The fall of the postural structural biomechanical model in manual and physical therapies: Exemplified by lower back pain

n by Eyal Lederman A response Professor Eyal Lederman in his second recent provocative offering has put down the gauntlet in challenging many existing approaches to the structural management of the ubiquitous problem in industrialised society low back pain. Many in the Physical therapies from whatever standpoint may be incensed perhaps that criticism has been made of the approaches and techniques which many rely on for ameliorating their patients complaints or providing for their own livelihood. As Ronald Melzack has suggested, models determine how one thinks and subsequently how one behaves. This may translate as to what we think the problem is and what we think we must do in any clinical situation. Melzack, a Canadian Psychiatrist , together with Patrick Wall a British Neurologist developed the pain gate theory, which was met with initial derision, scepticism and later acceptance. This model directly influenced approaches to pain management and has been superseded to some extent by the neuromatrix model. However, practically, as Patrick Wall suggested, it is often almost impossible to move from one simple model to one that is more complex since the memes of common sense and cultural engrained attitudes seldom permit this to occur. Most people in our culture (and that includes clinicians) seem to be subsumed in this meme of common sense. That is that structural problems need structural solutions. Daily I hear, my discs are out will you put them in, or reports of structurally based descriptions provided by various health providers - these are seldom helpful. There is overwhelming evidence from population studies, neuroscience, pain biology and world wide practical experience from pain clinics that this structural account of back pain in particular simply does not work. Modern society is immersed in chronic pain and disability and one of the main clinical problems, as most people are aware is low back pain. Every structure and approach aimed at fixing the problem has met with little success but every clinician will have his or her own favourite and successful method I am sure. The problem of low back pain has been studied with the wide lens of historical analysis and practical patient management in two influential and authoritative texts . Gordon Wadells,Back Pain Revolution and Nortin Hadlers recent Stabbed in the Back. Both of these authors overwhelming message is that structural approaches to the types of back pain seen most often in the clinics of Doctors , and Manual Therapists clinics has been a post-war disaster (considering the amount of persisting pain and disability reported). Recently, there has been a tidal change in the understanding of the elephant in the room the thing that causes patients to present to clinicians - pain. Pain is not in the tissues but is a brain related assessment of threat. The body can be extremely dysfunctional, be full of problems but unless the brain decides that things are amiss there will be little to complain about (unless things are pointed out to you perhaps.). This knowledge has been adopted by influential researchers such as Lormier Moseley and David Butler in the easily read Explain Pain.

Being solely tissue and structurally focussed is perhaps as equally myopic as suggesting that all problems are in the brain and therefore one should just adjust the thinking and get on with things I dont think this is the overall thrust of Ledermans argument at all. I personally think that the dominant modes of appraisal and conceptualisation of physical problems need a radial overhaul and so does the role we have in intervening with these often complex but benign (in terms of medical understanding of pathology) physical problems. At a local level we need to address the enormous diversity of models, methods, and approaches that are directed at the spine by various well meaning professions (and often sub groups within professions) - such is the diversity of belief and behaviour. Simply put, the current state of diverse opinion and practice seems to me to be more akin to religious behaviour with various forms of hierarchical leadership and knowledge base than an open scientific discourse . Subjected to impartial scientific appraisal little of the structurally directed approaches comes out well (other than in short term sensory changes) . However, most clinicians will probably challenge this when reflecting on their own experience. As Howard describes in the 2011 Edge think tank discussion forum "If American citizens, or, for that matter, citizens anywhere were motivated to describe the conditions under which they would relinquish their beliefs, they would begin to think scientifically. And if they admitted that empirical evidence would not change their minds, then at least they'd have indicated that their views have a religious or an ideological, rather than a scientific basis. I think that this is an important statement since Eyal Ledermans paper challenges ideololgy and seldom is ideology relinquished without some gnashing of teeth! History seldom reveals a smooth transition from one knowledge base to another and perhaps with the current tide rising in terms of neuroscience and basic science understanding we are on the verge of a paradigm shift which papers like this may assist in bringing forth? Ian Stevens MA, BSc (Hons) Physiotherapist Forth Valley http://www.cpdo.net/Lederman_The_fall_of_the_postural-structuralbiomechanical_model.pdf