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Janet Holly, PT

There has been much in the news about the benefits and evils of opioids. Currently, the Canadian government and media are paying attention to the importance of safe opioid prescription to address the Opioid crisis. What are rarely being talked about, however, are other pain management options.
 
Pain is part of the human existence. We all experience painful events and after a few hours they become less painful and the pain disappears. But what if it doesn’t? In these cases, many of us turn to pharmaceuticals.
 
With the advent of pharmaceuticals that control acute pain during and after painful procedures, there has been a heavy emphasis on prescribing these drugs. However, when it comes to persistent pain or complex pain, the research tells us that there are other options, often with better results. 
 
A great opportunity exists for physiotherapists to advocate for and implement therapy programs aimed at people who are at risk for developing persistent pain or whose acute pain is starting to become more complex. Surely, this applies only to physiotherapists who work in musculoskeletal outpatient settings. It does apply to these therapists but persistent pain affects vast populations of the patients we treat. The tables below demonstrate a very small snapshot of the persistent pain problem.
 
 
 
A study by Wylde et al. in 2015 looked at the incidence of persistent pain post-operatively in patients after total hip and knee replacement. They also assessed participants before surgery for widespread pain sensitivity using a pressure pain threshold technique in their forearms.  Patients with greater pain sensitivity scores pre-operatively had greater pain severity scores post-operatively and continued to have higher pain scores 12 months after surgery. Identifying patients who are centrally sensitized pre-operatively can save on needless surgeries as well as improve outcomes post-operatively.
 
Physiotherapists are ideally suited with our training to be leaders at both early identification and pain management. Knowing the difference between nociceptive pain and pain which is neuropathic or centrally mediated can allow a therapist to initiate a timely treatment program that is specific to the type of pain the patient is experiencing. There are several outcome tools that are quick and easily used in a busy clinical environment to help us with this. The Brief Pain Inventory, the Short form of the Leeds Assessment for Neuropathic pain, The DN4, and the STarT Back Assessment can all assist a busy clinician. For those that work in pediatrics, there is an even greater need to identify persistent pain in children, as the literature is demonstrating correlations between pain as a child and chronic pain as an adult. (Matthews et al., 2011)
 
We now know that requesting and sharing results of diagnostic imaging with patients can be harmful.  It leads to poorer outcomes and is correlated to more invasive medical interventions. (Webster et al., 2014). We also know that degenerative changes are a normal part of aging and are weakly correlated to pain, so why do we need imaging  (Brinjikji et al., 2015)? The solution is reserving imaging for only those individuals for which there are clinical findings indicative of a more serious pathology. Given the evidence of improved outcomes when imaging is avoided, helping patients understand why imaging is not usually needed for people with persistent pain is an important treatment strategy in its own right. 
 
    Science has told us that understanding how pain is created can change our pain experience and influence more optimal outcomes. Some of the best evidence around management of persistent pain can be found in educating the patient on how pain is created and how they can mediate it. (Louw et al., 2011, 2014; Moseley  et al., 2004; Van Oosterwijck et al., 2011, 2013; Nijs 2011) Results have shown decreases in health care utilization and improvements in pain and function. 
 
    You want to keep it simple, but there are certain principles you want to cover. Explain in detail how pain occurs from a neurophysiological approach for both acute and chronic pain. Do not assume your patient cannot understand. Make sure you explain the immune responses. Cover how emotions and critical thinking areas can contribute to pain. Describe what a “neurotag” or personalized pain signature looks like and how it functions. Patients need to understand the changes in alarm thresholds as well as the effects of their thoughts and beliefs on both the up regulation and down regulation of pain. You need to guide the patient to reflect on their current situation and how it is affecting the output of pain. Finally, give them practical tips to use to manage their present neurophysiology and allow for positive adaptation – Give them hope! 
So yes, just teaching can change outcomes in persistent pain. Consider how you teach and how your patient learns. Consider barriers to learning such as sleep deprivation, medications, literacy and comorbidities. Follow up with your patient to see if learning has actually occurred and is being applied.
 
    Another key treatment for pain is exercise. Study after study demonstrates the effectiveness of exercise for the management of pain. (Rodrigues et al., 2014; Naugle et al., 2012, Scheef 2012 Beumer et al., 2012). No one type of exercise has been found to be superior. What is important is that the exercise is meaningful for the patient. If not, it is highly unlikely they will continue it. 
 
    The important factor is movement. Supervised exercises have been found to be more effective than home programs (Koes et al., 2010) For those with persistent pain, graded activity is a nice starting point to movement. The available evidence suggests that graded activity in the short term and intermediate term is slightly more effective (Macedo et al., 2010). 
 
    For some populations, hydrotherapy may be a good exercise option. It has been found to be effective for fibromyalgia for decreasing pain and improving quality of life (Langhorst et al., 2009; McVeigh et al., 2008). In multiple sclerosis, hydrotherapy was found to decrease pain and improve function. (Castro-Sanchez et al., 2012). It is just as effective as land-based exercises for chronic low back pain (Geytenbeek ,2002). Hydrotherapy has been found to be effective in hemophilia for reducing pain and increasing range of motion. (Mazloum et al.,2014) In the end, get your patients moving. The important factor for success with exercise is the right prescription (dosage) for your patient and adequate support for maintaining it. It is not a one size fits all model.
 
There are more specific treatments for pain to be highlighted but are beyond the scope of this article. Hopefully, the clinician in you has had your interest peaked. “If you treat patients, you treat pain” and increasing your skills in this area will only benefit your outcomes. After all, uncontrolled pain affects immune function, promotes tumour growth, delays healing, and increases morbidity and mortality following surgery. (Liebeskind, 1991).
 
We can offer important treatments for people with pain including some of the strategies outlined in this article: targeted interventions for those at risk of developing chronic pain, effective education, as well as exercise and physical activity approaches. We can play a role in addressing the opioid epidemic by offering evidence-based treatments for people living with pain and by advocating for better access to multimodal pain management strategies for people living with pain. 
 
Consider joining the CPA Pain Science Division. Their website has many resources and professional development opportunities for assessing and treating pain.
by Janet Holly, PT.

 

 

References

 

Beumer, L., Wong, J., Warden, S., jKemp, J., Foster, P., & KM, C. (2015). Effects of exercise and manual therapy on pain associated with hip osteoarthritis: A systematic review and meta-analysis. Bristish Journal of Sports Medicine, 50(8), 443. doi:10.1136/bjsports-2015-095255

 

Borsook, D. (2012). Neurological diseases and pain. Brain, 135(2), 320-344. doi:10.1093/brain/awr271

 

Brinjikji, W., Luetmer, P., Comstock, B., Bresnahan, B., Chen, L., Deyo, R., & Wald, J. (2015). Systematic literature review of imaging features of spinal degeneration in asymptomatic populations. American Journal of Neuroradiology, 36(4), 811-816.

 

Cacchio, A., De Blassis, E., Necozione, S., & Santilli, V. (2009, August 6). Mirror therapy for chronic complex regional pain syndrome type 1 and stroke. New England Journal of Medicine, 361, 634-636. doi:10.1056/NEJMc0902799

 

Castro-Sanchez, A., Mataran-Penarrocha, G., Lara-Palermo, I., Saavedra-Hernadez, M., Arroyo-Morales, M., & Moreno-Lorenzo, C. (2012). Hydrotherapy for the treatment of pain inpeople with multiple sclerosis: A randomized controlled trial. Evidence-based complementary and Alternative Medicine, 1-8. doi:10.1155/2012/473963

 

Chouiniere, M., Watt-Watson, J., & Taillefer, M. (2014, April 15). Prevalence of and risk fartors for persistent post-operative nonanginal pain after cardiac surgery: a 2-year prospective multicentre study. Canadian Medical Association Journal, 186(7), E213-E223. doi:10.1503.cmaj.131012

 

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Koes, B., M, v. T., & Thomas, S. (2006). Diagnosis and treatment of low back pain. British Medical Journal, 332, 1430-1434.

 

Langhorst, J., Musial, F., Klose, P., & Hauser, W. (2009). Efficacy of hydrotherapy in fibromyalgia syndrome- a meta-analysis of randomized controlled clinical trials. Rheumatology, 48(9), 1155-9. doi:10.1093./rheumatology/kep182

 

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Macedo, L., Smeets, R., Maher, C., Latimer, J., & McAuley, J. (2010). Graded activity and graded exposure for persistent nonspecific low back pain: A systematic review. Physical Therapy, 90(6), 860-879. doi:10.2522/ptj.20090303

 

Matthews, L. (2011, January ). Pain in children: Neglected, unaddressed and mismanaged. Indian Journal of Palliative Care, 17(Suppl0, S70-S73.

 

Mazloum, V., Rahnama, N., & Khayambashi, K. (2014). Effects of therapeutic exercise and hydrotherapy on pain severity and knee range of motion in patients with hemophilia: A randomized controlled trial. International Journal of Preventative Medicine, 5(1), 83-88.

 

McVeigh, J., McGaughey, H., & Hall, M. e. (2008). The effectiveness of hydrotherapy in the management of fibromyalgia syndrome: A systematic review. Rheumatology International, 29(2), 119-30.

 

Moseley, L., Nicholas, M., & Hodges, P. (2004). A randomized controlled trial of intensive neurophysiology education in chronic low back pain. Clinical Journal of Pain, 20(5), 324-330.

 

Naugle, K., RB, F., & JL, R. (2012). A meta-analytic review of the hypoalgesic effects of exercise. The Journal of Pain, 13(12), 1139-1150.

 

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Rodrigues, E., Gomes, A., & Leite, N. (2014). Effects of exercise on pain of musculoskeletal disorders: a systematic review. Acta Orthopedica Brasileira, 22(6), 334-338.

 

Scheef, L., Jankowski, J., Daamen, M., Weyer, G., Klingenberg, M., Renner, J., . . . al., e. (2012). An fMRI study on the acute effects of exercise on pain processing in trained athletes. Pain, 153(8), 1702-14.

 

van Oosterwijck, M., Nijs, J., Meeus, M., Truijen, S., Craps, J., Van den Keybus, N., & Paul, L. (2011). Pain neurophysiology education improves cognitions, pain thresholds, and movement performance in people with chronic whiplash. Rehabilitation Research and Development Service, 48(1), 43-58.

 

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