Friday, February 15, 2013

Where is the therapeutic boundary?

Today I spotted this link posted to FaceBook: A good pain

The tagline reads, "Returning to action, safely, is paramount to junior hockey players who want to help the club and impress scouts"

I facepalmed through the entire news story, and I'll explain why.

At first glance, it seems like a nice story - PT helping an athlete with some shoulder pain - one of those feel good stories that promotes the profession and reminds everyone about athletes and how hard they work and what a great thing sports are, etc., etc. 

John Beesley is probably a fine, well-intentioned PT, who bought the idea and sincerely believes the delusion that his magic hands are physically rootling out and attacking knotted up muscle tissue. However, imposing his own mesodermalist belief system on a patient during treatment, or worse, reinforcing an existing mesodermalist belief system the patient might have about why they have pain, coupling it to what they feel from the therapist while being treated, and removing the patient's locus of control from them, over-riding their nociceptive threshold, is truly cringe-worthy. 

Some other cringeworthy points:

1. That athletes are somehow "special" people. 

"[Cooper]Rush, a six-foot-seven defenceman likely to be drafted in this summer's National Hockey League entry draft - isn't your average physiotherapy patient."

Well, no - he's 6 foot 7 inches and plays hockey. Other than that, he has a nervous system that could become sensitized, just like anybody else's. 
Furthermore [lest we forget..], Lance Armstrong, Oscar Pistorius. Athletes are not exactly the paragons they are made into by adoring fans. They are still human - the bigger they are, the harder they fall, in both the physical and theatrical sense.

2. That the thing they really-really "need" from physiotherapists is even more nociceptive input, inflicted by a professional, because it will "speed healing": 

"... it's hardly comfortable. 
"Is that tolerable?" Beesley asks Rush as he pushes into his shoulder."Pretty painful," comes the reply.
"Then I'll keep going," the physiotherapist says. "This is a good pain."

Major facepalm. 
As someone who has never liked this entrenched set of ideas, ideas that not only still circulate around in our profession but actually find traction in news stories, and are stirred, promoted by physiotherapy organizations linking them on Facebook, as though this nociception-inflicting and -accepting behaviour were something to be proud of.. it's really, really hard for me to get my face unstuck from my palms. As a PT who does not concur, I mean. 

I doubt the PT in the story understands the first thing about pain science. He probably still views pain as 'weakness leaving the body' (said in a deep, slow, gravelly, macho voice). He likely assumes pain is a signal sent up to the brain a la Descartes. He probably never heard of Clifford Wolfe or of central sensitization. If he had, he may have chosen different words to use, or may have realized he really didn't need to inflict more nociceptive input on his patient in order to help his shoulder; just rule out red flags, give him some novel input through manual therapy staying well INside the comfort range of the patient, leaving the patient with locus of control, put some strips of bright coloured tape on him until movement felt comfortable, encourage normal movement, prescribe a firm timeframe, and not hurt him. 

Why not? Athletes love pain don't they? 
They probably don't like the kind that can arrive seemingly out of the blue when the second order nociceptive ascending neurons figure out how to get better at their job, more efficient at doing it, so they can handle more traffic. Yes, it can happen, if the genetics are favourable for it, and a trigger exists. Not a great situation for any brain to have to unpredictably, and suddenly, face a tsunami of chronic pain to deal with. It's hard to know in advance who could end up becoming a chronic pain patient, even with the best of screening tools. Even if somebody who is young and an athlete used to taking a pounding isn't the likeliest candidate for such a fate, do we really want our profession to contribute support to a set of memes that is unsustainable and counterproductive for anyone who does have the potential to develop chronic pain? Do we really want PTs out there who are more physical than therapist? 

Suggested reading: 

1. Clifford Woolf, 2011. Central sensitization: Implications for the diagnosis and treatment of pain.  Pain. 2011 Mar;152(3 Suppl):S2-15 (open access)

2. Latremoliere A, Woolf C. Central sensitization: A generator of pain hypersensitivity by central neural plasticity. J Pain. 2009;10(9):895-926 (open access)

3. Costigan M, Scholz J, Woolf CJ;  Neuropathic pain: a maladaptive response of the nervous system to damage. Annu Rev Neurosci. 2009;32:1-32 (open access)

4.  Ji RR, Kohno T, Moore KA, Woolf CJ.; Central sensitization and LTP: do pain and memory share similar mechanisms? Trends Neurosci. 2003 Dec;26(12):696-705.


Rod said...

Hi Dianne,
There are people out there, who while immersed in the sports culture,are trying to educate athletes about pain.This link is more for your interest than me trying to argue any particular point. Athletics,sports,and I guess life in general is about managing this crazyness we call life.

Sebastian Asselbergs said...

Diane, THANK you. I agree 100% - and I hope that all who read your blog will check the references. They are crucial in this issue.

Thanks again.

Diane Jacobs said...

Thank you for your comment, and for the link, Rod.

Diane Jacobs said...

Thank you for your comment Sebastian.

Robert Daoust said...

Your views on pain, Dianne, ought to be taken into consideration in sports. Presently, sports are a "theater of pain" (, games are won by the most willing to endure, sports news are much about wounds, and players may despise a thousand woes for a professional career that will bring them glory and dollars by the millions. Meanwhile, retired players are often plagued by chronic pain and other sequels of heavy suffering. Meanwhile also, people continue to think that it is normal to use suffering for getting what you want from others or yourself, or for mere dramatic entertainment.

Diane Jacobs said...

Thank you for weighing in Robert. I concur. There are a lot of sides to the cultural perception of pain, for sure, some of them pretty dark.