Perspectives on the Contemporary Approach to Pain in Rehabilitation

Let me be clear from the beginning so there is absolutely no confusionI believe

that active care in the form of rehabilitation of primary and functional movement
patterns, combined with manual therapy, is the most effective method for treating
musculoskeletal conditions. That ultimately, control of movement patterns within
functional ranges of motion is our goal as rehabilitation experts. With that being
said, the consideration of the subjective complaint and location of pain is vitally
important to a proper and effective physical examination and assessment. The
patients pain should always be viewed as necessary information that ought to be
collected during every interaction, along with other pieces of data like range of
motion and muscle tone.
The recent obsession in the rehab realm that seemingly discounts the importance
of painful symptoms, while focusing primarily on exercise and function, is terribly
misleading, and appears to have led young healthcare professionals to equate
chasing pain with a mental disability; this attitude is not only ridiculous, but
arrogant and hypocritical.
Allow me to state the obvious. As we are all aware, a major majority of our patients
present to us with a primary complaint of pain, and we understand there is a decent
chance that the location of their painful symptoms is not the true culprit of their
dysfunction. But while we ought not to focus our entire attention on the painful
region, we should not completely disregard it either. Treating tender points and
muscle hypertonicity near the location of pain is at least as equally as important for
the patients wellbeing as restoring their distal ankle dysfunction, which, do not get
me wrong, can definitely be contributing to their current presentation. However,
to immediately dismiss your patients pain complaints as seemingly unimportant
(since we think holistically), while placing all your attention on dysfunctional,

painless tissues and joints is analogous to ditching the infamous infant with the
soiled tub water.
The point I attempted to make in the previous paragraph is that while a healthcare
provider who is serious about musculoskeletal medicine implicitly understands that
there is a likely chance that their patients subjective complaints of pain may not
exactly point to the true origin of their presentation, we must maintain that the
location of Pain, as well as the specific tissues directly causing symptoms is still
important. The specificity and location of Pain is at least important enough to be
scrutinized and directly treated in the same eager fashion that we have been taught
to assess and treat distally less painful joint restrictions, muscle tone abnormalities,
and functional movement patterns by todays fitness and rehab gurus.
I believe the current young generation of professionals who have been molded by
the mantras like Stop Chasing Pain and Dr. Karel Lewits infamous He who treats
the site of pain is lost have taken those ideas ludicrously too far, and that misstep
is a result of experts in the fields of rehabilitation, performance, and function
promoting one far end of the new paradigm which emphasizes movement over
everything else. It has gotten to the point where a physician or therapist is
considered mentally inadequate if they actually treat someones shoulder when
the patient complains of shoulder pain!
Of course I am not suggesting that we revert back to a myopic rehab philosophy,
but I fear with todays gurus staunchly stressing function, movement, and
activation, while at the same time trademarking their anti-pain slogans, we are
educating a future generation to be completely deaf and blind to their patients
primary complaint. Also, for those younger professionals, please pay attention to
the hypocrisy of experts who promote their function-centric view towards
rehabilitation and function, yet are the first to boast of how quickly they eliminated
their patients pain levels. If they are not as concerned with pain as they proclaim
to be, then why immediately tout their patients change in pain levels? Even when
the restoration of a specific functional activity is exclaimed, it is always qualified
with the caveat that their activity was done in a pain free manner.
Obviously, these experts care about painand they ought to. They carefully
consider its location and quality all the time. However, I believe that these same
experts, fueled with truly noble intentions, are now compensating for years of
misspent attention on painful symptoms by de-valuing them in favor of focusing

and stressing the importance of distal dysfunction and general movement patterns.
My point is that the rehab spectrum has specific techniques for local pain relief on
one end, and reeducation of functional motor patterns on the other, and that the
current approach being propagated by todays experts may lie too far to that
function side. Furthermore, this contemporary philosophy, with its functional
bias, may have unintentionally led to students and young professionals
condescendingly scoffing at local pain-relief techniques that do not appear to
directly impact performance.
Drift of the paradigm back towards the center is what is called for, where
movement and function are favored, but not so heavily as to disregard local pain
and the techniques that eliminate it.

William Tortoriello, D.C., Certified DNS Practitioner

www.integrative-chiropractic.com
www.chicagomovementspecialists.com