All aboard… the latest bandwagon!

We have all jumped onto a bandwagon at some point or other 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 and of course eccentric exercises can cure all tendon issues.

However, recently there is a rather large and impressive bandwagon that many therapists seemed to have jumped onto (and I include myself here) 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 it is the shift in the number of therapists learning more about the science of pain. Many therapists now have a far better understanding of this fasinating and complex area, and are slowly coming to the realisation that the traditional biomedical model and Descartes theory of pain = injury 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 are also now realising 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 so called biomechanic dysfunctions such as pronation as a cause for ankle, knee or hip pain (source source source). Nor 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 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 nociception!
  • isn’t simply an input caused by tissue damage, but rather an output created by the brain.
  • doesn’t need tissue damage to be experienced 
  • and not all tissue damage will result in pain.

Up to my Limbic System in it!

I think it’s fair to say that in these last 10 years we have learnt more about pain and our nervous systems and produced more research on it and its role in the experience of pain than we have in our entire history of evolution, and I for one love learning as much as my poor brain can handle.

 

I’m up to my limbic system in papers about neuromodulation, nervi nervorum, ruffini endings, amygdala’s, prefrontal cortexes, glial cells and tripartite synapses. I’m trying to wade my way through the muddy swamp of the neural compexities that occur via touch, massage and manipulation. 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!

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 persistant pain. Many therapists are now routinely assessing for the signs of central sensitisation, and have been trained to include new methods of assessment and treatment to those with persistent pain such as pain education, cognitive behavioural therapy and other self management strategies.

But… theres always a but!

As much as I myself encourage this biopsychosocial approach in the management of all patients, I think we also 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 start to loose sight of the bio in biopsychosocial

I will admit, I did, for a bit, loose the bio, when I started learning about pain science and I’m not alone. I have discussed this issue with other more experienced, more rationale, far brighter therapists than me who have said the same thing. And I have seen how this can negatively affect our patients when 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 had a fit, healthy, active middle aged lady who told me her story of being quickly diagnosed with persistent pain by her physio and doctor after fracturing her fibula six months ago! She had the usual history of a broken ankle, fell down a step, went to A&E, had an x-ray, a simple undisplaced fibula fracture was diagnosed, she had her foot casted for a few weeks, had a follow up x-ray that confirmed union and was sent to physio for rehab. Simple, routine, nothing to it!

Well not quite, she tells me that 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 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 medications for it. 

However, not fully convinced she decided to seek a second opinion still feeling something just wasn’t right with her foot and, to cut a long story short, a large osteochondral defect was found with a small loose body within her ankle joint, a second operation was performed, and her pain is now much better and she is progressing well.

Unecessary surgery

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, eg patients in chronic persistant pain having unecessary surgery in a belief it would fix them only to find the pain is the same, or worse after!

But I just want to highlight that there are two sides to the 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 pain.

I have also witnessed first hand some healthcare professionals using the ‘chronic pain’ tag simply because it is easier to ‘blame’ this than to exclude all the other possibilities! This is just lazy, sloppy, dangerous practice for which I have no tolerance for.

Monday Morning Syndrome

As awesome as the new advances and understanding into pain and neuro 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. 

Its a bit like ‘Monday morning syndrome’! You know the syndrome, it tends to strike after that super duper course you went on at the weekend with the latest guru, learning about the new thing. Then all of a sudden on Monday morning miraculously every patient you see just happens to have this thing that you just have been learning all about… how strange!

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 our highly sophisticated alarm system of potential threat, 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 when this alarm system of potential threat does go ‘nuts’ or ‘squiffy’ or into ‘over drive’, but perhaps not as easily, nor as often as maybe some would like to think! Finally lets try not too loose sight of the bio in biopsychosocial, lets not let the pendulum swing too far one way and lets not let the pain science bandwagon run away from us all.

As always thanks for reading

Adam

 


51 thoughts on “All aboard… the latest bandwagon!

  1. I was going to reply as I did on Twitter, Adam, but I feel like Cameron’s interaction here has revealed much of the overall concern about bandwagons and the role of staying current with evidence including pain science. Thank goodness someone has everything figured out!

    You are a brave man indeed to allow blog comments as well. Tip of that hat to you for controversial and much needed pot stirring around important issues. We often disagree but I respect your perspective and your ‘congruent authenticity.’
    Jason Silvernail

    • Hi Jason

      Thanks for taking the time to write a comment after your marathon response on Twitter.

      I have wondered if I should disable comments, but where’s the fun in that

      Thanks again, and as Gandhi said, “honest disagreement is usually the first sign of progress…” or something like that, it may have been Einstein???

      Adam

  2. I think Cameron made one good point out of all those responses in stating “Kory, ‘pain is pain’ was my way of saying that most of the diagnostic labels we use are unnecessary.” I do think as a profession and as a medical society in general we have over diagnosed leading to over medicalizing everything, resulting in increased drugs, increased unnecessary imaging and surgery. etc. I think back pain is sufficient vs. DDD, arthritis, lumbar HNP.

    This is where it’s important to diagnosed a PT diagnosis, such as lumbar extension hypomobility movement impairment syndrome. Says a lot more than “DDD.”

    Mainly where I disagree is along the same framework as everyone else. Pain is not pain, pain is an highly individualized/subjective experience and should be treated as so. You mention EBP has led you to your treatments; however I’m pretty sure there is different evidence for acute ankle sprain vs. 3 year CRPS. Just ask Moseley.

    Finally: tx’s should never be fillers! Everything prescribed should have critical thinking behind it, serve a distinct purpose, and benefit should always outweigh the risk of an intervention.

  3. P.S. Everyone thinks they get the best outcomes, but does the data back up the facts. What do you consider a good outcome? Someone who improves pain? Function? Do you look at reactivations?

  4. Hi Adam could you please remove my posts from this thread and related replies? It turned into something about my approach to physio which is nothing to do with bandwagons. I’ll just post on NOI from now on.
    Cameron

  5. Pingback: We’re not worthy! Being drawn into Wayne’s World

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