If you’re new to the field, it’s hard to know where we are as a profession on the continuum of learning, especially when it comes to pain science. Who’s going to bother reading a paper on “the history of pain science over the past 50 years”? That’s not what this blog is about, but you might find some interesting context here, considering Canada was host to 3 profoundly important seminar speakers this past month, in case you missed it. But before we get to Moseley, Shah and Srbely… picture this:
There is a forest. There are many paths that will take you the wrong way, and just a few paths that go the right way. You’re walking alone in the forest but you hear other people around, and some of them are going the wrong way too. You’re a bit confused and lost and someone shouts at you through a thick wood.
“Hey buddy, you’re going the wrong way!”
How does she know, you wonder. So, you ignore her. A little while later you hit a fork in the road and you meet a caring and confident person. You tell them where you are headed and they say,
“You know what, I don’t think you’re on the right path to get there. I’m kind of going that way myself. Let’s walk together.”
They seem kind, and interested in you, so you trust them. And sure enough, they’re correct, and following their advice gets you where you’re going. They changed your mind because they walked and talked with you. Let’s come back to this idea shortly.
The current evidence base on pain care is growing and changing rapidly and it can be hard for clinicians to keep up. Consider the work of 3 key researchers, all of whom spoke to Canadian audiences recently:
This fellow needs no introduction to astute pain-minded physios. Back in September he presented his most recent research to a room full of hundreds of clinicians in New Westminster, BC. Here’s a quick summary:
His current model for how to seek recovery from chronic back pain (the Resolve approach) boils down to 3 essential features:
Rethink the problem: Identify (and change) the inaccurate or unhelpful cognitions that your patient has about how pain works.
Rediscover and sharpen neural networks. Identify and improve the suboptimal sensory processing that is feeding into their pain experience (using the Fit-for-purpose model of pain).
Improve overall fitness. Expose them to mechanical load and other external stimuli to improve the actual health of their tissues so they can handle a return to activity.
Those of us who have been following the pain revolution over the past 30 years will see some subtle changes in this proposal. For example, it’s not just about “Explaining Pain”, which is a relief for those of us who have spent fruitless hours trying just this and losing our patients’ interest. Indeed, the current cultural literacy in the general Canadian public regarding how pain works and what is needed to treat it is not yet aligned with a simple “explain pain” approach. Folks aren’t primed and ready for it by the media yet. So, if you’ve used it successfully, it’s either because your patient had done some pre-reading and was already enlightened, or you did an amazing job of doing the education. Otherwise, you’re just a stranger shouting pain science at your patient from across the forest.
Here’s another approach that many of you use, whether you explicitly know it or not: Before you start trying to change your patient’s mind about the right way to proceed through their forest of pain, you spend some time walking with them. You approach the encounter not as if they are coming into your clinic to be blessed by your presence, but as if you are joining them on their walk and learning about them, their journey, and their destination.
You might spend time talking and listening to them while you perform ultrasound or soft tissue techniques. You might even approach the use of ultrasound as if its therapeutic power comes from the lower frequency sound (of your voice), more so than the ultrasound. You know the rest of the story. You gain their trust and an appreciation for where they are on their journey and you help them along on their next steps even if it’s not a full and complete understanding of modern pain science. Any step toward their goal is progress.
Jay Shah might be a new name to you. Remember it. Dr. Shah is a physiatrist, researcher and lecturer who just might be the Yin to Lorimer Moseley’s Yang. He sees patients and conducts research in the supportive, well-funded environment of the National Institutes of Health in Bethesda, Maryland. Among other things, he’ll likely be remembered far into the future for being the first scientist to use needle micro dialysis to investigate the unique chemistry of a myofascial trigger point.
In that landmark study, his research group proved that there is a distinctly different chemical milieu (environment) found in a trigger point compared to adjacent muscle. Specifically, there is a veritable cocktail of noxious substances found, which demonstrates that there is something fishy going on in a trigger point. This published research also provides evidence that this noxious environment is a definable thing, which was not universally agreed upon to that point.
Shah’s group essentially demonstrated that one of the downstream effects of central sensitization is neurogenic inflammation within a muscle trigger point.
Imagine understanding central sensitization to be not just a vague sense of “nociceptor pathways firing more easily than they are meant to” but rather a chemical process including things like Substance P and CGRP that physically sensitizes muscles to be nociceptive stimulators themselves - not because they’ve been injured but because they exist in the myotome linked to the sensitized spinal cord segment.
Shah spoke to a select group of keen clinicians in Laval, Quebec in early October. His research puts a powerful spin on the interplay between the painful ‘myofascial unit’ and the upregulated and sensitized nervous system. Put Jay Shah on your list of researchers to read, and to see in person if you get the chance.
Dr. Srbely is an Associate Professor and clinician-researcher at the University of Guelph in Ontario. Dr. Srbely has completed a series of likewise landmark studies, and he spoke about them in Laval along with Shah.
His research has provided evidence that sensitizing a spinal segment (in an experiment involving the application of capsacin cream on a dermatome), resulted in immediate upregulation of the autonomic nervous system, the muscles, and the skin of structures remote from the capsacin, but within the segmental innervation of the sensitzed tissues. That’s something worth noting. Again, this is central sensitization in process - visualized and induced experimentally. This helps us understand, for example, why examining the spine is vital for the assessment of chronic pain conditions due to visceral or peripheral causes e.g., endometriosis or plantar heel pain.
The work of Shah and Srbely comes at the problem of chronic pain from a uniquely different angle than Moseley. To gain profound reductions in chronic recalcitrant pain using their central sensitization model requires no “understanding of how pain works” on the part of the patient.
Have we solved pain then?
So, who is right here? Do we need to “Resolve Pain” with education, viewing images of twisted hands to regain “laterality awareness” and graded exposure to mechanical load? Or do we need to put acupuncture needles in sensitized spines to change the neurological activity that is perpetuating pain through biochemical “central sensitization.” These are just pieces in the pain puzzle. We’re slowly on our way to finding out what the final picture looks like, someday.
Do you meet your patients where they’re at? Do you join them on their forest walk towards healing? How about joining Shah, Srbely and Moseley on a walk through the research on how to master the art and science of rehabilitation?
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