LAS VEGAS—Are physical therapists the new gatekeepers in the management of patients with pain? That was the question explored by Kathleen A. Sluka, PT, PhD, professor of physical therapy and rehabilitation science at the University of Iowa Carver College of Medicine, Iowa City, Iowa, and Marie Hoeger Bement, PT, PhD, associate professor in the department of physical therapy, Marquette University, Milwaukee, Wisconsin.
Physical therapy is a key component of multidisciplinary pain control and is often a first point of entry for patients in the healthcare system. Physical therapy pain management focuses on education (posture, pacing, disease, remaining active), exercise (aerobic, strengthening, stretching, motor control), manual therapy (massage, joint mobilization and manipulation), electrical stimulation (TENS [transcutaneous electrical nerve stimulation], interferential current), heat modalities (hot packs, ultrasound), cold modalities (ice pack, ice bath), and motor imagery, sensory re-education, and virtual reality.
The goals of physical therapy pain management are to reduce pain and improve function. This involves a multidisciplinary approach that includes the patient as an active participant utilizing both active and passive approaches. Explaining the difference between active vs passive approaches for chronic pain, they noted that an active approach includes self-management, education, exercise, and sensory-motor re-education and a passive approach includes physical agents, electrical modalities, and manual therapies.
Self-management includes instruction on the disease process (central sensitization, chronic pain mechanism), remaining active (benefits of physical activity), and pacing activities; eg, managing pain response. A self-management plan “helps patients believe in their own capacity to control their pain,” Drs. Sluka and Hoeger Bement said. With the clinician serving as the guide or coach, the patient engages in an active program of problem-solving skills, decision making, and physical activity.
Finally, it is important for patients to understand physical inactivity increases risk for chronic pain, whichcan be reduced with increasing levels of physical activity. They admitted compliance is difficult; the majority of the population (>70%) is physically inactive. Group exercise programs may increase compliance.
Two myths: “no pain, no gain,” and a belief by patients that exercise, as instructed by the physical therapy, will make the pain—and condition—worse were dispelled. One challenge in treating patients with chronic pain is that they are physically deconditioned. For that reason, exercise should be started slowly and progressed slowly, with the patient instructed to stretch before and after. The type of exercise is generally not important and can include aerobic, strengthening, stretching, proprioceptive, and motor control exercises. Clinical evidence is moderate to strong for a variety of painful conditions, including fibromyalgia, osteoarthritis, rheumatoid arthritis, low back pain, neck pain, myofascial pain, and tendonitis.
An active management plan will help patients address what to do if their pain worsens and sets them back; therefore, an individualized plan for pain, sleep, stress and social roles should all be included in the toolbox. What also should be included is what the patient should do if he or she is doing really well. It is important to emphasize that pain can affect thinking, influencing whether a patient will have a “good day” or a “bad day.” When setting goals, they should be patient-specific, done in combination with the patient, incorporate daily activities, and be modified regularly. Goals—and patient confidence they can be achieved—should be realistic.