The Next Big Thing

It’s that time of the New Year for predictions on what the “Next Big Thing” for 2017 might be.

I want to go on record to say, pain neuroscience is NOT the “Next Big Thing” in physical therapy. This may surprise a few of you, but hopefully I can explain. Now that I get to check the “20+” box on surveys that ask how long I’ve been practicing physical therapy, I’ve seen just a few “Next Big Things” come and go in physical therapy. (It might be a fun Twitter experiment to list out PT interventions that were once the next big thing that came and went – #PT-NBTTCAW) I want to go over a few reasons, why I don’t think pain neuroscience is the next big thing in physical therapy and why it won’t come and go.

First, pain neuroscience is not new. Pain neuroscience is just the biology, psychology, and sociology of what happens during a pain experience for individuals. It has been around since biology began, people had brains, and walked the earth interacting with each other. I hear some people in internet chat rooms and Twittersphere say they don’t need to bother with understanding pain neuroscience. It might be because they only treat acute pain and not chronic pain. They argue that pain neuroscience only matters with chronic pain and not acute pain. Or maybe worse yet they still are under the assumption of Descartes. They still believe that the ‘pain’ they treat is only biomechanical and not the ‘pain’ being looked at in pain neuroscience research. The reality is pain neuroscience is happening in every patient that you treat with pain. It does not matter if acute or chronic, biomechanical or not, tall or short, male or female. Pain and the pain neuroscience behind that pain is always present during a pain experience. Whether you want to understand it or not is up to you. For me personally and professionally, I think it is best to try and understand all the processes going on in my patients. It is through the understanding of the biological, psychological and social processes going on with my patient that allows me to most effectively educate and treat them on what is going on in their body. It is through a shared understanding that we can work together to set up the best interventions to combat what they are dealing with.

Next, pain neuroscience is not going to go away. Pain neuroscience is just that ‘science’, a systematic process that builds and organizes knowledge in the form of testable explanations and predictions about the universe as it relates to pain specifically. Science helps reveal the mysteries of our universe and helps us explain natural phenomena that we see daily. Our understanding of pain neuroscience will continue to evolve and grow as our understanding and knowledge grows with the science.

diffusion of innovation

The “application” of pain neuroscience on the other hand will produce a few “next big things” in physical therapy and health care. Various applications of pain neuroscience will lead to innovations to clinical practice. One of those applications that is an innovation to clinical practice is pain neuroscience education. If we map it out on the Diffusion of Innovation curve, I think we could say it is somewhere around the middle to latter stages of early adopters. I don’t think we have hit the “tipping point” just yet. We have the early innovators with Louie Gifford and others about 20 years ago, and we have moved into the next phase with early adopters. Many of you reading this post and starting to incorporate it into your clinical practice, fall into this early adopter phase. I think how well pain neuroscience education is applied will help determine how well it moves along the innovation curve over time. If the application of pain neuroscience education stays rooted in the science of pain, it will be around forever and lead to significant innovation of practice. In order to do this, pain neuroscience education will have to evolve and change as the science and our understanding of pain evolves and changes. Pain neuroscience is not the Next Big Thing of 2017, but the application of it in the form of pain neuroscience education may very likely continue to grow as one of the next big things in physical therapy and health care. The question I might ask is where will you be at on the Diffusion of Innovation curve to pick up this innovation? Will you be the person that helps get it to the tipping point or a laggard?

9 responses to “The Next Big Thing

  1. Tim Mondale says:

    Great post Kory!

    If we’re going to evolve as a profession, to the top of the heap in terms of care of aches and pains (injuries and otherwise) we’re going to have to understand this. I like to be hopeful, but it’s frustratingly slow for wider acceptance and the use in application of this science.

    Keep up the good work.

    1. Kory Zimney, PT, DPT says:

      Thanks Tim. The diffusion curve doesn’t always move as quick as some of us would like

  2. Colleen Louw says:

    Kory – what bothers me is listening to therapist’s say “they know all about that”, but in reality….? They have not changed anything about how they approach patients…. :-(

    1. Tim Mondale says:

      I’m surrounded by not just therapists, but our medical colleagues who say they know all about that, but the patients they send us have never heard anything about pain outside of pathoanatomy from some diagnostics. We really must lead the way.

    2. Kory Zimney, PT, DPT says:

      Yes, knowing “about” pain neuroscience is entirely different than knowing pain neuroscience and practicing with that knowledge. For me this is a laggard posing as an early adopter.

  3. Terry Cox says:

    Kory, good post. I feel for those not including pain neuroscience education with the patients that they are seeing for acute pain. These patients don’t need the full story but certain elements of it are definitely of benefit. Maybe this will be the “Next Big Thing”. Best way to treat chronic pain – prevent it!

  4. GB says:

    This reminds me of a recent blog entry by David Butler:

    Could I be so bold to suggest that what science should be informing us is that…well….we can’t effectively “treat” pain. If we think of pain as one would fractal geometry (it is similar), then would it not be reasonable to conclude that we can never reliably “dry needle”, or “manipulate” or “educate” or “exercise” patients pain away?

    What if in all our efforts to categorize pain and treat it using modality A,B or C , all we are doing is short lived neuro-modulatory party trick but ultimately doing our patient population a grand disservice?

    What do I mean by that? Well, let’s take the stages of grief as an example (Denial, anger, bargaining, depression and finally acceptance). What if all our futile efforts to find the holy grail of treatments for pain is ultimately landing our patients perpetually in any of the 4 stages…prior to acceptance).

    What if WE are part of the problem with the growing epidemic of pain?

    What if our role was as simple as ruling out red flags, ruling out (or in) orthopaedic situations amenable to surgery…and then moving patients towards acceptance (coping if you will).

    Basic skilled orthopaedic evaluation followed by re-assurance and guidance towards self efficacy (in other words pain is a normal aspect of being human and not something to be eradicated by some mythical means).

    Some might argue that this would render our profession irrelevant however as far as I am concerned it moves us closer to respectable clinicians guided by science and true force multipliers.

    The persistent search for “the next best modality” (eh ehm…dry needling) on the other hand lands us securely in the realm of pseudo-science and in my view (after 20 years of clinician practice)…is not doing our patients any favours either.

    Let’s face it, for those of us who have been around this profession for a while, we know that 10, 20 years from now we will see yet another new fad arrive at our doorsteps…and disappear like all those before it.

    It’s because pain just doesn’t work that way. Our persistent desire to somehow “work around” the science seems laughable to me in many ways. I keep hearing things like “I use dry needling….or manipulation…..or whatever as a “re-set for the nervous system.”

    Stepping back and reflecting on what science should be informing us…does this not sound absurd to anyone else? Can you seriously tell me that sticking a needle into flesh will somehow “re-set” the nervous system which is probably multiple times more complex than fractal geometry?

    I think the Physical Therapy profession has a great deal to offer…if we would just get the heck out of our own way.

    A bit of a caustic and no doubt somewhat unwelcome slant….but there ya have it folks.

    1. Kory Zimney says:

      GB, thanks for the comments. I think you bring up a great point that we have to continually look at our biases. Are we letting our treatments take the lead so we can bend and squeeze the science into our already formed treatment tool box? Or, are we letting the science take the lead so that we bend and throw in or out treatments from that tool box.

  5. GB says:

    Thanks for the reply Kory. I still find the silence from the main EIM crew when dry needling gets questioned…deafening.

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