Providing physical therapy for patients whose pain complaints do not resolve over time can be a significant challenge. With our growing knowledge we have new opportunities to educate patients and give them the tools early during treatment to decrease the risk of chronic pain.
A brief look at recent evidence-based findings on pain and central sensitization:
- Nociceptor inputs can trigger a prolonged but reversible increase in the excitability and synaptic efficacy of neurons in central nociceptive pathways.
- Central sensitization has been linked with pain sensitivity in patients with fibromyalgia, osteoarthritis, musculoskeletal disorders and generalized pain hypersensitivity, headache, temporomandibular joint disorders, neuropathic pain, and post-surgical pain.
- Musculoskeletal disorders can also be characterized by a spread of pain sensitivity to deep uninjured tissue;low level peripheral inputs may maintain this.
Woolf, CJ. Pain (2011) 152:3. S2-S15.
The importance of the role of stress in chronic pain:
- Stress produces mechanical hyperalgesia in skeletal muscle and a significant decrease in the mechanical threshold of muscle nociceptors.
- Stress induces an increase in conduction velocity and increases variability in neuronal activity.
Chen, Green & Levine. Neuroscience (2011) 185:6. 166–173.
Application in clinical practice: Continue to shift our paradigm from only the biomedical model to the biopsychosocial model.
Key risk indicators during PT evaluation/during the episode of care include:
- Pain that persists beyond 12 weeks.
- Red flags for serious pathology have been ruled out.
- Negative findings with diagnostic tests.
- Pain complaints that appear exaggerated when compared with what would generally be expected for the injury.
- Patient reports of significant stressors and/or in your clinical judgment the patient appears to be highly stressed.
- For back pain patients, use of short screening tools such as the 6-item or 9-item STarT Back can be used to identify patients who are at high risk for chronic, disabling back pain.
Treatment tools the physical therapist can incorporate into treatment:
- Instruction in techniques of diaphragmatic breathing: The stretch receptors in the lungs and airways stimulate the vagus nerve, which in turn reduces heart rate, reduces blood pressure, and has an overall calming effect. This can modulate pain, decrease anxiety, and promote sleep.
- Patient education about basic anatomy of the nervous system: how the brain and spinal cord process and regulate pain information, central sensitization, differences between acute and chronic pain, and neuroplasticity.
- Help remove the perception of threat of harm or further injury: A feeling of safety allows the sympathetic nervous system to slow and the vagus response to increase. Reminding the patient of “hurt but no harm” during therapy.
- Motor imagery: Instruct the patients to visualize themselves doing physical activities that they have enjoyed prior to injury. Then, progress through a series of non-threatening exercises to build capacity and confidence to return to the former activity.
- Specific relaxation techniques.
- Teach mind-body therapies that reduce chronic pain: include restorative yoga and mindfulness meditation.
The interdisciplinary team at Pacific Rehabilitation Centers can provide therapy care through the spectrum of acute, sub-acute, and chronic phases of injury in conjunction with behavioral health services when warranted. Our psychologists can provide Cognitive Behavioral Therapy as well, as comprehensive evaluation and treatment for depression and anxiety.
Our team goal is to enable patients to feel a greater sense of control, reduce their pain intensity, and return to living and functioning at the highest level possible.
Christie Oliver, PT, CMPT joined Pacific Rehabilitation Centers in February of 2015 as an Outpatient PT Manager to help develop the “PT Only Program ” and commercial client base as well as to support the existing work with pain and work programs. Christie enjoys working with her patients to reach their individualized goals and to improve their functional abilities and quality of life.
Her clinical experiences include orthopedic and neurological physical therapy in both the outpatient and inpatient settings for Providence Medical Center and Swedish Health systems in Seattle Washington. She developed and acted as instructor in a comprehensive conditioning program for patients recovering from spine injuries at Providence Medical Center.