Eyal Lederman, and the “process approach”

Eyal Lederman is a big figure in osteopathy.  And unusually for osteopathy, he is even quite a big figure outside of osteopathy in the wider manual therapy world.  I don’t think he is in any osteopathic camp – classical, cranial, biomechanical – but he has forged his own interesting path.  If anything he fits neatly into the biopsychosocial movement, but was probably ahead of the curve.  When I was at college his name was synonymous with “harmonic technique”, and I remember when he came to give a guest lecture.  He attracted skepticism from a student body obsessed with manipulation and technical finesse.  He didn’t manipulate, apparently.  And moreover he was happy to spend half an hour swinging someone’s arm back and forth, and indeed his patients were happy with that too.  In our student clinic, a treatment was barely considered to be a treatment without at least one, preferably three, manipulations (cervical, thoracic and lumbar, just to prove you could do it, and sacroiliacs for the show-offs).  But back in 1995 he was emphasizing the way you handle patients, and talk to them, and frame their condition, as being of utmost importance for their outcomes.

He made quite an impact with his argument against the fashionable idea of ‘core stability’.  Now he is challenging the purely “Structural Model” in a paper entitled:  A process approach in manual and physical therapies: beyond the structural model.  This is published in the current issue of IJOM, but there is free access too via his own website.

I first listened to an interview he gave to Brooke Thomas, a rolfer.  She has a website called Liberated Body,  for “body nerds”, and “smart somatic types” where she also ventures into the “inner space”, and this blog is an attempt to provide a summary of both his paper and the interview on Liberated Body, for those of you who want to know what he says but are just a bit too busy. If you can spare a couple of hours, you would do better to

Listen to the whole hour-long interview here

Better still, read the paper here.

If you don’t have time, read on….

As someone who works on fascia, Brooke was interested in his declaration that we can move beyond the structural model.  Why? she asked.  Because, said Eyal, it doesn’t give information on why the person is suffering and how they will recover.  What is needed, he continued, is a “process approach”.  Now I’m aware of the “structural” approach, even the “functional” approach, but the “process” approach is fairly new terminology to me.  What  it does do, is to encapsulate many of the different themes in contemporary manual therapy.

What exactly is the Structural Approach?

He started by saying that we all agree that the body has an innate capacity for healing, but the structural model, in which the body is viewed as a machine, claims that this capacity is diminished or hindered by faulty biomechanics and posture.  If we remove those strains and faults, the person recovers by virtue of having had the somatic stress removed.  “Damaging stresses can be minimised and physiology improved.”  The structural model is logical and plausible and a model which patients like, but Lederman, along with many progressive thinkers in manual therapy, believes it is flawed.  First, he just doesn’t believe that it is so easy to alter biomechanics with pressure i.e. by pushing on a body you can’t deform or mould it.  He says the necessary force required to alter physical tissue is huge and it would take hours a day of pressure to change the structure.  (I do think, though, this rather sidesteps mentioning all those more subtle techniques we use which somehow trick the body into “letting go” and adjusting at a more fundamental level). Second, he thinks that many of those pain conditions we see are complex bio-psycho-behavioural processes and do not have a structural cause, so trying to correct the mechanics is not getting to the root of anything.  He points out that in the last two decades, it has been demonstrated that asymmetries and postural deviations are normal variations and are not associated with many common musculoskeletal and pain complaints.  That’s pretty much the opposite of  what I was taught when I was at college.

And what is the Process Approach?

The process approach is a different framework, in which the therapist’s job is to create, together with the patient, environments which support natural self-healing processes.    Those natural processes are a combination of 1) repair, 2) adaptation and 3) modulation or alleviation of symptoms, according to how chronic the condition is. We self-heal all the time, so professionally we need to mimic and amplify what nature does.

Lederman talks about these natural self-healing processes by asking us to consider what you would do if you had an injury with no medical help  around.  Initially you would reduce weight-bearing, maybe use gentle motion to check how things were functioning, but in time you would have to eat and excrete,  and so you simply would HAVE TO start slowly moving around and applying stresses and forces to the injured area.

Is touching the patient important?

He does think that touching “works”.  In fact he goes so far as to say “Everything works” and by “works” he means it alters something in the physiology.  He makes the point that even brushing past someone or sneezing next to someone will change something, but how substantial and lasting will those changes be?   Lederman points out that we get biological changes in the tissues when we treat, but also lots of psychological and behavioural factors come into play.

Lederman thinks we have an “undertouched” culture, and divides touch into

  1. Instrumental (e.g. changing a nappy, stretching a muscle)
  2. Expressive (e.g.soothing a crying baby)

He says people can pick up the difference very quickly.  He thinks we have tried to make manual therapy very mechanical and orthopaedic, to professionalize it, but we need to get back to the expressive and communicative aspect of touch.

More detail about the three recovery processes

He divides recovery process into three, depending on how acute or chronic a condition is.

Bear in mind these three processes can and do overlap, but one often dominates.

  1. Repair – e.g. following a fall on the ice.  This would be basic tissue repair, lasting 1 -3 weeks.  Examples are disc or ligament injuries, muscle tears and other acute conditions.  The associated behaviour here is that of resting vulnerable tissues which are inflamed.  It is followed by gradually loading the affected areas.
  2. Adaptation – e.g. following immobilisation of a broken leg.  This would involve adaptive tissue changes and central nervous system plasticity.  Examples he gives include strokes, changes in movement patterns/posture, the stiff phase of frozen shoulder or contractures post-surgery/injury.  The behaviour associated with this phase is that the patient will try to carry out tasks, and will have to stand and walk, increasing the periods of time doing this.  Active, task-based movements become more important than passive.
  3. Modulation/Alleviation of symptoms – e.g.  a year of low back pain.  You would not expect to see tissue changes, merely a change in the experience of symptoms.  Examples of these include whiplash, anxiety, stiffness, neck pain and tendinopathies.  Behaviours here include seeking support, reassurance and information, social and physical contact with others, maintaining daily activities and introducing progressive physical challenges.  The behaviours are also very dependent on the person’s motivations and psychological state, and their social, occupational and recreational environment.

The Role of the Therapist

Lederman likens the role of the therapist to the role of any caregiver when they try to alleviate distress.  What people naturally do is

  1. Touch, or even just seek the proximity of another person.  There might be some who crawl into a corner and want to be left alone, but many suffering people seek someone out.
  2. Gentle movement – if someone injures themself, almost the first thing you instinctively do is ask them if they can gently move the affected area a bit.  It reassures them and gives them confidence.
  3. Calming and soothing – saying calming and soothing things, and behaving in a calm and soothing manner

Although we are working as paid professionals, in essence what we are doing is emulating this natural behaviour.  We might call it central descending inhibition, or desensitization of fibres, but we are professionalizing natural behaviour and using it therapeutically.

Functioncise:  Make your life the gym

“Functioncise” sounds like the kind of thing that appears on the gym timetable once people have got fed up with “Yogalates”, and disappears 6 months later to be replaced by the next Les Mills invention.  But what Lederman is talking about is exercising according to what function you need or are missing.  Exercise through general daily activities is the general idea. “Make your life the gym” is his advice, and amplify what you already do.  Just push yourself a bit more.   e.g. If you have trouble walking long distances, try to walk a bit further each day.  I was vividly reminded of Lee Evans’ stand up routine:”They’re selling us steps now!  Why? We’ve already got steps!  They’re everywhere!  Just take your music to your front step and step up and down it a bit!  What next?  They’ll be selling us getting-in-and-out-of-bed-machines!”.

Lederman believes that functioncise is the most realistic exercise option, as not only does it mimic natural self-healing behaviours, but most people only have the time to do the bare essentials for their life, and learning and taking up new exercise regimes is neither practical nor effective, and as we all know many patients just don’t do it.

Why do some people never recover?

The ones that don’t recover,  don’t recover because they don’t know what behaviours support recovery.  They stall adaptation.  They might be scared, depressed, or misinformed about the risks of exercise; they might not have opportunities to engage in activities; they might have multiple health issues getting in the way. Some people just can’t modulate symptoms on their own.  They need someone else involved;  someone who understands the recovery processes and can help them with the behaviours.  The therapist can explore any obstacles impeding their progress, and can help to consider things they can do and provide support and encouragement.

So what does one actually do with patients with a process approach?

Well, Lederman says he spends a lot of time rewriting the narrative of what has happened to them.  The process approach makes the patient less dependent on the practitioner, and restores the locus of health to themselves.  The therapist becomes an educator and facilitator rather than a mechanic.  Manual techniques are there to support processes, rather than remove structural obstacles to healing.  They are also a “vehicle to deliver touch effects”, specifically calming and soothing, and articulation is there to provide “reassurance that movement is safe”.  His piece of advice to practitioners is:

When  you’re with a patient ask yourself this:

By which process is this person likely to recover?

And once you’ve identified either repair, adaptation or modulation of symptoms, you can go to figure 5 of the paper to get ideas about matching the most suitable techniques to that individual’s process of recovery.

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