Are we treating the REAL cause of persistent pain?

Posted: September 12, 2012 in Therapeutic Exercise


Homunculus Man!

The following blog is going to be a review of a recent study I read and a topic that has really been on my mind for the last several months. Essentially, from my visits to and reading Jason Silvernail and Barrett Dorko’s expert writing on the topic of pain, I have started to question my motivation for practicing the way I do. In making this short and simple, I will only say that being a reflective practitioner has made me question the framework I have chosen to use to treat my patients. When a client comes to be with chronic back pain, I assess them biomechanically and start manual therapy, patient education and corrective exercise to either “hold” the manual work I have done on them or to strengthen areas I deem as being weak leading to a painful dysfunction. But am I doing all that I can to help? Am I really even scratching the surface in terms of finding the cause of their pain? What if pain is actually all in the brain? What if the representation of pain from their back is so pronounced on their brain that manual therapy and exercise alone just won’t be enough?

The article I read that discussed just this is called ‘A neuroscience approach to managing athletes with low back pain’.  It comes from the journal Physical Therapy in Sport and was published in 2011. Basically, the premise of the article stipulates that recent neuroscience research into the biology of pain suggests that clinicians (me) involved in the management of the athlete with LPB should embrace a biopsychosocial approach by engaging the brain and nervous system. What does that mean? How does one even do such a thing? These are the questions I had and this article did a decent job of explaining it.

As per the article, a true biopsychosocial model includes a greater understanding of how the nervous system processes injury, disease, pain, threat and emotion. These components work homogenously to create the sensation of pain. This model includes several categories, some of which we are very good at working in at and others we probably should be doing more of. The categories include our working understanding of functional anatomy, biomechanics, tissue pathology, pain mechanisms, representation, psychosocial issues, and fear avoidance.

For me, the most interesting of these categories is representation. Essentially, this model of pain takes on the brain and its processing of pain to treat a patient. New functional MRI (fMRI) scans have allowed scientist to show that when the brain processes information from tissues, many areas are activated to deal with the THREAT of an injury, disease, or situation. These areas, via connections in the brain, generate a “pain map”, which is commonly referred to as a Neuromatrix. The key point here is that the neuromatrix is NOT dependent on any specific tissue (disc, facet, nerve etc), but rather the impending THREAT of pain. “Emotional pain uses similar area to physical pain”. Therefore, if the sum result of the brains processing of information concludes that tissues are in danger (real or perceived), it is logical for the brain to produce pain as a means of protection. This means that anytime the brain perceives pain even from non painful stimuli such as bending forward, or back exercises, this map activates and pain is produced. The problem is when other “maps” form in the brain regarding beliefs, perceived knowledge about pain, and social issues are formed.

Maybe that patient with chronic pain that I was speaking about before has built in maps of pain that can’t be fixed by manual therapy. What if his original back pain started when bending over to pick up a pencil? What if he also had financial or relationship issues when the pain started? These issues all factor in to his current pain state and how it needs to be addressed. The article does a fantastic job of summarizing this by stating:

“Therapists treating athletes with LBP should realize that by addressing the tissue issues (e.g. joint strain, instability etc) with typical therapeutic interventions (e.g. spinal stabilization exercises, manipulation etc) they are only addressing one of the perhaps many issues associated with the development of LBP. The athlete may have such an innate fear of LPB that any activation of the amygdala may activate the LBP map, even though “the tissues have healed”. If medical care continues on the path of seeking the injured joint or tissue and results in more medical tests, more opinions, and more failed treatment then fear itself may increase and LBP may persist”

We have all had those patients that just never seem to get better…don’t lie, I know you all have! Maybe with these patients treating their tissue through whatever technique or exercise you like to utilize is just not going to work. They might require a biospsychosocial model to help them understand their pain and reorganize those maps in their brains to really make them believe that hurt does NOT equal harm and that they will be just fine. The article makes the case that we must educate our patients on pain biology and why they feel pain. With a firmer understanding of their pain and why they experience it via educational sessions, it has been shown to have immediate improvements in patient’s moods regarding pain, improved physical capacity, and a better outlook on their future.

The article concludes by saying we should not abandon our manual therapy techniques at all. We should do all that we are doing so well with our clients, but we need to incorporate pain education by addressing the psychosocial aspects of pain, especially fear, anxiety, and faulty knowledge regarding the cause of their pain. Some practical advise would be:

  • Do NOT tell clients they have degenerative disc DISEASE! All they will here is that they have a disease and the fear and anxiety will surely become elevated. Instead tell them they are experiencing a normal phenomenon with ageing and that pain is only temporary and they should continue with their ADLs as tolerated.
  • Do not show clients pictures of their herniated discs, osteophyets etc. This does nothing but make them think they have a physical deformity in their back that requires surgery or will never get better on their own. Instead, explain that thousands of people have the same imaging findings and have zero pain! There is very little correlation between MRI/Xray findings and pain.
  • Explain that hurt does not equal harm and that pain will go away with appropriate care. Explain that manual therapy serves to reduce pain by stimulating the nervous system…not by moving a bone back in place. This breeds a dependence on passive care that, in my opinion, is so unfulfilling to treat.
  • Include aerobic exercise into your treatment of chronic pain. Aerobic exercise has been shown to help clients who have a very widespread pain neuromatrix. It helps by increasing oxygen and blood to various tissues and has been shown to actually decrease nerve pain from sensitized nerves, help patients sleep better, improves mood and reduces depression.

This article talked about so many great ideas on why we feel pain but I think I gave to the gist of it. Empower your patients to be active in their recovery. Challenge them to not let their pain “win” and they are stronger than their pain.

For a phenomenal resource that can be easily used to teach pain concepts and why we experience it, I would urge you to check out the patient education book ‘The Pain Truth and Nothing But‘ By Dr. Bahram Jam of the Advanced Physical Therapy Education Institute. It is simple to read, funny at times, and highly entertaining.

For a great educational video you can easily show your patients, take a look the youtube video ‘Understanding Pain: What to do About it in less than 5 minutes:


Puentedura, E., and A. Louw. “A Neuroscience Approach to Managing Athletes with Low Back Pain.” Physical Therapy in Sport 13 (2011): 123-33. Print.

  1. Thankyou so much, very interesting, is always good to challenge the framework we have that we work within!

  2. […] Are we treating the REAL cause of persistent pain? ( Chronic Pain, Pain, Reviews   Pain, pain relief, Reviews   […]

  3. jessephysio says:

    Thanks Vicky! I agree, we must always be questioning what we do and why we do it. This is what forces us to become better each day!

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