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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