Today I want to return to IFOMPT 2016 in Glasgow where keynote speaker Dr. Lorimer Moseley both enlightened and entertained a captive audience. If you haven’t had the pleasure of hearing him speak, I embedded a great video clip below where he addresses his perspective on how the body interprets pain. I also recommend this “pelvic tilt” video.
So let’s talk about pain. The International Association for the Study of Pain has carefully defined pain terminology to provide a more scientific and accurate taxonomy to different pain experiences. Moseley admits that he is not a manual therapist, but in the same breath complements IFOMPT and its focus on research and propelling the profession in a positive direction. If you have not been exposed to current pain science, his insights will likely alter your approach to patients.
Moseley started the lecture explaining the placebo effect, and that the pain experience can be altered by multiple factors, including the confidence and appearance of the medical professional, and the words one uses in a treatment room (see Bedell et. al). He states that how a patient is approached by a medical professional may be more impactful than the intervention itself. If you are not already guarding the words you use in the clinic, this should be considered. What may be thought as an innocuous comment, could increase your patient’s perception of pain. A simple, “that herniated disc of yours is pressing on the nerve” could stick with your patients longer than you think. An excellent reference for this is an earlier work by Mosley, A Pain Neuromatrix Approach to Patients with Chronic Pain.
Dr. Moseley also emphasized is that “Pain is just one part of a protective suite,” which includes:
- Endocrine System
- Pain, Nociception, behavior
- Motor System
- Sympathetic Nervous System
- Immune System
He points out that pain is the only aspect of the “protective suite” we are aware of. This, in effect, forces us to change our behavior. An example provided modulation of the eye’s blinking reflex according to arm movement (Wallwork et al. 2016). It is heightened when your hand is moving toward your face (determining that there is an increased possibility that you may poke your eye) and it is suppressed as the hand moves away from your face. If there is a soft barrier between your face and your hand while your arm is moving toward it, the blink reflex is suppressed. In the absence of a barrier it is heightened–pain response can be altered depending on the perception of a threat to tissue damage and not actual tissue damage.
Another fascinating fact he addressed is the role of the immune system in response to pain–a phenomenon called “Glial Priming,” where Tumor Necrosis Factor (TNF) can over-activate biochemically and contribute to the pain response. Immune factors increase over time, based on prior experiences, and can dramatically increase a person’s reaction to pain.
Dr. Moseley spoke for about 50 minutes and here are my take-aways …
- As therapists we need to be aware that our actions can impact our patients and the effectiveness of our interventions.
- Pain education is an important aspect of physical therapy treatments (videos like Understanding Pain can help educate patients.) The most prevalent erroneous belief by patients is that pain is proportional to tissue damage, and by explaining the factors that can impact levels of pain, patients can understand what they are feeling.
The positive aspect of the new pain phenomena is a broader understanding of what can contribute to chronic pain and an individual’s response to varying therapy interventions. A negative factor is a broadening impression in our profession that the biomechanical contribution to pain through altered movement patterns and type of intervention are not very important.
In reviewing the science of pain, it is easy to get caught up in the complexity of the nervous system and the neurobiology. Let’s ensure that in using different approaches we do not “reject the role of structural, biomechanical and functional disturbance of body tissue “(as mentioned above). NAIOMT offers an eclectic approach to current pain theories and emphasizes a high level of skill in evaluation and treatment in each patient (mentioned by Jull in last week’s post) with a heavy emphasis on scientific functional anatomy. This balanced approach, which does not ignore science nor the patient in front of us is effective and evidence based.
– Terry Pratt, MS, PT, COMT, FAAOMPT
Fall Manual Therapy Courses with Terry Pratt:
Cervical Spine I (Touro College NYC) +7 hrs Online, September 18 – September 19, 2016 in New York, NY
Terry is a Faculty and Clinical Fellowship Instructor for The North American Institute of Orthopaedic Manual Therapy and has lab assisted with the Institute since 2002. He’s served as adjunct faculty at several universities, developed teaching manuals for the McConnell Institute faculty, produced technique videos for NAIOMT, formatted and reviewed the textbook ‘Manipulative Thrust Techniques of the Spine’ by Erl Pettman, and the manual for distance mentoring for NAIOMT clinical fellowship instructors and fellows in training. Terry has written a section for a home study course for the Orthopedic Section of the APTA addressing treatment of the injured lumbar spine published in 2015. Learn more.