It is my belief that the human body is very resilient and robust, and we can manage and juggle many loads and stressors in our life. There is, on occasion times we can exceed our pain tolerance threshold when a number of these stressors exceed our capacity for dealing with stress and life loads (actual or perceived) at any particular moment in time causing sensitization.
Most people who present to the musculoskeletal (MSK) private sector physiotherapy clinics have MSK injuries, strains and sprains. On occasion more serious stuff comes through the door like DVT, AAA or VBI or possible autoimmune issues or possible cancer etc. But once these are screened and accounted for the vast majority of MSK injuries will get better in 6-8 weeks. The physiotherapist is very important in adding to the bodies natural history of recovery. This can come in many forms, education, manual therapy, exercise etc. I am aware that some people do get stuck, and pain can persist more than this timeline---it is then termed chronic pain. While in this 6–8-week period Physiotherapists use modalities like needles, ultrasound, massage, manipulation, mobilizations, exercise mc Kenzie, mc Williams exercises and nerve glides/flossing, etc. These methods do indeed work i believe by pain modulation –ie pain reduction. It is proposed that diffuse noxious inhibitory control, neurophysiological responses and or other mechanism account for this. These release happy hormones like dopamine in the brain and spinal cord causing pain to be down regulated or dampened. All these acute and sub acute stages interventions can be seen like pain medication in that they work in the short term to help relieve pain. They can in my opinion be lumped under the one umbrella of:” Pain modulation”. This in my opinion is a dirty little secret that some physiotherapists are not able to except or do not want to except.
So, most physiotherapists or indeed any medical professions think that their intervention is the best intervention ( all humans are bias –we just cant avoid it) because it gets 80% of people better. Sometimes we blame patients for not doing their exercises or say things to ourselves like you cannot get every one better. We are failing the very patients than need our help the most and that is the chronic pain patients. One of our major roles as physiotherapists is to prevent chronic pain issues from occurring.
Say for example you go and get your back manipulated and it increased your range of movement and decreased your pain dramatically. You were told you have lots of muscle imbalances and your lumbar spine and pelvis is out of alignment –the treatment made you feel better (at least temporarily), therefore you believe the narrative. Is this a bad thing? In most cases people get the treatment and move on with their lives and there are no ill consequences however what if pain persist and this method doesn’t work and now your left stuck thinking you have all these things that need fixing when really you have a hypersensitive nervous system which keeps you in this vicious cycle loop.
It can be very empowering to show someone in a short period of time that their pain is modifiable however using narratives “like breaking down scar tissue” “You have degenerative disc disease”, “Your pelvis is out of alignment” for some people is no problem. However, some people can get super attached to these narratives and they have a nocebic effect which causes clients to become stuck and perhaps feel hopeless and, in some cases, increase a person’s sensation of pain.
It is these people that I would love to help because these people are sometimes cast aside and have been through the medical system time and time again with the attitude that they need fixing.
We can empower our clients to embrace their own natural healing processes and allow their own endogenous opioids and happy hormone release to take care of pain or we can catastrophize the situation. Some manual therapy may be beneficial for 3 or 4 sessions in the short term to prove pain is modifiable but if it is used excessively and clients who have poor self efficacy just want this treatment and it is encouraged, I think we are setting clients up to fail as they believe they need fixing as opposed to just doing sometimes.
Remember there is caveats for all I have said above and of course there is always exceptions to the rule but for us to move forward as a profession we need to drop the guru outdated narratives of why we think our manual therapy interventions work as they can be harmful to some clients:
This is difficult for some people as it does not fit their business models and can lead to lots of cognitive dissonance.
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