Thursday Thoughts: Threat Assessment | Modern Manual Therapy Blog

Thursday Thoughts: Threat Assessment

Pain Science, and thus modern physical therapy talks about how perceived threat reduces pain and movement thresholds.

Thus, it is highly recommended to use Therapeutic Neuroscience Education to educate the patient on what pain is, and what pain is not. More importantly, what may constitute a threat? Many who have embraced modern pain science, including myself occasionally forget there are real peripheral and physical threats, in addition to the obviously important neurotags the patient may have.

Threats may be:
  • bad news regarding their scan
    • degeneration
    • spur
    • bulging disc, etc
  • movement asymmetry
  • asymmetry in loading capacity for LE - especially in runners
  • motor control asymmetry
  • breathing pattern disorders
  • beliefs about their condition based on
    • previous experience with other providers or resolution
    • persisted by their circle of support
    • enabling family members or their trusted "wellness" provider that treats them prophylactically monthly
What are usually not threats 
  • pelvis being rotated
  • positional fault of vertebrae
  • mild, moderate, severe changes or findings on many scans (we can't change them anyway)
  • "weak" core
I say "usually" to the above, because no one can really prove exactly what is threatening to the patient. Also, if their neurotags enhance the threat regarding a pelvic rotation, rib being out of place, etc, you may need to "address" that threat as well. Heck, I do not even really believe in ribs being out of place anymore, but that does not mean it didn't happen to me!

Bottom line: Assess the threats and address them!

Keeping it Eclectic...


  1. Great post again! Taking the history, I usually try to find that out using the question "Listening to you inside, what do you feel or think is causing you this problem?" and then I try to understand if the belief is a self-made belief based on other experiences or is coming from someone else's point of view (MD, DO, DC, PT , friends or family etc) if the patient is a smart or flexible one, I explain what the reality is about pain, but if the patient do really believe in his/her stuff, I go on with that, using a very short explanation with his/her words to make the thing fit (their belief and my treatment) the end of the session, I am interested in positive mobility/motor control and sx changing and so if he/she still wants to hear "what or why"or if the exercise or the manip restore the "right position" of something I do tell him/her that is! I think the culture level of the patient makes a big difference and the country habits aswell. In Italy most of people have been educated in pain=inflammation=something broken/lesion=MD=pills=resolution. We know the game is pretty different and we may better start changing the MD's beliefs to better reducate the usual patient, and also we better spread the new pain knowledge around the planet, not only in the clinic but starting from the family dinner table to the president house toilet :-)

  2. Hey Erson,

    What do you think about threatening patient with ours diagnosis and assesment findings like stiff that weak that kind of staff. I think that sometimes we are acting like mri scans and like to tell everything what we found. I didnt find any studies about it like about mri findings information but i think that mechanism could be similar.
    Greetings from Poland,

  3. Lukas, absolutely, those terms were first called thought viruses by Butler. The wrong words, actions, treatments can cause patient's fear and anxiety to rise, acting just like bad news from a scan. That's why we must be very careful of our interactions.

  4. Riccardo, it's the same everywhere! Even the home of modern pain science, Australia, tried to have a huge pain conference, inviting all kinds of docs, etc to it. Barely anyone showed up!