by Misty Seidenburg, DPT, OCS, cert. MDT
Chronic pain, defined as long-lasting pain that endures for more than 6 months, affects an astounding 30.7% of Americans—that is 116 million people. Half of these individuals report that their pain occurs daily, and more than 30% report pain as being severe (greater than 7/10 on a scale from 0 to 10).1
The traditional belief of pain stems from a historical medical model that pain is a response to an organic dysfunction, but there is a push in the medical community to change that thinking. Recent research has shifted to a “pain neuromatrix” model, as it has been demonstrated that pain is a response to altered neural control and cortical feedback, and not simply an “issue in the tissue.”2 When the brain perceives a threat to a person’s well-being beyond a normal tissue healing time or even without any injury, a “pain matrix” can be run, affecting many different body systems. Before long, the individual may be unable to sleep, unable to exercise, and become deconditioned—leading to arthritis or obesity, and a deterioration in relationships. That person may no longer be able to support a family and can become depressed and anxious. Chronic pain can undermine quality of life in all aspects.
Goal setting is an important part of a physical therapy program in that it should guide the treatment process. At Drayer Physical Therapy Institute, residents and fellows have extensive training in interview techniques and goal setting for best treatment. We advocate including the patient in goal setting and using these goals to guide the plan of care. Establishing goals will vary depending on the chronicity of the patient’s complaints.
In the acute phase, goals are often aimed at restoring mobility quickly and returning the patient to prior level of function. Because symptoms have not been present long, it is relatively simple to determine activities to which the patient should return.
When working with patients affected by chronic pain, establishing appropriate goals can be more difficult, and the focus should be on improving function. There is less focus on eliminating pain completely, as they realistically may always have some level of pain even as their activity level improves. Often, these patients have become deconditioned, and it can be difficult to establish what the patient should be able to return to doing.
After goals between the therapist and patient are established, ensuring compliance is key to a successful outcome. The goals are mutually agreed upon, which facilitates patient compliance. In addition, consistent communication between the therapist and patient, continuous re-assessment of function, and progress toward goals help to keep the patient motivated, because they are more aware of the changes that have been made. Goals can be adjusted throughout the care episode based on the patient’s response. Giving a patient choices during care—such as the order of exercises or how to make them more challenging—can make that individual a more active participant and improve outcomes.
Approaches to Treatment
When patients present with chronic pain, it is important to understand their pain as more than a mechanical issue, and realize that often pain symptoms are predominantly output-driven from the brain. There are different mechanisms that can be affected, and a combination of education, cardiovascular exercise, nerve mobilization, graded exposure, relaxation, and pain-relieving modalities are key to successful treatment.
In a program for patients in chronic pain, providing education during day 1 is integral to that program’s success. Research has demonstrated that helping an individual understand pain by increasing the patient’s awareness of the nervous system can create an immediate improvement in pain levels. Daily education should also be completed as a formal intervention during treatment. Instructing the patient about a progressive home exercise program and furthering the understanding of symptoms allows the patient to have ownership over symptoms being experienced.
Cardiovascular exercise, nerve mobilization, graded exposure, and relaxation exercises also must be addressed. Many patients affected by chronic pain have a fear of movement and, thus, believe that movement may cause further damage. In reality, graded exercise is one of the most beneficial things to manage pain. Educating the individual about the benefits of movement and prescribing appropriate levels and types of activity can help them return to previously avoided activities.
Although the focus with patient care in chronic pain is restoring mobility and function, oftentimes providing the patient with passive modalities can facilitate ease through a treatment session and assist in providing pain relief as the patient heals. Providing pain relief can be encouraging and promote a patient to continue the treatment needed to achieve their goals. Although the process of reducing pain levels is slower than in acute injuries, as patients better manage their pain they slowly increase functional mobility, and gradually improve activities of daily living.
Electrical stimulation such as TENS and H-Wave can help modulate the pain cycle and offer relief as patients begin increasing their function. There are two theories about how this works: the first is that it causes a relief of opioids to block pain; the second is that it blocks C-fiber nociception to the brain. It is this author’s experience that the use of electrical stimulation allows improved freedom of movement during therapy, and the immediate effects of pain relief improve patient compliance.
Heat and cold are simple therapies which, when used appropriately, can be tools for patients to use both in the clinic and at home to manage their symptoms. Among patients affected by chronic pain symptoms, heat is generally the preferred modality, as it can create muscular relaxation and improve tissue extensibility. Heat can also facilitate relaxation to the autonomic nervous system, which is heightened in a chronic pain state.3
Topical analgesics can sometimes be helpful for these individuals. The literature does not support the use of menthol or capsaicin for relieving pain, but anecdotally, many patients report that these creams help reduce their symptoms.
Low-Level Laser Therapy (LLLT)
LLLT is the use of red and near-infrared light to enhance the body’s natural healing process to mitigate chronic pain. It is applied by placing the light source in contact with skin to allow the photons to penetrate the tissue, where it interacts to increase circulation and cellular function. For reduction in pain, the mechanism is thought to inhibit C-fibers, increase opioid binding, and to mimic NSAID effects. The research is not concrete on effectiveness of LLLT, but initial studies are promising.4 Class IV and class 3B lasers are among those made to provide pain relief.
Patients affected by chronic pain can develop abnormal posturing as an attempt to protect the symptomatic area. Tape can be used to facilitate more normal movement patterns, reduce tone, and apply proprioceptive feedback for positioning. This gentle reminder during a patient’s daily activities can stop them from completing movements that may exacerbate symptoms. RM
Misty Seidenburg, DPT, OCS, cert. MDT, is the Drayer Physical Therapy Institute’s (DPTI) orthopedic residency manager. She is a graduate of the DPTI Orthopedic Residency and Spine Fellowship and is board-certified in orthopedics. For more information, contact [email protected].
The Evolution of Photobiomodulation Therapy
Until recently, the use of red and near-infrared light as a healing modality has struggled with an appropriate identification. The effects of light to reduce pain, inflammation, and edema were observed soon after the invention of lasers.1 Since those initial observations, numerous scientific studies have been conducted and therapy lasers have become a viable healing modality. Unfortunately, more than 75 terms have been used to describe the modality, including low-level laser therapy (LLLT), cold laser, soft laser, photobiostimulation, and photobiomodulation.2
The lack of a single name has created some concern for researchers in the field. One of the more frequently used terms has been low-level laser therapy (LLLT); however, the words “low” and “level” can be vague, if not somewhat inappropriate, especially with the advent of higher-power lasers. Additionally, light from sources other than lasers can be used to deliver LLLT responses.3 There reportedly was resistance to change from LLLT because it was a well-established MeSH (Medical Subject Heading) search term. MeSH is the National Library of Medicine’s controlled vocabulary, which consists of terms that are used to index articles in the world’s leading biomedical journals.4
At a 2014 joint meeting of the North American Association for Laser Therapy (NAALT) and the World Association of Laser Therapy (WALT), there reportedly was a nomenclature discussion meeting and, as a result of that meeting, the term “photobiomodulation therapy” will be added to the MeSH database.
Photobiomodulation therapy is defined as ‘‘a form of light therapy that utilizes non-ionizing forms of light sources, including lasers, LEDs, and broadband light, in the visible and infrared spectrum. It is a nonthermal process involving endogenous chromophores eliciting photophysical (ie, linear and nonlinear) and photochemical events at various biological scales. This process results in beneficial therapeutic outcomes, including but not limited to the alleviation of pain or inflammation, immunomodulation, and promotion of wound healing and tissue regeneration.’’3
The term “photobiomodulation (PBM) therapy” is reportedly now being used by researchers and practitioners. For example, NALT has changed the words that comprise its acronym name to North American Association of Photobiomodulation Therapy,2 the Optical Society held its second incubator on the subject but this time used the name photobiomodulation,5 and numerous scholarly articles are now being published with the term “photobiomodulation therapy.”
- Johannes CB, Le TK, Zhou X, Johnston JA, Dworkin RH. The prevalence of chronic pain in United States adults. Results of an internet-based survey. J Pain. 2010;11(11):1230-1239.
- Gaskin DJ, Richard P. Appendix C: The economic costs of pain in the United States. J Pain. 2012; 13(8):715-724.
- Moseley G. A pain neuromatrix approach to patients with chronic pain. Manual Therapy. 2003; 8(3):130-140.
- Lee YH, Park BR, Kim SH. The effects of heat and massage application on autonomic nervous system. Yonsei Medical Journal. 2011;52(6):982-989.
- Kingsely JD, Demchak T, Mathis R. Low-level laser therapy as a treatment for chronic pain. Front Physiol. 2014;5:306.