Acorns and Achilles Pain: A Case Study in Neuroscience Education

In the physical therapy world we are very slowly starting to become much more aware and educated on the topic of pain as a whole. Sure, there are still plenty of hold outs who cling on to the biomedical model with white knuckles and a death stare when you try to give a little “Explain Pain” talk. However, I’m optimistic and feel like maybe our newer generation of PTs are getting influenced by the likes of Lorimer Moseley, David Butler, Adriaan Louw, Diane Jacobs, Jason Silvernail, Greg Lehman, and many more. I’m am hoping that a new era of health care practitioners hatch from their cocoons into the world the emphasized the importance of the words we say to patients. Eloquence in explaining complex pain situations is something that every clinician should (and hopefully will) strive to perfect. Adrianne Louw has a quote that I love that goes something like:

“Patients come to us in pain and leave experts in anatomy”

Why do we do this? Why do patients come to us with back pain and leave knowing all about the annulus fibrosus, nucleus pulposus, facet joint degeneration, disc degeneration, transverse abdominus, mulitifidi, etc? Why aren’t patients leaving having learned about nociception, the plethora of studies showing poor correlation between tissue damage and pain, that discs heal, understanding that pain is a result of perceived threat by the brain and that there are a multitude of factors that can influence how much danger the brain perceives? I think there are many factors that play into this.

1.       Traditionally physical therapists, chiropractors, massage therapists, and even medical doctors are not educated more than an hour or two on pain in their entire curriculums. We simply just don’t know what we don’t know.

2.       We are all taught anatomy extremely well. We are forced to learn every muscle, bone, ligament, tendon, origin, insertion, and innervation in the entire body. Therefore, we really end up teaching what we know well.

3.       We have traditionally been trained in a biomedical model, and the psychosocial aspect of this model is “relatively” new and not well integrated into most programs across all disciplines.

4.       It’s easier to teach patients black and white concepts like anatomy than abstract concepts about higher level brain processing and neurophysiology, so we end up taking the easy road.

5.       Anatomy and biomechanics are sexy and easily show up in charts and models to use for patient demonstration.

6.       To piss me off………..making my job harder unlearning and re-teaching patients

But what happens when you have a patient that has pain you can’t explain anatomically or biomechanically without completely making up some crazy regional interdependence about the calcaneus to the left TMJ? These are the situation in which you need to be able to actually educate and explain pain to your patients. They hurt their back 5 years ago and they still have the same pain, but the tissues are surely healed. They had surgery several months ago and the tendon is surely well healed by now. The whiplash injury that led to a disc herniation was 53 years ago and the disc has likely healed and re-herniated more than once in this time frame. We run into these situations all the time, and if you aren’t well versed in the mechanisms of how pain actually works you tend to fall short of giving a good explanation to the patient; an explanation that HOPEFULLY decreases their fear and anxiety instead of strengthening it.  

I was lucky enough to recently have a patient in my clinic being treated by one of my co-workers (who uses the BPS model and explains pain well) have an amazing learning scenario happen. The patient was generous enough to give a small video explanation of this situation that he gave permission for me to use as an educational tool. To give a little background, the patient is a professional ballet dancer who had an Achilles tendon rupture and repair 3 months ago. He has had minimal pain for the last several weeks, is walking with no antalgia, and is recovering at an astounding rate due to his hard work and excellent prior physical condition. He goes on regular walks every day as part of his HEP and regular daily routine. He was recently on a walk just like any other when something interesting happened to him. Please follow the link to the video below

https://www.youtube.com/watch?v=EJE3GVSjh9w

Luckily we had spent plenty of time explaining to him how pain functions in the human body, as we do with almost every patient who comes through the door. With this knowledge he was able to rationalize that he had simply stepped on an acorn which made a snapping noise and caused vibration in his foot and that his Achilles had not actually torn again. This is an absolutely beautiful example of how pain can be present in absence of nociception. He had a painful neurotag activated due to a sound and vibratory input with no tissue damage present. To take it a step further, he was able to “self-treat” with understanding that he had simply experienced pain because his brain immediately perceived danger based on likeness to a traumatic experience that did result in tissue damage.  He simply "walked it off" and hasn't had issues since.

Below is an illustration to show a few of the parameters that were currently influencing Phil's brain that could have played a role in him experiencing pain without nociceptive input.

As you can see this is very much a different scenario than the heavily outdated model that is presented in the picture below. A model in which there is an ascending "pain pathway" that carries pain messages up the body to the brain. Phil experienced a high degree of pain in his Achilles area with no possible way for "pain messages" to be sent up the chain to his brain. His brain instead generated an output of pain based on several other inputs that it perceived to be dangerous based on his current mental status and previous experiences.

Hopefully this example will get a lot of circulation and serve as a strong example of how pain is more than just tissue damage to those who are still on the fence about accepting these concepts. It's time for us to move forward, and our patients deserve for us to be better.

Jarod Hall, PT, DPT, CSCS

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