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How do you treat chronic pain?

2/13/2014

2 Comments

 
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I performed 3 evaluations yesterday morning. The first individual has been having cervical pain since a MVA in 1991, the second low back pain since her first child 7 years ago, and the last individual was having bilateral radicular symptoms for the past 6 months following a discharge from the military. All 3 can be defined as having chronic pain. Knowing their duration of symptoms alone, how does this change my plan of care? How does it change my prognosis? What sort of goals need to be set between the patient and I?

When a patient presents to you with pain for >6 months, they often are having pain in multiple joints. This makes sense from both a biomechanical and cortical reorganizing perspective. Biomechanically, if an individual is having pain, they will often start to move more from other body regions to avoid pain. These abnormal movements cause repetitive microstrains and result in pain as well. Additionally, individuals with chronic pain will posture themselves in non-painful positions throughout the day. You will often see them in a guarded, fearful posture. Looking at chronic pain from the cortical level, many changes begin occurring in the cortex in the presence of pain. Cortical smudging occurs and other areas of the brain become activated in the presence of pain. Some of these other areas are those associated with cognitive functioning and emotion so you can imagine how the pain completely envelopes their life. 

As you can tell already, there is no magical solution to treating these patients. But good approaches include using graded exercises, addressing all barriers that will prevent them from succeeding, and creating realistic and specific goals to measure success. Graded exercise is essential because many of these people STOP exercising in the presence of pain. We see them completely deconditioned, making it difficult to distinguish between true tissue pain or simply the aches and soreness associated with starting a new exercise routine. Start small and start slow! For example, as part of their HEP, I gave one of these patients a home walking program (based off the results of their 6 minute walk test): Walk 4 minutes, 3x/day. Yes, it seems simple, but it is realistic! Barriers also need to be addressed. Typically if someone has been having pain for ~20 years, they have tried to seek care elsewhere but it has been unsuccessful. Why is it unsuccessful? Maybe the musculoskeletal pain is not the only factor. You need to determine if they have financial barriers, transportation issues, psychological issues, social barriers, and more (all of this is obtained during the subjective interview, but gathered much more throughout subsequent visits as you develop a relationship with the patient). Finally, realistic goals must be set. If someone believes they have 10/10 & have been having that pain for 7 years, completely eliminating their pain is not a realistic goal. You need to determine what the patient wants to achieve and set obtainable goals with a set time frame. 

As you can imagine, adherence and compliance with therapy is another huge problem. Throughout these treatments, education is KEY. Sometimes it may feel that we turn into psychologists. This is partly true, but I say we have a little more power than them. Our research shows that graded exercise is beneficial for individuals with chronic pain. We can spend 1 hour listening to and educating the patient while having them exercise. Early in the treatment you may be taking on a "general exercising and conditioning" approach. This is fine! Stick with it and you will likely find you are often successful.

-Jim   



2 Comments
Lee link
3/22/2014 07:22:35 pm

It would be a much better post if you'd attach evidence to your statements.
Who said what, which journal and maybe look a little further into what constitutes 'chronic pain' eg duration, I think you'll find the literature disputes your time frame.

Just a thought

Lee...

Reply
https://magicalkatrina.com/magiciansblog/a-magical-touch-to-your-wedding-day link
5/18/2023 05:53:48 am

Thank you for shedding light on the topic of chronic pain and providing valuable insights on how to effectively treat it. Your article not only emphasizes the importance of a holistic approach but also encourages individuals to seek professional help. Your words truly resonate with me, reminding us that 'acknowledging and addressing the root cause is essential for long-term relief.' Keep up the great work!

Reply



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  • Home
  • About Us
  • TSPT Academy
  • Resources
    • Newsletter
    • Orthopedic Blog
    • Featured Articles
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    • Residency Corner
  • Special Tests
    • Cervical Spine >
      • Alar Ligament Test
      • Bakody's Sign
      • Cervical Distraction Test
      • Cervical Rotation Lateral Flexion Test
      • Craniocervical Flexion Test (CCFT)
      • Deep Neck Flexor Endurance Test
      • Posterior-Anterior Segmental Mobility
      • Segmental Mobility
      • Sharp-Purser Test
      • Spurling's Maneuver
      • Transverse Ligament Test
      • ULNT - Median
      • ULNT - Radial
      • ULNT - Ulnar
      • Vertebral Artery Test
    • Thoracic Spine >
      • Adam's Forward Bend Test
      • Passive Neck Flexion Test
      • Thoracic Compression Test
      • Thoracic Distraction Test
      • Thoracic Foraminal Closure Test
    • Lumbar Spine/Sacroiliac Joint >
      • Active Sit-Up Test
      • Alternate Gillet Test
      • Crossed Straight Leg Raise Test
      • Extensor Endurance Test
      • FABER Test
      • Fortin's Sign
      • Gaenslen Test
      • Gillet Test
      • Gower's Sign
      • Lumbar Quadrant Test
      • POSH Test
      • Posteroanterior Mobility
      • Prone Knee Bend Test
      • Prone Instability Test
      • Resisted Abduction Test
      • Sacral Clearing Test
      • Seated Forward Flexion Test
      • SIJ Compression/Distraction Test
      • Slump Test
      • Sphinx Test
      • Spine Rotators & Multifidus Test
      • Squish Test
      • Standing Forward Flexion Test
      • Straight Leg Raise Test
      • Supine to Long Sit Test
    • Shoulder >
      • Active Compression Test
      • Anterior Apprehension
      • Biceps Load Test II
      • Drop Arm Sign
      • External Rotation Lag Sign
      • Hawkins-Kennedy Impingement Sign
      • Horizontal Adduction Test
      • Internal Rotation Lag Sign
      • Jobe Test
      • Ludington's Test
      • Neer Test
      • Painful Arc Sign
      • Pronated Load Test
      • Resisted Supination External Rotation Test
      • Speed's Test
      • Posterior Apprehension
      • Sulcus Sign
      • Thoracic Outlet Tests >
        • Adson's Test
        • Costoclavicular Brace
        • Hyperabduction Test
        • Roos (EAST)
      • Yergason's Test
    • Elbow >
      • Biceps Squeeze Test
      • Chair Sign
      • Cozen's Test
      • Elbow Extension Test
      • Medial Epicondylalgia Test
      • Mill's Test
      • Moving Valgus Stress Test
      • Push-up Sign
      • Ulnar Nerve Compression Test
      • Valgus Stress Test
      • Varus Stress Test
    • Wrist/Hand >
      • Allen's Test
      • Carpal Compression Test
      • Finkelstein Test
      • Phalen's Test
      • Reverse Phalen's Test
    • Hip >
      • Craig's Test
      • Dial Test
      • FABER Test
      • FAIR Test
      • Fitzgerald's Test
      • Hip Quadrant Test
      • Hop Test
      • Labral Anterior Impingement Test
      • Labral Posterior Impingement Test
      • Long-Axis Femoral Distraction Test
      • Noble Compression Test
      • Percussion Test
      • Sign of the Buttock
      • Trendelenburg Test
    • Knee >
      • Anterior Drawer Test
      • Dial Test (Tibial Rotation Test)
      • Joint Line Tenderness
      • Lachman Test
      • McMurray Test
      • Noble Compression Test
      • Pivot-Shift Test
      • Posterior Drawer Test
      • Posterior Sag Sign
      • Quad Active Test
      • Thessaly Test
      • Valgus Stress Test
      • Varus Stress Test
    • Foot/Ankle >
      • Anterior Drawer
      • Calf Squeeze Test
      • External Rotation Test
      • Fracture Screening Tests
      • Impingement Sign
      • Navicular Drop Test
      • Squeeze Test
      • Talar Tilt
      • Tarsal Tunnel Syndrome Test
      • Test for Interdigital Neuroma
      • Windlass Test