Til Luchau: Can you say something about yourself and your interests for people who don’t know you and your work?

Greg Lehman: Sure. My background is in biomechanics. I got my master’s in the ’90s, and then went on to do my chiropractic training. I was in clinical practice for almost a decade before I went back to school for physio, like physical therapy, in Canada. And throughout that time, I was also a researcher at the Canadian Memorial Chiropractic College—primarily on the physiology of manual therapy and exercise biomechanics. I’m still in clinical practice, just not full time like I was in the past. Now, I teach a course called Reconciling Biomechanics with Pain Science.

TL: That’s the course I did with you. Was it four, five years ago?

GL: That’s right.

TL: It was a colleague who said, “Hey, you should do this. It’s going to rock your world.”

GL: Oh no.

TL: It did. Well, maybe it was part of my world rocking at that time anyway, and you closed the deal, as it were, on the fact that I really needed to reassess how I was thinking and teaching. I’m actually a little worried talking to you today that I’m going to need another four or five years to revise what I do and get it back to a place where I feel good about presenting it.

GL: OK. I bet you’ll find it makes it simpler. I think often what happens is you have to go through this incredibly complicated critique of biomechanical intervention to say, “Oh, I don’t have to worry about that anymore.”

TL: That’s about right, in terms of my experience. What you were saying [then] about sensation and the brain matched what a lot of us had been thinking, but you challenged the biomechanical explanations I’d been trained in and was repeating in my own trainings. So, just to catch up a little bit, have there been changes in your perspective, say, in the last four or five years?

GL: No, and I know that sounds super arrogant. It’s just been solidified. [Five] or 10 years ago, maybe, I felt like I was the only person saying these things. I see more and more people saying these ideas now. I think the professions are changing.

Changing the Sacroiliac Narrative

TL: You and your collaborators just put out a paper titled “Changing the Narrative for Sacroiliac Pain.”1

GL: That’s right.

TL: I know you didn’t necessarily write it for manual therapists, but what are a couple of things you would want them to know?

GL: Actually, we were thinking of them a lot. Thorvaldur Palsson was the lead author. He’s our Icelandic Viking leader. I think he’s at Aalborg University in Denmark now, and his PhD was essentially [on the sacroiliac] (SI) joint.2

One of [Palsson’s] big studies found that people who have SI joint-related pain will often feel unsteady, unstable. There’s a weakness; a sense of discomfort when they lift their leg. For so long, people thought, “Oh, the joint’s unstable,” meaning it’s moving when it shouldn’t move. This was all based on [Andry] Vleeming and the form- and force-closure of the SI joint.3

TL: Right.

GL: What [Palsson] showed was that if you just irritate the joint or irritate the tissues around the joint, without inducing instability, people have the sense of disease, discomfort, and instability. So, it’s a perceptual feeling rather than a true instability. What he also showed was [that] people have more muscle activity when [irritation is] happening, so the joint is definitely stabilized and stiffer. So, we needed a rethink, [which] we had known for a while. His is just one piece of the [many] puzzles that support that [observation].

TL: So, rethinking of instability as a sensation, as opposed to a movement or muscular disfunction.

GL: Yeah. We don’t have the vocabulary to describe when something just feels wrong and off. Therapists tell us, “It’s unstable,” and then people reconceptualize that and say, “Oh, that’s what instability feels like.” [Really], it just feels wrong or it feels irritated—it just doesn’t feel good.

I’m sure you have patients or clients who say, “I feel really tight in my hamstrings.” Of course, you test their hamstrings and they have great flexibility, and they’re not tight at all. But we don’t have the language to describe tightness or instability.

We also see it in the knee. There’s a paper that came out just a few months ago, in the Journal of Orthopaedic and Sports Physical Therapy, where people with knee osteoarthritis have a sense of instability in their knee. You go and measure the actual ligamentous stability and laxity, and [the measurements don’t] correlate with the feeling.4 But what does correlate with the feeling of instability is pain and weakness. There are a lot of studies out like that right now. We’re not good at describing stiffness, we just feel wrong. So, we say it’s unstable.

TL: Fascinating. So, what causes [that] feeling?

GL: This is what sucks. We don’t know why we feel that way. And, what’s difficult in our profession, especially working with patients, is it’s a much easier explanation to tell someone they’re unstable or their joint is stuck, and then give them a manipulation or a massage or some manual therapy, [and] then the exercise to reinforce that. You wish you could say that, but it’s not true. So, the difficulty we’re having now is how do we give people an accurate explanation for this sense of feeling off?

Up-Slips, Rotations, and Torsions

TL: Well, the conventional explanations are positional. You have an up-slip, you have a down-slip, your sacrum is out, you have a rotation, etc., and those are thought to make the joints sensitive.

GL: Yeah.

TL: What do you think?

GL: When I taught at the chiro school, we were not really teaching motion palpation. We acknowledged it historically and it was done in the curriculum, but at the same time, we were reading papers saying there’s only a few millimeters of motion in the SI joint. The rotation is fractions of a degree. It doesn’t move a lot. That’d be like the Tullberg study, which is, gosh, 20 years old now.5 You can’t move it out of position. You can’t move it into position. And our test of up-slip and down-slip and torsion, those are all not reliable, meaning people can’t agree. If you can’t agree, they’re not valid. So, we just stopped saying that.

But at the same time, and again this is the thrust of the paper, no one is saying that the SI joint is not sensitive, or that it may not be a source of nociception; it can be irritated. It’s a biological signal that might be contributing to people’s sense of pain. We’re not saying it’s all in the head, we’re just saying it’s not because of some positional or movement flaw.

But in the same vein, we’re also not saying, “Don’t do manual therapy,” or “Don’t do exercise,” or “Don’t manipulate.” My master’s was in manipulation, and the conclusion was you can keep manipulating for pain relief. [Just don’t] say it’s because you’re repositioning a joint. The subtle, simple shift is that you can still do a lot of the things you do to help people. It’s just you have a different explanation or a different model for it. It’s to help with pain, which might lead to other beneficial things.

Pain is multidimensional, and the joint is just one part of it. Believe it or not, the [painful] joint can be in its right position. It’s not unstable. It’s just hurting. So manipulation can often help it hurt a little less, but there [are] other things we can work on too. It could be their sleep, their diet, doing more exercise, changing their view of their SI joint ... it’s actually strong and stable, but it is sensitive.

Too Tight, Too Loose, Or None of the Above?

TL: What about hypermobility?

GL: There’s nothing inherently wrong with being hypermobile, you just move more. Doesn’t mean it has to hurt more.

TL: Same for SI joints that don’t move?

GL: It’s just the motion is so tiny anyway. If you’re limited in your range of motion, it’s probably not your SI joint. It’s everything else. There are plenty of people with fused SI joints, and you can’t pick them out based on how they move. I have a colleague that took my course because she was in pain. She had years and years of SI joint pain and she even got it fused when she was younger, but that didn’t help. Now she has this beautiful deep squat. So, the immobile SI is not getting in the way of her mobility, and it’s certainly not getting in the way of her function. The reconceptualization with her was, “It’s sensitive, and your whole system is sensitive—your SI joint and your nervous system and you as a person—and that’s what we need to work on.”

How Does Hands-On Work Help?

TL: OK. So how might manipulation make things feel better? There are all the contextual effects. There’s all of the therapeutic ritual, all of that. But what are the significant physiological or biological effects of manipulation? I don’t mean a chiropractic manipulation of course, but hands-on bodywork.

GL: Yeah, I think it’s easier to explain [hands-on bodywork] than to explain a chiropractic manipulation. Just touch. Even going back to the boring old gate control theory of pain, which is not inaccurate; it’s just not ...

TL: Not the whole story.

GL: Yeah. I mean, you bang your thumb, you put your hands on it, it will feel better. With even gentle mobilization, you’ll have viscoelastic changes in tissue, meaning it will move more easily, and that might help people build some confidence. And it’ll feel different. You’re less stiff in the short term, and then you’re like, “Oh wow, I’m not as bad as I thought.” So, it’s like little wins that build on. You start changing what you feel like, how you view your body.

TL: I’m thinking that so many of the people I work with want to touch the problem. They want to say, “OK, tell me where to press or touch or move or feel so I can get my hands on it and change it.” I think that’s part of the conceptual shift we’re being faced with too.

GL: Yeah, and I think you can still do that. Touch can be a great desensitizer. It’s just having a better explanation for it.

Summary

TL: All right. Any other questions I should be asking?

GL: No. I would just reiterate, going back to the SI joint, you can use that model at every joint. So, people say, “Oh, you have scapular dyskinesis, and your shoulder blade rolls forward and it wings. That’s why you have pain, and then it impinges.” The other way to view it is, well ... impingement is normal. Scapular winging is normal. It hurts because something is sensitized in the shoulder. It could be the rotator cuff, it could be the capsule, it could be some nerve, it could be a bursa; and your worry about it, your lifestyle, your sleep, those are making you respond in a greater extent to the nociception there.

So, what do we work on? We work on all the things that sensitize you. We don’t have to blame the shoulder [blade] position. The SI joint, same thing. The SI joint is sensitized, there’s nothing wrong with the joint. You don’t have faulty movements, you don’t have faulty control. It just got sensitized somehow. So, let’s work on building it up and desensitizing it, and lots of things can do that. That’s why there are so many different people out there who [can] help. There’s not one right way. I would stress that to people.

TL: OK. Anything else?

GL: Like ... No, I’m good.

TL: Like, what? What were you going to say? I want to hear that one, that was sounding good.

GL: I was going to say, it must be interesting in the classes you teach. People probably have a lot of different techniques, and that just tells us what we want to do is find ... the common threads among different people. I think if we find these common threads, then ultimately maybe we find the true mediators of recovery. Why can someone have an exercise approach and help a group of people, and someone else could have a manual therapy approach and help a group of people? What’s the commonality [here]? We find those common threads, and then we’re like, “All right, wicked.” I know what really has to change, or what really has to occur, to mediate recovery.

To Learn More

• Greg Lehman’s Recovery Strategies book, written for both clients and practitioners, can be downloaded (free) at www.greglehman.ca.

• To read the full conversation with Greg Lehman and Til Luchau, go to a-t.tv/greglehman2019.

• For more info about the 2020 San Diego Pain Summit, visit www.sandiegopainsummit.com.

Watch Til Luchau’s technique videos and read his past articles in Massage & Bodywork’s digital edition, available at www.massageandbodyworkdigital.com, www.abmp.com, and on Advanced-Trainings.com’s YouTube channel. Watch Til’s ABMP video playlist, where all his videos have been compiled. [QR caption: “Watch Now”]

Notes

1. Thorvaldur Palsson et al., “Changing the Narrative in Diagnosis and Management of Pain in the Sacroiliac Joint Area,” Physical Therapy, Epub. ahead of print (July 2019), https://doi.org/10.1093/ptj/pzz108.

2. Thorvaldur S. Palsson, “Lumbopelvic Pain—Sensory and Motor Aspects” (PhD thesis, Center for Sensory Motor Interaction Department of Health Science and Technology Aalborg University, Denmark 2014), www.fysio.dk/globalassets/documents/fafo/afhandlinger/phd/2014/phd_thorvaldur-skuli-palsson_2014.pdf.

3. A. Vleeming and M. Schuenke, “Form and Force Closure of the Sacroiliac Joints,” PM & R 11, Supplement 1 (August 2019): S24–S31, https://doi.org/10.1002/pmrj.12205.

4. Ajit M. W. Chaudhari et al., “Perceived Instability Is Associated with Strength and Pain, Not Frontal Knee Laxity, in Patients with Advanced Knee Osteoarthritis,” Journal of Orthopaedic and Sports Physical Therapy 49, no.7 (2019): 513–17, https://doi.org/10.2519/jospt.2019.8619.

5. T. Tullberg et al., “Manipulation Does Not Alter the Position of the Sacroiliac Joint: A Roentgen Stereophotogrammetric Analysis,” Spine 23, no. 10 (May 1998): 1,124–28, https://doi.org/10.1097/00007632-199805150-00010.