The End of Pain

I’m Done Treating Pain.

Yes. You read that correctly. I’m over it.

Several different thoughts have crept into to my mind sparked by what I have read and conversations I have had. I would like to share these insights with you.

I remember when I was visiting Bill Hartman Dad a few months ago and we were talking about a specific treatment that is quite controversial in therapy today. He said something that really resonated with me:

“Maybe they measured the wrong thing.”

This sentiment was echoed in “Topical Issues in Pain 1” by Louis Gifford. Check out this fantastic excerpt:

“Thus, pain can be viewed as a single perceptual component of the stress response whose prime adaptive purpose is to powerfully motivate the organism to alter behavior in order to aid recovery and survive.”

Notice what I bolded there. Pain is a single component of the stress response. Not the stress response. Not a necessary component of the stress response. Just one possibility.

Anything is possible!!!!!!!
Anything is possible!!!!!!!

Why do we place so much importance on pain?

Many proponents of modern pain science (myself included) often use this statement against individuals who are over-biomedically inclined:

“Nociception is neither necessary nor sufficient for a pain experience.”

Agreed, pain is not always the occurring output when nociception is present. That said, pain is only one of several outputs that may occur when a tissue is injured. Just because pain is absent does not mean other outputs are also absent.

Many different outputs can occur when an individual is under threat.

Let me propose a new quote to those who focus solely on pain.

“Pain is neither a necessary nor sufficient output of the stress response.”

Why should we limit ourselves to only treating pain? Why should we limit ourselves to only treating outputs? (Spoiler alert, we can’t treat outputs, change them) I have a better idea.

Today, I start treating a human system under threat.

The Threat Matrix

 Dad showed me this great editorial here in which Eric Visser expands upon Melzack’s original pain neuromatrix.

Visser calls this idea the threat matrix. To simplify the idea, threatening inputs from the body and the environment enter the system, are scrutinized by the brain, and then the desired output to combat the threat occurs.

Input –> processing –> output

This framework explains how any output, desirable or undesirable, can occur from a stressful input.

Let’s apply this to an example that we have all been through; a breakup with a significant other.

Your significant other decides to leave you, how do you feel?

The answer depends on the individual. Some folks may feel depressed. Some may feel anger.

Some may even experience pain.

Or you may throw a party in your ex's name and not invite them
Some may throw a party in their ex’s name and not invite them

These feeling are all outputs that occur as a result from an input (i.e. the breakup) that disrupts homeostatic balance of the human system. The outputs that occur are the ones that the brain determines best aid the individual in recovery and survival.

Let’s now take this thought to the therapy realm. I sustain tissue damage and nociceptive information travels to the brain to be scrutinized. What output(s) could occur? Let’s think of a few possibilities.

  • Pain
  • Sympathetic dominance – increased sweat production, heart rate, blood pressure, etc.
  • Motor responses to protective patterns
  • Endocrine alterations in gut/reproductive function
  • Increased/decreased immune activity
  • Fatigue
  • Anxiety
  • Depression
  • Fear
  • Yada yada yada

All of these could occur, some of these could occur, or none of these could occur. The response to the offending input is going to depend on the individual’s brain scrutinizing the situation.

One could argue that a nociceptive event could lead to someone developing anxiety and poor immune function without ever experiencing pain if that is what the system feels best aids in survival.

Nonspecific Effects my Arse

There are many treatments out there that people deem worthless because research demonstrates minimal effects on pain compared to placebo. If someone gets better with this intervention, we deem that nonspecific effects led to the change in pain.

I call bullpoop…sort of.

Utter bullpoop
Utter bullpoop

Nonspecific effects could be a contributing factor to someone benefitting from a particular treatment, but the problem with most pain research is that often pain level is the only thing that is measured.

If pain is only one possible output of a system under threat, how do we know that a treatment didn’t affect a different output?

Answer: We don’t because it wasn’t measured!

Let’s take a controversial treatment for example: dry needling.

Talk amongst yourselves if verklempt
Talk amongst yourselves if verklempt

Some say it works wonders for pain, some are vehemently opposed, and research is mostly mixed. What do we do?

Perhaps both camps are wrong. Why? Pain is the only output being discussed.

What if this whole time, dry needling worked because it altered inputs coming in from the immune, autonomic, or [what the hell evahhhh] system, which led to changed output from this system primarily with pain output altered secondarily? And here is the kicker; the intervention only works if these systems respond as well as our pain system under a particular threat.

Well we don’t know that because we didn’t look at it. But looking at multiple systems when an intervention is implemented may give us more explanatory power as to why certain treatments help certain individuals. With this information, treatment could be streamlined and implemented.

Endless Possibilities

Making pain our only concern to treat severely limit our capacity to help individuals. If we think of treating the stress response itself, we open up a huge realm of issues our interventions may affect.

If you take a look at the book “Spark” and the corresponding research, we see how exercise can alter many different outputs.

Why can’t rehab folks be a piece of this puzzle? It does not seem unreasonable to me that we could get referrals for anxiety, depression, or whatever output the stress response creates.

Some really know how it feels to be...
Some really know how it feels to be…

Strategically implemented exercise can help alter the stress response. That possibility makes me so hopeful for our professions.

How can one best assess a system under threat?

Assessing Threat

If clinicians are to assess if an individual is undergoing a chronic stress response, we need to find a reproducible methodology that gives us this information. We must look at the human system from the input/output standpoint.

There are several outputs that can be measured to assess an individual’s homeostatic state:

  • Blood pressure
  • Heart rate
  • Respiratory rate
  • HRV
  • Blood work
  • Other specific medical tests

These are all great tests that can assess the amount of system stress an individual is undertaking. That said, I feel there is an even simpler method of assessing the stress response:

Our physical examination

But not patho
But not patho

Assessing the stress response begins with the subjective examination. This piece of the clinician-patient interaction helps us assess potential offending inputs as well as individual processing.

If we come across red or yellow flags, we can easily refer out to providers who can deal with that piece of the stress response. Here is where a psychologist, surgeon, oncologist, other medical professional can come into play. These individuals can alter the offending inputs or help influence processing that therapists and the like may not be able to touch.

There are always exceptions to what you wouldn't touch with a 10 foot pole.
There are always exceptions to what you wouldn’t touch with a 10 foot pole.

Let’s say we get through our subjective and we screen out that the above professionals do not need to be a part of this person’s care. Let us now proceed to our objective examination.

Assessing movement may be the simplest way to assess an individual’s stress status.

If we are to provide the “ideal” physical examination, we need to perform tests and measures that best differentiate a stressed from nonstressed individual.

To undertake this task, we need to have a few assumptions about what a nonstressed individual looks like. Let’s call this individual the “adaptable human.”

  • The adaptable human will have desirable multi-system variability. That is, human systems can perform as needed under certain situations without being “stuck” in a particular range. For example, blood pressure should stay lower when at rest and rise when performing physical activity. When blood pressure remains high at rest and with physical activity, that individual possesses system rigidity.
  • The adaptable human will have desirable multi-system capacity. That is, human systems can tolerate prolonged stressors without faltering. For example, a human can perform longer durations of physical activity with blood pressure remaining in levels that would not threaten one’s life.
  • The adaptable human will have desirable multi-system power. That is, human systems can tolerate intense stressors without faltering. For example, blood pressure can reach a desired level to allow for a particular physical activity to occur.

Our examinations ought to assess these three qualities: variability, capacity, and power.

Of the three, variability is most fundamental because almost every healthy human system functions in the manner. The movement system is no exception to this rule.

Movement variability, the ability to move in three planes, is the simplest reflection of this concept. A nonstressed system will possess movement variability. A stressed system shall become rigid and lose triplanar mobility.

Think to the last time you were stressed. Did your muscles tense or relax? As muscles tone increases, range of motion decreases. Assessing movement variability is an easy way to assess the general tone an individual has, and I speak more of why this notion is favorable here.

To assess variability, our examination must:

  • Look at the entire individual’s body
  • Cannot have bias toward one output (e.g. pain)
  • Must be reproducible and predictable

First, let’s look at popular rehab systems that I feel would not work in this instance and why.

  • Maitland: Biased toward altering one output (pain); segmental in nature.
  • McKenzie: Biased toward altering one output (pain); segmental in nature.
  • SFMA: Not necessarily biased toward one output, but does not look at entirety of human movement. Only two movement planes are assessed. Cannot see if an individual has variability in the frontal plane.
  • DNS: Wait? Do they even assess?

 

Just when you thought I couldn't diss DNS
Just when you thought I couldn’t diss DNS

I shall let my bias now creep in as I suggest the current best model we have for movement variability is PRI.

There are several reasons why I think PRI is currently the best model to assess threat:

  • It is not biased toward altering one output, as movement rigidity can occur along with several other outputs besides pain.
  • The entire human movement system is assessed in three planes.
  • The protective patterns one undergoes in threat are predictable and similar for all individuals.
  • When one deviates from these patterns, likely pathology had to be created in order to do so.

If an individual can produce nonpathological triplanar movement throughout his or her body, then movement variability is present. A movement system under threat will not have this capacity. A threatened movement system will become rigid.

Establishing movement variability is our primary way to reduce threat-response outputs.

If undesirable outputs remain once movement variability is established, then we know other interventions must be given to address these areas.

  • If pain is still present, then previously mentioned assessment systems hold value, as does graded exposure.
  • If psychosocial outputs are still occurring, we utilize therapeutic neuroscience education or refer to individuals that can address other factors.
  • If one has issues coming from another system, we refer to a practitioner that treats that system.
  • If one cannot perform a task well, then we build capacity and power.

The point being, once movement variability is restored the rehab clinician’s job for the most part is done.

The treatment is done so I guess I'll be leavin'
The treatment is done so I guess I’ll be leavin’

Movement freedom through triplanar inputs to establish variable motor behavior is the simplest way to let the brain know that an individual is not under threat.

A Call to Arms

 So I challenge you, my reader, to respect but look past pain. Look past the output. Let’s instead shift our focus to treating an individual who is under threat and stressed.

If you can attenuate threat with your current skillset, and refer to others who do the same with other skills, a much larger population can be helped.

Let’s continue to push our limits!

Uhhhhhhhhh
Uhhhhhhhhh

 

 

 

 

13 Replies to “The End of Pain”

  1. Great stuff! As you mentioned, a loss of fine scale variability has been shown to be an end result of stress and a general movement to all sorts of “bad” stuff.

    Loss of HRV is a risk factor for cardiovascular disease, loss of fine scale variability in gait may be a predictor of health and/or risk of falling, etc.

    When under more stress (threat), there is a loss of fine scale variability. Not good.

    The neuromatix of pain shows that many many inputs could result in pain –but the same input may NOT result in pain for person A and result in pain for person B based on their differences.

    I am not a physical therapist, however, many many times just getting someone to move better and more fluid results in a decrease in pain. Improve movement by reducing threat (breathing, eyes, vestibular, context, vision, etc etc) and viola!

    Big can o’ worms for sure! Thanks for the great post!
    Mike T Nelson

  2. Zach,

    Compelling thoughts that you propose and I like how you talk about treatment more than just pain. However, I feel as one of the three pillars of EBM would have use focus on “patient expectations”. If their primary concern is “pain” that that has to be the primary focus of the rehabilitation program. I too believe that usually starts with changing inputs to the CNS that can often alter movement and set the stage for the said “variability”.

    Also I am not disagreeing of your assessment of the other primary assessment strategies used by most practicing clinicians, but who says that you cannot combine the usage of these systems? That is what I have begun to do in clinical practice and I have found very good success in the past few months.

    I have gone through training in PRI by a group of PT’s that work in the healthcare system that I work for. My two big issues is that it assumes that functional limitations fit into one of 3 categories and that may not be the case. I was once assessed by one of the said clinicians and after her PRI assessment she noted that I “best fit into the AIC pattern, but that I had some signs of other patterns.” Thus leaving her to treat the AIC and few if any benefits were noted. Also, the exercises can be difficult and time consuming to teach patients thus I have found that compliance with the HEP has been difficult for patient’s I have tried teach some of the resets.

    I totally agree with you that variability is KEY! That is one thing that McKenzie does very well with the recommendations to do the exercises as much as possible. I think the combination of the more established “systems” as well as the “system” that PRI has established can work for many/most of the patients, but I also think that perhaps “variability” of the clinician’s clinical approach may also be necessary in order to help the largest number of patients/ clients.

    Continue to great thought provoking conversations…look forward to continued reading!

    Josh

    1. Hey Josh,

      Appreciate you commenting and the kind words.

      Although I write for dramatic effect, I absolutely address patient concerns/needs/expectations and the like. That is what the subjective and educational pieces are for. I often relate my educational piece to variability and it’s implications on pain.

      The outputs (e.g. pain) are relevant to the patient, but from a treatment standpoint the only thing we can do is look to alter threatening inputs with nonthreatening inputs. It’s up to the brain to decide if pain is necessary. Finding an activity that “feels good” to the patient (e.g. McKenzie) and reduces the pain output is reducing the perceived threat by altering a threatening input in some way. I am totally cool with that. Improving movement variability can do that as well, and in most cases that is my starting point. I’m also cool with using the other assessment strategies; just realize that you are not assessing movement variability. Also realize that certain methodologies (i.e. McKenzie) run the risk of reducing movement variability by biasing someone into extension.

      I question the PRI understanding of the group you learned from based on what you are telling me. There really is only one pattern that occurs across the 3 S bones (sacrum, sternum, sphenoid) called the LAIC/RBC/RTMCC. One can become bilateral (PEC/BBC/BTMCC) in any of those areas through extension as a further adaptation. The original pattern is still underneath that. If there is any deviation from that, then likely pathology had to be created in order to do so. Treatment success is going to depend on many influences and if you were given the “correct” input(s) needed to achieve neutrality.

      As for the exercises, they can be quite challenging to coach and can be time consuming. So I agree. I usually only do a few activities over the course of 1 hour, but make sure they are done savagely well. The PRI activities are just reminders of the components necessary to achieve left stance with right trunk rotation first, then alternating reciprocal activity second. Eventually, one hopes to get someone to the point where exercises are not needed and instead develop left-sided awareness throughout the day (e.g. standing on your left leg in left AF IR).

      I don’t want my patients to do the exercises as much as possible. I want them to be done enough to elicit the desired change, then reinforce the taught concepts throughout the day to maintain variability. You can use whatever methodology accomplishes this goal, as long as you improve variability. I’m not necessarily against learning other approaches, just that PRI has worked well for me in establishing variability.

      Does that kinda clarify my thought process? Appreciate the comments again.

      Zac

  3. Zac, been lurking on your site for quite some time and love it very much. This approach is indeed quite thought provoking.

    Couple questions:

    – Would you encourage teaching patient that even if they want to reduce symptoms/outputs (pain), that by reducing threat/stress you are going in that direction (good way to introduce pain science and explain to them how it works)

    – Would you work with a team right off the bat? While you work on movement variability, patient could see psychologist/nutrition expert/ any other expert that you deem valuable?

    You said in the article: When patient has attained movement variability, refer him out if pain or other threats are still present.

    Do you think movement is on top of the list or it’s because it’s what you do, and people go see you for that?

    In your opinion, would it be beneficial if you would refer to other professionnal WHILE you are treating said patient?

    Thanks so much, sorry I had more questions than I thought! 🙂

    Keep up the great work,

    Alex

    1. Hey Alex,

      Thank you for the kind words and I am glad that you have commented from out of the shadows 🙂

      I will try to answer your questions to the best of my ability, but the overarching answer will be “it depends.”

      1. Yes. We cannot treat outputs, only alter them for new outputs. Pain is one possible output in response to threat. Attenuate the threat, and in most cases the pain output should reduce. That threat could be a multitude of things.

      2. Ideally yes, but it depends on what team members are needed to meet someone’s goals. In my current setting with my current clientele I see how much I can do alone before I phone a friend. That is probably because I am still building the group of superfriends.

      3. The revised answer would be I would work with someone to maximize movement variability, capacity, and power. This model would include therapeutic neuroscience education, as one’s thoughts/beliefs could be limiting agents to these movement qualities. If those components are maximized yet there is still other symptoms/threats that may warrant a referral to another discipline. As a physical therapist and strength coach, bettering movement is my discipline.

      4. The referral basis could be simultaneous treatment or before treatment. For example, I integrate often with optometry and dentistry in my practice, and oftentimes I will need a patient to see those folks before I can take them to the next step. The referral process is a case-by-case basis.

      I hope my answers were helpful. Did I make a lick of sense?

      Appreciate you reaching out again,

      Zac

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