Chronic pain contributes to an estimated $600 billion in direct medical costs, lost productivity, and disability, and it is one of the most common reasons adults seek medical care. In the United States, it is estimated that approximately 20.4% of Americans face chronic pain (defined as pain on most days or every day for the past 6 months).1 Chronic pain is an immense burden to the medical system, but the traditional medical system itself is likewise an immense burden to chronic pain patients. Two examples of this are high-cost, low-value interventions such as surgeries andaddictive medications—both have proven dangerous and even deadly.
The danger of addictive medications in pain symptoms is difficult to overstate. In 2018, more than 130 people died each day from opioid-related drug overdoses and an estimated 10.3 million people misused prescription opioids.2 Even alongside drastic government regulation, multi-billion-dollar pharmaceutical lawsuits, and awareness campaigns, these appalling numbers continue to climb.
Physical Therapy: A Frontline Intervention
Physical therapy has begun to gain the support of physicians, patients, and the media, as peer-reviewed research continues to show its effectiveness, safety, and low cost. Physical therapy is a critical element in the treatment of chronic pain and is perfectly positioned to be a frontline intervention in chronic pain management.
It is now well-established in medical and physical therapy literature that a sensitized peripheral and central nervous system is crucial in the development and maintenance of chronic pain. Calming of the sensitized nervous system happens via three key interventions: education, active movement, and neurocognitive training. These are not mutually exclusive but must be intertwined based on the presentation of the individual patient and that person’s beliefs. It is important to recognize that passive modalities may play a very limited role in chronic pain management but “should be avoided as mono-therapy and not routinely be used, because they may increase the risk of illness behaviour and chronicity.”3
Pain Neuroscience Education
One way physical therapy can address chronic pain is to use it as an educational tool to help individuals affected by chronic pain learn more about the underlying biology related to their pain, known as pain neuroscience education (PNE). Strong evidence supports the use of PNE to reduce pain catastrophization and fear-avoidance, which in turn allows patients to move more – a critical element of pain management. Virtual reality (VR) has emerged as a tool that harnesses PNE to address catastrophization and fear-avoidance.
Researchers who have studied the neurobiology of virtual reality pain attenuation note that, “Because of its uniquely immersive nature, VR is a powerful means of modifying affect. Fears, anxieties, and cravings can be elicited or inhibited by specific VR environments.”4 Patients using a VR system are less distracted and more engaged. They simply find it much easier to pay attention in a relaxing environment of their choosing rather than a busy outpatient clinic.
The timing of education is where the real art of applying educational intervention lies. In a recent conference call with Adriaan Louw, PT, PhD, a researcher and educator who has several published works about pain neuroscience, Louw urged clinicians to consider patients’ stage of change. “If a patient is in the precontemplation stage of change, they are not a candidate for PNE. You’ll end up with frustrated patients and bad Google reviews.” Therapists must meet patients where they are and provide the right education at the right time to reduce fear of movement, reduce catastrophizing, and optimize their outcomes. People learn through stories, which also serves as opportunity to connect and validate their experiences.
Education in isolation is not an intervention that will lead to significant, long-lasting change in pain levels. Patients need active intervention to change the nervous system and experience that it is safe to move. The benefits of exercise in reducing pain are profound. A recent RCT published in Pain affirmed that aerobic exercise training is an effective intervention for CLBP management likely through enhancements in endogenous pain inhibition.5 Other studies have found both resistance training5,6,7 and condition-specific exercise8,9 to be effective at reducing pain symptoms. Exercise mode may change based on the patient’s beliefs and abilities, but the need for physical movement is paramount.10-12
Finally, one of the most profound ways we can influence the nervous system is through cognitive therapy. The popularity of terms such as mindfulness, meditation, relaxation, and self care are evidence of the massive amount of research and media attention that has been rightly directed at these interventions.
The role of chronic stress, cortisol dysfunction, and pain is well-explained in a 2014 study in Physical Therapy that notes: “Ultimately, a prolonged or exaggerated stress response may perpetuate cortisol dysfunction, widespread inflammation, and pain.” The study further explained that “coping, cognitive reappraisal, or confrontation of stressors may minimize cortisol secretion and prevent chronic, recurrent pain.”13 Guiding patients through diaphragmatic breathing, mindfulness training, or progressive relaxation can change patients pain immediately. Nutrition coaching, sleep hygiene training, and coping skills are interventions that pay dividends down the road, although the aforementioned are in no way conclusive.
Modalities and More
Louw and colleagues have identified 22 treatments commonly used by PTs to enhance the endogenous system which calms down a sensitive nervous system.14 Physical modalities are included in this list. While in isolation they are not very helpful, they can be applied to specifically target what triggers the nervous system. Among these modalities are electrical stimulation, which uses gate control to reduce nociceptive input into the CNS, a process that can ease pain. Low-power laser and therapeutic ultrasound has been found to play a role in reducing or optimizing inflammatory processes which are known to ramp up the nervous system.15 Recent studies have found that cryotherapy effectively slows sensory nerve signals transmitted by c-fibers, thus reducing perceived pain.16,17 Improving patients’ locus of control, particularly with thermal modalities, such as heat, is critical in building and maintaining therapeutic alliance. Therapeutic alliance should be considered and leveraged in the use of any modality as part of a multimodal treatment plan.
Therapeutic hot/cold products such as wraps and packs can be useful to therapists treating patients in the clinic but may also be an affordable, easy-to-use tool patients can use at home for temporary relief from pain symptoms. Likewise, topical analgesics can also be an economical, user-friendly source of temporary relief for some musculoskeletal pain symptoms. Both hot/cold and topical products are easy to find and available in a variety of sizes and formulations.
Biofeedback technologies are another tool therapists can to treat chronic pain symptoms. Biofeedback training is non-invasive and can help teach patients techniques they can use to manage their own pain. Sensors are attached to the body to monitor certain functions such as brain waves, heart rate, and breathing, and are fed back to the patient. Patients then can use the feedback to learn to control the body’s reaction through their own thoughts or behaviors.
An Elegant Touch
Physical therapy is essential and should be primary in the multidisciplinary treatment of chronic pain. The positive benefits continue to mount as society looks for non-pharmacologic ways to manage this troubling diagnosis. Education, movement, and cognitive therapies are the hallmarks in program design and have proven to be an effective solution. As therapists, the focus should be patient-specific with an elegant touch of empathy and connection. In the wise words of Adrian Louw, “The biggest thing you can give a patient in pain today is hope.” We can and we must change the way chronic pain is managed. The physical therapy profession is poised to be the catalyst of effective chronic pain management. RM
Stephen Clark, PT, DPT, ATC, is the Clinic Director at the Newnan, Georgia, Walmart Health location. He is a cum lade graduate of Georgia Southern University with a Bachelor of Science degree in Athletic Training and an honor graduate of Armstrong Atlantic State University as a Doctor of Physical Therapy. Clark has practiced in outpatient private practice since 2013. He has continued learning through the completion of Evidence in Motion’s Orthopedic Manual Therapy certification program in 2014, earned his Orthopedic Clinical Specialist (OCS) designation in 2015, and also graduated from Evidence in Motion’s Executive Program in Practice Management in 2018. Previously, Clark served as a clinic director with Texas Physical Therapy Specialists from 2015 to 2020 and was named TexPTS Team leader of the year. He was also a Confluent Health Team leader of the year finalist in 2020. For more information, contact RehabEditor@medqor.com.
- Dahlhamer J, Lucas J, Zelaya C, et al. Prevalence of chronic pain and high-impact chronic pain among adults – United States, 2016. MMWR Morb Mortal Wkly Rep. 2018;67(36):1001-1006. Published 2018 Sep 14. doi: 10.15585/mmwr.mm6736a2
- HHS.gov. 2019. What Is The U.S. Opioid Epidemic?. [online] Available at: https://www.hhs.gov/opioids/about-the-epidemic/index.html [Accessed 24 December 2020].
- van Tulder M, Becker A, Bekkering T, et al. Chapter 3. European guidelines for the management of acute nonspecific low back pain in primary care. Eur Spine J. 2006;15 Suppl 2(Suppl 2):S169-S191. doi: 10.1007/s00586-006-1071-2
- Gold JI, Belmont KA, Thomas DA. The neurobiology of virtual reality pain attenuation. Cyberpsychol Behav. 2007;10(4):536-544. doi: 10.1089/cpb.2007.9993
- Bruehl S, Burns JW, Koltyn K, et al. Are endogenous opioid mechanisms involved in the effects of aerobic exercise training on chronic low back pain? A randomized controlled trial. Pain. 2020;161(12):2887-2897. doi: 10.1097/j.pain.0000000000001969
- Koltyn KF, Arbogast RW. Perception of pain after resistance exercise. Br J Sports Med. 1998;32(1):20-24. doi: 10.1136/bjsm.32.1.20
- Vaegter HB, Handberg G, Graven-Nielsen T. Similarities between exercise-induced hypoalgesia and conditioned pain modulation in humans. Pain. 2014;155(1):158-167. doi: 10.1016/j.pain.2013.09.023
- O’Leary S, Falla D, Hodges PW, Jull G, Vicenzino B. Specific therapeutic exercise of the neck induces immediate local hypoalgesia. J Pain. 2007;8(11):832-839. doi: 10.1016/j.jpain.2007.05.014
- Ickmans K, Voogt L, Nijs J. Rehabilitation succeeds where technology and pharmacology failed: effective treatment of persistent pain across the lifespan. J Clin Med. 2019;8(12):2042. Published 2019 Nov 21. doi: 10.3390/jcm8122042
- Daenen L, Varkey E, Kellmann M, Nijs J. Exercise, not to exercise, or how to exercise in patients with chronic pain? Applying science to practice. Clin J Pain. 2015;31(2):108-114. doi: 10.1097/AJP.0000000000000099
- Wang XQ, Zheng JJ, Yu ZW, et al. A meta-analysis of core stability exercise versus general exercise for chronic low back pain. PLoS One. 2012;7(12):e52082. doi: 10.1371/journal.pone.0052082
- Macedo LG, Smeets RJ, Maher CG, Latimer J, McAuley JH. Graded activity and graded exposure for persistent nonspecific low back pain: a systematic review. Phys Ther. 2010;90(6):860-879. doi: 10.2522/ptj.20090303
- Hannibal KE, Bishop MD. Chronic stress, cortisol dysfunction, and pain: a psychoneuroendocrine rationale for stress management in pain rehabilitation. Phys Ther. 2014;94(12):1816-1825. doi: 10.2522/ptj.20130597
- Louw A, Puentedura E, Schmidt S, Zimney K. Pain Neuroscience Education Teaching People About Pain. Vol 2. Minneapolis: Orthopedic Physical Therapy Products; 2018.
- Algafly AA, George KP. The effect of cryotherapy on nerve conduction velocity, pain threshold and pain tolerance. Br J Sports Med. 2007;41(6):365-369. doi: 10.1136/bjsm.2006.031237
- Herrera E, Sandoval MC, Camargo DM, Salvini TF. Motor and sensory nerve conduction are affected differently by ice pack, ice massage, and cold water immersion. Phys Ther. 2010;90(4):581-591. doi: 10.2522/ptj.20090131
- Cotler HB, Chow RT, Hamblin MR, Carroll J. The use of low level laser therapy (LLLT) for musculoskeletal pain. MOJ Orthop Rheumatol. 2015;2(5):00068.