Physical Therapies in the Management of Pain

Kathryn Schopmeyer, DPT

Richard Jacob Boyce, DPT

Rebecca Vogsland, PT, DPT

OVERVIEW

Chronic, or persistent, pain is a complex condition with varied genetic, environmental, psychosocial, and cultural factors, each having disparate manifestations in patients both in terms of pain experience and impact on function.¹ Treatment of persistent pain in the United States has been pendular during the past half century, with rehabilitation and nonpharmacological approaches shifting into and out of focus. Beginning in the 1970s and continuing through the 1990s, multidisciplinary pain rehabilitation—specifically work-hardening and operant conditioning models—gained in popularity.²^,³^,⁴^,⁵ Although research demonstrated the benefits of multidisciplinary care, the use of rehabilitative and interdisciplinary treatment approaches for persistent pain declined from the late 1990s through the first decade of the 21st century,⁶ while prescriptions of opioid analgesics increased.⁷ Between 1999 and 2013, the amount of prescription opioids sold in the United States nearly quadrupled,⁸ yet there was no overall change in how much pain Americans reported or how successfully it was managed.⁹^,¹⁰^,¹¹ The medical profession increasingly relied on pharmaceuticals to treat pain because there was (1) consensus that chronic opioid therapy was safe,¹²^,¹³ (2) a perception that pain was being undertreated in the United States,¹⁴ and (3) aggressive marketing by large synthetic opioid manufacturers.⁴^,⁶^,⁷^,¹⁵^,¹⁶^,¹⁷

Giordano and Schatman discussed the ethical implications of these trends¹⁸^,¹⁹^,²⁰ and called for a return to a
multidisciplinary and integrative approach to pain care in 2008.²⁰ The Veterans Health Administration issued a national directive in 2009, mandating the implementation of at least 1 interdisciplinary pain rehabilitation program for each of the 21 Veterans Integrated Service Networks.²¹ Another rapid change occurred after the Centers for Disease Control and Prevention released its Guideline for Prescribing Opioids for Chronic Pain in March 2016, with a greater emphasis placed back on behavioral and rehabilitation approaches to managing persistent pain.²²^,²³ Both the National Institutes for Health and Centers for Disease Control and Prevention guidelines now recommend nonpharmacological physical therapy (PT) as a primary approach for the treatment of chronic, noncancer pain.¹^,²²

PHYSICAL THERAPISTS AND PHYSICAL THERAPY PRACTICE

Physical therapists are collaborative professionals working across the health care system in the United States. They are active in primary, secondary, and tertiary level clinical settings and have a scope of practice that allows for direct treatment of illness states as well as disease prevention and health promotion via wellness and fitness consultation, education, research, and health policy administration.²⁴ As of January 2015, all graduates of accredited PT programs are awarded a doctoral degree with training that readies them to deliver front-line health care services. In addition, curriculum content for graduate programs has been evolving to meet the demand of persistent pain problems in the United States.²⁵ All US states, including the District of Columbia, Puerto Rico, and the US Virgin Islands, now have “direct access” to physical therapy,²⁶ meaning that patients are afforded some level of access to PT services without a physician referral. The Guide to Physical Therapy Practice (2014) describes PT as “a dynamic profession with an established theoretical and scientific base and widespread clinical applications in the restoration, maintenance, and promotion of optimal physical function” (Figure 23-1). The enhancement of physical function allows the individual to regain or maintain health and optimize participation in valued activities, thus maximizing quality of life despite persisting pain.

FIGURE 23-1 APTA guide to physical therapy practice. From Guide to Physical Therapist Practice 3.0. Alexandria, VA: American Physical Therapy Association; 2014. Available at: http://guidetoptpractice.apta.org/. Accessed December 18, 2018.

PHYSICAL THERAPY FOR PERSISTENT PAIN

Physical therapists have sought to develop treatment-based classification systems for the diagnosis and treatment of musculoskeletal conditions²⁷^,²⁸^,²⁹ and clinical practice guidelines (CPG) to inform patient care.³⁰^,³¹^,³²^,³³^,³⁴^,³⁵^,³⁶^,³⁷ Practice that is congruent with CPG generally leads to improved outcomes and decreased health care costs.³⁸^,³⁹^,⁴⁰^,⁴¹ A subset of patients with persistent pain, however, respond poorly to PT interventions designed to address mechanically reproducible peripheral symptoms. A noted deficit in the existing guidelines and classification systems is a robust category for centrally mediated pain (central sensitization [CS]). Smart et al. (2010) proposed a classification system surrounding the underlying neurophysiological mechanisms of pain based on clinical findings. In this system, patients are classified based on clinical assessment findings into 1 of 3 categories: nociceptive pain, peripheral neuropathic pain, or CS (Table 23-1). Nociceptive pain refers to pain directly linked to afferent input from the periphery in response to noxious mechanical, chemical, or thermal stimuli.⁴² Peripheral neuropathic pain refers to pain directly resulting from a problem or lesion in the peripheral nervous system.⁴³ CS refers to pain arising from neurophysiologic changes in the central nervous system that leads to an amplification of neural signaling and ultimately hypersensitivity to afferent input.⁴⁴ People with chronic pain can fall into any of these 3 categories and may also present with a mix of symptoms, with 1 category being dominant. Using a mechanism-based approach may result in more accurate clinical reasoning and more effective treatment selections.¹^,⁴⁵ Physical therapists have knowledge and skills to manage patients in any of these categories. Primary aims of PT intervention are identifying and diagnosing movement impairments, facilitating recovery of function, teaching patients active self-management strategies, and increasing patients’ confidence so they can independently and successfully cope with recurrent acute or sustained chronic conditions, including pain, in the long term.

TABLE 23-1 Overview of Pain Mechanism Classifications

MECHANISM	CLUSTER OF CLINICAL FINDINGS
Primary Nociceptive	Pain is: Proportionate anatomical response to aggravating/alleviating factors Intermittent and sharp with mechanical provocation Constant dull ache at rest Localized to the area of concern Absence of: Other dysesthesias Night pain Burning or electric pain Antalgic movement patterns
Peripheral neuropathic	History of nerve pathology, injury, or compromise Pain provocation with mechanical/movement examination procedures Dermatomal or cutaneous distribution of pain
Central sensitization	Disproportionate to injury/pathology Associated with maladaptive psychosocial factors Disproportionate, unpredictable response to many ill-defined aggravating/alleviating factors Diffuse, nonanatomic distribution
Reprinted from Smart KM, Blake C, Staines A, Thacker M, Doody C. Mechanisms-based classifications of musculoskeletal pain: part 1 of 3: symptoms and signs of central sensitisation in patients with low back (±leg) pain. Man Ther. 2012;17(4):336-344. Copyright © 2012 Elsevier. With permission.

PASSIVE VERSUS ACTIVE APPROACHES TO PAIN MANAGEMENT

Passive treatments are those done to a patient, delivered by either a practitioner or a device, without cognitive or physical engagement by the patient. Persistent pain poses a treatment challenge because of the multidimensional complexity of the problem.⁴⁶^,⁴⁷ Health care professionals’ desire to alleviate pain and suffering for patients often means they recommend treatments designed to quell symptoms with minimal side effects, such as massage, electrical or thermal modalities, dry needling, or manual joint manipulations. The use of passive treatment interventions designed to reduce suffering may compromise long-term outcomes if psychosocial factors are not first considered when developing a pain care plan. There is an inherent risk of worsening outcomes if passive strategies are the primary elements of a care plan for patients with persistent pain and avoidant behavior or pain-related fear of movement.⁴⁸^,⁴⁹

Passive treatments are often used to create short-term results³⁷^,⁵⁰^,⁵¹ and may indeed have the potential for negative outcomes with prolonged use.⁵²^,⁵³ However, owing to the potential to decrease nociceptive input, and the likely central nervous system modulation that occurs with passive treatments,⁵⁴^,⁵⁵ it is reasonable to consider passive interventions as an option; there is evidence showing that various passive interventions can positively affect pain and function in the short term.⁵⁶^,⁵⁷ Ideally, passive interventions are utilized as “bridge therapies,” intended to create an opportunity to implement active strategies while pain symptoms are somewhat reduced. Finding ways for patients to apply passive treatments to themselves may afford them with a greater sense of control and self-efficacy regarding their own pain management.

In contrast, active treatments are those in which the patient is physically and/or cognitively engaged as a participant. The self-application of a passive modality
can be considered active, because the patient is taking ownership of the process. Active cognitive coping and self-management skills appear to be the most significant mediators of positive outcomes for those who participate in multidisciplinary pain rehabilitation programs.⁴⁷^,⁵⁸^,⁵⁹ Active strategies employed by physical therapists include education, adaptations, facilitation, graded motor imagery, exercise-based interventions, and graded exposure techniques.

Self-Efficacy and Persistent Pain

A psychosocial factor that is tightly correlated with disability due to pain is self-efficacy.⁶⁰ Self-efficacy is characterized as the belief in one’s own ability to achieve a specific goal or bring about a desired outcome.⁶¹ A strong sense of self-efficacy is a powerful mediator between pain and disability.⁶⁰^,⁶²^,⁶³^,⁶⁴^,⁶⁵ According to Bandura (1997), self-efficacy is impacted by the following: (1) past performances, (2) verbal persuasion, (3) vicarious experiences, and (4) physiologic feedback. Physical therapists are uniquely suited to positively impact the 4 components of self-efficacy in patients with persistent pain through education, facilitation of successful experiences, coaching/encouragement, behavior modeling, and exercise instruction. Physical activity and exercise increase self-efficacy in patients with pain.⁶²^,⁶⁶ Providing patients with the tools to implement active self-management strategies can help bolster their self-efficacy by improving successful performance of functional tasks and modulating physiologic feedback. The literature suggests a reciprocal relationship between high self-efficacy and ability to engage in valued physical activity.⁶² In addition, specialized education about pain, known as Pain Neuroscience Education, can act as verbal persuasion and also help mediate the interpretation of physiologic feedback, thereby positively impacting self-efficacy.

The remainder of this chapter will outline the prominent nonpharmacological, PT treatment elements with the strongest empirical support for the treatment of persistent pain conditions. Table 23-2 summarizes some main points.

ACTIVE TREATMENTS

Pain Neuroscience Education

Teaching patients the principles of pain physiology and neuroplasticity as a therapeutic intervention is now termed “Pain Neuroscience Education” (PNE).⁶⁷^,⁶⁸^,⁶⁹ PNE aims to reconceptualize pain as the nervous system’s response to perceived threat of danger, rather than a direct reflection of tissue injury.⁷⁰^,⁷¹ Patients living in pain want to know about their pain and why it persists,⁷² yet common frameworks to explain pain use a biomechanical or structural model. Traditional models of patient education that focus on pathoanatomy are not helpful for patients with chronic pain⁷³^,⁷⁴ and can even worsen both fear and pain.⁷⁵ A modern view of pain science rejects a strict biomechanical (nociception = pain) model and embraces the biological, psychological, and social impacts of pain on our physiology.⁷⁰^,⁷⁶^,⁷⁷^,⁷⁸ Cortical changes are likely more influential to ongoing pain than are structural tissue impairments for common persistent pain problems such as nonspecific low back pain, headache, neuropathic pain, postsurgical pain, osteoarthritis, whiplash, shoulder impingement syndromes, and elbow pain, so using a biomechanical/structural model is not only inaccurate but also incomplete.⁷³^,⁷⁷^,⁷⁹^,⁸⁰^,⁸¹^,⁸²

TABLE 23-2 Physical Therapies for Persistent Pain

Common physical therapies for persistent pain care with little or no empirical support:

Ultrasound (Desmeules et al., 2015; Wong et al., 2007; Robertson and Baker, 2001; Nussbaum, 1997; Gam and Johanssen, 1995)
Mechanical traction for axial spine pain (Young et al., 2009; Graham et al., 2008; Clarke et al., 2006; Guild, 2012; Madson and Hollman, 2016; Macario and Pergolizzi, 2006; Wegner et al., 2013)
Back braces (Chou and Huffman, 2007)

Effective physical therapies for persistent pain care (best used in combination and prescribed based on shared decision making, patient values, and SMART goals):

Individualized therapeutic exercise (Falla and Hodges, 2017) EULAR revised recs for FM
Manual and manipulative therapies
Graded motor imagery
Dry needling
Pain neuroscience education
Electrical stimulation (TENS, LLLT)
Classification-based cognitive functional therapy (Vibe Fersum et al., 2013)

There are now several resources available for clinicians to increase knowledge and teaching skills.⁷³^,⁸³^,⁸⁴^,⁸⁵^,⁸⁶ PNE has demonstrated efficacy for reducing pain and improving function and movement while decreasing disability, catastrophization, and health care utilization.⁷¹^,⁸⁷^,⁸⁸ Physical therapists have been the primary contributors to the body of evidence surrounding the development and use of PNE.

PNE can be delivered in various settings using different mediums, and some of the key components are in Table 23-3.⁷³^,⁸⁹ Although clinicians generally assume that patients will not comprehend the neurophysiology of pain, research shows that clinicians can learn to teach it and patients can understand the material with good effect.⁹⁰ PNE can have a direct impact on the element of self-efficacy related to interpretations of physiologic feedback processed by the brain. If the threat-value of such input can be decreased, it would follow that self-efficacy can be bolstered in relation to activity and pain management.

THE POWER OF LANGUAGE AND PERSISTENT PAIN

The major aims of PNE are to explain pain to people (rather than pathoanatomy) and to do so in a way that does not induce or promote fear in patients. Clinicians
commonly explain pain problems using anatomy references or in terms of pathoanatomy or disease states. Clinicians are likely unaware of how their word choice influences the cognitions and actions of patients, and having a deeper understanding of this might improve health care delivery.⁹¹^,⁹²^,⁹³ Metaphors help people understand and express experience through language,⁹⁴ although the metaphors we choose in health care could have unforeseen nocebo effects on patients, particularly if they evoke images of vulnerability, frailty, or damage. For example, a popular way to explain functions of the human body is by comparing it with a mechanical object with parts that break down after too much use or that the body must follow specific rules of alignment to function well and without pain. “Wear and tear” is considered benign by many health care providers, yet when patients describe their conditions in terms of degeneration, they demonstrate a poor self-prognosis.⁹⁵ Stress associated with fear, anxiety, and threat triggers a cascade of neurophysiological events, including systemic endocrine upregulation, enhanced immune response, and localized neurogenic inflammation.⁹⁶^,⁹⁷ Patients with chronic pain can exist in this state of perpetual stress and threat related to bodily sensations. The resultant biochemical cascade can negatively impact the body and mind, affecting cognition, endocrine function, sleep, and the experience of pain.⁹⁶^,⁹⁷^,⁹⁸ People who exist in a state of perpetual threat frequently develop maladaptive catastrophic thought patterns and/or kinesiophobia. They tend to avoid activity and are more likely to have poor long-term outcomes for pain and overall health. Choosing words with limited threat value and teaching about pain physiology, rather than strictly anatomy, can reduce fear-induced stress and improve the l ives of patients suffering with persistent pain conditions.⁹⁹^,¹⁰⁰^,¹⁰¹

TABLE 23-3 PNE Curriculum Contents

Nociception and nociceptive pathways

Neurons, synapses, and action potentials

No reference to anatomical/pathoanatomical descriptions

Spinal inhibition and facilitation

Peripheral and central sensitization

Contribution of psychosocial factors and beliefs

Plasticity of the nervous system

Neurophysiology of pain

Modified from Nijs J, Paul van Wilgen C, Van Oosterwijck J, van Ittersum M, Meeus M. How to explain central sensitization to patients with “unexplained” chronic musculoskeletal pain: practice guidelines. Man Ther. 2011;16(5):413-418. doi:10.1016/j.math.2011.04.005; Louw A, Zimney K, Puentedura EJ, Diener I. The efficacy of pain neuroscience education on musculoskeletal pain: a systematic review of the literature. Physiother Theory Pract. 2016;3985:1-24. http://www.ncbi.nlm.nih.gov/pubmed/27351541; Louw A, Zimney K, O’Hotto C, Hilton S. The clinical application of teaching people about pain. Physiother Theory Pract. 2016;32(5):385-395. doi:10.1080/09593985.2016.1194652; and Louw A, Puentedura E, Zimney K. Teaching patients about pain: it works, but what should we call it? Physiother Theory Pract. 2016;32(5):328-331. doi:10.1080/09593985.2016.1194669.

PHYSICAL THERAPY AND PAIN NEUROSCIENCE EDUCATION

PNE is best used in conjunction with other PT interventions. Table 23-4 outlines some of the interventions paired with PNE; one or more may be combined within a given episode of care or single treatment session. Physical therapists conduct highly skilled evaluations including subjective interviews and physical examinations, while taking into account several psychosocial concomitant factors, and are trained to screen out red flag symptoms or other signs of health impairments that require medical attention. The result of this detailed subjective and objective evaluation will help with categorization of the patient into 1 (or more) of the 3 pain mechanism types, which allows the therapist to more accurately explain a patient’s pain and help address pain-related fear. Physical therapists are able to apply their knowledge of anatomy, physiology, and pathophysiology to demystify symptoms and synthesize clinical and diagnostic medical imaging findings to explain ongoing pain states while normalizing the patient’s experiences. PNE would be an applicable active treatment approach for patients in all 3 pain mechanisms categories, especially as pain persists beyond normal tissue healing time and becomes chronic. The application of PNE early in an episode of care may be helpful to allow for deeper understanding of the plan of care and decreased fear of pain to promote engagement in movement-based approaches.⁷¹

Exercise Recommendations and Considerations for the Patient With Persistent Pain

When appropriately prescribed, regular exercise improves the majority of chronic medical conditions and provides substantial benefit to overall health.¹⁰²^,¹⁰³^,¹⁰⁴ In the presence of chronic pain conditions, however, patients and providers are often apprehensive regarding engagement in regular exercise and reasonably ask the
following questions: Will exercise cause harm? Is exercise beneficial as treatment of chronic pain? How should exercise be prescribed if it hurts to move?

TABLE 23-4 PNE as Adjunct Therapy

Manual therapy (Moseley, 2002; Ryan et al., 2010; Puentedura and Flynn, 2016)

Trigger point dry needling (Tellez-Garcia et al., 2014)

Aerobic exercise, including circuit training (Ryan et al., 2010)

Stabilization exercise/motor control (Moseley, 2002, 2003; Ryan et al., 2010; Beltran-Alacreu et al., 2015)

Aquatic exercise (Pires et al., 2015)

Movement exercise (Vibe Fersum et all., 2013)

Graded exposure and pacing strategies for daily tasks (Meeus et al., 2010; Vibe Fersum et al., 2013)

A movement and exercise plan for patients with chronic pain should take into consideration the following factors:

the neurobiological adaptations present in persistent pain states
patient expectations and goals
a patient’s past experiences with exercise
exercise mode accessibility

Exercise-based interventions are active interventions and may help promote self-efficacy in patients with persistent pain. Physical therapists can create a plan that meets the needs of the individual.

EXERCISE IS SAFE AND EFFECTIVE

Many musculoskeletal and degenerative conditions, such as osteoarthritis and degenerative disc disease, are commonly associated with persistent pain. Commonly held beliefs about the body based on the outdated biomechanical model influence behavior and medical advice that is either confusing or inconsistent with research: running after age 50 years should be avoided; exercise is not appropriate for arthritic conditions or will not be tolerated; “move through the pain no matter what”; “don’t move it if hurts.” Based on our current understanding of pain processing, we now know that the presence or absence of pain is not an accurate representation of the state of the tissues,⁷⁰^,⁸¹^,⁸²^,¹⁰⁵ and that the presence of a chronic degenerative condition is not an accurate predictor of pain.¹⁰⁶ We also know that exercising does not accelerate degenerative or chronic inflammatory conditions.¹⁰⁷^,¹⁰⁸^,¹⁰⁹^,¹¹⁰^,¹¹¹^,¹¹² In fact, when properly prescribed, engaging in regular exercise and activity is not only safe but also improves function, mood, physical fitness, self-efficacy, and quality of life and reduces pain, even in the presence of most degenerative conditions.¹⁰²^,¹⁰⁷^,¹⁰⁸^,¹⁰⁹^,¹¹⁰^,¹¹¹^,¹¹²^,¹¹³^,¹¹⁴ Physical therapists create exercise prescriptions for complex patient populations and are excellent resources when patients are fearful of movement because of pain.

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