Hello and Welcome!

I am excited to present to you the first edition of the Practical Pain Science newsletter. I created this newsletter in order to help providers like you better utilize pain science in your daily clinical practice. I hope that this is a helpful resource for you. I would love your feedback so please reach out to let me know what you think.

Dr. Orit Hickman, PT, DPT, TPS

When I started learning about pain science, these three articles were the ones that absolutely blew my mind in terms of being able to understand the complexity of pain in the patients I was treating. The authors clearly outlined the differences between nociceptive pain (“tissue based” cause of pain—muscles, joints, ligaments, skin, bone, etc.), peripheral neuropathic pain (still “tissue based” but the nerves specifically) and nociplastic pain (central nervous system pain). 

The articles include super clear tables to help a clinician be able to differentiate between these different types of pain. For example, nociplastic pain is “disproportionate, non-mechanical, unpredictable pattern of pain provocation in response to multiple/ non-specific aggravating/ easing factors.” I mean this made a ton of sense to me—patients who I just couldn’t pin down why their pain was occurring, I couldn’t easily and predictably reproduce their pain, I felt like I was chasing their pain, their pain would randomly flareup and I didn’t know why—these patients were most likely experiencing nociplastic pain. This totally made sense as it explained why my ‘traditional’ PT treatments weren't working for these patients. Even other traditional treatments such as massage, acupuncture, injections, surgery, were not making a dent in these patients' pain experiences OR they were only providing temporary symptom relief.

These articles are a great jumping off point for any clinician trying to incorporate pain science into their treatment. They will help you start the process of diagnosing the primary pain type your patient is experiencing. 

Check them out and let me know what you think.

• Keith Smart et al Article 1 on Nociplastic pain
• Keith Smart et al Article 2 on Peripheral neuropathic pain
• Keith Smart et al Article 3 on Nociceptive pain

In this video I go through how I educate patients on the mechanisms based classification in order to help a patient understand their diagnosis of nociplastic pain. I have found that this really helps to build therapeutic alliance early on with patients who have had lots of prior failed treatment for their persistent pain. Note: this video is one of the ones I use for internal team training.

The following story is a synthesis of experiences with multiple patients seen in my clinical setting. No one person is represented here. However, the findings are ones I have commonly seen over the years.

A 45 yo patient presented to my clinical setting s/p multiple MVAs over the course of 5 years. In that time period they experienced pain in the C-spine and L-spine which moved around their body and wasn't isolated to a specific area. Diagnoses from multiple providers (over the years) included cervical dysfunction, cervical dystonia, TOS (thoracic outlet syndrome), SIJ dysfunction, lumbar facet dysfunction, and sciatic nerve irritation. MRIs and X-rays of various areas showed mild-moderate arthritic changes but no significant other findings. The patient had undergone multiple injections in the cervical, lumbar, and SI joints without significant change in symptoms. Functionally they were limited in sitting and standing and driving tolerance. Sleep was also limited but managed with medications. The patient described having multiple flare-ups throughout the years which would limit function for 1-2 weeks then the patient would be able to return slowly back to activities. 

At initial evaluation the patient's history was taken, they were given the Ospro-17 to assess for yellow flags and assessed for hyperalgesia and allodynia. The Ospro was positive for kinesiophobia. The patient also had positive sensory testing for hyperalgesia and allodynia giving strong evidence that nociplastic pain was the primary pain at the time of evaluation. 

Treatment at the initial evaluation included education on the mechanisms-based classification of pain as well as discussion of the treatment plan of care. The patient reported feeling hopeful about PT being able to help their persistent pain.

In the next issue I will discuss how I assess for nociplastic pain.

Pain Science Physical Therapy is an outpatient community based woman-owned clinic located in Burien, WA. We treat patients 1:1 utilizing pain science to help diagnose and treat patients with persistent pain. Learn more about our clinic at www.painsciencept.com