Thursday Thoughts: Evaluation and Pain | Modern Manual Therapy Blog

Thursday Thoughts: Evaluation and Pain

Today's Thursday Thoughts was inspired by a recent DPT student who was filling me in on how his first semester of ortho was going.
As an avid reader of my blog, he naturally questions treatments that hurt. I've gone on enough the past few months about treatments that hurt, and applied that to exercise last Friday. Granted, I have to take this with a grain of salt, because it's just one person relaying information to another, but the student said, "The professor says treatment is not for the evaluation, because you have to spend your remaining time of the evaluation relieving them of the pain you caused during the exam."

Ok, if I was drinking something, I would have spit it out all over the place. Let's think about this logically, when someone comes to us in pain, should we be performing provocation testing? If a patient says flexion, texting, slouching, bending, and driving increase their complaints, are you really going to start your repeated motion exam out with, let's see what happens when you flex your neck or back forward 10-20 times?

You can rule things in and out without provocation tests, right? Goals of your evaluation should be to
  • establish a rapport
  • educate the patient on The Science of Pain
  • treat them via whatever means necessary to get them on a home program which is where the carryover and the lasting changes take place
I do not expect readers or course participants to go all the way in with giving up testing for pathoanatomical diagonses, but there is no reason you need to be poking, prodding, or having the patient assume positions that may contribue to perceived threat, or further sensitize an already peripherally and/or centrally sensitized nervous system.

I have stated this many times as well, sometimes the best we can do is not worsen a patient's existing pain, if we cannot find any position of relief or directional preference. However, if I were a patient, paying my hard earned $$ for a copay or cash based visit, and learned prior to the visit that I may be so sore just from the exam that real treatment for the actual condition I was coming in for would not start until the second visit, I would probably go elsewhere. Wouldn't you? Let's turn "pain and torture" into "patience and tenderness" - Thanks to blog reader Dr. V for that one!

Keeping it Eclectic...


  1. Dr. Ben Ness, PT, DPT, Crt MDTApril 2, 2015 at 1:47 PM

    Amen to that!!! Its funny, the more experience I have gained, credentials, etc the less time I take "examining" the patient and the longer I take "making them feel better" during the exam. I 100% agree with you and thank you for posting this. If a patient does leave my exam "feeling better (less CNS threat)", feeling like I truly listened to them, made them feel safe and comfortable (less CNS threat) and happier than when they walked in the door then I have failed them. Its like going to the MD for a rash caused by poison ivy and the MD stating, "Well, lets try rubbing a little on a different area of your body and see if the rash happens there as well" - its crazy. "Dr Ness, I hurt my back when I bent over and picked up my son and I couldn't straighten up for 2 days", "OK sir, well lets see how you do today bending over 20 times, NOT!". Good Post Dr. E!

  2. Wow. This makes me feel much more confident in my examination process during my last rotation. I tended to ignore provocation tests and opted to find positions and treatments of comfort instead. Could I justify what I thought the mechanical processes were with special tests? No, but I was to find positions of comfort for the patient to be able to sleep. Thank you for this post!

  3. Yeah, or how about, I'm not sure if it's a derangement, so I'll give you forward bending for home to see what happens. Just for their information, facepalm!

  4. When I was in your shoes I was doing 15 special tests on each patient! Good for you!