A Note To The Musculoskeletal Physiotherapist
A Note To The Musculoskeletal Physiotherapist
A Note To The Musculoskeletal Physiotherapist
DOI 10.3233/BMR-2012-0317
IOS Press
Abstract. Musculoskeletal (formerly manipulative) physiotherapy is widely used for the rehabilitation of patients with common
musculoskeletal pain and related disability. As part of its progress from largely empirical beginnings to becoming basic sciences
informed this sub-specialty of the physiotherapy profession has developed a profound interest in pain mechanisms, causal and
therapeutic. It is of some concern, however, that the use of pain terminology and classication among the fraternity has tended to
be typically idiosyncratic and at times inaccurate. This is not only confusing to followers of the wider medical science literature.
It also compromises clear communication between the physiotherapist and fellow orthodox health care professionals. This ‘note’
restates the acknowledged pain terminology and its applicability to recognised pain categories.
ISSN 1053-8127/12/$27.50 2012 – IOS Press and the authors. All rights reserved
104 M. Zusman / A note to the musculoskeletal physiotherapist
sation, without any identiable peripheral pathology is inammatory pain presentations at the clinical level has
also seen with so-called ‘functional’ pain (see below). proved more difcult than expected [31]. This is a
Central sensitisation is not synonymous with ‘central matter of concern not just to the MPT but universally.
pain’; this refers to pain-producing pathology of the Sufce it to say that denitive criteria have yet to be
central nervous system, for instance stroke, spinal cord fully agreed upon [32–35].
damage, multiple sclerosis [21]. Probably the best the MPT can do at this time is
to determine rstly whether the history is indicative
of nerve damage – for example trauma (knife wound,
5. Neuropathic pain surgery), vascular (diabetes), viral (post-herpetic), neo-
plastic (disease, treatment). Then determine that the
Now often termed ‘true’ neuropathic pain due to past pain and (any) sensory decits are more or less con-
confusion as to its nature, neuropathic pain is current- ned to the innervation territory of the lesioned nerve
ly dened as “pain arising as a direct consequence of or nerve root using ‘bedside’ sensory testing, and ques-
a lesion or disease affecting the somatosensory sys- tionnaire [31,32,36,37].
tem” [22]. Thus with peripheral neuropathic pain it Allowing for the occasional innervation territory
is necessary for there to be adequate peripheral axon- overlap (due for instance to anatomical aberration or
al/fascicular damage. central sensitisation), all in all the two together can be
At least initially, peripheral ‘sensitisation’ with neu- thought to be reasonably supportive of a positive di-
ropathic pain consists of the creation of neuronal sites agnosis. Ideally were this to also be backed by neu-
of ectopic nerve impulse generation [23]. Such sites roimaging or neurophysiological investigations such as
may occur at various locations on both damaged and nerve conduction studies, laser-evoked potentials or
undamaged large as well as small diameter peripheral nerve biopsy examination then the conclusion would
afferents. They discharge spontaneously, and are also then be much more denitive [21].
susceptible to the full range of naturally occurring me-
chanical, thermal and pathological chemical/immune
system stimuli [24,25]. 6. Functional pain
Impulses so produced enter the central nervous sys-
tem and initiate central sensitisation in much the same This title refers to a group of widespread and also
way as with inammatory pain. This probably also regional chronic pain conditions for which currently no
involves a signicant contribution from glia [26,27]. initiating peripheral pathology can be detected [19,38].
There is however an additional critical clinically signif- Logical treatment therefore is mainly directed towards
icant entity with respect to central sensitisation for neu- the central nervous system.
ropathic pain that should be noted by the MPT. This is The list includes bromyalgia, temporomandibu-
a lasting concerted disablement of certain components lar joint disorder, tension-type headache, non-cardiac
of in-built pain inhibitory systems [24,28]. Physiolog- chest pain, the pain of chronic fatigue and irritable bow-
ical and anatomical changes affecting mechanisms of el syndromes, ‘functional’ abdominal pain, interstitial
endogenous pain inhibition following peripheral nerve cystitis and vulvodynia [19,38]. The role of the MPT
damage render many common methods for the induc- with such syndromes is not clear. While the mainstay
tion of pain relief only partially effective/ineffective. treatment is frequently cognitive behavioural therapy,
Thus even with the best available science-based re- some of these patients may benet from physical treat-
sources the current management of the symptoms (let ments, including an active ‘exercise’ component, in a
alone the pathology) of true neuropathic pain is less multidisciplinary pain management setting. Whether
than satisfactory [29,30]. At the present time, from pain is widespread or regional what seems to be evident
the basic sciences (and clinical) evidence it is difcult with such cases is their rather generalised hypersensi-
to see how true neuropathic pain might be effectively tivity to various evoked stimuli, sometimes referred to
reduced by additional mechanical stimuli. as (indicative of) ‘central sensitisation’.
Given that there may be some degree of overlap, Central sensitisation – at least in the experimen-
discriminating between predominantly neuropathic and tal setting – denotes a peripheral nociceptive activity-
106 M. Zusman / A note to the musculoskeletal physiotherapist
initiated increase in the excitability of spinal dorsal clinical pain presentation and its attempted classica-
horn neurones [39]. The peripheral activity- (and later tion particularly in relation to ‘manual diagnosis’. It is
transcription-) dependent increases in the excitability hoped that together these will help inform MPT’s clini-
of dorsal horn neurones results in their expanding their cal reasoning and decision-making process and smooth
receptive elds, and responding to subsequent stim- the way for mutual understanding with fellow orthodox
uli/incoming information in an exaggerated and ‘ab- health care professionals.
normal’ manner. Clinically this manifests as patients
heightened perception of peripheral mechanical stim-
uli applied to normal tissue surrounding the patho- References
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