To do, or not to do Pain Science, that is the Question with Dr. Jason Silvernail, DPT

To-do-or-not-to do_

Through my work promoting Science, Science-Based Medicine and Modern Pain Science, I have for the last three years, been fortunate to have the opportunity to participate in a small closed group with International Pain Expert Dr. Jason Silvernail (DPT, DSc) and a few other experts.

Dr. Jason Silvernail is a Doctor of Physical Therapy, a Board-Certified in Orthopedic Physical Therapy, Fellowship-Trained in Manual Therapy, and a Certified Strength and Conditioning Specialist (CSCS), and a physiotherapist in the United States Army.

He is also a Moderator at SomaSimple. The SomaSimple forums are one of the best resources and debate groups (if not the best) for health professional who works with chronic pain clients. SomaSimple is a group of internet forums for science-minded physical therapists, osteopaths, chiropractors, massage therapists, personal trainers and manual therapists.

This weekend I just learned that Dr. Silvernail mentioned me in his lecture at the San Diego Pain Summit. Regarding the notion of internal vs external critical thinking, in the part of his lecture, where he was talking about not to worry about winning arguments, but to focus on internal critical thinking skills. I have talked quite extensively about the topic (of internal vs external critical thinking) with him, and I have learned a great deal from listening carefully to his wise words.

It is a huge honor, to be mentioned by Dr. Silvernail, I have learned so much from Dr. Jason Silvernail and continue to do. I am forever grateful to Dr. Silvernail for taking me under his wing, so to say.  So a way to show my gratitude for the huge help Dr. Silvernail has been to me, I would like to dedicate a blog to him, and share some of the quotes that I have collected from Dr. Silvernail.

The views expressed by Dr. Jason Silvernail here are his personal opinions and do not reflect the official policy or position of the United States Army, the Department of Defense, or the United States Government.

Without further ado, here are some 34 quotes from Dr. Silvernail:

“Pain is a perception. It is a judgment your mind makes after taking in all possible factors. Danger messages from your body tissues (called ‘nociception’) are a sensations, it is only one piece of information that your mind uses in making its judgment about pain. Vision is another perception. Ever seen an optical illusion? The sensation is the signal from your eye to your brain, seeing the pattern in the illusion is the perception.” Jason Silvernail, DPT

“When will we get over this constant search for holy grail therapy targets in the body? When will we run out of tissues to build castles of sand, dogma, gurus, and money out of? When will people realize the basic facts of pain perception and pain physiology? To treat painful problems, our target is and always has been the nervous system.

Some days I just get so tired of people trying to convince each other of the supreme relevance of some connective tissue they are all excited about.

Enough is enough already.” Dr. Jason Silvernail, DPT

“We need to collectively get over this pointless speculation about fascial restrictions, joint positioning, and trigger points. If people want to handle or treat their patients in ways traditionally associated with these methods, that’s fine. But keep the neuroscience of pain at the forefront, pay attention to the great research coming out on manual therapy mechanisms, and for crying out loud don’t give patients a giant nocebo by telling them they have fascia restrictions, inhibited muscles, or joints out of place.

Because then I have to explain to them that that’s not accurate. And that’s exhausting. It’s less about what you do and its more about how you explain it to patients and colleagues. You can explain it like a science-based practitioner or you can make up a story.

Frankly, I’m tired of correcting the messes people make by transmitting these ideas to patients about pain and function that don’t have any relation to modern pain science.” Dr. Jason Silvernail, DPT

“People who agree with you don’t make you better.” Dr. Jason Silvernail, DPT

“We are especially prone to cognitive errors when we deal with things we have an emotional attachment to one way or another” Dr. Jason Silvernail, DPT

“The 3 Stages of Recovery from Pain: Ever stubbed your toe? Bumped your funny bone? Twisted your ankle? If so, then you know all about the stages of recovery from pain. Read along, and keep your last injury in mind for comparison. When you experience pain, your nervous system goes through three separate stages. You move through these stages every time you have pain, without exception, as long as you are alive. These stages are: 1. Withdrawal 2. Protection 3. Resolution” Dr. Jason Silvernail, DPT

“The biggest take home message that I’d like people to be aware of is that pain is like vision – it’s a perception or judgment of what’s happening not a 100% accurate reflection of reality. Just as your eyes can fool you when you are seeing in low light or looking at an optical illusion, so can your pain processing system fool you when you have a pain problem.

There are many factors that can affect someone’s pain, and the severity of the pain does not necessarily mean there is a serious physical injury. The more people learn about how pain works, the better informed they can be in making accurate judgments on how to manage it – and finding a trusted source in the fitness and medical community to help them is very important. “ Dr. Jason Silvernail, DPT

“You need a critical thinking process to everything you do. Learning cognitive biases and common errors of thinking and rigorously applying them to what you do every day in every way. This takes an investment in time and effort and an intellectual commitment to humility and honesty.

I am interested in applying this to what I do, I am much less interested in seeing people apply these concepts to win debates or to score points in arguments – though there is a role for that as well. It must be a personal commitment to self-examination and change.”  Dr. Jason Silvernail, DPT

“You really need to limit your claims to just what you can defend with published evidence. Saying one approach is better than another, or one approach is effective for this or that is a specific claim that needs to be backed up with a specific citation of a scientific paper that actually matches what you are claiming. I have seen all kinds of different people make this mistake over the years.

If you don’t have a good paper to justify your claim, just be honest and label it as your opinion or experience. Nothing wrong with expert opinion as long as it is humble, open to challenge, and announced as merely a perspective. Be honest with yourself, use claims and testimonials responsibly, and you’d be surprised what that process will teach you about yourself.” Dr. Jason Silvernail, DPT

“The existing evidence in physical medicine does not show any clear value of static postural assessment either in prediction or treatment. If such a claim is made, appropriate evidence to support it must be provided” Dr. Jason Silvernail, DPT

“I think the big concept in understanding the origin of pain is recognizing the difference between a ‘Sensation’ and a ‘Perception’. A sensation is just a nerve impulse, a piece of information without a lot of processing involved. An example is a warning light in your car – it’s either lit or it isn’t. A ‘check engine’ light could represent a range of issues but by itself it only tells you one thing: a yes or no. A perception involves processing and thinking.

If you see your check engine light and you know your car has a problem with the sensor and the engine is fine, you have added processing and thinking and you make a judgment about that – your judgment is that your engine sensor is off. Now if the light came on and you could smell a burning smell in the engine, you would have a different perception, or judgment, about that check engine light. Your perception would be that you have a problem with your car and you better pull over! “  Dr. Jason Silvernail, DPT

“The body is a wonderfully self-corrective machine” Dr. Jason Silvernail, DPT

“Every time pain science gets discussed there are always people who push back and it’s nearly always, acknowledged or not, the straw man of “biomechanics doesn’t matter.” No one has said that biomechanics doesn’t matter. Mechanical origin pain by its nature is biomechanical and the concepts of neurodynamics are also.

The problem is that people have been trained to think things like pelvic tilt and core weakness and short muscles are significant biomechanical problems that must be creating a large nociceptive drive that therefore pain science discussions ignore nociceptive pain. But we need to put biomechanics “in its place” not “out of our mind” when thinking about pain.

We need to start to question closely our clinical reasoning processes and realize that not every impairment to movement or function is equally contributing to a pain experience, and many may be irrelevant. We discover which ones are relevant and worth correcting through a systematic assessment and reasoning process – two of the most common and most supported by randomized trials are the McKenzie MDT system and the Maitland manual therapy system.

What we don’t do is assume every kind of positional, movement, muscle length or strength, nerve mobility, or joint accessory movement impairment is contributing nociceptive drive.

And that they all need to be addressed and that acknowledging the published research evidence that many of these impairments are normal findings unrelated to the pain experience is somehow ‘ignoring biomechanics’. It’s a testament to how indoctrinated people are into the biomedical model that their concept of pain begins and ends with their ability to find things to blame and fix in the patients body.

I for one won’t apologize for trying to move people in the fitness and rehabilitation world away from such a simplistic, practitioner-centered, outdated view to a more complex, patient-centered, and modern view of the pain experience.

If people want to say that means ignoring biomechanics we will just have to keep pointing out this strawman argument when we see it – but I am really sick to death of this particular canned response. ” Jason Silvernail, DPT

“Most people who have a persistent pain problem are stuck in the protection phase – their system is still trying to protect itself, and it’s not able to move toward resolving the problem. When you’re stuck in the protection phase you may feel stiffness, coldness, and muscle spasm in the area. You may feel as if the body part does not want to move smoothly.” Dr. Jason Silvernail, DPT

“Typical strict biomechanical thinking – classic NASM. It’s was cutting edge stuff in 1978. Now – not so much.” Dr. Jason Silvernail, DPT

“By way of context while we argue about various noninvasive education and activity approaches to pain, there are thousands of spinal fusions and steroid injections given every year in the US. Claims and nocebos are serious in our field but context matters too.” Dr. Jason Slivernail, DPT

“First it was all about joint dysfunctions. Manual therapy was about finding and correcting misalignments and restoring normal position or movement to these dysfunctional segments. Then the research started to come in. Poor reliability between clinicians to find these misalignments. Plenty of “dysfunction” found in the asymptomatic. No valid way to demonstrate them or to connect them to any painful problem or show them changing as a result of treatment” Dr. Jason Silvernail, DPT

“Your APT is probably genetic like my big nose. Embrace it…” Dr. Jason Silvernail, DPT

“We are going to have to agree to disagree on the ‘evidence’ for Dr Sahrmann’s work – perhaps we are going back to the point you made about what is sufficient evidence and I definitely agree that is the issue in this case. When you mention Janda you aren’t really bolstering your position much – there’s even less evidence to support the crossed syndromes than there is some of Sahrmann’s work. When you mention that people followed her based on their anecdotal experience of success then that helps reinforce the points I’ve been making about the issues with anecdotal evidence, popularity in the absence of evidence and problems in clinical reasoning that plague most of musculoskeletal medicine.” Dr. Jason Silvernail, DPT

“In most cases I consider ultrasound less than useless — that’s 8-10 minutes wasted that could be used doing something that might actually help.” Dr. Jason Silvernail, DPT

“Brief manual therapy combined with exercise and self management isn’t by any means particular to Janda which I suspect you’re aware of. Maitland, McKenzie, and many other schools of manual therapy advocate that same approach. Additionally though all these schools of thought began with some theoretical baggage hat turned out to be incorrect there are some that more easily integrate modern pain science into their paradigms than others. In my opinion Janda’s system doesn’t integrate as well and it’s theoretical underpinnings in many ways are unhelpful to recovery for patients.” Dr. Jason Silvernail, DPT

“Alter what you do and why you do it as the evidence changes.” That’s how we trainers and massage therapists grow professionally.” Dr. Jason Silvernail, DPT

“Peripheral treatment is good for a lot of reasons, centrally, that may have little to do with the old ideas we had about titled pelvises, bad posture, and etc. Low threat, well tolerated, exercise and manual therapy can be beneficial on many levels. It’s too bad the majority of the practitioners (by survey data) are stuck in the old models of pain and function that Lars is trying to free them from here…” Dr. Jason Silvernail, DPT

“I wish I had a nickel for everyone who assumed that the statement ‘pain is an output of the brain’ meant that nociception was irrelevant. It’s such motivated reasoning that it is starting to come off as deliberately obtuse to me. Thanks Rod for linking my ground gears on that point. There appears to be no upper level of education or intelligence that is protective against this.

I think I’ll go have some lunch because I’m hungry. Hunger of course is another output of the brain. And of course by saying that I obviously mean my stomach and my need for actual food are completely irrelevant and pointless to even discuss because neuroscience.” Dr. Jason Silvernail, DPT

“His personal experience, regardless of his level of eliteness or whatnot, is still just a story – just an anecdote. Same for any story I might tell you. It shouldn’t be discounted – we should all acknowledge that that is the lowest possible level of evidence regardless of the source. ” Dr. Jason Silvernail, DPT

“Biomechanics has a very questionable relationship with symptoms. Not totally unrelated, but not near as close as many believe.” Dr. Jason Silvernail, DPT

“There’s nobody dumber than a smart man off topic” Dr. Jason Silvernail, DPT

“The depression screening questionnaire is far more beneficial, for me, in determining who has back pain and who doesn’t, history of depression is far more highly correlated in the literature with back pain, than herniated disc” Dr. Jason Silvernail , DPT

“I think we need to do three things here. First, you have to know the basic science, then you have to apply a critical thinking process to everything you do, and third you have to limit your specific claims to the published evidence.”  Dr. Jason Silvernail , DPT

“Factors influencing pain include the danger messages from body tissues (nociception), your body’s level of sensitivity, your past experiences, your thoughts about the problem, your social situation, and a hundred other things. What does that mean practically? It means that the level of pain people feel isn’t necessarily related to any damage to their body – because the perception, the judgment, comes from more than just the body tissues. Most of this processing is below the level of conscious control –it happens in the spinal cord and in the brain areas you don’t have easy access to with your thoughts.”  Dr. Jason Silvernail, DPT

“Gating is one explanation. Patrick Wall said there three phases to move through with pain and that the third one, resolution, had to include movement which was instinctive in nature. I always use the burned hand as a perfect example of Wall’s withdraw-protect-resolve process with patients who seem to be stuck in ‘protect’ mode.

Barrett Dorko uses this principle with the method of management he uses for painful problems that seeks to encourage the expression of this natural instinctive movement for pain relief.” Dr. Jason Silvernail, DPT

“The predictable pattern in pushing back against pain science is the strawman of discounting nociceptive origin pain from acute injury. Yet no one has done that – we just have so conflated these hyper-detailed assessments with nociception that people can’t seem to see the implicit logical leaps they’ve made. Claiming this whole thing boils down to terminology is just a transparent dodge.” Dr. Jason Silvernail, DPT

“I think we are seeing a trend of blogs and articles about pain science from reputable bloggers and practitioners passing on accurate pain science trying to push back against the entire culture of medicine and healthcare that is almost 100% based on outdated biomedical-only concepts of pain and function.

This results in a huge epidemic of pain being treated with chronic narcotics and surgical and interventional procedures which have very limited efficacy but which reimburse well for the providers. This is bankrupting our health care systems while not providing relief for our patients. If you feel that pushing back against this nonsense is old and tired and not necessary then I’m not sure what world you live in” Dr. Jason Silvernail, DPT

“People who don’t sleep well and are under emotional and mental stress are going to have a tougher time recovering from a pain problem. The good news story there is that there are research-based approaches that are available to anyone to help improve sleep quantity and quality and to reduce mental stress. You don’t need to be a medical practitioner to share these approaches with your clients and if you work in medicine you don’t need to be psychologist to do this either.” Dr. Jason Silvernail, DPT

“Posture is not related to pain. As a Physical Therapist I debunk this myth daily. Not only is there no good evidence that posture has anything to do with pain, there’s also no good evidence we can change posture with exercise or training.”  Dr. Jason Silvernail, DPT

“I think clinicians are still pretty far behind the longstanding and robust research that demonstrates the high prevalence of degenerative changes in the asymptomatic. I don’t think a day goes by in the clinic where I don’t have to deal with a frightened or pessimistic patient whose well-meaning but misinformed health care practitioner has convinced them that their imaging results mean their back is damaged or injured. It feeds into the fear and the natural evolution to invasive and surgical care that reimburses well but doesn’t have a good track record in the literature.”  Dr. Jason Silvernail, DPT

“Altered biomechanics is largely speculation and fraught with reliability and validity problems. Speaking of speculation, so are the latest assessment seminars full of determinations of “inhibited this and facilitated that” that are just recycling of old physical medicine ideas from years ago.  No plausibility, no reliability studies, no randomized trials” Dr. Jason Silvernail, DPT

 

Podcasts and articles with Dr. Jason Silvernail:

An Interview With Pain Expert Jason Silvernail (podcast)

Crossing the Chasm with Dr. Jason Silvernail (podcast)

A Primer on Pain with Dr. Jason Silvernail 

Starting conversations – has Jason hit the Silvernail on the head?