Physical therapists deal with people in pain every day. It is one of the basic reasons people come to us to seek treatment. Why is it that we are not experts in pain treatment? Pain affects everyone, that is a given. Usually our pain lasts as long as there is tissue damage and gradually subsides during the healing process. During our education of the physical therapy profession we learned about pain from the biomedical model. “The biomedical model assumes that all pain has a distinct physiological cause and that clinicians should be able to find and treat that physiological problem.” (Sluka, 2009) We enjoy and are rewarded by providing service to those with acute pain. In fact, we want to help everyone to the best of our abilities. Why should we be interested in chronic pain?
Because chronic pain treatment is a service we can provide
We consider ourselves as excellent, unprejudiced providers of musculoskeletal treatment. Although it’s impossible to be experts in every topic, we do need to be able to serve those who come to us for help. According the Centers for Disease Control and Prevention, one in ten US adults have pain that has lasted a year or more (CDC, 2006). That’s a lot of people who for the most part are lacking in cost-effective non-pharmacological treatment options. Offering chronic pain treatment could expand our services to those who are already coming in our door, but failing conservative treatments.
Because we are problem solvers
Can we solve the problem of chronic pain? Of course not, but by being attentive, reflective listeners we can make our patients feel understood. For instance, while listing the litany of complaints in the patient’s subjective, we can listen, formulate and reflect back the patient’s concerns of daily function. This not only exemplifies empathy but also provides a basis for the problem list, and therefore patient goals.
Although listening to endless tales of woe and pain may seem exhausting, once a person realizes you are actually listening and understanding, a surprising thing happens. They stop complaining as much. They smile in recognition when you see them next. Now you are an ally instead of a dictator commanding them what to do. Patients work harder towards their goals, which with our help, now appear achievable. Understanding creates hope.
Because there is a need
In the last ten years, chronic pain management programs that offer biopsychosocial treatments have proliferated in the world as pain science has evolved. The exception is the United States. Estimates of the number of interdisciplinary, biopsychosocial pain management programs in the United States have plummeted from over 1000 in 1999, to 150 in 2012. (Schatman, 2012) These numbers do not include commonly experienced pain management clinics based on the biomedical model, where the most common treatments include injections. Medicare expenditures for injections have increased from $24 million to over $175 million between 1994 and 2001. There has been a 271% increase in lumbar epidural steroid injections, while the incidence of low back pain has remained stable. Lumbar injections, much like some of our physical therapy modalities, have not shown reproducible clinical effectiveness. (Friedly, Chan e Deyo, 2007) “It is important to acknowledge… that none of the available treatments for chronic pain have been demonstrated to eliminate all pain for all patients.” (Turk, 2002) Although multidisciplinary clinics which provide medical, physical, and psychological treatment are more effective than one discipline alone, physical therapy treatment is better than no treatment. (Flor, Fydrich e Turk, 1992)
Because we are evidenced based practitioners
There is an abundance of evidence about chronic pain ripe for translational researchers to gather for clinical application. According to the International Association for the Study of Pain, pain is “an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage.” (Group, 2011) Chronic pain is now considered the impairment, and the pathology is a multifaceted original expression of the whole person: tissues, emotions, immune system, past experiences, nutrition, nerves, thoughts, hormones, genetics, social support, musculoskeletal response, culture, and meaning. (Melzack e Katz, 2013)
I believe physical therapists can be educated to treat not just the biological tissues, but also the psychosocial aspects of pain. A recent article in Physical Therapy (Nielsen M, 2014) studied the use of cognitive behavioral therapy by PTs to treat the pain of knee osteoarthritis. The impairment of chronic pain calls for a multifaceted treatment approach of a pain therapist who is able to combine physical movement, goal setting and attainment, education, neuromuscular reeducation, activity pacing, relaxation techniques, modalities and other available treatments. Instead of being condemned to a past of failed conservative physical therapy, we need to help patients with chronic pain discover their strengths to get through today, and to build upon their own self-efficacy.
Because we want to help
What can PTs do? First of all, we need an attitude adjustment. We need to stop demeaning our patients with our cynicism, disbelief and prejudices. People in chronic pain need someone to really stop and listen, even if it is difficult. They need someone to believe them, even if we don’t agree or can’t imagine what they are going through. They certainly don’t need someone to pigeon-hole them as disability or narcotic seekers. But they do need someone who will offer a caring, individualized approach to their treatment.
Even if our objective measurements don’t match up with the person’s complaints, the person still needs someone to listen, to understand, and to provide an explanation of what they’re going through. Even Waddell recognized the importance of looking at the whole person in his seminal article Nonorganic Physical Signs in Low-Back Pain: “Equally, all patients with pain show some emotional and behavioral reaction. Physical pathology and nonorganic reactions … are not alternative diagnoses.” (Waddel G, 1980) We can offer belief of their experience, empathy for their situation, and a process for them to learn how to function. Not much different than when a person needs to learn how to walk with crutches after a meniscus repair, except that we can’t see the impairment of pain. But we can accept what a person says as an expression of their suffering and offer a way to function through the pain, just as we offer those with straightforward orthopedic problems options to cope with their impairments.
Because we are innovators
Now is the time for us to take on chronic pain. Why? Because there is a need, we care and want to help. Because we have the time to spend conversing with people, listening and learning from and about them. We have the time to shape up their muscles and increase their exercise tolerance. We have the time to offer them hope of a life in which they can participate. We can provide education that highlights the fact that pain doesn’t necessarily mean there is tissue damage. We can encourage them to pace out their activities in order to function. There is a huge demand for chronic pain treatment in the United States, and PTs can supply that treatment if we are willing.
PTs need to be educated and able to provide the chronic pain population with clinically effective, cost effective biopsychosocial treatments which are currently not accessible for most people here in the US. PTs are in a strategic position to fill this gaping hole of treatment options for those in chronic pain. We have always been the profession to step up to the plate when an innovative, time consuming, and yes sometimes unpleasant treatment is required. Our resourcefulness developed during the post war eras, the polio epidemic, in wound care, and the running and athletic era that began in the 1970’s. Now is the time for us to take on chronic pain.
Because we want to help people reach their functional goals
Most people in chronic pain don’t expect their pain to be eliminated. We can help them discover what functional abilities are most important and achievable for each person. It is rewarding to help someone participate more in daily life. Improved function allows a person feel better about themself, which builds self-efficacy, which can continue to reap future health benefits.
This article optimistically will create more questions for discussion. Why is chronic pain so difficult to treat? Are we willing to help, or are we willing to try—only to determine we cannot help. What profession can take on the chronic pain problem? Why don’t PT schools teach the International Association for the Study of Pain’s curriculum on pain? How can we better educate ourselves in order to provide badly needed treatment? Where should a person with fibromyalgia or any other chronic pain problem turn for help? I hope physical therapists are interested in being a part of the answer.
CDC. (2006, November 15). NCHS Press Room. Retrieved February 11, 2014, from Centers for Disease Control and Prevention: http://www.cdc.gov/nchs/pressroom/06facts/hus06.htm
DC, T. (2002). Clinical Effectiveness and Cost-Effectiveness of Treatments for Patients with Chronic Pain. The Clinical Journal of Pain, 18(6), 355-365.
Flor H, F. T. (1992). Efficacy of Multidisciplinary Pain Treatment Centers; A Meta-Analytic Review. Pain, 48, 221-230.
Friedly J, C. L. (2007). Increases in Lumbosacral Injections in the Medicare Population 1994 to 2001. Spine, 32(16), 1754-1760.
ITW Group. (2011). IASP Pain Terminology. Retrieved January 21, 2014, from International Association for the Study of Pain: . http://www.iasp-pain.org/Content/NavigationMenu/GeneralResourceLinks/PainDefinitions/default.htm
Melzack R, K. J. (2013). WIREs Cognitive Science. Retrieved January 21, 2014
Nielsen M, K. F. (2014). Physical Therapist-Delivered Cognitive-Behavioral Therapy: A Qualitative Study of Physical Therapist’s Perceptions and Experiences. Physical Therapy(94), 197-209.
Schatman, M. (2012). Interdisciplinary Chronic Pain Management: International Perspectives. Pain Clinical Updates(xx).
Sluka, K. (2009). Mechanisms and Management of Pain for the Physical Therapist. Seattle, WA: IASP Press.
Waddel G, M. J. (1980, March/April). Nonorganic Physical Signs in Low-Back Pain. Spine, 5(2), 117-125.