Tea with discussions about combining manual therapy with pain neuroscience education   January 1st, 2014

Interpreting scientific results in clinical practice can be, to say at least, challenging. Especially when it is somewhat contradictory to what you have heard during all those years of extensive training in both physiotherapy education and other courses. As one of my friends recently put it this way: ‘The more I learn about pain, the less I know and the more confused I get.’ 

This friend and I have a lot of ‘tea with discussions’ (pretty similar to the blog I recently read about Julie’s coffee with Lorimer Moseley). Most of our discussions are about central sensitization and about which physiotherapy treatments of (chronic) pain we find most appropriate. We both have different backgrounds in physiotherapy, hers manual therapy and mine more psychosomatic focused, so you can imagine those discussions can be pretty heated sometimes. Which is good. As long as we both are open minded, those discussions contribute to the depth and quality of our clinical practice. 

For instance, the other day we we’re walking through the forest and we discussed manual oscillations. I argued that by manipulating and mobilizing joints the patient gets the illusion that they have a biomechanical problem. This illusion reinforces their (often) biomechanical perceptions, and thus reduces self-management because the patient beliefs that no one but the therapist can resolve the biomechanical problem (shortly summarized and kind of black-and-white). However, she reminded me that not only hands off techniques are helpful in reclaiming self-management of patients. She reminded me about the positive (temporary) analgesic effects of manual oscillations [1-3] as a start for therapy. Thereby arguing that therapists should mention the neurophysiologic changes in the central nervous system during those oscillations which cause these analgesic effects! She also added that she explains to patients that this is a start and by this they can move with less pain in the beginning and it’s a way to get out of their vicious circle. Combined with more in depth pain neuroscience education, coaching and hands off treatments such as graded activity, exercise therapy and relaxation they can, in the end, reclaim their own self-management. 

As you can imagine, I was kind of proud of my friend. Sure, I might choose a different treatment approach than initiating with hands-on treatment. Even though she is in doubt about all the information she has received and about the biomechanical background of the patients’ problem, she now knows that she is targeting the central nervous system during every kind of treatment she provides. 

However, there is still so much to gain. Yesterday I did a presentation about central sensitization and pain neuroscience education for a group of physiotherapists in their private practice in the Netherlands. Even though there is a growing number of physiotherapists like my friend, who are indeed aware of central sensitization and who provide pain neuroscience education, I was kind of shocked by the number of physiotherapists who did not know how to pronounce central sensitization. The more public and clinical discussion there is about central sensitization and pain neuroscience education the better. The more physiotherapists (and thus patients!) are informed. And yes, all the scientific research is sometimes confusing and hard to understand, but we owe it to our patients to be well informed about what actually happens and helps when people are in (chronic) pain!

Amarins J. Wijma, PT, MSc., PhD-researcher at the Vrije Universiteit Brussel 

2014 Pain in Motion


1. Sluka K.A., Wright A., Knee joint mobilization reduces secondary mechanical hyperalgesia induced by capsaicin injection into the ankle joint. European Journal of Pain, 5,1, 81-87, 2001. 

2. Skyba D.A, Radhakrishnan R., Rohlwing J.J., Wright A., Sluka K.A., Joint manipulation reduces hyperalgesia by activation of monoamine receptors but not opioid or GABA receptors in the spinal cord, Pain, 106, 1-2, 159-168, 2003. 

3. Moss P., Sluka K., Wright A., The initial effects of knee joint mobilization on osteoarthritic hyperalgesia, Manual Therapy, 12, 2, 109-18, 2007.