Critical Thinking

Pain Science is not a movement; Pain science is not a camp; Pain Science is Science

As we continue to learn about the complexity of pain, I have observed many refer to this as a “movement”.  I have also observed many refer to those who are sharing the knowledge a “camp”.  But as we begin to gain a better understanding of neurophysiology and the human experience, should we refer to this understanding as a movement or a camp?  Well let me answer that bluntly.  No.

Around this time last year, we saw researchers announce the discovery of a “new” knee ligament (published in Anatomy).  While this information quickly spread across social media, I saw practitioners actively engaged in exciting discussion.  It appeared (empirically) that many had a very easy time accepting this new anatomical reference.   But at this same time, I continued to observe (and engage) in debate and discussions regarding our evolving understanding of the physiology of pain.  From this, I hypothesized it must be easier to accept an objective anatomical observation (visually inspecting a tangible new ligament—even though many of us have yet to “see” it) vs. a subjective physiological observation (understanding a non-tangible process).

While this may or may not hold weight, the hypothesis is likely a partial reason why we are spending 600+ billion dollars per year in the management of pain.   We do a really great job at getting a stiff joint to move, or getting a weak muscle strong, but often get frustrated when pain is a limiting factor. We like to visualize and see progress, and when a subjective experience is limiting this progress, we tend to use words like “difficult” or “unresponsive”.  But what if the patient can’t even imagine themselves moving something, because of a smudge?   Is it the patient who is difficult?  Or is it a void in our understanding of a complex process?

I suspect we all need to attempt to challenge ourselves in understanding the processes which we cannot see.  We must stay current with physiological references because our understanding is changing.

I wouldn’t call pain science a “movement”. I wouldn’t call pain science a “camp”.   I would call it a subset of modern neurophysiology. Pain science is just as much of a camp or movement, as anatomy.

– Joe B

 

Learn more about Pain Science here from Dr. Adriaan Louw and other educators by subscribing to MedBridge for a discounted rate of $200 through the end of this month

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6 replies »

  1. Well said. One mistake I feel like we have made as a profession is moving ourselves into different “camps”. “He does McKenzie”. “She does Maitland”. “Isn’t he the stability guy?”. By doing this, we artificially limit ourselves to the little world we have prescribed for ourselves. Very few of these camps put any thought into the human being sitting in front of them. What is going on in their head (both from an emotional level and a processing level)? How can my words and actions potentially change that?

  2. The professional solipsism that Mike refers to above has been an unfortunate although inevitable consequence of failing to update and then incorporate our knowledge of pain neurophysiology into our treatment models and clinical practice. The results are being felt in many different ways in the profession. Most alarming to many is the continued downward drift in reimbursement, which is somewhat related to the perceived value of our interventions (although not as much as we’d like to believe). The systematic reviews that have come out over recent years demonstrating the small effect sizes from conservative therapies for common conditions like LBP are sobering.

    Yet, walk into any clinic today, and you’ll see different therapists trying all kinds of different interventions, many of them lacking scientific evidence, on patients with persistent LBP. However, what percentage of therapist are educating their patients about pain neurophysiology, which has a growing body of high quality evidence to support its use in the clinic? I’ll bet a much larger percentage of PTs are using heat and e-stim on patients with chronic LBP than pain neuroscience education. The former not only lacks evidence of effectiveness, there’s actual Cochrane reviews showing that interferential electrical stimulation is worthless for chronic LBP.

    Another way that professional solipsism is being felt in the profession, which troubles me even more than declining reimbursement (in fact, it might play a role in driving it to some extent), is the enduring tendency of PTs to embrace treatment fads. The latest and most prominent of these is dry needling. This is a particularly precarious move for PTs because, unlike some of the poorly supported modalities we’ve embraced in the past, like ultrasound, inserting needles into flesh comes with a very serious and substantial risk of harm. So, we’ve upped the ante here in our quest to find the “magic bullet” to treat the patient who has a primary complaint of pain. Some call this an “eclectic approach” or “another tool in the toolbox”. They invariably rely on empirical arguments to support interventions like dry needling even though the research evidence says it’s no better than sham.

    This intransigence in our profession to updating our knowledge of pain is frustrating for those of us who have spent the time reading about and discussing these concepts with other clinicians who’ve grown similarly disillusioned with the profession’s irrational attachment to tradition. I suppose our public commiserations are often perceived by those who have not adequately studied the science as our belonging to some “camp”. Well, if that’s what it’s come to- that applying science to clinical practice has become a “camp” and requires a “movement”, then I think PTs need to step back and take a good long look at where they want to see the profession go. Despite all the talk and logos about “moving forward”, the current trajectory appears to me that things are going to hit bottom sooner than later.

  3. I have been a physical therapist for 45 years and practice as an integrative practioner. I have formal training in integrative methods including mind-body, biofeedback. manual therapy, nutrition, exercise physiology, and pain physiology. I have been a member of the American Academy of Pain Management which is an interdisciplinary organization and has high standards. I have passed a rigorous examination to be recognized as a Diplomat in Pain Management. We need to be knowledgeable about nutrition and many modalities including energy practices, indigenous practices, homeopathy, botanical medicine, and “evidenced based practices” whatever ever that means. do not neglect the mouth as a cause of discomfort. Part of integrative medicine included one-year of dental medicine.

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