It’s Time to Quit Fooling ourselves…It’s time to Move Forward in the Treatment of Pain

The education within the field of Physical Therapy profession is rapidly changing. From the entry-level doctorate to residency and fellowship programs, the degree of education for clinicians is far greater than that of those who graduated years ago. But despite this increase in education, there appears to be a large divide when arriving at a common ground in understanding “why” our patients are in pain. While many practitioners understand how to classify and treat painful conditions, few have a good concept of the neuropsychological mechanisms that influence them.

Pain is the primary reason why individuals seek outpatient, physical therapy services. A significant amount of literature has been produced over the past decade which has explored the painful experience. In 1996, Ronald Melzack proposed the concept of the neuromatrix. The neuromatrix, in its most simplistic nature, is a combination of cortical mechanisms that when activated, send an output of pain. It tells us that pain is always an output from the brain. The Achilles tendon may be swollen. The multifidus may be weak. But pain is not experienced UNTIL the brain determines there is enough of a threat to the tissue. Pain is a top-down response, where the brain interprets a threat, and sends an output of pain to protect an area. This output is can occur without a nociceptive input and many psychological, contextual and environmental inputs can modulate it.

A recent article published in the Clinical Journal of Pain provided discriminative validity for the use of a mechanism-based classification of musculoskeletal pain. The authors suggest that we could be classifying pain by their underlying neurophysiological principles. There are three classifications (nociceptive, peripheral neuropathic and central sensitization) each with a particular cluster of signs and symptoms. Another recent study, published in the Journal of Pain, found that pain catastrophizing, pain-related fear of movement, and depression predicted pain and function one-year following total knee arthroplasty (TKA). This study found that the best prognostic indicators for those who will have long-term pain following a TKA appears to be correlated with psychological variables. These two studies (out of a load published over the pas several years) indicate the evolving nature of our understanding of how to handle pain.

The research that been published regarding the neuromatrix, the influence of psychological variables on pain and other related principles is wildly fascinating but unfortunately, many practitioners fail to understand the significance behind it. In addition, many accredited Physical Therapy programs have failed to fit pain science education into their curriculum and continue to focus on an outdated biomedical model of patient care (versus a biopsychosocial model, which supports the complex nature of pain). Given all of the recent advances and published literature on pain science, it is perplexing that its emphasis in Physical Therapy education is so limited. Please support our grassroots effort urging the Commission on Accreditation in Physical Therapy Education (CAPTE) to change this and incorporate pain science (from a biopsychosocial perspective) into entry-level physical therapy education. You can provide support by signing a petition here. And please become involved by sharing on facebook, emailing your colleagues and tweeting to followers! If you have any questions in how you can get involved, email Joseph @ joseph.brence@physiocorp.com

About Joseph Brence

Joseph BrenceJoe Brence is a DPT from Pittsburgh, PA (USA). He is a treating physical therapist who also performs literature reviews for forwardthinkingpt.com , theptproject.com, and sportex.net and clinical research investigating the neurophysiological effects of manual therapy techniques. He is highly interested in the incorporation of the pain science (using a biopsychosocial model) into clinical practice and believes its understanding is vital for us to define ourselves as evidence-based clinicians. On the weekends, he enjoys drinking a cold Guinness and watching the Pittsburgh Steelers (American Football).

References

1. Jones LE, & Hush JM (2011). Pain education for physiotherapists: is it time for curriculum reform? Journal of physiotherapy, 57 (4), 207-8 PMID: 22093117

2. Foster NE, & Delitto A (2011). Embedding psychosocial perspectives within clinical management of low back pain: integration of psychosocially informed management principles into physical therapist practice–challenges and opportunities. Physical therapy, 91 (5), 790-803 PMID: 21451095

3. Merskey H, Bogduk N. Classification of Chronic Pain. 2nd ed. Seattle: IASP; 1994

4. Moseley GL (2003). A pain neuromatrix approach to patients with chronic pain. Manual therapy, 8 (3), 130-40 PMID: 12909433

5. Smart KM, Blake C, Staines A, & Doody C (2011). The Discriminative validity of “nociceptive,” “peripheral neuropathic,” and “central sensitization” as mechanisms-based classifications of musculoskeletal pain. The Clinical journal of pain, 27 (8), 655-63 PMID: 21471812

6. Sullivan M, Tanzer M, Reardon G, Amirault D, Dunbar M, & Stanish W (2011). The role of presurgical expectancies in predicting pain and function one year following total knee arthroplasty. Pain, 152 (10), 2287-93 PMID: 21764515

Comments

  1. I agree that this should be taught to physiotherapy students and I am happy to say I teach integrated pain management (the neuroscience and the biopsychosocial approach at McGill University and here as well we will be starting an on-line master level certificate in chronic pain management for those clinicians who did not learn it in school. (it is 5 courses )
    Neuroscience and Behavioural Perspectives of Chronic Pain
    Pain Assessment in Clinical Practice
    Interdisciplinary Management of Chronic Pain
    Common Clinical Pain Syndromes
    Directed Practicum (elective)
    Contact us: For more information on fees, application procedures, deadlines, required technology and on the certificate itself visit our website http://www.mcgill.ca/spot/graduate-certificates/chronic-pain-management

    or contact Kimberley Smalridge at: Kimberley.smalridge@mcgill.ca

  2. After 4.5 years of glazed looks and blank stares I’ve found the only way to ‘stop fooling ourselves’ is to blab and tell my story (www.pudendalnerve.com.au) and try and create awareness as a team. I have a peripheral stimulation device (2 leads, one along the sacrum, the other along the coccyx) and have met a pudendalnerve (pelvic pain) specialist here in Melbourne who understands my pain language. As a result I’m making great progress (incredible what can happen when someone is able to identify your pudendal nerve and blocks it!) amongst giving you tips for pressure points, release positions etc. No one knew what I was talking about, no one could even define ‘i feel i have my finger in a powerpoint’ as ‘sensory’ or ‘neuropathic’… ‘go home and get comfortable is what i heard’. In Australia, it feels like we’re miles away but I’ll keep blabbing!
    Anyone can forward my website on… as I will this link.
    So lucky to have you BIM.

  3. David Nolan says:

    Noel, I’m quite slow generally. Can you explain what you mean by “quantumness of a 3-D chemical/ Physiological process…” as i have no idea what you’re talking about, but would like to!!

    noel Reply:

    Peace David,
    A 3-D chemical/physiological process is that which can be readily measured and the outcome accepted readily from the perspective of an observer in this plane. The quantumness is the “why does something work if “it” can not be rationally measured, the “reason” why the so called placebo effect “heals” people. Quantum mechanics tells us Dark Matter/Energy exsists but how “where is it?” A very small part of a DNA strand “does anything” but it would not function without the “junk DNA ” part communicating with the rest of the DNA, what is doing the communicating? Thanks for the question, not a very easy concept to explain, I am not a physicist, just enjoy reading about it and how it is influencing the universe.

  4. Peace,
    Joseph, I really like your statement “what if a simple P–>A glide of a lumbar vertebrae does little to the peripheral tissue, but instead remaps the brains virtual perception of that area of the body? ” I definetly agree that what goes on during a PT session (if the intention is there) is at the quantum level. We are trying to measure the “quantumness” of a 3-D chemical/physiological etc. process (quantum event) after implementation of a PT intervention. Thanks for following The Call to transform the PT perspective on pain.

  5. Julia Hush says:

    Joe: great post. The new IASP allied health pain curriculum (currently in development) will be a great resource to incorporate pain science into PT teaching internationally. Interesting and inspirational to see that you are lobbying for accreditation bodies to recognise the importance of this.
    Julia

    Joe Brence Reply:

    Thanks Julia! Your article def. assisted in this process. Could you send me your email address (my email is joseph.brence@physiocorp.com —you can directly email me vs. posting it)…I had a few questions for ya.

  6. Great post. Completely agree. I think it is pretty much the same here in the UK. I am always amazed when I speak to physios who work from a completely biomedical model but it reflects the fact that that is what is taught at an undergraduate level. Change is definitely needed.

  7. Thanks for the opportunity to post!!! Just one change, my website is now http://www.forwardthinkingpt.com …If you like the concepts discuss on BiM, come on over to my site too and lets help educate other PTs on how to better treat pain!!!!

    Robert Mollica Reply:

    Joe,
    Yes the science is explaining why the various manual therapy techniques work. As well it is pointing out gaps in the explanations we give patients for their recovery. In your opinion which peripheral treatment best fits the neuroscience and its current explanations?
    Sincerely,
    Bob

    Joseph Brence Reply:

    I would say that if I were to accept one “groups” approach that still makes sense with the understanding of modern neuroscience, I would say Maitland. G. Maitland said that the patients we see will either be pain or stiff dominant. We attempt to reproduce their comparable sign with our evaluation, assess the findings every tx session and then apply appropriate tx. This approach isn’t big on biomechanics or other theories which science is invalidating. He understood that our patients will have changes in their pain perception and therefore we must assess every session and modify our care based upon their presentation. He did say we should mobilize and I am totally cool with mobilizations. I do believe we need to rethink how they work. For instance, what if a simple P–>A glide of a lumbar vertebrae does little to the peripheral tissue, but instead remaps the brains virtual perception of that area of the body?

    I don’t think we need to stop what we do—I believe we need to rethink how what we do works.

    Heidi Reply:

    Thanks Joe. I’ve made the change in your bio. Great blog site you have there.