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PAIN: Victim or Culprit?

PAIN: Victim or Culprit?

My last blog gave an introduction to pain management through Mechanical Diagnosis and Therapy (MDT) by Robin McKenzie. However, for the effective management of pain, it is crucial to understand and interpret the pain. Patients should be able to identify the type of pain and quantify their pain for the clinician to identify the root cause of pain rather treating them symptomatically.

Pain, being very subjective makes it tasking to explain or describe.The best definition of pain thus far is one by Merskey (1975) who defined ‘Pain as an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage’. Yes, pain is not a mere physical sensation. Numerous factors like attitude, beliefs, personality and social factors influence pain which in turn affects mental and physical well being.

Only three mechanisms are known that can activate pain – thermal, mechanical and chemical (Bogduk, 1993). The human body has no specialized receptors exclusively designed to detect pain like receptors for touch, temperature, pressure or vibration. When the intensity of any of those sensations exceed the normal threshold, the body detects them as painful or noxious. For instance, when someone holds your hands for a shake hand, you feel the firm hold as pressure and touch receptors are activated. But when the person tries to intensify their hold, you perceive that sensation to be painful as the pressure receptors have activated and they have crossed their threshold. The body identifies that sensation as harmful and detrimental, and elicits the normal response to avoid it by withdrawing from the hand shake. Meanwhile, the brain creates an ‘engram’ of the event that seeing that person again we are forewarned of the past unpleasant encounter leading to avoidance of a handshake with that person. This is exactly what happens when a person finds a particular activity painful and tries to avoid that or any similar type of activities because of pain generation.This is called ‘fear avoidance’.

Similarly, when you sustain an injury the body initiates an inflammatory response to repair that area. But, allowing the body to go through it’s normal course of action towards healing,  compromises certain functions. This untreated inflammatory process becomes chronic forcing our body to adapt to it. Within few weeks, you notice certain limitations in activities you have normally done before. Every attempt at certain activities which were quite natural to you is now limited by pain. The undue stretch in the adaptive shortening of the surrounding tissue and the scar tissue from the actual injury itself causes pain. Fear of pain and re-injury may lead to avoidance of activities that are believed to be harmful. This leads patients to restrict their movements and withdraw from their normal life style. Reproduction of pain leaves victims with exaggerated fear of it, and hypervigilance to each and every discomfort. Such fear avoidance will result in adaptive changes in the surrounding tissues which further contribute to pain that in chronicity lead to disability (McKenzie 2003) .

A clinician trained in Mechanical Diagnosis and Therapy can intervene in any stage in the above mentioned cascade of events and determine the necessary corrective movements to restore the lost function. The physical therapy evaluation and following treatments are the start of an investigation where pain is the ‘victim’ and the search is for the ‘culprit’ to resolve the problem at its root. The treatment is based on loading the tissues at fault in a progressive manner to observe its response to those loading strategies. Once the direction of movement alleviating symptoms or pain is determined, patients have a huge responsibility in their own recovery. They are taking charge of loading those faulty tissues in the prescribed manner based on the ongoing evaluation findings to remodel and restore the lost functions. When the cause of pain is mechanical – they need to be treated mechanically through direction specific exercises and movements. When the cause is from inflammation which only last for 7-10 days they need to be treated chemically, with the help of drugs. Attempts to treat a mechanical pain with the help of drugs is deceiving the brain.

My upcoming blogs will explain in depth the treatment strategies involved in MDT. The beauty of these techniques are that patients have an active role in their recovery and once the ‘culprit’ is caught they don’t have to depend on the clinician in managing and preventing their pain. Unlike other treatments where patients run to clinicians seeking relief, here patients are in the driver’s seat cruising the road to recovery.

Sinju Thomas PT, DPT, OCS 
CEO & Senior Physical Therapist


1.  Merskey H (1975). Pain terms: a list with definitions and notes on usage. Pain 6.249-252

2.  Bogduk N (1993). The anatomy and physiology of nociception. In: Eds Crosbie J, McConnell J. Key Issues in Musculoskeletal Physiotherapy. Butterworth-Heineman, Oxford

3. McKenzie R, May S (2003). The Lumbar Spine Mechanical Diagnosis & Therapy.Volume 1. Spinal Publications New Zealand Ltd, Waikanae, New Zealand.

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