David M. Walton1 & Timothy H. Wideman2 1 School of Physical Therapy, Western University, London, Ontario, Canada 2 School of Physical and Occupational Therapy, McGill University, Montréal, Canada Physical therapists have long been focused on helping patients manage pain and engage in a satisfactory life trajectory. For the purposes of this chapter, physical therapy will be defined as a collective of non‐pharmaceutical and non‐surgical interventions. These are most commonly delivered by physical therapists / physiotherapists, but some or all may be delivered by other rehabilitation or movement‐based professionals depending on local regulatory and service delivery frameworks. This chapter, an update to the prior work of Simmonds and Wideman in the first edition of this book, will not describe all possible physical therapy approaches to pain management but instead provide an overview of common frameworks, strategies, and intended outcomes of such interventions. Physical therapy for pain has evolved over time, from a historical focus on pathomechanical understandings of pain to more contemporary biopsychosocial frameworks. Arguably the most widely‐recognized health framework in physical therapy is the International Classification of Functioning, Disability, and Health (ICF) [1]. Notably for physical therapists, the ICF model recognizes that disablement and pain are influenced by sets of variables unique to each person, including predisposing risk factors, intra‐individual factors (e.g. biology, lifestyle), psychosocial attributes (e.g. anxieties, fears, and coping skills) and extra‐individual physical and social factors (e.g. support networks, socioeconomic status) that can affect the presence or severity of disability. As such, similar lumbar structural pathology might be barely noticed or a minor inconvenience in one person while the same type of pathology can lead to pain, distress, and significant disablement in another. Self‐management and patient empowerment in managing their own pain are common hallmarks of physical therapy treatment strategies. Perhaps one of the most notable shifts in physical therapy practice over the previous 10‐15 years has been increased recognition of non‐specific effects of many interventions. For example, Fuentes and colleagues [2] conducted a randomized, single blind trial of the effect of transcutaneous electrical nerve stimulation (TENS) in chronic low back pain in which both the intervention (active vs. sham TENS) and interpersonal context (limited vs. enhanced therapeutic alliance) were manipulated. Their results showed that both active and sham TENS were nearly twice as effective under the enhanced therapeutic alliance condition. When interpreted in light of a growing body of observational research showing little to no association between findings of structural pathology and pain [3,4], physical therapy has seen a shift away from highly‐specific movement‐based therapies to adopt more non‐specific interventions that integrate person‐centered biology, psychology, and socio‐contextual factors into treatment decisions. With the increasing respect for individual person‐centric influences on pain and on the likelihood of successful rehabilitation, comprehensive assessment and evaluation of the patient’s pain experience is a key component to targeted physical therapy. Much of this has been described in Chapters 8–11 of this book so need not be repeated here, other than to reinforce that good assessment prioritizes the patient’s narrative as the closest thing to a ‘gold standard’ of pain currently available [5]. To this end, many physical therapy training programs have seen progressive movement towards emphasizing competencies that facilitate effective partnerships and alliances [6]. Mechanistic or phenotypic classifications of pain drivers have also seen increasing adoption by physical therapists. This information can be obtained through direct questioning and patient narratives, supplemented by questionnaires, medical diagnostics where appropriate, and clinical tests of physical function. This knowledge provides the therapist with an understanding of what modifiable factors (physical, psychological and/or social) should be targeted to positively impact pain, function and social participation. Several standardized self‐report assessment measures may be used by physical therapists to measure pain, beliefs, disability and quality of life. The measures range from simple one‐dimensional questionnaires that take a few seconds to complete, to complex multidimensional questionnaires that can sample a wide range of activities, thoughts and interference with social roles. Survey research has found that the most commonly used patient‐reported outcome (PRO) is the simple 0‐10 Numeric Pain Rating Scale (NPRS) [7]. While simple, quick, and useful as an omnibus indicator of current pain intensity, it is a non‐specific tool that provides little guidance for clinical decisions. Other longer but potentially more informative measures include the Brief Pain Inventory (BPI) [8] and Pain Disability Index (PDI) [9] as generic interference scales, and region‐specific tools such as the Neck Disability Index [10], Oswestry Disability Index [11], Lower Extremity Functional Scale [12] or Disabilities of the Arm, Shoulder, and Hand (DASH) scales [13]. These are intended to measure how much pain or related symptoms interfere with activity or sense of well‐being. It should be noted that activity interference questions are rarely calibrated to an external criterion standard (e.g. a rating of ‘5’ on a question of walking interference does not discriminate between walking from bed to bathroom or a long community walk), but many tools have published population‐based reference norms against which individual patient scores can be compared to estimate the level of disability. These highly standardized tools can be supplemented by more patient‐centered tools, such as the Patient Specific Functional Scale [14] or the Canadian Occupational Performance Measure [15] that allow patients to endorse personally‐important functions. More psychologically‐oriented tools, such as the Pain Catastrophizing Scale [16] or the Tampa Scale for Kinesiophobia [17], are increasingly used as prognostic or treatment modification tools, with practice frameworks evolving to better integrate their use in physical therapy. Unlike self‐report, which are based on patient perceptions, physical therapists will also use standardized performance tests to provide more quantitative information on physical ability (e.g. time, distance, strength or range of motion). While usually administered under clinically controlled conditions, when considered alongside responses to PROs and patient narrative they can provide a more comprehensive view of pain and resultant interference. Common tests include active range of motion through goniometry, timed‐up‐and‐go, six‐minute walk test, balance tasks (e.g. the star excursion [18] or Berg Balance [19] tests), and fine motor dexterity tests, among a host of others. Each source of information moves clinician and patient towards a shared understanding of the drivers of the pain experience, associated movement abilities and difficulties, and towards intervention decisions. The suite of tools available to physical therapists has evolved alongside the increasing recognition of the complexities of pain. Alternative or complementary tests include measures of joint position sense error (JPSE) [20], two‐point discrimination (2PD) [21], laterality recognition (measuring time and error when judging whether an image is of the left or right side of the body) [22], postural sway [23], smoothness (or ‘jerk’) of movement [24], and a suite of quantitative sensory tests (QST). The most common QST protocol currently in practice is measurement of pressure pain detection threshold (PPDT) through algometry. This is a psychophysical metric of mechanical pain sensitivity, most commonly tested through a handheld algometer with a 1cm2 rubber tip applied to the skin over top of the painful region. The pain threshold is that force (pressure) at which the patient indicates the sensation has changed from pressure to pain. The average of two or three repetitions has been found to provide good reliability in clinical settings [25], and can be an indicator of local or widespread hyperalgesia / sensitization when tested over different body regions. [26] PPDT is also a common test stimulus when exploring the phenomena of conditioned pain modulation [27] or exercise‐induced hyperalgesia [28], both potentially providing additional clues as to the best initial approach to managing pain and improving patient function. When working with patients for whom pain is a primary complaint, physical therapists have different options based on pain acuity. Acute pain: Physical therapists have traditionally focused on facilitating tissue healing in the acute stage of injury or pain. However, available research does not offer compelling evidence that intervention based on tissue ‘stages of healing’ leads to more rapid recovery.[29, 30] More recently, prognostic screening tools have been published that allow clinicians to identify the most likely recovery trajectories for patients with acute pain. Such tools exist for acute low back pain [31], acute traumatic neck pain [32], and mixed region acute pain [33, 34]. These can be used to identify those patients in the acute stage of injury that may be at greatest risk of persistent problems. A ‘prognosis‐based’ approach to acute pain management is seeing increasing support in the literature [35, 36]. Accordingly, a reasonable approach to managing acute musculoskeletal pain is to use prognostic tools to predict outcome, identify modifiable factors in those deemed high risk of non‐recovery and intervene early to prevent chronic problems, while taking a more arm’s‐length approach to those deemed low risk. Chronic Pain: In the chronic pain stage, the focus shifts from prognosis to managing primary pain drivers identified through the comprehensive assessment strategies described earlier and optimizing quality of life. Critical to achieving a successful outcomes is establishing what a successful outcome will be for each patient. Commonly these are resumption of some aspect of lost prior life activities, social roles or general symptom reduction and ease of life, but these should not be assumed to be the only acceptable outcomes for all people. Through discussion and reflection, clinicians hear patient concerns, fears, and desires and work with them to calibrate expectations, establish milestones of improvement, and build person‐centric intervention strategies. Described below are common treatment approaches employed by physical therapists for management of pain. Intended as an overview, readers should remember that nothing works for everyone, though everything will work for someone. While not all patients will need formal pain education, a common role of the physical therapist is to identify unhelpful or inaccurate beliefs and provide advice and education in a patient‐centered fashion. Education commonly attempts to validate and demystify the patient’s experiences of pain and help establish realistic and achievable expectations. Prior research has shown that people in pain tend to prioritize pathomechanical or biomedical explanations for pain [37] while related research suggests that strong beliefs in such explanations may contribute to beliefs that pain is associated with tissue fragility or damage, increasing experiences of fear and disablement [38,39]. Patients may benefit from reassurance from an expert that movement is safe and important for healthy tissues, and that it can facilitate pain reduction and contribute to a sense of control over pain. Pain‐related education can take many forms, and the optimal mode should be established by first understanding the knowledge base from which the patient is starting, their values, preferred learning style, and the purpose or outcomes expected as a result of the intervention. If delivered in an insensitive, patronizing, paternalistic, or generic way attempts at education can have the opposite effect – leading to further feelings of stigma or shame if the impression is that the therapist is blaming the patient for ‘thinking wrong’. For those who are likely to benefit from education, options range from informational pamphlets or infographics, through streaming online video sites, websites, blogs, podcasts, books, group classes, to personally‐tailored one‐on‐one educational sessions. An emerging competency for physical therapists lies in review and critical appraisal of these sources for their trustworthiness and relevance for different patients. A formalized type of education, commonly referred to as pain neuroscience education (PNE), usually follows a curriculum that can be tailored to the patient and is delivered in a direct one‐to‐one fashion. Drawn from principles of cognitive therapy, this type of education covers a range of topics, from the function of peripheral tissues and nerves, through to cortical neuroplasticity and biopsychosocial interactions in the experience of pain. Evidence is mounting to suggest that when delivered in the right way, to the right patient, at the right time, PNE can significantly reduce feelings of fear and distress about pain, improve range of motion, strength, and self‐efficacy [40]. Interestingly, that same evidence suggests that of all the effects of good PNE, its smallest effect is on pain severity itself, providing a sound reminder that pain, distress, and disability are related but distinct constructs.
Chapter 15
Physical therapy and rehabilitation
Pain and Physical Therapies
Clinical assessment
Patient Self‐report Tools
Physical performance tests
Other Clinical Tests
Synthesizing Assessment Findings with Treatment Planning
Treatment approaches
Reassurance, activity‐encouragement and education
Biophysical modalities
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