Pain science – an optional tool???

The professional journey of many physical therapists seems to have a lot of similarities.  Entering the profession we often feel pretty confident in our skills and then we are humbled by patient after patient who do not respond the way the text book had convinced us they should.  This often stimulates a quest to fill our “PT Toolbox” up with tools to address our perceived inadequacy.  With each tool procured, an invigorated therapist applies the tool with enthusiasm and confidence until eventually, while the tool may still help some in pain, it fails to provide the amazing across-the-board outcomes we thought it would.   It seems the view then (and unfortunately for some now) was that the patient was like a machine which just needed the right tool for the offending pathology or biomechanics that, when identified, would have the patient fixed and good as new.  David Butler had a great perspective on this when he shared his professional journey.

It often surprises me how some physical therapists look at pain science with such disdain.  It is often viewed as “the new shiny tool” in the toolbox by some and seen by others as a threat to practice.  Granted, as in any new theory, there are those who allow their clinical reasoning pendulum to swing too far and forget that there is a “bio” in the biopsychosocial model.  Pain science does not ask nor require a therapist to stop doing what they are doing.  It simply asks a clinician to rethink what they are doing, look at the effects beyond the periphery, and to consider mechanisms of effect that previously may not have been considered.  It permeates everything we do when treating a patient in pain whether it is in a pediatric, women’s health, neurologic, sports, orthopedic, geriatric, or a persistent pain setting.  It would seem common sense that if a patient’s main complaint is pain that it would behoove any professional who treats it to have the most up to date knowledge possible in order to best treat it and help the patient.

As we learn the complexities of a human pain experience it opens up huge potential to help many more people who often did not respond to traditional theory or methods in physical therapy and medicine.  This does require a clinician to be willing be exposed to the cognitive dissonance that can accompany exposing our traditional theories to new theory.   Our clinical comfort zone when challenged with new theory gives us a decision of two roads we can travel moving forward. We can choose the road where we seek out information and learn about new theory or we can hold tightly to old theory and the comfort it has given us for our careers.  Our healthcare system in the U.S. seems to have chosen the latter road of holding tightly to the biomedical model.  Chronic pain statistics along with the opioid crisis we currently are experiencing in this country are proof enough that it is grossly inadequate and at times harmful when it comes to dealing with patients in pain.  It would seem that modern pain science would and should be grabbed onto by the medical and physical therapy professions.  This of course has not been the case in medicine and with many in the physical therapy profession.  Upton Sinclair said it best when he stated:


“It is difficult to get a man to understand something, when his salary depends upon his not understanding it!”

Louis Gifford also had a great quote when he was discussing how a lot of our effect in manual therapy is often from a nervous system processing standpoint and not from the mechanical/peripheral standpoint that we traditionally had thought and held tightly to (1):


“If only you could all (understand) that you are all ultimately doing the same thing….playing with processing, yet because you don’t see that, you’re wasting a huge opportunity to help a great deal more and sell a great deal less”  

The last quote I will leave you with comes from Gordon Waddell (2):



“…It is no longer enough to know about anatomy and pathology. The biopsychosocial approach opens a whole new perspective on how people behave and cope with illness. It reveals the limitations of our treatment and of our professional skills. It exposes us to the difficulties and stress of dealing with emotions. We must accept that patients are not neat packages of mechanics or pathology, but suffering human beings. Professional life may be much simpler if we stick to physical treatment of mechanical problems, but health care demands that we treat human beings.”

What road will you travel?  Our patients demand we take the road of a greater understanding of pain.  The question is whether we can put our clinical egos aside.  In the end it is all about the patient.  It was never about us and it never should be.


  1. Gifford, L. S. (2014). Aches and Pains. Falmouth CNS Press.
  2. Waddell G. (2004). The Back Pain Revolution. Elsevier Health Sciences

4 responses to “Pain science – an optional tool???

  1. Paul says:

    Awesome perspective and very well put Mark. Appreciate especially the value of “re-thinking”. It is this type of mental posture that continues to make us better and is, in fact, out in front of “evidence based”. This is not to say we should not seek proof of our theories, rather, not be limited by the lack of proof that has YET to come. Pioneering, by nature, lacks proof but is not fearful of it.

    1. Mark Kargela says:

      Good points Paul. We have to be willing to leave the confines of our comfortable theories in order to make discoveries. Barb Stevens once shared a quote where she stated, “theory is no more than speculation with finely combed hair”. To me we need to keep this type of skepticism with any theory so we do not allow bias to cloud our clinical reasoning and judgement.

  2. Brett Neilson says:


    Fantastic! I especially like Gifford’s quote as this rings so true. We are all “doing the same thing” yet, we do not recognize this, often due to our own biases. The Bio is a HUGE part in the biopsychosocial model and cannot be forgotten. Often the best patient gains are achieved by approaching pain neuroscience principles through the “back door” through the words we use during hands on interventions.

    1. Mark Kargela says:

      Completely agree with you Brett. We help a lot more people when we consider that our words may be just as powerful as our hands but that requires us to let down our clinical ego. Skillful handling of a patient in pain is a must of course, but we cannot fail to consider the immense value of skillful communication.

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