As seen in Therapeutic Outlook Magazine | Volume 10, Issue 2: #ChoosePT

As discussed in the previous article in this issue, it is now widely accepted that pain is constructed by the brain in response to what we perceive as threatening or dangerous to us.

Traditionally, physical therapists (PT’s)treat pain with patient education, manual therapy, exercise, and modalities. These treatments are important for promoting health of tissues in different stages following injury. In our Physical Therapy Direct issue (Volume 9, Issue 1), we discussed the “Physical Therapy Treatment Pathways” ranging from treatment of an acute injury to remodeling of tissue after the initial phases of healing are complete (see next page). The goal of treatment during these stages is to promote tissue health, improve segmental mobility, increase functional movement, and condition the tissues. Now, consider that pain is often the primary concern to a patient and healthcare provider during these stages. Education, exercise, and manual therapy attempt to reduce pain, not just promote tissue health. Common sense tells us that using the Treatment Pathways should reduce pain following injury…and research confirms this (O’Sullivan et al. 1997, Hides et al. 2001, Goldby et al. 2006; Iversen, Chhabriya, et al. 2011; http://www.moveforwardpt.com/Resources/Detail/how-physical-therapists-manage-pain). If a person in pain sees a physical therapist (PT) quickly after the onset of pain or injury for treatment, as per the pathways above, then the pain experience can be broken up, limiting the likelihood of the pain continuing indefinitely.
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Does a Physical Therapist only help pain that is the result of injury?
What about persistent or “chronic” pain? We know that pain is not solely the result of tissue damage or injury, because 20% of the population experiences some form of chronic pain, which is defined as pain that continues after tissues have had time to heal.

Physical therapists are experts at performing skilled examinations to determine the presence and extent of tissue injury. A shift in treatment is quickly made when the tissues are found to be relatively healthy and not at high risk of re-injury, but significant pain persists. In this scenario, treatment is directed at the pain system itself.

Current evidence shows that traditional treatments in physical therapy work to reduce pain, but need to be partnered with a discussion regarding what pain actually is. Research shows the importance of understanding pain from a neuroscience perspective and how it relates to the entire person (biopsychosocial), not just their tissues (biomedical) (Louw, Diener, et al. 2011). When a PT takes the time to “explain pain” to a patient, that patient has less pain! (Moseley 2002; Moseley 2003; Meeus, Nijs et al. 2010; Ryan, Gray et al. 2010; Van Oosterwijck, Nijs et al. 2011). Furthermore, explaining pain to patients has been shown to reduce disability and improve function (Moseley 2002; Moseley 2003; Moseley, Hodges et al. 2004; Ryan, Gray et al. 2010; Van Oosterwijck, Nijs et al. 2011).

The biomedical model to explain and treat pain is centuries-old and does not take into account what improving studies and technology show us about how pain actually works. The biopsychosocial model to treat pain incorporates this more recent information and helps to treat problems that are “pain issues” more than “tissue injury issues.” It was this understanding of the difference between the experience of pain and tissue damage that led to a “Pain Revolution” in physical therapy (Gifford and Butler 1997; Gifford 1998).

Why does explaining pain work?
The brain has the amazing ability to release “pain killing” chemicals that travel down the spinal cord and are strong enough to disrupt the signal coming in from the tissues. This mechanism is able to change, or even eliminate, the pain experience. One treatment that has been shown to “tap in” to the release of these chemicals is education in the form of explaining pain. Consider the following case:

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Above is an actual brain scan of a patient with ongoing pain that has been given different explanations in the past for her pain. Treatments for the pain have not helped.

• Row 1: The patient is relaxing in the scanner, and you can see the brain is calm — no red blobs.
• Row 2: The patient moves her painful back. Many red blobs show us that her brain is processing the pain experience. She’s in pain!
• Row 3: The same patient undergoes a short educational session to explain how pain works. The focus is on how the nerves and brain become more sensitive to protect the painful area and how this can go on and on, even after a tissue injury has healed. The discussion also covers how the pain does not mean that any damage is actually occurring and that her tissues do not have to be injured for her to feel pain. Then the patient repeats the same back movement that caused the pain in Row 2. This time there are significantly fewer red blobs, showing us that her pain has decreased.

So….is that all physical therapy can do to treat pain? Is education alone enough? The answer, not surprisingly, is no. As discussed earlier, explaining pain needs to be partnered with other treatments that have been shown to help, and people must take an active role in their own treatment.

A summary of the “best evidence” ways that a physical therapist can help people with pain consistently includes four “Hallmarks.” When pain is persistent, the person suffering can change their life if they work consistently with their PT on these four below:

Hallmarks for Pain Management
1. Pain education
2. Aerobic exercise
3. Proper sleep practices
4. Patient-centered goal setting

What Else Is Needed for Physical Therapy to Reduce Pain?
Connection and trust between a patient and therapist is key. Do not underestimate the importance of providing a warm, safe, and caring environment when treating people in pain. Make interactions about the person in pain, not the clinician treating the pain. Patients must be engaged and feel empowered during their treatment (Bunzli, McEvoy, et al. 2016).

One consistency in research conducted over the past 20 years is that care must be focused on each individual. Treatment of pain should not be dictated solely by tissue, syndrome, or body location. A PT is in an excellent position to take the challenge of pain on with their patients. Research supports this based on studies already outlined in this article. Physical therapists have the time per visit, frequency of visits with each patient, and resources available to help them tackle pain. Also, physical therapy is a “hands-on” profession, which is valuable. Physical therapists are wellness-experts who recommend movement-based treatments that have been shown to help decrease pain. They have always worked with their patients to increase their understanding of their body, as well as to change their thoughts and beliefs about their injury or symptoms. Research now shows that this must occur to help people who are suffering from pain.