Question 1: How Dangerous Is This Pain?

It is self-evident that treatment is more cautiously performed and more closely monitored if the physical condition indicates that there is the potential for continuing damage to the nerve. Where there is a threat to the nerve by mechanical compression or traction, ischemia, disease, or treatment of a systemic pathology, the signs and symptoms that patients report have to be assumed to be nociceptive and indicators of potential existential threats to tissue. As a result, it is important for providers to discern the differences between those signs and symptoms that are indicative of true tissue threat and those that may be due to the triggering of a hypersensitive nervous system and fear-based behaviors.

For many patients with persistent neuropathic pain, the threat to neural tissue is no longer an issue. Patients are left with pain that is no longer produced by a continuing insult to the nerve but is produced by hypersensitive neural membranes, sensitized sensory processing mechanisms, and/or fear-based and learned responses to perceived environmental threats. Care for these patients addresses the behavioral components that trigger the pain and retrains the nervous system to discriminate between dangerous and nondangerous sensory information. For these patients, tissue threat is deemphasized as the source of their pain. The focus of care shifts to restructuring patient behaviors, thoughts, and fears associated with pain. For many patients the strict categorization of their sign and symptom patterns into acute or persistent neuropathic pain is not possible. During the recovery a patient’s condition changes, requiring frequent reassessments of the patient’s status.

Question 2: How Irritable Is the Condition?

Maitland defined the levels of irritability as tools to grade the intensity of the application of musculoskeletal mobilization/manipulation techniques and exercise. Butler expands Maitland’s ideas using irritability as a guide to the treatment of neural pathologies. Irritability is rated on a continuum from high (minor activities produced an increased sign or symptom response that took a prolonged period to return to the original state after activity) to nonirritable (significant activity may produce an increased sign or symptom response, with a rapid return to the original state). There are three components that need to be considered in the gradation of irritability: level of activity, patient response, and duration of that response. Irritability is often considered to be an indicator of the potential ease or difficulty with which activity produces a localized inflammatory response. Tracking the duration of the enhanced patient response after activity can be considered as a way of gauging the inflammatory character of the condition.

In 1961, Lishman described a “latency” characteristic to neuropathic pain. This characteristic is familiar to clinicians caring for patients with neuropathic pain. An activity may produce a transitory increase in discomfort during its performance that quickly resolves. Over the next 6–12 h, however, symptoms ramp up and remain elevated for 12–24 h before slowly degrading to baseline levels over the next 24–36 h. Clinicians often dismiss these patient reports because the patient demonstrated no increased discomfort when they left the office.

This pattern of symptom behavior can be correlated to the pattern of increased neuroimmune activity seen after stimulation by chemical, mechanical, behavioral, or neural triggers. Even after microglia decrease their elevated response, they remain in a heightened “alert” state so that lower intensity triggers can stimulate the response. Defining the level of patient irritability to activity and correctly grading the degree of engagement or challenge in treatment prevent unneeded patient discomfort and lower the potential of increased central sensitization during the treatment process. Irritability is a key component for deciding the type of therapeutic interventions to be used as the condition improves.

Clinicians and patients can use the irritability concept to grade the treatment program to prevent a neural flare response. Patients need to understand that this heightened response is not an indicator of actual tissue damage but its production cannot be ignored. If the treatment plan or activity levels continue to produce this hyperprotective response, the central nervous system (CNS) becomes more sensitized and the protective response is produced at progressively lower stress levels. This is a treatment response that must be avoided. The often used phrase “No pain, No gain” is only partially correct. The disciplined, controlled production of pain at activity levels below those that produce the neural flare is required to produce the restructuring of the CNS and tissue healing.

Question 3: What Are the Triggers That Produce a Change in the Patient’s Status?

Patients’ appraisals of threat and safety are important to the quality of treatment outcomes. Fear avoidance behaviors, depressive behaviors, dependency, kinesiophobia, rumination, and maladaptive thought loops all increase as threat perception caused by pain increases. Structural changes can develop in cortical areas that are involved in threat appraisal. The heightened threat appraisals also cause increased stress responses, increasing sympathetic nervous and endocrine system activities. The same changes can adversely affect the healing of neural tissue and general health status. Finding those entities that trigger the threat response is an important component of the initial evaluation. A thorough subjective examination facilitated by the use of Motivational Interviewing can uncover many of them. The metaphors, adjectives, and verbs that patients use to describe their pain are powerful indicators of how patients view their pain and appraise harm from it. Altering patient stories and language are powerful treatment tools. Psychometric testing and pain questionnaires can be used as initial screening tools to assess the patient’s psychological, threat appraisal, and pain states. They can provide guidance in exposing those triggers that raise or lower threat appraisals.

During the examination, practitioners risk becoming so focused on finding the threat or pain triggers that they fail to appraise those activities, beliefs, and ideations that trigger reductions in pain and encourage self-efficacy. Uncovering these during the initial examination and ongoing treatment can provide powerful tools to help patients self-regulate their pain, feel safe as new treatments are introduced or the program is advanced, and encourage patient independence. Finding and teaching patients to use these positive triggers can reinforce the therapeutic relationship between the provider and patient. Safety triggers are used not only to assist the patient in controlling the stress response but also to activate the placebo response. Research has demonstrated the power of trust and belief in activating both the placebo and nocebo responses.