Pain Science—just as colorful, convincing, and vocal as the old guard

Why, when we (as a profession) appear (according to the new pain science gurus) to have been so wrong before, do we appear to believe that we are right this time?

In this era of Post Truth, we read that biomechanical model is outdated, palpation is illusion, assessment has no value, stretching is no more than a back scratch, manual therapy is no more than placebo and so on … The debate on social media shows a current trend in manual therapy toward the “pain science” or biopsychosocial management of chronic pain. Some call for a less hands-on approach, as awareness of central sensitization leads to specific management trends and a move away from patho-anatomical or biomechanical considerations.

Authors Alan Taylor and Roger Kerry from University of Nottingham, UK wrote a viewpoint in the August 2017 Journal of Orthopaedic & Sports Physical Therapy  suggests that no approach, no matter how vocal and evangelistic its followers, would likely be any more certain than what preceded it. They pose the question, why, when we (as a profession) appear (according to the new pain science gurus) to have been so wrong before, do we appear to believe that we are right this time?

They presented a story of Geoff who has a chronic exercise-induced leg pain and low back pain (LBP), and has experienced a range of trends in musculoskeletal physical therapy over 35 years. In the early stages, he was diagnosed “sciatica”and underwent various manipulations. He was then diagnosed with a “disc buldge”.  MRI scans, injections. Further along he was convinced with “core stability” and who, again, was well intentioned but unsuccessful. An now, “pain education” interventions and the classification-based cognitive functional therapy were undoubtedly supported by the contemporary evidence.

The authors then pose a question Given that the physical therapy profession has clearly been wrong so many times before, why do the current pain science fads appear to suggest that this time we have it right?

The authors then suggested that given our history of (apparently) getting things so inadvertently wrong, to step back for a moment and analyze what we can learn:
1. Any school of thought or management approach can never be 100% right for every patient.
2. As physical therapy roles are increasingly “extended,” first-line practitioners will be exposed to more complex cases in both acute and chronic settings.
3. Chronic or persistent pain may well be indicative of central sensitization, but this is not a foregone conclusion.
There are subgroups of patients with chronic pain who display little or no central sensitization, and there are countless cases of delayed diagnosis and/or misdiagnosis.
4. The evidence base changes daily, and history suggests that many of the things we are sure about today will be questioned in the future.

With those things in mind, the authors suggest that to abandon appropriate physical examination and clinical reasoning, or to fail to consider systems and pathology, in favor of fashionable trends is a folly that could well end up in the court room or worse.

Current trend just simply replace “muscle” or “fascia” with “neurons” or “nerves”. Don’t follow the swing of the pendulum, but seek a middle ground. Use the best of the research to guide us,
yet at the same time be able to recognize bias, conflicts of interest, and fashionable trends when we see them.

Read the full article here