A Brief Review

Wow Jon,
This article certainly brings up some interesting questions with regards to pain. Is pain an accurate representation of our body telling us we are doing damage? I guess it depends when in the injury and rehab cycle we experience this pain.

For example, we can say with much confidence that the pain experienced during acute injury is due to the cascade of inflammatory mediators released due to tissue damage. These mediators (substance P, bradykinin etc) can cause a chemical sensitization to peripheral nerve receptors either directly associated with, or located near to the tissue damage. Lets forget the process of referred pain for now, so as not to complicate matters.

On the other hand, we have all seen the chronic pain patient walk into our practice after years of central pain sensitization. We know that these patients do experience real pain, but this pain is usually not equal to actual tissue damage.

From the studies that have been done on chronic pain patients using PET scans, it has been found that the homuncular area of the brain devoted to the specific painful area (eg their leg) increases in size the longer the patient has experienced pain in that area.

The brain essentially learns maladaptive coping strategies to deal with the pain experienced by the person.

The stand-out article I remember as being quite groundbreaking was the Alfredson et al (2003) chronic achilles tendonosis protocol. In this article I remember (correct me if I am wrong please) patients actually experiencing pain during their rehab, but then going on have outstanding results with regard to achilles strength and VAS pain levels.

As you mentioned Jon, the article you reviewed “goes against traditional physical therapy philosophy.” This both excites and torments me enormously.

It excites me because perhaps we are moving towards a new frontier in PT treatment and rehab. It torments me because I don’t know how much better or worse we may be making patients when we listen to them telling us they are in pain?

Your review article brings up a couple specific questions for me.

Does tissue damage occur long before perceived pain arises from tendon injuries?

Would the results of this eccentric shoulder article have been similar in the acute and sub-acute phase of rehab?

Perhaps a study looking at modified eccentric training program at the 3 major stages of tissue healing (acute, sub-acute and chronic) would be a very interesting step forward?

Thanks Jon

Jonathan,
I like the work you have been doing on the PT project! I always enjoy chatting with you about clinic related matters too when I have been invited as a guest speaker at New York PT. I would also like to say that incorporating any of the results found from this pilot study may have catastrophic effects on rotator cuff integrity. While Alfredson (4th author) has done some great work with tendinopathies specifically related to the achilles and patellar tendon we know better than to give the empty can as an intervention. Mike Reinold drives this point home as well…check out his website if possible. Furthermore, if one considers that torque = force x perpindicular distance then the torque about the glenohumeral joint is tremendous and may increase the risk of sustaining a rotator cuff injury. Very rarely do I incorporate resistance with this action because I find people are quick to kick in the upper trapezius which is the last thing a clinician would want. In closing I must compliment you for choosing an article that presents a very controversial topic. Keep up the good work John and look forward to the next time we get to chat. Happy New Year.

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Excellent stuff.