Alex Bengtsson, winner of the Emerging Leader Award, joins us to break down the neurophysiology of pain and the role of manual therapy in modern practice. In this insightful interview, Alex discusses:
How our nervous system blocks or amplifies pain signals.
The intersection of graded mobilization techniques and neuroscience.
His journey from clinical practice to research at Northwestern University.
Alex also addresses common misconceptions about manual therapy, its role in dependency, and how fellowship programs are adapting to include cutting-edge neurophysiological findings.
[00:00:00] The more you understand stuff, the more you can really apply it without having to be reliant on prescriptive stuff. I think that's the other beauty of it. The more you understand it, the more creative you can get with it. Instead of just taking a study and saying, well, I have to push on this segment for three minutes for it to work. I think just, again, the more you understand it, the more you say, you know what, there's nuance to it, I'm going to change things up. So I think adding creativity to it and a little bit more nuance, I think, is an important thing too.
[00:00:27] Today on Hands On, Hands Off, we're diving deep into the cutting-edge world of sensorimotor neurorehabilitation with Dr. Alex Bengtsson, a leading postdoctoral research fellow at Northwestern University. Alex is on the forefront of studying how the brain and the body manage pain, exploring the neurophysiology behind descending nociceptive inhibition, motor unit behaviors, and manual therapy mechanisms, all in one episode.
[00:00:54] When he's not in a lab, Alex is hands-on in outpatient orthopedics at the renowned Shirley Ryan Ability Lab, treating patients and mentoring the next generation of orthopedic specialists. His work in advanced orthopedic practice and pain neurophysiology isn't just science. It's shaping the future of fellowship education in orthopedic manual physical therapy. So what can neurophysiology teach us about our interventions and about advancing our profession as a whole?
[00:01:21] Let's find out with Alex on Hands On, Hands Off. Alex, congratulations. Thank you, thank you. Talk to us about this award that you got. Alex, yeah, it's the Emerging Leader Award. And first of all, thank you to everyone who nominated me, I guess, if you're watching this.
[00:01:46] But, yeah, I guess it's an award for people in their first 10 years of their career who've done certain things for service, for the academy, for the profession. Yeah, and I'm very honored that I got the award. That's fantastic. It's good when people get recognized for things, especially early in your career, get prompted for things like that. But who was sort of instrumental? Is there anybody that sort of prompted you to make sure that you continued your work? Yeah, there are a few people. I think the first person that comes to mind is Dr. Keller Courtney.
[00:02:16] She's been an inspiration professionally for a long time. One thing that always struck me with her is that she was able to combine clinical excellence with teaching excellence and research, frankly. So it's something I've always aspired to. And then maybe more from a leadership standpoint, too. First week in course in residency, our residency director, Dr. Eric Magrum, told a story about Jim Bizzell, who founded our residency.
[00:02:45] And he passed away, sadly, so I never had the chance to meet him. But there was a story that always stuck with me where Jim would take people, new grads, new colleagues, and at conferences would go up to big names, and he wouldn't know them. But you would pretend like you knew them, like they were old friends, and just introduce these new people to somebody they wanted to meet. So I always felt that was a nice way to bring people in. So one thing that I always enjoyed doing is doing the exact same thing for students or colleagues
[00:03:12] and introducing them to AOMD or introducing them to people around here. So for me, that was always a nice way to give back because I had so many good mentors in my career and people helping me along. Yeah, good to see you're still paying it forward. Yeah, it's something I enjoy. Fantastic. I'm going to make sure I'm going to read this to make sure I get it right. Your research focuses on the neurophysiology behind descending nociceptive inhibition and manual therapy mechanisms. Did I get that right? Yeah. It's a mouthful, but yeah. Translate it for people like me. What's that mean?
[00:03:41] So the main interest really is looking at what happens in the nervous system. So if you think, okay, you have a painful input or potentially painful input, right, nociception, the body has the ability to either block that signal or attenuate it or increase it, right? And in chronic pain, an input that shouldn't be painful oftentimes is attenuated. And a lot of that stuff happens way before we get to the brain.
[00:04:08] So we're thinking spinal cord, brainstem, right? So that's more the mechanisms I'm interested in. And I think the more we can really pin down what happens in the nervous system with interventions like manual therapy, I think the better off we are as a profession because we have a better idea of what's actually going on. Yeah. Not just know what to do, but know why what we're doing is doing the thing we hope it's doing. Exactly. Right. Being able to prove it. Yeah. And it's a tall order because there's a lot going on.
[00:04:37] And, you know, in humans, certain things you can't do research-wise, of course, right? But, you know, nonetheless, I think pushing forward and just, you know, we're standing on the shoulders of giants, you know, especially at AM, there are a lot of those people around. So I think pushing forward and taking the work that people have done and building on that is important. Yeah. You've got a breakout session tomorrow on manual therapy, specifically graded mobilization, pain, neurophysiology, without giving too much away, but you can give it away. I won't tell anybody. It's not very important. It's just between us, right?
[00:05:05] Help me understand the neurophysiology behind those interventions, key for practitioners. It's a similar area of your research, right? That's right down the middle for you. Yeah, exactly. Yeah. Yeah, and I have the pleasure of presenting with Dr. Kelly Courtney, and, you know, that's a very exciting thing for me to do. But, yeah, the idea is we want to combine, you know, some of the evolution of manual therapy and, you know, development of certain techniques, especially more the Australian approach, and how that really meshes with modern pain neurophysiology science.
[00:05:35] I'm always careful because sometimes people equate pain science with pain science education or pain neuroscience education. But, really, we're talking about the study of the neurophysiology. So, I just want to make that clear. Anyways, digress a little bit. Yeah, yeah. But, yeah, so the idea we're going to do tomorrow is really bring, you know, the clinical piece and then the neuroscience piece together. And the idea is, you know, we're talking about cases.
[00:06:01] We're talking about how some of these techniques evolved and how you grade it and why. And then how that relates to the neuroscience on a little bit deeper level. So, you know, going zooming into the neurotransmitter level, for example, and taking it right back out and seeing how that applies to the clinic on Monday, right? So, we want to make the science a little more palatable for people who aren't necessarily in that world. Because I think, again, if we can raise the level of understanding of some of that stuff across the board,
[00:06:30] I think that's going to be helpful too, right? Even for everyday clinicians. And up until very recently, I was a full-time clinician too. So, a lot of times people ask me, you know, why is this important to me? And I tell people I use that stuff every day in a clinic just to, you know, enhance my clinical reasoning. So, that's kind of the idea to pass it on and move it forward tomorrow. What made you want to take the pivot to go from full-time clinical practice to research? What about that? I always wanted to have a mix between clinic research and teaching.
[00:06:59] And I, frankly, I didn't really care what ratio. So, there was a point where I talked to Carol a couple years ago now. And I asked her if there was a way I can get more involved in a department in Northwestern and, you know, maybe help with some teaching. And at the time, I was already doing a little bit for the fellowship and just started with the residency as a mentor. And, yeah, she, you know, set up a meeting with the department chair who is now my primary mentor for the research, Jules DeWald.
[00:07:29] And I met with him and very quickly he told me about this postdoc. And so, Northwestern, they created a DPT postdoc. So, normally you do postdoc after a PhD or some terminal academic degree. But Northwestern created this position for people like me who want to get into research. But, you know, whether it's due to time, family commitments, finances, whatever it may be, you know, don't want to go the PhD route. And that's kind of how it started.
[00:07:53] You know, Carol, you know, again, as a mentor, you know, saw this opportunity for me and then helped me along and move it forward. So, yeah, it was great. It's great. Manual therapy remains a hot topic in physical therapy. I mean, obviously, we're on the hands-on, hands-off podcast. So, we know it has to be a topic. With varied opinions on its application and effectiveness. That's what gets discussed in hallways like this. From a neurophysiological perspective, how do you see manual therapy fitting into a modern pain approach?
[00:08:21] Yeah, I mean, it's exactly what we're going to talk about tomorrow. And it's just one of those things of if people don't really understand why it works, you know, it's easy to then say, well, you know, there are small effect sizes. Which is frankly true for pretty much every intervention we have and also for a lot of medical interventions, right? But on social media, a lot of times you see people quoting small effect sizes or, you know, saying things like it creates dependence, which there's really no evidence for that either. Right. So, it's just one of those things.
[00:08:49] And just as an aside, I've seen clinics where, you know, patients are just as dependent on somebody else for exercise because they've been there for 12 visits. And instead of being able to do their exercises, they're in line waiting for somebody to tell them what to do for an exercise. And if that happens after 12 visits, you know they're not doing it at home either. So, it's more, I think, more a question of bad management rather than, you know, the intervention itself. Let's put it that way.
[00:09:14] But I think understanding the mechanisms and, you know, why something works and why it may work for one person and not the other, I think that's the important part. And I think that's what's going to help us move forward as a profession. Yeah. Well said. You mentioned moving forward, looking to the future. How do you see fellowship education evolving to include new findings in neurophysiology and sensor motor research? What looks promising in the future? Yeah. I mean, it's one of those things. I think everybody has their own interests and their idea and they say, well, this is my interest.
[00:09:42] So, I think this is probably what's going to help move the profession forward or fellowship or whatever. So, I recognize my bias and, you know, I'm clearly biased towards the stuff we've been talking about the last few minutes. So, you know, I just want to put that out there. I'm aware of it. But, again, I do think the more we can understand these mechanisms, right, and a lot of times people throw on the term mechanisms a little bit loosely. But I'm really talking about what happens at, you know, at a neurotransmitter level. How do systems change?
[00:10:09] How do, you know, things like synaptic density, dorsal horn, for example, how does that change? Like real physiological changes. Because, again, I think it's relevant and not everybody has to know it at, you know, the deepest level. It's not what I'm saying. But I think general understanding of that is really, you know, I think it's going to make it easier to figure out how to treat, how to dose, who is appropriate for the treatment, right? Whether it's manual therapy, exercise, you know, TENS, whatever it may be. And, again, same thing with TENS.
[00:10:38] I think that's gotten poo-pooed for a long time too. Can I say that on the podcast? You can. Okay. I just want to make sure. I have an eight-month-old child now, so I want to make sure. I've adjusted my vocabulary a little bit. No, but, you know, TENS has been looked down upon for a while too. And I think some of it is, you know, maybe not having the right equipment. Some of it is also maybe not applying it in the right way, you know. And the same with manual therapy. So I think, again, the better we understand it, you know, the better treatments are going to be. Yeah.
[00:11:07] Beyond your research, you work directly with patients and outpatient orthopedics. You say you wanted a mix of research and teaching and clinical practice. Not necessarily didn't know what ratio you wanted. But how has your research influenced your approach in clinical practice? How has it worked that way? Yeah. And I think that's the thing. So my, you know, especially when I did the fellowship with Carol, a big focus was on the neurophysiology, right? So even from there, I already applied a lot of it to patient care. And I think that's what helped me grow a lot during that fellowship.
[00:11:38] And then now with even deeper understanding as I go through the postdoc, you know, I think it enhances even more. So I think just having a better understanding of saying this patient may respond a certain way. And you know what? Even though, you know, this patient seems like this type of, you know, fibromyalgia patient where you can't touch them at all. Now, if we figure out just the right dosage of maybe a higher intensity intervention, we may actually be able to make a change. Again, I think it's just taking it to the next level in short.
[00:12:05] And so I've had, you know, I think even more successes with that the more I understand this stuff. So again, that's where I think my bias comes from. I think this is one thing I would like to push. And then there are a lot of other things, you know, communication and, you know, a lot of psychosocial stuff. And, you know, I think that's important as well. But, you know, again, this is my bias. This is, you know, what I think is important. And I don't think it has to be mutually exclusive.
[00:12:29] And sometimes there's a dichotomy that people perceive that you're either a good researcher or you're good with science or you're a good clinician. And I frankly, I think that's, you know, it's silly that people insist that it has to be a dichotomy. I think you can well in all of those things. Yeah. All right. Last thing we do on each episode is called the parting shot. But so is there an idea, concept, a quote, something you'd want to leave as we wrap up for the audience? Oh, it's a lot of pressure. It's a little bit of pressure.
[00:12:56] I mean, you could even repeat like an idea or concept we've talked about today. Anything that you want to leave with people? Again, the more you understand stuff, the more you can really apply it without having to be, you know, reliant on prescriptive stuff. Right. So and I think that's the other beauty of it. The more you understand it, the more creative you can get with it. You know, and instead of just, you know, taking a study and saying, well, I have to push on this segment for three minutes for it to work. You know, I think just, again, the more you understand it, the more you say, you know what, there's nuance to it. I'm going to change things up.
[00:13:25] So I think adding creativity to it and a little bit more nuance, I think, is an important thing, too. Congratulations again on the award. I appreciate it. And appreciate you sitting down with us. Yeah, of course. Thank you for your time. Thanks, man.