by Chris Joyce, DPT
Pain. A word that ignites a cascade of thoughts and emotions in a person, often formulating as questions that are specific and situational to the individual. For example:
Clinician: Joint or muscle? Disc or neural tension? Movement patterns or structural lesion?
Athlete: Season ending? Same thing as teammate’s/professional athlete’s? Scholarship jeopardized?
Patient: Copay cost and insurance coverage? Time off from work? Old age?
The answers to these questions undoubtedly play a role in the success or failure of an individual’s rehabilitation, and as such it becomes paramount that the clinician considers any and all physical or mental restrictions. With the growing accessibility of diagnostic tests, diagnostic websites, and diagnostic friends/family, the practitioner faces the challenge of not only delivering successful interventions, but also guiding the patient’s cognitive state as they become overwhelmed with input. Fortunately, in the last 20-30 years we have seen an increased availability of information that can facilitate this type of high quality comprehensive patient care that encompasses both physical and psychological medicine. It is my personal belief that education in academia, in conjunction with numerous resources for continued knowledge, equips the AT/PT/Chiro/etc, with almost all the necessary physical skills to treat someone in pain. However in regards to formal education, the same thing cannot be said about the required understanding of the neurophysiology of pain, including it’s psychosocial contributions. Now, it is WAY outside my scope to attempt to educate my colleagues in the complexities of neuroscience and pain modulation. Rather, my goal is to highlight the importance of pain education within our professional development, and within our everyday patient interactions.
Surely we have all heard of the phenomenon “phantom pain,” where a person with a recent (or chronic) limb amputation continues to experience pain in the absence of his extremity. And surely we have heard of the opposite phenomenon, where a person takes significant physical damage to their body yet reports no symptoms at the time of insult. From these two examples, we can convincingly agree that pain is not simply an input from peripheral structures, but rather an output of a central processor (Melzack 2001). Scientific evidence that dispels structural pathologies as definitive pain sources is a study done in 2007, when images were taken of tennis players who have disc herniations, spondylolisthesis and stress reactions, yet were asymptomatic (Alyas 2007). Looking conversely, I’m sure we could all provide cases where patients complained of significant pain, were sent out for imagining and returned with normal findings. This does not mean the person is not experiencing pain, but rather that it is unlikely the source of the pain is an anatomical or even biomechanical dysfunction.
With this established, we know we have to consider the other factors that may affect the brain’s processing of pain, such as thoughts, beliefs and emotions. As illustrated in the introduction, these may differ greatly in an athlete or a patient, so they must be identified and addressed specific to each individual. One way proven to effectively mitigate pain and its associated impact is simply by providing education as an intervention. In various studies, neuroscience education has had immediate effect in pain thresholds during physical tasks (Mosely 2004), improved outcomes of therapeutic exercise (Mosely 2002), and decreased fear in a patient’s perception of his pain. The methods used for transferring this information can vary greatly, but the underlying concept is fundamental: people who understand why they may feel pain can manage their pain more effectively. Therefore, the patient/athlete education we provide is a critical component in rehabilitation. The clinician must become versed in the complex process of pain neurophysiology to be able to succinctly articulate the phenomenon.
We’re in the midst of an exciting shift in our orthopedic assessments to show greater respect to the neuromuscular system. Failing to incorporate current concepts of pain physiology would be detrimental to our vision of global movement and function. An excellent place to start is by reading the book Explain Pain, downloading the recently published article A neuroscience approach to managing athletes with low back pain, or attending the BSMPG course in May that will feature renown expert, Adriaan Louw.
Chris Joyce is a physical therapist at a sports orthopedic clinic in Boston. He’s currently completing a Sports Residency at Northeastern University, and can be reached at cjoyce@sportsandpt.com.
Alyas, F. Turner, M. Connell, D. (2007). MRI findings in the lumbar spines of asymptomatic, adolescent, elite tennis players. British Journal of Sports Medicine 41(11), 836-841.
Melzack, R. (2001) Pain and the neuromatrix of the brain. Journal of Dental Education, 65(12), 1378-1382.
Mosely, G.L., Nicholas, M.K., Hodges, P.W. (2004). A randomized controlled trail of intenseive neurophysiology education in chronic low back pain. Clinical Journal of Pain, 20(5), 324-330.
Mosely, G.L. (2002). Combined physical therapy and education if efficacious for chronic low back pain. Australian Journal of Phyisiotherapy, 45(4) 297-302.
Mosely (2003). A pain neuromatrix approach to patients with chronic pain. Manual Therapy, 8(3), 130-14.
