by Brian Allred
When I was fresh out of school and didn’t know anything, there were a few times when I would have a new patient come in and I would have absolutely no idea what was going on. It would go something like this:
Me: Tell me what brings you in here today.
New patient (let’s call him Joe): My back hurts. It started after I was lifting something heavy and I felt a pop. It’s better than it was, but it still hurts after 6 months. It’s worse when I’m sitting or bending over.
Me: [That sounds like a herniated disc. This will be easy.] Joe: I had an MRI and they said that I don’t have a herniated disc.
Me: [Well, crap. Maybe a facet syndrome or a muscle strain.] Joe: So what do you think?
Me: I have a few ideas. Let me do a few tests to narrow it down.
30 minutes later…
Me: [Everything that I thought might be wrong isn’t wrong and everything hurts that shouldn’t hurt. THIS DOESN’T MATCH ANYTHING THAT I KNOW!! I’ll just have them do a couple of generic exercises that at least won’t hurt anything so that I can save face and then I can try and figure this out.] Let’s try a couple of stretches!
So I go home and look at every textbook I own and go through my class notes and finally find some obscure reference to a journal article from the ’80s that talks about something that sounds like what I’m dealing with, but it’s in Swahili. I finally find a black-market English translation of this article and decide I know what to do when my patient comes back on Monday. On Monday morning when they return, it goes like this:
Me: How was your weekend?
Joe: Great! Whatever you did last time was amazing and my pain is gone! I’ve been dancing around all weekend! You are a physical therapy genius!
Me: [screaming internally] I’m glad to hear that!
Thankfully, in the years since then I’ve become confident enough to admit when I don’t know something, but it took me a while to understand why those people felt significantly better after doing a few worthless exercises that were not at all specific. I eventually realized that they just needed what I call Permission to Move. Let me explain.
When we develop pain, that changes the way that the brain works. We start to expect that we are hurting ourselves with every movement. At the most basic level, pain is our brain’s way of warning us against the danger of tissue damage. So when the brain expects damage, we feel pain. This can sound like some new-age, mind-over-matter baloney, but I’m sure you’ve experienced it. For example, a while ago I was cooking dinner and I reached across a pan on the front burner to stir a pan on the back burner. I bumped the pan in front with my arm and yelled in pain and jerked away. Then I realized that the pan I bumped wasn’t hot and I felt a little silly. The thing is, it really hurt for a second. My brain EXPECTED that I had burned myself and so it legitimately hurt when I bumped the pan. There was no damage, of course, but the pain was real.
When Joe up above hurt his back, most likely everything was healed by the time he saw me. But healed and pain-free are not the same thing and for the last 6 months his brain has been telling him with every motion that he might be irreparably damaging his back. When he comes in for physical therapy and I tell him to do some leg raises Joe’s brain says, “Brian has enough letters after his name that he MUST know what’s going on. These leg raises have to be safe.” He now has “permission to move” and realizes that he can do so safely. That is a bigger deal than most people think. Now when he bends over to tie his shoes, he doesn’t have the sirens going off in his brain. No sirens means no pain and suddenly I seem like a physical therapy genius even though I didn’t really do anything. All you have to know is that if there isn’t a specific reason not to move, movement will help.
You can trust me on this. Apparently I’m a physical therapy genius.