Episode 127 – Low Back Pain Update (with Whitney Lowe & Til Luchau)
Episode Transcript
Summary:
In this episode, Til and Whitney dive into strategies for addressing low back pain (LBP) with hands-on work, exploring LBP’s prevalence, causes, and treatments. Sharing the insights they’ve gained from experts such as Nikolai Bogduk, Stewart McGill, Paul Hodges, Lorimer Moseley, Helene Langevin and Antonio Stecco, they lay out the diverse views on both the structural and non-mechanical origins of LBP. Listeners will also learn about therapeutic approaches, the significance of practitioner confidence, and the importance of comprehensive evaluations. Tune in for a fascinating look at how practitioners and clients alike can better understand and work with low back pain.
Key Topics:
1. Prevalence of low back pain
- Over 60-70% of people have episodes of low back pain at some point [01:51]
- Leading cause of disability worldwide
- Huge economic impact
2. Potential evolutionary factors contributing to low back pain
- Transition to bipedalism and upright posture
- Differences in spinal curvature and hip mobility between cultures [05:45]
3. Causes and contributors to low back pain – [07:39]
- Overemphasis on disc and structural issues in the past
- Importance of comprehensive evaluation beyond just structural issues
- Role of soft tissue, muscular, and neural factor
4. Influence of practitioner perspective and confidence on outcomes [30:20]
- Importance of the therapeutic relationship and rapport
- Unexpected interventions can sometimes be effective [35:53]
5. Personal experiences with low back pain
- Overuse vs. underuse/immobility as contributors
- Debates about the significance of posture, load, and context [41:31]
- Limits of expertise vs. scope of practice for massage therapists
Whitney Lowe:
Hey, and The Thinking Practitioner Podcast is supported by ABMP, the Associated Bodywork and Massage Professionals. ABMP membership gives professional practitioners like you a package including individual liability insurance, free continuing education, quick reference apps, online scheduling and payments with PocketSuite, as well as much more.
Til Luchau:
ABMP CE courses, podcasts, and massage and bodywork magazine always feature expert voices and new perspectives in the profession, including myself, Til Luchau and my companion, you, Whitney Lowe. Thinking Practitioner listeners can save on joining ABMP at abmp.com/thinking. And coming up on October 1st, 2024, ABMP will host you, Whitney and me, Til and Dr. Joy Edwards for a special CE summit focused on low back pain.
This online event, including three hours of CE is free for everybody in the profession, not just members. Members can have access to the recording, but everybody can come to the live presentation for free and get the CE there. And in celebration of that, that’s what we’re talking about today and it’s a pleasure to see you and to discuss these ideas, Whitney.
Whitney Lowe:
All right, that sounds great. Well, I’m looking forward to having a good discussion on it.
Til Luchau:
Well, we’re going to take our different perspectives. We’re going to compare, preview, contrast, and then we’ll talk about again what we’re going to share at the summit itself. But I like some of the questions you’ve put in our roster for today, our agenda for today, and I’m looking forward to digging into those. How about we start with its prevalence or how common is it? How common is low back pain?
Whitney Lowe:
Yeah, I certainly think it’s… I think world experience and looking all the stats, very, very common. You got some stats I think on the percentages of it, and that’s similar to what I had put in a recent article too, upwards of 60% to 70% of people have some episode of low back pain at some point in their lives, and many of them have recurrent pain and the stats… I should pull this back up, I don’t remember off the top of my head the economic impact of that also is just gargantuan in terms of the millions and millions of dollars spent on trying to address low back pain.
Til Luchau:
That’s right. Leading cause of disability worldwide too, gets in the way of people being able to do their daily lives more than anything else in the world.
Whitney Lowe:
Yeah, yeah.
Til Luchau:
And the biggest reason that, or one of the most common reasons that people come to healthcare providers for help.
Whitney Lowe:
Yup, yeah. As we’re thinking about this, I was thinking about how prevalent this is. I don’t know why I just had this flash of memory. You might probably remember this. We’re of the same age group to remember. Do you remember commercials back in…
Til Luchau:
Spinal tap? Is that what you’re talking about?
Whitney Lowe:
No, this is back way before. This is the 60s I think for Doans pills.
Til Luchau:
Huh.
Whitney Lowe:
D-O-A-N Doan’s pills.
Til Luchau:
Yeah.
Whitney Lowe:
It was a remedy for back pain that was pretty…
Til Luchau:
Oh, right.
Whitney Lowe:
I don’t know what was in those things, but I remember just hearing commercials about them all the time for dealing with your back pain.
Til Luchau:
Okay. They’re not a sponsor of the show.
Whitney Lowe:
Yeah.
Til Luchau:
But that’s a great association, yeah, lots of remedies out there, lots of things being tried forever for this back pain question.
Whitney Lowe:
Yeah.
Til Luchau:
The stat I found every year about 15% to 30% of people adults experience low back pain.
Whitney Lowe:
Yeah, and it’s amazing as frequent and as common as that is that we have not found better and more consistent solutions for addressing it at this point of our modern healthcare evolution.
Til Luchau:
That’s right. There is so much research that’s been done and is being done, and it’s still such a big problem that you can get your grant approved by making it about back pain because there’s so much interest and need for that help.
Whitney Lowe:
Yeah. Out of curiosity, before we move on, I’m just going to ask you this question…
Til Luchau:
Yeah. Sure.
Whitney Lowe:
… because I ponder about it. I mean, there are people who point to the idea and I’d like to hear your opinion on, I mean, we don’t know because we can’t ask for example, quadruped animals if they have low back pain. But there’s a lot of suspicion that the prevalence and epidemic of low back pain has something to do with us becoming bipedal and standing upright and walking around.
Til Luchau:
That’s one of the narratives.
Whitney Lowe:
What do you think about that? Yeah.
Til Luchau:
What do I think about that? That makes some kind of sense. I don’t know how to test it. But yeah, the idea that if you go with evolution, which many of us do, it’s this idea that we evolved in a horizontal spine. And then, we’ve become upright. So, these structures that originally were functional, either swimming in the ocean or crawling in the land, and now vertical masts, that sounds like a recipe for some challenges.
Whitney Lowe:
Yeah.
Til Luchau:
Sounds right to me. There’s an interesting, just pulling trivia out of my storage closet, my brain. There is no scoliosis amongst any other species except humans, except for congenital deformities. But like adolescent scoliosis doesn’t happen in animals. It’s a human thing.
Whitney Lowe:
Yeah, yeah, and that makes sense for some degree of functional development of functional scoliosis because of those stresses of the vertical column, the vertical spinal column, that certainly does tend to make sense that that would develop there.
Til Luchau:
Yeah, and maybe that hurts.
Whitney Lowe:
Yeah.
Til Luchau:
That just hurts, who knows?
Whitney Lowe:
Yeah. And interesting when you look into some of these statistics too, there’s some other important considerations that I don’t think make it into the stats a lot that need to be considered, especially when you look at some of the different demographics of back pain amongst to different cultures. And we find back pain is not as prevalent in certain cultures, but I think a lot of times there’s cultural overlays about that.
And one of the stories I love, this is a story Doug Nelson tells. He is of Scandinavian descent. And Doug, pardon me if I get this wrong, but I believe it’s Norwegian that he’s from, where his family is from. He said one time, “Yeah, there’s a common thing in their culture of saying that, yeah, this hurts so much. I almost said something about it.” And so, for a lot of these cultures talking about a reporting pain is not common, so there’s probably some degree…
Til Luchau:
Probably, find of what we’re comparing when we compare the report.
Whitney Lowe:
… under reporting, yeah.
Til Luchau:
That’s right.
Whitney Lowe:
… of some of those things in certain cultures.
Til Luchau:
We’re comparing cultural expressiveness about pain as much as pain itself.
Whitney Lowe:
Yeah.
Til Luchau:
This interesting thought. I do remember some research, and this was in my second book I think about correlating spinal curves and hip mobility with back pain. And this was a bunch of work done in Japan where at this time people were sitting on the floor a lot more still and had much more hip flexion available to them than the average European and Westerner.
Whitney Lowe:
And that also has some things, if I’m understanding correctly too, to do with depth of the acetabulum depth of hip sockets and the capability…
Til Luchau:
Orientation, perhaps. Also…
Whitney Lowe:
… to get down into the squatting positions, yeah.
Til Luchau:
That’s right. Are the acetabula pointing up to the side? Are they pointing ahead? There’s a lot of variation amongst that between people.
Whitney Lowe:
Yeah.
Til Luchau:
That’s right.
Whitney Lowe:
Yeah. So…
Til Luchau:
Well, what are the… You have an article coming out, I look forward to seeing that. But you’ve been doing some thinking about this, what do you see as the common causes of low back pain that we see in our work? And especially, how can we address those things as hands-on therapists, massage therapists, et cetera?
Whitney Lowe:
Yeah, this is interesting. When I was looking up some of the stats on what the causes of low back pain are, there’s a lot of things that are reported very consistently of causes of back pain, disc protrusions, pressing on nerve roots, spondylolisthesis, sprains and strains and some other soft tissue injuries. But it is interesting the way that those things get reported because people like to have a diagnostic category for naming these conditions to report them as causes of low back pain.
Til Luchau:
Yeah.
Whitney Lowe:
And I personally believe that some of the very most common causes of low back pain don’t fit into a lot of those categories, which is just the muscular overuse low back pain isn’t really, it’s not a strain because we don’t have overstretched or torn muscle fibers. And the muscular hypertonicity come up as a diagnosis…
Til Luchau:
Right.
Whitney Lowe:
… or back pain complaints in a lot of instances. So, it’s really, I think there’s again, some skewing to those statistics and causes of what produces back pain. And I saw this a lot, especially in the clinical world when I was working back in orthopedic clinic back with Emory University in particular of the number of people who would come in with a diagnosis and their diagnostic label was lumbar sprain/strain.
And the more I learned about all this stuff, the more I started realizing, well, there’s a big difference between a sprain and a strain. One is focusing on ligamentous tissue and one is focusing on muscular tissues, and how do we really determine which of those is the primary problem, if there is a primary one, and how do we direct our treatment toward that?
Til Luchau:
And we’re describing pain inducing phenomenon in terms of physical damage, which is only an indirect relationship anyway.
Whitney Lowe:
Yeah.
Til Luchau:
So, there’s probably a whole lot of back pain related to soft tissues in some ways that wouldn’t fall into the, like you said, the sprain or strain category. They’re not either severe enough or maybe don’t even fall a physical injury or damage. It might be more of a sensitization phenomenon.
Whitney Lowe:
Absolutely. And this was all way before the whole pain science thing was coming around.
Til Luchau:
Right.
Whitney Lowe:
So, I think everybody… I don’t know if everybody, but the vast majority of people were looking at this through a mechanistic lens of we got to find a mechanical cause of what this back pain is. And so…
Til Luchau:
And then, we find that we can be mechanics and fix the mechanical problem and back pain will be gone. Wouldn’t that be nice?
Whitney Lowe:
Yeah, yeah.
Til Luchau:
You’re reminding me of a presentation Frank Willard did at the Facial Congress before the one you and I went to maybe say 2016, 2018, Berlin. He did his own research and it was fairly extensive, although he gave all the usual disclaimers about his own research. And he said that maybe 60%, 70% of back pain has a myofascial component or a soft tissue component, he was saying. And he was saying what we used to assume was the true for 80% of back pain disc issues as recently as three decades ago, people were saying 80% of back pain was related to disc issues.
Whitney Lowe:
Yeah.
Til Luchau:
You said current research points to about 4% directly.
Whitney Lowe:
I would tend to agree with that. I think that’s a lot more realistic. There’s a really good discussion of this whole historical trend and in Gordon Waddell’s book, The Back Pain Revolution.
Til Luchau:
Right, right.
Whitney Lowe:
When he refers to the dynasty of the disc.
Til Luchau:
That’s it.
Whitney Lowe:
And that was a good several decades of focus on blaming the disc for a lot of those back pain complaints. And I think we’re now recognized, especially now with the advent of the MRI…
Til Luchau:
Yes.
Whitney Lowe:
… and the fact that we identify so many people with no back pain who have some pretty significant structural challenges in there with disc status that we can’t really make those kind of assumptions any longer. And that really points to the critical necessity I think, of comprehensive evaluations and comprehensive assessments of what’s really going on there and not just an assumption looking at some imaging things automatically.
Til Luchau:
Well, Stuart McGill would agree with you on that.
Whitney Lowe:
Yeah.
Til Luchau:
He’s really the king of the thorough evaluation for sure.
Whitney Lowe:
Yeah, yeah, certainly. And there’s been some backlash against some of the things that Stuart McGill has advocated because he does tend to focus a great deal on saying that there’s almost always a cause that can be found if you’re thorough enough.
Til Luchau:
Okay. His statement is there’s probably no such thing as nonspecific back pain, back pain out and identifiable cause. I probably oversimplifying it, but he says, “If my eval is thorough enough, I can pin it down to some kind of mechanical cause.”
Whitney Lowe:
Yeah, and I think I would have to say I’m not really in that camp because I think there are quite a number of conditions of back pain that don’t have something mechanical that is causing them, and this is the whole psychosocial component of what might be producing back pain from historical things that happened to somebody previously or just that that’s where their pain is getting generated from, but not necessarily through a mechanical cause. I went back, I was listening to some of the things that we had when we were talking about in that episode and I was…
Til Luchau:
We’ve had him on twice. Yeah, if you say that, we should thank him again for coming. But what did you hear? What was it?
Whitney Lowe:
Yeah, well, this also came out of some discussions. I had an episode a couple of weeks ago with Laurel Beversdorf and Sarah Court, and we had talked about that some. They had discussed that on their podcast a good bit too, just that excluding people with a non-mechanical cause systemic disorders, major systemic illnesses or things like that that might manifest in back pain, things like fibromyalgia, all those kinds of things can manifest in back pain and you’re not going to find a mechanical cause for a lot of those people.
So, neural sensitivity. And that’s why, again, I was saying it’s so critical. I think that we be comprehensive in our evaluation and assessment process. So, taking a comprehensive and thorough history can begin to tease apart what might be of mechanical origin and what might be of a non-mechanical origin.
Til Luchau:
And if it’s a mechanical origin, do we work it differently than non-mechanical?
Whitney Lowe:
Yeah, that’s a big question. I would certainly tend to probably work in a different way about those things because I would tend to, again, on a case-by-case basis, it’s going to differ. But I would say, as a general guideline for a non-mechanical issue, I would probably tend to work less in a targeted and focused direction toward a specific tissue orientation and more towards a generalized reduce the nervous system, no-susceptive activity comprehensively kind of thing.
Til Luchau:
Okay. All right.
Whitney Lowe:
What about you? Do you…
Til Luchau:
Yeah, I think I would go with that in terms of specificity or general thinking. But I think I’m a bit more agnostic in terms of this question of causes. And maybe that’s just because I don’t know that I have the patience or specificity to do a Stuart McGill kind of two-and-half-hour evaluation where we get every single movement and every single bit of history and put that together into a grand unified theory of someone’s back pain.
Whitney Lowe:
Yeah.
Til Luchau:
I think I can actually find useful things to work with without the Newtonian universe being deconstructed to clockwork. In other words, maybe finding movements that are provoking of the pain and thinking about pain as an experience itself and divorcing it for a second from possible mechanical cause. We can do a lot to soothe pain, to change someone’s reaction around pain. And the fact that maybe pain is a reaction in of itself when we shift the way someone reacts to a sensation in their back, we’ve shifted their pain.
Whitney Lowe:
Yeah.
Til Luchau:
And so, I also keep in mind for myself, I’m kind of getting into our next question here. But that there’s so many different things that can contribute to the experience of back pain that aren’t local.
Whitney Lowe:
Yeah.
Til Luchau:
Can I talk about this for a second?
Whitney Lowe:
Yeah, yeah. I was going to ask you to expand on that a little bit because you brought some interesting things up in talking about that.
Til Luchau:
Well, started for me with Bogduk spinal researcher, pretty well-known, I believe this was in 90s or 2000s coming out with a study where he systematically would anesthetize different structures in the back of people with back pain and get them to report on their pain. And he categorized it down to different things in the back were responsible for this percentage of people back pain that we see in the clinic. And his assessment was that at least a sixth, about 15% of people coming and saying they have low back pain, got better, didn’t feel pain when he would numb out their SI joints.
And so, he’s saying, “Well, that’s a big contributor.” And then, Taguchi in the 2000s, this made a big splash in the facial research field. He was testing the sensitivity of the thoracolumbar fascia, which is thought from that perspective in the facial perspective to be a probable source for a lot of back pain. So, he went through and mapped out through irritating with saline solution and maybe think electrodes perhaps, where on this thoracolumbar fascia do people feel back pain? And where did they report it?
Whitney Lowe:
Yeah.
Til Luchau:
And he found that there’s huge overlaps in both people’s reporting. But also in the neurology, which neurons have inputs from different structures. And he found that, I don’t have the list here, but viscera was often experienced as a back pain, visceral pain, a leg pain, hip pain, skin pain would sometimes be reported, something people felt and experienced as a back pain that point to their back. The urge right there in the thoracolumbar fascia.
Whitney Lowe:
Yeah. Let me ask you a question…
Til Luchau:
Sure.
Whitney Lowe:
… because this brought up something interesting, I can’t remember the number. But quite a while ago you and I did an episode where we talked about the homunculus and the percentage of sensory input from different parts of the body in particular…
Til Luchau:
That’s right.
Whitney Lowe:
… lips, fingers, hands, and those distal sensory he thinks super large in terms of the amount of sensory information that comes. The back, not so much.
Til Luchau:
Not so big, not so huge.
Whitney Lowe:
Also, no, very difficult to tell, two-point discrimination on the back in terms of what that is for people not familiar with that is where you get two points of contact, like two little sharp tip ends of a compass or something like that. And how close can you put them together before you realize that there’s two points and not just one point or how far can you spread them apart.
Til Luchau:
So, it’s like a measurement of tactile acuity or your ability to be accurate with that part of your body, yeah.
Whitney Lowe:
And with the back, we just don’t have very good two-point discrimination at all. And it makes me wonder, like you were just saying here, how much of this might be a big part of misreporting from overlap of incorrect information that we’re getting summarized in the central nervous system?
Til Luchau:
Yeah, yeah. Well, the homunculus this is definitely a diversion, but I got to go there for a second. The homunculus turns out to be, have a lot of areas of overlap. I think we discussed that some in our episode on it. And this two-point discrimination thing like our guest Mark Bishop talked about is less accurate when there’s pain. People have to have the points much farther apart to tell there’s two and not just one when they’re in pain.
Whitney Lowe:
Yeah.
Til Luchau:
And so, this idea of helping someone develop sensory acuity or being able to feel accurately has some theoretical potential to reduce people’s pain. I don’t know if that’s been tested rigorously, but in my practice that’s a concept I use a lot. Can I have someone to report exactly where the edge of their pain is? And I’ll go out and work… I’m sorry, I’m still in this rabbit hole.
I’ll go out and work just the level of skin with a really light touch. And that’s actually where we start our sciatica training, which I just got done with in Maine, but we started with just a really light touch on the skin and you can really map with someone with back pain where the skin gets sensitive. You can find it out almost like a dermatome chart. It’s not going to follow the typical dermatome shapes all the time.
And then, I will actually keep in mind that that’s really changeable and plastic and moving all the time both in the brain and its relationships, but on the skin. And we can actually, with patients and the right touch and the right invitations to the client shift that sensitivity in the skin. And a lot of people report changes in their back pain too.
Whitney Lowe:
Yeah, and that’s also very closely tied in with that idea of cortical smudging of…
Til Luchau:
Exactly, exactly.
Whitney Lowe:
… especially with back pain, the difficulty of really being able to precisely tell or target where that pain is coming from. The worst the pain gets the worst the discrimination seems to get about being able to identify exactly where that’s coming from.
Til Luchau:
That’s right.
Whitney Lowe:
Yeah.
Til Luchau:
So, I can work with pain itself as an experience and taking a shortcut around the question of which structure is generating this pain with the knowledge that it could be a lot of things and it might not be identifiable just by sensation.
Whitney Lowe:
Yeah.
Til Luchau:
It’s more of an empirical approach, what seems to make a difference here?
Whitney Lowe:
Right. You had some other people that you mentioned also being influential with some of your ideas on this, yeah.
Til Luchau:
Yeah, yeah, Stuart McGill. We mentioned his specificity of his eval and his idea, there’s no nonspecific back pain. But also, his emphasis on stiffness was again a mind puzzle for me because pretty compelling evidence and stories from clients of mine and other therapists I know who use his methods to find ways to manage their back pain through essentially cultivating stiffness. I think that’s probably my unquestioned bias towards softening and relaxing that came with my bodywork training.
Whitney Lowe:
Yeah.
Til Luchau:
Physical therapists are more about strength and probably coordination. Body workers think, “Oh, it’s going to be better if we soften it.” And turns out, yeah, in the back, probably not at some point at least.
Whitney Lowe:
Yeah.
Til Luchau:
And I mentioned Paul Hodges there on my list that you’re looking at. Paul Hodges was, is an amazing researcher. I hope to get him on the show at some point. But a lot of his work, early work was about motor control in the spine and that’s like a more refined way to say strength and coordination of the back. And he really looked at the sequencing of things firing and the limitations of that model too. And he said, people really got out of control with the idea of core strength having to start with the multifidus and going through this exact sequence, which is what people quoted him a lot in that kind of research. But he says, “It’s not that lockstep, but there is some sort of control and coordination of back activation that we need.”
Whitney Lowe:
Yeah.
Til Luchau:
So, his ideas were influential. Do I use that in my work? I think it shifted me. He and Stuart McGill shifted me from thinking, let’s just get in there deep and soften it in a sense.
Whitney Lowe:
Yeah, and I think too that when you think about a lot of the discussions of… And a lot of this came out of this sort of pain science revolution, talking about pain being a protective mechanism that when we talk about motor control, a lot of times those back injuries you’ve heard over and over again about that 300-pound pencil.
Til Luchau:
No.
Whitney Lowe:
I didn’t do anything. I just reached over to pick up this pencil and my back went out as somebody says.
Til Luchau:
Right.
Whitney Lowe:
And so, and I think that’s getting into that whole idea of the motor controls like, your back was pretty close to being at the level of fatigue and something you did in that movement activity just made it fearful that you do this one more time and I’m not going to be able to withstand this load. And so, then the spasm comes along to protect it. And I think that’s really a motor control response that’s in there doing that, like you mentioned.
Til Luchau:
Yeah, the motor control might be an expression of some sort of central nervous system sensitization or protective response is being triggered too. That, of course, the proponent of those ideas was Lorimer Moseley. He was also been a guest on the show. Thank you, Dr. Moseley for coming in. But huge influence on my understanding of back pain.
Whitney Lowe:
Yeah.
Til Luchau:
And he was by, interestingly enough, he was Paul Hodges PhD student. Paul Hodges was a supervisor.
Whitney Lowe:
Oh, I didn’t know that. Interesting.
Til Luchau:
Yeah, they did some interesting, Todd Hargrove has a nice article about the two of them giving back-to-back lectures at a conference at some point. I’ll remember, and see if I can put a link in the show notes or something because they have different perspectives, but there’s really an interesting dovetailing and mutuality there, points of view.
Whitney Lowe:
Yeah, yeah, interesting.
Til Luchau:
The other name on my list, Helene Langevin, who’s been on the show. Antonio Stecco, who’s also been a guest. We’ve had an amazing back pain guest roster already. Their work collectively pointed to the role that tissue may play, especially thoracolumbar fascia may play and superficial fascia where there’s pretty clear correlation between thickness of those tissues and their mobility, their ability to glide especially, not particularly stretch. And this is not saying, this is not going to the debate about does fascia remodel. They’re not talking remodel. They’re talking about just the sliding and the thickness.
And Dr. Steckel’s research shows, at least in the neck fascia where he did it, that there’s a pretty clear effective manipulation toward both increasing the sliding and decreasing the thickness of those tissues, and that correlated with a reduction in pain.
Whitney Lowe:
That seems like that might also go along with your thoughts on stiffness too, that there’s maybe some degree of a greater, not some degree, a greater degree of stability associated with those fascial tissues that are playing a bigger role in maintaining the stiffness and stability in the spine.
Til Luchau:
Well, he elucidated us when he visited about the complexity of that stiffness question and the role of hydration in that and lots of factors beyond just a little bit of muscle contraction, which is from massage therapy point of view, what we might assume stiffness means or fascial density that we might assume from a fascial perspective is the stiffness.
Whitney Lowe:
Yeah. Right.
Til Luchau:
Yeah. That’s it. Those are my back pain influencers. And I think I take their concepts and ideas and try to apply them on the table in different ways.
Whitney Lowe:
Yeah, there’s so much out there, so much that has been written about this. And again, a whole lot of opposing opinions, people that say this is the solution. John Sarno was real big for a while with looking at that whole thing saying, “We’re off on the completely wrong track here.” And there seems to be some faddism periodically about something. We talked about the dynasty of the disc.
Til Luchau:
That’s right. The story of that evolution. That’s right.
Whitney Lowe:
Yeah, yeah, there’s certainly some faddism that goes along with these different places and through it all, we still have lots of people challenged and unable to find really good solutions for what seems to be ailing them so frequently.
Til Luchau:
And it was the famous quote, maybe it was Sayers, maybe I’m getting that wrong, said that, “When there’s a lot of remedies for a particular condition is because none of us really get it. None us really have the answer.”
Whitney Lowe:
That’s good, yeah.
Til Luchau:
Yeah.
Whitney Lowe:
Yeah, I think that’s good. There was… I talk about this study frequently, and I cannot remember the exact name of it, but this came out maybe early ’90s or something like that. And I think it was talking about in the cervical area, it was either cervical or low back region, but the study was about the different approaches that people take for addressing this.
And for example, they were making the comment essentially that if you’re a chiropractor, it’s a subluxation. If you’re an acupuncturist, it’s a chi flow blockage. If you’re massage therapist, it’s muscle tightness or whatever.
Til Luchau:
If you’re carpenter, just a nail.
Whitney Lowe:
That’s right, yeah. The study was something like who you see is what you have or what you have is who you see. And there is a certain element of that too that I think that is out there that we all have something that can be potentially beneficial in doing that. And it gets me thinking about our discussions about the descending modulation. We had an episode that we focused on this, and it’s like maybe really that’s what most of us are doing. If all these things work for certain people, maybe that’s more of what the reality is of what’s actually making the changes in a lot of those situations.
Til Luchau:
I got a story about that if I could. And a study, there was a study comparing different practitioners’ model of spinal biomechanics because there’s some very opposing principles of spinal biomechanics that are taught in different schools.
Whitney Lowe:
Yeah.
Til Luchau:
Some said when you side bend this way, a bend rotates that way, some say exactly the opposite. And so, they tested these different practitioners who were trained in these different schools on their… They didn’t test the outcomes because almost all the outcome studies show that method is not really related to outcome. But what they tested was these practitioners confident that they had made a difference for their client.
Whitney Lowe:
Yeah.
Til Luchau:
And they said, “Do what you’re trained in, and then do the opposite of what you’re trained in,” which one do you have more confidence made a difference for your client?
Whitney Lowe:
Yeah.
Til Luchau:
And as you can predict, the ones that people were trained in confidence was huge. So, there’s this role for the narrative we hold as practitioners and our confidence in it and how it makes sense to us or resonates with us or has some integrity for us being a lever for our own sense of confidence in what we’re doing, which as we know, the practitioner confidence actually does have a lot of nonspecific benefit for the actual client experience.
Whitney Lowe:
Yeah, that gets back to our discussion with Mark Bishop too about the impact and the outcomes and how that is influenced significantly by confidence levels of both the practitioner and the client that is experiencing that as well. And when there’s… All these, there’s a lot of discussions currently in our fields, in our rehab fields about how important it is to… How important the technique is. Is it really important? Does technique really do what we say it does? And unfortunately, I think what some people get out of that discussion is that the technique doesn’t matter.
Til Luchau:
Technical nihilism, it doesn’t matter if the techniques are compared equally. Why does it even matter what we do? Let’s just even do it or do whatever.
Whitney Lowe:
Yeah, my discussion about that is, I think that’s missing the point of what they’re saying because I think they do matter for this very reason that your confidence levels and your ability to get your client engaged in that therapeutic alliance with you by what you’re doing is greatly influenced by how effective you think you’re going to be with using those particular techniques. And so, I think it does matter significant, probably not in the way that we think it does, but I do think it matters.
Til Luchau:
Yeah, yeah, if it didn’t matter at all, I mean, I’m completely on board with the concept underneath that, but the conclusion that the technique doesn’t matter. My job would be a lot easier when I’m teaching a workshop because I’m giving lots of input about the hows. And it is mostly, the how, not even where, what we’re working on, but how we do it, seems to make such a huge difference. And that’s not easy to learn, but not easy to teach. And so, there’s a lot that matters there for getting the results that we’re looking for and our clients are looking for it too.
Whitney Lowe:
Yeah, and we have to think too, and you and I both have to grapple this as educators, that we probably do certain things a particular way because our body does it comfortably. And then, I know when I’m trying to teach the same technique to a 6’3″, very tall person with very long limbs…
Til Luchau:
That’s right.
Whitney Lowe:
… who doesn’t have that degree of finesse of technique that I can do maybe as a smaller person or something that doesn’t work for them, or when I’m trying to teach this same technique to a young person that’s 5’1″ and 110 pounds, they can’t do that sort of thing that we’ve just said. So, you’ve got to find a way that works for you in doing those particular types of things. And this is certainly true when you deal with things like low back area where you may be trying to do movement-oriented things along with some of the stuff that you’re doing with soft tissue manipulations.
Til Luchau:
That’s right.
Whitney Lowe:
It can be super challenging, I think.
Til Luchau:
It’s a big area, especially if you’re moving limbs around and things like that, it could demand a certain physicality.
Whitney Lowe:
Yeah.
Til Luchau:
So, you’re saying when we look for CE, we should look for a teacher that matches our stature physically.
Whitney Lowe:
Right.
Til Luchau:
Or…
Whitney Lowe:
If they know how to use their stature correctly.
Til Luchau:
Yeah, or has a faculty diverse enough, shameless plug here for our faculty…
Whitney Lowe:
Okay.
Til Luchau:
Diverse enough in their size and approach that you can learn, you can look for some universality in the approach.
Whitney Lowe:
Yeah, okay. So, in a nutshell, we can say size matters here on something on this aspect.
Til Luchau:
Okay. All right.
Whitney Lowe:
To a degree, yeah.
Til Luchau:
What else are we going to talk about?
Whitney Lowe:
Yeah, let’s see. Yeah, tell me about, what were you going to say?
Til Luchau:
I was going to tell you my story, my recent…
Whitney Lowe:
Yeah, I was going to say tell you, you got a story ee were going to talk a little bit about, have you had back pain yourself? Yeah, tell me a story there.
Til Luchau:
Yeah, this trip to Maine I mentioned it was up to go see Tom Myers and teach at his summer program was really fun. I drove after I got done teaching there. It was my first time back in the classroom for quite a while too, so I was kind of tired out. I really enjoyed it, but it was more exhausting I was used to. Pretty tired, sat in the car and drove for four hours in New England traffic. And then, went and visited a friend, slept in their very soft bed, and I woke up in the morning and I had one spot of low back pain off to the side somewhere. Maybe a transverse process or who knows? But that’s interesting.
So, I did some movement and that didn’t really reduce it. I went kayaking with my friend that day. We kayaked for most of the day. And when I got back, it was pretty sore. And getting up, getting down, bending over, it’s like, “Oh, okay, I’m doing my homework for this conversation I’m having with Whitney and this seminar going to teach for the ABMP.” And it was… Any of us who’ve been through an actual symptom that our clients come with us for help with really get how the experience of it is so different from the other side of the relationship.
Whitney Lowe:
Yeah, yeah.
Til Luchau:
So, there I was really hurting and not able to find comfort in all my clever movement practices and different things like that. So, rest helped. Oh, I went for a walk later the next day that helped. And then, I saw a friend of mine, a practitioner, Andrew Shire, I can say his name because I asked him, he lives in that area and I’ve known him forever. He does a kind of energy work, we called attunement, and very experienced at this.
And it’s not my model, it’s not how I tend to think about things in the overt way. I don’t think of myself as an energy worker. He really does that apologetically and is very skilled at it. And the experience was very pleasant, very expansive, very relaxing. And wouldn’t you know, when I stood up, there was not much back pain, go figure.
Whitney Lowe:
Yeah.
Til Luchau:
And so, when I asked him about that, he says, “I’m just listening to your energy field, in his terms, and not trying to fix it, not trying to change it. I’m just bringing it into connection with my own energy field, his term again. And that togetherness or that resonance helps, it regulate.”
Whitney Lowe:
Yeah.
Til Luchau:
And I think I could probably translate that into maybe a relationship language or something like that, that would be more my vocabulary. The way that we get rapport, say with clients by attuning to them, by aligning with them, by taking the time to listen and really getting on their page. Even though I don’t think about it in the same energetic terms he was describing. I think it’s easy for me to translate that into an approach that I could take through the rapport or the therapeutic relationship or something like that.
Whitney Lowe:
Yeah.
Til Luchau:
And in this case, that was enough. Darn it. Yeah.
Whitney Lowe:
Again, it really begs that interesting question like, what is the mechanism of change in so many of these different instances? Is there a right thing in something you would never probably have chosen or thought about initially as the solution turns out to be something that makes a significant change in there? And so, what is it? Just the right time, the right place, the right way for something to be done there? That worked.
Til Luchau:
Yeah, yeah, I think his skill and the context was all part of that too.
Whitney Lowe:
Yeah.
Til Luchau:
That’s right.
Whitney Lowe:
So, what’s…
Til Luchau:
How about you? Have you had any formative back pain experiences?
Whitney Lowe:
Yeah, your story made me think of something in particular that’s on the opposite end of a spectrum. And I’m curious to hear your take on this too, because we see so many of our clients have back pain that is the result of an overuse of the back like what you described there with doing the kayak and a lot of those physical activities. And I was thinking about like a back pain episode of my own that I remember significantly was about immobility. So, the flip side of that, not overusing my back, but underusing or maybe overusing it in a degree of static, constant contraction…
Til Luchau:
Sure.
Whitney Lowe:
… and this was a few years back, I was driving up taking one of our cars back up to when we were living up in Alaska. So, I was driving from Oregon to Alaska, which is 3,000 miles and probably five days…
Til Luchau:
That’s an office.
Whitney Lowe:
… in the car 14-hour driving days constantly. And I just had, by the time I was done, most horrendous back pain. Seats in this particular car were not very good. And you’re sitting there for long periods and I was driving about 14 hours each of those days, so it was very long, long driving sections of just being immobile. And I would get out periodically, try to stretch, try to move around, but it was never enough and it got so bad.
And then, as soon as I got there, I was actually supposed to go back down to Canada was teaching at one of the Canadian massage conferences or something like that. I had to wear a back brace to teach and I was doing a tremendous amount of pain just standing and moving, just reach down to do something a certain way. And then, all of a sudden, it would seize up that whole fear thing of making it do that.
Til Luchau:
Yes, yes.
Whitney Lowe:
And so, in that instance, eventually, the solution for that is movement, is moving within a safe, protected manner to gradually convince my back. That movement is okay, but it is interesting. I had try to work on myself with the Thera Cane, had people work on me and things like that like, those things were helpful. But eventually, just what does it is moving safely and comfortably.
And so, I think that’s a frequent issue with a lot of the muscle overuse, either overusing or in this instance, overusing constant isometric contraction probably from the posture, the way I was sitting with, yeah, because I have a feeling I was probably, I have a typical forward head posture when I drive and just back pelvic tilting probably not the ideal position so that I’m just tense somewhat to driving…
Til Luchau:
Okay. So, wait a minute. Posture does matter?
Whitney Lowe:
I think posture matters. I go back to that quote again, posture is not necessarily a cause of back pain except when it is.
Til Luchau:
Gotcha.
Whitney Lowe:
So, in that instance, I do think it matters under certain circumstances. So, yeah.
Til Luchau:
Sure. No, that makes sense to me too.
Whitney Lowe:
Yeah.
Til Luchau:
There’s that debate, of course, maybe it’s just in social media, maybe it’s elsewhere, that posture is hard to correlate with pain. There’s stories like this certainly in my own experience too, where it can make a difference to how we sit a body awareness, that kind of thing.
Whitney Lowe:
Yeah, yeah, I was talking with several people about this recently too. We were saying with that debate that we see all the time on social media about this discussion about structuralism and posture and does it really matter? I think part of the problem is, if you take posture as an isolated factor, it probably doesn’t matter that much. It’s posture plus load because you can have an aberrant posture of scoliosis or pelvis distortions or whatever they are, and you don’t overload them and it’s not that big a deal. It doesn’t really make that much difference, but you overload something with a poor posture. And now, you’re putting a significant stress on the whole system that is going to reduce or is going to result in the pain complaint.
Til Luchau:
I bet Stuart McGill would agree.
Whitney Lowe:
Yeah.
Til Luchau:
So, posture plus load times duration, maybe how long you stay there. And then, also there’s another multiplayer in there, which is probably context. Is this something that you’re in a protective state? Are you in an adaptive state? Those kind of questions are probably going to influence how that manifests as pain or…
Whitney Lowe:
Yeah, yup.
Til Luchau:
All right. How important do you think it is to educate our clients about some of these specific aspects?
Whitney Lowe:
I do think this helps a lot because especially with things like ergonomic challenges with a workstation or something like that, these are things that are particularly relevant and beneficial of getting somebody some suggestions of things to do. One of the bigger problems that I see along these lines is that as massage and manual therapists, this is not always in our ballpark of things we’re well-educated on.
The ergonomic things do require a fair amount of kinesiological knowledge to look at these various different factors and stretching and exercise and recommendations about how to do particular types of exercise and movement things, not something that a lot of us get really good training in unless we do specialized training in after we get out of school. And there’s certainly are plenty of people who do that. But I do want to just of call to everybody’s attention that just because you are a manual therapist doesn’t necessarily mean you have a good grounded knowledge in movement-oriented things…
Til Luchau:
For sure, yeah. That’s right.
Whitney Lowe:
… to give people suggestions about. And so, that’s the encouragement to learn some more, really to…
Til Luchau:
Learn some more or have referral resources or know the limits of our scope. I mean, that’s become clear to me the longer I practice. I’m pretty good at some stuff and there’s other stuff that it’s… I’m not that good at and haven’t spent that much time with or don’t embody in the same way to my body and better to hook somebody up with another person who can really help them.
Whitney Lowe:
Yeah, yeah. Again, back to that episode a couple of months back where I had that conversation with Laurel and Sarah, and we were talking about scope of practice versus scope of expertise. And there is a difference because something can be within your scope of practice of something that you could be doing, but it’s not within your scope of expertise of something that you’re really highly skilled at, at this point of where you are in your development. So, be wary and attentive to those two different types of boundaries because I think I see them as a circle within a circle.
Til Luchau:
Well, and it goes the other way too, doesn’t it? Something I could be really good at, might not be within the contract I have with my client.
Whitney Lowe:
Yeah.
Til Luchau:
So, as a massage therapist, giving someone I don’t know, psychological advice perhaps or who knows, there’s lots of examples like that.
Whitney Lowe:
Yeah, yeah. So, those things are a bit fluid and fluctuating and they require a fair amount of metacognition of thinking about your own self and your own skillsets and your own boundary levels of what you’re probably that…
Til Luchau:
My own back problems?
Whitney Lowe:
Yeah.
Til Luchau:
What the therapeutic agreement is, all those kind of things. That’s right.
Whitney Lowe:
Yeah, yeah.
Til Luchau:
Okay. Anything else you want to talk about?
Whitney Lowe:
I think we hit a lot of the main things that we were wanting to zero in on. So, again, an encouragement to folks to, if you’re listening to this before, early October, which hopefully you get a chance to, then we would encourage you to pop on over to the low back pain summit and we’ll be exploring some other things. And what are you going to be talking about at the summit?
Til Luchau:
Yeah, my presentation, I’m number two, you get to be number one. You get to open this up. As number two presenter that day, I’m focusing on application like, what are the hands-on things we can do for low back pain? And it’s basically, a deeper dive into some of the ideas that we’ve mentioned here today, systematically going through there and finding ways to apply those to an actual back pain scenario. That’s basically what I’m going to do.
Whitney Lowe:
Yeah.
Til Luchau:
How about you? What do you cover?
Whitney Lowe:
I’m going to talk a bit about some of the things that were in the article that I will have coming out at the beginning of the… I think it’s September, September-October issue, some of the primary causes of low back pain to go over them just to setting the groundwork. And then, I’m going to talk about some treatment strategies for those things as well like, what kinds of things would tend to be more appropriate for each of those different kinds of problems in more general senses. Not necessarily with a recipe or protocol, but just some important guidelines, and also some very important red flags to be watching out for in our attempts to treat people there.
Til Luchau:
Wow. Well, I get to follow you, so if I listen to your lecture and I realize I’m doing it all wrong, I’m going to pull my presentation and just start over.
Whitney Lowe:
And do it on the fly.
Til Luchau:
That’s it.
Whitney Lowe:
Yeah, okay. We’ll see how that goes.
Til Luchau:
I’m looking forward to that. That’s it.
Whitney Lowe:
Yeah, yeah, I don’t get that benefit of being able to learn from what everybody else did first and then change things.
Til Luchau:
Easier maybe in some ways, easier.
Whitney Lowe:
Yeah. So, okay, well, that sounds good. Obviously, lots of other things that we could dive into here, but we want to just touch base on some of those, and I think we got some good stuff in here. Maybe we’ll put some links to a few of the other resources and people that we mentioned in the presentation here as well in…
Til Luchau:
Check out the show notes, yeah.
Whitney Lowe:
Yeah. So, okay.
Til Luchau:
Closing sponsor who’s…
Whitney Lowe:
Yeah, today is Books of Discovery, and they have been a part of Massage Therapy and Bodywork World for over 25 years. Nearly, 3,000 schools around the globe teach with their textbooks, e-Textbooks and digital resources. They do like to say that learning adventures start here and find that same spirit here on the Thinking Practitioner Podcast and are proud to support our work knowing that we share the mission to bring the massage and bodywork community thought-provoking and enlivening content that advances our profession.
Til Luchau:
Instructors of manual therapy education programs can request complimentary copies of Books of Discovery’s textbooks. They’re pretty cool. What an offer to review for use in their programs. Please reach out at booksofdiscovery.com. Listeners, that’s you, listening, can explore their collection of learning resources for Anatomy, Pathology, Kinesiology, Physiology, Ethics, and Business Mastery at booksofdiscovery.com or Thinking Practitioner listeners say 15% by entering thinking at checkout.
Whitney Lowe:
And thank you to all of you listeners hanging out with us today. We do want to say our thanks to you for hanging out and staying with the show and checking some things out and giving us ideas about things that you’d like to hear more about. You can stop by our sites for the video, show notes, transcripts in any extras. You can find that over on my site at academyofclinicalmassage.com. And Til, where can they find that with you?
Til Luchau:
My site, advanced-trainings.com. As Whitney mentioned, if you have comments or questions or things, your feedback for us, anything you want to hear us talk about, just send us an email or record a short voice memo on your phone and email it to us at [email protected] or look for us on social media. My name is Til Luchau, that’s how you find me on social media. Whitney, where can people find you?
Whitney Lowe:
People can find me also under my name, that will not find me on TikTok. I’m not on that social chip. Some other things like that. I won’t be over there, but other places you can find me under my name there as well. You can also rate us on Apple Podcasts as it helps other people find the show, and you can hear us wherever you happen to listen on your favorite podcast app. Please do share the word and tell a friend, and we will look forward to seeing you in the next episode.
Til Luchau:
Thanks, Whitney.
Whitney Lowe:
All right. We’ll see you then.
