Finding the Balance: Integrating Biomechanics and Psychology in Modern Pain Care

[00:01:34] Mark Kargela: Welcome to the modern pain podcast where we challenge outdated narratives, explore cutting edge research and dive deep into what truly works in pain care today. I'm Mark Kargela and.

If you're a clinician looking to navigate the evolving landscape of pain treatment. You're in the right place. Let me take you back to when I first started treating pain. Back then, everything was about biomechanics. Pelvic tilts, posture corrections, transverse abdominis, fixing dysfunctions. And if you're anything like me, you were taught that pain was pretty much a mechanical phenomenon.

Find the problem, fix the problem, pain goes away. But then something didn't really add up. I started seeing patients whose symptoms really didn't match their imaging. People who weren't out of alignment, but were still struggling with persistent pain, and I say out of alignment, of course. And suddenly the old model really wasn't making any sense anymore.

And trust me, I rode this model hard. It was my security. It was my comfort in the clinic. It was my way to attempt to have certainty in the uncertain and chaotic space that is the clinic. [00:02:34] Leaving it was quite scary as it was letting go of my security blanket. It was a long and rough breakup.

The good news, we're still friends. Fast forward to today and we're seeing a major shift. The rise of psychologically informed care is changing how we approach pain, emphasizing thoughts, beliefs, and behaviors just as much as biomechanics. But here's the big question. Have we swung too far? Are we at risk of losing our identity as movement experts?

In today's episode We're breaking down this evolution from the traditional biomechanical model to the biopsychosocial approach and more importantly We'll talk about where the sweet spot really is because here's the truth Effective pain care isn't about choosing sides The best clinicians integrate both.

 We need to move beyond outdated body as a machine thinking without abandoning what still holds clinical value. At the same time, we can't let pain science just become another script. We have to keep movement at the core of what we do. 

[00:03:33] Announcer: [00:03:34] This is the Modern Pain Podcast with Mark Kargela.

[00:03:38] Mark Kargela: Okay, let's start at the beginning, the biomechanical model.

There are indeed some strengths in this model, despite what you might hear on social media. This model is founded in clinical reasoning, movement assessment, and manual skills. Now before you beat me up, yes, there are limits on what these things can do or tell us, but they have their place and utility in clinical practice.

This model also allows us to identify true structural issues when they're present, stress fractures, red flags, specific back pain such as a herniated disc with specific neurologic compromise, or other significant pathology. Of course, there is an issue with our overconfidence in identifying specific pathologies, especially when we know there is probably about 10 to 20 percent at most of specific low back pain pathologies.

I probably overestimate at 20%. And some of us have invented pathologies that supposedly only certified people can identify and successfully treat. But let's leave that for another [00:04:34] episode. This model often is one that is the entry point for many of our patients. People like tangible explanations and this model definitely will give them that.

The issue is when we give explanations that continue to push a body as a machine narrative and misses the other contributing factors to a person's pain experience that can at times be playing a much bigger role than their imaging findings. This gets to the limitations of the model when we use the body as a machine model and create pathologies such as our pelvis being out of alignment, Or discs being slipped which, despite the passion for which clinicians still clutching to these dated models defend them, hold minimal to no scientific support.

 I already am waiting for my comments on YouTube to fill up with rosy remarks about how ridiculous I am and that it was exactly my pelvis being put back into alignment or my disc becoming unslipped that allowed me to get my life back.

This model often led to an over reliance on passive treatments. Shoot, I spent 10 years trying to figure out how my hands could fix this type of [00:05:34] stuff. This often can disempower a patient. I remember distinctly spending a majority of my sessions doing various soft tissue and manual therapy techniques.

Which was seen as the true expertise at the time and then passing on the rest of the session filled with modalities and generic exercise programs to technicians. Lastly, this model falls completely flat when we have patients that supposedly have no issues on imaging or body's machine measurement devices yet are in debilitating pain.

I cringe when I recall my reaction to these patients. I clutch so tightly to the body's machine narrative that when it was threatened by someone like this, I blamed them. It couldn't be me as that reality was too harsh to consider. They were non compliant. They were symptom magnifiers, malingerers, or worse.

This was all in their head. So this brings us to a place that is extremely hard to find in today's algorithmically fed, click generating social media world. What is that place? The middle ground. In this place, a skilled clinician can [00:06:34] seamlessly weave between a skilled and precise physical assessment while recognizing its limitations. A psychologically informed conversation to get a handle on how someone is thinking and behaving around their condition And a patient centered approach that tailors our treatments to the specific needs of the unique person, their story, and the context they bring to a treatment encounter.

Let's look at a couple cases. Let's look at a case. A patient with knee pain has some mechanical irritation, but also a fear of movement. So in this case, we may use graded exposure to movement with some exposure based treatments and exposure with control education on pain science, but good old fashioned exercise and loading that we all learned in PT 101.

 Our next case could be a patient with chronic low back pain and MRI findings of degeneration. Of course, we're going to reframe their understanding of imaging findings while still working on the things we were taught in school, strength, mobility, while helping a person develop trust and confidence in their robustness of their spine and their body's ability to move well, despite imperfect imaging.

And lastly, it could be a case of a high [00:07:34] level athlete with an acute sprain who wants a clear rehab plan. This could be a more biomechanical or movement based approach, but still managing expectations and psychology.

This may come as a shock, but athletes have thoughts and behaviors around their condition as well. And at times can be maladaptive and requires some psychologically informed components to their care. So what do we do with this then as clinicians?

One. We need to continue to move past outdated biomechanical narratives and quit telling people they are unstable or things are out of place. 

Two, let's use biomechanics where it makes sense.

Tissue loading, progressive overload, and rehab progressions, amongst other things. Three, integrate psychologically informed strategies that go beyond simple screening and a scripted and pain splained delivery method, and truly adapts it to the person's unique story. Four, let's develop skills to weave these seamlessly together and not deliver them as some sort of separate interventions.

In the end, pain treatment isn't about picking sides. It's about balance. A modern clinician isn't just a manual [00:08:34] therapist or just a pain psychologist. There's someone who knows when to use which tool for the right person at the right time. I'd love to hear from you. How do you balance biomechanics and psychology in your practice?

Have you struggled with the pendulum swing?

Alright, before we wrap up, I have one quick favor to ask. If you found today's episode valuable, if it challenged the way you think about pain care or gave you something to apply in your practice, make sure you hit the subscribe button so you never miss an episode.

And if you're enjoying the podcast, it would mean the world to me if you could leave a quick review on Apple Podcasts or Spotify.

Your feedback not only helps me improve the show, but it also helps other clinicians just like you find this information and join the conversation. 

 And speaking of conversations, let's keep it going. My socials are linked in the profile below. I'd love to continue the conversation there. I'd love to hear your thoughts on today's episode.

 Do you think we've swung too far towards psychology and pain care, or is it exactly where we need to be? Drop me a message or tag me in a post and let's talk about it.

 All right, that's it for today.

Thanks for tuning in. I'll see you next time for another deep dive into modern pain care. [00:09:34] Until then, keep challenging the norm, keep evolving your practice, and keep making a difference in your patients. See you next time.

[00:09:40] Announcer: This has been another episode of the Modern Pain Podcast with Dr. Mark Kargela. Join us next time as we continue our journey to help change the story around pain. For more information on the show, visit modernpaincare. com. This podcast is for educational and informational purposes only. It is not a substitute for medical advice or treatment.

Please consult a licensed professional for your specific medical needs. Changing the story around pain. This is the Modern Pain Podcast.