0410 440 506
antony@physiodetective.com

Physio Detective Blog

Let It Go!

The Postural Structural Biomechanical (PSB) Model – It’s Time To Let It Go!

A different kind of blog post today. Today, I am going to tell you a bit of a story of change, one where I had to confront the difficult reality that what I knew and did was not complete and was not helping my patients for the reasons I thought it was. I had to confront my belief in the Postural / Structural / Biomechanical Model and let it go!

It's a difficult to story to tell so I have enlisted the help of Queen Elsa to help me tell it.

Part 1 - Life Before The Change

The snow glows white on the mountain tonight
Not a footprint to be seen
A kingdom of isolation
And it looks like I'm the queen

I used to be part of a very large community of physical therapists and other health and fitness professionals - in fact, most of the world think the way I used to. This is where posture was important, where making sure you had the right alignment was crucial, where activation of muscles in certain sequences was essential, and where if you weren't stacked the right way, your biomechanics would lead to pain and injury and brokenness and suffering. My whole theoretical model was based on these beliefs and I taught them to many others (I am sorry for doing that!) - it is important to acknowledge that I was doing the best I thought I could to help these people and have spent an ungodly amount of money in the pursuit of educating myself and others.

Like Elsa, I was there but still an outsider. I knew things weren't complete. I had a complex answer for everything but I knew a whole bunch of factors were also playing a part:

  • Why was that physio with very little skill and knowledge able to help patients and the experienced physio losing patients?
  • Why was I able to help someone when I barely did anything?
  • Was I helping people just because they like me?
  • Why was that patient not getting better when all the things I found to be important all improved?
  • Why is it when I applied the WRONG technique, the patient still got better "objectively" and subjectively?
  • Why is it that I couldn't feel what others were feeling on a course and yet I still helped people they couldn't help?
  • Why is it that a random "correction" was able to help someone just as much as a specific one?
  • Why was it that the kind of day my patient had affected how well I could improve them?

I had so many questions but I enjoyed being secure in the knowledge that I was making a difference and helping people.

But the one day at the end of 2013, Greg Lehman engages me in a conversation on Twitter about Thoracic Rings. This thing went on for days. but the key moment came when I asked him "does that mean I didn't help all those thousands of people?" to which he replied something along the lines of  "I didn't say you didn't help those people, I think it was for different reasons"...at least, that's how I remember it.

From that moment on, I realised I could let go of these techniques and models because they didn't define who I was. I realised I had let these things be my identity - that's why whenever someone attacked the models or techniques I used, it felt so personal...it was as if they were attacking me personally!

But I suddenly felt very isolated. I was free to question the models and techniques I had learned but now that meant I wasn't "one of them"...and I didn't know enough to be a part of the new crowd. I did try. I went onto a forum where a lot of them inhabited and asked questions but then was directed to read about 200 comments on a topic. Who has time for that?! It's not that I am lazy, it's just that I am busy! Where was the support, the short-cuts, the encouragement? It seemed like it was a rite of passage - we had to suffer to get here so you'll have to suffer to get here. I think that's stupid. It's a massive obstacle to change!

Part 2 - Decision Time and The Change

 

The wind is howling like this swirling storm inside
Couldn't keep it in, heaven knows I've tried
Don't let them in, don't let them see
Be the good girl you always have to be
Conceal, don't feel, don't let them know
Well, now they know
Let it go, let it go
Can't hold it back anymore
Let it go, let it go
Turn away and slam the door
I don't care what they're going to say
Let the storm rage on
The cold never bothered me anyway
I had tried to be as good a physiotherapist as I could be. I had spent a lot of money doing courses and a post-graduate degree and specialisation training. My intentions and my heart have always been in the right place - helping people is what I feel called to do. I struggled through undergraduate school with my narcolepsy (I daresay it affected my high school as well!) and even now I struggle with being passive too long. I worked hard to be the good physio - to learn my theory and anatomy and be good at what I was taught.
But now, that world was being cut down...what could I trust anymore? The only thing that I was able to hold on to was that I was able to help people...that didn't change.
The way I saw it, there were 3 options:
1. To stay the same as I had been - to double down, give the middle finger to all who attacked me and just rely on my results as the main justification for what I did. But for those that know me, you know I like to be right...and knowing that what I believed in was not right would eat away at me...this was not an option.
2. To dive deep into this other realm - I kinda do a lot of the things people proposed - I had these questions already and worked around them. I understood and had heard of the biopsychosocial model already. I understood the importance of the psychological and sociological contributing factors already and I was willing to learn more...but there was this air of superiority I didn't like...there was not enough of an attitude of remembering where they had come from, not enough empathy and understanding, too much jadedness...
3. So there was the third option - to go my own way...but that would mean being out in the cold. I would not be in either camp...but then, I was always a bit different...
Different. This word had been a part of my whole life. I was different in so many ways. One very specific childhood memory I have is my mother exclaiming "why do you have to be so DIFFERENT!?" to which I replied "I JUST AM!". My first Yellow Pages advertisement had the words "Feel The Difference". Advice I gave to youngsters was to do things differently to others otherwise you'll get the same results they get.
So I decided to let it go - slowly, of course! I decided to challenge my beliefs and think about my thinking. I chose the hardest way - to go my own way (it is not a unique way...just that I had to find it myself). I like being able to see what I did, I like being able to look back and say "ah, I used to do that". I like being able to see the change over the years. And it took YEARS to change and I expect it to take until I die to keep evolving how I practice.
But there was a sense of freedom. No longer was I a fraud for not being as good as others in feeling the small things that others could. As a natural contrarian, I relished in being able to break the rules and still help people get better. I had taken up CrossFit and I fell in love with it because it pushed so many boundaries and broke all the rules and I loved it for that.
It was time to start letting go of all my old beliefs that did not stand up to the challenge of being examined...

Part 3 - The Process Of Change

 It's funny how some distance makes everything seem small

And the fears that once controlled me can't get to me at all
It's time to see what I can do
To test the limits and break through
No right, no wrong, no rules for me
I'm free

Let it go, let it go
I am one with the wind and sky
Let it go, let it go
You'll never see me cry
Here I stand and here I stay
Let the storm rage on

So I started to challenge what I did. Everything that I felt was essential to helping someone got examined. I began to seek out information that challenged my biases and beliefs.

What did it mean if I could help someone without doing THIS or needing THAT to be right first?

If this test is positive, does it REALLY mean THAT?

I began to study about logical fallacies and cognitive biases...this is an ongoing study because there are A LOT of them!

I tested the limits and I broke through so many of the old obstacles and beliefs. I reduced what I did to three simple words - DO SOMETHING DIFFERENT.

I mean, that's all we really do anyway! We see what the person is currently doing and how it is associated with pain and we ask them to do things in a different way that is not associated with pain. We make fancy stories up around this but ultimately we are just doing things differently.

So on this rock, I rebuilt what I did. Different. Be Different. Do Something Different.

I had already developed quite a number of techniques to help CrossFitters I saw who were suffering from trying to do what others had told them was the right thing to do...I just showed them how to do it differently. Now a new language had to emerge.

Now I had to take this forward. Part of why I sold the practice was so I can focus more on developing the education side of my business. This is where I wanted to go next.

Part 4 - Encouraging Others To Change

My power flurries through the air into the ground
My soul is spiraling in frozen fractals all around
And one thought crystallizes like an icy blast
I'm never going back, the past is in the past
Let it go, let it go
And I'll rise like the break of dawn
Let it go, let it go
That perfect girl is gone
Here I stand in the light of day
Let the storm rage on
The cold never bothered me anyway
Back in 2013, I started running local seminars in CrossFit gyms for mobility and helping people improve and prevent their pain. This was before the conversation I had with Greg Lehman. Over time, these seminars developed into general seminars about improving technique, and helping people with musculoskeletal pain, and seminars focusing on women's health problems. I also started a podcast with Lori Forner which I eventually called "The Pelvic Health Podcast". Lori continues the good work on that podcast - I was there for 51 episodes.
Then, I got asked by Sandy Hilton and Sarah Haag to present a course on How To Treat CrossFitters. It is a biopsychosocial approach to helping CrossFit Athletes. That same summer of 2016, Tracy Sher asked me to present a course on The Female Athlete and Susan Clinton asked me to run one on Moving Beyond Motor Control. All were 2 day seminars and focused on providing an evidence-based approach to helping people with musculoskeletal, sports, and women's health problems.
Since then, I have revised the most popular course - The Female Athlete - into 4 evolutions...and soon to be a 5th!
This last bit of the song Let It Go is my favourite. I have been through the pain of change and I know I will continue to learn and change until I die. But this last section of the song is where I encourage those that come to my seminars to leave behind the old Postural / Structural / Biomechanical Model...
And one thought crystallizes like an icy blast
I'm never going back, the past is in the past

My hope is that from my seminars, from their interaction with others who are also promoting similar changes to our profession, I hope that each participant can say "I'm never going back [to the old postural/structural/biomechanical models], the past is in the past!"

Let it go, let it go
And I'll rise like the break of dawn
Let it go, let it go
That perfect girl is gone

If you let the old beliefs go, it will be a new dawn on your career. Let go of the fear, the beliefs that contradict each other, the burdening of patients to "get it right!".

But not only that, embrace not knowing. You don't have to be "perfect" - that person is gone! Embrace uncertainty. We don't know why what we do works! We do know it is a combination of so many things, and those things aren't perfect posture, correct alignment and proper biomechanics!

Here I stand in the light of day
Let the storm rage on
The cold never bothered me anyway
Stand up and be proud to be a part of the new dawn, the age of the biopsychosocial model. Be a part of what seems to be the best way to help our clients holistically. Let the storm of anger and defensiveness from others rage on around you.
But be warned. You will feel like you are out in the cold. You will be shunned, ridiculed, gossiped about. I have had friends lose their jobs over this type of thing. It is not an easy road but it is the right road. The cold never bothered me anyway but it might for you...

Part 5 - What Are You Going To Do?

...so know that you won't be alone! I am here and feel free to look to me and others like me for support. Change won't happen overnight. You won't get judgement from me. I won't call you names. I will acknowledge just how hard what you are trying to do is. And I will do my best to support you.
I'll simply ask you "what is the next logical step for you?" In what way are you going to let it go, just a little bit? In what way will you take that step away from the old beliefs and move towards a more biopsychosocial approach? What one belief will you address this week? What one patient will you review and reconsider this week?
Let me know how you are going and if you ever doubt what you are doing, listen to Elsa's song and remember that you are not alone 🙂

9 Responses

  1. Myranda Reimer

    This is very interesting to read through as a new physio graduate. In school we learn minimally about the biopsychosocial approach, it is important they say but then we get hammered with biomechanics and constant reoccuring conversation and teachings of posture. Carolyn Vandyken’s Pelvic Health Solution Level 3 course has taught me so much!!
    I understand what you are saying and support this idea of a moving posture vs a perfect posture but it is a difficult transition because of whats been engrained, however it is a frequent conversation I have with patients because society encourages a perfect posture! so although i dont believe it 100% quite yet i still talk about it because i do find people align with that better than saying you must sit like a plank of wood upright all day haha
    With clients that have a nagging injury i have trouble with progressing them. We try this and then that. I do ask about sleep nutrition but one conversation i see now that may be lacking is recovery. I have an athlete with chronic rotator cuff pain, she marathon canoes upwards of 8 to 10 km a day- thats what she does and doesnt want to change it. Lots to think about. It gets me excited!
    Thank you for sharing your journey! I am thankful to have access to information from physios all around the world through technology!! Do you have any suggestion for other resources or other physios to read on?

    1. Hi Myranda.

      I feel your pain.

      Firstly, there is no perfect posture. I had this conversation with my daughter last night – I told her about the blog post – and she said “but when I sit slouched my back hurts and then when I sit up straight, it feels better so isn’t sitting up straight better for you?” I just turned it around for her and said if you sat straight for the same length of time, what would it feel like and what would you want to do?” And she got it! She said “yeah, it would probably hurt and I would want to slouch”. So I followed up with “so that’s post hoc fallacy – you think sitting up straight is good because it took the pain away after slouching. But really, what you want is to change your posture. Your best posture is the next posture”.

      With clients with a nagging injury, there’s so much to think about. I summarise it as “do something different”. So while a boomechanical model might say they keep injuring it because of their technique, I frame it differently. They have preferences for movement that get associated with pain. So we teach what they can’t do or don’t prefer to do and work on dissociating from the pain they have associated with certain techniques.

      For your canoeing athlete, I suspect her technique doesn’t have enough variety in it. So keep her paddling but mix up her training and technique a bit by working with her coach.

      Good luck and let me know how you go!

    2. Hey Myranda, I have an ongoing collection of excellent resources that you may be interested in surrounding the topic of posture/alignment as it relates to pain and injury, significance, as well as long list of other PTs to follow that think critically and keep evolving and sharing as they evolve.
      Please contact me and I’d be happy to send you my growing list 🙂

      Shelly Prosko

  2. Rachel

    So how does this apply to lifting? Is any variation of picking up a bar fine…or are there points of performance that should rightly be enforced? I ponder this a lot as a coach. I want to be helping people improve their movement and performance and I’ve been a stickler on proper form and positioning since I started Crossfit (for various reasons: health/injury prevention, performance, and simply beauty/virtuosity) But as I’ve experienced my own saga’s of nagging pain while “trying to do everything right” and due to some obsessive researching and seeking out more…I’ve also learned that everyone is a little different and maybe due to our bodies we need to lift a certain way vs. another. But how do we know, haha. How then do we know when someone needs to adapt or change their movement or posture? If we wait until they stall or get injured…that doesn’t seem very helpful. But at the same time, I’d hate to try and make an adjustment that does actually make things worse. Ahhh, I feel like it gets so confusing so quickly 🙂

    I’ve been following you for awhile now Antony and I’m blown away by the information and encouragement you put out. Thanks for the work you are doing!!

    1. Hi Rachel. I’ll just go through and and answer as you have commented above. 🙂

      “So how does this apply to lifting? Is any variation of picking up a bar fine…or are there points of performance that should rightly be enforced? I ponder this a lot as a coach”

      Great questions! Love it! I teach what I call the pyramid of performance vs the pillar of performance. What I teach is that at low levels / low loads, variation is a lot broader. As you go higher in loads and complexity, the options narrow down (never to just one way, just less ways) for the highest loads and performance. So a broad base at low loads and narrower options at higher loads is the pyramid of performance. The pillar of performance is the idea that the empty bar warm up should be done like your 1RM. That’s just asking for trouble in my opinion because you don’t have enough variety and likely too much compression (not #tensiontotask). It’s like teaching Snatch. I know we start people on a pvc to try get the movement and all sorts of things are seen but I had to learn to let it go (hahaha) and focus on just one thing I wanted them to improve despite the 7 things I could see needed to change! And then you can have perfect pvc technique and it all changes as soon as weight appears. So these days, if I am teaching someone to snatch, I just start with pvc to get the idea and then the barbell so they get used to weight. I allow them to do “bad habits” because I set the framework and mindset up that we will be refining everything.

      “I want to be helping people improve their movement and performance and I’ve been a stickler on proper form and positioning since I started Crossfit (for various reasons: health/injury prevention, performance, and simply beauty/virtuosity) But as I’ve experienced my own saga’s of nagging pain while “trying to do everything right” and due to some obsessive researching and seeking out more…I’ve also learned that everyone is a little different and maybe due to our bodies we need to lift a certain way vs. another. But how do we know, haha”

      Yes. Most of what I do these days to help Crossfitters is simply see what they prefer to do and then teach them other ways they don’t prefer to do. Try it for yourself!

      For me, resilience means having good control and strength and power and speed of repetition over your whole range of motion. The load you can do in different ranges changes of course but that’s ok – it’s just a number. Get into awkward positions and learn how to cope there. The people that seem to be injury-free tend to have the most variety of movement – I call it movement vocabulary.

      “How then do we know when someone needs to adapt or change their movement or posture? If we wait until they stall or get injured…that doesn’t seem very helpful. But at the same time, I’d hate to try and make an adjustment that does actually make things worse. Ahhh, I feel like it gets so confusing so quickly 🙂”

      I feel your pain. You don’t have to change your movement standards, just change the language around it. They aren’t doing things in a bad way and your way is better…they’re moving in one movement preference and you are teaching them another way.

      For people doing things the way you want but still having issues, get them to move in 3D at low loads and teach them to do things that break the rules. One thing I do (remember that I assess people!) is to let them do “bad squats” – air squats with the knees “collapsing in”. It freaks coaches out but a few of those and athletes tend to feel better 😉

      Just one small example but take the concept and figure out what one small change in language or concept might be for you.

      “I’ve been following you for awhile now Antony and I’m blown away by the information and encouragement you put out. Thanks for the work you are doing!!”

      Thank you!

      Hopefully you can make it into the mentoring program or come to a course in person!

      Thanks for the comment. I hope this has helped!

  3. Rachel

    Oh and to piggy-back off of your daughter’s thoughts…what should we do/how should we sit/stand if we are in a situation that requires one position for an extended period of time.

    I’ve definitely come on to the idea that really it’s not the position itself that is the problem as much as the lack of movement = sustained position, whatever that position may be. SO do we just become fidgeters 😉 haha.

    1. Hi Rachel

      Yes, your best posture is your NEXT posture.

      There is discipline and benefit to learning how to sit still but not because it is better than moving, but because it’s just one variation. And I want you to be good at ALL the variations!

      Just relax more and move regularly. You actually do it unconsciously so just check in every now and then and see that it has happened!

  4. Hi Antony,

    Thank you for sharing your story. As you know, I went through a similar transformation after some of my beliefs were challenged as well several years ago (which I am so grateful for now, but at the time, it was uncomfortable).

    If you recall, you were there to help support me and help make sense of it all, but without ‘telling’ me what I should or shouldn’t believe. You helped me think more critically and feel comfortable with simply asking questions and challenging my own biases! When you shared your own story, it helped immensely and made me feel I wasn’t alone, and that it’s part of the journey of a truth seeker and critical thinker.

    That said, the door was already opening for me, as it wasn’t the first time I had come across a different paradigm and that the PSB model was being challenged. I was introduced to the value and science behind using a biopsychosocial approach to rehab decades ago in my integration of therapeutic yoga into my PT practice. Yoga was offering a new and different framework to work from.
    But even then, I still found myself stuck in the kinesiopathological model or approach to rehab.

    In my experience and in discussing this with some of my colleagues, we find out that it takes time to change — in some cases even considerable amounts of time — and takes repetition of hearing the same messages (explained in different ways by different people); doing my OWN research on what the literature was saying (instead of just parroting others); un-learning concepts and also un-learning patterns of thinking; re-learning ways to think; self-inquiry: what am I attached to? why? is ego involved? do I feel threatened if I admit what I just taught was inaccurate? etc); reflection; exploration during teaching and also with patients; trying it on/trying it out; being patient; having self-compassion; and having courage to make mistakes when trying to explain to others.

    It’s one thing to be on the path of having the courage and patience to challenge your own biases and open to change beliefs, and it’s another thing and different skill set to actually then go out and put it into practice, whether it’s changing the way we explain things to patients, or the course content we teach or the language we use as an educator, presenter and course provider. This takes time and practice; and for me, is not easy.

    So, it certainly doesn’t happen overnight. It’s an ongoing journey.

    But, I CAN say that a profound shift has happened in that I am not as attached to ideas now, and I am not as freaked out when I hear something or see some literature that challenges what I just taught the day before.

    I look at it now as an opportunity to learn and grow.

    I’m more ok with not having to know everything or be right.

    I’m ok with NOT knowing exactly why people get better when they get better — understanding that the human is incredibly complex.

    I’m more cognizant of my language and try not to make such blanket statements or claims like I used to (although, I still make loads of mistakes — especially when I get excited about something that does confirm my biases).

    For what’s it’s worth, I will say that it’s hard and a bit scary at first to challenge beliefs and change, but does get easier.
    And, what helped me most, and continues to help me, are people like you, Antony, and others that you mentioned, who are out there to support. There are other clinicians, researchers and educators out there that think in these ways.

    Thanks for this platform to share my experience — I hope it helps someone in some way maybe going through a similar experience!

    Shelly Prosko 🙂

Leave a Reply