Every human is incredibly complex. The world we live in is incredibly complex. The interactions between us—and everything else—are, unsurprisingly, also complex. Yet physical therapy can be simple. At least, its guiding principles can be.
Music for today: Fat Freddy's Drop - Slo Mo
There’s a danger in reducing complex ideas to simple principles: you might oversimplify, get it wrong, or miss nuances. Arrogance can sneak in if you think you’ve distilled the essence of something so multifaceted. But that doesn’t mean simplicity doesn’t have value.
So, with humility, I’d like to share a simple framework. It’s not new, revolutionary, or mine. But it’s easy to remember but at the same time, easy to forget. I'll try to keep it short.
“Calm shit down, build shit up.”
This quote, attributed to Greg Lehman (1), captures the essence of these principles in the most pithy way. In physical therapy, when we meet someone with a problem, we have to ask: Does the issue need to be calmed down? Or is it ready to be built back up? This clinical judgment might seem straightforward, especially in acute cases, but it’s not always obvious.
Let’s break this down:
Calming Things Down
Calming things down is associated (but not exclusively) with the parasympathetic nervous system, sometimes referred to as the "rest and digest" system. For this system to kick in, the body needs to perceive SAFETY. Without signals of safety, there is no rest, no recovery, and no healing. Both the quality and quantity of parasympathetic activation matter. More and better activation typically leads to better outcomes.
What Signals Safety?
The most critical signal of safety comes from cooperative others—people who genuinely have your best interests at heart. From an evolutionary perspective, isolation is dangerous, while connection fosters security. However, being surrounded by the wrong people can be worse than being alone. The quality of relationships matters.
Therapists play a vital role in fostering safety by utilizing clear communication, education, and non-verbal cues such as tone of voice, facial expressions, and posture. While these interactions can significantly promote a sense of security, the patient-therapist relationship is inherently limited in scope compared to the broader social environment the patient inhabits. Safety cues—or their absence—in settings like home, work, or school profoundly shape the patient’s overall state and progress.
Other ways to calm things down:
Gentle Movements: Opt for movements that are low in mechanical load and free from psychological or emotional charge. Subtle variations often work better than repetitive motions.
Manual Therapy: When delivered appropriately, touch can be a powerful signal of safety.
Breathing and Relaxation: Techniques like deep breathing, meditation, and progressive relaxation can calm the nervous system. Don’t overcomplicate these—simple is effective.
Sleep: The ultimate period of recovery. Improving sleep quality and quantity can have profound effects, though easier said than done.
Nature: Time spent in nature can significantly enhance parasympathetic activity.
Bonus points if you combine all of the above: e.g. a walk in the park with a friend, a hug, and a little nap in the sun.
Building Things Up
For builings things up, we need the sympathetic nervous system, often called the stress system (but I like the action system better). Increasing your capacity requires exposure to stressors, but preferably in controlled, intermittent bursts. The key word I associate with building things up is CHALLENGE.
What Challenges Can Physical Therapists Use?
The most important ones or movements, where we use mechanical load (bias for the tissues), movement complexity (bias for the central nervous system), psychological/emotional load (think graded exposure), or a combination of these.
It is interesting to think about manual therapy in this light: maybe some techniques are challenging enough for the nervous system (painful triggerpoints, manipulations, deep tissue massage)? I'm not sure and personally highly prefer the use of movement and exercise to build things up.
Recently, there's a big interest in other ways to challenge our biology. Emerging areas like thermal stress (e.g., cold plunges or heat exposure) and controlled breathing challenges (e.g., breath-holding or hyperventilation) are intriguing, and the evidence is promising, but limited. They’re worth exploring, though with caution.
Nuances
These two categories—calming and building—are not rigidly distinct. Safe, gentle movements can gradually increase in intensity or complexity, transitioning seamlessly from calming to challenging. Small challenges can even help promote recovery afterward.
It’s worth noting that simple doesn’t always mean easy. Safe movement may sound simple in theory, but executing it can be surprisingly challenging. Likewise, understanding social safety cues is one thing; applying them effectively is often far more difficult.
Clinical Decision-Making
When deciding whether to prioritize safety or challenge, we need to consider many factors: the symptoms, the patient’s story and history, feedback from previous treatments, knowledge of physiology and pathology, scientific guidelines, … This clinical decision is difficult.
As a rule of thumb, it’s better to err on the side of caution. Start conservatively and progress incrementally. Primum non nocere (“First, do no harm”) is always a good guiding principle.
Bridging Safety and Challenge
Once it feels appropriate (but not sooner), explore the "zone" between safety and challenge. This should feel like gentle experimentation rather than forced effort. Importantly, challenges should never feel imposed. Collaborative dialogue, education, and shared decision-making are vital for engaging the "conscious mind" of the patient. But remember, deeper parts of the brain also need to feel safe. Gently increase the challenge, pause to allow recovery and adaptation, and proceed only if no adverse reactions occur.
This framework isn’t revolutionary, but it’s profoundly effective when applied thoughtfully. Calm things down. Build things up. And always meet the patient where they are—with compassion, curiosity, and care.
What are your thoughts?
Some links to related topics:
Thanks for reading.
Pieter
(1) Greg Lehman is great. I've rarely followed a course of someone so knowledgable of scientific studies, so capable of connecting the dots while being truly funny!
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