My Response to Dr. Brence's All About Pain | Modern Manual Therapy Blog

My Response to Dr. Brence's All About Pain

First of all, Dr. Brence's post was very well written and explained pain and its various classifications well. I wish I had the time to write and cite a post as long as he did! It should help anyone with questions about the Pain Science approach. I use the biopsychosocial approach when needed, but don't think it fits all patients, like every approach, should be unique to the patient based on their presentation. It should compliment a practitioners toolbox, but not be the only tool.

I disagree with a few of his points. I think generalizing OMPT or any hands on technique as "poking something that hurts" is simplistic at best. That is equivalent to stating pain education is like teaching a chronic pain patient they are nuts.

Using MDT rules for all exercises and hands on techniques makes it nearly impossible to worsen a patient's condition if you actively listen to their subjective report. If any treatment, whether it is IASTM, joint mobs, functional release, neurodynamic tensioners, is causing discomfort, or even pain, I stop and ask the patient if the pain continues after cessation of the treatment. If it immediately stops, or goes away after a few minutes, the condition is not worsening. It is unlikely the CNS is becoming overly sensitized if the pain ceases immediately, gets better as the treatment progresses, and you are able to demonstrate improvement in an objective measure of strength, ROM, or function after the treatment.

I do agree that PT should not be "no pain, no gain." I only use force as a progression, despite using stainless steel tools to release tissues, you can be very light and progress your depth according to tissue release and patient tolerance. There is a difference between treatment and eliciting pain without any gain in function, strength, or ROM. Any manual technique may be uncomfortable, but only because there is a problem in the surrounding joints, tissues, or peripheral neurodynamics. This is outputted by the brain, but does not mean there are not peripheral "issues in the tissues" so to speak. Many of the areas I treat are either adjacent or sometimes farther away than the area the CNS may be perceiving as a threat, so I think the discomfort perceived is not only CNS sensitivity, but mechanical dysfunction. For example, a frozen shoulder may have elbow, forearm, cervical, and thoracic dysfunction, despite the patient only complaining of moderate to severe pain in and around the GH capsule. The other areas "don't hurt" but may be uncomfortable to treat.

Another clinician wanted to ask Joe, "How would you treat a patient that is already in pain, say s/p TKA?" Iit would be difficult to even move some of these patients without at least causing some discomfort. Hopefully this will generate some CIVILIZED discussion. Anything that gets out of hand will be moderated, and then closed.

I also wanted to add this great comment from a reader on Dr. Brence's original post.

Koen OverdijkCollapse
As a therapist who treats also a lot of chronic low back pain sufferers, I can not fully agree. Though there maybe by some patients in which catastrophizing and central sensitization play a role, the therapist has first to know how much this really blocks positive effects for a more biomedical approach. To my opinion this role has been and still is- exaggerated because of lacking of good concepts and results from other therapies. In my therapy I let patients under for them controllable circumstances (while exercising) experience a certain amount of pain as long as this produced pain subsides after a 10 till 15 minutes rest. Sensitized patients complain hereby about unpredictable pain levels from relative minor loading on unpredictable locations and often about more pain after hours or the next day. The latter says more about there expectations as that it is objectively to couple on the loading or the damaged body as seen on the x-rays or MRI´s. However the most chronic patients in my population DON'T show these reactions, but their extra pain produced while exercising subsides immediately or after a couple of minutes of rest. The explanation is then that this is safe as there has been done no new harm. When then also given a good mechanical explanation for there complaints about why which loading leads to more pain and how they can reach a better loading through specific exercising and posture control, this patients instantly loose their fear-avoidance and fear of pain. Also because of exercising themselves they get an inner locus of control and by an realistic prognosis become hopeful again. This leads to blow away depression and inactivity. In the past,I self- measured my results and scored good to excellent results (75 -100 resolution) by 50 to 60 percent of the chronic patients and fair to good results (50-75 resolution) by another 30 percent of the patients. On departing for the therapy the most wanted to continue the exercise to reach more results in the future. In contradiction my results by the few patients who I suppose to have a damaged pain perception like with central sensitization are very frustrating. This is still so, although I have tried to coach them exactly in the way you describes in your post. I have red several times from better functional results when they are exposed to an multidisciplinairy program of graded exposure where the loading is built up irrespectively of there experienced pain. At the end they are better in function but grossly unchanged in experienced pain (simply said they have learned that they can do more as they thought although they still have pain).

with respect and regards

Koen Overdijk.


  1. I think that there is room for an MDT/OMPT approach with what Joe discussed yesterday. I think that an MDT eval would best fit his first 2 categories: Nociceptive and peripheral neuropathic. It is when you move to the central sensitization category that I think the treatment approach has to change. McKenzie even says that "Failure to grasp this multifactorial, biopsychosocial model of pain and see it only as nociception leads to a failure to understand pain" (page 60 of The Human Extremities, but I believe it is discussed in all texts). Of course you don't know this until you've evaluated the patient, but I don't think that all pain can be treated from a purely biomechanical approach.

  2. Exactly! Both approaches have their uses in the clinic and neither can be used with all patients.

  3. I would say that every patient that is in pain, should be evaluated and treated utilizing my proposed approach...I don't think its a pick and choose model...You either follow a biomedical or biopsychosocial. I choose the biopsychosocial model bc of the overwhelming amount of validating literature that is being produced to support it.

    This stated, I think that something truly special happens when we put our hands on a patient. Especially if they think we can help them (expectation is key). I truly believe if our hands become the "threat", then we may be a deterrent to their recovery. Because pain is the brains reaction to a threat, if our manual treatment causes pain (even if is ceases as we remove it), we may be stimulating danger receptors. But that stated, manual therapy can be very effective and I am still yearning to learn more about it (and I recommend everyone continues to learn from this blog).

    To answer the above question: When I treat a patient s/p TKA, I do not perform any techniques which elicit pain. The motion will return. I am confident in this and actually am involved in a very large FDA study analyzing outcomes for unicompartment replacements (not just making statements based upon experience) I have worked with colleagues who crank, and crank and crank to improve knee motion but are ignoring all of the neurophysiological mechanisms that are occurring the process and cant understand why its taking months for the motion to return (for gosh sakes they are following the concave/convex rules) ---Literature tells us that mechanical deformation will not be effective if the nervous system perceives it as threatening. We must instead control symptoms, gradually improve motion and inhibit excessive swelling. We can do manual therapy, but within their pain limitations. I also want to refer you back to the study which I cited in my article which indicated one of the best predictors of how individuals will do 1 year post-TKA are pre-surgical psychological variables. This is rather exciting for those who work with this subgroup of patients and understand that some simply do not get better--- I recommend utilizing a pain catastrophizing scale and Tampa kinesiophobia scale to help screen those who may not benefit from more aggressive approaches and who may continue to have disability despite surgery.

    I also have a hypothesis that individuals who developed central sensitization due to severe knee pain pre-TKA may actually develop a form of phantom limb pain post-TKA. This is due to a mismatch between the actual body (which now has a metal implanted joint) vs. the brains virtual representation of that portion of the body (which was a severely arthritic joint). What if the continued output of pain, was because the brain does not recognize that the joint which sent continued peripheral input is now gone? What if it thinks it still needs to protect? What if it sees the trauma of surgery as more complications for that arthritic joint? With fMRI studies and other brain mapping research, this concept is not that far fetched.

    Overall, I appreciate everyone reading my article and hope it provides insight on what the literature is telling us about pain science, the biopsychosocial model and treating painful patients.

  4. I agree with Ann, and have stated that in context of MDT rules. I disagree (gasp) with Lorimer when stating we can't wait for a patient to "go chronic." For me, chronic is not a timeframe, it's a state of mind. These people who come to us are either well adjusted to their life/stressors, etc or not. They either have an easy going attitude, or think you, their enabling family member/job/circle of friends or lack thereof are a threat. We all know these patients as soon as we start our interactions. They're the ones we get a sinking feeling in our gut when we see their names on our schedule.

    Granted, there are some surprises and people who may be catastrophizing due to pain, and can relax over time, but in general, it seems to be frame of mind that I don't think we can change with mere education. Are we even able to as PTs or does it require a true multidisciplinary approach? Everything I do in terms of education, what to avoid, what to do, what their options are, what may happen without treatment, indications and contraindications for each treatment, and discussion of their improvement addresses CNS sensitization. There are techniques that may be painful, but if the pain does not last, or even gets better as the treatment progresses, and results in improved movement and function, I do not see any harm in it. Glad we could get some discussion going...

  5. Hey Ann,
    Thanks for the response. I like your approach of explaining to the patients who are in pain, post-surgically, that pain is simply a neurophysiological response to the surgical procedure. I think this helps them understand that the procedure did not fail and their joint isn't falling out. By you demonstrating this in a calm demeanor will set help them up for having expectations for recovery. And as I said earlier, we all have pretty good intuition on who will do well and who wont. This simply is validated with psychological subscoring. I would blame the surgeon for performing surgery on these individuals because I suspect they have the same intuition. They should first be referred to a pain psychologist.

    The majority of TKA patients, early on, will be in discomfort. When I say "do not elicit pain", I am implying not to provoke any more discomfort than they are already experiencing. If they can bend their knee to 90 degrees with relatively little discomfort but pushing to 95 degrees really hurts, then the danger receptors are triggering an output when exceeding 90 degrees. So I would have the patient perform 30 heels slides to 90 degrees, not pushing into pain, to help model the virtual body to recognize it can flex to a certain degree without the threat of tissue damage. All exercises would be done in this manner. Allow time for the normal post-surgical physiological response of swelling, etc to chill out.

    In terms of your "threat" question, our neuromatrices are individualistic. Different portions of my brain activate to react to a threat if compared to yours. This is why some individuals are able to do extremely well in rehab and some don't. I think this is due to our own graded exposure with life experiences. For example, everyone simply cannot be a good MMA fighter. These individuals likely started out as children wrestling, performing karate, etc. They didn't begin taking blows to the head on day 1. But over-time, the neuroplasticity of their brain adapted so that their bodies could accomidate to threats different than those who do not perform these techniques. This is evolutionary and makes us biological advantageous. If you started out taking blows to the head on day 1, peripheral input would cause immediate outputs of pain which could lead to a central disorder. So the majority of individuals who do well in rehab likely are more active individuals and have more resistance to the brain recognizing external threats than those who do not tolerate it. Look at everyone of the CPRs. CPRs tell us who will do well with a certain technique---or at least we thought. I believe they tell us who is healthy and who will do well with whatever we do for them.

    Pain and the neuromatrix is such an individualistic and subjective experience. And understanding this, will help us treat our patients.

    Btw, I know tweet: @joebrence9 ... could learn more from each other there