Best and Worst Analogies in Physical Therapy
If you are a regular reader of my blog you most likely realize by now that I’m definitely a little on the nerdy side. I spend a lot of time reading research and legitimately get pleasure out of educational discussion, new studies, knowing random facts, and philosophical questions. I value knowledge and feel like education is the most powerful tool we have as medical professionals. I personally spend a large portion of time talking with and educating my patients in clinic. I even regularly warn them that if I get boring or if they start to glaze over to cut me off and tell me they’ve had enough. Early on in my career I wasn’t as perceptive to the patient glaze over as I am now. I had so much information that I wanted to tell my patients…so much anatomy, physiology, physics, biomechanics, pain science, etc. that I had just learned and wanted to share. I had a trumped up ego that wanted to let everyone know I wasn’t “a personal trainer” and demonstrate that yes “I had gone to school for longer than a few months” to learn to how to be a physical therapist. I fell into the position of trying to make everything overly complicated in an attempt to demonstrate how much I knew. I had to make things complicated in order to show patients that they were lucky they found someone who could pick out all of the little imbalances, weaknesses, and asymmetries working together to create their unique dysfunction. However, the nitty gritty details didn’t seem to interest most patients like it did me. Even worse, as I learned more about pain sciences, I realized I was likely creating all sorts of nocebo driven thoughts and implanting fear of movement into my patients.
It has been said that the best educators and those who understand topics thoroughly can explain them simply to someone with minimal knowledge of the topic and have them walk away with a good understanding.
Now I don’t necessarily think this applies in all cases, but I do feel like there is some credence to this quote. An exceptional understanding of a topic leads to the ability to relate it other more simple or generally understood scenarios that happen in everyday life. This is where analogies come into play as one of the most powerful education tools you can use to improve your communication with patients. Almost every single physical therapist I’ve treated alongside uses analogies on a regular basis, but some of these ways we help people to “understand” what is “wrong” with them may not be optimal. I wanted to take the opportunity to talk about some commonly used analogies that may not be the best, as well as present a few you should consider adding to your patient education repertoire.
Bad analogies:
“Your body is a lot like a car that’s out of alignment. If you drive with your car out alignment for long enough parts start to wear out and that’s what is happening to your knee, ankle, foot, IT band, shoulder, etc”
When I was first in PT school this analogy seemed brilliant to me. I was learning all about biomechanics and how we could alter pelvic position and improve the posterior roll of a mal-aligned rib, or push an elevated first rib back into place, or even change someone’s resting posture to be less kyphotic to take care of that nasty impingement in their shoulder. However, the more I learned about the influence of posture in painful conditions/injuries, the inability to re-align pelvises, the high likelihood that we don’t release tissues, and pain sciences these body mechanic approaches made less and less sense. What’s worse is I realized that not only did they not have clinical significance the vast majority of the time, but they could even be causing a negative effect by implanting a mindset into my patient that their body was easily distorted. A mindset that they are not robust enough to withstand the demands of daily activities without getting out of whack and needing me, “the human mechanic”, to fix them up. I hate this analogy because it implies that the human body is not a living, adaptable, and dynamic creation. We know well that humans respond favorably to physical stress. In fact, placing the right amount of overload on tissues is exactly what we do every day to make ourselves stronger. Running to improve CV fitness, weight lifting for increased strength, plyometrics to jump higher and run faster, and growing calluses on our hands to protect against abrasive work are all examples of how the body reacts positively to stress in order to protect us; in order to make us better equipped to survive the demands of life. Saying the body is just like a car completely negates the fact that the body can heal and adapt to imparted demands. Additionally, this analogy completely disregards the fact the human body has a nervous system and a brain. A nervous system and brain that are necessary to experience pain. We know from a plethora of research that pain and tissue damage do not go hand in hand all the time, and simply stating that everything that hurts is because its worn out or due to poor alignment is at best misguided and at worst completely wrong.
“If you have a weak core it’s a lot like a brick wall stacked up without mortar between the bricks. It’s weak and you could easily push the wall over, but if you strengthen your core stabilizing muscles it’s like putting the mortar between the bricks. It makes the wall strong and you won’t have back pain anymore”
There are so many things wrong with this analogy, but I will try to stick with the basics. Like the fact that we can now be quite sure “core weakness” is not indicated as a cause of or treatment for low back pain or really any other issues. Smith et al. RE-demonstrated that with their update on the last systematic review that found core stabilization exercises are not better for treating back pain than any other exercise intervention including general exercise. Not to mention good ole common sense tells us that we see plenty of people who have generalized weakness and no back pain to speak of while simultaneously seeing plenty of people who are strong as an ox with back pain. This really goes back to Hodges et al studies in the 1990s with a few patients that showed possible muscle activation onset delays in those with back pain. This is great and all, and maybe the transverse abdominus does play a significant role in spinal bracing and increasing intra-abdominal pressure, but it’s quite the leap to say that a 50ms delay in the onset of the muscle is a cause of back pain. Additionally, they could have very easily theorized instead that the delayed activation in TA was a protective mechanism that stemmed from the back pain instead of the cause of the back pain. We have a chicken or egg situation that in the end doesn’t really matter. It doesn’t matter because we can’t palpate a 50ms lag in onset time, therefore we cannot say the muscle is dysfunctional. Moreover, there have been several studies conducted since that show no changes in muscle activation patterns once people go through weeks of motor control exercises, yet they no longer have back pain. This type of thinking in back pain and this analogy don’t respect that back pain can be incredibly complex with a multitude of psychosocial factors instead of just a “weak core”. Finally, this analogy yet again imparts the idea that the body isn’t robust, and that it could be so weak that it is unstable. These thoughts can lead to fear avoidance behavior and increase the back pain due to the idea it can’t hold up to regularly imparted demands without getting out of whack.
“Your disc looks and functions a lot like a jelly doughnut. When you damage it the jelly squirts out and presses on the nerve causing you pain”
I have to admit, early in my career I explained the disc this way to patients on a few occasions. However, I have since come to stand in strong opposition to the use of this analogy for a few different reasons. The first reason is the fact that it illustrates quite a scary situation to a patient. A jelly doughnut is very soft, weak, fragile, and once the filling squirts out it would be basically impossible to put it back in. This represents a nice example of nocebo being exemplified at its finest. Secondly, we have a plethora of research to date demonstrating that discs heal, and in fact, they heal very well. You can read more on this herein a corresponding article I have written. Imagery of a squashed pastry that would be near impossible to relocate the jelly does not impart this idea to a patient. Finally, we know from even more research that a very large proportion of the population has disc bulges and herniations without any pain at all. In most radiculopathy scenarios SOMETHING has happened to sensitize the nervous system to certain movements, positions, or postures which leads to danger perception and/or nociception. There may or may not be a disc involvement, and often times the disc on that MRI the patient brought you isn’t even the cause.
For the time being these are the poor analogies I want to present and strongly recommend you challenge yourself to throw away and hide the key. Next, I would like to move on to more positive analogies you may be able to start implementing in order to educate, decrease anxiety, fear avoidance, and empower your patients.
The first analogy I would like to present was created by Dr. Jason Silvernail, PT, DPT, DSc, FAAOMPT.
“Understanding how to help you nerve tissue recover and tolerate physical stress/load again is a lot like watering your lawn. Its not question of waiting enough time for healing, It’s a question of providing the right environment and the right time for it to recover, and then the right stresses to build up its strength. We need to do three things to grow back health grass- give it a rest so it can take root, water it consistently to grow it, and then walk on it carefully to build its strength and resilience back up.”
Stage 1: Rest - Let it Take Root
To get your grass to grow back, you first need to stop walking on it while it’s growing. Depending on how brown it is, you may want to walk on it just a little, or not at all. If you have a volleyball game on it, you can be sure that will REALLY slow down the process. Your nerve tissue is the same way. As it heals, you can load it with exercise, activity, or prolonged postures more successfully. But early in this process, you need to minimize aggravating activities and prolonged positions, in order to maximize your healing. You will notice slowly that you can tolerate more activity and a longer time in different postures, but this ability is a direct result of how often you are doing the movement therapy to “dose” the tissue with blood. This stage ends when you are past the worst of the pain.
Stage 2: Build - Let it Grow
In addition to resting it, you also need to water it, that’s how it gets its nourishment. Your nerve tissue is like that, too – only instead of water, it needs a regular blood supply and reduced mechanical stress in order to recover. Doing the movement therapy you’ve been practicing is how you both supply the tissue with blood and reduce the mechanical strain on the tissue. You will feel better as a direct result of the frequency that you do this in most cases. Now, if your grass is brown and dying, you don’t want to just dump a lot of water on it the first day – that will just get you a lot of mud. You need to start slowly and work yourself up. Some increased pain is expected after you start to do the movement therapy properly. This will go away with continued movement and activity. This stage ends when most of your daily pain is gone.
Stage 3: Strengthen - Toughen it Up
After your grass has started to grow back, you need to build up the root structure so that it will be stronger. You do this by slowly walking on it at first and then spending more time on it to allow it to build up. A healthy lawn is one that is strong enough to play games on without getting torn up. Your nerve tissue isn’t different - after it grows back in, you need to build up its tolerance by loading it with exercise and physical stress. The more you build up it’s tolerance, the less likely it is to get irritated again. This stage ends when you have minimal pain and you can do daily activities and additional things (like work or exercise) with relatively few symptoms.
How Long Does It Take?
It’s hard to predict the recovery of nerve irritation and nervous system sensitivity. As long as you are following the 3 step plan, you will get much better over time. It’s impossible to predict exactly WHEN or HOW MUCH you improve, but if you are doing your part, it’s simply a matter of time before things improve.
Rules for Regrowing Grass Rules for Healing Nerve Tissue
1. Keep off the grass to let it take root ---------------------------------------1. Avoid aggravating things early
2. Water it slowly to build it up ----------------------------------------------2. Restore it’s health with therapy
3. Toughen it up with activity ------------------------------------------------------3. Strengthen it with exercise
“Pain is a lot like an alarm system. It’s there to let you know when your brain THINKS something is going wrong or dangerous”
I picked this analogy up off of Dr. Adriaan Louw, PT, PhD, CSMT. He advised that we can very easily explain pain to a patient in terms of a home alarm system. Just as your home alarm system triggers when a burglar breaks the window, the pain alarm goes off if it perceives danger or threat. This is an attempt to alert and protect us in order to increase the chance for survival. However, occasionally the alarm may dysfunction. In fact that reminds me of a time when the smoke alarm in my apartment had a low battery and decided to go off full blast at 3 in the morning and wake me from a dead sleep. Even after I put my heart back in my chest, stood on a chair in the dim light and ripped it off the ceiling it kept screaming at me. It didn’t stop until I grabbed a hammer and smashed it into a million pieces….well maybe that last part didn’t happen and I simply pulled the battery out, but I wanted to smash it. But I digress, during persistent pain the trigger on the alarm system can become very easy to set off for reasons other than tissue damage or danger (low battery= poor sleep, stress, memories, emotions, etc). Instead of needing a burglar to break a window to set the alarm off, the wind only needs to blow on the grass in the front yard to set it off. Just the same, instead of tissue damage occurring or something physically being “wrong” to cause pain, the smallest movements can set off the alarm system and cause one to unnecessarily experience pain. This analogy tends to be a great ice breaker into talking deeper about pain sciences with patients. To take the alarm system analogy a step further, it can be used to explain spreading pain or pain in other locations of the body. If you were out of town and your house alarm went off and you weren’t there to turn it off, it’s likely that it would end up waking your neighbors. Similarly if the alarm system in the body is consistently ringing, it is likely that you could “wake your neighbors” and begin to experience pain in a wider area than the original area, or even in old injury areas that the brain has previously developed a neurotag to elicit pain.
The next analogy is one I recently created….I think (please tell me if you have heard this before and I subconsciously stole it)
I use this analogy when trying to explain a neurotag to a patient and how it’s possible for factors other than just tissue damage to cause pain. I explain to patients that pain is like a light in a room with multiple light switches for the same light. If the light comes on it means they have pain, but the room could have 5, 10, or even 20 light switches. Tissue damage is likely a light switch, but maybe bending forward is also a switch. Maybe stress, bending sideways, lack of sleep, anxiety, cold weather, or even a memory could each act as a light switch. The light/pain can be turned on by any one of these switches at any time and the result is the same. Then I explain a scenario they are familiar with. I illustrate that once you’ve lived in a house for a long time you can turn on all the switches without even having to think about it. It often happens subconsciously with hardly any effort at all. This is just like how the painful neurotag switches can be so easily turned on if you’ve experienced persistent pain for a long period of time.
The next two analogies go hand in and hand by addressing the nervous system and musculoskeletal interface. I will present them both simultaneously and let you choose which you prefer. The first I have heard before, but was recently re-presented to me by Dr. Mark Powers, PT, DPT, OCS, COMT.
“Muscles and joints are similar to the hardware in a computer, while the nervous system is very similar to the software and operating system. The best hardware in the world is useless without a good operating system/software.”
The second of these two similar analogies I can’t remember where I heard. I have taken the liberty of adapting it a little, but please let me know if you are aware of the origin, or it could be improved upon!
“Muscle and connective tissues are very much like the employees while the nervous system is much like the employer in a business. If there is tightness, stiffness, guarding, or pain in a muscle it is often that the employer is telling the employee how to act, and much less likely that you have a dysfunctional employee. We need to work together to take the stress off of the employee by calming down the employer and stopping it’s overbearing micromanagement that is leading the employee to act up.”
The final analogy is an old one that I’ve used several times, but it was recently brought back to my attention by Adriaan Louw. It has to do with calming patient’s after whiplash type injuries.
“Your neck is very similar to your ankle. It has lots of little joints on each side of it that have small ligaments that can get sprained just like when you roll your ankle. It’s likely that when you were in your accident your head was shaken around a little bit and you ended up with some tiny sprained ankles in your neck. They are probably swollen up and very painful just as if you had sprained your ankle, but we know that just like that ankle the joints in your neck will heal well with just a short amount of time. For a small sprain it could be two weeks, and for larger sprains in may take 6 weeks to heal. We need to keep your neck gently moving just like we would your ankle in order to maintain your range of motion and strength as well as increase blood flow in order to heal well.”
I love this analogy because it validates the patient’s pain and that the patient likely did have some tissue damage that will take some time to heal, but also shows them that there is hope and that their neck is just like any other body tissue that has the capacity to heal and recover. It encourages active recovery strategies and can be paired with the alarm system analogy when their nervous system is ramped up as often is the case after a whiplash type injury.
I know that there are tons of other great analogies out there, however, at the sake of not writing a novel I decided to only choose these for the moment. I encourage you to comment with some of your own and help all of our learning!
Thank you for taking the time to read!
Jarod Hall, PT, DPT, CSCS
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