But

Reconceptualizing
Biomechanics within BPS
when biomechanics matters

It is unfair to completely neglect biomechanics

This ignores the BIO of BPS
We just need to put it in its place
We need to be cautious in how we frame its
importance

When Biomechanics Matters (WBM)

Acute injuries to protect damaged tissue
High load activities
Interruption of habits associated with pain
Temporary changes to desensitize the ecosystem
Disconnect between task/sport demands and
current function
Respect for adaptation (MSQ)

acute injuries the need for protection

when biomechanics matters

Acute Injury Protection/Desensitizing

Taping the arch or heel lift during acute Plantar
Fasciosis (6 weeks to desensitize)
Taping the knee for stair pain
Others and thoughts?

but
we still start with a BPS explanation even
with acute injuries or flare ups.

Reactive Tendinopathy
re-enforce that the pain is protective and
is not well correlated with damage
gentle exercise/isometrics is still helpful
we let it desensitize and then build back
up

heavy load activities

when biomechanics matters

High Load Activities

Heavy Squats, Deadlifts, Olympic Lifts
tissue has a finite capacity of tolerating stress.
form can influence the load on tissue
Its here where we learn a lot from biomechanists
(e.g Stu McGill)

Injuries with Flexion and Compression

Specimens had a lower yield point (43--63%) and ultimate compressive strength
(23--47%) when in a flexed posture than when in a neutral posture
Gunning et al (2001)

Dynamic testing was conducted to a maximum of 86400 bending cycles

Herniationoccurred with relatively modest joint compression but with highly repetitive flexion/
extension moments. Increased magnitudes of axial compressive force resulted in more
frequent and more severe disc injuries.
The results support the notion that intervertebral disc herniation may be more linked to
repeated flexion extension motions than applied joint compression, at least with younger,
non-degenerated specimens
Callaghan & McGill 2000

A practical message
while we have some research suggesting
the loads on the spine are comparable
to trying to maintain neutral there is no
research strongly saying that a flexed
spine under heavy conditions is safer

but
Do not confuse the safely threshold gained in
heavy loading with a need for that safety
threshold during simple tasks (sitting, standing,
picking up a feather)

The dreaded hip collapse

Dynamic Knee
Valgus and PFPS/
ITBS
correlational studies
prospective studies

High Loads and Dynamic Valgus

(Myer 2015)

a KAM above 25.3 Nm was associated with a

6.8% risk for subsequent ACL injury compared
to a 0.4% risk if below the established ACL risk
threshold
Maybe under heavy loading we look at changing
lower extremity mechanics.
But can we explain this another way too?

perhaps
under low loads the
biomechanical variable is not as
consistently related to pain

Do not again confuse the safely threshold gained in

heavy loading with a need for that safety
threshold during simple tasks (running, kneeling,
low load squats)

Habit Interruption

habit interruption
when biomechanics matters

Dankaerts et al 2006
during sitting NSCLBP patients with a flexion pattern
disorder position themselves near the end of the
available flexion range at the symptomatic region of
the spine,whereas patients with an active extension
pattern disorder hold themselves actively into
hyperextension (potentially leading to abnormal
tissue strain and pain).

Pain can become coupled with certain postures and

movements.
What one person can tolerate another with a
sensitized ecosystem can not.

Moving and Pain Memories

Biomechanics matters here because certain
patterns of movement have become associated
with pain
We need to change those patterns to interrupt that
habit
In the past we would say this is more optimal
Perhaps we are increasing comprehensive capacity
and movement repertoire

Changing habits need not be forever

We change the habit for a reprieve
This reinforces belief of modifiable sensitivity
We dont want to reinforce that they can never
perform that movement

a thought

Only that they are currently sensitized to that

movement or posture

McKenzie

McGill

Running Re-education

SFMA

are all structural

treatments merely habit
changers?
CB-CFT
Sahrmann

if we have the capacity to adapt

perhaps all running re-education
interventions merely shift stress
for a period of time that allows
the body to desensitize

Temporary Changes to Desensitize the Ecosystem

temporary changes
to desensitize the
ecosystem
when biomechanics matters

Changes in form
Changes in habitual postures
All used as temporary measures to minimize
irritation or to break a pain habit
Not to be considered BAD form or correcting faulty
function
Examples (squatting, running interventions, hip
hinge)

Sensitized Tendon: Avoid Compression

Avoid calf stretching for achilles
Increase running stride rate
Increased hip hinge squat

Tape can Desensitize

This is just a band aid
Explain that it is purely neuromodulatory to
desensitize in the short term
Stress that nothing is being corrected

Avoid hip dropping for Greater Trochanteric pain

Reconciling the SICK scap

do we need to worry
about subtle changes in
alignment or form?
reconciling the SICK Scapula

Can these cases be as simple as supraspinatus

tendinopathy
The tendon is sensitive and normal pinching with
elevation leads to pain
SAT can be neuromodulatory as skin puckering
does the same Sx modulation
What is a pragmatic approach that recognizes this
clinical doubt but is empowering?
Greg Lehman MSc, DC, MScPT

Biomechanics in the BPS Framework

Reiterate that pain is more about sensitivity than
damage
When it is about damage then focus on the bodies
ability to adapt to load rather than a multitude of
impairments

Treating the SICK scap

Load the irritated tendon
Find neuromodulatory movements to break the pain
habit/couple with arm elevation
Assess for other protective behaviours (trunk and
neck stiffness) and encourage novel movements
Encourage painfree loading of both the scapula
and GH muscles
Train in all planes and progress to comprehensive
capacity

What do we say?
The tendon is sensitive
It hasnt been given a reason to adapt so it stays
protective and defensive

The positive message continued

None of these explanations blame the patient, their
anatomy or impairments
Shifts to defensive protection mode

Other body regions do the same

We convince the body protection is not necessary

We anticipate pain with movement so we have to

get comfortable raising the arm again

We avoid correcting posture because this does not

have to change and if we sell that they can worry
about this defect.

Modifications are short term bandaids to desenstive

Do we care about structural source of

nociception?
No. We dont even have to know if an impairment
is the cause or consequence
Use symptom modifiying techniques to change
sensitivity and perhaps we corrected form but its
not relevant
Use comprehensive capacity to cover all our bases

matching sport demands

to individual function
when biomechanics matters

WBM: Matching sport demands to

individual function
Strength is protective (Laursen 2015)
Strength needs are task specific

Simple strength is important

Groin injury and strength is linked

(Ryan 2014)

OR= 4.28 (1.31-14) for weak hip adductors

Hockey
Mobility is needed in certain sports
Gymnastics
Golf
Blanket statements are difficult
Individuals are also able to adapt and tolerate load

Hamstring Eccentrics in Soccer Players

(Petersen 2011)

Comparing intervention versus the control group, overall

acute hamstring injury rates per 100 player seasons
were 3.8 versus 13.1 (adjusted rate ratio [RR], 0.293;
95% confidence interval [CI], 0.150-0.572; P < .001).

Hamstring Strain Prevention

Hamstring Loading

Nordic Hamstring Curl

Arnason (2007)

The main finding of the present study was that eccentric strength
training with Nordic hamstring lowers combined with warm-up
stretching seems to be effective in preventing hamstring strains in
soccer.
In contrast, stretching during warm-up and flexibility training of the
hamstrings group had no effect on the incidence of hamstring strains

Big Study (n=942)

10 week intervention performed on MidSeason Break
27 sessions of Nordic Hamstrings over 10 weeks

Nordic Hamstring

Results
67 acute hamstring injuries
44 new and 23 recurrent
15 injuries in intervention group (12 new and 3 recurrent)
52 injuries in the control group (32 new and 20 recurrent)
no injuries during the exercise
Number needed to treat (NNT) = 13 to prevent 1 injury
NNT for a new injury = 25
NNT for a recurrent injury = 3

Petersen (2011)

screening
implications?
all physical assessment screenings should be both
simpler (test biomotor abilities) and more complex (test
the exact demands of the sport)

Not a panacea
Strength and mobility training may be most useful
when loading approaches tolerance
Does not make sense in activities when loading is
not near tolerance

respect for adaptation

when biomechanics matters

Although we can promote general strength and

fitness training for other reasons to modulate pain

Respect for Adaptation (MSQ)

Too much too soon happens frequently and many
athletes get away with it but many dont

Load matterssometimes
Nyman 2009

Evaluate the training program of your painful

patients
Do people persist in poking the bear when they
have exceeded their threshold to adapt
What factors in their life might influence their
threshold to adapt

In the cohort analysis, the association between high physical workload and the group with
any one symptom (LBP and/or NSP) was OR 1.47 (95% CI 1.37 to 1.57). The co-twin
control analyses indicated that the association was not confounded by genetic and shared
environmental factors with OR 1.34 (95% CI 1.02 to 1.75) for dizygotic twins and OR 1.44
(95% CI 1.06 to 1.95) for monozygotic twins

Hartvigsen 2003

Statistically significant graded relations were found for increasing workload and
LBP of longer duration but not for LBP of shorter duration (</=30 days during
the past year).

Many factors influence adaptability

Consider the ecosystem

when biomechanics
matters?
they are part of the ecosystem and are influenced by a
myriad of factors.
We will never parse their exact importance and will continue
to be deceived into believing they are extremely important
or not important at all based on the limits of our own
personal interactions