The End of the Structural Model? with Eyal Lederman (LBP 054)

Dr. Eyal Lederman joined me in season one to talk about his paper on the myth of core stability. As if that topic alone wasn’t controversial enough, I heard from many listeners afterwards that the really challenging part of that talk was his rejection of the structural model- his point of view that it just plain does not give us much information about why a person is having pain or dysfunction and, more importantly, how that person will recover. To shed some light on that, today we talk about his paper titled “A process approach in manual and physical therapies: beyond the structural model.” We’re talking about why he says the structural model is outdated and needs to be replaced, what he sees it replaced with and how patients are treated at his clinic, and what the benefits are to people when we expand beyond structural explanations for things as well as structural approaches to treatment.

Dr. Lederman is the director of CPDO, which provides continuing professional development for manual and physical therapists. He is also the co-director of a masters of science in Manual and Physical Therapy in Musculoskeletal Health at University College London. He graduated from the British School of Osteopathy and completed his PhD in physiotherapy at King's College, London, where he researched the neurophysiology of manual therapy. He has a number of papers to his name and has also authored several books including Fundamentals of Manual Therapy and Neuromuscular Rehabilitation in Manual and Physical Therapy.




Conversation highlights

  • What is a process approach?  Co-creating with the individual to support their capacity for self-healing.
  • Most of the conditions seen in the clinic are not to do with biomechanics or structural reasons, but rather represent biopsychosocial processes in the person.
  • The forces that go through the body during daily activities are tremendous the body is really tough stuff- can you change the structure and biomechanics? It’s highly unlikely- it has to withstand tremendous forces during the day that cannot be replicated in manual therapy.
  • I ask - yes but hasn't our model been wrong? We are learning based on cadavers and living tissue is different. It's more like soft matter physics rather than hard matter physics. [resources- paper on hyluranon]
  • Everything works. If you brush against somebody something will change in their body- massage will get a change. The question is what is the magnitude of change? Is it going to be an amazing change? How long is the change going to be there before homeostasis resets it to its original level. Most of the effects in manual therapy are unlikely to last the duration of the treatment and beyond that. Manual therapy should not be the sole therapy.
  • It is problematic that our clinics becomes a temple of healing- the person is then not aware that healing happens in their body. Healing depends on self-healing capacity.
  • How is the process approach informed by biopsychosocial research?
  • We are being called to work in the psychological and behavioral dimension of a person as well for true healing to occur.
  • For example imagine someone has knee surgery and it is a brilliant surgery- if they are elderly, have no social support, and have depression all the wonderful rehab is ineffective- there is nothing to maintain what happens in the clinic.
  • You have to co-create with a patient an environment in which they can improve.
  • Functioncise is using your own movement repetoire and then challenging the things you are missing.
  • There are three processes by which people can heal: repair, adaptation, and modulation of symptoms.
  • Imagine a patient with lower back pain. In an MRI scan before and after you wouldn't see anything really different, this person is still living with the underlying issues. A lot of what we seeing as healing and recovery has to do with the modulation of symptoms.
  • In chronic conditions you are looking at neuroplasticity.
  • Ask the question what the best environment is for recovery? We need to create an environment that will support each phase of recovery.
  • Most of the time we get better without any kind of help.
  • A historical mistake in physiotherapy is when they gave remedial exercise based on body building health industries. Quite often clinics look like gyms. You have to wonder why do we give activities that don’t resemble anything that people do in their lives?
  • Don’t invent anything for the patient, use their own movement and pick activities to challenge their losses
  • Imagine soothing and calming a child after a fall. Manual therapy is emulating what happens naturally. All we are doing is giving it fancy names- ultimately we are using the same behavior and professionalizing it.
  • Why do some people fail to recover?
  • When we are in pain we can’t sit in the dark alone and manage it ourselves. Having other people helps a lot.
  • Pathologizing of things blocks people from their innate self healing because we are inserting fear into the equation. There is a disparity between pain and pathology. It’s very damaging to pathologize things.
  • A lot of my clinic is helping people to re-work the narrative about what happened to them and what they are going through. The fear of movement is the nail in the coffin.


Eyal Lederman at CPDO

Dr. Lederman's paper "A process approach in manual and physical therapies: beyond the structural model"

The paper I refer to: "Mathmatical analysis of the flow of hyaluronic acid around the fascia during manual therapy motions"

Dr. John Sarno

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