Low back pain & ecological dynamics

Have you ever seen or heard the word ‘ecological’ and not really known what it means when it comes to pain or rehab? If yes, then this is blog for you as I will aim to describe what it is in 10 minutes! The linked articles / chapters are hugely valuable so be sure to check them out!

 Ecological psychology is the branch of science looking cognition with a heavy component on the link between perception and action. And when it comes to people with pain, perception matters… a lot! It is a well-supported theory that the brain is actually a predictive processor, constantly generating hypotheses and expectations based on past experiences to anticipate and interpret incoming sensory information. Within an ecological-enactive approach to pain, pain does not only exist in the tissues (brain, joints, soft tissues e.t.c) but emerges through dynamic interactions between a person and their environment (and not just the physical one).

 Could it be that a part of the persistent pain process involves a hiccup somewhere along the way so that stimulus picked up by the senses that shouldn’t be a threat to someone, actually is?

 This is where understanding a little more about how we perceive things can come in handy, and one of the most commonly accepted theories in this area is one of ‘Embodied Perception’. In fancy words, embodied perception is the process by which sensory experiences are intricately intertwined with bodily actions, emotions, and contextual factors, shaping our understanding of the world through our physical interactions within it. In less fancy words, we perceive the world directly in terms of how we can interact with it at that moment in time. Understanding it through a sporting lens may be useful for some or through a video game analogy.

This is largely based on the theory of affordances pioneered initially by James J Gibson, an American psychologist particularly active in the 1950’s-70’s. An affordance can be described as an invitation to action from the environment to the person who is perceiving it, it’s a reciprocal relationship.

Imagine you are entering your mates’ house, just outside the front door. If you are someone who has no physical or mental impairments, the handle that is attached to the door invites you to grab it and affords the ability to pull open the door. How often would you consciously think about the location, shape or size of the door handle directly? I’d bet not an awful lot. You probably look at the door and intrinsically know that you can open it based on the fact you have a physical body with enough movement at each joint (degrees of freedom), perception of enough strength and experience of opening doors previously, both of the latter based on prior experience / cognition.

But what if you are in a wheelchair and the handle is situated a bit too high to leverage it properly to open the door? What if you have had a cerebellar stroke and don’t have the ability to control your base of support as you pull and move the door? In these scenarios does the door afford the ability to be opened?

We perceive our environment directly in terms of what it affords us, not actual dimensions and locations of certain things unless we specifically break down that information consciously.

So, what about someone who has persistent low back pain? Imagine that you do for the following scenario.

You’ve now successfully opened the door to your friend’s house and your senses are bombarded with information, and as touched upon above, we will perceive the majority of this sensory information in terms of what it affords us / what interactions we can have with it. This can be termed as our ‘field of affordances’.

You’re the last one to arrive to your mates’ house and there are only two chairs left. One of them is a wooden dining chair with one of those flimsy cushions on the bottom and the other is the couch, one of those really low and deep ones with super soft cushions. How might having persistent back pain affect you in this situation?

If you have a back that doesn’t really like bending, it might be that you look at the deep, low couch and immediately perceive ‘I could only sit in that for 5 minutes’, ‘Nope’ or ‘That is going to kick my back off’. We’ve probably all been there even if it’s more acute back pain we are experiencing. The dimensions of the couch don’t get a look in, in the fractions of a second that our brain is predicting and processing this information. The same could be said for the wooden dining chair, or not, the key is that it ultimately depends on how the person is in that moment! You might perceive things different if you have been doing housework all day and your back is already a bit irritable, or if you’ve already been on the beers at home before going out and actually your back is feeling a bit better than usual.

The idea that pain shrinks our field of affordances when it comes to being able to do things with pain is an interesting one. It shifts the focus for us away from more biomechanical and easily tangible measurements to a more holistic model that intrinsically ties together perception, expectancy, fear avoidance e.t.c. It is appreciating all the aspects of the biopsychosocial model without slicing it into three distinctly separate parts; it’s an enactive-biopsychosocial approach.

If we can start to think about patients’ field of affordances as part of our clinical reasoning, it has the potential to open up doors to different rehab approaches. It affords us more variability in how we practice (excuse the incredibly nerdy pun), which when presented with so much variability in clinical caseloads is probably a step in the right direction!

So how to do it? One approach could be expectancy violation and reducing bodily doubt, which is probably occurring in approaches like ‘graded exposure’.

‘Bodily doubt’ is a term that has appeared in literature recently that I think is fantastic and simply encapsulates complex, background theory. It ties together perception, action and cognition in true ecological fashion. If you have a patient with low back pain that sees a heavy box on the floor in front of them, they might experience bodily doubt. The intrinsic feeling that the body will fail to fulfil its previous functions; whereas once they would be able to pick up the sandbag with ease (bodily certainty), now their injured back will fall short of the task.

From a rehab perspective, one way in which we could attempt to build up someones function is through providing an exercise that promotes movement variability and will aim to expand the individuals field of affordances. For example, we could challenge the patient to pick up a relatively light (to start with) box or weight 10 times and ask them to complete a different approach or method each time. If we used something soft and unlikely to break, we could even ask them to push the boat a little bit and throw it out in front of them to set the scene for the next pick up or throw it over their shoulder. Why not add a little fun to the whole experience by making a bet with them or giving them a time challenge e.t.c! The aim is to start to violate expectations of pain associated with movement and perhaps look to break down once protective, but now problematic, movement patterns.

Through the experience of being able to achieve more ‘function’ or movement (not necessarily with low or no pain) the environment the patient is in might start to invite them to do more. The heavy objects on the floor might be perceived as lighter than it did pre-rehab, or the predictive brain is intrinsically less threatened by the mere sight of it because it now directly perceives that they CAN lift it based off previous experiences. There may be more bodily certainty.

For me this is really helpful in explaining why we haven’t found a consistent answer in high versus low loads, working on ‘core strength’ or mobility of the lower back. People who get better from these approaches might have done so due to expansion of their field of affordances and reduction of bodily doubt. Kind of an unconscious ‘oh shit I can actually do this’; but for people who have different backgrounds, fears and beliefs that particular intervention only gave them more bodily doubt from bad experiences or just simply did nothing to their bodily doubt and affordances because they didn’t believe it would have any effect… even if it physiologically did!

So, there we have it, an ecological approach is the name given for a rehab approach that appreciates and values embodied perception and affordance theory. An enactive-ecological approach to pain encompasses the ecological psychology aspect whilst also appreciating that pain arises due to an interaction between an individual and the environment in which they are embedded, which is biopsychosocial in nature.

If you ask me, it’s steps in the right direction. I’m excited to see what we can unpick about this in the future.

Hope you found this helpful.

 Jeff