Are You a Responsible Pain Modulator?

As I have read further and further into the neuroscience literature in search of an explanation for a lot of the effect we see as far as treatment is concerned, a common topic seems to always arise – conditioned pain modulation.  Conditioned pain modulation (CPM) is a test of the body’s pain inhibitory capabilities.  Often in studies it is tested using a “pain inhibits pain” paradigm.  These studies use a noxious stimulus as the conditioning stimulus to induce reduction in pain from another later stimulus.  ‘How much does this pinch hurt if I take a sledgehammer to your toe first?’ David Yarnitsky is a world leading researcher on the topic out of Israel.  In a study discussing the pain inhibits pain paradigm, he states (1):

The author would like to stress a point often neglected in the context of CPM. The application of this paradigm is done in order to assess the endogenous analgesia capability of the individual being assessed. To that end, a variety of other conditioning stimuli could have been used, including stress, hypnotic suggestion, and such like.
The common use of a painful stimulus as the means of conditioning is due to it being an easy and quick way to induce activity in the descending pain modulatory pathways.

I think this topic is of great relevance to PT as we frequently see painful interventions used with impressive pain relief and short-term change.  A few that come to mind are foam rolling the IT band, aggressive instrumented massage, cross-friction massage to painful areas, painful “releases” to muscles, or needling.  I don’t know about you but the last time I attempted to roll on my IT band I hated every millisecond of it because it hurt like crazy.  Despite this pain I have seen numerous patients come in swearing by it.  Science has pointed to the fact that we cannot, using human created force, produce structural deformation of the IT band.  Then what the heck are we doing???  Conditioned pain modulation fits here.  We can consider the painful stimulus of rolling on the foam roller as the conditioning stimulus that can take any previously painful clinical sign and change it due to this effect.  The question we must ask ourselves is whether the pain modulation from the foam roller is worth it.  Can we produce this type of effect without having to provide a noxious input to the patient?

Another important thing we need to consider: can we utilize other less or even a non-noxious stimuli to condition this response?  It seems the rave these days is to lean on the massive gray area that is neurophysiological effects of our interventions.  What if our interventions are driven by this exact pain modulation whether painful or not?  Sure different interventions may utilize different modulating pathways (opioid vs canninaboid vs. etc), but what if the common thread is an input that is processed by the central nervous system and produces favorable modulation of output i.e. pain?

The following is a quote from Derek Griffin who has a PhD in pain and is a Specialist MSK Physiotherapist in Ireland that caught my eye on Twitter.  Diffuse Noxious Inhibitory Control (DNIC) is a term that has recently been suggested to be changed to CPM.

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This quote really brings up questions we need to be willing to ask ourselves.  If needling, iastm, or manipulation is just one avenue for such modulation then why and when do we choose it?  Should passive ways of eliciting this effect be the hallmark of our care of patients in pain?  I continue to hear physical therapists talk about how personal trainers and chiropractors can do exercise so we need to separate ourselves by saddling up onto passive interventions.  Shiny tools and techniques often come with theatrics and non-specifics that may be more easy to elicit these effects.  These effects, though, are temporary.  Should we just choose the easy road of short-term change?  Are we going to just hope we made a short-term change that is enough for patient to decide movement is safe on their own?

From my experience, it can be a monumental task to have a patient tap into their own modulation actively when the medical system has created such a sense of damage and frailty.  For example, creating a sense of safety for the organism to move their back when the medical system has told them they have the back of an 80 year old or another practitioner has shown them the balloon model of a disc pushing into nerves is tough work.  It is not a change that often occurs in the short-term. It often takes a large cognitive shift of the patient and time.

If we truly want to be the change agents in the care of pain, then passive interventions need to be used judiciously and with good clinical reasoning.  People in persistent pain will come to you with stories about how they tried everything and while most worked well in the short-term they did not create lasting change.  Why do we think our short-term changes are any different?  Conditioned pain modulation is a short-lived phenomena and if we are the only ones who can elicit in a patient’s life then are we truly helping?  Sure patients will line up for us to modulate their pain but when we see the same patients continue to line up when do we decide that maybe short-term changes are not the answer?   Our goal should be a patient who can modulate their pain actively on their own and have an internal locus of control.  Good old fashioned movement and cardiovascular exercise may not be as sexy as some of the techniques and tools out there but I would put the literature supporting the use of it up against any other intervention out there.

Listening to a patient’s story and digging into the their attitudes, beliefs, cognition, behaviors, and other psychosocial issues and barriers is a must if we intend to identify what prevents a patient from a sense of safety in movement.  It is hard work to move patients into graded exposure and graded activity programs to get them moving.  This work though is what gives them the locus of control the biomedical way of treating their pain has taken away from them.  Let’s not become another profession who takes this from a patient.

 

Mark Kargela, PT, DPT, OCS, FAAOMPT

 

  1. Yarnitsky D 2010 Conditioned pain modulation (the diffuse noxious inhibitory control-like effect): Its relevance for acute and chronic pain states. Current Opinion in Anaesthesiology 23: 611-615

17 responses to “Are You a Responsible Pain Modulator?

  1. Tim Mondale says:

    Thanks Mark, Great post. As tempting as it may be to disparage any of our preferred methods of putting our hands on our patients, or at least making contact with something to the patient. I think the question is which inputs are the most powerful, and In what combinations and context to change the output of a protective pain experience, when there is no danger? Let’s remember all output changes start as early and short lived, until they aren’t. I try to give my patients perspective; your brain has been trying to protect you when you really don’t need it for a long time (variable of course), and we are natural born survivors, and learners, and our systems just don’t give that up that easily. But what we should be completely confident about is that if we understand and stay the course with activity and return to full engagement in life, they’re pain should go away. If we define pain as an unpleasant sensory and emotional experience output only by the brain, that reflects the brains interpretation of the body or body part’s safety at any given time. Then by definition if the brain no longer sees danger there will not be pain (as complex as it is, it really is that simple). This would be true regardless of what the MRI, x-ray, muscle testing, passive joint testing, muscle fatty infiltrate, postural deficiencies, or any other results were.

    Then back to the question, how best to turn the brain from concerned, to not. Seems to me that’s the challenge we need to accept. I ask my patients to ask of themselves “why is my brain trying to protect me now, when I’m not in danger?” This helps to shift the focus from the tissues being damaged and fragile, and toward belief, thoughts, and actions that help the brain see safety rather than danger. I think with what we know, we can be that bold. If our patients only existed in the vacuum of understanding and information that we provided them, it would probably be much easier to have the effects we seek….alas.

    1. Mark Kargela says:

      Thanks for the feedback Tim. I agree with you that we need to figure out what inputs are most powerful. I think we need to have an understanding of conditioned pain modulation in order to determine if there are interventions out there that best elicit it and why. If it is based on just non-specific effects then we need to be willing to use explanatory models Kory Zimney pointed out in his post last week. I think conditioned pain modulation is the common language that we can see in the effect of our interventions. Unfortunately our profession has created different languages in the form of techniques, certifications, and treatment tools that, in my opinion, really are missing the point that we are speaking the same language but not recognizing it.

      1. Tim Mondale PT says:

        Thanks Mark,

        I actually think the problem is we aren’t speaking the same language. I think we are mostly doing the same thing, that is input the brain/system to change the protective output/modulate. But we use some of the most ludicrous language to describe what we are doing, and why. (Many examples from previous posts, from all). If we all got on the same explanation/s and it was supported by the science of what we know about pain, I think we would be much better off. I then don’t imagine it would much matter what we were doing with them.

        1. Mark Kargela says:

          You put it better than I did Tim. I was meaning that what we are doing could easily be spoken in the same language instead of the many scientifically implausible explanatory models we tend to use. This also makes it hard for the public to know exactly what the heck a PT does.

  2. Jessie Podolak says:

    Hey Mark, nice post. I agree 100% that the mainstays of good old fashioned movement and cardiovascular exercise are critical to maintaining a desirable outcome in the long term rather than a temporary quick fix.

    I do see value though, in the judicious (key word, judicious) use of skillful handling/manual therapy, even in a patient with chronic pain. It’s all in how we frame it to the patient and in how we think about it ourselves. If we can accept that our intervention is simply a “nudge” in the right direction, i.e. a catalyst for changing the patient’s neuro tag for pain versus “fixing the problem,” we can see positive results. I often consider the idea of a tipping point: what will it take to get this patient to reach the tipping point where his or her brain realizes enough has been done…the treat is contained…I can stop protecting now. That may well be a combination of education, movement, and a modality or manual technique.

    In terms of manual therapy, an explanation as simple as this can truly empower a patient and put the onus for their progress on them :
    “I found a few areas in your spine that felt stiff, so I would like to do a few hands on techniques to loosen them up. What I do today isn’t anything magic, but it will start the ball rolling. I’ll move you from the outside-in, and then I’ll show you how to achieve the same motion from the inside out. If you can follow theough consistently with the exercises in your home program, that will keep the ball rolling in the right direction, towards a nice, limber spine and I’m confident we’ll see some lasting change in your symptoms. If you “drop the ball” so to speak, and bail on your exercise program, odds are, we won’t get very far.”

    I’ve also had this conversation with patients: “Ever wonder why you feel so good after the adjustments by your chiropractor, but it always comes back? Moving a stiff area helps! But keeping it moving helps for the long term. Motion is lotion, and you need way more motion in your life than I can provide once or twice a week in therapy.”

    A good pep talk, which honestly explains why we are employing the technique we are using, be it passive or active, goes a long way in promoting self-care and empowerment.

    So, I’m hoping I can still use some of those “sexy” techniques, just in a responsible, pain modulating way. Variety is the spice of life!!! :-)

    1. Jessie Podolak says:

      **threat is contained, not treat…dang auto-correct. I wouldn’t mind a treat though…maybe it was a Freudian slip…

    2. Mark Kargela says:

      I am in complete agreement. My main concern was with conversations I have had with some practitioners who say we need to latch onto passive interventions and leave the exercise to the personal trainers or chiropractors. To me that is a scary way for our profession to move as, in my opinion, we just move toward being another profession with bells and whistles and no long-term change. I love your explanatory model for manual therapy. I use a very similar model. I know plenty of great therapists who use passive interventions judiciously as you pointed out Jessie. I use manual therapy daily. Just framed in a way where the patient understands that it is passive and the most important person to move them is themselves.

  3. gabriel delfino PT, PhD says:

    First of all, I want to congratulate for the great post and the comments as well. Here in Brazil we are also discussing how to change the conception of tissue damage and pain to pain as result of brain perception of damage. The main problem of course is that not all professional are following these growing knowledge in neuroscience education, so in every assessment and treatment we first have to re conceptualize the beliefs reinforced by the past treatments, past doctors, and also the patient personal beliefs. It is not an easy pathway but I think that PTs are ahead of other professional to change this paradigm.

    1. Mark Kargela says:

      Thanks for the feedback Gabriel! Happy to hear Brazil is working hard on the same issues.

  4. Lisa Lavene says:

    Thank you for this great post Mark. I also appreciate Jessie’s sample explanations for the judicious use of manual therapy. These explanations help establish therapeutic alliance. We must earn patient trust for them to be willing to take the journey for long term results. Now we just need to spread the word to get more healthcare providers updated on pain science and speaking the same launguage.

    1. Mark Kargela says:

      Agreed Lisa. Keep up the fight!

  5. Mary says:

    What a great post and thank you for your contribution to the evolution of the physical therapy profession. My frustration lies in the knowledge that there is so much more scientific support for these concepts, however there are many individuals who do not seek out this information. I continue to see modalities being used on patients that have already long ago been shown to be ineffective in the literature. We have professionals breaking away from the APTA and forming their own organizations. In a day in age when communication is now made easier, why is it so challenging for us to practice in a more standardized manner? How do we get the supportive and well researched evidence to all clinicians so that the scope, definition, and practice of physical therapy becomes more standardized?

    1. Mark Kargela says:

      Great question Mary. I share your frustration. Our profession has massive potential that is untapped. I think sometimes it is scary for us to change habits that have given us clinical comfort. I know it was scary for me when I began to question and doubt some of the explanatory models I had studied hard and paid good money to learn. If we put patients first then this shouldn’t be as difficult

  6. Keith Roper says:

    Brilliant post, Mark.

    Having been in the profession for 30 years, I have seen many techniques, ideas, “shiny tools”, and trends come and go. The research I read continues to reinforce the concept that How we do is more important than What we do. The one constant, from my observation, in PT is exercise. I can’t imagine giving this tool up to someone else, as I consider it my most fundamental tool. PT’s have historically been the medical providers best educated in, and who most consistently apply, exercise as treatment. Interestingly, even within exercise, research seems to indicate that How (much) we exercise may be more important that What (which specific exercise) we do. (There goes another PT trend into proverbial circular file…)

    While I don’t think we should abandon the search for which input is the most powerful, I am not sure we will ever find it. Humans are variable, and Gifford’s MOM indicates that the sampling/scrutinizing process coupled with experiential history will affect output/response. The “best” treatment for me may not be the “best” for you as we have different experiential histories and, likely, beliefs. Helping a patient find relief from symptoms and return to function will always, I believe, be a combination of science and art, and the master clinician will be one who can artfully/scientifically modify the intervention based on the person in front of them.

    Along with exercise, education has always been the other cornerstone of my practice. As I have studied the work of Gifford, Butler, Moseley, O’Sullivan, Louw and others, the content of my education sessions has shifted profoundly. As I read your post, I couldn’t help but think of the reduction of sx reported by patients after a single session of CFT with O’Sullivan, Explain Pain with Moseley, or TNE with Louw, and wonder if what they are tapping into with education is not exactly what Griffin is proposing in the above quote. Perceived threat or dysfunction is reduced through education rather than manipulation, and the patient experiences relief of symptoms. The intervention need not be painful nor specific to elicit pain modulation.

    If all we have in our toolbox is a collection of techniques, we will continue to search for a better one, with the hope we can “fix” every patient by applying the proper technique. It’s a sexy idea, but one I feel is doomed to fail. I continue to believe that touching the patient is very important, don’t get me wrong, but sometimes the touch need be no more than a reassuring hand on the shoulder as we educate them and guide them back into movement. Our interaction and communication with the person in front of us is the Art of what we do, and one of our most powerful tools.

    I know that John Childs is going through the EIM//ISPI pain certification program right now, what say you on this topic, John?

    1. Mark Kargela says:

      Great thoughts Keith. I agree with you that education has the power to bring forth favorable modulation of a patient’s pain experience.

      The interaction is an art. There are so many variables that exist in a human being in pain that I agree that it will be impossible to find the tool that works for everyone. The commonality is our work in driving a patient to a belief in their body again and its healing capacity.

  7. Graham Yates says:

    Great post. I use manual therapy on nearly every patient.
    I just read an article that showed there is more stress shown when someone is unsure whether they are about to receive stimulation, than when they are told they definitely will receive a noxious stimulus.
    This suggests the suffering element experienced in chronic pain may be partly due to the uncertainty of how their pain will pan out on any given day.
    Perhaps manual therapy is producing an understandable pain that can be coded as a good pain and therefore changes for a short time the stress around not knowing. The old thinking may then return when the unpredictability starts to recreate suffering.
    I think the mindfulness approach is a good way by turning toward the pain with an accepting stance, rather than the inevitable suffering that comes with the fight against it.

    1. Mark Kargela says:

      Thanks for sharing your thoughts Graham. It makes sense that pain that is delivered and most importantly is perceived as therapeutic by the patient has the potential for positive pain modulation. The key is getting a patient to modulate their own pain situation which can bring out some obstacles we typically do not consider such as social and environmental contexts that make it hard for them to gain a sense of safety in movement.

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