A Valuable

Tool for Pain

ManagementPHYSICAL THERAPY

Identify evidence based non-pharmacologic interventions

for pain.

Describe the ways in which Physical Therapy can skillfully

deliver evidence based interventions for pain.

Describe how physicians and allied health team members’

can address common barriers to referral and participation

in Physical Therapy

Illustrate how primary care providers and allied health

team members knowledge of the specific interventions

employed in physical therapy can support the patient’s

recovery.

OBJECTIVES

EMOTIONS

▪ Stress

management

▪ Pleasant

activity

scheduling

▪ Resilience

3

PT’s CONTRIBUTION TO E.R.A.S.E.

REFLECTIONS

▪ Reframing

▪ Relaxation

ACTIONS

▪ Exercise

▪ Pacing

▪ Problem

solving

SLEEP

▪ Reinforce

sleep

hygiene

ENVIRONMENT

Mi-CCSI Care Management Care Review Collaborative Presentation | Dave Williams PhD | February 16, 2018

PAIN & PT

Low back pain. A review of >60 randomized controlled trials

(RCTs) evaluating exercise therapy for adults with low back

pain found that such treatment can decrease pain, improve

function, and help people return to work.1

Before & after surgery. A review of 35 RCTs (~3,000 THA

patients): preoperative exercise and education led to

significant reductions in pain, shorter lengths of stay

postoperatively and improvements in function.2

Arthritis. PT exercise programs can reduce pain and improve

physical function among individuals with hip and knee

osteoarthritis.3,4

5

Advantages:

▪ Time

▪ Assessment

▪ Treatment

▪ Education

▪ Experts in neuromusculoskeletal assessment and treatment

▪ Screen for red flags, impact of co-morbidities, patient safety

▪ Provides Experiential Learning

▪ Effective Training regimens

▪ Timing of Care

▪ Secondary Prevention : halt the progression from Acute to Chronic Pain

▪ Able to simultaneously treat an acute flare up in the presence of

a chronic pain state.

HOW?

Physical Therapy can help safely dose patients with aerobic

exercise according to their specific needs, co -morbidities, and

patient preferences 5,6

BEST EVIDENCE: AEROBIC EXERCISEE.R.A.S.E: ACTION

Evidence Based Formats :

• Graded exposure

• Rating of Perceived Exertion

scale (RPE)

• 6-7 is the target for

effort that produces

optimal results

• To foster patient

engagement: may start

lower… however, too low

jeopardizes results.

Physical Therapy can evaluate for weakness and deconditioning that is increasing the demand on a patient to complete their ADL’s.

▪ Sit to stand

▪ Stair climbing

▪ Lift / push / pull / carry.

Pro’s 7,8

▪ Efficient: frequency can be 1-2 times a week

▪ Useful when patient has access and a history of strength training

▪ Endogenous opiate release

Con’s

▪ Dose/response carefully monitored and scripted to not further sensitize patient to becoming active.

MODERATE EVIDENCE: STRENGTH TRAININGE.R.A.S.E: ACTION

0

1

2

3

4

5

6

7

8

9

Boom / Bust Cycle

Activity

0

1

2

3

4

5

6

7

8

9

Pacing / Graded Activity 9,10,11

Activity

Avg: 3 hrs/ week

BEST EVIDENCE: EDUCATIONE.R.A.S.E: ACTION

Activity

tolerance

Avg: 2 hrs/ week

PSYCHOLOGICALLY INFORMED CARE

Screen for

modifiable

psychosocial

targets

▪ Depression

▪ Fear Avoidance-

Kinesiophobia

▪ Catastrophizing

▪ Anxiety

▪ Faulty Beliefs

Interventions-

1. Motivational

Interviewing

2. Neuroscience of Pain

3. Behavior Modification

• CBT

• ACT

• Operant Conditioning

• Graded Exposure

10

EVIDENCE BASED BUFFET

Traditional

Physical

Therapy

Physical Therapy

+Psychologically

Informed Care 12-16

Behavioral

Health

Psychosocial

factors

addressed by

Placebo

Intentional Integration of

Behavioral / Motivational

Strategies with

Traditional Biomechanical

Treatments

Behavioral /

Motivational

Strategies

PSYCHOLOGICALLY INFORMED CARE

& PT

Sullivan et al.17

Patients who participated in the psychosocial intervention in

addition to physiotherapy showed significantly greater

reductions in pain catastrophizing, fear of movement, and

depression than patients who received only the

physiotherapy intervention.

Reductions in psychosocial risk factors contributed to

reduced use of the health care system, reduced use of pain

medication, and improved return -to-work outcomes.

12

PIC PT VS. TRADITIONAL PT

Bodes-Pardo et . al . (2018, RCT)18

Combining pain neurophysiology education (PNE) with

exercise (TE) resulted in significantly better results for

participants with CLBP, with a large effect size.

Malfl iet , et al . (2018 RCT in JAMA Neurology )19

Pain neuroscience education combined with cognition -

targeted motor control training appears to be more effective

than current best-evidence physiotherapy.

Vibe-Fersum, et . al . (2013 RCT)20

The classification-based cognitive functional therapy group

displayed significantly superior outcomes to the manual

therapy and exercise group, both statistically (p < 0.001) and

clinically.13

Pain is always real , but not always the result of a physical injury.

The brain is constantly asking:

▪ How dangerous is this?

▪ Constantly scanning the body and environment for potential threats.

▪ The brain notices a threat and reacts with a pain sensation.

• Sometimes the brain continues to send a pain signal long after the injury has healed for several reasons:

• Increased stress and anxiety from:

• Not knowing the cause of the pain

• Not knowing how long the pain will last

• Unsuccessful pain treatments

• Pain limiting normal activity

BEST EVIDENCE: EDUCATIONE.R.A.S.E: REFRAMING

Neuroscience of PainNerves send messages to your brain and your brain decides

how much pain you feel—a lot, a little, or none at all.21

HOWEVER,

“Information is to behavioural change as spaghetti is to a brick” William Fordyce

▪PIC PT intervention is mostly concerned with changing actual behavior not necessarily cognitions

BEST EVIDENCE: CBTE.R.A.S.E: REFRAMING & ACTION

Experiential Learning Facilitated in PT

▪Exercise or Activities of Daily Living Despite Pain22

▪ Modification of movement: patient is taught strategies to

complete common tasks with minimal or no pain

▪Pre-determined task termination:23

▪Frequency of exposure is key to changing behavior

▪ Schedule activity 3-6 times per day.

▪ Change behavior long enough and new belief emerges.

BEST EVIDENCE: EDUCATIONE.R.A.S.E: REFRAMING & ACTION

Diaphragm breathing

▪ Stop accessory muscles (limbic system activation)

▪ Emphasis on slowing respiration rate through increased length

of exhalation

▪ “Gap” after full exhalation

▪ Intentional practice

▪ Habits/Mneunonics

Concept of total stress (total load on the organism)

▪ Biopsychosocial contributions to pain (SPACE)

E.R.A.S.E: STRESS MANAGEMENT & RELAXATION

Tangible Skills

▪ Alternative movement strategies

▪ Adaptive equipment

▪ Job Jar

▪ Swipe card at the gym

E.R.A.S.E: PROBLEM SOLVING & RESILIENCE

Allied Health

Teams APPLICATION

"I don't believe that either you or I (as a provider) is

satisfied with how you are feeling." (a change is

needed).

“We have a resource that helps people in pain

decrease the amount of suffering that pain brings”

“Other patients (with chronic pain) report that they

are better prepared to deal with pain and they are

able to do more of the things in life that they

need/want to do.”

DO DIFFERENT - TO GET DIFFERENT

Motivation:

▪Suffering

▪Acute on chronic musculoskeletal dx

▪Addition of 1 more life stressor

Step 1.▪ A change is needed: scripting

Step 2▪ Where do your deficits/ barriers

lie? (SPACE)

Step 3 Where do you see yourself

changing?

Step 4▪ Self Management, PT, and/or

Behavioral Health: ERASE

Step 5 ▪ PDSA

REFERRAL

Chronic Pain

Setting Proper Expectations

Goal is: Less pain & Increased Activity

▪ Time▪ 6+ months, not 6

visits

▪ Neuroplastic changes take time

▪ Setbacks are to be expected▪ Focus is on building

Resilience

0

5

10

15

20

25

30 60 90 120 150 180

Am

ou

nt

of

Im

pro

vem

en

t

Days

Patient Progress

LIFE IS CURVY

Sleep Deficits

▪ Sleep Hygiene: education

▪ Sleep Apnea: central vs

obstructive: referral

Comorbid Conditions

▪ COPD, Asthma, DM II, HTN

smoking, etc.

▪ Medication/Inhaler dosing and

compliance

▪ Psychosocial and Psychiatric

health

OPTIMIZING HEALTH

I’m 80 yrs oldI’m 80 yrs old

What should each team member reinforce about the different

disciplines when the patient does not see the benefit?

▪ Content: (Evidence based vs. non- EBP)

▪ Passive Tx? Hot pack, US, e-stim, massage, Aquatics, too many

patients in the room.

▪ Participation: Effective dosage ever achieved?

▪ Practical skills learned? (transfers, self-soothing, positions

of comfort, pacing, sleep hygiene, etc.)

▪ Expectations:

▪ Mechanical pain (nociceptive & some neuropathic):

▪ quick responses to treatment

▪ Neuro Pain (neuropathic and central sensitization):

▪ 12 weeks, +12 more weeks once control is established

▪ Disruptors: weather, stress, gaps in care, adherence

INTERDISCIPLINARY COLLABORATION

During & Post Exercise Sensations

▪ Any negative or unknown experience is reason enough to stop activity

▪ Please explore with your patient:

▪ Activity dosage errors: too much, too soon, for too long.

▪ Hurt vs. Harm…

▪ Post exercise hyperalgesia

▪ Malaise after exercise instead of the expected endogenous opiate release

▪ Normalizing the experience without dismissing it .

▪ Forecasting is essential to decreasing anxiety around activity

PT MADE ME WORSE!!

Failure to progress is not necessarily due to the

wrong treatment:

▪ Chronic/complex patients need even more

reinforcement/encouragement/ reassurance of safety.

▪ “I didn’t send you to PT to get fixed, I sent you to PT to get

better: whatever, better looks like…”

prescribe vs. PRESCRIBE PT!!!

▪ Follow up with the same vigor that you would regarding a

medication.

▪ Expect Positive outcomes

REINFORCEMENT

CASE STUDIES

29 y.o M referred to PT for Neck Pain. Pain has become progressively more intense and frequent over the past year & presents after increased activity (work or ADL’s) in the last 4 months he has also been suffering from HA and his right arm is numb and tingling at times.

Hx of head injury at 15 yrs old, depression, anxiety. He has had neck pain on/off since he was 15 yrs old.

PT eval:

▪ Patient labile at evaluation as he recounts near death experience with head injury.

▪ Negative for red flags, radiculopathy

▪ + for right thoracic outlet syndrome and increased cervical/thoracic muscle tension

▪ Pain is isolating him from social interaction: comes home after work & naps. Declines invitations to socialize

CASE STUDIES

PT Treatment

Diaphragm breathing

Stretch right pectoral minor

Neuroscience of pain▪ Explore emotional aspects

of pain

Wean from naps: restore normal sleep cycle.

Strengthening: tolerance to work demands

Goals:

▪Perform ADL’s on good pain days & bad

▪Start accepting invitations to socialize

▪ Increase positional tolerance (sit/stand) to enable social interaction.

▪ Independent with self care (diaphragm breathing, stretching)

CASE STUDY

56 y.o F referred to PT with chronic LBP on disability for 25

yrs. MRI shows normal age related changes. Patient has

dif ficulty with transferring in/out of bed. Patient reports that

once pain starts on a given day: it can’t be stopped - patient

stops all activity.

PT Eval:

Negative for red flags, reflexes/sensation: WNL, myotomal

strength 5/5

Poor transfer technique with sit to stand as well as supine to

sit. When modified: patient experiences less discomfort and

greater ease.

Patient is skeptical, disengaged at the visit, also shares that

she is not sure how PT can help her when her spine is

crumbling (MRI findings)

CASE STUDY

PT Treatment

Transfer training

HEP: bike riding

Education: MRI

findings

Very slow progress

▪Barrier: MRI findings

PCP “I didn’t send you to PT to

get fixed, I sent you to PT

to get better: whatever,

better looks like…”

Renewed effort

▪Added throwing a

softball with her

grandkids

▪ Increased miles on

bike.

CASE STUDY

SUMMARY

PT can utilize evidence based treatments that are

highly effective for both Acute and Chronic pain.

Psychologically Informed Care and Neuroscience

education is a growing specialty with PT.

PT can provide valuable patient education and

experiential learning in regard to activity.

PT can address acute and chronic pain episodes,

within the context of other chronic disease burden.

Physician and Allied Health team play an important

role in supporting the patient and PT plan of care

through exploring activity dosage, barriers to activity,

and forming accurate expectations for progress.

SUMMARY

How to refer:▪ Psychologically Informed Care (PT)

▪ Therapeutic Neuroscience Education (TNE)

▪ Pain Science / Neuroscience of Pain

▪ Therapeutic Pain Specialist (TPS)

▪ Biopsychosocial Management of Pain

▪ CBT and PT

▪ Pain Neuroscience Education (PNE)

PIC PT

REFERENCES

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35

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1 8 . B o d e s P a r d o G , L l u c h G i r b é s E , R o u s s e l N A , G a l l e g o I z q u i e r d o T , J i m é n e z P e n i c k V , P e c o s M a r t í n D . P a i n N e u r o p h y s i o l o g y E d u c a t i o n a n d T h e r a p e u t i c E x e r c i s e f o r P a t i e n t s W i t h C h r o n i c L o w B a c k P a i n : A S i n g l e -B l i n d R a n d o m i z e d C o n t r o l l e d T r i a l . A r c h P h y s M e d R e h a b i l . 2 0 1 8 F e b ; 9 9 ( 2 ) : 3 3 8 - 3 4 7 . d o i : 1 0 . 1 0 1 6 / j . a p m r . 2 0 1 7 . 1 0 . 0 1 6 . E p u b 2 0 1 7 N o v 1 1 . P u b M e d P M I D : 2 9 1 3 8 0 4 9 .

1 9 . M a l f l i e t A , K r e g e l J , C o p p i e t e r s I , D e P a u w R , M e e u s M , R o u s s e l N , C a g n i e B , D a n n e e l s L , N i j s J . E f f e c t o f P a i n N e u r o s c i e n c e E d u c a t i o n C o m b i n e d W i t h C o g n i t i o n - T a r g e t e d M o t o r C o n t r o l T r a i n i n g o n C h r o n i c S p i n a l P a i n : A R a n d o m i z e d C l i n i c a l T r i a l . J A M A N e u r o l . 2 0 1 8 A p r 1 6 . d o i : 1 0 . 1 0 0 1 / j a m a n e u r o l . 2 0 1 8 . 0 4 9 2 . [ E p u ba h e a d o f p r i n t ] P u b M e d P M I D : 2 9 7 1 0 0 9 9 .

2 0 . V i b e F e r s u m K , O ' S u l l i v a n P , S k o u e n J S , S m i t h A , K v å l e A . E f f i c a c y o f c l a s s i f i c a t i o n - b a s e d c o g n i t i v e f u n c t i o n a l t h e r a p y i n p a t i e n t s w i t h n o n - s p e c i f i c c h r o n i c l o w b a c k p a i n : a r a n d o m i z e d c o n t r o l l e d t r i a l . E u r J P a i n . 2 0 1 3 J u l ; 1 7 ( 6 ) : 9 1 6 - 2 8 . d o i : 1 0 . 1 0 0 2 / j . 1 5 3 2 - 2 1 4 9 . 2 0 1 2 . 0 0 2 5 2 . x . E p u b 2 0 1 2 D e c 4 . P u b M e d P M I D : 2 3 2 0 8 9 4 5 ; P u b M e d C e n t r a l P M C I D : P M C 3 7 9 6 8 6 6

2 1 . L o u w A , Z i m n e y K , P u e n t e d u r a E J , D i e n e r I . T h e e f f i c a c y o f p a i n n e u r o s c i e n c e e d u c a t i o n o n m u s c u l o s k e l e t a l p a i n : A s y s t e m a t i c r e v i e w o f t h e l i t e r a t u r e . P h y s i o t h e r T h e o r y P r a c t . 2 0 1 6 J u l ; 3 2 ( 5 ) : 3 3 2 -5 5 . d o i : 1 0 . 1 0 8 0 / 0 9 5 9 3 9 8 5 . 2 0 1 6 . 1 1 9 4 6 4 6 . E p u b 2 0 1 6 J u n 2 8 . R e v i e w . P u b M e d P M I D : 2 7 3 5 1 5 4 1 .

2 2 . L e h m a n G J . T h e R o l e a n d V a l u e o f S y m p t o m - M o d i f i c a t i o n A p p r o a c h e s i n M u s c u l o s k e l e t a l P r a c t i c e . J O r t h o pS p o r t s P h y s T h e r . 2 0 1 8 J u n ; 4 8 ( 6 ) : 4 3 0 - 4 3 5 .

2 3 . W i d e m a n T H , S u l l i v a n M J . R e d u c i n g c a t a s t r o p h i c t h i n k i n g a s s o c i a t e d w i t h p a i n . P a i n M a n a g . 2 0 1 1 M a y ; 1 ( 3 ) : 2 4 9 - 5 6 . d o i : 1 0 . 2 2 1 7 / p m t . 1 1 . 1 4 . P u b M e d P M I D : 2 4 6 4 6 3 9 1 .

2 4 . A P T A W h i t e P a p e r “ B e y o n d O p i o i d s : H o w P h y s i c a l T h e r a p y C a n T r a n s f o r m P a i n M a n a g e m e n t t o I m p r o v e H e a l t h . ” h t t p s : / / w w w . a p t a . o r g / u p l o a d e d F i l e s / A P T A o r g / A d v o c a c y / F e d e r a l / L e g i s l a t i v e _ I s s u e s / O p i o i d / A P T A O p i o i d W hi t e P a p e r . p d f

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