The Pendulum that Places Our Profession at Risk – Pain Science

I am a Physical Therapist and am proud of it.  I am proud of where our profession has come and proud of where it is going.  I also have concerns about the decisions we make as a profession and how we ride the waves of the next, “Hot Topic”.  I’ve written about this before in the form of Evidence Informed Practice.  We experience these ebbs and flows with the passing of each new emerging technique or thought process as we find something that works and look at it as the holy grail. We throw out the old and bring in the new.  This is progressive and most of this thinking is exactly what we need!  BUT, and this is a big BUT, we need to also recognize the limitations of our new thinking and determine what portions of our old habits can still breed success in our patients.

Lately, I see a new movement, Pain Science.  I am incredibly excited about it.  I read the literature and see great minds coming up with new theories and successfully testing them.  It’s a whole new world for our profession that did not exist 20 years ago.  There are tons of great resources on this topic and if you haven’t been exposed to them yet, you need to check these out immediately!  Many of your patients will thank you.

So why do I say, “The Pendulum that Places Our Profession at Risk:  Pain Science”?  I have seen a recent trend towards eliminating manual therapy.  There is a push going on with former manual therapists (who became pain science practitioners) to remove manual therapy from their skill set. The thought process I hear is that manual therapy may create a dependence of our patients.  They state that anything that can be performed with manual therapy can be performed with exercise and solid pain education procedures. I would agree with a small portion of this.  If we are not properly using our manual techniques, then it COULD create a dependence. If we tell our patients, something is “Out” and they need an “adjustment” and it will likely be “out” again in a few days, then this is problematic.  That’s not what our profession is about though!

Manual therapy is a strong adjunct to your treatments.  If you encounter a hypomobile ankle after an ankle sprain and deem that a manipulation would increase the pace of progress, then you should be manipulating it.  We have clinical prediction rules to support thisand even literature to support normal arthokinematics often not returning despite recovery of function.2  We see case reports demonstrating the utilization in a patient who failed to recover from an ankle sprain and benefited from manual intervention.6  Just recently, I consulted on a patient who sustained a Grade I lateral ankle sprain 2 months prior and had failed to return to activity due to ongoing pain. I immediately noticed a hypomobile talocrural joint and saw that his pain was recreated with a single leg squat. I manipulated it and performed a few minutes of mobilizations with movement.  His single leg squat was normalized and pain-free.  The patient was d/c’d one week later with a full return to all sports activities, no reports of pain, and a perfect functional outcome survey.  All it took was 10 minutes of assessment and manual intervention.  I certainly could have discussed the fact that he was depressed about his lack of participation in sports, avoiding running due to the pain, or the sensitivity of his pain system.  This may have been warranted, but if our goal is returning our patients to what they love and reducing their pain and their fear of movement, didn’t we accomplish our goals more quickly with the manual intervention?

Strong statements stating that there is no need for manual therapy hurts our profession in so many ways. It discredits a large portion of what we have been doing for years.  It hurts our ability to present this as a skilled service to an insurance company. It even hurts our ability to educate future Physical Therapists.  We need to look at the how this pendulum is constantly swinging.  It has swung towards the idea of pain science, but this is not the only method of treatment, even in the face of ongoing pain. There’s no need for us to look away from the incredible results seen in studies, such as Tim Flynn’s CPR on manipulation3, or Josh Cleland’s presentation on thoracic manipulation improving cervical pain.1  If we do, we are doing a disservice to our patients who could benefit from it!

We need to progress. We need ideas such as central sensitization, and graded progressions to exercise, and all of the other up and coming ideas such as mirror-box training and identifying symmetry abnormalities. We just don’t need to fully discredit such an important aspect of our profession.  Use your manual therapy when appropriate!

I’d like to end with a quick patient story.  Seven years ago there was a patient with chronic neck pain and headaches.  He reported a 10+ year history.  He was an active and educated individual and had been placed on migraine medications in the past.  The headaches had plagued him to the point where he rarely had a day he didn’t wake up without a headache.  He reported that it felt like he was going through life in a fog.  He snapped at people more often because he was in chronic pain and frankly, going through life like this was upsetting and even depressing.  He often avoided activities, which in the past had shown to flare his neck pain. He was a Physical Therapist and was a part of a residency program, so inevitably he had worked on his deep neck flexors and tried to manage his issues with all types of headache-based exercise. While there were small improvements, there had been no fix.

During his residency program, he was being instructed on cervical manipulations.  One of the instructors noticed a lack of mobility at C2/3, a prime joint for driving headaches.  After the appropriate screening procedures were completed, the instructor manipulated the joint.  The neck pain immediately began to fade.  The fog was lifted.  The next morning, he woke up without a headache for the first time in years.

If you haven’t guessed it yet, that patient was me.  I was a prime chronic pain patient that was helped by a skilled manual therapist. Maybe I am biased because of this? But this was life changing for me. I haven’t taken migraine medications in nearly a decade and isn’t that part of our goal as pain practitioners?

My take home message is that we MUST continue to strive to understand pain better and better and incorporate all of the procedures that are coming out.  Let’s not swing the pendulum too far however and assume the same solution for every patient.  If you haven’t read this pain article in JOSPT yet, take a moment to do so.4  We all suffer from confirmation bias.  It’s inevitable.  Keep an open mind and recognize the pendulum swings which occur and where our minds and treatments take us in the process.

Thank you,

A Chronic Pain Patient Whose Life Was Changed With a Manual Intervention

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  1. Cleland JA, Childs JD, McRae M, Palmer JA, Stowell T. Immediate effects of thoracic manipulation in patients with neck pain:  a randomized clinical trial.  ManTher.  2005;10(2):127-135.
  2. Denegar CR, Hertel J, Fonseca J. The effect of lateral ankle sprain of dorsiflexion range of motion, posterior talar glide, and joint laxity.  J Orthop Sports Phys Ther 2002;32:166–173.
  3. Flynn T, Fritz J, Whitman J, et al. A clinical prediction rule for classifying patients with low back pain who demonstrate short-term improvement with spinal manipulation. Spine. 2002;27:2835.
  4. Taylor AJ, Kerry R.  When chronic pain is not ”chronic pain”:  Lessons from 3 decades of pain.  J Orthop Sports Phys Ther.  2017;47(8):515-517.
  5. Whitman JM, Cleland JA, Mintken P, et al. Predicting short-term response to thrust and nonthrust manipulation and exercise in patients post inversion ankle sprain.  J Othop Sports Phys Ther. 2009;39(3):188-200.
  6. Whitman JM, Childs JD, Walker V.  The use of manipulation in a patient with an ankle sprain injury not responding to conventional management:  a case report.  Manual Therapy.  2005;10:224-231.

 

Sensorimotor Impairment in Neck Pain

Join Chris Worsfold in this short online course to learn about the evaluation and rehabilitation of sensorimotor impairment in patients with neck pain.