“Hands on” versus “Hands off” in treating Central Sensitization in OA

With growing knowledge in pain sciences, clinicians are moving further away from just “fixing” anatomy and appreciate the contribution of psychosocial issues in pain recovery.


This paper brings into light that, as PTs, we must be careful not to swing the pendulum too far away from the biomedical model of pain. Specifically, we should not be abandoning the “hands-on” approach for patients with persistent OA-related pain. Every patient requires a unique balance between hands-on and other treatments addressing central sensitization.


Traditionally the goal of manual therapy has been to resolve pain using the biomedical model of pain. Patients are frequently informed that the goal of the manual therapy is to “loosen” something, “move” something or “put something in place”.


However when manual therapy is applied to patients with centrally sensitized OA the “find it and fix it” approach may not be appropriate as it may fuel biomechanical beliefs (Nijs et al 2013). One of the aims of pain education is to educate patients to not assume that all pain is directly associated with a damaged structure. Therefore, our explanations to patients regarding the purpose of manual therapy should be modified.


As PTs we could say that the purpose of manual therapy is to increase mobility, relax muscles and reduce pain by helping to reduce the hypersensitivity of the nervous system.


Another suggestion is to reduce the frequency of using the threatening word pain. Perhaps the word “pain” could be replaced by “discomfort” or “symptoms”. For instance, inform the patient, “Please tell me if you have any discomfort while I do this mobilization”.

Reference: Lluch Girbés E et al Balancing “hands-on” with “hands-off” physical therapy interventions for the treatment of central sensitization pain in osteoarthritis. Man Ther. 2015 Apr;20(2):349-52.

Knee OA

A Lochman
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