Willem Kramer

Several months ago I shared an article “The fall of the postural-structural-biomechanical model in manual and physical therapies; exemplified by lower back pain.” with about twenty of my colleague therapists and asked for their feedback and opinion. The reactions I received or the lack thereof actually surprised me.

For those of you who didn’t read the article in question, the text composed by Eyal Lederman questions, based on statistical analysis in regard to PSB factors and lower back pain, the validity of the often used and currently very popular postural-structural-biomechanical (PSB) model. According to Lederman the therapists applying the model falsely assume structural imbalances and asymmetries to be the cause of (lower back) pain. He thinks to prove this by sharing statistical research that fails to confirm a relationship between several postural-structural-biomechanical properties and (the occurrence of) lower back pain. While questioning the relationship between lower back pain and trunk asymmetries, low muscle strength, lumbar lordosis, disc degeneration, short (tight) hamstrings and psoas muscles he emphasizes the importance of what he refers to as the “biological reserve” (stress-resistance or adaptability as I prefer calling it).

To my surprise nearly all inquired colleagues – most of which look at their clients especially through a pair of PSB model glasses – regarded Lederman’s opinion simply as wrong or avoided discussing it all together. One often heard argument opposing Lederman’s ideas was, “I’ve applied the PSB model with success, which proves it does work therefore proving Lederman wrong.” Although understandable, this explanation doesn’t make much sense when thinking of the many influences (known and unknown) we exert during our treatment and exercise sessions and all that follows (known and unknown) in reaction to them. We can never say, beyond a doubt, what it is that makes our clients feel better. Unsettling as it might be, even the most knowledgeable therapists among us can merely make an educated guess, no more.

Only one colleague had the brightness of mind to imply that Lederman’s point of view was a righteous one. He argued that questioning the validity (or for that matter the existence) of one single, strongly distinct and fenced approach to all pain problems, and lower back pain in specific, was justified. There is after all far more to consider than only the postural-structural-biomechanical (postural, structural and biomechanical) variables of our clients suffering (lower back) pain. He concluded, “The PSB model is just a single approach to physical complaints, one of many.”

What struck me as odd is that of all inquired colleagues merely one thought to think of the complexity of (lower back) pain, all the possibly involved factors (known and unknown) and the possible solutions and/or remedies (known and unknown). Surely he could not be the only therapist realizing that no client is alike, pain comes in many different shapes and forms, is influenced by many internal and external factors and might therefore be approached from many different angles and eased in many different ways.

Although the reasons for the absence of an all encompassing answer from all my colleagues are likely manifold, I think I might have received more enlightening feedback if only Lederman would have reached a hand. Instead, he makes the same unfortunate mistake as those he tries to educate. By seemingly denying the possible use of the PSB model all together he displays a limited point of view equal to those who only work according to the very model he questions. I can’t help but think that his rather one-sided deliberation is probably not conducive to starting a useful discussion but instead shuts the door on exchanging thoughts. It would have been great if he’d have mentioned that, “although the PSB model might be effective at times – this despite the fact that certain statistics seem to prove otherwise – there is far more to consider, for example the biological reserve or stress-resistance of our clients”.

Be that as it may, I think the regrettable form in which Lederman shares his ideas does not excuse my colleagues from displaying an equally black and white train of thought – we should know better.

While I do not expect all of us to agree with every therapy philosophy, approach or technique I do feel we should at least acknowledge that there is more than we agree with, more than we know about, more than we (think we) understand and more than we are comfortable with. Just like stories, our clients and the pain they experience have many, many sides to them – as therapists maybe our thinking should be just as multifaceted.