In two quick days of Clinical Internship my Clinical Instructor (CI) and I have seen many patients (thankfully and optimally in a 1-on-1 environment!).
Having minimally discussed deep hypothetical and theoretical pain science with my CI, we HAVE touched on the practical presentation of pain in the clinic. The ‘most-bang-for-your-buck’ clinical thought process when confronted with a pain complaint has two major prongs.
The two prongs are irritability and nature.
Irritability has a range of states. Basically you can think high to low. It has to do with how sensitive, jumpy, acute, or consuming the pain is for the patient. This becomes important for both examination and treatment. Therapeutic techniques need to be aimed at calming everything down to a level that will allow both a proper examination and increase the breadth of treatment options to help the patient.
Nature has two main considerations as well (removing environmental and psychosocial influences which are variable in their display). The first is mechanical pain origin the other is chemical pain origin. (OK: really it’s mechanical and chemical nociception). When a patient can move “in or out of pain” with certain positions it leads us to think about mechanical causes. If there is constant pain or pain at rest then we can think about chemical mediators of pain.
The highly irritable patient (and I don’t mean personality) often has both… or even more chemical pain which precludes finding the mechanical triggers. Think lots of inflammation and swelling with a Total Knee Arthroscopy: The chemical pain and swelling can be worse than the mechanical insult, and only once those prostaglandins and IL-6s and substance-P molecules are flushed out can you work on easing the biomedical nociception. When taking ROM for example, you get stopped way short of mechanical end range due to pain. This makes sense.
I enjoyed this practical and easy-to-digest approach of looking at pain presentation. My cerebral interests are still clearly in the Therapeutic Alliance, placebo/nocebo, therapeutic environmental context, nueromaticies and touch, etc and I know that these play a large role in treating patients. That being said, the above system of looking at pain (from Maitland) proves quite useful when a patient is 4 feet away from you looking for answers.
Experience is a great platform from which to think.
– Matt D