Risk, Threat, And Prediction | Part 2

Part two is going to start laying down a theoretical framework for why anything is effective at all when helping someone come back from an injury. If you are at all involved in the world of training and/or rehabilitation, you are well aware there are a million ways to spend your money on some kind of device or tool. You will also notice there are a million more ways to work on how you move and even more people you can make an appointment with to work you over and tell you all sorts of things about your current situation (only some of which is likely to be true).

What are you supposed to do when you are met with all these options? If you are someone experiencing pain (and even worse if the pain is severe), you are desperately seeking the advice of anyone who can help you experience less pain. This appears to be a reasonable idea. We don’t like to experience pain. It isn’t fun. It can interfere greatly with your everyday life, activities, work, and relationships. Who you decide to seek advice from will also dramatically effect the outcome and your entire future predictions about similar situations and your ability to do or not do things the rest of your life. This is not hyperbole. My apologies if I am scaring you a little.

There are entire professions surrounding the act of reducing your pain experience. I am a chiropractor. I know all too well the different ways people in my profession (or similar professions) can massage the information you have given them, and the information they collect from an exam, and deliver to you a very convincing narrative about why you will need their services for some amount of time they have determined. I am by no means suggesting all the folks in these different professions are acting nefariously, I am just saying it is a bit of an odd arrangement. I know you have all had that feeling when you get dropped into the system, as I like to call it, and notice it can be a lot like taking your car in to get it fixed. You don’t really know some of the words they are using, they show you some parts that you aren’t familiar with, and next thing you know you are saying yes to some stuff that may not be relevant. In my line of work there is a tried and true way to help convince someone they need stuff they don’t really need; imaging.

Imaging comes in many forms. You could get an x-ray, a CT scan, or MRI. Imaging has a purpose, and that purpose is to rule out serious pathology given any red flags that show up during a thorough history and examination. They are not particularly useful beyond that, and likely just show a lot of stuff that isn’t particularly relevant, but looks nasty, and can be used to shape a narrative. Imaging is about the worst way to identify any reason a person is experiencing pain unless there is a fracture, dislocation, or a serious malignant pathology present. One important thing to understand about the body, is there are these things called nociceptors.

I am going to use this definition straight off Wikipedia because I think it is the best and most up to date explanation of the process of nociception-

“A nociceptor is a sensory neuron that responds to damaging or potentially damaging stimuli by sending “possible threat” signals to the spinal cord and the brain. If the brain perceives the threat as credible, it creates the sensation of pain to direct attention to the body part, so the threat can hopefully be mitigated; this process is called nociception.”

Two important things to take from that definition. First, nociceptors can send information if something is actually being damaged or if they feel there is a threat of damage. The other important part is the brain has to take in the information and make a decision. It can either view the information as credible and create a pain experience so you take some sort of action, or the brain can decide the information from the nociceptors is not relevant and ignore it. This would not result in the experience of pain. So nociceptors can fire and facilitate a pain experience or they can fire and nothing happens. The flip side is your brain can create a pain experience without any information coming in from nociceptors. Now you may be confused, and that’s ok. Most people in neuroscience have been confused by this for a very long time and there still isn’t a consensus on how this all works.

Now if you think critically about this, it is all really about information. Your brain is taking in a lot of information all the time. It has to create some sort of system to decide what needs to be addressed and what can wait or be ignored. It has to vet the source and make a quick decision, like an investigative journalist. The brain has to compare the information to other information and put it against information it has received in the past from similar or identical situations and form a prediction about what will happen if it acts on the information. It will allow or not allow certain things based on this whole process.

If the intensity of the signal it is receiving from the nociceptors is very high and the information is viewed as a credible threat, the brain will act on the information and form a response. Let’s go back to the classic deadlift and back pain situation. Something about the information your brain was receiving about a particular set of deadlifts created a pain experience. You put the bar down, walked around a bit, maybe tried another set, and headed home. You were still feeling tightness and pain the next day and remembered a friend of yours who herniated some discs on a set of deadlifts (or something to that effect). You call up a provider and make an appointment. Before we go any further, most pain from something like this, in absence of severe radiating pain, motor and sensory deficits, and loss of bowel and bladder function, will resolve on its own with activity modification, not letting yourself catastrophize, and working back into your activities of daily living. You will likely be pretty much back to normal in a few days to a few weeks. It should also come as no surprise to you at this point, that depending on who you see about the issue, the initial narrative you are given is what will make or break the situation. If you drop into a clinic and they go on and on about all the things they see wrong on your imaging and in their examination and how this is twisted or out of place and this is tight or that is not firing and you need them to help you fix it, you are more likely to buy into that line of thinking.

I also want you to understand the concepts of regression to the mean and the natural course of a particular issue, like this back pain after deadlifting example. In the previous paragraph, I discussed the natural course of a back issue. Understanding this when something happens to you is very important as it will keep you from panicking and lower your anxiety and threat level. Regression to the mean is understanding the pain experience will likely be exquisite up front, but will regress back towards a baseline. The issue is you typically end up in a clinicians office when the pain experience is at its most intense. This is where people tend to get trapped into tests, imaging, and treatment plans that likely aren’t necessary.

Here is where things get tricky. Hopefully you found yourself in a clinic where they offer you empathy, reassurance, guidance, and a path towards independence and self efficacy. Some manual therapy may be done, there can be some limited value initially. I will explain concisely why it may work at all (and by manual therapy I mean joint manipulation, soft tissue work by hand or instrument assisted, dry needling, cupping, taping, or whatever other weekend seminar your clinician recently went to). In the end it is likely due to changing the information the brain has to work with for creating more accurate predictions.

There are a lot of narratives clinicians will give to explain why a particular option they pick to work with you will be effective. You have probably heard phrases like, “put you back in line,” “break up adhesions and scar tissue,” and “relieve that pinched nerve.” None of this is happening when a practitioner does anything to you. None of it. Your body is not that fragile that someone can move you around with their hands or an instrument and make any of that happen. If a nerve was truly being pinched off by some sort of disc herniation, it would need surgical intervention.

So what is going on then? It’s not that some of the manual therapy options can’t be useful. It is just the way they are presented that is a problem. I don’t think everyone you go see has nefarious motives, but there is part of seeing a manual therapy provider that can create dependency and, in some respects, an addiction. The body is a system of systems and all of these systems interact with the nervous system to provide information so the brain can formulate a prediction. If manual therapies work at all, it is likely at the level of helping the brain receive more useful information from a joint, muscle, or fascial system the brain is currently having difficulty interpreting the information from. The more scientist are finding out about how the nervous system works, the more I am starting to understand how manual therapy, in a limited sense, can be helpful in getting a person back to training.

It is really about information. With manual therapy, whether that is joint manipulation or some kind of instrument assisted work, I can create a pretty intense sensorimotor stimulus. I can introduce mildly aggravating non-threatening motion to a system. I can help a person explore the physiologic end ranges and capabilities of the neuromuscular system and allow the brain to gain better perspective around a particular area and start to improve the accuracy of prediction. In a sense, as with this low back example, I can manipulate the lumbar joints and show the brain the joints can be safely moved through different ranges without catastrophe occurring. The theory would then be threat level is lowered, the brain perceives less risk in allowing movement, and we can get to work. Same could be said for any modality, except things like scraping and dry needling would be working more at the muscular and fascial level. You can get to this point without manual therapy, but I am just theorizing, given current understanding of the nervous system, why it may be useful at all. Do not discredit the use of manual therapies totally, but understand why and when they may be effective in the overall plan of returning you to your training and goals.

This is also why it is important to get you back to things that look like training as soon as we can. We don’t want you to develop a long term prediction issue with a particular movement your brain is currently assigning a high level of threat due to this pain experience. This cycle has to be broken quickly, as your brain is really into protecting the body from perceived threats. This is why I feel like a lot of people have recurring issues when they have sought the services of a provider for a lower back tweak. Many times the practitioner will recommend resting from the offending activity or, worse, never doing the offending activity again. This starts the process of detraining. This is bad. Yes, modifications of training will likely have to be made for a bit. We may have to control range, volume, intensity, density, and so forth, but completely abandoning the lift is not useful.

You may get sucked into lots of “corrective work” after being told to back off the lifts in question. This is to activate this muscle and fire that muscle and restore your reflexes or whatever other thing you were told while being examined. In reality, this likely works in the process of pain reduction more because of regression to the mean and the natural course of the pain experience than it does anything else. Doing tons of stuff that tries to focus on a particular small muscle group around the spine or improve the strength of your stabilizers or whatever narrative is being used has no real guarantee of helping your body organize itself better and reduce the perceived threat of the original exercises that landed you in this situation.

Much of the benefit likely lies in making you actually go through the process of warming your body up and being more intentional with how you do things. I don’t feel there is anything particularly special about any of the corrective work that is out there, and I don’t spend much time adding it to the programming of people I work with. We might do a little crawling, some Turkish get up variations, loaded carries, and maybe some planks and side planks, but beyond that, you can waste a lot of training time doing lots of stuff that doesn’t really matter. I would much rather see you doing things like banded RDLs and good mornings than the newest variation of the dead bug.

A final and important reason anything works is placebo and perceived effectiveness. You are expecting whatever narrative you are being given to work. You heard it worked for a friend. The clinician assures you it has worked for a lot of people like you in the past. You went on the internet and found a few websites that “proved” the effectiveness of the treatment you are seeking. Your favorite athlete has a video on Instagram of them receiving the treatment and giving a shout out to the person delivering the service and how great they are and what an expert they must be. Whether the clinician understands it (or wants to admit to it) much of clinical practice is theater. I have long joked about comparing a treatment session to a magic trick involving sleight of hand and misdirection.

I’m not saying any of this to make you think seeking clinical advice is pointless and worthless. Patient perception of an issue is very important, and if you feel something is sketchy or not improving (or getting worse), go see an experienced provider who can rule out anything serious and help reassure you your current situation will start to improve. I just want you to better understand how to navigate the situation. Sound clinical advice is rooted in empathy and reassurance and helping you guide yourself back to your goals with confidence and vigor. It should not be about using fear of a current situation to create dependence and a customer of the system.