[headline style=”1″ align=”center” headline_tag=”h2″]Pain Science: Introduction

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Pain science has been a hot topic for the past several years in physical therapy. It has helped many clinicians and patients including myself. Although this has been great advancement to clinicians, many apply this content with every patient even though they have glaring tissue pathology, biomechanical limitations, or when the examination appears to be elusive.  In this post, I defend the stance on normal traditional treatment and assessment means and what populations I have found pain science to applicable with, when and when not to apply this form of treatment, and finally how I implement pain science in my practice.

[headline style=”1″ align=”center” headline_tag=”h2″]When To Apply Pain Science

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It has been through my clinical practice that certain populations respond to pain science while at other times it isn’t needed. Typically I apply it with the majority of my chronic pain patients who don’t understand why they are in pain after injuring themselves months or years ago. For instance, the best patients are those that think they have “bulging” and “herniated” discs, yet, they don’t show any of these signs and symptoms. I will also use it with acute patients who have abnormal views on why they are in pain, are afraid to return to work, begin to be socially inactive, or have other similiar behaviors.

Another great population to use pain science is when patients have increased sensitivity. A great way to detect sensitivity is to brush the injured area with your hand. If they jump off the table or are in excruciating pain, they have increased sensitivity. In essence, you are applying a non-painful stimulus, yet it is painful on the patient.

 

“Use pain science with patients who have abnormal views as to why they are in pain or they are afraid to move”

 -Dr. Scott Gray

[headline style=”1″ align=”center” headline_tag=”h2″]When Not To Apply Pain Science

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Never tell your patient’s their pain is in their head.

Clinically, I don’t apply pain science treatment if a patient doesn’t have abnormal views about why they are in pain, aren’t in chronic pain (most cases), are not apprehensive to movement, or clearly have tissue pathology.

For instance, I had an athlete come in with a hamstring strain and was told by another clinician nothing was wrong and she needed to take her mind off of her injury. Yet, she showed remarkable tissue pathology with weakness, pain when stretching the area, and tender to palpation. This type of patient will not and should not get pain science treatment. She responded well to traditional treatment methods and loading.

Additionally, I saw a lady that suffered from chronic lower back pain but was told it was all in her head. After a quick evaluation, it was apparent why she had pain anytime she ran, stood for a longer period of time, or walked – she was compressing her facet joints because her hip flexors were extremely tight, yet, everyone wrote her off as her pain was all in head.

This is just a few examples of where clinically I don’t think it is applicable to apply pain science.

[headline style=”1″ align=”center” headline_tag=”h2″]How I Apply Pain Science

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When I do find a patient with increased sensitivity and is an ideal candidate, I apply this form of treatment by doing three things:

  1. Gaining the patient’s trust
  2. Changing the context
  3. Altering or tweaking movement patterns and loads.

If a patient doesn’t believe in you they will never get better. Period. So developing their trust is essential when trying to get your patients better. Some ways I do this is by empathetically listening and asking open ended questions. By the way, this may be the most important thing you do in treatment.

In regards to context, this is changing environment that a specific movement pattern is performed. For instance, if a patient comes into the clinic after hurting their back lifting a heavy block of concrete and you have them try to do this clinically, it may cause them more pain. This is because they associate this situation to their prior episode when they hurt their back. As a result, they still have back pain even though they are healed and biomechanically efficient.

So what do you need to do?

You need to change the context.

A way to change the context is to say, “can you help me move this object real quick”? This now takes the patient’s mind off the task and he thinks he is helping you move something in the clinic. This is just one scenario but it is up to you to change the context.

What are some other ways you can change the context in the sample above?

Finally, you need to be able to adjust loads, vectors, angles, and positions. This is one of the many reasons why I love Gary Gray’s work on 3D loading and movement not only for its applicability to depict biomechanical issues, but providing movement variability.

For instance, if a patient has a hard time reaching to pick up a box from the floor I could change their foot position, the angle of the reach (plane), the load, the rate, etc. Once they find success I may then go back to the original movement pattern which is often pain free. Cool, right?

Please note that I never tell a patient their pain is in their head.

“Never tell a patient their pain is in their head”

-Dr. Scott Gray

[headline style=”1″ align=”center” headline_tag=”h2″]Conclusion

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Although pain science has been great for the physical therapy profession it still isn’t the end all be all. Just like any other form of treatment, it has its time and place. The basic principles of rehabilitation still apply for the majority of patients. Instead of reverting to pain science when a “tough” case appears in the clinic, clinicians still need to follow a through and precise examination to detect biomechanical or other system impairments, and once this is ruled out, revert to pain science. Again, I leave you with this question:

Has pain science gone too far?