Applying The Biopsychosocial Model In Clinical Practice

 

The biopsychosocial (BPS) model is one of those things you probably feel like you should be doing but maybe don’t know exactly how or you don’t have the skills? There does seem to be a fair amount of uncertainty and a bit of anxiety associated with the BPS model HERE and even the papers that discuss it rarely seem to actually define it!

This take on the Dan Ariely “big data” quote sums it up quite nicely (kudos to the author!)

Biopsychosocial management of back pain

Is like teenage sex;

Everybody talks about it;

Nobody really knows how to do it;

Everyone thinks everyone is doing it;

So everybody claims to be doing it.

But maybe we don’t need to FULLY define or understand the BPS to start to implement it in some way. The first thing we need to do is actually know MORE about it. I was told recently that the BPS model is “old and we should move on” in a Twitter discussion. A little bit further into the discussion, it turned out the other party had not read much about it, I think this happens a lot. We all seem to have our own interpretations around what BPS is and is not, so this is my attempt!

What Is It?

 

There seem to be two main perspectives that are summed up in these quite differing quotes:

“The centre of interest in biopsychosocial model is not the disease but a sick individual”  – Havelka  

 “The Biopsychosocial model was first conceptualised by George Engel in 1977, suggesting that to understand a person’s medical condition it is not simply the biological factors to consider, but also the psychological and social factors” Physiopedia

The first is focused more on the person we are treating and the second is more focused on the condition or problem, so no wonder we have a bunch of confusion and NEITHER really give much guidance about what to do next.

One of the perspectives that I feel gets lost in some views of the BPS model is the focus on the ‘humanisation’ of healthcare which is a feature of Engel’s writing. To understand the biopsychosocial model we also have to understand why we needed it in the first place and this was to come away from the reduction of healthcare to pathology and numbers that was the biomedical model.

Isn’t it fascinating we now quantify the success of a BPS approach simply by an outcome measure!?

Philosophy Of Care And Person Focus

 

Maybe this is the real spirit of the BPS? A ‘philosophy of care’ and a person focus.

The cool thing is it does not require extensive training to implement, instead, it simply requires us to appreciate there is another person who is more than a disc or a tendon or whatever issue they have. They also will have a history and experiences that shape their emotions, perspectives and ultimately behaviours.

This for me is summed up nicely in this quote.

“Look at the world through the patients eyes and walk through the world in the patients shoes” –   

 This quote from Joanne Bourke also sums up how we can focus more on the pain than the person who has it.

Pain’, rather than a person-in-pain, is given agency. A pain-event always belongs to the individual’s life; it is a part of her life story”  

When it comes to the human side of the BPS perhaps we can get stuck on the idea that everything we do has to result in a better outcome e.g. a change in pain. So this interaction is measured and judged via change in pain, empathy is measured via change in pain, you get the idea. This is exactly the positivist/empirical perspective Engel seemed to be arguing against, reducing everything to a hyperfocus on the problem and then measuring its change! We should be being aware of how we interact NOT just to get a better outcome measure but also because it’s the RIGHT THING TO DO!

Evidence-based medicine is important but not at the expense of a person. We really need to zoom out to the whole often rather than separating into smaller parts and descending DOWN Engel’s hierarchy of systems.

The aspect of the BPS model that is probably most important is our own self-reflection on how we think, act and interact but I have rarely seen this discussed. Just reflecting on how we communicate or care for the other party or conduct ourselves is enormously valuable.

The thing is that if we want the BPS to be an effective treatment tool then it probably requires the human aspect that is being discussed here. Many psychosocial factors that relate to pain require changes in behaviour. These changes also require trust and belief in what we are saying and this can be tough when it is contrary to all the other concepts and ideas around pain that people get exposed to.

There are a number of points that we can appreciate to implement a more person-focused version of the BPS model that is NOT directly treatment-focused but might have an effect on the process.

  • Having pain can affect our emotions as much as our emotions might affect pain. It is a BI-DIRECTIONAL model.
  • Socioeconomic status and health literacy directly affect the entire therapeutic process
  • Appreciate how beliefs are in part formed at a societal level and this can make them pretty sticky. They often don’t simply change in a session
  • Having pain is HARD and can limit motivation and belief in recovery
  • This person may have had to tell their story multiple times and this can be very frustrating
  • A constant search for the answer can be frustrating and tiring. Modern medicine can paint the picture there is one to be found
  • Uncertainty and the worry it brings makes people feel worse. Not just their pain but also their well being
  • Hope, motivation, optimism and instilling confidence are important not just for pain but also for LIFE and the person

None of these things are treatments but do help us understand the person and their levels of engagement, optimism and outlook for the future. The appreciation of these points also does not require a huge amount of training to implement.

Causes And Treatment Focus

 

A more traditional diagnostic and treatment-focused use of the BPS seems to be the most popular way it is interpreted and implemented and perhaps this can cause a bunch of issues for both clinicians and patients. To treat thing’s specifically the thought is we have to kind of know what the problem IS first and we can get hyper-focused on finding the CAUSE of the problem, but now we have way more potential problems across lots more areas to confuse us! Sticking to traditional pathologies can be hard enough and this is without having to be an expert in other fields too!

I think there is a case that we could see this as a biomedical application of the BPS as we could treat multiple BPS ‘factors’ WITHOUT actually treating the person in the spirit of the BPS and with a focus on person-centred care. A real aim would be to successfully implement a person AND pain-focused model.  Many of the factors we need to identify to implement a pain-focused model actually need the person-centred model to make them work anyway. Without a good therapeutic relationship and trust and rapport, how do we get people to tell us the information we need? How do we help implement the behaviour changes that are often required? The simple answer is we don’t.

Triggers Not Causes

 

Maybe a better way to see this all would be factors/behaviours that TRIGGER pain not always viewing it through a causation lens. Many things might trigger, exacerbate or modulate a painful state. Is this semantics? Potentially, but maybe less focus on CAUSE might take the pressure off clinicians to pinpoint a cause and does not feed people’s desire to find the one thing that they need to fix their pain. We might swap disc/nerve/alignment for stress/sleep/job and a triggers perspective may help people make sense of their pain situation rather than search for the cure or fix it in the same way that can often prove frustrating and demoralizing.

As we can see HERE 9, yes 9 psychological factors were identified as being involved with rotator cuff tendinopathy pain, function and quality of life. No wonder a BPS find and fix it model is seriously daunting for most clinicians.

A good analogy might be that of a cut that is grumbling away in the background. Sometimes I am unaware of it, others it is giving a slight twinge. But get something in it that irritates it and it’s a whole other story. This added element has interacted with the cut and triggered a response. Without the cut it might not have done so perhaps on its own we might not see it as a casual element. There is sometimes a danger we simply swap biomechanical impairments for psychosocial ones.

The interaction of BPS factors is inherently messy. Humans are a complex web of interrelating systems that display non-linear responses between things acting on the system and the responses it makes. This can mean we could have huge changes in a variable such as stress but only minor changes in how it affects a target variable such as pain. We also might target one variable, that may not change significantly, but another mediating variable change and this changes a target variable. This may be different to the sometimes linear approaches that we can see in research and clinical models that involve a primary outcome measure and intervention.

If we approach the BPS model as a simple view of linear causation and impairment fixing this kind of goes straight back to a biomedical perspective.

 

Positives Not Negatives?

 

There are positives and negatives to this messy non-linearity of the BPS with treatment. Positive in that treatments can have wide-ranging effects across many variables and the negative that they also might not! Exercise can have implications for general health, mental health and pain through a whole bunch of different mediating variables. One way to start to approach the BPS model is not in trying to fix an impairment but to improve aspects we know are beneficial and may provide an overall effect. This would fit with Antonoskys salutogenic model of focusing on wellness rather than illness.

Screen Shot 2020 06 10 At 11.04.02

 

Perhaps an issue is we now see it as “just do some exercise” and the person will be ok.

Exercise ‘works’ is a common perspective but this really does not tell the story of the data. It is not so much if it ‘works’ at a population level but how much effect does it have for this person in front of me. For all this potential to have wide-ranging effects we still don’t see dramatic benefits in the research and often clinically too on the outcome measure of pain. Maybe this is because we expect exercise to automatically transfer to whatever the issues are? Effects on strength, sleep, mental health and ultimately pain are all potential effects/mediators that we see in the research base but we are not GUARANTEED these effects. This paper found HERE found that strength and power scores did not make people feel automatically ready to return to play. Although physical conditioning MIGHT make people FEEL mentally stronger it is not an automatic and linear relationship.

Summing Up

 

We probably need a bit of both perspectives to make things work effectively.

If we put this into context, firstly we need to consider the effects we might want from exercise based on finding out more about the person we are working with. Do we want to improve health? Wellbeing? Function? Exposure? We might have to set up exercise in some different ways to achieve these different aims. Secondly, our deeper knowledge of this person and their journey might help us frame, explain and implement the exercise in some different ways that could have a better potential to have the desired effect.

If a BPS approach just ends up in do some exercise because it CAN have wide-ranging effects I think we have lost sight of what the BPS just might be!

 

Talking Templates for Common Misconceptions

I saw a post on Facebook a couple of weeks ago where a therapist was looking for advice on communicating with their patients.

This is partially because of frustration when a patient has an outdated belief around pain and their body, but you’re now trying to give them a different story.

This can be tough, especially as we learn new research and terminology and try to update ourselves.

Sometimes we want to vomit all the info we know, and people aren’t always receptive to this new information.

So, I figured I’d take a shot at how we can better communicate some of the things in question.

Here we go.

Do I Feel Tight?

This one is a classic.

I’m sure we’ve all had that person get on the table, turn and look at us, then ask, “Am I the tightest you’ve ever felt!?”

The funny thing about “tight” is that somehow as a society, we’ve bastardized this into being something associated with pain. Tight is just a sensation, and it’s a very personalized sensation.

I like feeling tight. When I go to the gym in the morning and do a good workout, I usually feel “tight” for the rest of the day. It makes me feel like I’ve accomplished something, and I’m taking care of myself. However, I don’t associate this feeling with pain (but again, this is a personal, subjective experience).

I think back to an experience I had working with some athletes a few years ago, and this is usually how the conversation goes with someone who asks about this:

Athlete: Do I feel tight?

Me: I don’t know. I’ve never treated you before, so how would I know if you feel tight or not?

Athlete: Oh, well, it’s just that my therapist at home always tells me how tight I am.

Me: Well, the more important thing is how you feel. Do you feel especially tight today?

Athlete: No, I don’t really feel tight at all?

Me: Then you’re probably good!

We then carried on the treatment, and at least for the rest of the camp, the athlete never really worried about feeling tight.

In the case where this is someone who maybe we’ve seen for a while, and they come in and ask if they feel tight, we could change the term to “protected”.

Perhaps we say something like: “well if this area is feeling tight to you, maybe for some reason the body is trying to protect the area, let’s just try to calm the area down and send some safety signals to decrease that protection”.

Whatever language we develop around something like this, let’s make sure we’re not using language that could cause someone to catastrophize what’s happening.

Don’t be the therapist telling people they’re “tight” like it’s a bad thing; let’s reassure them this is okay, normal, and they’re not damaged or broken.

My Posture Is So Bad

Unfortunately, there is so much in the media these days proclaiming that bad posture is the root of all evil.

People have heard things like “sitting is the new smoking” or that they have “text neck”.

Well, we know neither of these things is true, but it’s likely our patients don’t.

But this is where we could take a little time to educate them and even ask questions like, “well why do you think your posture is so bad”?

Depending on their answer, we could try to re-direct their thoughts by making some comparisons.

On things like text neck, we could point out that in the past, we’ve never seen anything like “encyclopedia neck,” “knitting neck,” or in reverse “ceiling painters neck”.

When it comes to sitting, we could point out how any posture held for an extended period will likely get irritating. I can’t imagine how those guards outside Buckingham Palace who have to stand in that “perfect” position all day aren’t going home and just wanting to sit for extended periods after work.

The reality is our best posture is our next posture (I don’t remember where I first heard that to reference it, but I think it was Greg Lehman).

Just showing them that any posture is safe and frequently moving to change your posture is a good idea might be enough to get rid of those old beliefs.

If not, we could cite several research articles that show posture doesn’t correlate to pain, but I’m not sure how many non-therapists want to dig deeply into that info.

Did You Feel That Release?

Well, we know that we can’t actually “release” anything with our hands.

However, many people have been told by other very well-meaning practitioners that they’ve released their fascia, a muscle, or a trigger point.

So what would be a simple way to communicate how we aren’t “releasing” anything but rather are having an influence on the nervous system?

As we mentioned earlier, it could be a matter of changing the language to a chat about protection mode and sending a safety signal to reduce that protection.

Another way is to say:

“Well all the new research has shown us that we’re actually having more of an influence on the nervous system. So, this area is probably a little sensitized right now, we’re not actually releasing something, we’re just calming down that sensitized area. So what you felt is more likely just the nervous system calming down.”

We will all have our way of communicating these things, and I’m sure you can come up with something better than what I’ve jotted down (and honestly, I’d love to hear your take on it).

Let’s make sure that we’re changing the narratives on many of these things along with the techniques we use, and we’re not giving our patients any reason to catastrophize an individualized sensation. We can do better than that.

Putting Patient Preferences and Values Back In EBP

Evidence-based practice (EBP) has been the accepted norm in medicine and rehabilitation for nearly 30 years, though exploration began of its concepts in the early 1970s (Zimerman, 2013).

EBP consists of three elements: the best available evidence, the clinician’s knowledge, and skills, and the patient’s wants and needs (APTA, 2020).

This latter component is also stated as patient perspectives and values (ASHA). All descriptions of the EBP model point to an equal weighting among the three tenets, though most provide little detailed instructions on how to assure the weighting is carried out in that fashion. Many professional bodies established clinical guidelines and pathways to determine how to rank evidence, with case studies and clinician experience at the bottom of the ranking and systematic reviews and RCTs at the top. Clinicians are expected to use their clinical reasoning, expertise, and judgment to apply the evidence appropriately. However, how to go about assuring patient preferences and values are met is a bit unclear.

I have a specific podcast that I am particularly fond of, as the presenter speaks on topics dear to my values (and clicks my bias button continually). On a recent podcast, there was a conversation about applying principles of EBP while assuring the uniqueness of the individual patient was met, something not always addressed in EBP. As the best available evidence requires rigorous trials involving randomized groups, single incidents are often seen as less-than-relevant, though there is a trend toward allowing such individual cases greater weight (Anjum, 2020). While discussing how to apply EBP within such emerging models and how to allow weight to patient perspectives and values, a comment was made to the effect, “well, it is not like we can have our patients choose the intervention.” Really? Why not?

Patients lack the depth of knowledge and experience to build their treatment plan, and if they did, why would they need us? However, can’t they contribute?

In my 35-plus years as a physical therapist, I’ve overheard many different ways that clinicians try to assure that patient expectations and values are met. However, most fall short of the 33% contribution mandate of EBP standards. In a manual therapy setting, asking, “how’s the pressure?” seems to suffice for many, while in the exercise-based setting, so much power is given over to the clinician that few questions are asked. Patients often assume that we know the cause of a problem and also know the best way to intervene. Power is given. However, are there better ways to go further in allowing patient input to be equivalent to clinician input?

I once studied with a brilliant clinician who had a deep level of knowledge about how past psychological aspects often led to certain functional problems and applied his manual therapy skillset to remediate those problems.

However, I saw as problematic that though psychosocial factors leading to those problems were acknowledged, little if any attention was given to those factors during the intervention. The clinician simply applied what they knew to be necessary for the problem that they palpated. Did the clinician have an impact? Indeed, and their work was published and well-regarded. However, could they have improved their allowance of patient perspectives and values in the therapeutic interaction? Yes, indeed.

How can we elevate that 3rd leg of the EBP model to assure an equal weight is allowed to patient perspectives and values?

Many ways, but to start, we can include them more in the decision-making process. In my work, which is to improve function and reduce pain using a manual therapy-based and movement-based blended model, I make it a requirement that my patient fully participates in treatment decisions. This mandate is not always straightforward for the patient to accept, as they often feel ill-informed in treatment decisions. It takes some time to establish both the need for their input and the skillset for them to put this plan into action.

Below is an excerpt from one of my seminar manuals, in which I describe the basics of such a patient-centred model.

Once you have collected their history and complaints and spoken on their functional needs, ask them where they feel their issue. The issue/location could be where they feel the pain, the part of their body where they feel their movement difficulty, where their voice has challenges, where swallowing is impaired, where the tongue gets tight, or whatever brought them to you. Ask them where they feel the problem lies. Some may have no idea, while most will be able to localize the problem area.
• Let them know that the point of this evaluation process is for you to be able to touch, press, stretch, or do something with your hand(s) that connects them to their complaint. You may increase the feeling to a point where you bring it to the edge of the patient’s awareness or even calm the issue to a point where it is barely apparent, but either way, you need to do something with them that they feel relevant. You are looking to replicate a familiar feeling.
• If they are confused by this, or ask, “why do you want to make me feel it?” I suggest that you tell them that it is not your goal to make them worse or to make the problem worse. However, this work’s nature is such that to know that we can help requires us to connect them with their issues. If we cannot replicate the symptom or link them to their problem, both from the periphery (the tissues) and their perception (sensation), then we stand a lessened chance of helping.
• If at rest, they feel nothing, none of their issues, let them know that you may be seeking to allow them to begin to feel it through the therapy process. The concept of bringing their concern to their awareness may be difficult for them, as, for instance, they only notice the problem after doing something. Someone with a vocal strain that only occurs after a performance may wonder how you will be able to replicate the feeling when they have not sung. Someone suffering from back pain that comes on only after standing for a certain length of time may wonder how you will be able to get them to feel something familiar when they have been sitting and have no pain. Let them know that this is your mandate; to connect them with their issue, whether it is present at that moment or not.
• Ask permission to touch them and then place a hand or hands on the identified area. Initially, do nothing; allow your hand to rest on their skin lightly. I will typically then ask them if they feel any of their issues. That gives me an idea if I need to mildly replicate the feeling of the problem or try to reduce it with my stretch.

• Begin to apply a light stretch in the 1-2/10 range on your scale.
• Work in slow-motion; do not move quickly or apply heavy or aggressive pressure. Your pressure might be a lateral
stretch in any direction to the skin or deeper layers, used with a combination of pressure or gentle inward probing. The type and orientation of stretch necessary to connect with the patient’s condition are unique, varying from person to person. Think of this process as one of talking to a person who speaks another language. Each of you has little ability to speak each other’s language, and communication will be slow. It takes each of you a while to find the correct word to communicate an idea correctly, so you work your way through the process until each of you made your point. This process of evaluation is similar. You are trying to find a direction and pressure of stretch in and around the soft and hard tissues, one that your patient begins to feel that you have touched their problem.
• Once you have found a connection, you will need to work out if what you are doing should be continued as treatment. Ask the patient:
• Does this feel familiar?
• Are you feeling a replication or lessening of the issue?
• Does this stretch feel like it might be helpful?
• Is there anything about what you feel that feels like it could be harmful?
• Would you like me to add more pressure? If yes, slowly add pressure until the patient says that now better feel
connected to their issue.
• Finally, once you have adjusted the pressures and direction, ask them if they want you to continue with the stretch.
• When you start to use this work, hold a stretch for 2-4 minutes. During the stretch, you are asking the
patient if they still feel like the stretch is helpful. After 2-4 minutes, slowly release your pressures and retest. Do they
feel different? Have you been able to help them modify the sensation of the issue?

• Depending on your comfort with the techniques, you may now wish to treat more in the same spot or try a slightly
different area. If the patient has felt a change, you might move into the other intervention strategies you use.
• Treating for 2-4 minutes is a suggestion. I spend much longer with this work, often allowing a series of stretches
interventions to a single area take up nearly the entire session.
• No matter if you are using just this manual therapy work or combining it with other interventions, always teach the patient self-treatment. Many forms of manual therapy are too passive; they do not build self-efficacy. I always encourage my patients to follow through with self-stretching, if it feels helpful to them, and increase their movement through exercise, strengthening, or simply moving more. Passivity happens when we do not include the patient in treatment decisions, whether it is through manual therapy or exercise-based models of care.

The original intentions of EBP have been lost, though many feel they honor it. I think we can do better.

  • Anjum, R.L., Copeland, S. and Rocca, E. (Eds) (2020) Rethinking Causality, Complexity and Evidence for the Unique Patient. A CauseHealth Resource for Health Professionals and the Clinical Encounter, Springer (open access book).
  • Components of Evidence-Based Practice, 2020. APTA.org.
  • Evidence-Based Practice (EBP), ASHA.org.
  • Zimerman, AL. 2013. Evidence-Based Medicine: A Short History of a Modern Medical Movement, AMA J of Ethics, 15(1):71-76.

Amazing Low Back Exercises to Try Right Now.

Sometimes coming up with exercises in your clinic room can be difficult. Even more difficult is finding some that you can recommend as good home care.

Last week we went over how to do a great exercise called the “Dead Bug”.

This week we’re basically going to flip that over and progress the exercise to something called the “Bird Dog”.

What I love about these, is you can do it right on your table, and they’re easy for a patient to do at home.

Once your patient is confident with doing this exercise on top of the swiss ball, we can make things more difficult by removing the swiss ball.

This can still be easily done on your table in your clinic room, but it’s just a bit more difficult and will build a bit more confidence than when you’re using the swiss ball.

 

Now we can ramp things up just a bit more after your patient is confident with these movements.

By using an exercise band we can make things just a little more difficult and still build more confidence in movement with our patients.

Give these a try.

Doing movements like these will reinforce everything you did with your hands on the table and bring about greater outcomes with your patients.

If you’d like to learn more on how to incorporate more things like this into your treatments, and generate greater outcomes, register for our newest online course “Clinical Applications Of Pain Management Using Therapeutic Movement” by clicking HERE

An Attempt At Simplifying Central Sensitization

 

Have you ever had one of those appointments where you’re not sure of the outcome or the patient interaction?

I remember having a patient back in college who would come in for treatment of back pain. The person was in their early 20’s and told me they were dealing with chronic pain in the area. 

During the first treatment, as soon as I put my hands on them and pressed down, they quickly informed me that was too much pressure! So, of course, I backed off and used a much gentler touch. 

I felt like I was barely touching them. 

So, I treated the person a few times; then, they booked in with one of my classmates. 

However, during their treatment, the patient said “your treatment was okay, but you don’t use as much pressure as Jamie”!

We were both perplexed as my classmate said they were using very light touch (I think I had put something in the treatment notes about pressure). 

Neither of us could figure out what was the correct approach. There is a chance this was just therapist preference, but there’s also the possibility of something called Central Sensitization. 

Understanding Pain

It’s probably important to start by talking about Nociception. 

Nociception itself is not pain; it is the detection of noxious stimuli, which is a protective response that generates a reflex withdrawal to get us to stop doing whatever thing we are doing that could cause tissue damage. (1) Another result of this is it helps us avoid doing those things again (think the first time you put your hand on a hot stove, and will likely never do that again). 

When sensitization of this nociceptive system is repeated or more intense than usual, then the amount of stimulus needed to create pain decreases and becomes amplified. (1)

So, for Central Sensitization to occur, an intense stimulus has to happen repeatedly over an extended period. (1) Think of something like jabbing your forearm with a sharp pen for a couple of minutes (don’t actually do it, I’m just giving examples!). Doing the same thing with the pen for 5 seconds won’t have the same result. 

When this happens, it leads to Nociception no longer being a protection, and pain can arise out of nowhere. 

This can result in allodynia and hyperalgesia, and it is necessary to recognize the difference between the two. 

Hyperalgesia is where an increased response at a normal threshold or increased threshold creates an enhanced pain sensitivity. This is common for things like neuropathy. 

Allodynia is pain from something that shouldn’t be painful. Like the touch of a feather, as you can see in the image below.(2) 

 

Image from: Tsagareli, Merab. (2013). Pain and memory: Do they share similar mechanisms?. World Journal of Neuroscience. 3. 39-48. 10.4236/wjns.2013.31005.  

 

As well, pain can be exaggerated and prolonged because of its response to noxious stimuli and can spread to other parts of the body, which is called secondary hyperalgesia

The research papers cited show a whole host of molecular changes and activities in the spinal cord that lead to CS, but I’m not sure we have to know those specifics. It is important to know that these changes are happening in the dorsal horn of the spinal cord which is sending signals to the brain. 

Another essential takeaway is how there is no single defining mechanism; it’s a general phenomenon that changes how a stimulus is interpreted. 

So, how often have you had a patient come in where maybe their pain experience didn’t make sense? Perhaps their arm hit the door as they walked in, and it was excruciating? Maybe their description of what they are going through didn’t make sense? 

Well, this may be in part because of some CS occurring with them. Because tissue injury is not necessary, and pain can be maintained even though there isn’t any injury that has happened (recently), these may be signs that something more is going on. 

However, we aren’t able to diagnose this, but it may be vital for us to recognize it. So, let’s look at some conditions where this is common for people to experience this. 

What About Clinically? 

So, part of the issue with CS is that the CNS can change, distort, and amplify pain all without an actual noxious input. When we look at the lack of an injury, it may seem as though the pain isn’t real, but it most definitely is.(3)

So, imagine what this is like for the patient sitting in front of you. Especially when there could be things like work-related compensation etc. involved. (3) 

Another aspect regarding this condition is that it is complicated to diagnose because we cannot measure sensory input. So, pain hypersensitivity alone isn’t enough to say someone has CS. Some of the things they look at to determine if it is CS are (and remember how I said ‘a whole host of molecular changes and activities in the spinal cord that lead to CS, but I’m not sure we have to know those specifics’): (3)

  • pain mediated by low threshold fibres (but they have to use nerve blockers and electrical stimulation to figure that out)
  • spread of pain sensitivity to other areas without any injury
  • aftersensations (prolonged sensation after stimuli has been removed)
  • something called ‘temporal summation’ (basically things happening at the action potentials of nerve conduction)
  • pain continuing on from a small stimulus that usually wouldn’t cause pain

So, clearly, for us as Massage Therapists we wouldn’t be able to develop an accurate diagnosis for one of our patients, as much of this would have to be seen under MRI. 

However, we can look at some conditions where we are more likely to see this as CS can influence the following:(3)

Rheumatoid Arthritis

  • during flare ups more pain in the joints and remote areas could set up a state of CS

Osteoarthritis

  • degree of pain does not always correlate to extent of joint damage or active inflammation

Temporomandibular Issues

  •  associated with increase in generalized pain sensitivity after isometrics of orofacial muscles
  •  widespread bilateral mechanical and thermal pain sensitivity in women
  •  greater referred pain from trigger points
  •  mechanical allodynia with inflamed teeth, don’t become a dentist

Fibromyalgia 

  •  several studies showed increased sensitivity to pressure, thermal stimuli, and electrical stimulation of muscle and skin support CS
  •  they use medications in this case to treat the CNS

Musculoskeletal conditions

  •  Whiplash
  •  shoulder impingement syndrome
  •  tennis elbow (widespread bilateral mechanical pain)
  •  deep tissue hyperalgesia in chronic radiating low back pain, with intervertebral disc herniation
  •  characterized by spread of pain and sensitivity to deep uninjured tissue

Headache

  •  spontaneous body pain and allodynia preceeding migraine attacks
  •  chronic tension headaches referring to hyperalgesia of neck muscles
  •  CS may contribute to to chronification of tension headaches

Neuropathic Pain

  •  studies have looked at things like carpal tunnel that had enhanced bilateral sensitivity and spread of symptoms with nerve entrapment which supports CS

Complex Regional Pain Syndrome

  •  presents with increase in tactile and pressure invoked pain, presence of contralateral hypersensitivity in the absence of any inflammatory process

Post Surgical Pain

  •  depends on anasthesia and very important during recovery

Visceral pain

  •  IBS/referred pain – use local rectal anasthesia to help
  •  Non-cardiac chest pain have esophogeal  hypersensitivity   
  •  chronic pancreatitis – generalized deep pressure hyperalgesia
  •  urological tract hypersensitivity associated with: 
  •  interstitial cystitis
  •  chronic prostatitis
  •  endometriosis
  •  vulvodynia

Comorbidities

  •  fibromyalgia, tension headache, tmj, IBS
  •  no inflammation or cause which suggest CS
  •  good chance of genetic factors
  •  can contribute to depression, fatigue, joint pain

Okay I get it, that’s a LONG list. This post was intended to be a way to simplify what CS is, but there really are no ‘simple’ answers, especially for what we do to help patients. So there may not be a lot we can do treatment-wise, but what’s really important is to recognize what the person is going through. They may not get a CS diagnosis; they may not get any kind of diagnosis at all. 

And we know that patients (and insurance companies) really want to get a diagnosis to understand what is going on. So, our role may be to simply VALIDATE, VALIDATE, VALIDATE, the person sitting in front of us. You may be the first person who believes this person is in pain. Take the time to listen to them, let them talk, and support them! While you will likely have to adjust the pressure you use during treatment, those treatments may become supported self-management, and you may become their biggest ally for their journey. I don’t know to this day if that person I saw while I was a student had CS, I just hope I did a good enough job of minimizing their pain and feeling good, even for just an hour at a time. 

If you’d like to get more in-depth with the topic of Central Sensitization, Dr. Melissa Farmer has a great four-part series on the topic which you can read HERE

References

  1. Latremoliere A, Woolf CJ. Central sensitization: a generator of pain hypersensitivity by central neural plasticity. The journal of pain. 2009 Sep 1;10(9):895-926.
  2. Tsagareli, Merab. (2013). Pain and memory: Do they share similar mechanisms?. World Journal of Neuroscience. 3. 39-48. 10.4236/wjns.2013.31005.  
  3. Woolf CJ. Central sensitization: implications for the diagnosis and treatment of pain. Pain. 2011 Mar 1;152(3):S2-15

 

Downplaying Pathology

One of my favorite podcasts is Dr. Oliver Thomson’s Words Matter. Through his podcast, Dr. Thomson addresses a wide range of topics relevant to my practice, both as a physical therapist as well as an educator. While an entire hour spent unpacking concepts surrounding the way a clinician approaches a patient presenting with back pain may sound rather niche-y and not of particular interest to an SLP, voice professional, or other professionals, but the episode that I just finished listening to is completely relevant for all of us. If you can broaden the context to include all aspects of diagnoses and envision how our patients enter our clinic, you’ll see the immediate relevance of the information covered in this episode.

One of the takeaways is revealed in the portion of the talk that looks at patient expectations in how we assess, and the expectation of all of the things that we will find wrong with the patient.

Much of this feeds into the traditional medical model that is ramped up in manual therapy evaluations. Our patients pay us to find out what is wrong with them and then do things to make them less wrong. In past articles I’ve covered my views on concepts of causation and pathology and how, when presented in the silo-based format of a specific manual therapy mindset, makes us seem the expert on finding problems with their fascia (or joint, or muscle, or trigger points).

They expect this from us, but by telling them what is wrong, we may be doing a disservice at many levels.

First off, our silo-based training makes every problem look like a problem based on our training. In my post life as an MFR therapist, every problem was explained in fascial-based language. But that language, and the concepts that underpinned it, are not ones accepted by the outside medical community.

So by telling my patient what was wrong with their fascia, I may have been telling mistrusts.

Second, by telling what is wrong with them I am reinforcing how broken they are. Sure, I am offering solutions (my services), but layering on pathological perceptions builds strongly on nocebic concepts (not a good thing).

In the podcast episode, Dr. Thomson and his guest, Dr. Ben Darlow, speak about how reinforcing the positive during an evaluation can step our patients back from the edge of feeling broken. While most want a diagnosis, what most really want is reassurance that they are NOT broken.

Most patients come to us having seen a few other professionals and, most likely, have been told some rather sorry explanations for why they are having problems. 

If the poor input came from someone at the top of the food chain, such as the ortho surgeon, or similar, those explanations are hard to undo. One cannot forget what they’ve already heard. But many of the bad explanations for problems come from those on a equivalent level, professional-wise. It’s not easy to undo the crappy thoughts injected into our patient’s brains by others, but we can start by telling our patients what is NOT wrong as we assess. The podcast explains this much better than I can, and there are a whole lot more gems that I believe all will benefit from.

You can listen to the entire podcast from the links at this page.