“Pain Provocation Testing Provides Relief for Cervical Pain? A Pain Neuroscience Perspective”
Monday, 20 June 2016
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In PT school, we are all taught special tests to rule in/out specific tissue pathology or to find pain generators. We were taught that if these tests were positive you could be sure about what biomechanical issue you were dealing with, and if they were negative you could move on from that diagnosis as the target tissues didn’t elicit pain. The more I practice and learn about current pain neuroscience, I find that these tests can be significantly flawed or at times contraindicated for multiple reasons.
When it comes to neck and arm pain, there is a clinical prediction rule for the diagnosis of cervical radiculopathy by Wainner, et al that has been validated and is based on 3 special tests (Spurling’s, Distraction, ULTT 1 median nerve bias) and 1 ROM assessment (C spine rotation less than 60 deg).1 One of those tests is the Spurling’s maneuver.
— Spurling’s Test (reproduction of symptoms)
¡ Sensitivity 30% Specificity 93%
— Distraction Test (resolution of symptoms)
¡ Sensitivity 44% Specificity 90%
— ULTT (reproduction of symptoms)
¡ Sensitivity 97% Specificity 22%
— Cervical Rotation < 60 deg
Wainner et al found a 99% specificity and (+) likelihood ratio of 30.3 when patient was positive for all aspects of the above cluster. But is this really always the case? Let’s get into the good stuff. A younger patient walked into my clinic who had neck and arm pain and a referring diagnosis of cervical radiculopathy. She is experiencing an acute exacerbation from a 9 month history of neck pain. The patient reports “my MRI says I have bulging discs in my neck and they are likely contributing to my pain.” The pain was so severe that she even went to the ER 2.5 weeks ago. She explained that she has never had PT, so being the biomechanical expert I am, I let her know that today was a day to find the pain generating tissue and light her up in order to know what the cause of her pain was…. Just kidding.
I make sure to let all my patients that day 1 is to get a baseline of their current level of function without significantly increasing their pain. In fact, I aim to do the opposite of what they perceive PT to be (pain and torture.. no pain, no gain). The real goal of the evaluation is to identify strategies to alleviate their pain, to educate them on their pain, and to decrease their fear/concerns.
While performing a thorough exam I get to the oh-so special tests, and of course, I perform cervical compression and Spurling’s test, seated and supine. During this PAIN PROVOCATION TEST she indicates that it feels really good and alleviates her pain. How could this be? How could a pain inducing test feel good to this patient who MRI confirmed disc herniations and radicular symptoms? There was a short period when I was just out of school that I thought the patient was lying, malingering, or BS’ing, and even though it felt good to them, I would refuse to do it because it didn’t make sense to me and there was no way in hell it should feel better if I was “compressing” their spine/bulging discs that it would alleviate their pain. I used to scratch my head when this happened, or I used to challenge the patient as to why this could possible feel better…but that was then, and this is now.
Instead of talking about how this can’t be true, we could instead talk about how it could. Did you know that there are specific areas in our brain that have neuronal maps of our body parts? These areas account for our “body schema” or body related self-visual cortical representations. They are a mini me in our brain. For example, this is how when we close our eyes, we are able to touch our fingertip to our nose or lift up our left hand when asked. Do you remember the somatosensory homunculus…
You might be thinking, “sorry guy, I did an information dump after the boards, I treat an orthopedic population, and I do not treat neuro patients…” Now that is BS. We all treat PEOPLE, PEOPLE with a NERVOUS SYSTEM. Now, what if I told you that when we are in pain, these maps can become less clear (smudged or disrupted). What if I told you, the less we use our body, the less we move, the less clear these maps become. Contrary to popular belief, it actually is true that if you don’t use it, you lose it. This is a function of neuroplasticity.2-3
What if I told you when we exercise patients we are likely sharpening the maps. What if I told you when we do patellar taping on people we are not correcting any malalignment, but instead we are actually improving neural feedback and proprioception4. These paired inputs are likely sharpening the cortical maps. What if I told you that when we perform joint mobilizations we aren’t lengthening tissues, but we are in fact providing a stimulus that helps reduce peripheral sensitization subsequently decreasing threat and sharpening these maps. What if I told you that the more clear and “crisp” these maps are, the better our body schema or self-visual representation is, and consequently the less pain we might experience.2-3
So back to cervical compression and Spurling’s. What if I told you that when we perform these maneuvers we are applying a novel stimulus that decreases threat through joint approximation by increasing afferent input to proprioceptive centers in the brain which can in turn can sharpen cortical maps and subsequently reduce pain. I think you can see how this might be a better explanation for this phenomena as compared to the former reaction I had of labeling the patient as a malingerer and accusing them of magnifying their pain. Maybe the next time you perform this test and get this response, you do the opposite of what I used to do and actually utilize this as a treatment option to modulate pain. You can also take the opportunity to de-emphasize biomedical models and educate your patient on how their bulging disc might not be the cause of their pain.
At the end of the day, do not forget we are living organisms with a functioning nervous system and that the body perceives what the brain sees. If the body schema or the maps are unclear or altered, then the individual will likely experience pain and poor quality movement. If you sharpen the maps, you can reduce pain, even if you are compressing or pressing down on someone’s neck.
What the brain "sees" is reality for each individual. Sometimes patients may present in a non-traditional manner, or even opposite of what you expect based on the "textbook". This doesn't mean that their pain is any less real than those patients that follow normal patterns. They likely aren't making it up, and maybe it's you who needs to change your examining lens. Having a working knowledge of therapeutic neuroscience education (TNE) regarding pain is imperative for crossing the chasm between what "should be" and what often is.
Dr. Lopez graduated from the University of Texas El Paso in 2012. He then completed an orthopedic residency program at the University of Texas Southwestern Medical Center in 2014 and is currently completing International Spine and Pain Institute’s Therapeutic Pain Specialist (TPS) certification. He presented at the Texas Physical Therapy Association Annual Conference in 2013 and 2014 on the efficacy of utilizing pain neuroscience education in patient care and methods to improve the therapeutic alliance through optimizing contextual effects. He currently resides in Dallas, Texas where he practices at 3D Physical Therapy, a private practice outpatient clinic.
