December 28, 2016

Why Look At Other Joints? Limitations With Narrowed PT Treatments

Author: Maggie Henjum


Areas that seem more underdeveloped are other concepts discussed around RI:11 biopsychosocial, somatovisceral or neurophysiological.

As we know, biosychosocial model correlates patients’ social and psychological outlook with biological findings.  Thus, how does RI incorporate with this thinking? I think some of the more “heavy hitter” literature lies outside of our field. Stress is a large topic of this area, a 2012 study surveyed 186 million US adults about stress. Thirty percent thought that stress affected their health a lot or to some extent. Interestingly enough, the patients who had a PERCEPTION that stress is detrimental to their health had pre-mature death.1 Again, a meta-analysis of perceived health and heart disease was correlated to patients who perceived stress was correlated to CHD – not stress in isolation.2 We translate this into our world with active vs. passive coping or pain behaviors. Patients who expect prolonged disability or pain (as determined with Revised Illness Perception Questionnaire), or perceived serious outcomes, and who felt out of control with their pain have been shown to match their expectations and have poor outcomes.3 Self fulfilling prophecy in some aspects, thus the continued importance for setting expectations and encouraging recovery of perceived perceptions and dysfunction. This is not an original correlation – this has been thrown around on the blogosphere and web discussions multiple times. The common topic of, what if we approach pain as manageable and match patient perception of their treatment – would they improve regardless of treatment?

Next, somatovisceral symptoms are of interest within RI discussion. This area is probably underdeveloped within literature. A review by Sengupta about visceral pain was an interesting read to brush up on this concept. It describes this issue as a complex one due to sexual dimorphism, psychological stress, genetic trait, and the nature of predisposed disease.7They described this pretty spot on with the following discussion: “(1) sensitization of primary sensory afferents innervating the viscera, (2) hyperexcitability of spinal ascending neurons (central sensitization) receiving synaptic input from the viscera, and (3) dysregulation of descending pathways that modulate spinal nociceptive transmission.”7 This is an interesting article, only 40 pages long – check it out. Numerous examples exist – probably the most interesting one to me is T4 syndrome. Clinical features of this condition is: glove like paresthesias, along with headaches and stiffness of upper thoracic spine.4  As described by Dr. Mintken, T4 has intricacies with sympathetic nervous system that may refer symptoms to the extremities.6 Thus manual treatments at T4 have been shown to reduce distal symptoms – with an uncorrelated dermatomal explanation. RI is a must with this patient, if we look at their physical examination we may miss the driving cause.

Lastly, neurophysiological is discussed this week. The nervous system is a complex creature. We had an excellent discussion surrounding this during a last week’s upper extremity course with Dr. Fearon. Discussion driven from nerve tensioning, and sliders and what we are doing with this approach. Questions arose if we are changing the container or are we moving neural tissue to stimulate some neuro-response and why this is not understood. Neurophysiological understanding of pain science is vast and complex. Although this seems to touch into our drive for patient care – manual therapy. This discussion has been evoked numerous times during this class. What are we completing with manual, adjusting a pain cycle, or fixing a dysfunction – to be determined. If we are looking to change neurophysiological response then a hypoalgesia response may be of interest. Manual therapy has been found to complete a hypoalgesia affect in the lower extremity following lumbar manipulation and in the elbow following cervical mobilization.8,9

Whatever the reason for RI from a musucloskeletal, neurophysiological, somatovisceral or biosychosocial model – or a combination of a few reasons – RI can be affective for patient and therapist. The biggest downfall to RI approach is that it can be overwhelming – but very effective anecdotally. I think looking at the patient’s movement patterns, and adjusting these by tapping into them with a myriad of treatments is the best approach. Unfortunately, idiosyncrasies to each patient drives different rationales and approach – thus why RI approach may take flexibility, focus, and furious persistence.


Original post: October 14, 2013



1)      Keller A, LItzelman K, Witt WP. Does the Perception that Stress Affects Health Matter? The Association with Health and Mortality. Health Psychological. 2012. 31(5): 677-684.

2)      Richardson S, Shaffer JA, Falzon L, Krupka D, Davidson KW, Edmondson D. Meta-Analysis of Perceived Stress and Its Association With Incident Coronary Heart Disease.  American Journal of Cardiology. 2012. 110: 1111-1117.

3)      Foster NE, Bishop A, Thomas E, Main C, Horne R,  Weinman J, Hay Elaine. Illness perceptions of low back pain patients in primary care: What are they, do they change and are they associated with outcome? Pain. 2008; 177-189.

4)      DeFranca GG, Levine LF. The T4 Syndrome. J Manipulative Physiol Ther. 1995 Jan;18(1):34-7.

5)      Mellick and Mellick. Journal of Manipulative Physiological Therapy. 2006; 29: 403-408.

6)      Lecture by Paul Mintken. October of 2013. EIM

7)      Jyoti N. Sengupta. Visceral Pain: The Neurophysiological Mechanism. Handbook Exp Pharm. 2009; 194; 31-74.

8)      Vicenzino B, Collins D, Benson H, Wright A. An investigation of the interrelationship between manipulative therapy-induced hypoalgesia and sympathoexcitation. J Manipulative Physiol Ther. 1998;21:448-453.

9)      George SZ, Bishop MD, Bialosky JE, Zeppieri G, Jr., Robinson ME. Immediate effects of spinal manipu lation on thermal pain sensitivity: an experimental study.BMC Musculoskelet Disord.2006;7:68.

10)   Strunce JB, Walker MJ, Boyles RE, Young BA. The Immediate Effects of Thoracic Spine and Rib Manipulation on Subjects with Primary Complaints of Shoulder Pain.  Pain, 17(4), 1–7

11)   Lecture by Dr. Wainner. October of 2013. EIM