Episode Transcript

Summary: Whitney and Til catch up with physiotherapist and chiropractor Greg Lehman about the evolution of his influential “Reconciling Biomechanics with Pain Science” course, and his thinking on specifics like SI Joint pain, “flat arches,” and more.

Topics:

– Introduction to The Thinking Practitioner Podcast (0:00)

– Opening sponsor: ABMP (1:00)

– Introduction of Greg Lehman (2:00)

– Greg’s background and expertise (3:00)

– Greg’s approach to reading and translating research (5:00)

– The concept of Movement Optimism (7:00)

– Shifting from a pessimistic view of the body to a more optimistic view (9:00)

– Explaining pain to patients (11:00)

– The importance of building healthy systems and ecosystems (13:00)

– The fundamentals of treating people with pain (15:00)

– The role of faulty firing patterns in muscles (17:00)

– The concept of alignment and its importance (19:00)

– The role of alignment in pain and function (21:00)

– The debate between different perspectives in the field (23:00)

– The importance of individualized care and patient-centered approaches (25:00)

– The role of biomechanics in treating pain (27:00)

– The influence of research on clinical practice (29:00)

– The overselling of the need to stay updated on research (31:00)

– The importance of fundamentals and common threads in treatment (33:00)

– Greg’s eBook “Recovery Strategies” (35:00)

– Greg’s views on flat feet and when they matter (37:00)

– The limitations of isolating variables in research (39:00)

– The need for humility and openness in the field (41:00)

– Greg’s upcoming teaching schedule and website (43:00)

– Conclusion and thanks (45:00)

Whitney Lowe:

Welcome to The Thinking Practitioner Podcast.

Til Luchau:

A podcast where we dig into the fascinating issues, conditions, and quandaries in the massage and manual therapy world today.

Whitney Lowe:

I’m Whitney Lowe.

Til Luchau:

And I’m Til Luchau.

Welcome to the Thinking Practitioner.

Whitney Lowe:

Welcome to the Thinking Practitioner.

Til Luchau:

The Thinking Practitioner Podcast is supported by ABMP, Associated Bodywork and Massage Professionals. ABMP membership gives professional practitioners like you a package, including individual liability insurance, free continuing education, and quick reference apps, online scheduling, and payments with Pocket Suite, and much more.

Whitney Lowe:

And ABMPC E-Courses, Podcast, and Massage and Bodywork Magazine always feature expert voices and new perspectives in the profession, including Til and myself. And Thinking Practitioner listeners can save on joining ABMP at ABMP.com/thinking.

Welcome again to The Thinking Practitioner Podcast, and we are absolutely delighted to have Greg Lehman here with us today. So, Greg, thank you for joining the Thinking Practitioner with us today.

Greg Lehman:

Yeah, thanks for having me.

Whitney Lowe:

For those who don’t know you, Greg is incredibly well versed across a diverse group of fields. You are a, if I understand correctly, physiotherapist, chiropractor, and biomechanist, and all-around research authority on all kinds of stuff, manual therapy. So, is that kind of in a nutshell there?

Greg Lehman:

Well, I mean, I’m not a chiropractor anymore. I let my license go. I don’t know. I don’t know if you need your license to call yourself a chiropractor. And then, I like research, but I don’t conduct a lot of research any more. I just read it. But I did do my masters a long time ago in manual therapy and exercise biomechanics. I only have like, I don’t know, 25 publications or something like that. So, real researchers, they’ll have like 200 or amazing. I’m a dabbler.

Whitney Lowe:

I think there’s a lot to be said, however, about your incredible ability to read voraciously on this research and distill a lot of the key points out there for all of us who are focusing on practitioner stuff. So, anyway, we certainly do appreciate your work in those areas.

Greg Lehman:

Yeah, I’d be more of a knowledge translator That would be the better term because I have a pretty diverse background. And still…

Whitney Lowe:

Yeah.

Til Luchau:

And I was going to say, your ability to cite the sources and the variables it involved and the sample size for an unbelievable variety of things, means I’ll never get in an argument with you that relies on sanitations, that’s for sure. I don’t want there.

Greg Lehman:

Yeah, that’s my Rain Man skill.

Til Luchau:

Okay.

Whitney Lowe:

You’re right. Yeah. Greg, you’ve got a new podcast out called Movement Optimism, which I love by the way. And I wanted to hear a little bit more about that concept of Movement Optimism. So, tell us about that. What is Movement Optimism? And how does that kind of color your approach to working with people?

Greg Lehman:

So, if you think back to a lot of manual therapy or chiro, physio and massage, a lot of it is like predicated on finding faults in people. It’s like, you find something that’s wrong, and then we think we got to go fix it. And that’s just not in those fields. I just had a patient who saw their sports medicine doctor and their sports medicine doctor was just trying to look for all of these things that were… I wouldn’t even call them problematic, but they viewed as problematic and being like, “Ah, that’s why you have pain because this thing over here, this muscle is tight or this isn’t firing or yet a previous injury here.” It was really a pessimistic view of the body viewing the body.

Whitney Lowe:

Yeah.

Til Luchau:

Of course…

Greg Lehman:

Sorry, go ahead, yeah.

Til Luchau:

We don’t do that in massage body work and manual therapy. In fact, I’m right with you. We do that. We do that a lot. So, I’m glad you… I hear you’re talking about this.

Greg Lehman:

No, it’s everything. And so, the impetus was like, I still like the treatments that everyone’s doing. I like the treatments that philosophy inspired. I just thought it needed a reframing and a reconciling. And that’s the takeoff of Movement Optimism is like, often what we’re doing is we aren’t fixing things with people, but we’re doing something else to build them up to help them tolerate these things that may or may not even be problematic. But it’s really about building healthy people, and to be more mechanical healthy systems or healthy ecosystems.

Whitney Lowe:

I’m curious about that, the whole concept. I mean, I love the idea and I see a lot of practitioners moving in the direction of trying to reframe how they think about things to do that more positively. My curiosity too is how do you address that from the patient or client’s perspective? Because they often come in and want to know like, “What’s wrong with me?” And they want that answer too. So, how do you do that from, or how do you address that from their perspective?

Greg Lehman:

Yeah. So, I mean, it depends on your style, but I like simple things. I like to say like, pain is a result of when all the stressors in your life and your characteristics, who you are as a person once they’re greater than what you can handle. So, I use the cup analogy for pain, which is all the stressors and who you are is in your cup. You might have too much too soon, past history of trauma, depression, anxiety, tendinopathy, whatever, wear and tear, whatever people are calling it. That’s in your cup. And then, you have pain when your cup overflows.

So, I try to give a pretty holistic explanation for why things hurt. And then, the idea of patient centered care is we can say, “Well, what would you like to work on? These are the options to help you here.” There’s no one thing that probably needs to be done. There’s a lot of things that can help you out. So, that’s how it’s explained to the person.

And sometimes, it’s super simple. They just come in, they tear a muscle, we’re like, “Oh, we’re going to build up that muscle. It’ll be fine. It’ll heal around it. Or my back hurts because I was gardening all weekend.” You don’t need to go into childhood trauma or something like that, or at their anxiety and depression. You’re like, “Oh, this makes sense.” You just did too much too soon for you. And that’s it, let’s calm it down.

Til Luchau:

You were the first person I saw using that bucket or a help model do you called it, where there’s multiple factors that can go into something like a pain experience. And it was compelling, and it’s been something that I’ve used since then to help understand how there’s many things that go into what we experience as pain or stress, and that the upside of that is as many things we can do or in many places to start with it as well.

Greg Lehman:

Yeah, that’s the optimism of that model because it can… The biopsychosocial can be not only daunting for therapists because you feel like you have to fix everything, but it can be daunting for people in pain because they’re like, “Oh, my God, look at all these things that mess me up.” And the better way to view it is, look at all these things that we could work on, and we don’t have to work on everything, right?

Til Luchau:

Yeah.

Greg Lehman:

You can be anxious and depressed, and you can have a labral tear and joint degeneration. And you can be thriving and living well and be either, not just you can be out of pain or you can have some pain, but you’re not suffering and you’re living well. So, there’s options here.

Whitney Lowe:

One of the things I wanted to ask, I was curious, I mean, you’ve been so well-known for this wonderful course that you put together years back, Reconciling Biomechanics with Pain Science, and I know it has been available as an in-person course for many years. And now, also online on your website. I’m curious to know what kinds of things might have changed in your thinking around treating people with pain over the course of the time that that’s been out?

Greg Lehman:

So, I always try to change it because I feel like I should, there’s pressure. And then, I go back and I look at my old lectures and I actually have to be cautious in not changing it. The course doesn’t get into the details. It focuses on fundamentals. And I think, once you find good fundamentals, then you run with them.

So, it’s been 10 years and I honestly, I don’t know. I wouldn’t really change too much of the fundamentals. If anything, I’m more open for other avenues of care to achieve those fundamentals. Whereas, maybe in the past I was more, “You got to do this,” the things that I liked. And now, I’m like, I think there’s a lot of ways that we can achieve these fundamentals. So, I don’t think the fundamentals go out of style.

Whitney Lowe:

Yeah.

Til Luchau:

Yeah.

Whitney Lowe:

Certainly, another thing I was curious about your background and understanding biomechanics at such a high level, and understanding the rehab processes from your clinical work. I’ve listened to a number of things that you’ve said on other podcasts and other places too, and I’m curious to hear about this. This is one of the things that I see a lot in our profession, in our field that I’m constantly scratching my head about is this whole issue about faulty firing patterns and muscles. And I’m wondering, what’s your take on this? Is this something that we could really evaluate with any kind of credibility? And how much does it matter?

Greg Lehman:

So, you certainly can’t, at a clinical level. It would take EMG to do that. And then, even if you have EMG, it takes like… This would be timing, when muscles turn on and when they turn off and the balance there. We’re talking milliseconds here. So, this all would’ve started the transverse abdominus craze and multifidus, and there’d be delays in firing with people with pain. Or it also started with the VMO. People would say the VMO is not firing.

And again, it was always firing. It was just delayed 60 milliseconds, and these things don’t really matter. And so, even the people who started that research are now saying, “Don’t worry about these things.” These are epiphenomenon. They’re red herring. They’re probably a consequence of pain, or they’re a consequence of whatever it was that caused the pain. They caused these things as well. But these things aren’t the things that need to change to get out of pain.

They’re side effects of whatever is causing the pain, and we confuse them. It’s like your house is burning down. And I guarantee your fence will be hot. You wouldn’t go and cool down your fence with water thinking that will help the house from burning down. That’s how you want to view these things.

So, it’s like, sure, they might be associated with pain, but they’re not really an issue and they shouldn’t guide your treatment. And so, the VMO is the best example. The originators of that Dr. Cowan and Dr. Crossley, Kay Crossley. They were doing that research 30 years ago now. They…

Til Luchau:

This would be vastus medialis involvement…

Greg Lehman:

Yes, right.

Til Luchau:

… and knee pain, yup.

Greg Lehman:

Yeah, it’s just a theory like that if the muscle was inhibited and firing late, it would lead to a tracking problem in the kneecap, and that’s something that you needed to fix. And now, they just say, “Hey, just load it.”

Til Luchau:

Yup.

Greg Lehman:

Load that knee up. It’s allowed to hurt a little bit. Find the goal tasks that they want to do, calm it down, build it back up, get them doing the things that they love again, address negative beliefs about their knee. And there you go. It can take time, but they’ll recover. So, they’ll even do that.

Til Luchau:

Yeah, I think you’ve given me the answer to what I’m about to ask, but let’s see. Another one of those areas that gets tossed around a lot is the idea of alignment, especially in my background as a role for structural integration practitioner, where alignment was or in many cases still is the goal in and of itself. And if it’s not an alignment, that’s thought to be faulty itself. How would you address that? Or let’s take it one step further, how would we address a client who comes in who wants to be better aligned or has been told that they’re hurting because they’re out of alignment?

Greg Lehman:

Yeah. So, first thing, you don’t want to ask them more questions about what they think about that alignment, why they think it needs to change, really understand. And then, I’m not saying I’m confrontational, but I often ask like, can I tell you something that’s probably a little bit different than what you’ve said before? Or what you’ve been told before? And I would say, a lot of the things… What I’ll say is, a lot of the interventions that you might have tried before in the past to change this alignment, they can absolutely help your pain. But your alignment doesn’t have to change.

So, someone with scoliosis or leg length inequality, scoliosis doesn’t have to change for you to have less pain. So, a lot of the exercise programming or the soft tissue work that people do trying to change alignment can totally help with pain and function. But when you measure alignment in the long term, nothing changes. And that’s okay.

So, it’s like, what if we could get you more comfortable and pain-free in the alignment that you have right now? And I would say, sometimes chasing this alignment change is just so frustrating and it’s the wrong thing to chase, and it just makes it harder and harder to recover. So, would you be open to that? That’s how I’ll talk to people with that.

And then, of course, sometimes, you could change alignment. It’d be like, if you just want someone to have more back flexibility and arch more backwards, sure. Then, we could work on that as well.

Til Luchau:

Except what you just described was a movement change, not a position change.

Greg Lehman:

Yeah, that’s the thing. So, you’d have to go in and say, “Well, what do you mean by alignment?” And I might say, “When I do the snatch exercise or with me when I do back handsprings, I want to have a greater mobility there.” I’m like, “Oh, we can totally work on that. That’s reasonable.” And they say, “If I want to sit up straight more,” I’d be like, “Well, just sit up straight.” There’s nothing special…

Til Luchau:

Sit up straight, yeah, I love that.

Greg Lehman:

I asked, “Why do you want to sit up straighter?” “Oh, I thought I had to from my back.” I’m like, “No, this is great. You don’t have to if you don’t want to.”

Til Luchau:

Well, I mean, again, at some point we take the pathway that leads to the table if we’re doing manual therapy, but in the conversation, there might also be questions like, what gets in your way? What makes it hard to sit up straight? What happens those moments when you don’t sit up straight? What are your options there? So, there could be lots of inquiry into that.

Greg Lehman:

Yeah, I always digging deeper, trying to understand. And I’ll tell everyone, there’s no doubt I’ve had patients that are really caught up in thinking that they need to change their alignment and their posture. And I might not be the right person for them, morale. And I’ve had those talks and I apologize, I say, “If you can totally see someone else, I’ll be here in the future and we can have these talks.” So, I am pretty not direct, I am direct, but I’m gentle with it. So, you could potentially lose a client with this. They might not be ready for it. That’s okay.

Whitney Lowe:

Would you also say there is a time at which you would possibly maybe just say like, “Well, I’m going to zip my lips because this person has a model about what they think is happening.” And maybe, that’s not what’s really happening, but it’s working for them and they’re making headway there.

Greg Lehman:

Oh, absolutely. So, they might have a negative belief about the body that isn’t unhelpful. That’s the thing, you got to make that poll. So, I’ve had patients that think like, their IT Band is riddled with scar tissue and stuck to their leg all the way down, and they foam roll it every day.

And I don’t talk about… I don’t I agree with that, but I don’t talk about that because the rehab program that we’ve come up with together, they’re happy with and they’re doing all the other things to help them out, and they’re succeeding. So, that’s not a belief that’s worth fighting over because it’s nothing. It’s just something else. Who cares? People have different takes on things. And if it’s not a barrier to recovery, then don’t get into the fight.

Til Luchau:

Right. We don’t need to argue about narrative…

Greg Lehman:

No.

Til Luchau:

… and just do the work.

Greg Lehman:

Yeah.

Til Luchau:

That’s right. Okay. Here’s one that came into my office in the last couple of months. I worked with two very experienced dancers. Both were over 60, professional dancers, really body people in many ways. Both had SI joint pain and both happened to say, “Oh, my SI hurts because it’s hypermobile, and there’s a lot of things I shouldn’t do because in fact, we’re going to do some work.” She says, “Oh, don’t work with my SI joint because if it gets more mobile, it’s going to hurt.”

Greg Lehman:

Well, okay. Yeah.

Til Luchau:

So, what would you say at that point?

Greg Lehman:

So, this is where I say, where did you hear that? I’d want to know more on their take on that. And then, I’d direct and I apologize, and I’d say, I’m sorry. This might be different, what you’ve been told. And sometimes, it’s frustrating when you have people giving you different information. But here’s my biomechanical take on that, which is like there’s a few things.

Til Luchau:

Tell us, yeah, briefly, because you and I had spoken about that. But tell us what’s your biomechanical take?

Greg Lehman:

So, we want the SI joint to move a little bit. It doesn’t move a lot. It only moves a couple degrees. It slides a little bit. Even if it’s moving a lot, it doesn’t mean it’s unstable. It just means it’s moving. It’s a joint that’s inherently stable, that doesn’t take a lot to keep it stable. I mean, if you were in a car accident and there’s a fracture, maybe it’s unstable. But in general, it’s probably not unstable.

However, it’s super sensitive. It’s loaded with nerves back there. And there’s only two of them, and it’s the connection between your lower body and your upper body, and it takes a lot of stress and you probably do a lot of activities that stress it a lot. So, it’s not weird for it to be sensitive. So, it’s sensitive, it’s safe, it’s sore and it’s stable. And that would be the idea there.

And then, I would say, so a lot of our manual therapy here, what might surprise you as well is it can help with the sensitivity and the pain. But manual therapy, stretching, all these things, this will really surprise you. It doesn’t make you less stable. We’re not able to… This is where you can get into the weeds of research. Those types of interventions don’t decrease our stiffness and don’t decrease our stability. Even stretching where people thinks it decreases stability of connective tissue, it doesn’t.

The only thing that decreases stability or stiffness in a joint is going to space like immobilizing something and injuries actually damaging tissue. So, manual therapy is a desensitizer. It can make you feel less stiff in the short-term, you can be less stiff. But in the long-term, you are not less stiff, you can just feel better. That’s the great thing about it.

So, there’s lots in there and I’d be like, I’m sorry, that’s a lot. What do you think about that? Or I’ll often just reference someone else and say, go read this. Tell me what you think about it. I can still help you. There’s another way that we can think about this.

Til Luchau:

That’s great. No, that’s great. I started down, maybe the other road you described were inquiring about it, and I got to the point where this might be a narrative I don’t need to try to challenge today. These women were very sure about their bodies, and who was I to argue with their experience? So, let’s do something else and see how it goes.

Greg Lehman:

So, it wouldn’t surprise me, I guess maybe. I’m just guessing here; is maybe they had some work done before and it really flared them up.

Til Luchau:

Yes.

Greg Lehman:

That’s prompt. And then, they just attributed it to instability.

Til Luchau:

Yeah, that’s the explanation?

Greg Lehman:

Yeah. So, I’m cool. Oh, we can avoid that in the future if we want to go after that because we might be able to. Let’s take some time. So, you got to develop that relationship.

Whitney Lowe:

I think for it too, what I see perceptually a lot in our field of… I’m a massage therapist. And so, I’ll speak from that perspective, is that there is a sense too that people come in with having been told all kinds of different things from lots of different practitioners.

And there may be a little bit of an attitude on the part of both the massage therapist practitioner as well as the client, where I’m just a massage therapist, so how should I question what somebody else has told me who might have more letters after their name? That’s got to mean more. That’s got to be more accurate.

Greg Lehman:

We all have that. I get that with surgeons and doctors. And then, again, I acknowledge that it can be frustrating because there’s people tell them different things. And often, what I’ll do is I’ll just refer them to read something else like say, we’re trying to encourage someone to be active and they’re worried about having knee OA. I’d be like, “Go read this article by Dr. Howard Luks.” He’s an orthopedic surgeon.

I almost like I have a reference list of other people with lots of letters to say the same thing that I want to say. Or I like to say there’s a grain of truth in what they said, but it’s just not everything. So, are there other things that we can work on here? That would be the idea.

Whitney Lowe:

Right.

Greg Lehman:

You don’t have to have those debates. I used to work in clinics that had 38 doctors, and they all be told, “You have knee pain, you have knee OA.” And then, you’re doomed. And I’ll be like, “Ah, it’s a part of the puzzle.”

Til Luchau:

Osteoarthritis, yeah.

Greg Lehman:

Yes, right. Yeah, osteoarthritis. It’s part of the puzzle, but it’s not everything. So, let’s work on other things.

Whitney Lowe:

Yeah, bold. So, I know you’ve been a strong critic of the Kinesiopathological model in the past. And also said, there are times where it may seem to work. That model might work with some people. I was going to… Curious. If you can explain a little bit about what you see that model to be? And when does it work and when does it not work?

Greg Lehman:

Yeah, so if you look at the Kinesiopath model, it essentially is deviations from a neutral posture where you go far outside of the neutral zone. Well, either great current pain or in the future will lead to some joint degeneration, and you’ll have pain in the future. It’s sort of saying, there’s an optimal way for the body to move, and if you don’t move this way, you’re more likely to have pain.

So, knee valgus, the knee caving and spine flexion. And then, so where I think there’s utility and why that model is helpful is one, they’ll often… Someone comes in and their knee hurts or their hip hurts with the valgus movement pattern. And then, the therapist says, “Okay, don’t do that.” And they just teach them different ways to move that have less pain. And I’m like, “Great.” That will help sometimes.

So, it wasn’t that valgus was faulty and was leading to long-term damage in the knee. It was just sensitive, and they just taught them other ways to move. It’s like anytime you’re sitting, I keep moving around when I sit because something is sore. It doesn’t mean my sitting posture was faulty. It was just sore in that position. And then, I move to another one. I am just as sore if I sit up straight as I am when I slouch.

Whitney Lowe:

Right.

Greg Lehman:

Neither of them are faulty.

Whitney Lowe:

Yeah.

Greg Lehman:

The other way is when you look, say someone like Dr. Shirley Sahrmann or Linda Van Dillen. Dr. Van Dillen who does the research with her is, they give you these exercise programs that are designed to change movement patterns and help people to change these patterns to get out of these faulty movement patterns. And when you look at the exercise program, it’s just really comprehensive.

And so, I would say that exercise program is working not because you changed moving patterns, but because exercise and moving again and loading up the body is just inherently good. That’s why, it’s helpful. It has nothing to do with changing muscle timing or changing how you move.

So, it’s really easy to confuse causation like, “Oh, this person got better when I did this intervention,” say I’m a chiropractor and I crack a neck. Therefore, their joint was out of place before. No, I’m guessing on the mechanism. And that’s what people unfortunately do. And then, they double down on their theories.

Whitney Lowe:

And create a whole modality empire around it too.

Greg Lehman:

Totally, totally.

Whitney Lowe:

That’s right. Yeah. So, one other thing I wanted to ask again along the biomechanics root here, lots of people in our fields of massage and manual therapy bow at the altar of the psoas as the root of all problems in the body. I’m curious to hear from, at least from the biomechanical point of view, how crucial do you think that is in the realm of a lot of back pain or function stability, all those other things where it gets tagged as being responsible for?

Greg Lehman:

Oh, I don’t think so at all. I think it’s… This is actually, I did some research on this many years ago. I think that all goes back to Vladimir Janda’s hypothesis of the lower crossed syndrome, which essentially is you have a tight hip flexor or psoas. And then, therefore, you have a weak glutes and you have a tight erector spinae and weak abs, and that will cause anterior pelvic tilt. And if you have anterior pelvic tilt, that’ll put more stress on the facets in the spine or something like that. That’s really the theory.

And then, so that’s the hypothesis that having more anterior pelvic tilt will cause more pain because more stress. And then, you have to go back from there and you’re like, “Look at all the hypothesis.” And like, “So, what if you have more stress back there?” It’s not really a lot of stress, and you rarely maintain that position as soon as you’re walking and bending your hip flexors and moving your back, it’ll change the stress. And otherwise, stress is a good thing. It’s what catalyzes adaptation. It’s not inherently bad.

And then, when you go even deeper, you’re like, “Well, why does sitting even make your hip flexors more stiff or decrease their mobility?” And maybe, maybe not, that’s all over the place. And then, you have to say, “Well, can you even decrease the stiffness of your hip flexors?” And this will surprise some people, but you can in the short-term, like 30 minutes. But in the long-term when we stretch or do manual therapy, it actually doesn’t change the stiffness of a muscle, which and the stiffness is what would pull a joint into a different position.

And so, stretching the hip flexors or mobility work or manual therapy might give you more mobility, but it’s not going to change the stiffness. So, probably, it wouldn’t even change anterior pelvic tilt. And that’d be like the work of Joan Scannell. I think there’s a guy named Steven Priest who works on this, but he still thinks anterior pelvic tilt is important. But you probably can’t even change it because you can’t really decrease the stiffness of a muscle at its resting length.

So, it has all of these, you just got to dig deeper like, okay, if it’s this, then this, then this. What are all the hypotheses? And then, you want to go and check all the theories behind it, and you won’t see it as being supported. However, I say all that. And then, hip flexor work, strength training the glutes, working the glutes, doing manual therapy around that will help people. It’s just has nothing to do because you changed the stiffness of the psoas.

Whitney Lowe:

Yeah.

Greg Lehman:

That’s it.

Til Luchau:

That’s it.

Whitney Lowe:

Well, you’re talking about stiffness in the low back makes me think of Stuart McGill…

Greg Lehman:

Right.

Whitney Lowe:

… who has been on the show twice now. And then, we had Lorimer Moseley a week or two ago. And afterwards, a listener wrote in says, “Listen, I want to hear the two of them talking to each other.” So, I want to ask you for our listeners, how would they be seen as representing different points of view? And how do you think that conversation would go?

Greg Lehman:

So, let me go back a second. I mentioned Joan Scannell’s research paper. McGill was her PhD supervisor, right?

Whitney Lowe:

Okay. So, that’s the lineage, yeah.

Greg Lehman:

So, it’s his work that has shown that you can’t change lumbar posture despite doing all the work to stiffen something up and loosen something up. Yeah, I have a blog that’s like 10 years old on that, and then all those things. So, back to what he said, how would they… So, one, I guarantee that debate will never happen.

Til Luchau:

In our imagination. That’s what we’re talking about.

Greg Lehman:

Yeah. I mean, McGill’s retired. But I never really heard him… I knew him when he was a lot younger and I was way… I was 22, that’s when I worked with him. And I am a great fan. I’m forever indebted to him. We do disagree on lots of stuff, and I hope that can be done respectfully. But the debate would be difficult because I’m concerned that they might talk around each other.

I don’t think Moseley would maybe address the biomechanics and the relevant of tissue to injury. And I’m afraid that maybe McGill would minimize the role of the neuroscience when it comes to pain. So, that’s what I think would happen. I think a debate is the wrong way to do it. I believe in a dialectic, which is, they both should say, “Don’t start from ignorance.” But say, “How can we get closer to the truth?”

And I just worry that people being very different, that just might talk around each other. That’s it. Moseley would give some explanation for pain that could be totally valid. McGill might give an explanation for pain that’s more tissue-based, which in some people absolutely is totally valid, right? And they would just still double down on that. And we wouldn’t, I don’t know. I don’t know if that makes sense. I don’t think we get further ahead. You have to have some humility here. And they’re both so successful. Not humility, but I don’t know, openness to the other side. And I don’t know if anything would come of that debate.

Til Luchau:

Well, whether through their own efforts or not, they’ve come to be somewhat of a figurehead for different points of view, each of them. And so, the juxtaposing like that is in some ways juxtaposing the different paradigms. And you’re saying there may not be, in spite of the name of your course, Reconciling Biomechanics and Pain Science, there may be ways that at least the personalities involved aren’t the people to be talking about this.

Greg Lehman:

Yeah. So, McGill is kind of famous for treating powerlifters or something. I don’t know how Moseley would treat a powerlifter who wanted to lift heavy loads again. But at the same time, I don’t know how McGill would treat someone with complex regional pain syndrome or phantom limb pain. They’re almost seeing, yeah, they’re both involved with people with pain, but are they really seeing the same people? I think a better debate would maybe be Peter O’Sullivan and McGill or something like that, right?

Til Luchau:

Yeah, there was…

Greg Lehman:

Both working with different populations. Yeah, sorry, go ahead.

Til Luchau:

That’s right. No, I’m just thinking there was one with Diane Lee and was it… I have to go look that up. Go find that. There was a really rich conversation between her…

Greg Lehman:

Antony Lo?

Til Luchau:

Maybe it was Peter O’Sullivan, but I have to go back about that.

Whitney Lowe:

So, in one of your other recent blog posts, you were talking about cognitive functional therapy. I was curious about that. If you can expand on that a little bit, what that is and how might that play into a lot of the things that we’re doing with people?

Greg Lehman:

Yeah. So, that’s Peter O’Sullivan’s group. To me, it’s one manifestation of the biopsychosocial model, which means that pain is an interplay between the tissue, tissue damage, nociception that’s like the irritation signal from the tissue, and how our beliefs, stress, emotions, anxiety, interact with that tissue sensitivity.

And so, treatment should be looking at beliefs and cognitions as well as function and biomechanics. But Pete would be very much into the camp of mine, and he’s changed through the years, which is the spine is incredibly robust and adaptable. You’re allowed to slouch, you can bend, you can lift a number of different ways. If it hurts, maybe we teach you another way to lift.

So, it’s actually how I practice. Sometimes, I’ll admit I do like bias. I’ll say this research paper is great because it’s my bias. So, I understand that’s not the best way to evaluate something. I am critical of them though. I’m critical of everything. But they’re my favorite research group where they really go out of their way. They have a theory, and then they go and try and test it with RCTs.

Til Luchau:

Yeah, it’s great. This is a great… I’m enjoying the conversation because the chance to empty out my pockets of the little ideas that what would Greg say about this? Because your thinking was influential for me when I went and did your course, whatever it was, eight, 10 years ago. And it’s been ruminating quite a bit. So, here’s one, just this nitty-gritty one. What are your views on flat feet? And when do they matter?

Greg Lehman:

I mean, they’re great for walking on water. That’s about it. I actually… So, there’s the thing like, when you look at the research there, I work with a lot of runners. It’s probably my area of expertise. I don’t care.

Til Luchau:

You don’t care.

Greg Lehman:

I mean, maybe if they’re older and they have ankle shin pain, I’m a bit worried about a tibialis posterior dysfunction, where it’s actually born. So, if it’s dysfunctional flat feet. But if someone was just born with flat feet, I would allow them to join the military or it’d be fine. I don’t see the research link. And so, that would be the classic KPM is that a flat foot is a risk for injury. And in general, I don’t see the literature saying it is. That being said…

Til Luchau:

The pathological model says that flat feet are a problem. You’re saying the research doesn’t bear that out?

Greg Lehman:

Yeah, I mean, yeah, they’ll measure that with the Navicular Drop Test…

Til Luchau:

Right.

Greg Lehman:

… that bone in the foot moves. It doesn’t seem to tell you who is more likely to get injured. That being said, if you have flat feet and there’s a large navicular drop and the inside of your foot hurts when you run or walk, it’s totally reasonable to try an orthotic, excuse me, or tape the foot or do foot strengthening exercises. That can be helpful for people as well. But I would also do the same thing for people who didn’t have flat feet.

Til Luchau:

Thank you.

Whitney Lowe:

Yeah.

Greg Lehman:

Okay.

Whitney Lowe:

One of the other things I wanted to hear from you, probably one of your sayings that’s gotten the most attention over many years is this idea or a thing that you’ve said of calm shit down and build shit back up. And I thought that that so incredibly encapsulates what we all really should be doing. So, I’d like to know where did that come from? And what does that kind of essentially mean to you for those who might not have heard that before?

Greg Lehman:

So, it’s me. It’s hard to be a clinician because you can always feel like someone else knows more, and someone has all the answers. And so, I really like to simplify things and find common threads. And I’m like, “Why do we have so many people who are disagreeing?” And I know that they’re all disagreeing, but they would all be able to help the same person. And I was like, “So, what the hell is going on there?”

And so, that was like, this is it. This is what they’re all doing. They calm shit down in some way, meaning they decrease the sensitivity of the system, manual therapy, acupuncture, like validating the person, tape or thought, whatever it happens to be doing a little bit less, change a little bit less, changing how people move.

And then, you don’t just leave it there, then it’s like, okay, how do we build you back up to do the things that you love again? Which again, so many different ways to do that. Load management, exercise, prescription, coaching someone, being there for them and with their setbacks. And then, I’m like, “Boom, there.” That’s how we can all get along.

Whitney Lowe:

Yeah. And I wanted to note too, just for those people who don’t know, I’ve just been astounded by your gracious generosity over the years in sharing information. And for those people that don’t know, you’ve got a fantastic eBook on your site called Recovery Strategies. Can you talk a little bit more about what’s in there and who’s that really aimed at?

Greg Lehman:

Yeah. So, I love it. There’s so much stuff that comes out that you have to buy. There’s stuff rewritten all the time. And I was looking at that the other day because I had someone with I was like, “Should I update this and change it?” And I would change maybe 4% of it. Again, it’s the fundamentals. It’s a book that tells people, explains a little bit about pain. It has simple messages. It doesn’t go into the hardcore neuroscience, which people don’t need to go into.

You can read the whole book. It’s only 71 pages. You can read the whole book and it can be helpful. Or if you’re a clinician and a massage therapist, there’s a section where you can just, it’s all set up as infographics, so you can just print out one page and give it to someone, right?

Whitney Lowe:

Yeah.

Greg Lehman:

So, that would be one thing about pain here, read this about pain. It’s like, you have this amazing ability to adapt if we get the dose right or pain is influenced by lots of things in your life, or you’re safe, but sore, whatever the key message that you want someone to understand. So, I’m proud of that book. And it’s all… It’s open access. I don’t want people to feel… You don’t even have to sign up with your email anymore. It’s just a PDF. It’s translated.

I had so many wonderful people. I said, “Anyone who wants to translate this, you could translate it.” So, I think it might be in, I don’t know, seven or 10 languages. And that’s all free on the website.

Whitney Lowe:

Yeah, that’s great.

Greg Lehman:

I wish people would do more of that.

Til Luchau:

We’ll link to that in the show notes. And then, you’re also just kudos on your podcast. I just started listening to that the other day, and it was great to hear you getting going with your wish list of guests there. And I especially liked it that you said, “Hey, I’m going to keep it to under half an hour.”

Greg Lehman:

I haven’t done that yet, but we’ll try.

Til Luchau:

We haven’t done that either.

Greg Lehman:

That’s inspirational.

Whitney Lowe:

I saw that. How do you have a conversation with Greg in under half an hour?

Greg Lehman:

You should see, I just shut my mouth. You wouldn’t even recognize me. My wife doesn’t know who I am.

Til Luchau:

Right. We’ll put a link to that as well. But I was intrigued by one of your blog posts recently where you said that the need to stay updated on research is probably oversold.

Greg Lehman:

Oh, yeah.

Til Luchau:

So, can you tell us a bit more about that?

Greg Lehman:

It is. I think once you get your…

Whitney Lowe:

I’d like to know too, did you get hammered for that?

Greg Lehman:

So, I actually got more support for that. Again, I feel there’s this push in our profession is to make people feel like they don’t know enough. And it really bothers me. And I’m like, “If you’ve done your work at the start, you have your fundamentals.” And then, the fundamentals really aren’t changing. Every time I read the state-of-the-art review, I’m like, “It’s not state-of-the-art.” And it’ll just be… The fundamentals rehash too much too soon. We’ve all known this for sport injuries or any injury.

But then, now people will call it the acute to chronic workload ratio. And I have all these papers on, they got to read all these papers. And they don’t say anything more than, just don’t do too much too soon. And they’re like, “Fuck, we knew that 30 years ago,” or all these things. I swear research is… Newer research is just undoing our love affair with older research that we never should have listened to in the first place.

So, people are like, “Oh, you got to read the new research on the spine where all these different things, exercises can help with low back pain.” You don’t have to do multifidus training. And I’m like, “Well, we shouldn’t have been adopting the multifidus training without reservations 25 years ago.” So, that new research is only new and helpful because you were wrong for adopting the old research too quickly. So, we didn’t have that old research, we would’ve been fine.

Whitney Lowe:

Yeah.

Til Luchau:

And so, essentially, you’re fighting the patho academic model that says, we don’t know enough.

Greg Lehman:

I feel horrible for academics. I think I even had an apology in there. They have this pressure to produce, and they have this pressure to write a discussion that says this is why it’s relevant. And they should just be writing. We have no idea why if this is going to be relevant. We put it out there, maybe you can use it. Maybe it’ll make sense 20 years from now because someone else built on it.

Whitney Lowe:

Yeah, I think this was something that you said to me when I was in your class a number of years ago. So, if it wasn’t attributed to you, then correct me on it. But you had said something like, “You know how a lot of the biomechanics research out there gets done? It’s like, you go into the lab and you look around and you see, well, what do we have equipment that we can measure?” So, then that’s the paper or the study gets done on. Is that…

Greg Lehman:

Yeah, that’s it. I mean, it’s a little offensive. But certainly, with my masters, I was like, I have to do something. And so, I just took something that someone else did for another part of the body and I applied it here. Or you’re like, “Oh, I want to study low back pain.” So, you’re going to do something that your supervisor did. And that’s actually, useful in some way because you’re building a body of knowledge in that area.

But usually, we just do that where we do a cross-sectional study, how are people different with low back pain? And they’ll find some variable. There’s a hundred variables where when you have low back pain, you’re different than someone who doesn’t have low back pain. But then, no one is able to go on and do the next step, which is like, well, why do we even care about these things? That’s my jadedness.

Whitney Lowe:

Yeah, and there is inherently a catch-22 in this. And I think this was in your discussion with Ebonie Rio on your podcast recently, noting that if you’re going to do good quality research, you have to isolate a variable and say, “We’ve excluded everything else except this one thing that we’re studying and you’re going to measure it.” But in reality, that’s not how a treatment actually works many times in the clinic because a lot of times it works because of all these things that you do together and mix them all in there.

Greg Lehman:

Yeah. So, it depends on your research design, you and what you’re trying to prove or the question you have. You can do pragmatic trials. So, I just had Neil Meigh on the podcast, and he’s the kettlebell physio. He did a pragmatic trial that just looked at training older adults with kettlebells. And the program was almost different. It wasn’t a recipe program. It was different for everyone just to see how they would all see, I’ll change.

So, it was like he’s almost testing. This is how people do it in the wild. It doesn’t let him answer a research question like, this is superior to this, or why did this research? Why is it helpful? Why is this intervention helpful? So, you can do pragmatic stuff, which is fine. But yeah, it is tough with three. Ebonie’s a good example of that. She did like isometric training, neuroplastic training where it’s paced to a metronome. And then, she did it isometric, which is not moving. And then, isotonic and paced to a metronome. And then, both groups got better. So, you can’t say much. You could say you got those two interventions that you can do, but we have no idea why.

Whitney Lowe:

Yeah. Well, Greg, that’s probably a good place for us to wrap up here today. But I want to thank you so much for your spending some time with us here today in our earbuds. And for those of our listeners, where can people find out more about you? What you’re doing? Where you’re teaching? What kinds of things you’re up to?

Greg Lehman:

So, I’m all over the world with teaching the next few months. It’s like, I’m in Miami, Florida. That’s cool. I’ve never been there before in April. And then, in March I’m in Ottawa and Gilbert, Arizona. And I’m in the UK, if anyone’s in the UK, and I don’t know, sometime next few months. And then, greglehman.ca is just my website that has everything there. And that’s Instagram and Twitter as well. And that’s where the workbook is, the free workbook is there.

And the other thing, if you work with people with knee osteoarthritis, I do have a free webpage that I think is excellent too, compared to the stuff you can buy, which is called OA Optimism. It’s just like five to seven-minute educational videos. And education is a hallmark of good treatment and basic exercise stuff because we over complicate exercise and you don’t need to.

Whitney Lowe:

Yup. Well, wonderful. It certainly, has given us a great deal of food for thought here and also a seed for, hopefully, we can have you come back again and talk to us about some more stuff some other time. This has been extremely rich and extremely valuable here.

Greg Lehman:

Oh, thank you.

Whitney Lowe:

Yeah. So, Books of Discovery has been a part of massage therapy and bodywork world for over 25 years. And nearly 3,000 schools around the globe teach with their textbooks, eTextbooks and digital resources. Books of Discovery likes to say learning adventures start here. And they find that same spirit here on the Thinking Practitioner Podcast and are proud to support our work knowing 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 textbooks to review for use in their programs. Please reach out at booksofdiscovery.com. Listeners like you can explore their collection of learning resources for anatomy, pathology, kinesiology, physiology, ethics, and Business Mastery at booksofdiscovery.com, where Thinking Practitioner listeners say 15% by entering “thinking” at checkout.

Whitney Lowe:

So, again, thanks to all of our listeners and to our sponsors here. You can stop by our sites for our video, show notes, transcripts, and any extras. You can find that over on my site at academyofclinicalmassage.com. And Til, where can they find that with you?

Til Luchau:

Advanced-trainings.com. If you have comments, questions, or things you’d like to hear us talk about, guests you’d like us to invite, just record a short voice memo on your phone and email it to us at [email protected]. Maybe we’ll play it on the air. You can also just write us a regular email or you can look for us on social media. I am at Til Luchau, my name. Whitney, where do people find you?

Whitney Lowe:

Also, under my name, Whitney Lowe on social media. You can, if you will, write us on Apple Podcasts. It does help other people find the show. And you can hear us on Spotify, Stitcher, Podbean or wherever else you happen to listen. So, please do share the word, tell a friend. And thanks again very much for listening. And Greg, thanks again so much for joining us here today.

Greg Lehman:

Thank you.

Til Luchau:

Thank you, Greg.