Manual Therapy (1999) 4(4), 185186

# 1999 Harcourt Publishers Ltd

Editorial
This issue of Manual Therapy provides a timely look
at the most important factor that encourages patients
to seek the services of manipulative therapists, pain.
In the past pain was viewed purely as a symptom of
disease and consequently the solution to the problem
of alleviating pain was to reverse the underlying
disease process. In the eld of manipulative therapy
this approach was exemplied by an emphasis on
restoring the normal function and biomechanics of
joints in the belief that this would correct the
underlying dysfunction and relieve pain. The past
35 years have seen an explosion of research in
relation to pain and nociception and the expansion
of knowledge continues at a dramatic pace. In the last
few years we have seen a tremendous increase in
research addressing the genetics and molecular
biology of pain. As a result our knowledge of pain
and the complexities of perception and modulation of
pain has greatly increased. We have become aware of
pain as a pathophysiological entity in its own right.
The complexity of pathophysiological mechanisms in
some chronic pain states is highlighted by Bushnell
and Cobo-Castro's article (p221) on complex regional
pain syndrome.
This increased knowledge has been reected in the
eld of manipulative therapy by a much greater
emphasis on pain as an important topic in our
educational systems; a greater emphasis on the need
to integrate pain science into our clinical reasoning
processes; greater involvement of manipulative therapists in pain-related research; and an acceptance that
it is not necessary to ascribe all aspects of a patient's
pain presentation to peripheral sources of pathology.
We are becoming increasingly aware of the importance of social and psychological factors inuencing
the patient's pain presentation, particularly in those
patients who experience chronic pain. Pain is rightfully taking a central role in the eld of manipulative
therapy as an important topic in relation to clinical
practice, education and research.
The explosion of research in relation to pain can be
traced back to the publication of Melzack and Wall's
gate control theory of pain in 1965 (Melzack & Wall
1965). The gate control theory was inuential and
important because it moved our thinking away from
a hard-wired concept of pain, in which pathology
generated nociception, which invariably led to pain

that was in some sense proportional to the pathology

to a much more exible concept in which it is possible
to conceive of pain as a heavily modulated experience, rather than a pure sensation. The gate control
theory allowed for the possibility that the pain
experience could be both up-regulated and downregulated depending on the set of the central nervous
system. It allowed us to conceive of situations in
which no pain is experienced despite major tissue
damage and situations in which pain is reported in
the absence of any identiable tissue damage or
pathology. Psychological states could inuence pain
perception in a bi-directional manner by contributing
to either opening or closing the gate. Peripheral
stimuli could also modulate the processing of
nociceptive information in a bi-directional manner.
This has been of great importance to our understanding of chronic pain states and to our understanding of the mechanisms whereby physiologically
based treatments such as manipulative therapy might
bring about pain relief. The increased acceptance of
therapeutic approaches such as manipulative therapy
and acupuncture in the medical mainstream is in no
small measure related to the improved understanding
of pain that has emerged since the publication of the
gate control theory. Looking back across a period of
35 years it is not easy to recognize just how new,
controversial and revolutionary the gate control
theory was. We all owe a great debt of gratitude to
Patrick Wall and Ronald Melzack for the courage
they showed in publishing what has turned out to be
one of the most important scientic papers of this
century.
An important consequence of the gate control
theory was that it spawned research into the
psychosocial aspects of the pain experience. This
has been of great importance both to our understanding of pain and to our improved management of
pain. This issue includes an article by Main and
Watson (p203) specically addressing this aspect of
pain. This is an area that manipulative therapists
need to embrace more fully in the coming years.
Articles by Giord (p229) and Vlaeyan and Crombez
(p187) provide guidance in this direction.
Manipulative therapists have shown themselves
willing to draw on information generated in the pain
sciences and to use that information to provide an
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186 Manual Therapy

improved rationale for many of the therapeutic

procedures that we use. Increasingly, we are generating research that provides an improved understanding of musculoskeletal pain states in particular. An
important next step is to increase our participation in
and our inuence on basic science research to ensure
that it is as relevant as possible to the needs of our
patient populations. One specic area in which we
can make a very important contribution is in terms of
stimulating basic science research at the interface
between pain and motor control. As indicated above,
there is now a huge research literature in relation to
pain and nociception. There is an equally large
literature in relation to motor control. Yet the
amount of research activity at the interface between
these two areas is relatively small. As manipulative
therapists, most of our clinical work takes place at
this interface. Our activities are all about reducing
pain and restoring motor function and we are acutely
aware of how interrelated these two factors are. We
can and should be doing more to stimulate research
addressing the interface between pain and motor
function.
We are increasingly integrating our knowledge of
pain into clinical reasoning processes. This needs to
continue and to move to higher levels of sophistication. To this end, the article by Strong (p216)
provides useful insights into pain assessment procedures. In particular there is a clear need for us to
recognize and specically address psychosocial issues
in our assessment and management of patients. That
is not to say that we need, or would wish, to become
clinical psychologists but we do need to improve our
ability to address psychological yellow ags through
assessment and management processes. We need to
acquire the skills and knowledge to enable us to refer
appropriate patients to psychologists as routinely as

Manual Therapy (1999) 4(4), 185186

we would refer patients to orthopaedic surgeons or

rheumatologists. We also need to embrace more fully
a cognitive behavioural approach to the management
of many of our patients and nd ways to integrate
this approach with our traditional hands-on methods.
One other aspect of the pain revolution has been an
increased emphasis on the need for a multidisciplinary approach to the management of patients with
pain and particularly those who experience chronic
pain. Manipulative therapists are developing their
role as members of pain management teams, whether
in formal centres or in more loosely based community
groupings. This is a process that needs to continue so
that we can contribute our skills and draw on the
skills of other professionals for the benet of the
maximum number of patients.
As we are about to enter the new millennium it is
apparent that the second half of the 20th century saw
a giant leap in our understanding of pain. Over the
last two decades manipulative therapists have taken
many steps to embrace this new knowledge. There is
still a great deal more that we can do to integrate this
knowledge and to shape research in this eld. I hope
that you will take the time to read the articles in this
issue and to give pain the same prominence in your
thinking that it has in our patients' thinking when
they come to visit us.
Professor Anthony Wright
School of Medical Rehabilitation
University of Manitoba
Winnipeg
Canada
Reference
Melzack R, Wall PD 1965 Pain Mechanisms: a new theory. Science
150(699): 971979

# 1999 Harcourt Publishers Ltd