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Steven: I think we need to be careful to avoid “throwing out the baby with the bath water”, particularly in our patients with acute or post-op conditions. It is still necessary to query and examine for red flags and I think it is still appropriate to fall back on some of your basic biologic and hystologic knowledge regarding stages of healing and expected healing times for specific tissues (think about deep aching pain in a patient that is 4 weeks post fracture). It seems to me that the appropriate place for PNE in this situation is to begin educating the patient regarding the expected trajectory of their symptoms and to be equipped to recognize when a patient is beginning to experience pain that is not in proportion to their injury or is lasting longer than expected.
One concept that I found very interesting was the idea of progressing the patients “load” in every aspect of the biopsychosocial model. He pointed out that we are very good as PTs about progressing mechanical load, but that we tend to neglect advancement of psychological load or biologic load when prescribing and progressing our interventions. The examples that he gave were having the patient do the exercise while they are thinking about being on an important conference call (psychologic load) or after they have eaten a large meal (biologic load). Has anyone tried intentionally altering these variables with their patients with chronic pain and if so, how did they respond?