My Response to Dr. Brence's All About Pain

First of all, Dr. Brence's post was very well written and explained pain and its various classifications well. I wish I had the time to write and cite a post as long as he did! It should help anyone with questions about the Pain Science approach. I use the biopsychosocial approach when needed, but don't think it fits all patients, like every approach, should be unique to the patient based on their presentation. It should compliment a practitioners toolbox, but not be the only tool.

I disagree with a few of his points. I think generalizing OMPT or any hands on technique as "poking something that hurts" is simplistic at best. That is equivalent to stating pain education is like teaching a chronic pain patient they are nuts.

Using MDT rules for all exercises and hands on techniques makes it nearly impossible to worsen a patient's condition if you actively listen to their subjective report. If any treatment, whether it is IASTM, joint mobs, functional release, neurodynamic tensioners, is causing discomfort, or even pain, I stop and ask the patient if the pain continues after cessation of the treatment. If it immediately stops, or goes away after a few minutes, the condition is not worsening. It is unlikely the CNS is becoming overly sensitized if the pain ceases immediately, gets better as the treatment progresses, and you are able to demonstrate improvement in an objective measure of strength, ROM, or function after the treatment.

I do agree that PT should not be "no pain, no gain." I only use force as a progression, despite using stainless steel tools to release tissues, you can be very light and progress your depth according to tissue release and patient tolerance. There is a difference between treatment and eliciting pain without any gain in function, strength, or ROM. Any manual technique may be uncomfortable, but only because there is a problem in the surrounding joints, tissues, or peripheral neurodynamics. This is outputted by the brain, but does not mean there are not peripheral "issues in the tissues" so to speak. Many of the areas I treat are either adjacent or sometimes farther away than the area the CNS may be perceiving as a threat, so I think the discomfort perceived is not only CNS sensitivity, but mechanical dysfunction. For example, a frozen shoulder may have elbow, forearm, cervical, and thoracic dysfunction, despite the patient only complaining of moderate to severe pain in and around the GH capsule. The other areas "don't hurt" but may be uncomfortable to treat.

Another clinician wanted to ask Joe, "How would you treat a patient that is already in pain, say s/p TKA?" Iit would be difficult to even move some of these patients without at least causing some discomfort. Hopefully this will generate some CIVILIZED discussion. Anything that gets out of hand will be moderated, and then closed.

I also wanted to add this great comment from a reader on Dr. Brence's original post.

Koen OverdijkCollapse

As a therapist who treats also a lot of chronic low back pain sufferers, I can not fully agree. Though there maybe by some patients in which catastrophizing and central sensitization play a role, the therapist has first to know how much this really blocks positive effects for a more biomedical approach. To my opinion this role has been and still is- exaggerated because of lacking of good concepts and results from other therapies. In my therapy I let patients under for them controllable circumstances (while exercising) experience a certain amount of pain as long as this produced pain subsides after a 10 till 15 minutes rest. Sensitized patients complain hereby about unpredictable pain levels from relative minor loading on unpredictable locations and often about more pain after hours or the next day. The latter says more about there expectations as that it is objectively to couple on the loading or the damaged body as seen on the x-rays or MRI´s. However the most chronic patients in my population DON'T show these reactions, but their extra pain produced while exercising subsides immediately or after a couple of minutes of rest. The explanation is then that this is safe as there has been done no new harm. When then also given a good mechanical explanation for there complaints about why which loading leads to more pain and how they can reach a better loading through specific exercising and posture control, this patients instantly loose their fear-avoidance and fear of pain. Also because of exercising themselves they get an inner locus of control and by an realistic prognosis become hopeful again. This leads to blow away depression and inactivity. In the past,I self- measured my results and scored good to excellent results (75 -100 resolution) by 50 to 60 percent of the chronic patients and fair to good results (50-75 resolution) by another 30 percent of the patients. On departing for the therapy the most wanted to continue the exercise to reach more results in the future. In contradiction my results by the few patients who I suppose to have a damaged pain perception like with central sensitization are very frustrating. This is still so, although I have tried to coach them exactly in the way you describes in your post. I have red several times from better functional results when they are exposed to an multidisciplinairy program of graded exposure where the loading is built up irrespectively of there experienced pain. At the end they are better in function but grossly unchanged in experienced pain (simply said they have learned that they can do more as they thought although they still have pain).

with respect and regards

Koen Overdijk.