Top-Down Effects in a Bottom-Up World

Physical therapy treatments traditionally have been focused on identifying the tissue at fault and providing a treatment to correct the proposed dysfunction, misalignment, positional fault, torsion, imbalance, …..(insert your favorite here).  Of course tissue-based explanations hold much more water when healing time frames align with pain and the clinical presentation fits with a more nociceptive/tissue-driven pain problem.    These are the patients that often fit into a Utopian, black and white, textbook-defined world.  We know that attempting to place someone in a pain OR tissue problem likely is an oversimplification of a very complex process.  Patients who fit these nice black and white rules give us comfort and confidence in a clinical world that is dominated by uncertainty and wide-ranging gray areas.  It is this uncertainty and these gray areas that often cause us to seek opportunities to group together with therapists who share common beliefs.

 It helps us all to consider that the principles we were all taught in school and often on many of our weekend courses were often heavily slanted toward looking at pain from a peripheral perspective.  Interventions were delivered from a bottom-up direction with the ending output from the patient being thought to be a product of peripheral changes.  Of course there are patients who respond well to this and in fact do have a pain state that is driven by peripheral issues.  There are also patients who respond to these bottom-up interventions more due to a change in neural processing or top-down effects.  In this situation our interventions produced a neuro-immune-endocrine system that decided, based on the treatment delivered with its accompanying input, that movement was now safe.   This decision is much more complex than a simple peripheral change that traveled up to the brain and rang a bell like Descartes would have liked us to believe.  The input must navigate a non-linear nervous system with accompanying multidimensional inputs that Melzack and his neuromatrix model (1) show us below.  A patient’s beliefs and expectations can be huge contributors in this type of response.  Even the most scientifically implausible story can grab a patient’s attention and belief and as a result influence this decision.  Just watch late-night television and watch all of the amazing testimonials regarding various miracle cures or listen to the patient who is still swooned by the debunked subluxation story that is continued to be told.

 Traditional considerations we have often have regarding our interventions is often limited to the sensory signaling systems contained in the tissues we propose to affect and the resulting pain perception output a patient reports to us.

My Past Treatment Approach

Treatment was aimed at the tissue or fault I most recently took a course on to blame.  Likely there were top-down treatments occurring yet I did not consider the patient’s beliefs, attitudes, conceptions, behaviors.   I also had no consideration of the power of the theatrics of my intervention, my confidence, my comfortable handling, the confident explanation that I was going to correct or fix the root of their problem, the pop that accompanied a manipulation, or the patient’s expectations.  Looking back I was just lobbing a technique into the patients body and hoping a favorable result occurred.

If things were better I patted myself on the back and further strengthened my belief that I had “fixed” the pain generator and it was all about me and my masterful technique.  With my lack of consideration of top-down effects of the technique I drifted further into a strict consideration of periphery in my treatments.   I created a following of patients who aligned with the story I was telling on biomechanics and pathoanatomy.  Some of it fit but a lot of it, looking back, was me trying to fit them into my story instead of me attempting to understand their story.  They would come back as repeat patients and this of course was their fault as I was applying techniques that were correcting their issues so it couldn’t be me.     It was a nice way to create a practice that could only give me more confidence that I was on right path.  I was in a state of unconscious incompetence bliss.

If things went poorly or the patient came back complaining of worsening pain then of course it had to be the patient’s fault.  My technique was performed perfectly so it had to be something they did.  My clinical reasoning did not include much beyond what tissue I convinced myself I was specifically affecting by my technique.  Patients who didn’t fit this story often lasted no more than 1-3 visits before I flared them enough or failed to “fix” them as they had hoped.  The easy road I often traveled was simply to blame “psychological issues” or “non-organic pathology” on the problem.  Their trip on the medical merry-go-round continued after my failed stop which was okay as it was their problem and not mine.  Getting them off my schedule just opened more room from those whose beliefs aligned with my story.

Will we move forward?

    If we follow the evidence and research we can no longer apply technique with ONLY consideration of the peripheral story to a patient’s problem.  We have to listen and understand our patients and the unique stories that drive the top-down contribution to their current pain state.  We waste a huge opportunity to learn, grow, and help more people if we choose to just stick to the comfortable confines of a practice that only applies techniques with no such consideration.  Keeping these factors in mind should make us question the main effects of our interventions and if, when, and how we apply them.  No one is telling anyone to throw successful treatments away, but to consider effects beyond the tissue level.  The University of Florida seems to be leading the way in consideration of these effects when it comes to manual therapy (2).  We also are seeing new ways of looking at and treating people in persistent pain with these effects in mind (3,4,5).


    Ian Harris raises some very interesting points in his book, “Surgery, The Ultimate Placebo”(on my to-read list). It appears to be a refreshing critique and hopefully raises some uncomfortable questions within the health professions who perform surgery.  Let’s not hold our breaths here as surgery is such a huge revenue generator and ingrained treatment in our health system.  Are we, as a profession, ready to ask some uncomfortable questions?  Are we willing to consider that it may be very possible that the majority of the effects of SOME of our treatments (regardless of how much money we have invested in them) may be top-down effects?  If we truly want to move forward as a profession we must ask these questions.  Of course we can just stick to our stories like those who still tell the subluxation story.  We will gain a captive audience as any story often does (especially if we market the heck out of it), but we are better than that right????

  1. Melzack, R., & Katz, J. (2012). Pain. WIREs Cogn Sci, 4(1), 1-15.
  2. Bialosky, J. E., Bishop, M. D., Price, D. D., Robinson, M. E., & George, S. Z. (2009). The mechanisms of manual therapy in the treatment of musculoskeletal pain: A comprehensive model. Man Ther, 14(5), 531-538. 
  3. Louw, A., Diener, I., Butler, D. S., & Puentedura, E. J. (2011). The effect of neuroscience education on pain, disability, anxiety, and stress in chronic musculoskeletal pain. Arch Phys Med Rehabil, 92(12), 2041-2056. doi:10.1016/j.apmr.2011.07.198
  4. Wand, B. M., O’Connell, N. E., Di Pietro, F., & Bulsara, M. (2011). Managing chronic nonspecific low back pain with a sensorimotor retraining approach: exploratory multiple-baseline study of 3 participants. Phys Ther, 91(4), 535-546.  
  5. Vibe Fersum, K., O’Sullivan, P., Skouen, J. S., Smith, A., & Kvale, A. (2013). Efficacy of classification-based cognitive functional therapy in patients with non-specific chronic low back pain: a randomized controlled trial. Eur J Pain, 17(6), 916-928.
Mark Kargela

Mark has been practicing physical therapy since 2003. He spent the his career pursuing expertise in manual therapy treatments. When he recognized that manual therapy had limited success in chronic pain he began intense study of pain neuroscience and advanced training. He practices in Glendale, Arizona where he is a Clinical Assistant Professor and runs Midwestern University's Physical Therapy Institute. He also teaches nationally for Modern Pain Care and lectures across the country on spine care and persistent pain.