Beyond the muscle: an interview with Hubert Van Griensven
Persistent pain is never just a musculoskeletal issue. Neuropathies, neuropathic pain, and dysfunctions of the autonomic nervous system have a profound impact on symptoms, treatment response, and people’s recovery pathways.
In this interview, the instructor of the course “Valutazione Avanzata e Trattamento di Neuropatie, Dolore Neuropatico e Sistema Nervoso Autonomo”, promoted by Sinergia & Sviluppo and SALUS – Centro di Terapia Manuale e Fisioterapia in Foligno (PG), guides physiotherapists through a broader and more integrated clinical reasoning process: from listening to the patient to neurological assessment, from the use of neurodynamics to understanding the role of the autonomic nervous system and contextual effects in everyday clinical practice.
An advanced, practical approach aimed at genuinely improving clinical outcomes in cases of complex pain.
Ahead of the course, scheduled for 13–14–15 February 2026 in Foligno, we interviewed the instructor Hubert Van Griensven, who will be teaching alongside Gianpiero Capra.
- In everyday clinical practice, what are the key signs that should raise suspicion of peripheral or autonomic nervous system involvement in persistent pain?
In my experience, the most important part of every assessment is listening to what the patient tells me. Patients with persistent pain have lived with their symptoms for a long time and are usually able to describe their experience in detail. They may mention symptoms such as shooting pains, sensitivity to cold and tingling. That said, patients may find neuropathic pain difficult to describe, because it can consist of a strange mixture of sensations. If a patient struggles to say what their pain is like, they may have neuropathic pain. I therefore recommend that physiotherapists give a patient time to describe their pain in their own words. In the examination, clinicians should do standard neurological tests, but they should be aware that these tests are focused almost entirely on thick nerve fibres (A alpha and A beta). However, we now know that painful minor neuropathies involve compromise of the small sensory fibres and that those fibres can play a role in pain, so we teach more refined sensory tests as well as neurodynamic tests for effective diagnosis and physiotherapy treatment.
Autonomic involvement may be part of general arousal, for instance in patients who have persistent stress. It may manifest in a number of ways such as poor sleep and concentration, pale skin, sweating and altered breathing patterns. Autonomic functions include circulation and perfusion, which in turn affect tissue health and the body’s ability to respond to physiotherapy treatment. On the course, we teach physiotherapists about stress management and relaxation, because it is so important for health and wellbeing.
I should add that autonomic function is much more refined than many clinicians think. We’re not just in either a sympathetic or a parasympathetic state. Regulation of circulation and organ function, for example, is a lot more sophisticated and specific. Local changes in sympathetic function can be seen in altered perfusion and tissue quality of the soft tissues of the back. We therefore teach physiotherapists to assess and treat these changes, in order to improve specific autonomic functions. Once they know what to look for, therapists are often amazed that they have never noticed those changes before. They are even more amazed when they learn how much effect they can have with well-chosen manual techniques. - Why is neurological assessment still perceived by many physiotherapists as complex or “of limited clinical usefulness”, and how can it be made a truly practical clinical tool?
Physiotherapists may see traditional neurological examination as a way to decide whether a patient needs to be referred to a specialist. Although significant and persistent neuropathy can be a reason for referral, it is clear from physiotherapy research that neurodynamic treatment can help to restore the health of nerves and the tissues that surround them.
It is also worth noting that traditional neurological examination is usually limited to deficits. It focuses on what neural structures may be damaged or not functioning. This is useful, but physiotherapists have to deal with a wider range of issues such as pain and sensitisation. For example, they see patients with peripheral neuropathies and radicular pain related to a spinal problem. Neurologists don’t deal with pain problems, but physiotherapists do, every day. I teach how to examine and treat patients with neuropathic pain, based on modern research, to empower physiotherapists. - How can the integration of neurodynamics, autonomic nervous system assessment, and contextual effects (placebo/nocebo) influence treatment outcomes in musculoskeletal pain?
To me, your question contains some important terms. The first is integration. To me this relates to a more comprehensive view of what is going on with the patient. Physiotherapists are experts in musculoskeletal examination and treatment. However, pain is mediated by, and influenced by, the nervous system. Even though a patient may feel that a joint or muscle hurts, their physiotherapist needs to consider wider issues – what role does the sensory nervous system play and do I need to address it in my treatment? Could I address autonomic function to improve tissue health and function?
The other important term is contextual effects. This includes how we come across as a therapist, as well as our ability to give realistic reassurance, empower our patients and provide a positive expectation of recovery. We can only do this if we take into account a broad range of aspects of the patient’s pain, not just their musculoskeletal system but also the nervous system and general wellbeing. This does not only apply to the physical examination and treatment. When a therapist does the subjective examination, patients appreciate being asked detailed questions, because it tells them that the therapist really wants to understand their problem. This is very reassuring and contributes to a positive therapeutic alliance. - From your international experience, what are the most common mistakes in the management of neuropathic pain, and which competencies truly make the difference today?
I must say that physiotherapists’ understanding of neuropathic pain has increased enormously over the past ten years or so. For example, neuropathic pain was often interpreted as a trapped nerve in the past, which meant that therapists either did not treat, or tried treatments that were ineffective or inappropriate. This situation has improved a lot. However, there is still work to do. For example, being able to establish whether you are dealing with neuropathic pain or somatic referred pain, helps you to choose appropriate treatments. Deciding whether a pain originates in a spinal nerve root or a more distal nerve trunk is also important. Neuropathic pain is complex and often requires a multi-faceted approach. We therefore teach desensitisation and sensory re-education. Finally, it is important to understand that regular pain medication does not help and that the correct medication was often developed for other conditions such as depression and epilepsy. We teach physiotherapists about this, so that they can educate their patients and collaborate with doctors. - After more than 35 years of clinical practice and teaching, what do you believe is still underestimated in physiotherapists’ clinical reasoning when dealing with the nervous system and complex pain?
I would say that the first issue is a tendency to focus on musculoskeletal tissues. Although persistent pain may be due to an ongoing pathology, it is likely that other factors play a role. Of course it is important that physiotherapists do a thorough examination and establish whether there is a specific diagnosis. However, they should also consider whether all the information is consistent with a musculoskeletal problem. For instance, is the pain better on some days and worse on others, or does it vary for no clear reason? Did it start during a period of stress? Is the patient’s understanding helpful or could it add to their problem?
Although I have noticed this focus on the physical, the opposite also happens. Ever since it became clear that pain should be viewed from a biopsychosocial perspective, there has been a tendency among some therapists not to touch patients with persistent pain. This is not helpful in my view. A good subjective and objective examination, including touch, can be immensely reassuring to the patient. And although psychological and social approaches can be appropriate in many cases, as well as more modern therapies aimed at normalising pain-related brain function, there is a place for well-chosen physical interventions and exercises. I have always been for integration. I believe that when the therapeutic elements are chosen within an overall understanding of pain and in collaboration with the patient, we have the best chance of success.
To finish, I’d like to say that communication and reflection are our strongest tools for development. Listen to your patients, talk to colleagues, keep learning and be a reflective pratitioner. And come to our course!
Integrating neurological assessment, the autonomic nervous system, and contextual factors does not mean making clinical practice more complex, but rather more precise, effective, and person-centred: this is where pain treatment truly makes the difference. Join the course:“Valutazione avanzata e trattamento di neuropatie, dolore neuropatico e sistema nervoso autonomo”.