Therapeutic pain science educated has sky-rocketed in the past few years. Even though the concepts have been around for quite some time, it seems to have found a place among on-line discussions, continuing education courses and a slew of YouTube videos since my graduate studies.

I have become quite fond of the information myself and continuing to mingle it into my treatment interventions. Even though it has not become a primary intervention in my practice, it has a notch in patient education and helps me understand chronic pain—which should lead to patients understanding their condition more.

Just recently, a colleague of mine was educating a patient about central sensitization and how it can be a reason for his chronic pain. Read the following letter that was written by this PT to a patient’s physician. From reading, you will know why the physical therapist performed this intervention and even why this note was written:

Dr. ****: Mr *** was recently referred to In Touch Therapy for treatment of low back pain. Upon examination, it was observed that this patient demonstrated intense pain of the low back, upper back, neck, and right upper extremity. He exhibited high fear avoidance to movement and exercises. Pt stated that he has significant issues and damage to his back that will not respond to physical therapy interventions. Mr *** was unable to tolerate even low intensity exercises and manual therapy interventions during the initial evaluation despite utilization of therapeutic modalities to lower irritability of symptoms. Application of electrical stimulation pads was reported to be significantly painful. While seated receiving moist heat and electrical stimulation, pt reported increased pain in the back due to the floor vibrating as therapists and other patients walked past him. Second and third treatment sessions were focused on improving joint mobility in a pain free range to manage symptoms and decrease fear of movement. Again, all activities that were expected to be pain relieving were reported as painful. Due to allodynia, inability to complete low intensity exercises, and lack of improvement; pt was educated on central sensitization phenomenon and plan of care was discussed. Pt appeared disinterested and stated that this concept makes sense but does not apply to him due to severity of damage in his back. Although he did not agree with explanation, he appeared willing to continue with PT POC to improve mobility and decrease central nervous system hypersensitivity. Pt returned to the clinic this morning (10/6/2014) agitated. He states that he will no longer come to this clinic to receive treatment due to physical therapist’s belief that the pain is in the patient’s head (not what we were suggesting or educating him about). Communication was attempted with the patient to explain this misconception of what was discussed at the prior visit, but he declined. Pt stated that he is going back to the VA to tell them what he thinks of this clinic and he would not return. Based on these findings and the patient’s reaction to treatment, it is my belief that Mr ***will not benefit from physical therapy interventions at this time. If you have any questions or comments, please feel free to contact me at ***-***-**** Sincerely, Dr. ****

Professionally, I feel my colleague made the right call to educate about central sensitization based on the negative patient response thus far to manual therapy, therapeutic exercise and even modalities. The patient’s presentation is also classical of central sensitization as backed by recognition factors from Nijs et al 2010.

This type of reaction hopefully will not happen to anyone but is a good learning experience for us all. I will say, this is an extreme reaction from a patient. We have to tread down this type of education path with care and caution as we do not know how patients will perceive it though. This is especially important in chronic pain patients, who could have some other psychological condition and in this case, a diagnosis of PTSD.

Even though I do NOT recommend disregarding the “bio “in biopsychosocial aspect of pain; in this particular case, the “bio” was EXTREMELY difficult to address secondary to allodynic response, therefore, a psychosocial aspect was implemented and unfortunately, back-fired.

What are your thoughts on this case? Has this ever happened to you?

Should WE, as physical therapist, be educating about a biopsychosocial approach or leave this to psychologists?

With information provided, what would YOU do differently in this case?

Do you think this patient was going to get better ANYWAY? Could we have just pushed aerobic exercise, non-specific movements and bullshit modalities for 8 week…or even placed him with a tech to complete core exercises, strengthening and motor control?