No Pain, No Patient? | Modern Manual Therapy Blog

No Pain, No Patient?


One of my favorite sayings from Dr. Mariano Rocabado is "It's not, no pain, no patient." This was in regard to a non-painful click in the TMJ.

This particular concept was educating dentists who erroneously tell their patients it's not an issue if their jaw is clicking if it does not hurt. This would just tell us a lack of perceived threat. Just as the CNS can magnify a threat, it can also not detect one. Do you treat areas that do not move well and also do not hurt?

This is one of the concepts behind the FMS and SFMA research on asymmetries predicting future injury.The asymmetries are more than ROM, it is balance and motor control as well. You can definitely make the argument that only people who are active than your typical sedentary individual are at risk. That is most likely true as the research was performed on firefighters, military, and NFL athletes.

Gray Cook tells us to use the SFMA upon evaluation and the FMS as a screen (which it is) when you are getting closer to discharge. Your d/c criteria should be more than the proximal DP no longer hurting. If someone's cervical spine is no longer hurting, but their left shoulder still is DN compared to their right, and their thoracic spine is also DN in left rotation, are you just going to leave these things be?

I take these things on a per patient basis and work on them within reason. For my more active patients, I screen them with the FMS and work on asymmetries that more often than do cause no pain. It's easy to convince a runner, who came in for shoulder pain to have their tibial internal rotation and single leg stance balance worked on. In contrast, the sedentary office worker is often happy with a lack of lumbar pain, but often wants to "risk it" by not having areas that are no where near their pain location. I present them with the choice, and suggest it would be beneficial, but I can't hold a gun to their head, forcing them to attend more PT.

You can discharge your patients with asymmetries, and there is a chance they may reinjure themselves. Screens like the FMS predict risk, but it does not mean injury WILL happen. Risk factors, like obesity, high cholesterol may cause a MI, and should be addressed, so why not asymmetries in movement, motor control, and balance? Unless you just want the built in obsolescence of an incomplete rehab, then just let your more active patients go, and watch them come back... or go someplace else.

Keeing it Eclectic....

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