In the traditional model of physical therapy, the physical therapist prescribes stretches and exercises for the patient in order to improve function in one part of his or her body.
For example, if you have back pain, your PT will probably give you strengthening exercises to build up the muscles in your back and your core. If you have a knee injury, she’ll probably give you exercises to strengthen the muscles around the knee. This is why when most of us picture physical therapy, we imagine a patient grunting and sweating in a gym while the therapist looks on.
Pain neurophysiology education, however, draws from a different treatment model. This model is not based on the idea that the patient’s pain is coming an injury in one specific part of the body. Instead, it targets the sensitized nervous system directly as a source of pain.
The best way I can try to describe this is with graphs. The first graph below shows the way most people imagine pain to work. It also shows what most physical therapists are imagining when they prescribe stretches and exercises to improve a patient’s function:
You can see how, as the intensity of the injury diminishes (represented by the black line) the intensity of the pain diminishes as well (represented by the red line). This matches our experience of pain in most minor situations: getting a tooth drilled, pulling out a splinter. When the stimulus goes away, the pain goes away.
However, in situations involving chronic pain (generally defined as a painful experience that lasts for at least two to three months) the pain response works differently. Prolonged exposure to a painful stimulus actually produces changes in how a person’s nervous system works. It’s as if it sets off a feedback loop in which pain signals continue to be produced independently of the level of injury. For this reason, pain persists even after the initial injury has healed:
This second graph is an accurate representation of the state I was in when I was first introduced to pain neurophysiology education by my physical therapist Tim. I had a very high level of pain, but it was not correlated with a high level of injury in my body. This is why I hadn’t seen much improvement with any of my past physical therapists– my pain was coming from my nervous system, not from a specific injury in my body.
“If pain is the patient’s primary symptom, then pain relief should be the primary goal of treatment.”
I once read something along those lines in a blog comment section, and it really stuck with me.
Most physical therapy programs are designed to improve function of a certain part of the body. But when your pain isn’t coming from a problem with a certain part of your body, you can stretch and strengthen until the cows come home. It still won’t change your level of pain.
This is why none of the physical therapists I had seen before had been able to help me. They were all stuck on the idea that I needed to strengthen my back; strengthen my abs; strengthen everything. Of course, in some ways they were right. I wasn’t in the greatest shape.
But what Tim was able to identify is that there was a common denominator behind all of the pain I was experiencing in different parts of my body. Rather than looking at each one as unrelated, he recognized them as the symptoms of an overactive nervous system, or, as he taught me, body alarm system.
The goal of PNE is basically to help the patient’s body “remember” what an accurate pain response is supposed to be. There are a few ways to accomplish this, and I will be discussing them in upcoming posts. But the general goal of these various techniques is to help the patient’s nervous system get back in touch with with the reality of what’s happening in his or her body.
This graph shows the general goal of treatment:
The role of the physical therapist is basically to help the patient’s nervous system realize it doesn’t need to be on high alert all the time, and to slowly help it calm down. The idea is that as time goes on, the discrepancy between what the person’s nervous system feels and the actual level of dysfunction in his or her body will slowly shrink.
Now, to be honest, I’m not sure you will ever be able to fully reverse the process of central sensitization. It’s probably possible, but it hasn’t happened yet for me. That’s why I didn’t draw the red line going all the way back down to the bottom. An overactive pain response will always probably be somewhat of a factor for me, but it is a million times better for me now than it used to be. I’d much rather have the red line close to zero than soaring way up high, totally out of touch with my physical reality.
P.S. I adapted this post from Part 3 of my series on my own patient experience with pain neurophysiology education, entitled “How a physical therapist helped me through my lowest point.” I’m experimenting with different ways to present information, to find out what works best for people. Definitely check out that series if you’d like to know more! I would love to hear any comments or questions you might have.