Pain: everything works, but nothing is effective


March 26, 2019 Facebook Twitter LinkedIn Google+ Articles of Interest



When treating patients, some therapists love their treatment of choice and share their testimonials of how it works. While other therapists love to bash that treatment of choice and share the research on how that treatment has not been shown to be effective. I don’t even want to begin the laundry list of “tools” in the “toolbox” that PT’s seem to pile up course after course when learning to treat their patients in pain. My hope is one day we can move past the methods (tools) of treating an individual in pain and understand the principles that can help. After attending #APTACSM 2017 in San Antonio this year, I continue to wonder if many therapists struggle with how their methods/tools fit into the principles of pain neuroscience.

I was shocked during a Thursday afternoon lecture when the speaker asked a crowd of probably 200-some PT’s about their knowledge of psychologically informed practice and only around 10 of us raised our hands. Maybe the phrase “psychologically informed practice” is new to them, even though it has been around in the literature at least since 2011. Or maybe we have a long way to go to fully understand the application of the biopsychosocial model in physical therapy. I thought Skulpan Asavasopon and Chris Powers did a great job trying to help the clinician link together biomechanical and psychosocial problems and interventions that can be occurring together in patients during their Saturday educational session: “A Cognitive-Biomechanical Approach to Common Chronic Musculoskeletal Conditions”.

Treating pain is challenging, but doing what we have always done will not move us to better care with these individuals. As Patrick Wall stated: “If we are so good, why are our patients so bad?”. The IOM report in 2011 states there are over 100 million people dealing with chronic pain conditions regularly. Why does this number grow when we hear from therapists claiming their great success with their treatment tool of choice? Why does science never seem to validate these treatment methods to work any better, if at all, than anything else? Could there be bigger underlying principles we have to understand than just learning another method when it comes to caring for those in pain?

I want to offer this thought for the readers to ponder: An apple a day keeps the doctor away. But you can keep the doctor away and never eat an apple your whole live. It is less about the apple and more about the principle the apple represents (healthy food). When we look at some of our interventions, we maybe need to see that at times it may be less about the specific intervention and more about what those interventions represent.

A specific exercise may not be improving posture or fixing a muscle imbalance. It might be improving a person’s self-efficacy because they are able to advance from one level to another in the program. Possibly also providing some gradual graded exposure in a safe environment so as to not run a pain neurosignature to reduce a learned response of pain. Or perhaps allowing the person to develop some sense of resiliency and expectancy violation with activity thus combating learned helplessness.

Manual therapy may not be putting anything back into place or releasing a restriction. It might be sharpening a patient’s homunculus of where body parts are within their sense of self. Possibly it is reducing some threat in allowing that area to be touched and developing some decreased sensitivity in the area through graded exposure. Or perhaps some non-specific effects of descending modulation are occurring with being in the presence of a health care provider.

My hope is that our profession can continue to understand the principles of what we provide through being more psychologically informed. Someday we might be less concerned about the methods of what we do and focus more on the principles behind them. A mind that can grasp principles will develop the methods needed for the person in front of them (and most likely it will not be yourtreatment of choice, but more of the patient’s treatment of choice). So my challenge and question to you is – do you understand ALL of the principles (biomechanically, psychologically, and sociologically) behind the methods you use, why or why not?