I’d like to share a metaphor about freedom of movement, pain, adaptive and maladaptive behaviour, and the role a therapist could have in these processes. Of course, like all metaphors, it has its limits, but it’s served me rather well, both for me guiding my clinical reasoning, and for my patients and their understanding of the rehab process. Explaining this, and all the interesting details will probably take me multiple posts, so bear with me…
Imagine a house in an area where heavy storms, or hurricanes and tornados are frequent (1). In that house, there’s one particular room that serves as a safe room in case a storm hits the house. That safe room is a strong, fortified structure, where one is protected against the forces of nature. Of course, the safety is only relative; there’s no guarantee for total protection.
The house is a metaphor for movement behaviour, or even behaviour tout court.
Some people have a big house and property: they have a rich movement repertoire. Some have a small house; they are rather limited in movement options. Some of the variance can be explained by genetics, but most probably is explained by lifestyle and past movement behaviour. And surely, the size and complexity of the house can change over time, in multiple directions.
The storm is the metaphor for a threat.
A threat to the integrity of the body, of the system, of you as a person. This can be a mechanical load, cumulative stress, injury, surgery, … but also psychological stress, a load in a particular context, a load with a specific meaning for the organism.
If a storm is raging over your house, it is a very normal reaction to take shelter in the safe room. If the storm has died down, you don’t have stay in that room any longer. It’s rather boring in there.
The safe room is the metaphor for the protective responses the human animal makes in threatening situations.
So in case of a threat, it is normal to take protective measures: avoidance behaviour, muscle guarding, relaxation of some tissues, reflex inhibition, decreased movement variability, re-emerging of primitive reflexes, increased fatigue and a more depressive mood (the last two enhance rest), fear of certain movements, … And, almost needless to say, the conscious experience of pain is also part of these protective measures. In my metaphor, all these are part of ‘taking shelter in the safe room’.
It is important to note that these changes are not black-or-white, not all-or-nothing, not just straightforward, not one size-fits-all. For a nice overview article, read Hodges & Smeets (2015) Interaction Between Pain, Movement, and Physical Activity. Short-term Benefits, Long-term Consequences, and Targets for Treatment. Clinical Journal of Pain. The figure is taken from this paper.
Although these changes can be different in different people, in different situations, for different threats, it basically comes down to this: we sacrifice freedom for protection. Safety is such a biological imperative that we don’t mind giving up some freedom. At least, for a while.
Also very important to note is that these strategies are part of an adaptive response. They promote recovery. They are not defects, but defenses. They are symptoms and signs of the problem, not the cause of it. The safe room is not the nicest place of the house to be in, but there’s a reason why you take shelter.
So far so good. But some problems can arise:
Some people take shelter too early, or too late.
Some people take shelter for much too long, or they feel the costs it takes to protect.
Some people take shelter at the right time, for the right amount of time, but make mistakes when leaving the safe room.
When do you go inside the safe room? How long do stay in? And how do you get out of it?
I’ll explore these problems in the next posts. I’ll focus on the practical implications for both patients and therapists. As therapists, there are quite a lot of pitfalls to avoid, and possibly some new or interesting insights to learn. For now, maybe you, the intelligent reader, can already think ahead and tinker with it.
Cheers,
Pieter
(1) One could make the same metaphor, but using, earthquakes, 2nd world war, terrorist, … situations. I prefer a heavy storm for my story.