Redefining Rehabilitation: A Deep Dive into the Human Rehabilitation Framework

Welcome back to this week's episode of the Modern Pain Podcast. This week we're talking with someone I've known for over a decade. When I first met Leonard, I could immediately tell he was someone who thought very deeply on topics and always was questioning things. He has since had an impressive career where he has started his own practice dynamic movement and recovery where he serves the greater Grand Rapids Michigan area. Leonard also owns and runs a continued education wing named Dynamic Principles, where he teaches about his unique framework, the human rehabilitation framework. In this episode we discussed Leonard's journey. We discussed the limitations of the biopsychosocial framework as it's currently being applied. We're also going to talk a little bit about evidence-based practice and the limitations of current research methods when it comes to understanding and helping unique people in pain. Finally, we're going to discuss the human rehabilitation framework and how it applies a process-based approach to clinical care to address some of the shortcomings of current healthcare and approaches to pain. We're going to have all the links to Leonard's projects in the show notes and also some articles that can help you get a better understanding of the topics we're going to discuss. Thanks again for being a listener of the podcast. My only ask is that you consider subscribing on your podcast vendor or leaving a review. If you could subscribe on YouTube, that would help us a lot as well. Enjoy the episode.

This is the Modern Pain Podcast with Mark Kargela.

Welcome to the podcast, Leonard.

Thanks so much for having me, Mark. I really appreciate it.

We go actually quite a ways back. I fondly remember my time when I was in Grand Valley State. I went there as a graduate of PT myself. I went through when it was a master's program. I remember being fortunate to get back in there and do some adjunct work as a professor in some of their labs. Leonard was going through Grand Valley State as I was doing some of my adjunct work. Then, as I progressed in my career, definitely had bumped into Leonard. As I was working in Grand Rapids we went through the therapeutic pain specialist program together with Adrian Lo's group. It was always been just knowing Leonard. He's always just a high-level thinker and I've always appreciated that with him. We'll get into that today and really talk about some of the good stuff he's doing with his current clinics that he was running and some of the amazing frameworks that he's coming up with that I think are going to really be a positive impact on our profession and not even just our profession, I think, overall pain care as a whole. Before we get into that, leonard, I'd love for you to introduce yourself to the audience, for folks that may not be aware of you, and give them a little bit of an update on what you're up to.

I appreciate it. Mark, that's always a hard question. Professionally, obviously, working as a physical therapist and also licensed athletic trainer, and background, just much like a lot of your other guests long background in my own circles, with pain from childhood, migraines through childhood and then later on in life, lots of injuries as I tried to become a semi-professional stuntman and a lot of other things. My road's converged and ultimately obviously led me down to these professions movement profession, rehab, profession as a whole. There A lot of other things also led me down the direction of question and literature. Even my first experience with putting together a research design and conducting it in undergrad and was just really enlightened me on some of the misunderstandings very basic things like even stretching and introduced me to the concept of nociception. Having a role in things other than pain led me up to a point where, after going through school, going through different programs, gathering as much as I could from others, to having to make a decision which was pretty hard. I mean anyone who's been at this crossroads where you're giving up a stable job and possibility for a lot of benefits and things like that to gamble everything and start a practice with the intention of? I wanted to have it be more of a clinical research site. About 2018, that process started and then really took the jump in 2019 with a physical location. The intention was we wanted to be able to build up to where we are right now, which is we're just launching a nonprofit for some of our thinking around clinical reasoning and around introducing wisdom back into the clinical practices as a whole. There we had to make sure that we could address the front end as well as the back end. There are aspects of how healthcare and clinics are managed in terms of customer service, in terms of administration, in addition to the clinical practice. We wanted to be able to have as much relative control as we could. As we're trying to collect data and determine what measures we're going to do, as we're looking at how we can affect trajectories of individuals, we're struggling. We got the clinic practice going. We're up to 12 employees now 8 clinicians. We've grown quite a bit, which wasn't the intention. It was to be small, but unfortunately there is such a need in the community in this area that it grew. At the same time, we've been trying to build our educational arm for a number of years. Dynamic Principles has been around before I even went off and started the practice to be able to do some more research. Then it just all came together right around that time where we could start to develop some of the actual philosophical and structural frameworks of clinical reasoning. That we felt was a convergence of everything that was currently being discussed as well as maybe we took a few extra steps backwards to really clarify some of our understandings and biases and how we look at things, before we went forward and we developed what ultimately became the human rehabilitation framework. The human rehabilitation framework is now a working prototype of our larger vision, which is to bring in contextualistic thinking towards human health, wellness and performance. That's where the nonprofit is now coming into play as we go forward, and we want to develop a research and education entity really built around this contextualistic way of thinking. I think that brings us up to date without getting into too many details.

We'll get into the details, sir, don't you worry about that, as I've seen you develop and I've seen your work online and had the opportunity to work with one of your colleagues, cameron Foller. He's another sharp thinker. He was a member of the modern pain care team for a bit and then has done some amazing things. I still touch base with Cameron from time to time. We all had these discussions with Cameron and then I obviously see you having the same discussions and struggles online with some of the traditional ways we've gone about things. One of the big things I've had some criticisms with I know you shared is this as an evidence based practice model, the way it's been applied and some of the footings of philosophy that inform it, where we're looking at group level for statistics and group means and averages and trying to reduce that to one unique individual that doesn't always fit the average. Some of the average folks are the folks that aren't even getting into your clinic. To be honest with us, I'm curious. I'd love to hear your perspective on some of the struggles and failings we've had in evidence based practice as far as how it's missed the mark when we're working with unique people with unique problems and unique context that they live and function in. I'd love to hear your thoughts on that.

Yeah, no, it's again pretty heavy question. A lot of directions. We can go there. We can again. I think the people who are listening to this podcast are obviously very aware of where we've sort of to a large degree maximized the biomedical model and we're trying to look at how do we operationalize the biopsychosocial model. One of the challenges I think, if I really take the idea of stepping back was we needed to. I think there's been some good discussions about more systematic philosophy and looking at epistemology and ontology, but there's this step back that we haven't taken that I think was really really important for us to do. There was a philosopher and actually I can't remember the aesthetics kind of a professor at Berkeley or University of California, berkeley in the 1942 that came up with this theory for this sort of like before systematic philosophy called world hypothesis and what we gained from that which again, how it was introduced to this was from the psychology world. The psychology world has obviously a number of its own crises and Stephen Hayes is a psychologist who's doing a lot of work in trying to move and blow forward with those crises, as well as with introducing his approach in Hoffman and Suryaishi's kind of perspectives on process based thinking. But more importantly, they also, or they kind of really introduce the idea of like stepping back and looking at this lens by which we even look at our philosophy and look at our assumptions of how we interpret everything or design our research and do our analysis, research and looking at the world and the universe around us. And anyway, coming back to the idea of this world hypothesis that was introduced by Stephen Pepper in 1942, what he basically came out to say was that if we look at all these thousands of different sort of systematic forms of philosophy and all these different sort of subsets, is that you can use something he calls a root metaphor, which are these sort of metaphors that combine sort of common sense and refined knowledge to really kind of organize everything that has ever existed philosophically up to that point and ideally into the future, which we would say he's been pretty accurate up this point. I mean, there hasn't been a lot of arguments about it but falling under about seven or eight sort of these world hypotheses or worldviews, and of those only about four of them are really relatively adequate to address, you know, the entirety of everything as a whole there, you know, including metaphysics, spirituality and all those kind of pieces. So we're looking at these worldviews as the step back before we even get to philosophy, before we even get to a philosophy of science, before we start to get into, you know, everything that we're doing up to this point the two sort of underlying philosophies that I think that are, or the two worldviews that are most relevant, although there's one that's starting to gain some traction right now and I'll talk about that in a moment. But mechanism is again this worldview that was based on this root metaphor of the machine and it is the basis of the biomedical model. And we don't want to belittle the biomedical model because it has done so much for us. Obviously, so many of us wouldn't even be alive today if it wasn't for the biomedical model and this sort of mechanistic thinking. Many of the many of our things that we appreciate on day to day basis on tech, from technology and from societal advances, are based in sort of this root metaphor of the machine and all the parts of the machine coming together. You know, whether you're looking at a human being or whether you're looking at societies, you're looking at a universe or any level of science, it's done tremendous things for science to have this sort of mechanistic perspective of things. So I want to be very clear that this is still this has done so much good for us. They're still good for us, ongoing. But one of the problems that it has is it has limitations with scope, and so two qualities that are related to these will hypothesis range from include scope and precision. And it's very good mechanism, is very good at very precision like things. Like we can keep analytically breaking things down into little parts and molecules and you know, to the smallest things and atoms as a whole there. But it has a hard time as things get more complex and more multi-layered and multi-dimensional. It's not that I can't do it, it's just that because it's so focused on this precision and the specificity, complexity is very hard to address with that sort of perspective of looking at problems and if you're exclusively looking at things from that lens, it's very hard to address with the complexity of human problems, in particular pain. So it's not impossible but it's a bit more challenging. The other kind of worldview that we think that is important to discuss and I want to make sure it's brought up here because it's central to our institute and everything is contextualism, and so contextualism has this sort of root metaphor of the historical act in context. And so what that gives us is the ability to really again sort of have this time continuum with the context continuum, and there's just a lot more flexibility for uncertainty than there is in mechanism or in some of the other kind of world hypotheses as a whole there. And so one of the things that we also like about it is that it has a bit of a truth criterion that is, I think, useful from a practical standpoint, because it's contextualism is sort of the worldview in which pragmatism sort of exists as a whole there, and this truth criterion is called successful working, and successful working is something that also Stephen Hayes, early on in his career, along with a number of others, kind of presented as a way of tweaking contextualism into a scientific philosophy, because the way that peppers originally describe it, it wasn't related to science or art or to religion or anything. That was the general idea of like, how do we look at everything you know this preexisting before we look at our, before we think philosophically about things, what's even before them? Now, what we're talking about with this philosophy of science is now we're starting to kind of look at the analytic level, and what Hayes introduced was this idea that if we put the successful working at the front by calling it functional and then the whole sort of scientific philosophy being called functional contextualism, what it does for us is number one is it addresses some of the complexity and almost sort of like it can get a little crazy and sort of explosive in terms of how you look at problems if you're just looking at things contextually, because you can constantly think about the history and the context and you can just layer into this very complex thing but by specifically stating your goal upfront what is the function you're targeting and what are you trying to address this again, this functional piece of it, by saying we want to accomplish successful working. It also has this unique capacity for us to also take on another worldview for the purpose of successful working. We essentially would pretend to be a mechanist or pretend to be some of the other worldviews of organisms or formists, whatever the case may be, if it lends us towards a functional outcome or successful working as a whole there. And so we, we adopted first again this, this global worldview of contextualism, as a way of looking at things differently and as a way, as I'll talk about, to address some of the shortcomings of the biopsychosocial model. But the the big thing here is that by taking on sort of this contextual worldview now we can develop a scientific philosophy, this functional contextualism, and we can use that now to start to develop our frameworks, our theories and everything kind of from there leading up to, ultimately, the intervention, but a lot of steps up to that point. One of the things that I want to talk about that I didn't mention right at the start is there's an importance in us realizing that the way that we look at problems in these worldviews that we take on, we all naturally shift through forms of them in daily conversation, as you and I are going to be talking today, as we think in our own heads, we're constantly pivoting between sort of more mechanistic ways of looking at things, more contextualistic ways of looking things, more thermistic ways of doing things and Papers would call this, he would call this eclecticism, and that there's forms of eclecticism that are, that are part of normal, just human existence that we do. We just tend to maybe have a bend for a number of reasons, towards one worldview or another, and that's that's to. By his perspective, that's acceptable because we just we're just going to do it. But when we're trying to address a problem and we're trying to do science or we're trying to do something very particular, we run into an issue with eclecticism where we start to lose coherence. We start to things start to not make a lot of sense as you start to mishmash parts. It's sort of like if you are, you have a room and you're looking at like an object at the center of the room and you have four different chairs. Each chair has a different perspective that you can look at that object. Now if you are trying to say like, oh, I'm just going to straddle between these two chairs, you're not really creating a new kind of viewpoint, you're really just trying to combine multiple viewpoints and it's it's not actually creating something useful to kind of eclectically combine these worldviews without running into an issue where things start to not make a lot of sense. So it's part of the reason that we we had to sort of take the step back was how do we make things more coherent? Because that's been one of the biggest complaints with operational, with operational operationalizing the biopsychosocial model is we were very coherent in the biomedical model by being mechanistic and the biopsychosocial model you try and be mechanistic all of a sudden. That's why we we run into people wanting to pull the bio from the psychos, the social, and somehow integrate them together, because integration is, is. This is sort of a form of keeping things in these reductionistic sort of defined, specific ways and trying to somehow put them together without, you know, losing any of their original qualities, whereas if we choose a worldview or a perspective that's a little bit more synthetic, we get a little closer to where I think we all want to get to intuitively, which is we realize that the borders between things biology, psychology, sociology, sociology is, is is great and it's it's, it's soft and porous, and so we have to be very, very clear about you know how we're looking at these problems as we're trying to address the issues with. You know the biopsychosocial model, where the biggest thing number one has been, you know it, there wasn't a coherent sort of philosophy, especially scientific philosophy, to, to, to look at it, and we, without a scientific philosophy that's coherent, it's very hard to have scientific validity, it's very hard to develop content that is, you know, that is specific to. You know the biopsychosocial model, and so we start to run into some eclectic mishmashing things, and we wanted to try and avoid that by being very clear that this is the way that we're looking at things in advance. We're looking at it from this contextualistic worldview and, more specifically, this functional contextualistic lens, and it's our way of trying to. We're going to move beyond the biomedical model and operationalize the biopsychosocial model. We need to clarify again where we're. We're looking at the problems that are presented in the biopsychosocial model.

So yeah, no, I very interesting stuff there and I I definitely, as we talked before, this, all this kind of sinks to our biases and the process that I think and I didn't really recognize this process, you know, coming out of school or any of these things this whole metacognitive piece of like thinking about our thinking and what informs our thinking, what implicitly do we function under as we're doing things, where we just make these decisions? But if we step back and take that step back and then what's informing our belief that this is the truth of what we're experiencing in this clinical encounter and things? And it was a destabilizing step back for a lot for me, definitely, because it really made me realize that, you know, things were stand on a pillar of sand, not is, is concrete and is, um, you know, rigid and and kind of formed with this, you know universal truth. That I thought it was so very interesting stuff and I like the discussions about this coherence issue that we have with the biopsychosocial model, because I think it is an issue where we still want to use these categorical putting things in a nice neat bucket and we have a health care system that is filled withologists who I always. The analogy I always say is we got so many tree specialists who and very few folks that can put it together in the forest and or a forest specialist who can take the context and all the things that inform these complex systems that are not these nice linear systems that you know and you're right, like I. We're not here to bang on the biosephomitico model. It's done some amazing things. I mean, there are diseases that no longer exist on planet earth thanks to the biomedical model and it's. It's done some things, but it's obviously we need to take a step further and we've definitely. It falls short when it comes to addressing some complex issues, especially those around pain. But let's come back to the biopsychosocial model. You touched upon it in the coherence issue. But any other things you would add as far as what you see out there in just a day to day, whether it be social media or things you see in our practice patterns as clinicians maybe not even just physios, but when we're saying we wanna be biopsychosocial practitioners and we recognize, okay, this is probably a good way to operate. Yet the application piece kind of falls apart a little bit. I'm curious what your thoughts are as far as where that issues are and maybe how we can help those.

Yeah, I think one of the you know, thematically, one of the biggest things that we run into is, I think, that we were still drawing from sort of this mechanistic perspective of like. It's sort of like, you know, a plus B equals C, and if I do B or A, it's going to get me C, and so, as a result, we run into like a tendency for us to jump into interventions very quickly, even as we're going into the biopsychosocial model or, to some degree, we get overwhelmed with, you know, okay, well, this person with a little back pain has struggling with depression and anxiety, has PTSD, has these health comorbidities in addition to the back pain, and there's this tendency that there's. It's easy to get overwhelmed with like multiple diagnosis, multiple you know morbidity, and to now be focusing on interventions. You're going to have like a gazillion like interventions you're going to have to try and do if you're just sort of like saying like oh, that's the thing I'm going to address that. But they're all sort of overlapping and paralleling and there's a lot of porous sort of kind of spread of things. And so when we see it on social media, when we obviously have people coming in that have seen other providers again, it's this. You know, they get so many different like labels and then each label has a different intervention and then different providers are going to have different interventions for that label and different perspectives. So you know, I think kind of the other thing we're running into is that the biomedical model and the mechanistic way of looking at things tends to lean towards protocols. And even for people who say they don't really follow protocols and that they're trying to treat the person in front of them, they kind of still are doing a bit of protocols. They just don't realize it because protocols are sort of like well, here's the label, I'm going to do X, you know, to try and address it, and what we're seeing and what we're trying to introduce is that we got to slow down and clarify a little bit more, and we need to be able to, we need to be able to find a way to, you know, work with complexity more efficiently without losing some level of you know some, without losing scope, precision and then also depth, which is another piece that I didn't mention about earlier, where the realization that, from a scientific depth per standing, and kind of coming back to the coherence thing, if we're trying to do an intervention or we're trying to label something and the problem is that the scientific depth behind that theory is not able to sort of translate from, you know, from the clinical to the neuroscience, to the endocrinology, to the immunology, to the sociologic, all these different sort of levels and dimensions as a whole there, and it can't survive scrutiny or can't somehow support across those different forms of sciences. Then that theory might not be super well thought out with and we're just sort of like throwing something out there rather than really being clear about what's going on. And so we have to find a way that we can look at the biosec and social model in a way that we're maintaining adequate scope, individual precision because again we're trying to do this person-centered care but at the same time also maintain scientific depth and a number of you know programs and continued education and social media, and everything is again oriented to this, like just here's this magical intervention. It's about intervention first and it's basically like how do you make an excuse for doing your intervention, rather than like clarifying, like what is the underpinnings of this? And so we adopted again kind of going down the first our worldview, contextualism, functional, contextualistic science, and then going into okay, how do we develop a framework and what are the fewest number of things that account for the most amount of outcomes? How do we move beyond the necessity for a label that we've gotta quickly come up with so we can intervene and figure out these things that make up a lot of different labels? You know something that might be someone who presents with low back pain, depression, anxiety, has some socioeconomic factors related to unemployment, related to some sort of family dynamics that are difficult there. You can't possibly do one-offs on all of those, it's just impossible. So if we can instead kind of find what we call these well, we don't, but we inherited from the psychologist Hayes, hoffman and many of their collaborators these processes of change as a way of kind of looking at in rational science a little bit differently, where we're slowing down first and clarifying what are the processes of change that overlap between the pain biophysiology, the depression biophysiology, the sociocultural sort of level. These are both levels that we're operating on. That allows us to just have a few things. So you know, to give an example we might address on what we consider with our human rehabilitation framework, something from a movement and postural dimension or positioning dimension I should say thanks to Diane Jacobs for helping us commit to the term positioning versus posturing and anyway, so we could look at this dimension of movement and positioning related to low back pain, so how they're moving, looking at motor variability, processes that are related to how they're moving and also how they're sitting and maintaining positions as a whole, but at the same time, realize that some of that is being sustained at the cognitive level, related to what thoughts they have, some of those that is being sustained at the self level, and the self level will also parallel with the social level, because it's them versus you know, I versus you, here versus there, where we start to have, like these multiple dimensions. So now we've got movement, positioning, we've got cognitive, we've got self, and then from the emotional or affective domain, we might have things that are related to fear, sadness as opposed to depression which is this label? Different emotional responses, and how do these all sort of intertwine? And what are interventions that actually address all of those, instead of just like, oh, now I'm gonna target this, now I'm gonna target this. With this process-based approach, what we're able to do is we can introduce a movement experiment with a certain type of language that's going to operate on again this motor behavioral level, going to operate on this cognitive level, on the self level, on this emotional level, and it's just one thing and it's something that they could maintain and do in their life, versus, you know, a set of exercises that they're probably not gonna have the motivation or reason or behavioral tendencies to commit to as a whole there. So yeah, and in a long way again, I tend to be very kind of extended on these things I think the biggest thing that I see as a problem is we continue to do these kind of protocol driven jump to the intervention, which means we gotta label it intervene, versus like let's slow down, let's see what are all this sort of overlapping, porous sort of levels and dimensions that are present in this problem for this person, and what's the fewest number of things that we can use that can target all of these and creatively again cater it at the individual level?

You know I appreciate the explanation. I think you hit it as far as my thoughts on it as well. As far as we have this so reductionist, I need to get to the find it and fix it mode of kind of like I gotta identify the dysfunction and it's usually in the, you know, biomechanical realm. Traditionally. Of course we're doing better considering that, but then again we try to just do these, like you said, one-offs of like with a depression. But can you start bringing these processes and consider them as a whole as, like all the processes you know to our best ability to understand them that are going on in the context, and bring that into interventions versus just intervening on one factor on the facet glide or whatever it may be that you know I've definitely been there with that. But and maybe like, are there some supportive movement things we can do that address some of the emotional, the cognitive pieces and different things. And we're seeing some research you know Eoinne's group and stuff talking about cognition targeted exercise. It's still a little bit fragmented as far as like we'll see pieces of these processes that we're trying to consider in clinical care that are out there in the research. It's just a framework that kind of brings them all together in one kind of palatable way to kind of interact. So you've really already touched upon this a little bit as far as some of the kind of operationally how the human rehab framework kind of works. But maybe you can break it down. I mean, obviously you can I know you teach a whole weekend course on this thing and we'll make sure we link that if you guys want to check it out because it's definitely would be a worthwhile time spent for you. But you've kind of talked about some of the domains the emotions, the cognitive, the positional, the positioning. I wonder if you can kind of give a little bit 10,000 foot view of that framework and how you feel it kind of. You've already touched upon how it addresses some of this fragmented kind of interventionalist approach. But I'd love to hear kind of your thoughts on the framework and how you feel it kind of addresses things.

Yeah, absolutely yeah, certainly, and unfortunately, I wish I could say can do it even in the weekend, where we're at the point where it's like we had to create 150 hours of worth of content to really feel satisfied that we've at least given people enough resources to work on it. But yeah, in terms of what we did, is we again? We really wanted to make sure we are stepping outside of our comfort zone and so we drew heavily again on the work in the psychology profession. With their own crisis. They've got 600 forms of different psychotherapies and they're struggling to figure out how do we dress with. Some of the crisis is there and tends to be also very protocol driven and also very mechanistically, and how they look at the mind and that thoughts are dysfunctional, all these different things. So we decided to, you know, obviously draw from that for one part, is that they're really doing some really good work and we really dive with the idea that they're contextualistically thinking about these things. But the other part of it is we wanted to emphasize this idea of, you know, moving forward. We need to be more transdisciplinary, and Matt Lowe was kind of hinting at that too. I loved where he was talking about sort of like the edges between the professions being a little bit blurry or a little soft I can't remember exact words that he said, but that's exactly where we were seeing things too is that we need to be able to be across, think across disciplines and communicate across disciplines, and so one of the biggest things we committed to until we find out something else might be a better way to do it was to adopt one of their kind of kind of some of their central ideas, which is they develop a meta model. So essentially again, a meta model is sort of the step back and then the models underneath it. You can have countless theories and things that could build into it. So they built this meta model called the extended evolutionary meta model or the EAM, and what we did is we communicated with them and wanted to make sure that we can continue, in a collaborative way, to build on this, and we developed their own modified version of what we call the EAM-HRF or EAM Human Rehabilitation Framework, because it allows us to be able to now have a language that is at least between two disciplines being able to be discussed, that we can now start to talk between disciplines without having to be pivoting and doing all sorts of translations. It becomes a form of sort of you know, multi-discipline translation, and we started to test it more and more with physicians, nurse practitioners, pas, and they're also you know, our initial sort of surveys are showing oh yeah, they do understand this language when we organize it in these nine dimensions. And these nine dimensions are operating on two different levels. So the original aim that the psychology world introduced was six dimensions operating on the psychological sorry biophysiologic levels and the sociocultural levels. And these six dimensions were cognition, attention sorry affect, motivation, self, and the other was over behavior. And so those six dimensions again was really really good for the domain of psychology. What we did is with the EMH-RF is we added in three more dimensions. We added the motor or technically we'll say the movement and positioning dimension, the communication dimension and then the loading capacity dimension, because we believe that those three dimensions encapsulates everything that's ever been done in rehab across rehab disciplines and likely everything that ever will. So again, until someone proves is wrong, we think that those will cover some of the things that we do in addition to the dimensions that are related to the psychological domain. So by having again the shared language, that's sort of step one, the other part. That's again the keyword in there is that evolution. And so what they really did is they brought in applied evolutionary science into the psychology domain and we are proposing the same thing, which is where we start to look at problems from the sense of variation, selection, retention and context. And then again, what dimension, what level are they working on? And so these evolutionary sort of applied evolutionary sciences effectively becomes a new way of looking at evidence-based, evidence-based, evidence-based plan of care, because to a large degree, you are now, with every person you're working on, you are doing to some degree a research study and you're sort of tracking. If I introduce a variation, number one is on the individual level are they going to select that and why would they select that and is it appropriate for them? On the retention level are how are they going to retain that variation that they now selected and want to retain? And then, how does it operate under multiple contexts? And then recognizing that these again are operating on the biophysiologic and social-cultural levels at the same time, and how does the possibility that any layer that you're interacting in any variation you're introducing, in affecting another layer as you go along? So yeah, that's probably a way for us to kind of encapsulate it. The other part of it is sort of the qualities which I mentioned before, which is that whatever we're doing, does it have scope, does it have precision, does it have depth in terms of what processes do we target under these dimensions and the types of processes that you can select? It all depends on your model. So we offer some specific processes of change that we have selected that we believe is valuable. We have a long way to go, just like the psychology world, to determine what are the actual, the most meaningful mediating sort of processes of change as we go along. But we at least have a place for us to start. But it also gives us the ability that as people develop new models that could potentially be more useful than the model we have, it will still fit under our meta-model. We'll still be able to plug in new thinking, new ways of looking at it as we go along. There Again, looking at some of the work from Solvents Group so much that fits beautifully inside of the EMHRF, some of the Prisma work I think that's coming from Jotara there's a lot of different things that can fit underneath this that are developing as we go along. Then there was another worldview I didn't introduce earlier, called Organicism. You have to be careful with saying that. But the Organicist worldview is another way of looking at the biopsychosocial model that gains some traction. So when we're looking in active approaches, we're looking at an active, embodied, embedded, extended model to 4E stuff. Those are organicistic ways of looking at the biopsychosocial model. Even though that's a different worldview than what we're operating within for our models, it can plug into our meta-model if it's practical. So it gives us the flexibility that we can start to gain from other people's progress and their advancements. It still allows us to be able to maintain a framework that's flexible and adaptable to constantly advancing science.

Sure Science, and that's definitely a strength when it's not like you haven't painted yourself into a corner of this, is it? And there's no? If science tells me otherwise, I'm pot committed. I cannot. The sunken cost is there and I'm not moving. I like that aspect of it to where you've opened up space to incorporate other thinking and being open to hey, if there's a better way that science points out that would work better within the model, then let's pull that in. I'm not sure 100 percent if you can do this, but I would love to hear maybe and I think maybe the audience would love to hear too like maybe an example of a patient or a case, or you don't have to get too super specific, but maybe how you would look at it and with this framework in mind and apply it to maybe a unique case or unique presentation.

Sure, I usually do a knee example in my courses. I'm just going to do maybe a shoulder, so a painful shoulder, and we can scale it up or scale it down. Someone presents with a painful shoulder presentation and again let's make it relatively in the wheelhouse. What would look like it's in our normal wheelhouse of protocol-based approaches that there's some active range flexion and at a certain point in time there's that painful arc or that painful movement. If we're starting an analysis, we call it functional analysis, trailing on the behavioral psychology, traditional as a whole, there we can, on the movement spectrum, start to talk about what is happening from a motor behavior variability standpoint in terms of is the variability that's present in that movement adequate to be adaptable, to be active, lifting the arm overhead, or is it maladaptive in some way? In that maladaptivity, if we're going really zoning in on the biophysiologic level, is this a nociceptive biophysiologic presentation? Most likely is. It's probably not going to be neuropathic, but it might be nocoplastic on the biophysiological level. We're not going to know that for sure, especially in that initial encounter, and perhaps at all, because there's just some alterations on the biophysiological level related to, at a certain angle, the loading of the musculature, the tendons is resulting in some nociceptive activation as a whole. There we start with defining what they present with, which might be again that this active motion pain and then recognizing that as a whole there. But then we need to start to clarify what is the actual problem. Is this person having a problem with taking care of their home or doing their work? What is the context in which that this motion is relevant as a whole? There you have this two-way conversation, as we've always talked about these person-centered pieces. What is the actual problem? Because I don't know if you have encountered this, but I have had a lot of people where you can get rid of their pain and they are miserable. They are so dissatisfied with the fact that their pain is gone that it's like they were the worse off than when they had it, kind of thing. If we don't clarify again, is it about getting rid of the pain in the context of the activity or is it something else that's layered into that situation? Let's say that this person is just they're trying to clean cupboards in their house and that might be the function. They can't clean cupboards in their house because of the pain that's occurring when they're reaching and holding their arm up in that angle we have on the dimension of movement. We have again this motor behavior invariability. We might notice where there's this tendency. Maybe the scapula doesn't actually want to elevate in a way that allows the glenohumeral joint to be able to be a little bit more adaptive to loading the tissues in a more distributed fashion. We lose maybe a degree of freedom from a biomechanical standpoint, so we can get very narrow there. But then at the same time we want to start to think about okay, what is the impact of this person's thoughts about the pain? Do they think that they're injuring themselves, as we've a lot of times gone down? Is this a thought, belief related to injury that might be involved here? Is there an emotional response? Is it actually fear, because a lot of times we focus so much on fear, avoidance or catastrophization. What if it's not? What if it's frustration? What if it's anger? What if it's sadness? And what is that related on the individual level, the self level, related to their identity, their self? Does this person have a role in their family that this is now impaired and is there a lot of pressure socially that might be impacting it, which in turn again is introducing now on the biophysiologic, global endocrine responses, particularly elevations of cortisol, adrenaline, which now that's going to impair, impact again, nociceptive processes. So now we start to add in cognition and emotion and self Motivation. Again we kind of hinted at what's important as a person, what are their values? What is their role? Is it a family? Is family important? Is contribution important? And then how does that relate to, again, cognition and emotion? And on the biophysiologic global, what does that mean with adrenaline? What does that mean with nociceptive processes? And let's bring in again the immune system. So if we're now looking at loading capacity and we're thinking about the neuroendocrine immune axis, you know how long has this problem been going on? Has it developed perhaps some sort of neurogenic inflammatory sort of response that could be going on at a very peripheral, maybe again, sort of some central, depending on where you're looking at DRG, sort of regulation of substance P and producing sort of that localized inflammatory response and however far you want to go down that rabbit hole. But on a loading capacity, now you've got this neuroendocrine immune sort of axis, sort of network that could be present in this case. And again, how is that influenced from the cognitive level? How is this acting on the emotional level, on the self level, on the motivational level, and so I'm going to kind of constrain things a little bit. I'm just going to stick with movement, cognition, emotions, self and motivation and say that that ends up being that we're working with this person and we realize, okay, the way that we think that this network of processes are interacting and becoming maladaptive is these four are interacting in some way. Now some of them might be more dominant, you know, maybe again, maybe it's more on the movement. So, on a very simple case, you introduce some movement behavior variability and that's enough to really disrupt the network which is, again, if they start to feel confident, it's going to start to address at the cognitive level, which will address an emotional level which is going to affect on motivational and self and all those kind of things. But what if it's not? Or what if it is temporarily there and it starts to shift and change dynamically, as you're working with this person and now we're starting to see, okay, they're less concerned about the pain and they're more worried about, like, their family dynamics and you find out that there's a lot of stressors that are present there. That that's actually, it's almost the avoidance of the task, it's the avoidance of doing the work that's kind of really, you know, at an unconscious or a conscious level that might be driving some of that, and so that when they do move, that no, she's after processes so much more intense because of getting from a biophysiological level, it's it prime to be more intense, and so the problem could shift dynamically, moment by moment. And this process based approach and combining it from a network kind of analysis of different sort of functions allows us to be able to monitor it as it changes day by day, moment by moment, and also make sure that we're keeping everything at some level of awareness that we're not missing anything serious as well, because there are some cases again, we might have to kind of dive down on the biophysiological level and determine is there something that requires, you know, further testing for their imaging further, whatever the case may be? But we always have that in the background because it's part of the network. We're able to sort of kind of really be very precise and in scope down on that biophysiological level or we can scan back out and start to realize why is this person not shifting? Why are they not satisfied with the progress that they've made? Why are they, you know, pain free and not happy, you know that kind of thing. And so we want to be able to just kind of embrace the dynamic, constant sort of variation that presents in a problem. And you know that will bring us into that word. We briefly talked about the ergotosity, but I'm going to just pause for a moment and make sure I didn't deviate too far from her.

No, no, I think you touched upon it. I like the fact you know you're taking this, you know and you see these spider plots. You know the CFT group uses them where there's these different domains and they're really seeing which one. And it seems similar as far as you're trying to take really just being aware, explicitly considering these different domains or different processes that might be, you know, creating a spider web within a problem, within a person, and then making a clinical decision of, okay, which one seems to be the most important. Like you said, if we can change the movement variability piece in your example, maybe that's enough to drive change in the cognitive and the emotional and even socioculturally affect that level of things, because they're not able to participate in a role that's of value to them, that functions as them or gets them back functioning within a social group in society. I just like the fact that you've kind of put it in a framework that you know makes sense and it kind of takes a lot of these fragmented things that we hear about with the biopsychosocial model and the shift we need to make and considering all these things, and it kind of puts it in a model. Now, why don't we touch upon the word that you speak of? Because I think it was one that, honestly, I talked to. Leonard sent me some ideas. I'm like Leonard. I honestly don't. I have not heard that word. Now the definition of that word. I am 100%, I'm like man. How didn't I know this word? I might want to even make a t-shirt out of this word, because it makes complete sense and it's definitely an issue that we've kind of pounded the drum on here. But I'd love if you can touch on Ergadosity. I don't even want to say it because I'm a butcher.

Ergadosity.

There it is, I'm going to say it one more time, ergadosity, let us know what your thoughts on that are, and then we'll try to, in the interest of respecting your time, we can maybe, you know, kind of discuss any other last things you feel like we need to touch upon.

So Ergadosity again was just a fancy word for me. It was hard enough to like go there because I've always had an avoidance of mathematical things, but it's such an important thing because it comes into again. You know Chad Cook was talking about like the problems with systematic reviews and the subsets of that. The one of the biggest problems that we have right now is that the way that we do science, the way that we do evidence-based sort of processes, is an assumption of a phenomenon called ergodosity, which was again really kind of more well-known for in the physics world than it has been in other domains. But again, leave it to the psychologists to pull that out and then us trying to figure out what the heck. Oh yeah, that's kind of important, but it basically again it's an assumption that that whenever you're analyzing anything, that the properties of that thing, in this case a person, is somehow static, that it's set, and that when you're comparing multiple individuals, that somehow they're exactly the same and that they're gonna remain the same over time. And so ergodosity would mean that again we all have to be like these perfect clones with absolutely no change. And actually Jacob Templar just reminded me that even clones are never going to be exactly the same. So it's even harder to really figure out. How do you get that exact kind of static sort of starting place and how it goes from there? And what it lends to? Is that our assumptions and, like anything that we do randomized control, trial generally right now is this idea that we can apply from the group level to the individual. And we all know, logically, that's not gonna work well. And now well, not now. I mean, it's been around for a while but mathematically doesn't work well either. Our statistics inherently have this sort of flaw where they assume ergodosity, and we have to. We have to now start to take ownership of that, because to a large degree I mean, we've got all these things with key hacking and we've got all these things with replication crisis, but if we're not addressing ergodosity as well, we're not gonna make as much progress as we'd like. To simplify it more, what this fundamentally means is that we've been trying to do group novel analysis, use that to apply to the individual. We need to now kind of really revisit the idea and go to the individual level first, over time and likely with repeated measures, and to be able to really kind of understand at the individual level and do an individual level analysis before we consider going towards the group level. So the two terms that are related to individual and group is a geographic analysis, individual and no aesthetic. Is this group level sort of analysis? And we've again kind of done everything at this group level before. One of the proposals, again from Hazel's group and so on, is if we are going to make good randomized control trials or some other form of study design for how do we learn from the group, we have to collect large numbers of longitudinal, high density data. On the individual level and with process-based thinking, that means we have to gather data related to process of change and outcomes and then we need to pull that into a large data set and then see if clusters, rather than grouping, see if clusters of processes might show up at the group level then. But before we can apply to the individual level, we have to make sure that whatever is determined in those clusters that may be related to the individual actually has fit on the individual level, and so the term they've coined is called idionomic, and I think it has a lot of potential. Again, it might fall apart, who knows, but it's, I think, has a lot of potential for us to look at research in the future where we have to get larger volumes of individual level data, do some sort of machine learning analytical process where we can take that data and then apply it back to the individual and their operating network and see whether it's helpful or not that we can learn from groups as a whole there. So I think it's super important for us from a science perspective that we respect that term, because it forces us to now start to look at new ways of doing statistics, new ways of doing analysis, and again put the focus back on the individual first before we try and draw assumptions at the group level, because unfortunately again, we really have a hard time applying the majority of our randomized control trials to the person in front of us. It's just in many cases just not true, just not the case. So big changes, I think, ahead in that term, or good or good, assi is gonna be central to it.

Yeah, we had discussion with Mornhu and some others talking about really stripping out to the case-based series and case-based type approach where we're trying to see what's driving change, like you said, at the individual level. And I like how you've kind of taken it further to like let's reverse engineer things versus like stop trying to impose the group means and averages and norms upon unique individuals and let's find, pull a bunch of data of what's driving change within individuals and see, can we see what processes are the drivers of effect of some of these things and then bring it to group testing. I think, yeah, I like that thought process. I think it definitely. I don't know how much longer we have to see that RCTs and systematic reviews and all those things aren't meeting the needs of unique humans before we'll start that approach. But I don't know how much the research industry has. I don't know. I would hope that that ship has not sailed, but I think there's obviously great people like Steven Hayes, yourself and others who are really recognizing we have the whole cause, health group and different things who are really trying to say whoa, some of the philosophical underpinnings of what we consider knowledge, which is always this empirical, very categorical data point versus a very much more complex, interwoven with a lot of processes type data of approach that you're looking at. Yeah, I think we got a ways to go, but some exciting, hopefully future things that will develop out of that. For sure, leonard, what would be? Because I definitely I'm reading some of the things. You got some publications I know coming out in regards to this. You also obviously are teaching it currently. I'd love for you to share kind of if folks are interested in really digging deeper into this, which I highly encourage you all to do, because I think it's probably the first well, I shouldn't say first, but definitely the strongest, I would say right now that's really taken into account the breadth of complexity and really trying to give you a palatable process to start working with complexity in your practice, cause I again, I don't know how much longer we have to see that RCTs aren't answering the bell. They can be helpful and there's some evidence-based principles that interweave within this stuff, but I'd love to hear kind of how folks can go a little deeper with this.

Absolutely. I think the number one place is our kind of community online right now hrfhomecom. We recently put up a Facebook group as well. A lot of this we are open sourcing. You know we're trying to basically get it out to the world and you know we created sort of this living document, this white paper that will have a lot of information. Obviously we do have to get some things published that are going to be behind paywalls, but hopefully we can get some permission to do some of them and eventually I have the budget to do more open sort of open access sort of publications as a whole there. But hrfhomecom it has a lot of like introduction resources. We also have our first go at a kind of client manual with the we've written. So we tried to take a lot of the process-based approach in the hrf and we created client-based language and created our first sort of draft of what that would look like with the intention that you can customize it to your organization, your clinic. We will work with you on that. We can find out a way to do that, but you can see a version of that at the hrfhomecom. So there's the clinical side kind of gets into nitty-gritty, there's the client side, and then certainly a research community and now the nonprofit. You know we're constantly looking at people who are willing to volunteer, people are willing to donate. Whatever it ends up being for us to kind of move this forward and to start to kind of develop a research machine as we're going forward. And so hrfhomecom probably the best place to start it links to dynamic principles. So our education company we have, you know. Basically, like I said, we have 150 hours of content that we've developed. Not everyone's gonna need that. Some people are gonna need less, some people are gonna need more. The idea is that we kind of organize it. We also organize it a little bit by disciplines. Do we know that even some psychologist is interested in the way that we're looking at and counselors are looking at the way that we can integrate against some of these rehab processes where there's as well? So we have different suggestions on how that can happen. We do offer a certification if it's important to your organization or your group. We don't want people to think that they have to be certified in anything. It's just that sometimes, again, as you know, in certain organizations and certain structures, it's nice to have those letters and we do offer that if that's what you need to incentivize, to get it paid, so we do offer that as well. And yeah, other than that, it's just you know we're open book. The Facebook community again is a big piece and certainly can get a hold of me on LinkedIn and now I guess threads, as we're doing different things.

Sure no, and we'll link all that. I'll have, Leonard, send me the links to all that stuff. We'll put them in the show notes for those of you listening. You can check those out on your podcast provider, and then also those of you on YouTube. It should be in the description of the show so you'll be able to check those out and look at them in your own leisure. But I again, I highly recommend you take a look at that and help your practice. And then, obviously, the big thing is let's help more people, because our current approach isn't meeting the needs of the people, as we see chronic pain just getting worse over time. So, leonard man, I really want to thank you for your time today, really excited to see the future of what you got going there. I've made some exciting stuff. Keep up the good work up there.

I really appreciate it, mark, really honored to be here, and thank you for all the work you do. Keep it going so we will.

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This has been another episode of the Modern Pain podcast with Dr Mark Karjula. Join us next time as we continue our journey to help change the story around pain. For more information on the show, visit modernpaincarecom. Also visit the Pain Masterminds Network on Facebook for free education and resources. 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.