Don't ignore what's going on outside the brain

painPhysiotherapist love trends. The current trend which has been around for a good number of years now is that all pain, especially persistent pain is a result of some level of central nervous system (CNS) dysfunction, an output of the brain effectively.

As such it is argued we should now forget about structure and the periphery and simply target the central nervous system when treating clients. This basically means talking therapy and exercise, so vociferously promoted by the biopsychosocial pain model zealots. Hands on treatment is now considered an act of high treason and anyone admitting to doing so risk being shamed and admonished. As for acupuncture or dry needling, such techniques are considered by these folk as being so worthless you’d be better off rolling around in a thorn bush for the good it would do you.

Now of course the CNS plays a role in how we perceive pain, how could it not? Given how inextricably linked the peripheral (which supplies the spinal structuctures and limbs etc) and central nervous systems are both physiologically and anatomically, one will of course influence the other. For some, pain may be due to a combination of both peripheral and central nervous system 'wind up'.

So should we be so quick to ignore the possibility of a peripheral pain generator i.e something which may be sending stimuli to the brain which are then being interpreted as being painful or unpleasant.  One’s attitudes and beliefs around pain will influence to some extent how the CNS responds to these stimuli and to what extent the CNS may get involved. This in turn may effect pain severity, degree of ‘bothersomeness’, behaviour and social impact etc. But what if we could identify and treat the periphepheral pain generator, ideally before any maladaptive changes take place within the CNS?

Studies have shown that doing just this, treating and dampening the stimuli arising from a peripheral source, allows the CNS to regulate (if required) without any further input. This has been shown to include thalamic and other central cortical maladaptive effects which seem to disappear. As such, if there is some degree of 'central sensitivity' within the brain and other parts of the CNS which may have occurred over time, and which may be partly repsonsible for onging pain, these may resolve once the peripheral pain generator is treated.

The key is to be able to assess, identify and treat the peripheral pain generator. Unfortunately many physiotherapists are unable to do this effectively, and therefore it’s easier to resort to the ‘it must all be in the brain’ approach.

However for those who have the skills, being able to assess for and treat myofascial trigger points, for example, as peripheral sources of potentially painful stimuli may be very beneficial for the client. Of course there is plenty of deniability regarding the existence of trigger points due to the mechanisms which generate and sustain them being somewhat unclear, I accept that.

But for those who have actually handled muscle, treated trigger points effectively, usually with needling techniques, the results in terms of pain relief and restoration of function really can’t be refuted.

I recently had a client who was in persistent pain for 8 months, which fully resolved after three sessions of mainly needling in combination with some simple manual therapy (large mechanisms overlap with needling) and appropriate exercises (which of course he did not do!).

In his case, it is very likely given the stress the pain was causing him, the lack of sleep, his emotional lability etc that there was some degree of central sensitivity. But did I have to sit him down and counsel him regarding his attitude and beliefs around pain, and how this ‘thinking’ is getting in the way of his pain going away…no, I simply needled him effectively and now he is a different person.

Here I’m going to sign off. If I had the comments section for this blog activated, I’m sure I’d receive barrage of abuse from those who would be questioning my reasoning, telling me how unreliable trigger point assessment techniques are, convincing me they don’t exist, arguing the needling is all a placebo effect etc…yes yes I’ve heard it all before!

At the end of the day I’m only concerned with my clients, looking after them, trying to get them better as quickly as possible within a safe and as far as possible evidence based manner, as well as setting them up to be able to looking after themselves moving forwards. How I do that is up to me.

By Simon

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