(1) Improved approach to Subjective History:
Everyone has their own way of obtaining information form a patient. The subjective history can provide many important indicators if a non-nociceptive pain mechanism (NNPM) is the dominant pain mechanism (e.g., neuropathic or nociplastic). Questionnaires may also be helpful. When a NNPM is suspected, this can change the direction of the subjective history in many ways. For example, you may look for causation (e.g., signs of low grade systemic inflammation, family history of type 2 diabetes neurodevelopmental disorders, cognitive decline, or other psychiatric diagnoses), more deeply explore beliefs, expectations than you would have if there was a nociceptive pain mechanism.
(2) Facilitates a more targeted approach to Physical Assessment:
When a NNPM is suspected from the subjective history or from questionnaires the therapist should consider a different approach to the assessment than if there was a nociceptive pain mechanism. Clients with a NNPM can easily be flared up with a “mechanical” based assessment. The physical assessment can provide information to help support or refute a NNPM (e.g., quantitative sensory testing, sensory motor assessment, neurodynamic assessment, response to movement test).
(3) Helps answer the question “What’s wrong with me”
– many special tests require pain provocation. When non-nociceptive pain mechanisms are present, these tests will be skewed. Many of these tests will be positive and leave the clinician (and likely the patient) with uncertainty.
Sub-grouping of NNPM further aids in patient education and may increase treatment compliance, therapeutic relationship. In my experience, patients are very receptive to education on pain mechanisms (provided the education is given with causation and an intervention directive that relates to the causation).
(Note: diagnostic accuracy research has not addressed this issue (NNPM) and is likely a major flaw in this knowledge base)
(4) Helps you answer the question “how long will it take”
– NNPM time frames can be very different than nociceptive. This facilitates patient education and understanding
(5) Helps in treatment recommendations (when causation is considered)
e.g., Nociplastic
-metabolic treatment
-targeted nutrition
-techniques for sensory dysfunction in neurodevelopmental disorders
e.g., Neuropathic
-Neural mobilization
-Ketogenic diet
-whole kinetic chain considerations in motor control
(6) When a NNPM is present it helps recommend against certain interventions (e.g., ones in which we expect a mechanical response, whether this is short or long term):
e.g., -repeated movements, manual therapies, stretching, segmental stabilization exercise, specific movement pattern control exercise
(7) Patient Education in pain mechanisms helps manage expectations
e.g., – if a patient expects an intervention like general exercise, manual therapy, stretching, it helps patients understand why other therapies have not helped (if seen other health care professionals).
(8) It helps in communication with other health care professionals. It allows them to understand the issues related to a NNPM (e.g., time frames, non-mechanical behaviour of pain).
(9) Sub-grouping of NNPM may influence the physician’s choice of how to work with the pt in selecting a medication. A letter to the patient’s physician can improve management
(10) What differentiates a Physiotherapist from a personal trainer? The ability to assess the nervous system (+/- interpret lab work) and subgroup pain mechanisms to facilitate targeted Rx is an important difference
Like it or not or understand it or not, 3rd party payers are looking very closely at the very flawed evidence that suggests:
(1) no need to make a diagnosis
(2) just get people active (doesn’t matter what type)
(3) be nice and establish a therapeutic relationship – the outcomes are the same
According to this, personal trainers are cheaper and can get the same outcomes. Why wouldn’t you use them instead of Physiotherapy? Sub-grouping pain mechanisms is an important aspect of care and scope of practice
Link to a recent reference
https://www.sciencedirect.com/science/article/abs/pii/S2665991323003247
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