We have all jumped onto a bandwagon at some point in our professional life. Come on admit it, if it wasn’t some electrotherapy gadget or something involving a needle, it was core stability or brightly coloured stretchy tape. Even my beloved exercise therapy isn’t immune from bandwagons with a recent epidemic for isometrics for pain or eccentrics for all tendon issues.
However, recently there has been a rather large and impressive bandwagon that many therapists seemed to have jumped onto (and I include myself here as well) and it seems to be gaining more momentum and speed, and if we are not careful it could, as bandwagons tend to do, completely run away from us.
What is this bandwagon?
Well its the shift of a lot of therapists learning more about the science of pain. Many therapists now read and have a far better understanding of this fascinating and complex topic, and many are slowly coming to the realisation that the traditional biomedical model of pain = injury or tissue damage just doesn’t hold up to scrutiny or to the evidence base anymore.
Many healthcare professionals now understand that pain isn’t only due to a tissue, joint, or nerve injury. Many healthcare professionals now realise that we can no longer associate an individuals position, posture, occupation, or activity as a primary or sole factor for pain (source source source). Nor can we only blame biomechanical dysfunctions such as foot pronation for ankle, knee or hip pain (source source source). Or scapula dyskinesia for shoulder pain (source source source), and I could go on and on presenting research paper after paper that blows ‘barn door’ size holes in many of the previously commonly held structural and biomechanical beliefs as a cause of injury, dysfunction, and pain.
More and more therapists are now aware that many other factors other than posture, structure or biomechanics contribute to the sensation of pain thanks to the excellent work and research done by the likes of the NOI group, Body In Mind and the PainEd teams amongst many others.
Therapists now understand that pain…. isn’t only nociception and isn’t simply caused by tissue damage!
I think it’s fair to say that in these last 10 years we have all learnt more about pain and our nervous systems and read more research on it and its role in the experiences of pain than we have in our entire history of our profession, and I for one love learning as much as my poor brain can handle.
Up to my Limbic System in it!
I’m reading about sensory afferent pathways, neurotags, cortical smudging, and the processes of diffuse noxious inhibitory control. I’m trying to get my grey matter around the other nuisances of pain such as sociology, psychology, mood states, contextual situations and past experiences, all in an effort to understand how I can better help those I see day in, day out who are in pain!
I’m swamped in papers about neuromodulation, nervi nervorum, ruffini endings, amygdala’s, prefrontal cortexes, glial cells and tripartite synapses. And I’m trying to wade my way through the muddy swamp of the neural complexities that occur via touch, massage and manipulation.
And there are thousands of other therapists all doing the same thing all over the world, and this has lead to the development of new methods of assessment and treatment for patients in persistent pain. Many therapists are now routinely assess for the signs of central sensitisation, and other psychosocial factors contributing to symptoms, and have been trained to include new methods of treatment for those suffering with persistent pain such as cognitive behavioural therapy and other strategies.
But… theres always a but!
As much as I encourage this approach in the management of patients with persistent pain, I think we need to be careful to ensure that the pendulum doesn’t swing too far, and that the pain science bandwagon doesn’t go careering too fast, too quickly out of control, and we start to treat all those we see with pain as if they have persistent pain or even loose sight of the bio in biopsychosocial.
I will admit, I did, for a bit, loose the bio, when I started learning more about pain science and I’m not alone. I have discussed this issue with other experienced, rationale, far brighter therapists than me who have said the same thing. And I have seen how this can negatively affect our patients when us therapists rule out the tissue or the biomechanics too quickly, too easily, just because a pain doesn’t seem to present or respond in the way, or in the time frame they think it should.
For example, I recently saw a fit, healthy, active middle aged lady in my clinic who told me her story of being quickly diagnosed with persistent pain by a physio and doctor after she fractured her ankle six months ago! She had the usual history of a nasty inversion injury and unable to weight bear, went to A&E, had an x-ray, got diagnosed simple undisplaced fibula fracture, had a cast placed on for a few weeks with a follow up x-ray that confirmed union and sent to physio for rehab. Simple, routine, nothing to it!
Well not quite, because she told me she just could not get her foot and ankle going again due to the pain becoming worse and worse the more she tried. Over the following months she was told quickly told that she had CRPS and chronic pain and was referred to a pain management service where she was told she would need extensive cognitive rehabilitation and pain medications.
However, not fully convinced she decided to seek a second opinion as she felt something was just wasn’t right with her ankle and to cut a long story short a large osteochondral defect was found in her ankle with a loose body within her ankle joint. A small operation was performed and her pain and function were almost instantly better and she continues to progress well.
Now this is just one example, and I’m sure, in fact I know, there are just as many, if not more patient stories that go the other way, with patients in chronic persistent pain being told its due to faulty biomechanics, muscle imbalances, and even having unnecessary surgery in a belief it would fix them only to find their pain is the same, or worse after!
But I do want to highlight that there are two sides to every pain coin, and that I have come across patients whose doctors and therapists have not fully considered or excluded that there maybe a structural or biomechanical factor for their ongoing pain.
I have also seen and heard some healthcare professionals using the ‘chronic pain’ tag simply because it is easier to ‘blame’ this than to spend the time and use the brain power to exclude all the other possibilities! This is just lazy, sloppy, dangerous practice for which I have no tolerance for.
As awesome as the new advances and understanding into pain science are, I do think they have inadvertently become the new ‘cool kid’ in town that everyone whats to hang around with, the new skill everyone wants to demonstrate they are at using, showing how up to date they are with current research.
This ‘cool kid factor’ is what, at times, makes some rush to diagnose and treat patients as persistent, non structural pain without checking all other possibilities first!
So in summary, lets not be too quick in diagnosing our patients with chronic, persistent non structural pain. Lets not be too quick in blaming the brain for getting it ‘wrong’. Lets remember that pain is a highly sophisticated process that has been developed and honed through thousands of years of evolution and is pretty damn good at doing its job.
Yes ok, at times, this alarm system does go ‘nuts’ or ‘squiffy’ or into ‘over drive’, but perhaps not as easily, nor as often as some would like to think! And finally lets try not too loose sight of the bio in biopsychosocial, and lets not let the pendulum swing too far one way and the pain science bandwagon run away from us all.
As always thanks for reading