I have attended dozens of continuing education courses in my almost 15 year career, and I rarely write reviews. I was inspired to write this blog when a colleague asked me, ‘what is the best continuing education course you’ve taken?’ That answer was easy, Edge Work and Novel Movements with Cory Blickenstaff!
When I reflect on those who have influenced my professional life, Cory Blickenstaff is one who is at or near the top of my list. I first saw him present at the inaugural San Diego Pain Summit in 2015. Lorimer Moseley was the star of the show that weekend, but Cory and many others presented such great information and provided me some insight into how to think differently about treating those experiencing pain through manual therapy and movement interventions.
The second year at SDPS I asked Cory to come teach his course in Victoria, BC. We’ve been fortunate to have him here twice. The first time was in 2016, then again in June 2019. This review is from the most recent workshop. For other upcoming courses my clinic hosts please visit here, https://www.achievehealth.ca/courses-and-workshops/
It had been almost 3 years between courses and it was wonderful to see how the material has been updated and the content altered to make it even more digestible and clinically applicable. Cory has an interest in philosophy which I found fascinating as it challenges us to think differently and to question our assumptions. He is a very humble presenter with a wide breadth of knowledge. His ability to site good quality research to support the subject matter is admirable. Cory can comfortably reference research from the fields of musculoskeletal care, pain, occupational health, psychology and sociology. Being aware of where he lacks knowledge is even more important in my opinion. It’s always the sign of a good educator when they are comfortable with saying, ‘I don’t know.’
Lucky for me, Cory appreciates craft beer and we had some great conversations over beers on Friday and Saturday night. My good friends and partners in business and education, Richard and Jamie , collectively known as ‘The Canadians,’ when we travel, were there on Saturday night. We covered a vast amount of material including current research and its relevance to practice, the scientific method, limitations and future directions of the BPS model, integration and opportunities for the roles of manual therapists in pain management, and the influence of culture on our beliefs and behaviours.
These are my key learning points gained from his course:
Context matters. Our experiences are based on context. The therapists’ objective is to positively influence the patient’s context. This is pliable. The importance of priming was emphasized. It can impact how we shape patient thoughts and beliefs. It is possible to change our experiences through priming. Example of using youthful vs elderly words impacted speed of walking. This idea resonates with me and I love the simplicity of this concept.
Process oriented approach rather than throwing tools from the toolbox at a problem.
Our beliefs, subtle and unconscious can influence our patients and their outcomes.
Interaction effects provide a more positive outcome than specific treatment effects. Example of RCT to highlight 4 different treatments for acute low back pain that all resulted in similar outcomes. The specifics of the treatment matter less, it matters more that something was done. Outcomes result in slight improvements over natural history.
Norman Hadler, I need to explore more of his work. I listened to the podcast with him and it was fascinating. It’s almost 60 minutes of non-stop glorious quotes. Check it out here.
I appreciated his emphasis on the differences between illness and disease. ‘Disease is something that an organ has, an illness is something that a person has.’ Osteoarthritis of the knee is a disease within the joint, the illness is the person’s experience of knee pain.
‘How’s that sit with phantom limb?’ Moseley quote. In reference to limitations of pathoanatomical model of pain.
Problem with BPS as a pain theory. It was originally based on general systems theory. Is the theory falsifiable? I love this concept. Something to reflect on and learn more about… It is a model to direct care. Framework provides a general idea of how to apply treatment, model directs treatment and a theory is how to test treatments and/or mechanisms.
Central sensitization (CS) is a particular manifestation of nociplastic activity.
We still don’t have a working model of pain, ‘The Hard Problem of Consciousness.’ Solid understanding of physiology and how the various body systems work, however, this input enters a black box where the unknown happens and somehow this leads to the conscious experience of pain.
Pain is mutually recognizable, does not limit pain to a verbal description. We can recognize when someone is in pain. Prior pain definition limits the understanding of pain from the observer to the ability of them to describe their pain to us in words we can understand. We ourselves understand what it is like to experience pain. We can not completely understand what another’s unique experience is, because the observer is denied access.
‘What would you do?’ We should change that to, ‘What would you do if you were me?’ This requires empathy.
Self-efficacy – The most important objective we need to achieve as clinicians. An abundance of studies were discussed on the importance of self-efficacy. How do we measure self-efficacy? Through the PSEQ – Pain self-efficacy questionnaire. This was a measure I was not familiar with. Patients are building a narrative of things that you as a therapist think are important. Words we use, how we take notes, our touch and things we assess for all influence the patients expectations of what is deemed important. DO NOT STEAL SELF-EFFICACY!
Prospect Theory – we are risk averse when it comes to loss. Opportunities for change, flip the script. Context architecture, we need to be the architect of change. Allow the patient to figure out for themselves how to achieve goals. ‘Our role is to construct the interaction towards a narrative of recovery.’ ‘Let the change be their idea.’
Confirmation bias – was emphasized through some creative exercises and examples. Backfire effect – more information may not change beliefs and behaviours. What often happens, when beliefs are challenged by contradictory evidence, beliefs get stronger.
Random effects in a large population can result in us assigning a meaningful effect when it may just be a random effect, such as regression to the mean, natural history.
In addition to the wealth of interesting science and philosophical topics, the entire second day was practical with simple to apply and very clinically useful approaches to helping people hurt less and move more comfortably.
Using science to inform our practice and theories we work from:
- Ask a good question
- Make a prediction
- Set out to prove it wrong
- Repeat the experiment
Find the edge, play there. I like this concept of finding the area of a sensitive and protective movement and then exploring the barriers by combining other movements, resistance and distraction to turn down sensitivity level. Nudge – move up to and away from the edge. Then explore any further movements that may become available.
Fill in the spaces – think rotational or circular movements.
Staking the deck – adding something that is already associated with a positive change. For example, diaphragmatic breathing, isometric contractions.
An interesting series of movements for the fingers, hand, wrist and forearm was new to me. This is something I so rarely encounter in the clinic. The meat and potatoes of spinal and shoulder concerns far outnumbers the distal limb visits. Some new knowledge of treatment and assessment options for this area was welcomed.
On the second day we did a sequence on motivational interviewing (MI). I think this is such a useful skill for therapists to possess. When I was first introduced to MI 4 or 5 years ago it made me feel very uncomfortable and awkward because it was so unfamiliar to what I had learned and how I conducted my clinical interviews and assessments.
Change the opinion, change the story. Change the story, change the behaviour.
The overriding clinical message I received from this weekend was to foster and encourage patient self-efficacy through exposure to movement.
Cory can be found at his website, https://forwardmotionpt.com.