Despite the advances in our understanding of pain in the last sixty years in research, many manual therapists and fitness professionals are still being taught and adopting outdated ideas about pain. However, there is a small and emerging population of therapists and trainers who are gradually learning (and unlearning) about pain science and how to apply research with their patients or clients.
Even with this gradual movement, we see a lot of myths and misconceptions about pain being posted on social media from practitioners and continuing education courses. This leads to some major debunking of these myths online that we often see over and over again like it’s Groundhog’s Day. If you’re sick of seeing the same myths on social media, five manual therapists tackle five myths about pain and treatment that many practitioners still believe and pass them on to their patients.
Myth #1: I Need an X-ray or Scan to Detect the Source of My Back Pain
“The scientific evidence suggest that scans are only necessary for a few people with back pain. These are the people who have more serious forms of back pain, for example, back pain due to a fracture or infection,” said physiotherapist Bruno Saragiotto, who is a Ph.D. student at The George Institute for Global Health at The University of Sydney.
“A thorough clinical examination will identify those people who may have a more serious form of back pain where imaging is needed. Most people with back pain have ‘non-specific’ back pain that is not due to a serious disease or injury and so imaging is not necessary. If your doctor tells you that you don’t need imaging, it is good news.”
However, what would happen if doctors imaged all of their patients with back pain just to make sure they had not missed something important?
“In these patients, findings from X-ray or scans are unhelpful and can even be harmful,” Saragiotto said. “For example, a recent study has shown that patients who are sent for MRI ended up more disabled and underwent more surgery than those who weren’t sent for scans. Patients can misinterpret scan results and become more worried; which makes their pain worse and delays recovery.
“Imaging findings, such as ‘disc degeneration’ or ‘disc bulge,’ sound quite worrying until you know that these findings are common in people of the same age without back pain. Beyond the needless worry and delay in recovery, unnecessary scans waste money and expose patients to the risks of radiation exposure. The wise clinician uses imaging for only a few of their patients with back pain and explains the results.”
Myth #2: Pain Science Doesn’t Apply to Acute Pain From an Injury
“Pain science is simply the science of understanding and explaining the phenomenon of pain. It applies to anyone and everyone who experiences pain,” Dr. Jarod Hall described, who is a physical therapist practicing in Fort Worth, Texas. “In fact, it is presently proposed among experts that a better overall understanding of pain by the general public may be quite beneficial in preventing people from developing as many persistently painful conditions. To better explain this topic I will provide a few examples below.
“The myth that pain science doesn’t apply to pain from a normal injury is a common thought process from patients and clinicians alike across the globe. We often fall into a habit of thinking that acute pain immediately after an injury is an INPUT from the body to the brain letting us know about how damaged our tissues are because it ‘makes sense’in this context.
“However, we must not forget that all pain is actually created as an OUTPUT by the brain in response to a variety of factors. Acute injuries like spraining your ankle activate specific receptors in your tissues that send messages to you brain letting it know that there has been tissue damage or that there is inflammation.
“Conversely, in situations where people develop chronic pain in areas long after tissues have healed and when there is no evidence of tissue injury or active inflammation this pain is also created as an OUTPUT by the brain in response to a variety of factors including, but not limited to, depression, fear of movement, fear that the body is weak or damaged, stress, lack of sleep, poor nutrition, etc.
“The idea of ‘peri-pain education’ or simply spending time educating patients with acute injuries and ‘normal’ painful responses or even the non-painful general public about how pain works may actually dramatically reduce the rate at which acute pain slides into a more persistent nature.
“As you can see, pain science is much more than lecturing people in chronic pain about psychological factors that may increase the experience of pain.”
Myth #3: Pain Science Can Help Explain Someone’s Pain Experience
“The short answer is no. Pain science can help you understand some of the mechanisms involved in the process,” explains Monica Noy, who is an osteopath practicing in Toronto, Ontario. “Pain education and neuroscience education provide information about neurological processes and resultant changes, as well as psychosocial factors that can contribute to the neurological experience. I like to think of it as the nuts and bolts. It is important information, but it’s not explanatory of the pain being experienced by the person in front of you.
“What we expect and get from science are ways of knowing the world we can observe. Laws, rules, measurements and outcomes that represent progression or observation over time. An individual experience of pain is something different than the science of what might be occurring during. Experience is ongoing, constantly changing and influenced by a multitude of factors, some of which can be quantified by science.
“This compartmentalization of pain experience vs. science of pain is, in part, a crux of incorporating into treatment that science and a biopsychosocial perspective. The science and the experience are reliant on each other and yet are in no way explanatory of each other. A person’s pain experience cannot tell you what, exactly, is happening in their body. Even knowing what exactly is happening (e.g. MRI of the brain) can tell you very little about the person’s experience — except perhaps that they will be having one.”
Myth #4: Pain science is compatible with the tissue-plasticity model
“The traditional narrative of tissue-plasticity, or myofascial release, they use for explaining treatment outcomes runs counter to pain science and science in general. You can’t think you’re releasing adhesions to alleviate pain AND concede to pain being independent from the state of the tissues,” said Rey Allen, who is a Rolfer in New York City.
“I’ve known many practitioners that take an honest look at pain science and concede to the biopsychosocial framework of client care, but that’s where it ends for them. They seem to overlook, or not feel moved by, the evidence demonstrating that people without pain often have the same degree of pathoanatomy as those with pain. Somewhere, somehow, the lessons of pain science are lost on them and they carry on thinking they’re breaking up adhesions with their bare hands.
“Trained as a Rolfer, I am intimately familiar with the cognitive dissonance that occurs when these two narratives collide. When I first learned about the science of pain it was like someone gifting me a shiny new toy and punching me in the nose at the same time. It was exciting, but also difficult, when I first had to accept the facts.
“I understand that pointing out this conundrum doesn’t make communicating the science any easier for these folks, but I don’t know what the solution is. These two narratives are simply incompatible.”
Myth #5: Psychosocial factors are only important in people with persistent pain
“We’ve all looked down at a bruise and wondered, ‘how on earth did I get that?’ We also know only too well that moment when, on a day when we’re feeling a bit down in the dumps, perhaps a bit sleepy, or even a bit irritated, we accidentally kick our shin on something! Doesn’t it hurt?!” Dr. Bronnie L. Thompson inquired, who is a pain researcher and Senior Lecturer in the Department of Orthopaedic Surgery & Musculoskeletal Medicine at the University of Otago Christchurch Health Sciences in New Zealand.
Dr. Thompson suggested that we to define what “psychosocial factors” mean. “These have been popularised as the ‘yellow flags’ or risk factors associated with increased risk for difficulty recovering from an acute musculoskeletal problem,” she told Massage & Fitness Magazine. “Psychosocial is a term that refers to interactions between social factors and individual thoughts, beliefs and behaviours. In this instance, social refers to families, communities, societies, and the systems and processes used to influence beliefs and behaviour within these settings.
“Generally, psychological factors associated with pain include things like how much attention we pay to the experience, our interpretation of what that experience means for now and the future, our emotions and the things we do as part of interpreting the experience we call pain. There’s a good deal of research showing that pain can disrupt our attention, it can intrude on what we’re focusing on, the experience can interrupt the formation and retrieval of memory, and the influence is both from ‘top down’ (relating to the priorities we’re placing on what’s going on around us in relation to our goals), as well as ‘bottom up’ in terms of the intensity of the experience, and other aspects of what, where and why we feel what we do.
“These processes occur around us all the time. We’re not a blank brain waiting for something to come to our attention. We’re always busy thinking and scanning our internal and external environment for factors that might disrupt the status quo. Much of this activity is not conscious and we only become aware of the sampling our mind/body is doing when our mind/body judges it as important (or more important than other things we’re attending to).
“Thinking of the social factors, from the time we’re born we’re creatures of connection. We inhabit a social world, and develop knowledge of ourselves and our sense of self through our relationships with others. At the same time as we’re becoming aware of who we are, possibilities in our environment are constrained by social systems such as driving laws (who decided we all had to drive on this side of the road?), or social norms (yes, you generally do need to wear clothing in public places), or cultural practices (tattoos are common in young people, less common in elderly folks).”
For acute pain, this to our attention when the resolving the pain is more important than our current goal. “As a psychological experience, all pain involves psychological processes – and at the same time, those processes are interacting with social processes such as family habits and attitudes, our social group’s normal responses to pain, and our society’s common practices regarding pain and health,” Thompson described.
“While there’s little doubt that tissue damage, which is often but not always associated with acute pain, can be part of the process of experiencing pain, tissue issues don’t reflect pain intensity in a straightforward way — especially as time goes on.
“Psychosocial factors, however, are present from before we experience pain — and on until we die. They’re always present, and thankfully so because without them we wouldn’t be able to protect our sense of self from harm or potential harm. So, in my mind, psychosocial factors need to be factored in from the moment a person reports they have pain – and perhaps even before, if we’re to change the way pain is managed.”
1. PainScience: A “Wikipedia” source for all things about pain relating to massage, physical therapy, exercise, and alternative medicine with a tongue-in-cheek humour.
2. My Cuppa Jo: A personal account of how one American woman in Colorado learn and deal with her chronic pain that caused her to search her answers via pain science.
3. Better Clinician Project: A comprehensive resource, including science-based continuing education courses, for physiotherapists and other manual therapists.
4. San Diego Pain Summit: A series of online presentations and resources, including continuing education, for phyiotherapists, massage therapists, and other healthcare professionals. These presentations bridge the gap between research and practice.