Phillip Snell- Fix your own back
When teaching an Exercise-2 course in Portland, Oregon, USA I had the pleasure of spending some good time with Phillip Snell, the organizer of the course, who really made my visit very enjoyable.
Phillip is not only a great course organizer, he is also a Chiropractor with some very interesting ideas and functional approaches for people with back-pain helping them helping themselves.
Here is an interview I made with Phillip Snell:
Who is Phillip Snell?
You are very much an advocate for the Functional approach of rehabilitation and Sports-performance, how would you describe your way of working as a chiropractor?
It sounds trite, but probably the simplest way of explaining it is that I try to treat people the way that I would like to be treated. I like to be able to move somewhat well and I have better places to be than a doctor’s office. I assume the same for my patients. I try to keep them doing the things they want to do by minimizing need for care. That, to me, is a decent definition of ‘functional’ as it pertains to rehab. That functionality differs for the 65 y.o. grandmother who wants to be able to be on her feet for several hours to cook Christmas dinner for her extended family without her knees hurting vs. a competitive athlete who wants to compete without knee pain. However, both cases might benefit from being able to squat well without pain. I like the idea of ‘scalable movement’. I will teach that grandmother the same things I’ve learned from world champs like powerlifter, Chris Duffin. She can add weight to that pattern and build resilience to her daily tasks and to the occasional unexpected activity curves life throws at you. I try to deliver that information in a way that is consistent with my reading of the pain science literature by reducing fear and delivering an empowering message. That conversation might look like…“So it hurts to squat the way that you were before, but when you use the methods we covered, you can squat painlessly? You have the choice to squat in a way that does not hurt. Want to not have to pay attention to how you squat in order to avoid pain? Use what you learned about painless squatting , “lather, rinse and repeat” by increasing the volume and perhaps load on that painless squat pattern until that pattern becomes your default way of squatting.”
Within the tools available to me within my professional scope of practice, nothing has better evidence to prevent illness and injury than exercise. Exercise is also the most powerful tool we have to tilt at rehabilitation of injury. Currently it’s one of the few tools we possess to address chronic pain and has some of the best evidence at helping to improve the disinhibition of descending pain pathways that set up shop in those with chronic pain. In my work as a chiropractor, I have a solid base of training in manual techniques including manipulation. However, I use those methods of passive care as a means to an end to try to get people to move more freely and more frequently without pain. In general, patients in my clinic as well as other chiropractors seem to think that approach of teaching empowerment and reducing need for care runs counter to their experience of or beliefs about the chiropractic profession.
What are your thoughts about the regularly advocated recommendations of “take it easy”, “rest” and “be very careful” approach to back related problems?
That all depends on the patient I’m working with at the time. For instance, I have competing powerlifters and runners who are injured right now who would benefit from some judicious application of that message to allow some time for injured tissues to mend. To use an old equestrian analogy, you need to know when to “put a bit in the mouth and when to put a riding crop on the rump.”
In general though, I have seen the “be cautious”, “rest”, “avoid activity” message has been a disservice to most with back pain…acute and chronic. In our clinic, we prioritize movement-based interventions to address back pain. These can be remarkably effective whether the pain is mechanical in nature or neuropathic in nature. For example, we see a lot of discogenic back pain and radiculopathy in our clinic on a daily basis that has typically been through a variety of other clinical approaches. As many reading this will know, those types of back pain can be the most debilitating and most challenging to manage. We have found great success in our patients by using the Mckenzie approach to identify directional preference, followed by re-ordering of basic forward bending movement to promote hip hinging. We then load that pattern with weight to challenge the patient’s beliefs that lifting harms their backs. We use ADL levels of weight between 20-50 pounds. We do this in 60-90 minutes in the first encounter and usually don’t apply manual therapy, manipulation or passive modalities. Just lifting with performance-informed methods. Rather than cultivating a mindset of “If I’m not careful, and if I don’t move just right, then my back will break”, we aim for “If I move well, not only can I do things that previously hurt me, I can become stronger than I ever was before.” I always make a point to ask the patient afterward, “Does your back feel better or worse than it did before you lifted?” Invariably, they feel remarkably better. I then ask, “Who just made your back feel better?” They usually need no prompting to answer, “I did!” with a big smile. They will need to lift things at home, my job is to teach them how to do those functional tasks in a way that they can manage without fear or injury.
How would you like to see the chiropractic profession evolve in the future?
I’d like to see my profession respond effectively to the current need in public health to manage the low back pain epidemic (no hyperbole) which costs about as much to manage in the US as does heart disease. Accomplishing this goal will require more than a knowledge of how to manipulate L4-5 “six ways from Sunday” and how to create dependency using an “effective review of findings” to “better educate” patients about the “philosophy” of chiropractic and the importance of getting their spines manipulated 3X/week to become self-actualized.
As a profession, there is no need to continue to try to create an ephemeral condition that does not exist, and then market yourself as the only ones in the healthcare arena who can see and address that condition, in order to be successful. There is an existing market in the 80% lifetime prevalence and 30% point prevalence in all humans for back pain. Address that condition better, by becoming more informed about the various tools at your disposal to manage it effectively and the world will beat a path to your door. Find the need and fill it.
Where do you see DNS fit in?
The things I’ve learned from Prague School have formed much of the foundation for my work with patients. The DNS material has shown itself as effective in my practice in both rehab and in performance. That is anecdotal evidence though and I wish there was more evidence on the method. Historically, owing to the healthcare delivery in that part of the world, there was little pressure to publish. Now, given the international interest, they are turning that tide and the results have been supportive of the claims some of us have made after seeing those methods benefit our patients and athletes. At this point, it seems the performance benefits are pushing the popularity of DNS. We see athletes seeking a competitive edge benefit and set records after incorporating DNS principles in their training. By the time that work becomes “evidence-based”, there will be something else. In the meantime, those of us in the rehab-performance continuum who are utilizing these effective methods will continue to enjoy the benefits as patients seek better care and athletes push the human potential curve. I think it’s worth noting that lack of evidence does not necessarily mean lack of effect. I’m confident that the evidence will catch up to the observed benefits. For now, I have no philosophical problem applying these principles to a patient base being poorly served by other methods and to athletes seeking that edge. When the N=1 is responding better by using one treatment as opposed to another, that is the only evidence-based treatment that actually means anything.
In the Fixyourownback program you have put together a great on-line tool for people suffering from disc related problems. Can you describe the program, from the quick self-test test to the procedures involved in solving the issue?
I decided to put together the FixYourOwnBack (http://www.fixyourownback.com/) site after a disc herniation patient I had quick success with plaintively asked me “Where was I supposed to have learned this?” Since much of what I had applied with that patient was not manually based, I wondered if it might be possible to leverage technology to deliver that information to patients with lumbar disc herniation who were being poorly served by other methods. I see the site as a way for me to remove the walls from my clinic and offer an affordable self-help option to patients that need more help than poorly chosen surgery, steroid injections, and endless passive care. I have essentially reproduced the education and exercise methods we use to manage disc injury, both acute and chronic, in our clinic. Essential to the process is an appreciation of effective ordering of interventions that have shown well in the literature. We use an interactive workbook approach that walks patients at a self-guided pace through specific objectives for pain management, movement quality, mobility, stability, etc. The work of Stuart McGill, Robin McKenzie, Gray Cook, Prague School, Craig Liebenson, David Butler, Lorimer Moseley, Michael Shacklock and many others figures heavily in the program. I view the site as an effective, low-cost, ‘better mousetrap’ to address one of the most expensive and costly public health issues in the developed world. Yeah, it’s that good!
You are also behind the MyRehabExercises.com, how would you describe that and what is the aim of the website?
In true Portland, OR fashion, MyRehabExercise (https://www.myrehabexercise.com/about/?section=learn_more) developed organically. Early in the web days, I had put videos of commonly used rehab exercises I used with my patients on an open source website for my own patients to use. Other clinicians stumbled across the site and used it with their patients and found the patients loved it and their outcomes improved. The clinicians often asked if I had plans to add more videos. Many suggested that I should expand the library, charge a fee for my efforts, and make it available as a subscription based site for clinicians. I added about 300 movement-focused functional rehab exercises in the form of video tutorials in “plain-English” language to help patients with the exercises. We improved the delivery system so that a clinician or trainer can spend about 30 seconds to send a customized exercise prescription to their patient or client via email. I kept the cost low to allow clinicians to add this exercise “plug-in” to their practice easily and without too much of a learning curve. I also offer a 30 day trial to the program for $1 and after that the cost is $19.99 USD monthly.
Tell us about the type of courses you organize and host, as well as those you run yourself. What courses are coming up?
A common refrain you have heard from me is that I started many of the projects I’m involved with because someone else asked me to. I don’t really feel comfortable marketing myself but really like trying to help people. The courses I host and teach are no different. When local clinicians, trainers and students lamented the travel costs associated with the course work they had seen me use effectively in clinic, I brought that course work to Portland to make it easier for them. I’ve hosted Stuart McGill, the DNS courses and the Stecco Fascial Manipulation courses. When other clinicians wanted to learn more about how to apply the FixYourOwnBack approach clinically, I put together a course for that. Candidly, I’m a bit of a hermit so I don’t market that course too much since the primary market is the general public. However, I’m willing to uproot myself from my web-projects and clinical practice to put on that hat when interested folks ask nicely.
I’m currently taking a break from hosting more courses in 2017, but we have the Stecco Module 2 courses in November and December for those that have completed Module 1 training. I also have another DNS Exercise 3 course scheduled for January 2017 for those that have completed Exercise 1 and 2. You can find all of those courses at https://fixyourownback.com/clinical-courses/.
Any other new projects on the horizon?
My colleague, Dr. Justin Dean (http://www.back2running.com) and I are putting together a website to support the so-called YAP material we’ve been working with. We hope to launch the site in a couple of months as a low cost plug-in for anyone who employs manual methods in practice. That might be chiropractors, physical therapists, acupuncturists, massage therapists, naturopaths or MDs. It doesn’t replace any of those other methods, it just makes those methods more effective, we have found, by adding neuro-centric assessment and novel manual methods combined with customized patient home care. It’s quick to use, freakishly effective in many cases at removing pain from a movement pattern and consistent with our understanding of both pain science and functional rehab. Plus, it has an easy to remember 3 letter acronym! For those interested in learning when the site is live, you can sign up on the mailing list here (https://yankawaypain.com) and we’ll send you an email when that happens.
Thank you Phillip for inviting me to teach in Portland, and also for all the effort you put in to make my stay so fabulous!