Greg Lehman is a physiotherapist and strength and conditioning specialist, specializing in musculoskeletal disorders within a biopsychosocial model.
He teaches two internationally recognized continuing education courses: Reconciling Biomechanics with Pain Science and Running Resiliency, which have been conducted over 100 times in 40+ countries and 5 continents.
Prior to clinical work, Greg conducted biomechanics research at the University of Waterloo, publishing 20+ papers. As an assistant professor, he taught Spine Biomechanics and Instrumentation and led numerous research experiments.
Greg Lehman’s expertise spans biomechanics and neuroscience, emphasizing simple yet effective techniques for managing musculoskeletal disorders. Greg enjoys actively engaging in knowledge sharing on social media.
CLICK HERE TO LEARN MORE ABOUT GREG’S UPCOMING COURSE AT PRACTICE HUMAN.
Find out more about Greg’s work at greglehman.ca. Check out his youtube channel www.youtube.com/@glehman. Follow him on Instagram @greglehman. Additionally you can reach out via email at greglehmanphysio@gmail.com.
What’s covered in this episode?
- What is a “Movement Optimist”?
- When does exercise prescription need to be specific and when can it be generalized across a broad array of symptoms or diagnoses?
- How does prescribing exercise based on a patient’s interests affect treatment outcomes?
- What is included in the ecosystem of factors that influence pain, function, and rehab prognosis?
- What are some strategies for prescribing cardio exercise in a rehab setting, and how does metabolic health change pain sensitivity?
- Pros and cons of cross training.
- When and how a clinician should integrate strength and conditioning into a treatment plan.
- What is non-specific low back pain? Why is this diagnosis useful and how does it relate to the biopsychosocial model?
Episode Transcript
Caitlin: Hello, everyone. Welcome back to the Practice Human Podcast. I’m your host, Caitlin Casella. I am starting today’s episode with a quick update on my running journey. For those of you who have been asking and wondering what it has evolved into, I just completed the Brooklyn Half Marathon on Sunday. It was super exciting.
It was my first ever run. Running race. As some of you know, if you’ve been following along, I, for the first time ever in September, 2022, that’s about a year and a half ago, I ran a full mile. without stopping to walk. And this was a big deal for me. I did this at age 40 when I first started running, running with the intent to like improve my running and be able to tolerate running over more distance and for longer periods of time.
On Sunday, I ran my first half marathon and I’m sharing this. Really not because I think it’s all that exceptional or all that special. I am sharing this as a testament to what is possible with steady, consistent training over a long period of time, because I truly believe that what I have achieved a little bit later in life, just starting in my forties with deciding that I wanted to run and going from not even being able to run a mile to being able to run.
13. 1 miles a few days ago is something that is quite achievable. And, I wanted to share a saying that has really resonated with me. It’s informed and inspired my, really my general goal for a sustainable health and athleticism and independence as I am aging. And I don’t know who to attribute this to.
It’s just something I’ve kind of heard and I have followed for a while. And that’s that we. overestimate what we can do in a day and underestimate what we can do in a year. So when I ran my half marathon, I felt really pretty good during and after. I’d had a lot of aches and pains, pretty much pain in every part of my lower body that could have pain.
My toes, my feet, my ankles, my knees, my hips on both sides while I was gradually progressing my running volume and adapting my body to become more tolerant of running. Were any of those pains actually injuries? I don’t think so. I was feeling things because my body was exposed to new forces and that comes with new sensations and there were periods where things flared up and then resolved and then another thing would come.
and catch my attention and then resolve. And what I found was that I was able to continue running with some modification of my pace, my frequency in the week, the distances that I was running, the types of surfaces I was running on, my intention with the running, right, whether I was running, really for time or just running to run.
I looked at a lot of different measures when I was running. I looked at. I looked at mileage, I also looked at duration of time running, I looked at my heart rate and how it was responding. Some runs were to try to run so slow that I controlled my heart rate and kept it at a low level. Some runs I was letting my heart rate spike up for periods and working with intervals and working with speed.
So there’s a lot of variability in my training. I learned a lot. about the body and adaptation, and it’s really bolstered my understanding of rehabilitation. Having gone through this process of upping my tolerance for running gradually over a period of time, as I very slowly and gradually progressed my weekly mileage, I prioritized adequate rest and recovery, and I kept up with a strength training program, a fairly moderate strength training program.
throughout the past 10 weeks when I was in the actual half marathon training period. I feel great having completed it. And, again, it’s like, I don’t think that’s exceptional. I think that’s, well, nothing is really predictable. There is some predictability. Deadness and consistency and within all the ups and downs in the trial and error that we have when we’re deliberately applying stress to the body.
We learn a lot from how our bodies respond. We learn a lot from setbacks. We learn a lot from trial and error and those aches and pains. And so I kind of took on every, every moment of, uh, experiencing something shifting, something changing, whether it was, felt like a positive or felt like a negative, I kind of took it on as just.
better and more information for my next steps forward. And I kept moving forward. So it was, it was really a success. And again, just to speak to predictability from training, I knew I was ready for the run. I was like, Oh, I’m probably going to run it in about. Two hours, 10 minutes, two hours, 20 minutes, somewhere in there.
But I didn’t really care about the time. So that took the stress off for me and I was able to enjoy it and have fun. And I ran it in an hour and 16 minutes. So it was, it was right in line with what I had expected. And the Brooklyn Half Marathon, the NYC Runs Brooklyn Half Marathon is so much fun. It is a wild and hilly course.
I had no idea, Brooklyn, that you have so many hills, but wow. but again, it, it felt surprisingly just doable, right? After all of that training for about a year and a half, truly a year and a half leading up to it, all of that training, under my belt, all of the people I know who have run races since I completed my race on Sunday have asked me, when’s your next one?
And I guess. Yes, they know what I didn’t yet know. I know now that this stuff is addictive. So I will keep you tuned for my next race and, and I’ll continue to share my story. And I share this really because, so many people have told me. That hearing about just the way I’ve gone about taking on running, deciding I’m going to run, playing around with it, giving myself just a really long period of time to progress it has, has encouraged a lot of other people to take on some things that they never thought they could do.
Right? And truly, I think anything is possible given enough time and consistency. So I’ll keep you posted on my next race. And I think this is all a really good story and good opportunity to introduce my guest on the podcast today, Greg Lehman. Greg Lehman considers himself a movement optimist. And as we get into our talk, we do talk quite a bit about exercise for the joy of it, doing things that you enjoy.
Enjoy that you care about or even just anything in life that you enjoy and you care about and how those Experiences can raise the overall health level in a person’s system to make their symptoms More manageable and make them function better in life. So it’s a great talk. I was really honored to have Greg on the podcast.
I feel like, I mean, Greg doesn’t know this, but he’s been a mentor for me for many, many years since I was a yoga teacher before I went to PT school. And the whole time I was in PT school, I was following Greg’s work and reading his blog and, just looking at his take on the research for the literature for exercise really as treatment for treatment in rehab for musculoskeletal pain.
And when I applied for my first PT job out of school at Gotham Physical Therapy, my former boss, Zach Getz, had also studied with Greg Lehman, taken one of his courses, and we connected a little bit by dropping Greg’s name in my interview. So I could tell that we were sort of hitting things off and having a similar treatment philosophy.
At that interview, that ended up being my first job out of PT school. That also ended up being what created the opportunity for me to start my own practice here in New York, practice HUMAN. When Zach decided to close his practice, I took over his lease. I took over the space. I retained all of my patients.
So, and I think just kind of a serendipitous series of events, the mention potentially of the work of Greg Lehmann in my interview right out of school, kind of kicked things off on this path for, for me working with Zach, who was a wonderful mentor for me and and then, and then growing my own business out of that.
So thank you, Zach. Thank you, Greg. I’m excited to host Greg Lehmann here in New York City at Practice Human the weekend of July 13th through 14th. He will be presenting his course, Reconciling Biomechanics with Pain Science. If you’re interested in finding out more about that project, Of course, you can go to greglehman.ca. You can also visit the Practice Human website, practicehuman.com/events, and you’ll see Greg’s course listed there. And around the time of me publishing this episode, I’ll have a link up in my bio link on Instagram. So if you follow me on Instagram at Practice Human, you can click through there to a direct link to read all the details.
for Greg’s course in New York City in July. All right, so I hope you enjoy my conversation with Greg Lehman.
I am delighted to welcome Greg Lehman to the podcast. Dr. Greg Lehman is a physiotherapist, chiropractor, and strength and conditioning specialist treating musculoskeletal disorders within a biopsychosocial model. While Greg has a strong biomechanics background. He was introduced to the field of neuroscience and the importance of psychological risk factors in pain and injury management almost two decades ago.
He believes successful injury management and prevention can use simple techniques that still address the multifactorial and complex nature of musculoskeletal disorders. Greg is active on social media. That’s where I know you from initially, and considers the discussion and dissemination of knowledge an important component of responsible practice.
And I couldn’t agree with that more. Greg currently teaches two two day continuing education courses to health and fitness professionals throughout the world. Reconciling Biomechanics with Pain Science and Running Resiliency. And Greg will be here in New York City in my studio, Practice Human, to teach the Reconciling Biomechanics with Pain Science course this July.
So Greg, I’m really excited to have you on for a little chat today.
Greg: Yeah, awesome. Where’s that bio from? Is that like my website or something?
Caitlin: I got it off your website.
Greg: Oh, that’s not bad because I always get asked for a bio and I have to like, write one. I’m like, I don’t have anything formal and I like I like, that was, that was, that was pithy enough.
Like that was okay. I like that one. That was not bad. I’m glad that worked for
Caitlin: you. Yeah. Yeah. I chose a few pithy sentences and thought it was a good illustration of at least what I know of your work and Yeah, that’s right.
Greg: Well I’m not, I’m not, like technically I’m no longer a chiropractor. I let my parents go because there’s like no point in maintaining dual registration and paying like 3, 000 a year.
Caitlin: Totally. Totally. But I know that’s part of your background and I’ve heard you speak on that and I actually one of the things, this, this is quite a tangent already early on and we won’t go into it a lot in this talk, but one of the things that’s, that’s interested me and things you’ve said a while back is like how different your experience was in school to be a chiropractor than a Physio.
Totally. especially along the lines of being able to question things in the curriculum or something like that. There was something you said about that a while back that I was like, oh, that’s interesting.
Greg: Yeah. Did you want me to comment on that? Sure. Oh, okay. Sure, go ahead.
Caitlin: Because everybody’s going to be wondering now.
Greg: So, so Chiro was four years. Physio was two.
Caitlin: Yeah.
Greg: Uh, Chiro was overcooked. It was way too much material. They have a bit of a chip on their shoulder, but it, but, but everyone’s really well meaning. Physio was probably a little undercooked. But they really pared it down, I thought. And they really focused on the essentials and they really cared and they were happy if everyone got eighties or nineties, whereas Chiro felt like they just wanted to beat the crap out of you, you know, and keep the marks low.
And, you know, you’re in class for 20 to 30 hours a week. And we were in the anatomy lab for two years straight, you know, four hours a week, stuff like that in the like brain anatomy as well. And then in class, four to five hours of anatomy. You’re learning the Krebs cycle like in four courses, so it was too much.
But then in terms of questioning, they, a lot, not everyone at the Chiro College, but two of my colleagues, Kim Ross and Dave Bresnik, for sure, who I did my master’s while they were doing their PhD. They were wonderful at asking good questions, simplifying manual therapy. Their PhD helped do that. My master’s helped a little bit with that.
And we really threw off a lot of the silly things that people would say about manual therapy. Uh, within those six years, and then when I went to physio, physio school, you know, ten years later, they were saying the old things that were outdated and disproven, and they really didn’t like it with me saying, you can’t do those things.
Like you can’t say you’re manipulating the spine. You can’t really say I’m moving L4 on L5, or you can’t palpate and say, oh, L3 is stuck and not moving well on L2. You can’t do that, those things. And we knew that in the 90s. Chiro was throwing it off in Canada, but the physio was holding on to it. So that really surprised me.
And now it’s like the physios are catching on. They, I’ve argued with people because they’re like, Oh, we’re leading the way in this new modern manual therapy. And I’m like, it’s not modern. That’s from the 90s. Like you were just holding on. Just ignored it.
Caitlin: You just kind of ignored it.
Greg: Yeah, It just bugs me.
I’m old now. I’m 50 and I’m all crotchety. I’m like, it’s not new. I was doing this forever ago. Like I just, I resent them. Anyone who says that they’re cutting edge. And I’m like, you just don’t know your history.
Caitlin: Yeah. Yeah.
Greg: Sorry. I’m starting off on an angry flip.
Caitlin: It’s perfect though. Well, it’s a perfect lead into just kind of how I wanted to introduce you to my audience and how I know your work.
Too angry. No, because like I was kind of angry in PT school, right? So like I was a yoga teacher for 14 years before I decided to go back to school later in life for physical therapy. And I followed your work before I went to PT school. I think I mean, I started PT school in 2018. I think I became aware of you and what you were doing through some collaboration with Jules Mitchell or Katherine Bruni Young and it’s in the yoga world.
And I came to know your work before 2018. And then when I went to PT school, I had a bit of like, Kind of like what you’re describing when you went to school to be a physio is like, I’m already coming with this knowledge about manual therapy and some things I know about like, you know, what, what are we actually doing with manual therapy?
And then this just really biomechanical approach that was taught in the curriculum at my school. So it made for a really challenging time for me in PT school because I was questioning a lot of what I was hearing. it also made it, you know, made me a good student of the subject because I was Delving really deeply into questioning some of the things that I was studying in school, which, you know, helps you understand a topic in much, much, much more detail and nuance.
So
Greg: yeah, I bet, I bet they, they probably would have some idea that, Oh, you’re a yoga person. You probably are flexing people’s spine. How dare you do that? You’re going to cause instability or stretch out the hip joint capsule or something like that. Like they’ll have all these preconceived notions where they.
think they know the biomechanics and they don’t. That’s my take on a lot of, a lot of physio where we too quickly judge someone else and think that we know something and we’re wrong.
Caitlin: Right, right. Yeah. I mean, I think it’s just all about staying fluid and that’s why I appreciate your work. And I thought we could start just for folks who are kind of new, new point of entry to you and to your work by talking about this, what we’re describing already, this kinesio pathological model or kinesio biomechanical pathological type of model.
What that means for our listeners, because that was definitely the lens of, of my curriculum when at least in the orthopedic, orthopedic outpatient type of classes, that I was taking my program. Definitely. was heavily the lens in my curriculum. So maybe you could start there in terms of what that means.
What is that kinesio pathological model?
Greg: Yeah, so you can essentially see it on Instagram. What they’ll have, they’ll have like a green check mark beside a way to do a squat or an exercise, and then like a red X. That’s what you typically see. That’s the kinesiopath where the red X will be someone who does a single leg squat and their knee moves inward and their hip drops a little and their foot pronates and they’ll say, don’t do this.
This is horrible to not have your joints aligned and stacked and all these things and this is this causes detrimental forces through the body and the green check mark will be this Aligned where the toe has to be over like under the the kneecap and the kneecap has to be under the femoral head and the pelvis Needs to be you know parallel to the earth.
So that’s the classic KPM, which is such a defeatist An inaccurate and pessimistic view of the body that we’re limited to this small bandwidth of human function and deviations from this bandwidth. It leads you to having pain and, injury and, divorces or whatever it happens to be. Yeah. It’s horrible.
It’s a horrible view.
Caitlin: Yeah. Yeah. And I think it’s a very mechanical view. Correct? Like, like our, our bodies are machines and they can break down. down with, you know, repetition like machines can, or that they can be fixed the way that a mechanic would go in and fix a machine when, when actually they are brilliant self organizing systems that can adapt and can learn and change and be shaped by environments and be shaped by our activities.
And so, and then, so I think that is kind of the flip side to that, which is your stance. You call yourself a movement. So I’d love for you to speak about what that means, why you identify as a movement optimist, what that is to you.
Greg: So it, it, it’s, it’s not that I don’t think biomechanics and physical forces on the body are, are relevant.
It’s just that if you really know the biomechanics, if you ask me, like, it says that we have way more options on how to move well and be healthy. Like pronation is a really good example. People will vilify and say pronation is something to be corrected, and I would say the reason we pronate is because it helps you absorb load, right?
And we’re gonna have, like, you roll inwards, you absorb that load, and then you supinate and push back off when you’re walking or running. And we’ll have natural variability across people and how, in the shape of their bones, their connective tissue stiffness. And so people are just going to do it differently to figure out the best way for them.
So that’s really movement optimism in a nutshell. That if we knew more about mechanics, then we can understand how there’s all these benefits. And then fundamentally, at its simplest, we would say the body does have this amazing ability to adapt so we can adapt to these positions that people think are problematic.
I just, I don’t even, how I’ve evolved it, I don’t even want to say that the only reason these positions that people consider bad are safe is that we can adapt. It’s not just that. It’s more that sometimes these positions that people think are bad, they aren’t just safe because we can adapt. It’s more that we can adapt.
But they’re actually just inherently safe. Right. Like there’s, there’s no more load or stress on the body in those positions. That, that would be the, it’s just a different type of load. Like when you run there, you can run four foot or heel strike. There’s not one right way to do it. They’re just different stressors on the person.
Caitlin: Right. Yeah. Or different, kind of what I look at it from a rehab perspective is kind of different levers that we can pull in rehab to maybe offload forces from one place and put them in another place if there’s a problem, but it’s a It’s the kind of thing that’s like, maybe it isn’t a problem unless there’s a problem, right?
Greg: Yeah. Yeah. It’s just that the KPM is so much like. You’re doing it wrong, I need to fix you to do it the right way. Right. And the classic would be 30 years ago, when people have kneecap pain, and the VMO is firing late or something. Mm hmm. And, there’d be some research showing that. But the thing is, that was probably a red herring or an epiphenomenon.
Meaning, yeah, it fires differently because someone had pain. But it wasn’t a barrier to someone recovering, it was just secondary. So the, the people who originally taught that and researched that, they’ve since changed over the past 10 years. And they’re like, we don’t really worry about the VMO. We just want to build people up to do the things that they love.
Caitlin: Yeah, yeah. And we’ll get to that a little bit. Because I have some questions for you about knee rehab specifically. I thought for the purposes of this episode and for everybody listening, we could kind of stick to low back pain and knee pain. Because I know, I mean, that’s definitely like, my wheelhouse I know is a big component for you and what you teach about nonspecific low back pain and biopsychosocial factors with that and then also knee osteoarthritis.
So we’ll get into all of that as we move along but I just want to point out something that I noticed in some of your writing that I thought was really key and probably key to this discussion moving forward about how you know how we’re looking at biomechanics is you wrote that this Movement optimism or a biopsychosocial model versus the kinesiopathological model are sort of a, might be looked at as a false dichotomy, that really they’re not opposites, but we can all identify biomechanics as potentially an important consideration, but we might disagree on why the biomechanics are, are important or not important.
Could you say a little bit more specifically about that or give an example?
Greg: I think I can. Like, it’s more. I think an example of that would be, you can do too much too soon, right? If you want to start running or walking or a yoga practice, you could certainly jump in there and do way more than what your body can tolerate.
Right. So we would all recognize that that load is a factor in people getting injured and having pain, right? It wouldn’t just be like physical load. It’s all the stressors In your in your life. And so what I’m kind of rejecting is people will say well You can tolerate, this is the kinesiopathological model, you can tolerate more loads if you have your body in the right position.
And I would say these tiny little things like that, like changing your technique, they are tiny. They probably don’t really mitigate your injury risk. If you’re concerned about load, then be concerned about all the loads and really work us on, focus on like how much you’re training, how fast you train, you know, what your sleep is.
And so getting caught up on like the tiny things of technique, that’s really not the thing to be worrying about.
Caitlin: Right. Does that, does
Greg: that make sense? Does that address that?
Caitlin: Totally. Totally. Yeah. The too much too soon is a good example. I also think of things like patients that I see in the clinic that sit at a desk all the, all day and there’s just some kind of like postural stress from not moving.
It’s not that their position or their posture is bad and causing injury, but when it starts to become a problem and they start to have like just kind of chronic feelings of tightness and soreness and achiness, then we might need to address. It’s changing a few things that might not necessarily be just their posture.
Maybe they start an exercise program. Maybe they, we look at their sleep. Maybe we look at their diet. Maybe we look at whether they’re taking breaks and during their job and how stressful their day is when they sit at their desk. So yeah. So it’s like not just the, the static posture that they’re in that is the problem necessarily, although that might be contributing in some way, might be some factor.
Right.
Greg: With that, with that example, it’d be more like, it’s not how you sit, it’s the fact that you’re sitting. You’re just sedentary. Right.
Caitlin: Right?
Greg: Or, or the other way to view sitting related pain is you’re sitting eight to ten hours a day. That’s really hard to change if you have to sit. And so you don’t want to get caught up on changing your sitting and thinking there’s a right way to sit.
So you say, well, my pain just manifests when I’m sitting. It’s because my system is sensitive. What else can I do in my life to decrease the sensitivity of my system? Right? Or me, the person. And then you can tolerate sitting again. Like sitting isn’t, it just shows up when you’re sitting. It’s not the sitting that’s the driver of the problem necessarily.
Caitlin: Yeah. Yeah. So I think that that was one of the things I wanted you to expand on a bit in this talk for people who don’t know your analogy of building a bigger cup. But I think what you just described is building a bigger cup. Can you explain what that means? Or like in, like in that context?
Greg: It’s the idea that pain is multidimensional.
So you have all these stressors in your life and your genetics and who you are and your personal traits. All these stressors kind of go in your cup. And these are sometimes negative things. And when your cup overflows, you might have pain. So Things that could be in your cup would be like worried about when you’re in pain, you’re, you’re worried about having tissue damage.
You have all these people telling you different things. So it’s very stressful. You don’t have a good answer for what’s going on. You could have some joint changes on a scan that could contribute to pain. You know, when you do exercise, you don’t, you don’t exercise for three weeks and then you jump back into it and do too much too soon.
So these are all potential stressors that might nudge you. into having pain. And so the idea is when, when your cup overflows, you have pain and the optimistic way to view this is like that cup does not have to be empty because that is, that’s way too stressful to like to say, Oh, you don’t sleep well, therefore you’re doomed to have pain.
Some people will always not sleep well, you know, and that’s just something that they have to cope with. Or some people will have a genetic predisposition to having more pain. So they work on coping that. And that’s the idea of building up the cup. Okay. So you can tolerate these negative, unhelpful things in your life.
Caitlin: Right, right. Yeah. would you also put exercise as something that can build a bigger cup, like building a little more capacity or using exercise to calm down sensitivity and things like that?
Greg: For, for, for sure. Like exercising more. Spending time with your friends, you know, if you’re like a spiritual person, you like, you’re not going to church again cause you’re worried about your back.
Start going to church again. You know.
Caitlin: I
Greg: don’t go to church. That’s a kid, but anyways, I I’d prescribe it if I was meaningful to someone. So whatever it happens to be, that’s, that’s the like. The crude theory of helping someone with pain, which I never say to people, but this is the thought process. We’re like, get healthy again.
Get happy again. There. Giddy up.
Caitlin: Easy. Easy. I
Greg: know. That’s why I say it. Like it’s so glib.
Caitlin: Right. Right. But that’s sort of the
Greg: idea. Easy to say. You know, hard to do.
Caitlin: Right. Right. And I think that just, yeah, that’s that right there in a nutshell is kind of the bio, biopsychosocial model. Like, what are, what are all the contributing factors in this person’s life?
And what motivates them? What interests them? What makes them, what can make them feel good? Really just in anything, anything that’s accessible, accessible and available to them. Yeah. To help them feel more healthy.
Greg: Like when I have someone who has a yoga practice and they’re told they have to stop their yoga practice because they have like, A former disc herniation in the past or some knee OA or a hip relatable tear.
My favorite thing to say is like, you should start doing yoga again. Like that’s building up your cup.
Caitlin: Right. Right.
Greg: And then I can even say, and then I can even speak in the mechanical world. I’d be like, even if you have a former disc herniation, you should be doing it. Like, that’s what I mean about movement optimism.
Like you had this in the past. If you want to build that disc up again, you have to stress it in a smart way.
Caitlin: So
Greg: let’s, let’s start doing those postures and poses you like.
Caitlin: Right, right. That that exposure has a protective quality, not a quality that’s going to start breaking them down further.
Greg: Right? Yeah.
Caitlin: Yeah.
Greg: That’s the view.
Caitlin: Yes. Very cool. Let’s talk a little bit about a couple specific clinical diagnoses. Uh, I mentioned we would cover a bit about nonspecific low back pain and also talk about knee pain or knee osteoarthritis, but also I’m just kind of interested in your take on knee pain in general.
Let’s start with nonspecific low back pain. And for our listeners, can you describe what What this specific diagnosis means, this specific diagnosis of non specific low back pain, what it means and why it’s important, why it’s part of the discussion here.
Greg: So, what it acknowledges is that, when someone has low back pain, we can’t exactly say what tissue is sensitive and, contributing to their pain.
pain problem. We can make best guesses, but it’s really hard to say it. And it’s the same thing happens with the shoulder and many other joints. It’s hard to do because there’s so many structures back there that, that overlap, right? So it’s, it’s about having a structural diagnosis. Like if someone has a cut on their Achilles tendon and they tear it, or they have a knife to their Achilles, I can say, yeah, your Achilles probably hurts because someone stuck a knife in there.
Right? But when it comes to your back, because it’s so complex, there could be so many things that are sensitized. So we don’t have good tests to say, it’s this muscle, it’s this joint, it’s the facet joint, it’s the disc, it’s a nerve for the most part. Right? So that’s what it means. But it doesn’t mean like, It doesn’t mean we can’t help people, and it doesn’t mean we can’t tailor our interventions to people.
Because we could say, well what might be contributing to your spine being sensitive? And then we tailor our interventions to that person.
Caitlin: Yeah.
Greg: That’s a simple idea.
Caitlin: Yeah. Yeah. So it’s, I mean I kind of think of it as like, The interventions are specific to the person, but they might not have to deal with very specific types of exercises.
Greg: Yeah, there’s lots of ways to many roads to do that. Yeah,
Caitlin: whatever. Yeah,
Greg: I was gonna say skin a cat, but I don’t really like that We foster cats like who the fuck made that up like that
For like the bird one, what’s that like, why are we always hurting animals? to prove our point that we have redundancy. I
Caitlin: never thought of it that way. So the other, the other thing I just wanted to mention and get your take on is knee pain when, so when I was a, a new clinician starting to treat an outpatient setting, I got so intimidated every time somebody was eval on their knee because I felt it.
completely, I don’t know why it was the knee. I felt confident with other body regions, but for a while, I felt just so incapable of deciding which structures may or may not be implicated in the knee with our special tests and with movement testing and loading. And like, it’s like the knee just hurts and it hurts in a lot of different places, kind of diffuse.
and it moves around and
Greg: the
Caitlin: way people describe their symptoms in the knee can be very confusing and it’s not always really clear correlations with like activity and when it flares up or when it feels better. I got a lot more confident in the clinic treating knees when after a period of time, I was able I realized all knees got better with pretty much the same sorts of exercise prescription and plans of care.
So I just wanted to get your take on that because I know you wrote a little blog post about that, that was helpful for me. I,
Greg: I, because I swear clinicians, they want other clinicians, they either, they want to pump them, pump up, like pump themselves up or make other. People feel like they don’t know anything.
They feel like they clinicians want to act like they’re mechanics, like they’re going to find the exact thing that’s wrong in there. And that’s has some specific fix. And for the most part, it doesn’t, it doesn’t matter. Like, so if you had someone who was a 23 year old or a 43 year old volleyball player, and you We want to find out, okay, it’s a knee problem.
It definitely, definitely the knee. That’s the, the source of the tissue sensitivity. It’s not coming from the hip. It’s not coming from the spine. Right? So potentially the diagnosis could be patella femoral. So the kneecap hurts the patellar tendon, the knee joint itself. So a meniscus or early knee OA or IT band or a distal hamstring strain.
Okay. So we know what tissue is sensitive. If she wants to get back to playing volleyball, it’s the volleyball that’s gonna guide your rehab. It’s what she has trouble doing and what she wants to do that tells you what to do for exercise. If you do manual therapy, well you’re just gonna do manual therapy on the hip and the foot and the calf, like, and the knee.
Like, it doesn’t, it doesn’t change anything. So, like, the specific tissue diagnosis doesn’t often change things because we have, like, a very We don’t have a specific intervention. If you do, if you inject something with a needle, fine, then you probably need to be more specific.
Caitlin: Right.
Greg: Right. But because our approach, our physio is so global, it doesn’t matter much.
So the, so what you’re always asking is, okay, is this something where we need to be specific? And, the only thing in the need there could be like. Is it a stress fracture? Is it a tibial plateau fracture where you say, well, shoot, we’re not going to do exercise. We just have to, we have to back off and put you in a brace for six weeks.
But then after that, your rehab is going to be the same as anything else.
Caitlin: Right. Right. She’s
Greg: getting back to volleyball. And that’s what you found. It’s just you were brave enough to admit it. I swear, just people won’t, won’t admit this. In my course, I make them admit it.
Caitlin: Right, right. Well, and also like we, there’s so much we can’t diagnose with clinical tests, right?
Like, so I see kind of this difference between somebody might receive a medical diagnosis from some kind of imaging or going to an orthopedic doctor who looks at MRI and gives them a diagnosis. But then when they’re here in the clinic and we’re, we’re looking at, There’s symptoms, their function, their lifestyle, their motivation, their goals, all those things that we address with the person in front of us in the clinic.
There’s only so far we can go to really be certain with clinical testing, like what’s actually going on there, right? Because also we know that things on imaging don’t correlate with symptoms or decreases in function necessarily. So there’s this, this difference between like someone might get a medical type diagnosis and then what is our physical therapist?
It’s going to be different and more based on their symptoms and their function, right?
Greg: For sure. And we can acknowledge, let’s say it’s the shoulder, we could say, Oh, you might have some supraspinatus teninopathy, but you want to get back to golf or you want to get back to knitting or you want to just have less pain when you’re reaching up for a cup.
So, the, the, the tissue doesn’t tell us too much, right? It’s, yeah, it’s all the things that you mentioned. Yeah, yeah. So I always acknowledge, the tissue’s a part, but it’s one thing. That, that medical diagnosis is one thing in the cup. Yes. Maybe.
Caitlin: Yeah, and it’s, and it’s gonna be important to the patient. I mean, right, typically somebody comes in and they show you a printout of their MRI and they’ve been living with that and kind of identifying with that, that’s a very important factor for them and not something that just kind of dismisses like, you know, yeah, yeah, it’s important.
If it’s important to them, it’s important.
Greg: Yeah, exactly.
Caitlin: Right? Uh, yeah, so I think kind of the same thing could be said of treating nonspecific low back pain, right? That it’s like, yeah, we don’t, we, we can’t say for certain exactly. We can rule certain things out, certain specific diagnoses out, but after that we can’t really say for certain that there’s any specific structure or mechanical thing going on that we’re treating and we just treat the person more broadly.
Greg: For the most part. I mean in the spine sometimes you can certainly have a disc herniation and if leg pain is worse than low back pain and you have an MRI and it seems like the disc is pressing on the nerve root. Yeah. Okay. Then, that information does lead you to think, I think it’s a radiculopathy caused by a disc herniation.
So that’s a specific case.
Caitlin: Yep.
Greg: But, but it has to, it’s so much harder with, with other things where you can’t really do that.
Caitlin: Yeah. So I wanted to talk a bit more about exercise prescription. You put out a solo podcast. I think the title was something like to physio, suck it, exercise prescription and correct me if I’m wrong, but I feel like your kind of main thrust or point with that episode was that clinicians, therapists are operating under kind of different sets of criteria.
Conditions are a different environment when prescribing exercise than someone that is a strength and conditioning coach, right? Rehab is different than someone’s goals with a coach that might look more like general health and fitness for longevity or might look like more performance related, although we definitely get into performance related things in the clinic, but how the way we treat in the clinic with prescriptive exercise can look very different than what, what a strength and conditioning coach might program.
Greg: Yeah, that’s one way to view it. The other way was also, I didn’t, there’s this thrust in our profession where physios or strength coaches are saying that physios don’t understand the basics of strength and conditioning. And therefore, they are getting sub optimal outcomes from their rehab. And I really reject that.
You know, because, and then when I hear their arguments, they’ll say, you do three sets of ten to get someone stronger. And the best way to do that is, Five sets of four, you have to train really heavy. Like they’ll get into the weeds. And I’m like, again, this is a perfect example. When you know the literature really well, you’re like, that’s an old antiquated idea about getting stronger.
You can get just as strong doing three sets of 10 as doing five sets of five, or they’ll be like physios only, you know, they train every day or something. I, whatever it happens to be, they’ll, they’ll say something. And, it’s not really that well supported. But then I say, well, Tell me what the basics of strength and conditioning that you think that physios don’t know.
And they’re like, well, they don’t, they’re not getting people stronger. And I did this in an Instagram reply to someone. And I said, listen, this is how someone there’s like, how do physios get someone stronger than I said, well, here. Do 3 10 reps every week, train 1 4 times if you wanted to because you can spread it out, the frequency doesn’t matter.
Do 3 15 reps, so you can, you can choose 3 reps or you can do 15 or 8 or 7 or 6. Either go to failure or have one to three reps in reserve. So that means you could, you could do more. Train the body part or the movement that you want to get stronger and then slowly progress that over time. All right, there you go.
There’s the basics of strength and conditioning. Now you all know it.
Caitlin: Right.
Greg: Like, do you really think that physios don’t know that stuff? Yeah. That’s, and they’ll say, well, what, how do you, then anyone can do this? I’m like, yeah, to get stronger. It is the, the, the clinical challenge that we have. isn’t the details of the strength and conditioning.
It’s it’s knowing when you can do that, you know, for whom that you can do that. It’s knowing when strength is actually an important mediator of recovery. Do you know what I mean? No, knowing that they’re safe to do it because you’ve done a good assessment and it’s not a stress fracture and tying it into something that’s meaningful for the person.
Caitlin: The
Greg: details of the strength and conditioning are bloody easy.
Caitlin: Yeah. Yeah. And I think there’s so many people just get so hung up on like what they see as optimization, like trying to go for like, you know, the, the best way to do it. But I just don’t think the literature supports that there’s really any, like you’re saying, any best way in terms of frequency sets, reps, all of, all of those factors.
Greg: Or like with, with, can I, sorry, you got me excited. Like with knee OA, people will say, Oh look, they’re doing a yoga program for their knee. Yeah. And they’ll say it’s really like low intensity, which I know yoga isn’t like that bad. That’s why that person won’t get better when they have knee OA, because they’re not training heavy with leg extensions or hack squats, and they’re not training at 85 percent of their max.
And if they just followed these strength and conditioning principles, they’d do better. And I’d be like, that’s an unsupported statement by the research. That’s your bias that you think someone has to get stronger. on this task to recover and that is not supported in the literature, right? So they’re, they’re elevating what they think is important and they don’t know the literature enough to know that.
Those things aren’t you can absolutely train heavy and do better with me away, but you can absolutely Start a running program a yoga practice or a hiking program and do better as well All right, you don’t suck if you don’t follow a strength and conditioning program, which is this is funny because that is my bias That’s actually how I treat these things I like having it.
So I’m the perfect, I think I’m the perfect person to challenge it.
Caitlin: Probably.
Greg: Cause I, yeah.
Caitlin: Yeah. And I think there’s also, I’d like to get your take on this too, this, maybe it’s, I kind of, when I phrased my question for you and wrote this out, I was like, there’s a conundrum in exercise literature, but maybe it’s not a conundrum.
Maybe it’s more like an opportunity. It’s like exercise affects so many systems of the body and affects people mentally and emotionally and we can never really control for specific reasons why exercise makes someone better, right? Because anybody does any exercise, it’s going to affect so many different people.
So, you had mentioned something about kind of what’s mediating the changes. In a lot of ways, would you say that with exercise, we don’t really know? I mean, we know about things specific that are about like tissue, specific tissue loading to make tissues thicker and stronger and stuff like that, but otherwise, in terms of reducing pain and improving someone’s function, recovering from injury, there’s a lot we don’t know.
Greg: Yeah, that’s it. Exactly. So you could, you could do a study with someone with low back pain, give them all deadlifts and squats and they will get stronger and they will on average do better and have less pain. Someone could, could then say, look, there’s a correlation between improvements in pain and strength.
Therefore, strength is important, right? That would be, you know, spacious. That that’s not a good conclusion that the strength is just a potential side effect. It isn’t the reason the person recovered, right? Like I could give you a strength training program and a juggling program at the same time. You’re juggling will improve and so will your low back pain.
No one would think that you have less back pain cause you’re juggling improved, but that’s, that’s what we do with that type of limited research, right? We make conclusions on mechanisms which, which we shouldn’t. What people will run with is they will then judge prematurely a program, a rehab program, that doesn’t, couldn’t potentially make someone stronger or a tendon stiffer or change the cartilage and they’ll say whatever, and they’ll say that program isn’t helpful because people have an assumption of what has to happen for someone to recover based on weak research and then we too quickly judge some other intervention.
Like manual therapy. Like that would be an example of that. With Achilles tendinopathy, we assume, people argue the tendon must get stiffer and stronger. The way to do that, you have to train it heavy. And so they’ll say, Oh, never stretch a tendon or don’t do manual therapy. It won’t make the tendon stiffer and stronger.
Therefore it’s not useful. But again, you have to go back to what they originally said and say, well, what’s the proof that the tendon has, has to get stiffer and stronger for someone to recover.
Caitlin: Right.
Greg: That’s it. Sorry, lots of words there.
Caitlin: No, no. I get it. Absolutely. Oh, good. I think something you touched on there too with like this idea of like people don’t necessarily need to get stronger to get better.
It just might be kind of a, a secondary result. Yeah. There’s, there’s a lot of, I feel like there’s a lot of like dissing of a low, low intensity, low weight. type of exercises, right? It’s like the yellow TheraBand physical therapy or whatever. Like, there are situations where people are not Transcripts provided by Transcription Outsourcing, LLC.
that will help modulate pain and will help them get better. So I think there’s a lot of instances where somebody would be like, Oh, that’s too low of a dose, not an effective dose for strength. But like, we’re not going for strength.
Greg: Exactly. Yeah. That, that, that, that’s it. Like, or that person might get stronger because they have less pain.
That’s the thing. Or, they have less pain and then they just start doing more of their life again and that’s what makes them stronger and more functional. You know, so like, that’s what we have to watch with all of these things is these judgments. Like that are much too soon.
Caitlin: Yeah. Yeah. What’s your take on prescribing cardio in a rehab setting?
Greg: So this is what’s neat. Like you, it’s often harder to sell and that’s why if we view a lot of pain as like, it’s just manifestation of something within the ecosystem, a sensitivity in the ecosystem. So you could argue that cardio of any form could help someone with knee osteoarthritis because knee osteoarthritis.
It’s like a manifestation of the health of the whole system, right? So that’s how you would, that that’s where cardio can be helpful or, or believe it or not, someone with Achilles tendinopathy, we would see people think you need to just do, you know, foot exercises. Sure you, you could, but they could also benefit from running in a pool.
Right? Where there’s no load, uh, on there, but it improves their metabolic health.
Caitlin: Right.
Greg: Which could then even help frozen shoulder, by just pool running, because it improves the metabolic health of the person, which might be driving the sensitivity of that shoulder or that foot.
Caitlin: Yes.
Greg: It’s just harder to sell, to be honest, and it’s because it’s so, like, non linear.
That’s the thing. That’s the issue there. We’re talking systems and that doesn’t always make sense to people. And if people think they need something specific, then uh, it ain’t gonna work.
Caitlin: Yeah, yeah, yeah. You, you kind of joke about this phrase like you’re gonna pay for it later. How that gets used a lot.
and I’d like to hear your thoughts on the types of overuse injuries, not. You did too much too soon, but somebody who’s a runner and has been running high mileage and only running for a very long time or someone who is a power lifter and has been lifting heavy and not really doing much other kind of movement for a very long time.
And I kind of my take is that some people could just go on doing that thing and they’re going to be fine. And then I sometimes see people in the clinic who like, I see them and then it becomes a problem and then giving them something different to cross train, novel, whatever it is, just novel stimuli for their system, getting them to do a little more of something else and doing a little less of the thing they’ve been doing a lot of, you know, to our discussion of like, we don’t really know what all the mechanisms are, but some change might be needed if they’re having a problem.
I’d like to hear your thoughts on cross training, like do runners need to strength train? Do power lifters need to do mobility? workouts and train cardio and just kind of from your lenses, strength and conditioning.
Greg: So for performance and general health, I would advocate a comprehensive program for, for those people.
So performance and health, that, that’s a, a no, a no brainer. So runner, If they wanted to build their bone density more, then yeah, they should probably be strength training or hopping or something, something like that if they want to, I don’t know, I think running would still mitigate sarcopenia, like muscle loss as we age, but to make sure we should do it like I know when I ran a lot, like 60 to 90 kilometers a week.
I was very fit for running, but I didn’t feel that fit in general, if that makes sense. So I would consciously add stuff. So there’s certainly something there for general fitness in terms of like their health, like related to injuries. I don’t think they need to. I think like the, the, the best way to prepare yourself to do the goal task is to do the goal task.
However, when they do get injured or have pain, what you recommended is just like do a little bit less of this and build something else up. That seems like a great way to, for, for rehab. But, but I just don’t know if we could advocate for someone to safely do the thing that they love, power lifting or running, that they have to add these other things.
That’s that’s where it gets really, really tough. Yeah. But for health and performance, sure, you could sell it.
Caitlin: Yeah. Yeah. Totally with you on that. So, Greg, I see you on social media, tumbling, doing back handsprings, uh, there was some skateboarding for a little, for a little while. I like to end all of these interviews by asking about stuff that you do.
So, for fun, for pleasure, that’s not necessarily related to the clinic and research and, all of our, our work that we also do for fun, but, uh, can you share just a little bit more about like what got you into all of that?
Greg: I taught like poor trampoline when I was a kid, like a teenager just for a couple years, and then I didn’t do anything forever and then my kids started doing cheerleading, so I just jumped into gymnastics six years ago.
And now I probably do I’ve had some time off, but I’m starting and trying to do more now. Gymnastics and trampoline. So that’s, that’s probably my big sport. And then, cause I don’t really like just working out. I find it super boring. But I’d rather do stuff. And actually I did used to skateboard the past couple years.
Not a lot, but I suck. And they’re like, the legit injury risk is so high compared to the health and fitness benefits. Yeah. Like, like there’s no fitness benefits and yet the injury risk is so there. And then, and then I would get injured and then it would screw up gymnastics and stuff like that or golf.
So yeah, so I’m going to get more into gymnastics again now.
Caitlin: Yeah, I like it. I
Greg: did a lot a couple of years ago. And I’m going to double down and. Do some double backflips again.
Caitlin: Sweet.
Greg: That’s
Caitlin: the goal. It’s fun. It’s fun to follow your progress on that. It’s exciting.
Greg: It’s just hard because like they’re, the, my gym has adult gymnastics, but they, the classes fill up.
It’s so popular here in Toronto. You know, it’s like really hard to find a place to do it.
Caitlin: That’s great. I mean, it’s like refreshing to hear that adult gymnastics classes are so popular there. I don’t really know that much about New York. They used to
Greg: have. I know that there is one in New York that I know of, though.
Oh, I’m sure there is. Probably over by Chelsea
Caitlin: Piers or something.
Greg: Yeah, yeah, yeah. Yeah. That, that, that, that, that’s the one. Yeah, we used to have like adult drop in during the day so I could get out for like an hour and a half and no one would be there. That was awesome. That’s where I did most of my stuff.
I was actually in my, Daughters when she was seven and, the oldest were seven and ten. I was literally in their tumbling class at cheerleading. Like I worked up and got good enough to be able to be in the level three.
Caitlin: Yeah. This was me, me
Greg: the 46 year old and my seven year old.
Caitlin: That’s awesome. I love it.
Yeah, I’ve got some friends out in L. A. that are like, started like skateboarding with their kids. Yeah, so I’ve heard of them. The kind of horror stories of injuries that can happen. It’s like, whoops. Just doing
Greg: nothing. Yeah. Not even on anything big. Just standing on the ground and something happens.
Because that’s the nature of the sport. You’re going to fall. Everyone I know who’s good falls all the time. I don’t know how they don’t get injured.
Caitlin: Yeah. Yeah. Awesome. Well, thank you so much for coming on the podcast. I would love for you to say a little bit about where people should start if they’re new to your work and want to learn more.
What do you think is like a good entry point for beginners?
Greg: My website would, would be the best. I have like a, I still like doing blogs. I just don’t want to keep repeating myself. but so that’s been around for 14 years and that has everything. And then And on my website is a, a book called Recovery Strategies, which is for patients, but I know therapists also read it to help with their practice.
It’s just about pain and things that people can do and, uh, it kind of lays out the, the, the framework here.
Caitlin: And your website is? Oh,
Greg: greglayman. ca. Greglayman.
Caitlin: ca. Yeah.
Greg: Yeah. Canadian. Yeah.
Caitlin: CA. All right. And then you’re going to be here in New York City in July. 13th through 14th with Reconciling Biomechanics with Pain Science.
Anybody interested in that course with Greg can find it through your website, gregleyman.ca under the course listings. Uh, we also have a link through to the registration page for the course on the Practice Human website. So if you go to practicehuman. com slash events, you’ll see Greg’s course listed there for July.
And, I’m really excited to host you here. I think it’s something that’s going to resonate really well with A lot of the folks I know in my community here in New York and that I’ve known from back before I was a PT as a yoga teacher and I’m excited to have you here.
Greg: Oh, cool. Me too. All right,
Caitlin: Well, thanks a lot, Greg.
Greg: Oh, thank you. My pleasure. Bye, everybody.
Caitlin: Thank you so much for listening, everyone. If you have any questions, comments, concerns, observations to share with us here at Practice Human, you can always email us at hello. at practicehuman. com. We would love to see you in New York City for Greg’s course in July.
I know quite a few of the people who are signed up and it is going to be an amazing mix of teachers and coaches and clinicians in the room. So not to be missed if you are in the area. Thanks again for listening and I’m looking forward to continuing the conversation soon.