Pain Management

10/3/2013

A few of the faculty members at the Harris Health System Orthopedic Residency started a Manual Therapy Fellowship program, OPTIM PT, last year. Part of their fellowship is devoted to pain management and how to incorporate manual therapy in the treatment of chronic pain. To introduce the topic of pain management, they brought in Rod Henderson, physical therapist and specialist in pain management. As a bonus, they let the Orthopedic residents attend the course as well. During the course, we covered the physiology of pain, pain theories, how to educate, and select appropriate interventions. Let me be clear now, we are not just talking about chronic low back pain. Chronic pain is present in a significant number of musculoskeletal problems. Consider the knee replacement patient who has had pain and decreased quality of life for the past few years; or consider any type of tendinopathy patient. Both of these patients are in a chronic state of pain.

Before we begin talking about pain, it is important to accurately define the word. Pain can be defined as a sensory and emotional experience in response to actual or potential tissue damage. The pain response has both protective and adaptive abilities, and is a necessary and important part of our lives. While it is necessary, the transformation from acute to chronic pain is where it can become a problem.

The dominating theory of pain science today is the Pain Neuromatrix, a theory that has not fully made it into physical therapy schools yet. In this theory, there is no true "Center of Pain." The Neuromatrix theory suggests that there are several factors (inputs) that determine a person's reaction to pain (output). Inputs include sensory, cognitive, and affective components that all interact with each other to determine how the person will perceive a stimuli, what actions need to be taken, and the appropriate stress regulations. The inputs are heavily determined by past experiences and the person's expectation to a certain situation. When you have chronic pain, there is an expansion of the receptive fields that send input to the brain. Certain stimuli will begin to have heightened states of sensitivity. This can manifest as pain with light touch, an increased heart rate, or sending the patient into tears. For example, a stimulus that previously went unnoticed, like putting on a pair of socks, can become immensely painful if your nerves are sending mass amounts of improper triggers to your brain. It is our task to rewire these inputs, using graded exercise, desensitization, and proper education.

A few take home points to remember when treating any chronic pain patient:
-All pain originates in the brain. I would suggest finding a tactful method to tell the patient that news. They probably will not come back if you simply say the pain is just in their head.
-The amount they hurt does not equal the amount of tissue damage that is present. Think about a paper cut on your index finger. It is rather small, but it can hurt a whole lot. Many people with chronic pain have completely healed "paper cuts", but their brain is responding as if the event just happened.
-Patients with chronic pain have maladaptive thoughts and beliefs. Many of these thoughts and beliefs go beyond their physical appearance. Most have additional stresses at work and home, complicating their musculoskeletal pains. Address these issues in your plan of care.
-Chronic pain implies that the issue has been present for a long time. Do not expect to heal these people in 1 or 2 treatments.

I know you did not go to PT school to become a psychotherapist, but other than psychologists we spend more time with our patients than any other healthcare provider. This is an unique advantage. Chronic pain is everywhere. If you are not learning how to incorporate the biopsychosocial model into your clinical practice now, you need to start. Understanding this will take your outcomes from good to great.

-Jim

6 Comments

Jackie

10/4/2013 07:50:53 am

I go to Cleveland State in Cleve, OH and we actually went over the Neuromatrix theory in depth in class. It was taught during our second year in the program in addition to the third... this was a great summary to read. i really enjoyed it! thanks!

Jim

10/4/2013 11:39:05 pm

Thanks Jackie. I am happy to hear programs are starting to incorporate this model. I know the major focus at my program were the Gate Control Theory and Opiate Analgesia Theories.

John

7/31/2015 03:34:59 am

There is a Neuromatrix treatment process which the theory involves treatment of C1-C2 relating to its involvement in tractioning of the meninges with regards to fibromyalgia. Unfortunately the treatment and education is found only within the chiropractic community and hasn't made it's way into PT practice, except for a handful of providers. I find that this treatment is highly effective in reduction of symptoms and improving AROM in the C/S.

Treatment of chronic pain has to do more with the skills and tools of the clinician vs. patient perception. Although the brain is certainly involved with up-regulation and down-regulation of pain based on a number of factors along with physiological remapping of pain perception over what was previously light touch, vibration, etc. you cannot discount the fact that there was and is a source of the pain in the musculoskeletal system. To say that "it is all in their head" is a cop out. We all need to know our strengths and weaknesses. We also must be able to admit when we simply don't know instead of taking sides on an already heated debate like fibromyalgia. Certainly manual therapy has its place in the treatment of chronic pain as does modalities. If you have the typical exercise model and expose your patients to the evidence based model for chronic pain you are likely to get smoke blown your know where by your patients. They know based on attitude, body language and clinical treatment whether or not you believe their complaints. I get patients that have been to other PTs and even chiropractors without relief or just temporary relief.
As a PT we need to think outside the box (the PT bubble) and take con-ed classes designed mostly for Chiros and ATCs to stay ahead of the curve while boosting patient outcomes. We are a cog in the healthcare continuum and need to keep open minds with a bit of scrutiny. Many of our current treatments were not born in PT.

Lets remember EBP doesn't have the designs on healing, it helps our practice in many ways but is limited. EBP can guide you to practice in new ways with new concepts, but it typically provides substantiation to seasoned PTs practice patterns years later.
I've found this true in the use of modalities, treatment procedures and therapeutic exercises.
Evidence was 3-5 years behind my treatment of neuro patients too.

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11/28/2022 01:16:01 am

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Pain Management

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