Changing the Narrative:
A Conversation with Greg Lehman

(The full version of an interview published in Massage & Bodywork Magazine, Jan-Feb 2020.)

Nov 2019

By Til Luchau

I had the opportunity to speak with Canadian physiotherapist, chiropractor, and presenter Greg Lehman about several topics, including his part in a recent paper “Changing The Narrative For Sacroiliac Pain.” This transcript of our conversation has been lightly edited for clarity.
—Til Luchau, Nov 2019

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’s 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.

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

Greg: That’s right.

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

Greg: Oh no.

Til: 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.

Greg: Okay. 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 bio-mechanical intervention to say, “Oh, I don’t have to worry about that anymore.”

Til: That’s about right, in terms of my experience. What you were saying 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?

Greg: No, and I know that sounds super arrogant. It’s just been solidified. When five or ten years ago, maybe I felt like I 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

Til: You and your collaborators just put out a paper titled Changing The Narrative For Sacroiliac Pain.[1]

Greg: That’s right.

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

Greg: Actually, we were thinking of them a lot. So 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 in the SI joint.[2] One of his 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 Vleeming and that whole research group, the form- and force-closure of the SI joint.

Til: Right.

Greg: What Thorvaldur 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 and discomfort and instability. So it’s a perceptual feeling rather than a true instability. What he also showed was people have more muscle activity when that’s happening, so the joint is definitely stabilized and stiffer. So we needed a rethink and we had known that for a while. His is just one piece of the puzzles that support that.

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

Greg: 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 re-conceptualize that and say, “Oh, that’s what instability feels like.”, where no, it just feels wrong or it feels irritated, it just doesn’t feel good.

Greg: 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 & 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 it doesn’t correlate with the feeling.[3] 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.

Til: Fascinating. So what causes that feeling?

Greg: 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, then the exercise to reinforce that. You wish you could say that, but it’s not true. So the difficulty that we’re having now is how do we give people an accurate explanation for this sense of feeling off. Martin Rabey, one of the authors on the paper, wrote a quick blog on the Pain-Ed website, going into the idea that perhaps when we have pain, there’s a disruption in how we perceive body part. This is the old cortical body map or the sensory representation of our body. It’s sort of this neuroplastic change or bioplastic change that occurs when we have persistent pain. But this is the problem. What explanation sounds easier to tell our patients? That’s what we’re struggling with.

Greg Lehman PhD

Up-slips, Rotations, and Torsions

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

Greg: Yeah.

Til: What do you think?

Greg: When I taught at the chiro school, we were not really teaching motion palpation. We acknowledged it historically, 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.[4] 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 therefore not valid. So we just stopped saying that.

Greg: 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. So we’re not saying it’s all in the head, we’re just saying it’s not because of some positional or movement flaw.

Greg: 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. You just don’t need to say it’s because you’re repositioning a joint. The subtle simple shift is that you can still do a lot of the things that 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.

Greg: 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’s other things that 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, or Too Loose? Or, None of the Above?

Til: What about hyper-mobility?

Greg: Yeah. There’s nothing inherently wrong with being hyper-mobile, you just move more. Doesn’t mean it has to hurt more.

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

Greg: 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’re 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 re-conceptualization 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.”

So How Does Hands-on Work Help

Til: Okay. So how does manipulation, how might it 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.

Greg: Yeah, I think it’s easier to explain that, 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-

Til: Not the whole story.

Greg: Yeah. I mean you bang your thumb, you put your hands on, 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. If 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.

Til: I’m thinking that so many of the people I work with want to touch the problem. They want to say, “Okay, 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 that we’re being faced with too.

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

Mechanism Chasing

Greg: But honestly, I used to chase mechanisms, that was my master’s, and I don’t care anymore. It’s like exercise. I’m a huge proponent of exercise for anything. I really have no idea how it helps people with pain. Oh, you got stronger? Well, so what? Just because you’re stronger doesn’t mean you have less pain. There’s plenty of people who are strong that have pain, and you can be weak and pain-free. So I don’t really know mechanisms.

Til: I’m with you. But I get pressed by students for mechanisms.

Greg: I know.

Til: I think maybe what’s behind the questioning is “How should I think about it,” or even, “What do I tell my clients I am doing?” If we know all this stuff we used to put first maybe isn’t that significant, what is significant? What are we doing?

Manual Therapy as Stressing

Greg: This is where people need principles and fundamentals. I think they go across professions, and some people might have other ones. But a huge fundamental for me is that the body and people respond to stress and movement, and usually positively. So in manual therapy where you’re moving someone, or they’re moving, you’re stressing that person to show them that they can adapt, that movement is inherently good, and that stress is inherently good. Yes, we can do too much too soon, and sometimes the dose is wrong, and people flare up. But the body likes to move. If you’re just sitting down all day, you’re going to be sore, whether or not you have persistent pain or not.

Leg Lengths, Scoliosis

Til: Okay. Fascinating. What about SI pain with leg length differences? Same thing?

Greg: Same thing. We’ve got to acknowledge the body responds to stress and it can adapt and it has built-in redundancy, and an incredible ability to adapt. Meaning if you have scoliosis or leg length discrepancy, that’s nothing. If you have leg length discrepancy, when you walk-

Til: What do you mean that’s nothing?

Greg: It’s not related to pain. It’s just not enough stress to cause a problem. We adapt to the legs not being the same length.

Til: Do you think that’s true no matter what the magnitude of leg length discrepancy or scoliosis? Is there a point at which you modify that, or is that the case all across the spectrum?

Greg: There’s a point with scoliosis or things like that where breathing would be compromised, but we’re able to have these things, and do OK. Usain Bolt is a perfect example. I know it’s an anecdote, but the research also supports it. He has a scoliosis and he’s kyphotic and anterior pelvic tilt and when he runs, he doesn’t run with the same force going through both legs either. And that’s normal. You draw a line down your face, your left side will be different from your right side. You part your hair on the left, it’s going to look weird and not like a mirror if you start parting it on the right. So we have these built-in asymmetries and so what I believe, and what I’ve been trying to say for decades now, is that we’ve pathologized normal asymmetries.

Head Forward?

Greg: People get caught up in that and they think, “No wonder I have pain because my head goes forward a little bit, and I’ve been trying to change it for two years and I can’t change it, so it’s my fault.” I’m like, “No, let your head go forward. Who cares?” There’s other things you can work on. You’re setting yourself up to fail if you think you have to change your leg length or forward head posture or whatever it happens to be.

Til: OK, forward head posture. That came up yesterday in a different conversation and the people there were skeptical or even stunned to hear that there’s debate around it being related to pain. We’re deeply trained to assume that if the head is forward, it’s a problem.

Greg: Yeah. Prospectively, it doesn’t seem to predispose people [to pain]. It wouldn’t doubt me that there’s a subset of the people who slouch and have forward head posture that hurts, and then they try to go in neutral and it feels better. But you also have a subset of people who go in neutral and that hurts and then they slouch and feel better. So if you’re movement optimist, you say just move however you like. Find positions of ease; the mechanical is just one small part of it.

Til: OK, so if it’s a small part, when does it matter most?

Greg: Biomechanics, like your position and all those things, might matter more for performance. So I still advocate that my patients “work on their posture”, meaning work on being upright or even backward bending, because I want them to be able to reach over their heads and climb a ladder and reach the shelf above their cupboard. It’s for performance. But that’s it.

Are These Ideas Difficult to Apply?

Til: So I hear a lot on social media, and then again at a pain conference I was at recently, how hard people think it is to apply these ideas. That the biopsychosocial point of view is great as a theory, but in manual therapy it’s complex and difficult to actually apply. Do you agree?

Greg: Yeah. It is difficult if you think your job is to fix every single psychosocial contributor to pain. That’s where I think people go to, and that’s where I felt discombobulated 15 years ago. They take a course and are like, “Oh, you have to identify these and fix them.” I was like, “No, you don’t.” You just have to know that they’re potentially there. People don’t always have to fix those things. You can acknowledge that anxiety and depression are related to pain, and sometimes [hearing] that can help people understand their pain. That can be a bit freeing, and then they have a little bit of hope.

But you can also say that at the same time, “But listen, you don’t have to change anxiety and depression. Those can exist and you can be pain-free.” There are a bunch of contributors to pain, but not all of them have to change. You can build people up so that they can tolerate those other contributors to pain, and people can be great. Does that make sense? That’s where I think people feel overwhelmed.

Alex Mit, iStock

Til: You’re saying we build people up through things like letting them know that making changes wherever they can will help them feel better.

Greg: Exactly, and that’s why I use the cup analogy (Image 3). All these potential stressors are contributors to pain go into someone’s cup, and you have pain when that cup overflows. So treatment is either changing a couple of things in the cup a little bit, maybe just one thing, or building a bigger cup, which could be resuming hobbies and activities they love. It could be adding more exercise, it could be backing off of some exercise. It could be changing how they view it. So it’s all of these different things. So there’s lots of stuff we can do.

Til: Changing the contributors, and changing the capacity, both. Building resilience.

Greg: Tolerance. Yeah. Resilience.

Summary

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

Greg: 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’s 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.

Til: Okay. Anything else?

Greg: Like … No, I’m good.

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

Greg: 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 what are the common threads amongst 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 amongst those two things which seem different? 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.

Til: Love it.

Greg: We’ll get there maybe.

Til: Thanks for all that you shared, Greg.

Greg: Oh, no problem.

To Learn More:

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

Notes

[1] Palsson TS, Gibson W, Darlow B, Bunzli S, Lehman G, Rabey M, Moloney N, Vaegter HB, Bagg MK, Travers M. (2019). Changing the Narrative in Diagnosis and Management of Pain in the Sacroiliac Joint Area. Phys Ther. 2019 Jul 29. pii: pzz108. doi: 10.1093/ptj/pzz108. [Epub ahead of print]
[2] Thorvaldur Skuli Palsson. (2014). Lumbopelvic Pain - Sensory and Motor Aspects (PhD thesis). Center for Sensory Motor Interaction Department of Health Science and Technology Aalborg University Denmark. Retrieved from https://www.fysio.dk/globalassets/documents/fafo/afhandlinger/phd/2014/phd_thorvaldur-skuli-palsson_2014.pdf

[3] Ajit M.W. Chaudhari, Laura C. Schmitt, Gregory M. Freisinger, Jacqueline M. Lewis, Erin E. Hutter, Xueliang Pan, and Robert A. Siston. (2019). Perceived Instability Is Associated With Strength and Pain, Not Frontal Knee Laxity, in Patients With Advanced Knee Osteoarthritis. Journal of Orthopaedic & Sports Physical Therapy 2019 49:7, 513-517 doi: 10.2519/jospt.2019.8619

[4] Tullberg T, Blomberg S, Branth B, Johnsson R. (1998). Manipulation does not alter the position of the sacroiliac joint. A roentgen stereophotogrammetric analysis. Spine (Phila Pa 1976). 1998 May 15;23(10):1124-8; discussion 1129. PMID: 9615363 DOI: 10.1097/00007632-199805150-00010

"Look at pain as the overflowing of a cup…The multidimensional nature of pain means there are a multitude of things that can help with pain. You can decrease one contributor a great deal or perhaps address a few of them. What you can also do is BUILD A BIGGER CUP. This means over time you can build resiliency or coping that allows you to adapt and tolerate all the stressors in your life."
-- Greg Lehman, from Recovery Strategies

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