Thursday Thoughts: No Pain, No Pain | Modern Manual Therapy Blog

Thursday Thoughts: No Pain, No Pain

At a recent The Eclectic Approach UQ and LQ Assessment, a participant pulled me aside at lunch and had a few comments.

He really liked the concept of a positive interaction and threat reduction. He realized long ago that introducing painful techniques to a caseload that was in pain made little sense. He worded it very eloquently, "When a patient has a painful technique done on them, and it's successful at decreasing pain, improving motion/function etc, the success is associated with the pain." I'm paraphrasing it, but I want you to think about that. How many times have you done a painful or uncomfortable neurodynamic stretch, 1st rib mobilization, pec minor "release," gotten some amazing results, and a patient commented, "No pain, no gain, am I right?"

If we know that pain can persist, altering perceptions of body awareness and motor control, why is it acceptable for any but a small minority of techniques under specific conditions to be painful? My short list of techniques that are temporarily uncomfortable would be
  • lumbar shift correction for true shifts
  • repeated loading strategies to a directional preference that changes within 1-2 sets
    • after 1-2 sets if no changes are made, that's when I introduce another input (IASTM, joint manip/mob, compression wrapping)
    • then I retest the repeated loading strategy
  • if a patient already has true constant pain, you should at least try not to increase that pain during any movement/technique

David Butler says it best when it really should be, "No pain, no pain." Plenty of rapid gains can be made with completely pain free and non-threatening techniques. Once you learn that nearly every technique you can perform on a patient can a should be pain free, and you persist in causing discomfort, what does that make you?

Keeping it Eclectic...


  1. Reminds me of the old saying ' physioterrorist' . Luckily haven't heard that saying in a while

  2. I think that is a deserved title for many practitioners who think it's necessary to be overly aggressive on their patients. Too bad fascial deformation and breaking up scar tissue is still taught in most curricula.

  3. I've found that using this approach greatly helps with rapidly assisting most patients to gain function quickly, however I'd like to get you're thoughts on decreasing threat that has inadvertently been introduced during the examination Dr. E.
    I've had several patients on my caseload who have definitely had ramped up sensitivity to movement. Sometimes simple movements or motions will set them off in the treatment room such that it's very difficult to continue with any thing manual, active, or passive movement wise without setting off alarm bells. Do you have any techniques or methods for helping to "hit the reset button" so to speak and allow treatment to continue?

  4. Great! Thanks Dr. E, look forward to it.

  5. Howard Knudsen, DPTJanuary 22, 2015 at 9:35 PM

    I am using a model in which the treatments are quite painful but the benefits are immediate. Functional loss is markedly improved. Example: Patient limps in with an acute ankle sprain and walk out pain-free. Another patient with chronic ankle sprains (3 sprains in the past month) is pain-free, testing strong, and feeling "normal" in 1 week. She was consulting about surgery when referred to me. The mind-body is so complex! I would never rule out the possibility that I don't know everything.

  6. If that model includes TDN, then I understand about the pain, and the rapid response. However, if it's any kind of soft tissue work, joint work, etc, that can get the same exact rapid responses, without any kind of pain. Just because you get results from a painful technique does not mean it has to be painful, that was the point of the blog post and my entire approach.