The education within the field of Physical Therapy profession is rapidly changing. From the entry-level doctorate to residency and fellowship programs, the degree of education for clinicians is far greater than that of those who graduated years ago. But despite this increase in education, there appears to be a large divide when arriving at a common ground in understanding “why” our patients are in pain. While many practitioners understand how to classify and treat painful conditions, few have a good concept of the neuropsychological mechanisms that influence them.
Pain is the primary reason why individuals seek outpatient, physical therapy services. A significant amount of literature has been produced over the past decade which has explored the painful experience. In 1996, Ronald Melzack proposed the concept of the neuromatrix. The neuromatrix, in its most simplistic nature, is a combination of cortical mechanisms that when activated, send an output of pain. It tells us that pain is always an output from the brain. The Achilles tendon may be swollen. The multifidus may be weak. But pain is not experienced UNTIL the brain determines there is enough of a threat to the tissue. Pain is a top-down response, where the brain interprets a threat, and sends an output of pain to protect an area. This output is can occur without a nociceptive input and many psychological, contextual and environmental inputs can modulate it.
A recent article published in the Clinical Journal of Pain provided discriminative validity for the use of a mechanism-based classification of musculoskeletal pain. The authors suggest that we could be classifying pain by their underlying neurophysiological principles. There are three classifications (nociceptive, peripheral neuropathic and central sensitization) each with a particular cluster of signs and symptoms. Another recent study, published in the Journal of Pain, found that pain catastrophizing, pain-related fear of movement, and depression predicted pain and function one-year following total knee arthroplasty (TKA). This study found that the best prognostic indicators for those who will have long-term pain following a TKA appears to be correlated with psychological variables. These two studies (out of a load published over the pas several years) indicate the evolving nature of our understanding of how to handle pain.
The research that been published regarding the neuromatrix, the influence of psychological variables on pain and other related principles is wildly fascinating but unfortunately, many practitioners fail to understand the significance behind it. In addition, many accredited Physical Therapy programs have failed to fit pain science education into their curriculum and continue to focus on an outdated biomedical model of patient care (versus a biopsychosocial model, which supports the complex nature of pain). Given all of the recent advances and published literature on pain science, it is perplexing that its emphasis in Physical Therapy education is so limited. Please support our grassroots effort urging the Commission on Accreditation in Physical Therapy Education (CAPTE) to change this and incorporate pain science (from a biopsychosocial perspective) into entry-level physical therapy education. You can provide support by signing a petition here. And please become involved by sharing on facebook, emailing your colleagues and tweeting to followers! If you have any questions in how you can get involved, email Joseph @ joseph.brence@physiocorp.com
About Joseph Brence
Joe Brence is a DPT from Pittsburgh, PA (USA). He is a treating physical therapist who also performs literature reviews for forwardthinkingpt.com , theptproject.com, and sportex.net and clinical research investigating the neurophysiological effects of manual therapy techniques. He is highly interested in the incorporation of the pain science (using a biopsychosocial model) into clinical practice and believes its understanding is vital for us to define ourselves as evidence-based clinicians. On the weekends, he enjoys drinking a cold Guinness and watching the Pittsburgh Steelers (American Football).
References
1. Jones LE, & Hush JM (2011). Pain education for physiotherapists: is it time for curriculum reform? Journal of physiotherapy, 57 (4), 207-8 PMID: 22093117
2. Foster NE, & Delitto A (2011). Embedding psychosocial perspectives within clinical management of low back pain: integration of psychosocially informed management principles into physical therapist practice–challenges and opportunities. Physical therapy, 91 (5), 790-803 PMID: 21451095
3. Merskey H, Bogduk N. Classification of Chronic Pain. 2nd ed. Seattle: IASP; 1994
4. Moseley GL (2003). A pain neuromatrix approach to patients with chronic pain. Manual therapy, 8 (3), 130-40 PMID: 12909433
5. Smart KM, Blake C, Staines A, & Doody C (2011). The Discriminative validity of “nociceptive,” “peripheral neuropathic,” and “central sensitization” as mechanisms-based classifications of musculoskeletal pain. The Clinical journal of pain, 27 (8), 655-63 PMID: 21471812
6. Sullivan M, Tanzer M, Reardon G, Amirault D, Dunbar M, & Stanish W (2011). The role of presurgical expectancies in predicting pain and function one year following total knee arthroplasty. Pain, 152 (10), 2287-93 PMID: 21764515