This physiotherapist’s approach to treating Persistent Pain

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Published on: October 30, 2020

Audience: Patients and other health care providers

Purpose: To explain my treatment approach to Persistent Pain Problems.

Overview of the Treatment Program:

  1. Pain Physiology Education
  2. Movement (Graded exercise/activity exposure)
  3. Manual Therapy

The Simple Goals of Treatment

  1. Decrease pain and sufferring
  2. Resume or increase the activities of a patient’s life that are important to them

Assumptions that inform the Treatment Program

Pain is the brain’s response to a perceived threat

Pain is an output from the brain that is meant to protect us.  It is influenced by a lot of things including, but not limited to, situation/context, past history, beliefs and expectations. Pain is a threat detector and set up to motivate us to do something about that perceived threat.  It is not good at telling us how much damage there is or even where there is a problem.  Think about people who have pain in a phantom limb. They don’t have a bloody thumb yet that thumb sure can hurt. There is no problem in the periphery as there is no periphery.  Or how about when someone has a heart attack and they feel pain in their back or jaw or arm.

One difficulty with pain is that we can get better at producing it.  It become a habit.  We need to break that habit.  What scientists call this habit is our pain “neurosignature”.

More information about pain can be found here and here

Inappropriate beliefs about pain further the pain experience

Understanding pain science itself can help decrease the pain that patient’s feel.  Learning about pain improves coping skills, decreases catastrophizing, increases activity through reductions in fear and can change how the brain creates movement.  Patients are capable of learning complicated neurophysiological facts about pain and this in turn can improve their situation.

Pain influences all facets of our physiological function and our social lives

Pain is more than just a booboo in some tissue. Pain is an output and pain can influence other outputs of the brain. Pain influences our stress response, our immune function, endocrine function and our movement (e.g. kinesiophobia).  Pain can be linked with psychosocial factors like perceptions of injustic, castrophizing, depression and anxiety.

Tissue Damage (nociception) does not equal pain

Patients are not their x-rays or MRIs.  The link between tissue damage (e.g joint degeneration or muscle tears) is very poor. Pain persists long after tissue healing occurs and pain can occur without even an initial injury.

Continuing to believe that the source of pain is purely in the body can lead to further impairment. Old biomechanical models of tissue breakdown as the source of pain contribute to false beliefs that lead to more pain.  Addressing these beliefs and learning about pain neuroscience guides an individual’s treatment program.

More information here and here.

Treatment Program Details

Pain Physiology Education

Knowledge really is power.  If we know that our achey knees aren’t falling apart and the pain in our elbow isn’t due to some serious muscle damage then that knowledge teaches the brain and the patient to be empowered, confident and optimistic.

Pain education starts on the first visit and continues during the movement/exercise therapy and during manual therapy.  Pain education is supported with website links and written material.

Movement (Graded exercise/activity exposure)

Motion is lotion. Pain can be seen as a habit of our brain.  When in pain many of the areas of the brain are activated and we can call this a NeuroSignature.  We want to sneak under the radar of that neurosignature and teach the nervous system that we are in control.  Graded movement (e.g. slowly building) allows to choose novel, non-threatening movements/exercises that increase our capacity to move and be active.  At the same time doing movements that are different and new can downregulate our pain response.  Movement is the key to the drug cabinet in our brains. Movement is medicine. The movements that we choose are not always pain free but they shouldn’t be so intense that you experience “wind-up” or a huge flare up the next day.  Choosing movements and activities like this can increase our threshold for flare ups and pain.

Movement and exercise selection is not about increasing stability, strength or range of motion.  These constructs are poorly related to pain resolution.  While we often get increases in strength and range of motion following treatment it is not because we increased strength or range of motion.  These were side benefits to the program.  Last, I believe that words like instability or stability or inappropriately used to explain why people have painful problems.  It is highly unlikely that a patient’s spine or hip is unstable.  When we use these words I believe we create a sense of fragility and doom. Most patients are robust.  It is our nervous system’s over-sensitivity that promotes pain not some weakness in tissue capacity.

Manual Therapy

Very simply manual therapy can modulate the nervous system’s production of pain. We have more than two decades of research showing that the means that manual therapy work is through changing nervous system function.  This is not about joints being out of place, breaking down scar tissue or merely strengthening or stretching muscles.  Immediate changes in the perception of pain, production of strength or change in range of motion can be seen.  Its not logical to assume that a 30 minute treatment session healed tissue, broke down scar tissue or suddenly made a muscle stronger. The only physiological component that can change this quick is our nervous system.  Manual therapy affects the nervous system and can improve our function.  All manual therapy techniques can be effective.

Treatment can included peripheral nerve mobilizations, soft tissue massage, joint manipulation/mobilization, movement pattern corrections (e.g subtlely changing how we move to not activate the pain signature), dermoneuromodulation and mobilizations with movement.  Treatment is typically pain free. I’m of the opinion that pain begets pain and treating with aggressive painful techniques can reinforce our pain habits in some patients.  While a short term pain relief can be felt following aggressive treatment (mostly likely due to something called Diffuse Noxious Inhibitory Control) I feel that this is temporary and unlikely to effect long lasting change.




The Why’s and How’s of Treatment Justification

This post is more about the “Why” and “What” of treating pain and injury.  It is not a full explanation on the “how” of treatment.  The “how” of treatment is important because it explains the mechanisms of what we think we are doing.  If we can understand a mechanism of how pain persists and how it can be alleviated we can change our treatment techniques appropriately.  Future posts will look into the mechanisms of treatment.

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