Weekly Pulse: Reframing Chronic Pain Through the Lens of Physical Therapy

Chronic pain is one of the most urgent and complex challenges in physical therapy. Affecting nearly 50 million adults in the U.S., it accounts for enormous societal costs, significant healthcare utilization, and growing frustration—both for patients and providers. But perhaps the most dangerous misconception we still carry is that chronic pain is merely persistent pain. It’s more than that—it’s a systems-level dysfunction, demanding systems-level thinking.

In this week’s literature roundup, we explore five perspectives that challenge the outdated biomechanical paradigm and offer an integrated path forward. From pain neuroscience education to the therapeutic experience of underserved patients, from neurophysiology to manual therapy, the message is clear: we must evolve, not abandon, our practice.

Monday: The Promise—and Pitfalls—of Pain Neuroscience Education

📖 Know Pain, Know Gain? A Perspective on Pain Neuroscience Education in Physical Therapy
Louw et al., 2016
👉 Read it here

Pain Neuroscience Education (PNE) has become a cornerstone of modern chronic pain treatment. It teaches patients how the brain processes pain, why pain doesn’t always equal damage, and how to move beyond fear. Evidence suggests it can reduce catastrophizing, improve function, and even lower post-op healthcare costs (Louw et al., 2016).

But there’s a catch: it must lead to behavior change, not just insight. The authors caution against presenting PNE as a standalone intervention. Real outcomes are achieved when it’s paired with graded exercise, pacing, and manual therapy. If we treat pain education as a lecture rather than a lived process, we risk repeating the errors of previous models: strong in theory, weak in practice.

Tuesday: What Underserved Patients Can Teach Us About Healing

📖 Beyond the Pain: A Qualitative Study Exploring the Physical Therapy Experience in Underserved Adults with Chronic Low Back Pain
Joyce et al., 2023
👉 Read it here

Too often, we study interventions in controlled, idealized settings. But real healing happens in messy, complex contexts—especially for patients who have been historically marginalized. Joyce et al. (2023) interviewed low-income, racially diverse adults receiving PT for chronic low back pain. Their stories underscore the power of PT to create empowerment through movement, education, and community.

Patients reported improved function and mood—even when pain remained. They credited strong therapeutic alliances, encouragement from peers, and the feeling of being seen and heard. These findings align with Bandura’s self-efficacy theory and highlight that PT isn’t just about protocols. It’s about people, relationships, and belief in recovery.

Wednesday: Central Sensitization, Mechanism-Based Care, and Clinical Clarity

📖 Mechanisms of Chronic Pain – Key Considerations for Appropriate Physical Therapy Management
Courtney et al., 2017
👉 Read it here

The transition from acute to chronic pain is not just a matter of duration—it reflects deeper changes in the nervous system. Courtney et al. (2017) provide a roadmap for understanding and identifying central sensitization, the process where the brain and spinal cord amplify pain signals, often without ongoing tissue damage.

They outline how quantitative sensory testing (QST)—like pressure pain thresholds and conditioned pain modulation—can help clinicians discern peripheral from central mechanisms. This matters, because the choice between aerobic exercise, isometrics, manual therapy, or education should depend on the dominant pain mechanism.

The article calls for a multimodal, patient-centered approach: one that incorporates psychological, social, and lifestyle factors as much as structural assessment. For clinicians, the takeaway is simple but profound: treat the person, not just the part.

Thursday: Toward an Integrated Understanding—Pain With Movement

📖 Toward a Transformed Understanding: From Pain and Movement to Pain With Movement
Butera et al., 2016
👉 Read it here

Historically, pain and movement have been treated as separate variables. But in chronic pain, they are inseparably linked. Butera, Fox, and George (2016) propose a transformative idea: stop thinking about “pain and movement,” and start seeing it as “pain with movement.”

Their model integrates sensory, psychological, and motor domains to explain how pain reshapes movement, and how maladaptive movement, in turn, sustains pain. Over time, this loop can mask the original injury and instead reflect changes in the central nervous system.

This has major implications for assessment and treatment. We must move beyond tissue-based impairments and examine movement as behavior. Is the guarding we see due to instability, or learned fear? Is the rigidity in movement compensatory, or protective? Their framework supports individualized, neuroscience-informed rehabilitation—a north star for the movement system expert.

Friday: Manual Therapy Reimagined—Context, Connection, and Complexity

📖 Manual Physical Therapy for Chronic Pain: The Complex Whole Is Greater Than the Sum of Its Parts
Coronado & Bialosky, 2017
👉 Read it here

Manual therapy often gets caught in the debate between hands-on and hands-off care. But Coronado and Bialosky (2017) argue we’re asking the wrong question. The issue isn’t whether manual therapy works, it’s how and why it works.

They suggest that its value lies not only in mechanical effects, but in the interaction of biological, psychological, and contextual variables. Expectations, therapeutic alliance, and cultural resonance can all shape outcomes. When paired with adjuncts like pain education or mindfulness, manual therapy becomes more than a technique, it becomes a relational, mechanism-informed intervention.

Their call to action is clear: ditch reductionism. Embrace complexity. Respect the human experience. That’s where healing happens.

Final Thoughts: A Weekly Reflection

Across these five articles, a shared truth emerges: chronic pain is not a diagnosis, it’s a dynamic state of the nervous system, the body, and the person.

To address it, physical therapists must evolve:

• From pain reduction to function restoration

• From tissue models to mechanism-informed frameworks

• From technique delivery to relational, contextual care

• From isolated education to integrated behavior change

In a healthcare system increasingly driven by volume, speed, and fragmentation, we must defend what makes physical therapy uniquely valuable: the ability to deliver whole-person care that adapts to complexity rather than avoids it.

As we look ahead, let this be a rallying point, not only for clinical care, but for how we design education, implement technology, and define our profession’s future.

References

1. Louw, A., Puentedura, E. J., Zimney, K., & Schmidt, S. (2016). Know pain, know gain? A perspective on pain neuroscience education in physical therapy. Journal of Orthopaedic & Sports Physical Therapy, 46(3), 131–134. https://doi.org/10.2519/jospt.2016.0602

2. Joyce, C., Keysor, J., Stevans, J., Ready, K., Roseen, E. J., & Saper, R. B. (2023). Beyond the pain: A qualitative study exploring the physical therapy experience in underserved adults with chronic low back pain. Physiotherapy Theory and Practice, 39(4), 803–813. https://doi.org/10.1080/09593985.2022.2029650

3. Courtney, C. A., Fernández-de-las-Peñas, C., & Bond, S. (2017). Mechanisms of chronic pain–key considerations for appropriate physical therapy management. Journal of Manual & Manipulative Therapy, 25(3), 118–127. https://doi.org/10.1080/10669817.2017.1300397

4. Butera, K. A., Fox, E. J., & George, S. Z. (2016). Toward a transformed understanding: From pain and movement to pain with movement. Physical Therapy, 96(10), 1503–1507. https://doi.org/10.2522/ptj.20160211

5. Coronado, R. A., & Bialosky, J. E. (2017). Manual physical therapy for chronic pain: The complex whole is greater than the sum of its parts. Journal of Manual & Manipulative Therapy, 25(3), 115–117. https://doi.org/10.1080/10669817.2017.1309344