; Paananen, M; O'Sullivan, P; Beales, D; Straker, L. (2016) Trajectories of low-back pain from adolescence to young adulthood, Arthritis Care & Research in press 1.6.16.
  10.  O’Sullivan P, Caniero JP, O’Keefe M, O’Sullivan K, (2016) Unravelling the complexity of low back pain, JOSPT, in press
  11. O'Sullivan K, Dankaerts W, O'Sullivan L, O'Sullivan PB; Cognitive Functional Therapy for Disabling Nonspecific Chronic Low Back Pain: Multiple Case-Cohort Study. Phys Ther. 2015 Nov;95(11):1478-88 (FULL TEXT)


Back pain - separating fact from fiction - Prof Peter O'Sullivan 15:21

Making Sense of Low Back Pain 1:24:45

Prof Peter O'Sullivan and Core Stability - April 2012