I have just begun to re-read Louis Gifford’s “Topical Issues in Pain” series. This need to re-indulge has been sparked by my most recent EIM course entitled “Pain Sciences and Psychosocial Implications in Musculoskeletal Care” (part of EIM’s Manual Therapy Pre-Fellowship Program) and the work done by David Butler. Butler discusses the critical need for physiotherapists to integrate pain awareness into practice, particularly in patients with chronic pain but in consideration of acute injuries as well. He brings up the dysfunctional relationship between researchers and clinicians as the two are constantly asking different questions. The researcher wants to know “what does this contribute to the body of literature?” While the clinician wants to know “what does this do for my patients?” There is often a disconnect from the true purpose of clinical research which is not aimed at defining steadfast conclusions but guiding clinical decision making in individual scenarios with individual patients. Butlers call to action regarding this relationship is that we must review our relationship with science and shift from experiential based approaches to approaches that adopt evidence critically.
We have talked at length during my pain sciences course regarding the medical community’s death grip on the structural pathology model even when patients have clearly moved on from the acute stage and well beyond normal tissue healing times. We can point the finger at our colleagues in medicine quite easily as there is a gross over-utilization of medication, imaging and surgical intervention with these patients in attempt to address “slipped disc”, “pinched nerve”, and blanket terms such as degenerative joint disease. Despite the blaming we do and the cries to come see us first or see us as “primary physical therapists” we traditionally subscribe to a similar model with structural based examinations, in an almost one size fits all approach. While our techniques are significantly less invasive and have proven to cost less, we miss the boat in showing our true value by perpetuating outdated models and continue to misuse evidence regarding the multifactorial pain experience.
As a new graduate working largely with chronic pain, I quickly fell victim to early signs of burnout as energy stores beyond my work hours were completely depleted. I currently work in a hospital based outpatient facility in the heart of Baltimore where my caseload is about 70% chronic pain. I quickly began to question my abilities with these patients as my efforts to chase pain led me down a rabbit hole to wonderland. Short-term solutions via manipulation and modalities are great especially when considering the influence of graded exposure and tying these into pain free functional improvements. However, blissfully I would send these patients off on their own after a couple of weeks with a finalized home exercise program only to see them back on my schedule 2-3 months later. It made me question to what extent I can value short-term benefits and perhaps there was something I was missing.
The pain science course and a better understanding of the pain experience has helped to me to understand that patients bring to our clinics, more than just pain, they bring a unique perception of their pain which is shaped by past experiences, social interactions/contexts, past successful/non-successful behaviors as well as their general knowledge of pain shaped by a host of medical providers, friends and internet searches etc.
The MOM is a visual representation of the CNS’s coordinated response to nociception based upon self-sampling
I had an experience with a patient just this afternoon that may sound familiar. The patient sat in my exam room frustrated. It is obvious that she could not get comfortable as she squirmed around in her chair clutching her lower back with her hand as if she was trying to keep something from falling out. She began expressing her feelings of frustration as attempts at increasing her pain medication and injections have not been helpful and the recent talk of surgery has her frightened as she has a young son to look after. The persistent pain that she is experiencing is keeping her out of work and limiting quality time with her son. “I just want to know what is going on inside my back so we can figure out the correct way to treat this!” she exclaimed. This patient’s pain has persisted for several years now and the after all of these years pain has not been explained to this women. She recalls experiences with providers one after the other throwing a new term onto her laundry list of meaningless diagnoses. Attempts at upper her medication despite it not being helpful. The most frightening was her recollection of a past experience in physical therapy where her last provider told her that he was not able to help her and “he told me he did not believe that I was actually experiencing pain.”
I spent a whole hour with this patient. A lot of the session was allowing the patient to vent on her obvious frustrations. As I have been seeing this patient for a few weeks I felt like we had developed a pretty strong relationship. We discussed several concepts highlighted in the teachings of Lorimer Moseley starting with the idea that nociception and pain are not synonymous. We discussed how we can feel our clothes on our skin however the brain has the ability to modulate these sensations interpreting them as non-threating to the body thus silencing them. “But how come this pain feels like it did when I first injured myself?” she asked. I explained that persistent nociception can alter the abilities for the brain to modulate pain (as discussed before). We know from the research that pain is very much a response from the brain based on perceived threat to the tissues all of which is shaped by past experiences, emotions, social interactions (including poor explanations for her persistent pain in the past) and environmental factors. We discussed that overtime this can cause receptors in your skin responsible for even light touch to stimulate a pain response over these areas if your brain perceives them as potential threat. “The pain feels like it is spreading, doesn’t that mean that something could be getting worse?” she asked. At this point I broke out the picture of the homunculus as the representation of the sensory cortex in relation to our body. I discussed with her that increased nociception to areas of the body represented on this map can cause areas with more stimulation to grow and spread. David Butler described this phenomenon as “cortical smudging.” I explained to the patient that this can account for pain that not only spreads throughout the back or limb but explains mirror pain as well. Throughout this whole session I am testing the patients understanding of what I am telling her based upon her ability to feed the information back to me. I am gathering a strong sense of understanding throughout our hour long session.
Exercise even in the most basic of forms with this patient has been a trigger for her lower back pain. I decided today to hold off on movement and impart some principles of graded motor imagery as described by Lorimer Moseley and NOI group. Today following pain education, we initiated laterality training in conjunction with constant electrical stimulation to the lower back and upper thoracic region. As we were discussing further the patient looked up at me and said “I am not feeling the electrical stimulation on my upper back anymore” I looked down quickly to check and see if the machine was still on, it was. Before I could say anything the patient asked “is my brain modulating this right now?” YES, YES, YES! I saw with my own eyes and ears as my patient was connecting the dots for herself and it was one of the most exciting moments of my day.
We are in a unique position as physical therapist to make a huge impact on our patients, particularly those with chronic pain. It is important that we realize the limitations of a structural pathology model with these patients, as well as the limitations of structural assessments particularly in cases of persistent pain states. It is important that we put evidence based practice to a higher standard which includes adapting with advancements in the literature and helping our patients more accurately understand their pain. We are in unique position to set ourselves apart from the plethora of professions who attempt to “own” manual therapies, movement dysfunction models and treatments of pain.
TJ Janicky, PT, DPT
TJ is a current student in EIM’s Manual Physical Therapy Certificate Pre-Fellowship Program.
Gifford, L. (2013). Topical Issues in pain 1: Whiplash: Science and management, Fear-avoidance beliefs and behavior. Bloomington, IN: Authorhouse.
Moseley, G. L., & Flor, H. (2012). Targeting Cortical Representations in the Treatment of Chronic Pain: A Review. Neurorehabilitation and Neural Repair, 26(6), 646-652. doi:10.1177/1545968311433209
Butler, D. S., & Moseley, G. L. (2003). Explain pain. Adelaide: Noigroup Publications.
Bowering, K. J., O’connell, N. E., Tabor, A., Catley, M. J., Leake, H. B., Moseley, G. L., & Stanton, T. R. (2013). The Effects of Graded Motor Imagery and Its Components on Chronic Pain: A Systematic Review and Meta-Analysis. The Journal of Pain, 14(1), 3-13. doi:10.1016/j.jpain.2012.09.007