Jared Powell:
Okay, here we are with Greg Lehman. I just chatting off air a moment ago and I, I think Greg has been the voice to a generation and it might sound a bit crucial cause I'm talking to him here, but I really think that, uh, Greg I'm, I'm 33, 34 years old. And I think that Greg has been the voice of us as we've gone through university over the last 10 years or so. So I want to thank you for that, Greg. And I also want to introduce you as well. Thanks for coming on and having with me.
Greg Lehman:
Yeah. Thank you. Looking forward to it.
Jared Powell:
Yeah, no problem. So you, you, you're quite interesting in your background. You've had a, as far as I'm aware training in chiropractic and also physiotherapy, and you've also done some postgrad or masters work in mechanic, is that right?
Greg Lehman:
Uh, yeah, I did that first before the Chi and the physio. Yeah.
Jared Powell:
Oh, cool. Okay. So I think that has you in a really, you need sort of, uh, position to have a very interesting voice on pain because you've got you've, you've seemingly got both sides of the coin covered and in terms of biomechanics, and then I know you are quite an advocate of the biocycle social approach to pain as well. So could you just sort of speak to potentially how your interpretation of pain started when you were doing spine and biomechanics and, and all of that. And then we could sort of come to how it's evolved over the past 10, 15, 20 years or so.
Greg Lehman:
So, uh, it's actually funny. It hasn't evolved much I didn't have to go through any cosmic shifts, like, uh, other people did. I, I was actually introduced to the multidimensional nature of pain, uh, 20 years ago. So I, when I was in my undergrad, uh, just in kinesiology, I was reading John Sarno. Uh, I was reading about how posture influenced mood I even asked to do like my thesis in that I, that wasn't allowed, uh, that, that was too weird. Uh, um, but I know I wrote a paper on it in my, during my masters and in ergonomics course, I wrote a paper about like where the pain was coming from. That was 1997. And I wrote about central sensitization. Uh, I got into like more of Nazi section, you know, like, like the pain fiber. So I was a little bit wrong there, but, but I, we still talked about how it's influenced by a number of factors.
Greg Lehman:
Um, the professors at the university of Waterloo at the time. So my supervisor w with Stu McGill, but his, his supervisor decades before, uh, was Bob Norman, uh, who was an occupational biomechanist. And he, and they would go in and try to prevent injuries at a workplace, but they always talked about the psychosocial factors being a big driver of pain. And then one of my first papers was on spine manipul. Uh, and in it, we talk about how and we're wrong, but we talked about how , uh, spine manipulation might influence central sensitization. So I, I honestly, I was pretty lucky, lucky I would, I would just go through bouts in my career where I probably like, not necessarily over size the biomechanics, cause I still think they're important, but like I got it wrong, how biomechanics was important. So that that's only that's, those are the shifts I've had, but I never had to be like, had to change my view on how pain was multidimensional.
Jared Powell:
That's that's fascinating. And, and contrary to probably a lot of people have experienced over the last 10 to 15 years as well. Uh, certainly my training I, psychosocial factors were, were glanced at, in the last paragraph potentially of a, of a, of a case study that you looked at. Um, everything was about tissue, irritability, strength, testing, range of motion, testing, all of these things. And then potentially if that didn't explain symptoms, then you looked at some other factors. So I'm fascinated that despite your heavy biomechanics training, that you were exposed to that quite early, why, why do you think that has potentially not gathered more momentum over the last 10 years? So
Greg Lehman:
That's always been my disappointment, like, and so I would give lecture decades ago, like, gosh, uh, even in the year, 2000, that's when I started lecturing and I was quite young and I was a student at the chiro college, but I was lecturing in the grad department just the way it's set up. Um, I always found like all these biomechanic ideas could be challenged by biomechanics and people would just hold on and people would, this is what I would say. Like, no, it doesn't work that way that the SI joint is not out of position. Uh, C3 is not stuck on C4. There's no adhesions there of scar tissue. That's not why you have pain. You know, this is an active release technique jargon that we would hear in chiro college. And I'm like, none of these makes sense. And so people would get cuz we'd like, well, what the hell do we do then?
Greg Lehman:
Like people there was like a vacuum, right? There's there's like, well, if, if none of these things are really valid, well then how do I practice? And so that's why I think people held on because they had to do something and they were also helping people. So their explanations might be faulty. The reasoning could be dodgy, but they still help people. So that, that, that's why I think there, there hasn't been a massive impetus to change. And I would also say like the it's not like bio psychosocially informed interventions are like dramatically, uh, outperforming ultrasound or back cracking or whatever in, in studies. That's that's gonna hold people back too. Hmm.
Jared Powell:
Yeah. Yeah. That, that's a great, that's actually a really good point because the effects sizes are, are pretty small for, for exercise and similar to manual therapy and everything else. So despite the fact, it may be more accurate from a scientific perspective, results wise. It's it's not a slam dunk really? Is it?
Greg Lehman:
Yeah. It always, it, it always disappoints me. Like evidence based practitioners are so quick to like on things. And then they say do this instead. And I'm like, where's the evidence for that? like, like there there's a, there's a knife clinical review on patellafemoral pain. And uh, they say don't do ultrasound. You know, it doesn't, you know, there's no evidence for it, it's it. And then what they mean is like, when you look at the ultrasound trials, they have a sham group. So both groups for knee pain, if they get get ultrasound and one's sham and one's real, they'll have decreases in pain like 30 to 50%, but the real ultrasound doesn't outperform the sham. So then they conclude, oh, it's all sham and placebo, but then they'll say exercise or change movement patterns, and then, or do gate retraining. And then you go look at those studies and they recommend those things. But those studies never have a sham group right. Like they never have a good control group. And though, although those are the things that I do and I don't do ultrasound, I'm not defending it. I'm sort of like questioning how are of thinking here. They it's only, we can only recommend exercise or gate retraining, um, because they don't the, the studies aren't as well controlled so yeah. Yeah. I mean, maybe they will outperform a sham, but who knows? Yeah.
Jared Powell:
This is pure cognitive dissonance, isn't it? When you can believe two opposing things and it's well on that, there's a, there's a paper just come out a week or two ago and I'm into, into shoulders on exercise versus placebo or, or, or sort of non-exercise intervention. Oh, really review for cuff tendinopathy. And the, the result was pretty startling for an exercise advocate. It's a clinically insignificant, uh, superior benefit for exercise versus non, um, or placebo. So look very like there were three or four papers viewed, uh, included in the systematic review. So more be done, but interesting.
Greg Lehman:
I know I hate it cuz I'm like, you that's, my bias is gay retraining exercise, you know, cognitive restructuring, and then often it's not better, but you do. I mean what everyone says, you know, we all say, well there, maybe there's a subset
Jared Powell:
Yeah. I, I just think, I think that just speaks more to indivi, like things work differently for different people at different times. And it's really hard to scientifically capture all of that in these reviews. And I'm not, I'm not saying we shouldn't study it and, and be rigorous scientifically just think it's always gonna be a similar outcome with these studies because everybody's different
Greg Lehman:
Yeah. That's I mean, and, and it's difficult cuz we, people have been trying to subgroup for 20 years and like doing classification and then those often don't, uh, outperform. Cause, cause you can't have subgroups, you can, but everyone's a subgroup of one. That's the . Yeah, but that could be test, you could test tailored treatment to non tailored, but I, I actually believe, and this might people off, but like there are general things that all of us could recommend to our patients and we're gonna help out a massive number of people and, and, and why I think therapists don't like it, cuz we, we wanna think that we're mechanics and we're diagnosing diagnosing and we're precise and we've, we've, we've figured out exactly what to do for this person and, and general things, you know, it's Le it's less sexy. It's not, it's simpler, but I, I think general good, um, interventions can help a lot, but people hate that. Yeah.
Jared Powell:
Yeah. Well, and then the nonspecific kind of exercise really speaks to that in terms of the literature as well, doesn't it, it all works and this is there's, there's non superiority over different exercise interventions. It seems for a lot of conditions and some people don't like that as well. And I, I can understand that. And also as, as physios who we want to, you know, use our intellectual faculties, our training in, in movement analysis and all of these things, right. And we wanna have these huge effects, but pragmatically probably as long as we're recommending a couple of different things, stay active, done things that, you know, sleep, all these sorts of things. Are we gonna be helping people mainly from that perspective?
Greg Lehman:
What do you think? No, that, that, that's what I'm saying. And I think that there's, there's a small subset of people who we do need to tailor it to, uh, like we start my course, my FA my, my favorite thing. My is me and my course, my favorite thing, uh, uh, I love this question. It says like, when do we need to be specific? Right. That's how, that's how we start my course. Like, and like, if, if, if it was 20 years ago and you're a Mulligan practitioner, you'd be like, oh, a lot. You need to, if you know, C3 is not moving on, C4 in this direction need to be bare very specific in your line of drive. If it's elbow pain, you have to specifically glide the radius laterally. You know, now people will be like, no, no, no, you get symptom modify.
Greg Lehman:
But, but I still think there's probably times where if we could find out like, um, principles of when you need specificity. So here here's, here's like an example. I, I everyone's listening. Right. What the hell do you mean? It, it would be something like someone tears, their ACL or someone has kneecap related pain. There's a subset of people who will, um, unconsciously protect that knee. And that knee becomes unloaded. They, if you, they do a squat and you look at them, they'll look symmetrical, but they're not loading the pain or the reconstructed knee, the same amount. There's less stress on it and you can't see it. Right. So they're protecting that knee. So if that person, you know, wants to get back to sports or high demands, they're able to like somehow modify their moving patterns to keep protecting it. So they'll never, you, you could argue, they'll never get an enough of a stimulus during the activity, the goal like running or squatting to challenge that need to catalyze it, to make it like get stronger.
Greg Lehman:
It'll always have that deficit. Now, most people, that's fine if they're not going back to, uh, high demand sport, but the person who has to go to the high demands, they probably need specific kneecap, quadriceps strengthening that won't just come from running or playing the sport or whatever, like tumbling or gymnastics they'll need that specific exercise because they might get into the situation where they can't compensate and that weakness will show up and you actually need, and that specific situation. And then they get a re-injury. So there's like a small subset. And that's probably why. And that might only be 4% of people where the vast majority of people will get lots of benefits from general stuff. But they're that 4% fi I don't know, 8% they need it. And then that'll lead to re-injury. So that wouldn't show up in a research paper, but there's like the clinical reasoning.
Greg Lehman:
And I, and I, I, I think it would be a really, sorry, I'm talking too much, a real talking too much, a real cool research paper to find out what are those cases, right? So psychosocially, you might say, like, we know that pain science education in general, doesn't help, but there might be a subset of people where if you don't change that unhelpful UN unhelpful belief like that, they have a rotator cuff tear and that, and that means they have to protect it. And then they'll just stop doing, and they'll never get better unless they actually start to use their shoulder, but they'll never use their shoulder, unless you, you convince them that they're safe. So you need, you know, pain science, like you need to change a cognition. So there might be like specific cases like that. I don't know if research can ever go into that, but I like the thought process.
Jared Powell:
Yeah. Well kind of a little bit being proven in the shoulder with the importance of expectations and, and self and all this sort of stuff where, you know, we can maybe improve expectations via adequate and, and appropriate advice. Education. I, I totally agree with what you've, what you've painted there in conceptually anyway, in terms of biomechanics, for sure matters and low tolerance and capacity and all these things that you matters for subset of people. And the argument should never be that it doesn't matter. It matters for certain people at certain times, but for, for the vast majority where pain and function and just getting back into activities of daily living or, or something like that, it may not matter. And it, it, we can still pursue it. We can still pursue it. And this is really, this is key and something that I'm researching a little bit at the moment is when we look at all the trials with, with shoulder pain, for example, actually people don't get stronger in, in intervention, in, in randomized control trials, but their pain function dramatically improved. So what's the application of load or exercise doing that doing.
Greg Lehman:
Yeah, that's, that's my other favorite question is like, how does exercise actually mediate recovery? You know, when does, was, does strength matter? And I think strength for the most part is just a byproduct. It's a epi phenomenon. It's a, it's a side effect that doesn't drive the most clinic, uh, improvements. It just ha happens if it does happen. And it it's secondary. Yeah. I'm not. Uh, but strength training in and of itself is helpful that you just don't need to get stronger
Jared Powell:
Strength. Strength is emergence much like much like consciousness and all of these things potentially when you, when you undergo a rehabilitation regime, which
Greg Lehman:
Yeah, yeah. Going, I, I was just gonna say that some people, again, don't like that, cuz our, our history is find a weakness and impairment, correct it and they get better. And, and I, and so they argue, oh, you need to build hip strength. And, and I would say you don't need to be weak to benefit fit from hip strength training. If you have low back pain or knee pain. Right. The pain is the reason to do the hip strength training. Like we, we, we're all, we all, again, we, everyone wants to be, you know, like, uh, mechanics where we plug that thing into the car and find out exactly what's wrong with that. But doesn't too complicated. It's like, we're trying to create a tornado. And I don't know how I know that's just complex. It's like a butterfly somewhere. I don't know. What's that, that butterfly. That's more what we do. I think I don't wanna get into chaos theory, but no,
Jared Powell:
That's yeah. , we'll stick, we'll stick to pain. Right. Cause we can keep talking for hours. And if I imagine I what, okay, so we've, we've started out that potentially you've always been woke as it were into the multidimensional nature of pain. So can you for it, for everybody out there potentially, what is your current interpretation of pain? Do you define it in a certain way? Do you have a model that you kinda to, I know it's semantics with definition. It's pretty frustrating, but what's your Ted talk on?
Greg Lehman:
No, I, I, uh, no, I I'm a, I'm a simpleton. I, I don't like all the discussions that people have. I don't, I don't know. I, I don't think it helps anything like be, so if someone says they hurt, that's all I need to know. Is that something hurts there that that's that's pain and it's bothering them. Let's what
Jared Powell:
About in your head though? What, no,
Greg Lehman:
That's it.
Jared Powell:
I, yeah, you've got a whole handbook on it, Greg. So surely you've got some info.
Greg Lehman:
So I, I like in terms of definition, but uh, and in, in terms of like, what I tend to focus on is just solutions. That's, that's what I'm, I'm more in into, right? What's uh, and the only reason I wanna understand and like, I would recommend people understand pain or go into the details of like what, what drives pain and sensitivity is that it often helps people make better choices, right? As soon as people can realize pain is more than just their knee caving in when they walk or then they squat like, and that, no, you you're safe to start walking again. Who cares if your knee caves in like that, that's a huge messaging. So my, my messaging is really simple in the book. It's like, pain is more about sensitivity than damage. You can have all these things that are messed up with you and none of them have to change to get better. Like the, it, like, I think you, you can spin the complexity of pain, which is like, look at all these things that can influence pain and be like, oh no, I'm messed up. I have all these things wrong with me. But the optimistic spin is like, look at all these things that can influence pain. So that means I have lots of options on how to get better. So that, that's how I tend to look at pain is like more pragmatic rather than academic discussions.
Jared Powell:
Yeah. That's for sure. How would you, how would you describe it to other clinicians, for example, or up and coming new graduates who potentially have just been exposed to of, of pain? Is there, is there a simple way in which you could sort of get them to shift their understanding of it?
Greg Lehman:
Sure. I'd be like, think of a cake that you had recently and ask them, what's your favorite ingredient in that cake? like, what, you know what I mean? Like, you can't taste the sugar or the flour or the egg, but they all went in there and that's sort of the, that's how pain works. You have all of these factors that influence and influence it and then it, it, like you said, it emerges, it's greater than the, the sum of it it's parts. Right.
Jared Powell:
It's, it's a homogenous kind of, uh, mixture that is inseparable. All its constituent components. Aren't separable from each other.
Greg Lehman:
Yeah. Yeah. And, uh, or you can look at it like, uh, a chemical equation if that's their, their background. Like it it's, it's it pain is multifactorial doesn't mean additive, you know, it's just like add, add, and boom, suddenly a pain, you can have one little change and you can have a massive, massive change in the pain that, that we have. So it's, you know, it's, it's exponential sometime, right? You just, you don't sleep well. You're stressed about something. You run a little bit more than usual and just boom, you're set off. And then, then we get into a cycle. I, I guess I do use the word overprotection when it comes to pain or protection. You, when you, when we seem to keep having pain, I like to view it as like you're, you're helping yourself too much.
Jared Powell:
Yeah, no, I think I'll, I think I got a little sentence from your, your handbook. Just I was looking for it before, it's it? Pain prompts, action. It sort of, it stimulates the person who has experienced it to do something. Could you speak
Greg Lehman:
To that a little bit? So that, I mean, that's a lo mostly David Butler thing, but I'm sure actually, maybe I didn't hear it for them. Cause I, I actually, I was only introduced to Laura Mosley like 10 years ago. Mm. I didn't know his stuff before. I'm, I'm kind of embarrassed about that. He wasn't one of my original, uh, teachers, but that, that, that's more of, uh, their idea. Like we pain is an alarm that wants to get you to do, to do something. Right. And the problem with alarms is, you know, they, they can't tell you how big the fire is. They can't tell you if there is a fire, they can't tell you how much smoke's just, just triggered. And then the other issue with alarms or with pain is, uh, after a while, whatever the initial cause was, that can be gone and the alarms just going off. So, and the, and, and then when it comes to alarms or like the protection idea, they can be more easily triggered. We just become more sensitive that's and that's what sucks. There's not a lot of wisdom and alarm sometimes it's absolutely accurate, but sometimes it's, it's not.
Jared Powell:
Yeah. Laura has been a big influence in my career in, in all Australian physios obviously. And, um, we sort of grew, grew up with his model and it's interesting to there's there is some work out there actually looking at pain as an alarm and, and prompts, protective action and safety seeking behavior and all, and all these sorts of things. And it's, you sort of explain it quite nicely in, in your handbook where, and I don't know if this is exact is exactly what you say, but the argument is that pain as an alarm from an evolutionary perspective is gonna go off more often than it should, because the cost of not going off at all would be catastrophic for the organism. Right. So it'll go off to alert you to something, and then you, we can cognitively reappraise it if, if we need to, but that alarm going off doesn't always mean that there's something sinister or pathological going on.
Greg Lehman:
Yeah. And I, I would even run with that more, cuz that seems, I logical to a lot of people with pain. And I would say that's the default for a lot of human function is that we overdo these protective responses. So again, like my third favorite thing in my course, no, it's my, my third, my third, most favorite thing. It's my favorite one is, uh, it's really fun to have people say, okay, think of all the times where you overprotect and then people can't think of any and then you start pulling them out. And it's amazing how many times the body isn't that wise, like anxiety is a great example. When people have like a panic attack, it's normal to have anxiety, you should be worried about a number of things, but we overdo it. If you, um, if you break a bone, you normally produce more bone.
Greg Lehman:
If you get hit in the quad with a baseball, some of us will have myositis OAN right. It's O overheating, uh, scar tissue, or like KES. When you, when you get burn, you know, we all like autoimmune diseases. Like we wanna have an immune system, but sometimes we overdo. Right. That, that that's the, the problem. So it's, it's not weird that we overdo pain if you actually frame it in that model. And then you can start finding out all of these examples where, where we overdo it and you're like, that's just what humans do.
Jared Powell:
Yeah. And that, that kind of gets to a whole nother, perhaps persistent pain and whatever you wanna call it is a simple epiphenomenon or byproduct of, of the human pain experience. And whether we can actually truly change it manifestly in at a, at large scale. I don't know, is that, is that, is that something that is a worthy, of course it's worthy, but is it realistic?
Greg Lehman:
It's I think, I think what you're asking there, uh, is maybe like how much do our beliefs really drive this overprotective response? And I think that they do in some people, but I think there's a lot of people, if you told them that they had scar tissue and they have faulty by, you said all the negative things to them and their x-rays were horrible, they'd still do fine. But I think there's a subset of people who really respond negatively to, to, um, what they've been told. So I don't know if that'd be like the best use of money of public funds.
Jared Powell:
yeah. It just, it just there's some people who I don't, this is, is not proven. This is conceptual and in some work on it that who have just this phenotype, that is when something happens at some point there's a nociceptive event or a pain event or something that all of these, the factors that are intrinsic to them as human beings will cause pain to stick around longer than somebody else who has a different phenotype. So how I, I, I am sort of cautious and a little bit cynical on how much we can materially change. Somebody's phenotype from that perspective. And there's not much work done on how we can change expect or self-efficacy, or, or these sorts of things. We know they predict outcomes, but can we change that expectation to change an outcome? That's not really been studied as far as I'm aware.
Greg Lehman:
No, I've, I've read some negative stuff about changing. Self-efficacy where it's hard, very hard to change and some people, yeah. So I'm not sure, I'm not sure if you can change other things that like, that would help you cope with low self-efficacy. Uh, um, but so, so I, I don't know, that's, that's one of the things, the, the only thing I, I do think about, I, uh, with people like that, like, yes, some people are definitely more predisposed to pain, uh, but there was a time in their life when they didn't have pain. So that always gives me some hope, you know, and they probably had these same traits of low self-efficacy or whatever. So what was it that changed? I like, how can we get them back to the, the way they were before when they, they were doing okay.
Jared Powell:
Yeah. That's a great way to look at it. And I, I tend to say that if somebody's come in pain has just gotten stuck for a period of time. It's, it's an alarm to use your analogy and, and others that it's just gone off. And maybe we can diminish this down by a death bell or two. And to ultimately it goes away to a manageable level where you can return to meaningful activity. I think that's a nice way to look at it.
Greg Lehman:
Yeah. I like it too. And that's why, I mean, if I were to take another course, I I'm, I'd be interested in taking like the act courses on pain, the acceptance and commitments that that's that idea where you, you can cope with these things, like using the anxiety model. It's really unfair to someone who's has anxiety say, we're just going to get rid of all your anxiety. That's that that's not happening. It's how you cope with those, those thoughts. You know, like my, my middle daughter has that stuff where she'll just have, um, these thoughts that, that really get in the way, like she, she, the last night she said, when I a shower, I have to make sure I have this thought where I have to make sure I get water or water in my eyes. Cuz then if I don't, when I go to sleep, then I'll die.
Greg Lehman:
I'm like, all right, buddy. So what are you gonna do with that? And so we, she has these all the time, these ideas where she was really upset was her, her older sister birthday, her birthday, the other day. And she came in, she's like, I ha it's the end of the night. They sleep in the same bed. And she's like, uh, can I, I told I, not sure. I told violet happy birthday properly. I'm like, you've told her. Yeah. But I don't know if I did it right now. I keep ha feeling like I have to tell her happy birthday, well, how many, how times have you done in the past hours? Like, like 10 times, but I'm not sure I'm doing it. Right. Yeah. So, yeah. So anyways, uh, uh, like things like that, we're not gonna cure her of this. Right. That's her trait since she's like a little kid.
Greg Lehman:
Right. So, so it, it it's coping and managing with that. And that, that's the idea. I think sometimes with pain, you can, you can have pain, but you can help with the suffering and the disability would be the idea. Yeah. I think we could learn a lot a as physios from the anxiety model, because then I think often you do a mechanical intervention. Like you do physio stuff, you just have like a process of maybe exercises or movements and explaining it that kind of uses this anxiety model. I think that's where we, we can evolve and get better, including me. Yeah.
Jared Powell:
That that's really well articulated in that it's the, and, and perhaps, uh, Brony, Thompson's actually done a paper on living well with pain and the she's she's found, you know, certain traits or certain activities that people do who have chronic pain, but have less disability and suffering, suffering associated with the pain. And it's essentially meaningful activity and intentional activity and support and all these sorts of things. Which
Greg Lehman:
Is, has she published a paper or is that, um, yeah. You,
Jared Powell:
Yeah, she did. She did a PhD. She did a PhD in it. I'll um, I'll send you, send you a paper if you like. And it's, uh, really fascinating. She's got chronic pain herself and it's, um, quite interesting.
Greg Lehman:
Ah, she just says she does. So it makes her look better. kidding. Brownie.
Jared Powell:
Like I know where you're coming from. I've got pain to yeah. I'll say it all the time. Yeah,
Greg Lehman:
No, I, uh, I refer people to her website all the time. Yeah, yeah, yeah. It's great. And I say the exact same thing that you said, she's got a PhD in fibro and she has it.
Jared Powell:
She must know what she's talking about. Yeah, yeah. But, um, no, it's well on that anxiety model. So we're kind of, this is leading nicely into great exposure because the best treatment for anxiety is, is greater exposure. Uh, as far as I can see anyway, in terms of the psychological literature and it's making a huge come, I it's making a comeback, but it's making a in, in physiotherapy circles for the past 10 years or so, which is probably a good thing. So graded exposure, very simple. When you think about it, it's just gradually exposing people to previously painful movement, um, in a systematic, in, in regimented way, probably in the clinical to context where they're feeling safe and there's an expert watching on. Um, so, so would you say that this, this graded exposure type of in intervention in conjunction with explain pain type of stuff as well? And, and when I say explain pain, I'm not talking about deep neuroscience. Uh, you think that's where we're heading?
Greg Lehman:
Uh, I mean, I it's certainly how I practice. I either do graded exposure or graded activity. Um, sometimes like with the graded exposure, like with the Valin model, they're they? So the way they do it in CFT, like cognitive functional therapy, they, they do it very similarly as well. And they, I call like they they've done the process for over a decade, but now they've adopted what seems like the psychological language behind it. Like they talk about these move, like behavioral experiments, where you find a feared or avoided activity, you start to do it and you have movement modifiers. And what they say is, is that they're not adding things, they're removing safety behaviors so that, so someone else might add bracing when you lift something up to make it feel better, what they would do is remove the bracing or remove it. So someone would say, oh, you're just adding looseness.
Greg Lehman:
And they're like, no, we're not adding fluidity. We're removing stiffness. that's. And that's important cuz that, that's the idea of like, when you do an exposure, you have to take away the safety behavior. You have to, you, you, as like people think that they can only do it one way. And so they need these safety behaviors. And the argument is those safety behaviors are driving the pain and the fear they, they might have been helpful, but before, but now they're linked, they're associated, you know, with, with, with the pain phenomenon. So you get rid of those and then you do the task and either you have less pain, that's ideal or like you, you do it and you don't suffer the consequences of what you might expect, which would be harm or something like that. Uh, and then it makes the person reevaluate, you know, they call it expectancy violation, you have an expectation and you violate that, that didn't occur. My issue with it is it's. I don't think you can do it every one and dramatically have a change in pain. Like if they're an expectation is to have pain, sometimes it's okay to do things even when it hurts and that's still a success and that's still great at exposure. If you're always driving, if you're trying to get rid of pain all the time, I think that's a bit of, bit of an issue. I think just doing the feared or avoided tasks with pain is still a success.
Jared Powell:
Yeah. Like I don't think, and that is, that is so interrupt. That is the definition of self-efficacy the belief or the ability to do something despite your pain or your, your issue at the time. And I think the application of exercise can sort of prompt or can encourage that behavior where look, I just lifted two kilos. It hurt, but here I am. Yeah. It, you know, I'm not flawed.
Greg Lehman:
Yeah. I, I think I probably do more of that. Like I'll take, you know, Peter O Sullivans and, and uh, uh, uh, uh, Sharpton and, and Kirin O Sullivan, their courses is, and you know, often people have these dramatic reductions in pain, but so would Mulligan right. And now I know Mulligan practitioners who describe what they're doing as, as, uh, as kind of graded exposure with violation expectancy. But, but I don't, I don't trust and it's not O cell cause why I respect him so much. Is he never tests himself in his trials? It's always people they train. Um, uh, I don't trust the, the theatrics on the stage just cuz someone got better immediately. There's too many confounds. And I don't think that people should like put that stress on themselves to immediately change symptom in that one session. Totally. Because when you see the CFT protocols, they're usually seen at least 10 times, so you can't do violation expectancy every single session, right? It's it's their intervention is, is more than that. Mm-hmm so I think it's more just, you could prob people will get, do just as well without any of the, uh, they could just screw, do graded activity and healthy activities and better sleep and understanding pain. And they do just as well. I don't know if you need that. The graded exposure, the way it's done in the like psychological way that is popular now.
Jared Powell:
Well, the CFT one is, is interesting. Cause I think there's three, there's three dimensions there. The education aspect, there's the guided behavioral experiments. And then is the lifestyle advice, which I think is a really important dimension that a lot of physios does. This is mental, but we don't look at it. We don't look at, we don't encourage the physic regular physical activity. It it's crazy, but we don't, we don't, we don't look at other habits that people have in their lifestyle. Well smoking, for example, all these sorts of things. So that, I think that's a really important dimension to add as well. Cause you can do the best bloody, greater exposure that, that you like. But if they've got all these other bad habits in their life, potentially gonna
Greg Lehman:
Come back. Yeah. Let me tell you one of my favorite questions from my course,
Jared Powell:
You? The highlights of the Greg Lehmans course start science.
Greg Lehman:
No, what I love doing in my class is like asking everyone the questions that I struggle with and then I incorporated into the course and pretended I came up it, but like when I would read the psychological literature and definitely after taking the CFT course, I'd be like, Ugh, like I don't often know what has to change when it comes to like all of these multidimensional factors, there would be those spider plots. We try to guess how much I'm like, I can't do this. And I was like, and I, so what, what I say to all my patients and what I, and what I have people do in the course is just say, okay, everyone, tell me all the things that you can do to be healthier. So we, we split into groups, everyone does it, they come up with 20 things and then we look at them on the board and I'm like, are all of these things linked with pain?
Greg Lehman:
And yes they are. So what does that mean? You could work on with all of your patients, right? It doesn't mean you're gonna do all of them, but you're gonna like recommend that maybe they know, go, go see someone else or you ask your patient, okay. What do you wanna work on? You know, these are things, these are the things to help you with. But if you wanna work on these other things, well, let's get someone else involved. So that's how I deal with the like complexity of pain is ask that question and then you're like, oh, okay. I get it. I, I, I see how pain is multifactorial doesn't mean I fixed their depression.
Jared Powell:
Yeah. Acknowledge it that beautifully. So it's, you've, you've nailed it. I think, um, that's, that's, that's a really, that's a really important point. So, so let's, let's, if we can maybe have a bit of a practical example, say for you, you are interested in, in running. I, I think so knee pain, somebody comes in, they've got knee pain. It's developed over a period of, of, of weeks to months on the background of increasing activity. They're training for something there's a bunch of other risk factors there. So potentially, um, there is some underlying suppressive or anxiety symptoms. There might be some sleeping issues. There might be some, some weight issues. There might not be doing any going to conditioning. I know I'm making this quite difficult. So where, where would you start there? So, and I know, I know that everybody's different, but if you could hypothesize and you could just, if there's somebody that comes to the front of your mind that you've seen similar to this, like where do you, where do you go there?
Greg Lehman:
Oh yeah. So, I mean, um, so I work with all kinds of runners and some are ridiculous, like running 200 kilometers per week and stuff like that and fast marathoners. Um, but I always start with, with, um, ruling sinister pathology, that's always number one, be a good clinician first. And, and with a runner, especially a female, you wanna rule out like stress fractures, that those are the things that worried about. And then even that stratify it, like you don't like a femoral neck, neck stress fracture is more concerning than a fibula stress fracture. So if, if you have any suspicion, then you gotta say, we gotta shut it down or something like that. So that, that that's the, the first step there is like, make sure it's just a pain injury or whatever. So sensitivity problem. Uh, and then you're like, okay, well how, again, I'm crude here, but how can we calm stuff down and build that person back up?
Greg Lehman:
Right. And there, you're trying to think like, what are all the sensitizers in their life that we could change right now? What are the ones where we just acknowledge that might help them understand their pain? Uh, and then often pragmatically, you you're, you're usually changing something about their training. That's usually the first let's change something. Maybe we drop a speed session for two weeks, maybe instead of just, if they're running a lot more than usual, we would say try running twice a day, instead of one long session in the morning, you're just trying to play with their training and the stressors. And then again, look at all the other stressors. If, if, if they're building a house and they're renovating it, then they probably can't always train through that. Something has to change. So like give them some yeah. Permissions sort of to be flexible. So I look at the big things like, like that first, and then you might start talking about adding a little bit of strength training or something like that, but usually it's changing the stressors on, on them, in the, the, the big areas.
Jared Powell:
So you could, could you walk a away from a consultation like that? And even though, even if you see them, uh, a few times over a period of weeks or month, you could just simply modify a variable in their training program or in their lifestyle without implementing a strength and conditioning regime.
Greg Lehman:
I mean, I, so the IRA just very comprehensively, cuz I understand that I don't know it has to be done. So usually everyone gets as three exercises cuz that's, that's what they can do. So, um, and, but I, I would always wonder, do I even need those things? That, that's the question. So like it cuz often the athletes I'm working with are, have worked with a coach. So I know they've already been managed well in the load management area. So that's why I'm probably giving more, um, exercise. But some people who aren't working with a coach and they don't do a lot of mileage or they're just building up their mileage, then I think it's more of a mileage like load thing. Um, but honestly like the past five athletes in the past two weeks or so very elite runners it's, they've already pulled back all their, all their mileage and, and they all have tendon problems. So when we talk about, when you at the be specific, that's where I'm giving exercises and I'm just loading them up at yeah. Cuz the, my, the concept there is we can't, you've already changed the loads well, and you should be able to adapt to them, but you're not. So how, but we build up a tolerance to increase your ability to adapt or how, but we, you know, cause some adaptation so that you can tolerate the running stressors. That's the mindset there.
Jared Powell:
Yeah. Cool. So if, if the modification of a variable doesn't seem like it's doing something or it's already been done or somebody else is attempted to play with it, then you can try and change their capacity or change their system somehow to build it up, to match the demand they wanna put.
Greg Lehman:
Yeah. I just don't use the word capacity. I mean, I would've used it 15 years ago. That's an old like model, although it's very popular now. I just think, um, it's missing something. I think it's not capacity like exercise that assumes that we know the mechanism of what exercises do. Dunno if it's building capacity or just changing sensitivity something. So, but, but I get that.
Jared Powell:
Yeah. Yeah. The way capacity from my which steel cook and all that sort of talk about is it's just doing something without aggravating symptoms or injury or I think it's meant to just be broad. I, I like it. I, I don't, I don't care. I think it's better than using strength, which is often what's used around, you know, you gotta build strength in your shoulder. I think that, I think a patient can MIS misinterpret that quite quickly and especially strong people who come in, I get a lot of body builders and heavy lifts coming in, like mate bench kilos, what he talking about. So it's different from that perspective I
Greg Lehman:
Think. Yeah. Yeah. No, if it's used generically, like I use the term comprehensive capacity and I need it as like generic as it can get as you can get, like it's not specific at all. Yeah. I've just heard it used, but people talk about load it's like, it seems, it seems a little like a little too physical anyways, that
Jared Powell:
To, yeah. Load's another interesting one. Um, when you talk about load and I think it's really helpful to define all these terms, especially for, for young new graduates as well, load resilience tolerance, all of nobody really knows what they mean. And when you talk about load, you've gotta, you've gotta, you've gotta separate into external load and, and internal load. And the internal load is the thing that I think is always forgotten about, which is the response to an external demand. And, and that's that's, you can't have one with a out the other.
Greg Lehman:
No. And so the like pragmatic again, what are we doing? Are we changing life's loads? Are we changing our response? You know, and you can use that. I think at a, at a more mechanistic level, like there's an argument we always have ception we always have that tissue here to, but it's what we do with it. That leads to pain. So, and that, that might be what happens with tendonopathy. We don't actually change the capacity of the tendon we there's always there's tendon out. There's some, some, some things change in the tendon there's ception but exercise might change, change your response to that, to that ception at the spinal cord or the level of the brain. And that's why I'm so like Jill cook is so adamant, like it, you need to build the tendon and the whole system to tolerate that. And like don't ever stretch and manual therapy sucks. And that is like,
Greg Lehman:
You can only be so certain when you know, the mechanism of what's happening and we don't. So you, I can't throw any treatment under the bus so readily. Right. I bet there's a massive number of people with tendonosis and tendinopathy who will respond better to man therapy. Then they will to a graduated loading program, cuz there's nothing wrong with the quality of their tendon or their muscles. There's some just sensitivity issue. Right. That's what, cause if we know people can have tendonosis and have pain, then, well, why do I need to build up the tendon around it? Yeah. How do I know? It's not just a nervous system thing. Yeah. So I can't, I just can't throw shade. I can't be so like, and I was before a little too strident in like that's. And I think that if, once you understand the complexity of pain, then you should be open to how other things could be helpful or at least be open to knowing that you don't know everything.
Jared Powell:
That is. I totally agree there. It's um, it it's, again, it's cognitive dissonance. If you're gonna say pain is complicated, but then say, but this is how you have to do it. Yeah. Not fair. They don't agree with each other. It's um, I think in fairness to Jill, uh, some of her students, so Ebony Rio, Sean docking, they've published on the local effects of loading and capacity and then the system or organism capacity kind of issue as well. Cause then it's, they look at the tendon capacity and then they look at the sensitivity or, or, um, general person levels as well. So, so some of her students have gone on to further. Oh, so
Greg Lehman:
I mean there, but all of them are great. She she's fantastic. She's pushed the needle the, the right way. I'm just like hesitant when people ares like seven things not to do. And then, and then we all pretend like we're evidence based and you're like, where's the research like? Yeah. Everyone's like, don't like, don't stretch your ITB or stretch your Achilles. And you're like, where is the study that compared a stretching protocol with a loading protocol doesn't exist. Like if you want, you could go, there's a few papers where they just stretch Achilles and people get better. Yeah. I mean, even, uh, I always forget his name. He's he's he's down there by you. uh, uh, he's an interesting person to talk to. He, he did an Achilles, he's a sports medicine doctor and a decade ago he did an Achilles lo loading program was stretching in it. He held it. Okay. Like it was stretching based, it was an eccentric loading, but they're doing higher than 15 reps and then holding it for 30 seconds. He's getting comparable results to everybody else. What the hell is his name, man? Uh, sports me.
Jared Powell:
He's a sports doctor. Is he? Yeah.
Greg Lehman:
He always argues with Jill cook. It's hilarious.
Jared Powell:
Cool. That's that's, that's interesting. I, I used to be in the UK and I did a bit of work with, um Alfredson and okay. Uh, the eccentric guy and, um, that was a fascinating conversation cause he clearly still into eccentric loading and then he does a lot of this debridement surgery yeah. Of the, of the Achilles now with very good outcomes. Now this mm-hmm he honestly, and this might be too much, but he has like 95%, um, success rate in terms of his Achilles debridement surgery. So, you know, that speaks to an element of adhesions or whatever you want to talk about between the per attendant and the tendon. So it's not a slam dunk with loading and, and tendonopathy well,
Greg Lehman:
Well look at so people, people say, oh, you, uh, stretchings useless or, or endurance exercises are useless because it won't change the stiffness of the Achilles tendon. The Achilles tendon, you know, has to undergo, you know, four and a half percent strain to adapt. That's about 70% max exercise, which is, you know, 12 reps. Uh, so you have to train heavy. And yet the Alfredson Ecentra program is 15 reps. It's about 63 centimeter max and it's comparable to doing a heavy resistance training. So the most famous program that seems to help lots of people that won't even change the tendon quality. So how important is building up the tendon quality when someone has tendinopathy? Yeah. If, if doing it or like hopping ho hopping is great. Of course I would have all my patients with Achilles tendinopathy get into hopping if they need to. But at the same time, I know that hopping is not gonna change the quality of the tendon. It's not consistently it'll do something else. So then, and what's driving your treatment. You're just what I think you're saying is what does this person have to do? Okay. Let's do that.
Jared Powell:
Greg Lehman:
Well, no.
Jared Powell:
Yeah. Yeah. I know. Right. It's it's a bit, plaing when you can talk about all this stuff and then you're like, ah, just, just do what you wanna do. But back it on fraction,
Greg Lehman:
Back it off, and then like, or you, or you, you break it down and you just do you do more in the gym than what you're gonna do outside. Yeah. So the gym prepares you. So what's outside is easy. That's that's the simple way to look at it.
Jared Powell:
Give yourself a buffer for the, for the real world, right? Like, yeah. Capacity here, capacity. Sorry. I know you don't like that term. And then your requirements here. Right? Give yourself a bit of leeway.
Greg Lehman:
I think I don't like it cuz it's too much like me. It's like, I've been saying it and then I just, something has changed in me where I'm like, there's something wrong about that. I'm tired of hearing it all the time. I can't quite put my finger on it yet, but
Jared Powell:
I don't know what probably cuz everybody else is you it now Greg, I think that's you do like to be contrary
Greg Lehman:
honestly like the, the capacity model where people always quote, uh, Scott dye from like two, two thousands. Yeah, yeah. That that was Stu McGill in 1996. The same thing. He's like, here's the loads. Here's your tolerance just don't have the load above your tolerance. Yeah. And everyone like quote, that guy that was 25 years ago yet they, the
Jared Powell:
Envelope of function. Yeah. I can't believe
Greg Lehman:
It. It's so simple. Everyone loves it. Like it was preceded by so many other people yet that's the one that gets popular. That's yeah.
Jared Powell:
Isn't, isn't that funny? It's the same thing with um, with progressive loading. Right. And uh, acute chronic workload ratios and all these
Greg Lehman:
Sorts of things they're gonna be started.
Jared Powell:
You know, that's funny. Cause that's starting to be quite, uh, challenged now by, by an Australian guy. Franco Inari yeah. They've um, anyway, so what,
Greg Lehman:
No, I've talked a lot about that with Franco. He always direct message messages me, cuz he knows that I'm an ally. What, what we have an issue with is we don't question the concept of which is don't do too much too soon. No we've been saying that's what has always bugged me about the acute to chronic workload ratio. Like there's nothing new in it. You just reframed it differently. What got popular was that there was, you could actually predict and say there's a certain amount that you have to stay under. There's a certain envelope. Yeah. And that's what Franco said. No, there's not that that research hasn't been shown. So the research really hasn't helped anyone beyond just saying don't do too much too soon. Another way it's not actionable yet. The concept seems great, but right now pragmatically, whatever
Jared Powell:
yeah. Arguably I did, I, I do think it brought it to sort of mainstream attention. And now you've got LeBron James doing load management,
Greg Lehman:
Which is insane to me that it had to happen. Like I, I guess I've just worked with running coaches for 20 years or, or actually hockey coaches and basketball coaches because I used to be a strength coach and uh, they all thought of that stuff. I always thought that coaches were the first biocycle socialists. Right? If you're working with high school kids or college kids and you hear that one, guy's going through a breakup or stressful time with school, that good coaches like back the training off or they figure out a way for him, for her to adapt. Like I wrote an article years ago saying that was my thesis. That coaches were the first bio psycho socialist, at least good ones were.
Jared Powell:
Yeah. And that that's mate, that is, that's a really good way to, uh, to round off this conversation. I think that's what we should be. Right. We should be a coach. We're coaching somebody back to health. And so we need to consider the full aspect of the human condition, which is a, which is a nightmare sometimes, and it's not what we're trained for. And that is my biggest bug there because I was so awkward, discussing many D I, I didn't even ask the question. Uh, is there something going on in your life? Cause I don't know what to do with the answer. Um, but I think that's something we should be much more comfortable in discussing, even if we're not going to intervene and treat which we should not that ask then we referrals.
Greg Lehman:
Yep. Comanage
Jared Powell:
Perfect. All right. Um, just to, just to finish off we've, we've covered a lot of territories, uh, which is, which is what I knew I was getting into when I was gonna chat to you so that, um, hopefully people get to evaluate it. So what, what do you like to do for a bit of fun, Greg? I see you on Instagram doing some tumbling around. Uh, I know you've got, uh, a young family. So what what's meaningful for you?
Greg Lehman:
Uh, I do a lot of trampoline right now. Um, what got you into that? I would rock climb. What's that?
Jared Powell:
What got you into the, the, the trampoline and tumbling?
Greg Lehman:
Um, so when I was a teenager, I just, I taught trampoline, but I like a really low level. I picked it up when I was older, I couldn't do anything. And then my girls started cheerleading. So I used to go in their classes for tumbling. That was three years ago. And then I just started going on my own. And when the gyms are open, I'd go two or three times a week. We have a trampoline in our backyard, a tumble track. It's like a bouncy thing to tumble on. Mm-hmm
Jared Powell:
Yeah, that's what I, how's it going? You're getting better. How's the, how's the old body going?
Greg Lehman:
Uh, I mean, there'll be more stuff on the trampoline. I can't tumbling on the ground's hard. Like you have to, in order to get better, you have to put in the work, but it's so much work it's beyond what I can tolerate. So I was pretty achy when I was trying to do stuff on the ground. So it's a trade off there. That's hard. Yeah. But trampoline, I I'll bailed to do it. Like I just did a double back flip before COVID that was huge. So you can do that stuff. You can progress that you can do that until you're 80 or more. Yeah,
Jared Powell:
That's awesome, man. And, um, are you any injuries out of it so far? Anything, any acute chronic workload issues
Greg Lehman:
Mate, there, there, there was like two years ago now when I was trying to get like backhanding, some back flips on the floor, had a train so much. So my risks were sore for a long time. They still are, but I, cause I was doing four to five days a week, but I had to do that or I wouldn't get better. So, and I knew that, so it was just a trade off
Jared Powell:
isn't it. Isn't that funny trying to, I, listen, I can't listen to my, I own advice when I'm, when I'm doing, I like to do some weights and I like to surf. And then when the surfs good, I go out for three hours because it's pumping and oven surface six weeks. I'm like, but you, you, can't not, I just have to do it. Right. And then the next morning is a disaster and I can't go out if I session would've been way. Yeah. Anyway, um, thanks having a chat mate. So what, what's the best platform for people to get you on? Is it Twitter? What, what's your preferred platform?
Greg Lehman:
Yeah, probably Twitter. Yeah. Twitter and
Jared Powell:
Your, what? What's your handle there?
Greg Lehman:
It's just Greg Lehman.
Jared Powell:
Craig Lehman. Well, there you go, mate. Thanks for having a chat with me, buddy. Uh, we'll catch up soon.
Greg Lehman:
All right. Thank you.
