Online CPD course videos for manual and physical therapists › Forums › MEET THE RESEARCHER › Forum – Stiffness in the Back: Biomechanical or Stretch Sensitivity? Tasha Stanton
3 October 2017 at 17:41 #1732
Hi All & Tasha
I would like to welcome you all and Tasha to the forum. I would also like to thank Tasha and her team for researching this important area.
Chronic experience of stiffness in the back and neck is probably the second most common complaint after pain. Whether it is due to biomechanical changes in the tissues or stretch sensitivity have important implications to all physical therapists and trainers; in particular:
• Clinically, how can we differentiate between biomechanical stiffness and stretch sensitivity?
• If stiffness in chronic conditions is not biomechanical what is the point of stretching?
• How can we help alleviate stretch sensitivity?
Stretch sensitivity is a topic that has been raised in the past but has not received enough attention in physical therapy education and practice. I hope that this research and forum will help bring this important issue to awareness. Below are some further references related to this topic.
You can download a certificate of attendance for your CPD points (learning with others) from here: http://www.cpdoathome.com/cpd-resources/tasha-stanton
Dr Eyal Lederman
Hultman G, Saraste H, Ohlsen H 1992 Anthropometry, spinal canal width, and flexibility of the spine and hamstring muscles in 45-55-year-old men with and without low back pain. J Spinal Disord. Sep; 5 (3): 245-53.
Esola MA, McClure PW, Fitzgerald GK, Siegler S 1996 Analysis of lumbar spine and hip motion during forward bending in subjects with and without a history of low back pain. Spine (Phila Pa 1976). Jan 1; 21 (1): 71-8.
Halbertsma JP, Göeken LN, Hof AL, et al 2001 Extensibility and stiffness of the hamstrings in patients with nonspecific low back pain. Arch Phys Med Rehabil. Feb;82(2):232-8.
Owens EF Jr, DeVocht JW, Gudavalli MR, Wilder DG, Meeker WC. Comparison of posteroanterior spinal stiffness measures to clinical and demographic findings at baseline in patients enrolled in a clinical study of spinal manipulation for low back pain. J Manipulative Physiol Ther. 2007 Sep;30(7):493-500.
Lederman E 2013 Therapeutic stretching: towards a functional approach (see Chapters 9 & 10: Pain and stretch sensitivity & Stretch tolerance). Elsevier
Hand LE, Hopwood TW, Dickson SH, et al. 2016 The circadian clock regulates inflammatory arthritis. The FASEB Journal, 2016;
3 October 2017 at 17:52 #1738
3 October 2017 at 17:55 #1739
3 October 2017 at 18:00 #1741
Hi Eyal and hello to all who are joining today! I look forward to discussing some of these points with you.
3 October 2017 at 18:03 #1743
Perhaps we can start with the first question, is there a way of differentiating between the two “stiff” states?
3 October 2017 at 18:03 #1742
Do let me know if you have any questions about my study or if there were parts that you wanted clarification on.
3 October 2017 at 18:09 #1744
hi there/good evening
Not sure exactly how this all works! But here goes:
One question I would like to ask is what positive key messages would you give (to patients) regarding the sensation/sound of crepitus within their ?painful spine that is supported by your excellent research/article?
3 October 2017 at 18:10 #1745
Hi Tasha, do you think it could have been useful to have a third “neutral” sound as a sort of control?
3 October 2017 at 18:10 #1746
Yes it is a great question and one that doesn’t have a simple answer unfortunately.
I would argue that all the sensations that we have are created, so to speak, in our brains using the available information. I think in the past, we only considered the ‘available information’ to be that which comes from the periphery. However, we know that this information can be modulated both at the spinal cord level and in the brain. It can also be argued that sensations do not come into our conscious awareness until they have reached the brain. As such, numerous other features can then potentially modulate the sensations. That is, perhaps being fearful of movement can have a modulatory effect on the information coming from the periphery. My paper, specifically looked at whether additional congruent sensory information (sound) could modulate perceptions at the back. And what I found was that adding sound information to pressure applied to the back had very specific effects on perception. And also that , in people with chronic back stiffness, a feeliing of stiffness was different to biomechanical measures of spinal stiffness. The evidence suggests that this type of central modulation of sensations can occur with experimental pain, acute pain and chronic pain
In terms of differentiating the two – I do think chronicity can play a role
3 October 2017 at 18:11 #1747
Id like to know what the response is to Eyal’s question – its not showing, thanks:
‘Perhaps we can start with the first question, is there a way of differentiating between the two “stiff” states?’
3 October 2017 at 18:13 #1748
Hi Tasha – I was particularly interested in the sounds used as part of the multi sensory test and the impact that seemed to have. Have you plans (or have you already) looked at the impact of verbal cues given by therapists – i.e the verbal equivalent of the creaking door sound – words such as wear and tear – even the word stiffness vs supple etc.
3 October 2017 at 18:17 #1749
When you were looking at the ‘feeling stiff verses being stiff’ did you look at passive movements as well?
There are always patients who actively can not move well due to feeling stiff but passively have a good range of motion. If stress receptors are acting in a protective capacity why are they not activating with passive movement?
3 October 2017 at 18:17 #1750
Would you agree that the research may highlight the need to focus in clinic on finding what the patient is being protective of – and to get information as to whether their protectiveness is truly helpful for them, and protecting them against ‘damage’ – be it on physical or other level, or whether their stiffness is is stemming from over protectiveness/ catastrophising which might cause them more harm in the long term
3 October 2017 at 18:18 #1751
Great question. I think that we need to positively reframe what grinding, crepitus sounds mean. For example, many times pops or clicks or grinding isn’t painful. This can be used to highlight that it is nothing necessarily going wrong. In some people, they do have pain while they move, but it isn’t necessarily meaning that the crepitus is reflective of why things hurt.
Pain neuroscience supports the idea that pain is a protective response. That is, it is a sensation that occurs when the perceived level of danger outweighs the perceived safety. Thus being scared of the crepitus may literally be sensitising the nervous system and resulting in more pain!
I wonder whether it might be reframing the sounds by explaining that our body is a wonderful adapter. Sometimes when you have injured an area, the body then adapts to help you heal. One of those adaptions can be that bone can be laid down (for example body spurs). This can sometimes then cause noises during movement. However, this isn’t a noise of damage, this is a noise of your body doing what it needs to in order to create a stable, robust joint.
3 October 2017 at 18:20 #1752
Hello Tasha I do find that in your conclusion people in pain are more sensitive to detecting change and it can be hard to tone down this sensitivity when the injury has improved.
3 October 2017 at 18:22 #1753
Hi ekelsey, Yes, we could have also used a neutral sound – but we were interested in seeing if we could elicit opposite effects by a sound that increased the potential need for protection (creaky noise) and a sound that decrased the potential need for protection (whoosh- signifying nice clean movement). We did compare to a control sound. Further we also showed that it wasn’t just the sound itself but it’s context – a creaky noise that decreased over time had an opposite effect on perception as compared to a creaky noise that did not decrease over time.
We were a bit limited in that people could only withstand so many indentations on a sore back!
3 October 2017 at 18:25 #1754
technical question – which is the ‘refresh’ button to see latest posts pls
3 October 2017 at 18:26 #1756
It is the button on the right of the address bar on the top..
3 October 2017 at 18:26 #1755
Hi Matt Brabner – great question! Yes, we have started to look at the impact of words. Specifically in people with knee osteoarthritis, they are often given the explanation of bone-on-bone and wear and tear (implying that activity will wear out already damaged joints) and some of my new work is evaluating hte impact of this. Sorry no result to share yet!
Emma Karran, a PhD student from the body in Mind research group that I work in, is evaluating what happens when you positively reframe imaging results in people with back pain. Again, just under way but watch the body in mind group’s space for the results (www.bodyinmind.org/).
I think it is massively important to think carefully about our words. Especially for patients without any medical background – saying their disc has slipped or their back is out can be taken literally and this can have devastating consequences for activity. Peter O’Sullivan has shared some great stuff about this on twitter, as has David Butler on Noigroup
3 October 2017 at 18:28 #1757
Thanks Tasha – you have probably seen it but there is a good paper /dissertation on wording with patients by Oliver Thompson at The BSO. I will look at Bodyinmind too.
3 October 2017 at 18:30 #1758
So we recruited people who reported feeling back stiffness, but in many of them, they had active range of motion within normal limits (some were ++ limited). Our measure of ‘being stiff’ could actually be described as a passive movement – we were applying a posterior to anterior pressure to the L3 spinous process and measuring the resultant displacement of the vertebrae.
But I think you hit the nail on the head that often times there is a disconnect between actual movement (active), possible movement (passive) and feelings of stiffness. This then can further support the idea that these sensations might not reflect the biomechanical state of the tissues.
3 October 2017 at 18:34 #1760
Sue – re: question about whether we have to look into consider individual reasons why people may be protective.
YES! I definitely think this is important to do. I do wonder whether some things might tend to always relate to being more protective – for example, if a person’s has high pain catastrophisation, then this may always relate to increased feelings of stiffness. However, it doesn’t meant that every person who feels still is a high pain catastrophiser.
Pain neuroscience suggests that our sensations are created based on input from numerous different sources and we need to explore this within the individual. I think this is where Pain Education (as per Lorimer Moseley and David Bulter) is a nice way to go about this as it directly explores with a person what their beliefs are about their injury, etc..
This is where I would like our further research to go. Thanks for the question!
3 October 2017 at 18:39 #1761
Yes we did find that people that had chronic back pain and feelings of stiffness were more sensitive to changes in pressure applied to their back. That is, they were over-protective (thought they were getting more force than they truly were) but were also hyper-aware. In the acute state this is actually probably a good thing – it helps us to prevent further injury. However, in a chronic state, this may become maladaptive.
So we know that when people better understand what pain is, what affects their pain levels, and that pain doesn’t equal damage, then they often experience less pain with movement (despite nothing changing with their actual back). Often this involves challenging unhelpful beliefs about pain.
So it is interesting to consider, if pain is a protective inference that occurs when we perceive ourselves to be in a dangerous situation (consciously or unconsciously), could other sensations such as stiffness (that relate closely to protective responses at the back) also be able to be modulated. For example, if we told people that the pressure applied to their back was actually helping to promote movement in a safe manner and that any pain that is felt is not representative of any further damage but merely of sensitised tissues, is it possible that we could actually decrease this sensitised response (detecting a smaller change in force)? Maybe! I would love to find out.
3 October 2017 at 18:41 #1762
And its so helpful to despcribe whats happening with positive suggestions as opposed to negative labels as you suggest. It is our responsibility to teach patients that and some of us are naturally more fearful of what may be happening and those patients need extra support.
3 October 2017 at 18:42 #1763
Hi Sue, I realised that I didn’t answer your other question following up on detecting the difference between two stiff states. I am going to do this now (in my next post)
3 October 2017 at 18:44 #1764
Could it also be helpful if we challenge negative comments/labels that are heard/seen outside the treatment room? For example on social media.
3 October 2017 at 18:46 #1765
Hi Tasha, thanks for the research! oftentimes one may feel stiff, but not necessarily have to act this way. Is it just too simplistic to think that way? using guided imagery may change the internal picture and help create a whole new atmosphere for movement
3 October 2017 at 18:47 #1766
It would be interesting to find out how much the use of tapes like Kinesiology tape help to override the perceived stiffness and dampen the pain perception. I find with some of my chronic patients telling them that the tape will support their back and prevent them from moving beyond the normal range of movement has a dramatic effect on their pain perception and ability to move.
Could it be similar effect to the sounds modulating the perception of stiffness and pain?
3 October 2017 at 18:52 #1767
Technical note: you may have to press the refresh button on your server to get the latest posted messages
3 October 2017 at 18:53 #1768
I would argue at the moment that it isn’t an exact science to determine the difference between biomechanical and stretch sensitivity (as termed by eyal). I think a term I am a bit more comfortable with is centrally mediated stiffness.
As I mentioned above, I think there is a central component to all feelings of stiffness, regardless of whether there are literal biomechanical changes that impinge on movement (like ankylosing spondylitis) or whether there are no biomechanical changes. However, I do think that there are people in which the relationship between biomechanical changes and feelings are less robust or absent (as was in our sample). This seems to occur most often with chronicity.
Given the evidence for pain neuroscience education in decreasing things like fear of movement or catastrophising (which can feasibly relate to someone being more overprotective of a painful body part – and thus sensitising the system), perhaps an interesting way to test this is to target these concepts in people and then see what happens to their sensations of stiffness (and their active movement). We have findings that we are currently writing up that show that understanding that pain does not equal tissue damage allows people with back pain to bend and move further than a person that does not understand this. This raises the possibility that an ‘intervention’ type test such as this might be useful.
Sorry that I don’t have a better answer but super interesting question!
3 October 2017 at 18:59 #1771
I use the terms stretch sensitivity or ROM sensitisation.. but open to suggestions. Patients seem to understand stretch sensitivity..
3 October 2017 at 18:56 #1769
Suzanne – yes absolutely! I think this is a critical aspect because many people get their information from social media and from other sources that are not that well evidenced.
Even a look at various supposedly health websites show that people can be misled. For example: https://www.arthritis-health.com/blog/crepitus-may-be-early-warning-sign-knee-arthritis – how terrifying is this for someone?
I think that is why education of patients is so important and has to be a key feature of our treatment. I.e., I wonder whether we schedule in allocated time that is literally, “let’s myth bust so that you understand your condition”.
3 October 2017 at 18:59 #1770
Thanks Tasha and thanks for sharing/discussing your research. I will share this idea with the #osteopathyworks facebook group to see if we can share widely myth busting.
3 October 2017 at 19:00 #1772
Thanks again for taking the time to discuss your research with our members. It has been very useful and interesting discussion. Keep us posted on your research.
To all participants
Thank for your input and sharing your thoughts on this important topic. We are planning more exciting sessions with researchers in the coming months.
Your certificate of attendance can be downloaded from the link pasted in the introduction at the beginning of forum..
Dr. Eyal Lederman
3 October 2017 at 19:01 #1773
Yosefa – great comment. There are certainly people who are not very limited despite feeling quite a lot of back stiffness. We had some in our sample that had very low levels of fear and very low levels of disability and interestingly, still exhibited protective behavoiur in terms of their back (thought they were getting much more force than they truly were). I don’t know if increasing one’s ability to use guided imagery would alter feelings of stiffness but it would be very interesting to try this! This could be particularly interesting to test in people that have feelings of stiffness during specific ranges of movement – is their implicit motor imagery less robust in those postures? I don’t know!
3 October 2017 at 19:03 #1774
3 October 2017 at 19:04 #1775
Hi Sue, really interesting suggestion about use of tape. I think this is a brilliant example of increasing the safety factor. I work with a physio here in Adelaide who has a really interesting approach that uses an active (vs more passive, like taping) strategy with people with back pain. He does a very thorough objective and subjective assessment and then if he doesn’t find anything that he is concerned about, then he has them do a dead lift/squats on the very first day. To challenge their perceptions and beliefs of their back (obviously ++ clinical judgement needed here!). I interviewed one of his patients on a ABC RN Health Report episode – see here:http://www.abc.net.au/radionational/programs/healthreport/the-brains-role-in-pain/7735610
I think your strategy is great! How do you wean them off the tape?
3 October 2017 at 19:04 #1776
3 October 2017 at 19:05 #1777
Thank you Tasha and Eyal
3 October 2017 at 19:05 #1778
I’m very new here and please accept my opinion may be out of point.
I’m so interested in the idea that the pain is a protective response of the body. My idea is when the tension gap between superficial fascia and deep fascia or muscles exists, the person feels “stiff” even if anything is stiff. Just loose superficial fascia there and it makes the ROM larger, As Ruth said, taping tape gives support to restrict the looseness of superficial fascia and gives the patient secure. Dr Tsutomu Ben Fukui mentioned crease of skin (it may be superficial fascia) Increases the joint of ROM.
Could you tell me your idea?
3 October 2017 at 19:09 #1779
3 October 2017 at 19:09 #1780
3 October 2017 at 19:09 #1781
I never need to. Once the pain has gone and they have functioned normally that sense of needing support goes.
3 October 2017 at 19:18 #1782
Thank you Tasha and Eyal
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