• Feature

    Rewiring the Brain to Ease Chronic Pain

    Strategies for treating pain are evolving—and physical therapists are helping to lead the way.

    Physical therapists (PTs) are very comfortable treating musculoskeletal conditions and prescribing programs that restore or improve movement. When they're working with patients with persistent pain, however, Leonard Van Gelder, PT, DPT, ATC, notes that they must seek out the patients' "thoughts and feelings, and understand how they can influence their experience of pain." Accordingly, Van Gelder says his approach with these patients involves "navigating a variety of factors—physiological and psychosocial—that may or may not be affecting their pain."

    One recent patient, he recalls, came to him with a history of rheumatoid arthritis and fibromyalgia. The individual's pain had worsened over time and even led to a brief hospitalization.

    As with any patient, Van Gelder first conducted his evaluation to ensure "there wasn't something obvious anatomically, physiologically, or disease-related that needed to be addressed."

    Eventually, as he worked with the patient over the course of several sessions, "she started to open up about her life and job, and how pressure from top management was sometimes inappropriate and was causing tremendous stress." It's rare, Van Gelder says, for a patient ultimately to see that the answer to his or her pain may be new employment. "But that's what this particular patient decided to do, and that—more than anything else—led to profound improvements in her ability to function and be productive."

    It's fair to say that Van Gelder's entire career had been leading up to his recent launch of a physical therapy clinic focused on helping patients who struggle with pain. Three years ago he completed training as a therapeutic pain specialist through the International Spine and Pain Institute (ISPI), then established and directed a pain treatment division within Generation Care, a therapy-services provider in Grand Rapids, Michigan.

    His new practice, Dynamic Movement and Recovery, also in Grand Rapids, was founded on the idea that to effectively address people's pain "you need to understand their whole story," he says. It's important to know how pain works, he explains, but the key to treatment is to see "how the patient's life, history, and social and mental health all play into the bigger picture."

    New Initiatives and Approaches

    For as long as PTs have provided care to patients, they've tried to help alleviate their pain. But now many therapists, including Van Gelder, say it's time for the profession to make pain a priority—to not only understand its causes and manifestations but also to ensure that best practices in pain management are employed by PTs across all clinical settings.

    APTA, which already had been active in promoting physical therapy as an effective method to address myriad pains, in 2016 unveiled #ChoosePT, a broad public relations effort to educate consumers about the opioid epidemic and urge them to choose physical therapy to manage pain without the risks of opioids. (See "#ChoosePT and Other APTA Pain Initiatives" on the facing page.)

    Carolyn McManus, PT, MPT, MA, says she tends to see patients who have struggled with pain for a year or more. She is a staff PT at Swedish Medical Center in Seattle and president of the APTA Academy of Orthopaedic Physical Therapy's Pain Special Interest Group.

    Many of McManus's patients already have undergone multiple courses of physical therapy and come to her—the facility's only outpatient rehab pain specialist—hoping to finally find a solution to their pain. "They've been on medications, sometimes they've had surgeries, and everything they've tried has failed," McManus says. Some patients experience debilitating headaches, she explains, while others have fibromyalgia or chronic back pain, or diabetic or chemotherapy-induced neuropathies.

    McManus works with her patients in collaboration with other PTs in the facility who provide traditional exercise and movement therapy, but she describes her approach as innovative. "I tell patients, 'Your brain has gotten really good at generating pain. Now we're going to give it other things to do.'"

    Toward that goal, McManus says, she typically sees patients for 2 to 6 visits and usually begins with basic pain education. "The mechanisms that give rise to acute pain are different from those that give rise to chronic pain," she notes. "It can be helpful to patients to understand that the sensitivity of their nervous system can contribute to a chronic pain condition."

    Persistent pain is not necessarily related to any kind of physical injury, she explains. "The metaphor I like to use is the fire alarm system in our building. It usually would take a fire to set off the alarm, but if the wires are too sensitive that alarm might be triggered by overly warm temperatures." For many people with persistent pain, McManus says, their alarms are going off without any fire. "They experience pain, but there may not be any tissue damage. The problem is in the wiring."

    Once patients understand that pain doesn't necessarily mean there's something physically wrong with their bodies, "they stop seeing pain as a threat and they don't get as frightened," McManus says. At that point she'll typically begin coaching the patient to interpret the pain in a different way. "We'll focus on breathing exercises and body awareness—calm observation of whether their body is tense or relaxed. And I'll give a patient very specific strategies for self-regulating stress reactions."

    For many individuals, stressors that are common in modern life can have an outsized influence on how they experience pain, McManus explains. "Rush hour traffic, a long line at Starbucks—most of us just deal with it. But if you have persistent pain, these are the kinds of triggers that can make it worse."

    Many of her patients, McManus says, eventually learn to use mindful awareness and focus on the present to "not freak out anymore" when confronted with a potentially stressful situation. "The motto of one woman I worked with became, 'If I stay calm, my nerves stay calm.' As patients and clients see that pain is a sensation, and that it's how they react to that sensation that determines their experience of pain, they usually start to do better. Once they 'get it,' it's like learning to ride a bicycle. They don't need me anymore."

    A Different Patient Experience

    Another PT with extensive experience treating patients with pain (and a copanelist with McManus and others on the future of pain science at APTA's Combined Sections Meeting this past January) is Mark Shepherd, PT, DPT. Shepherd, a board-certified clinical specialist in orthopaedic physical therapy, is assistant director of the Orthopaedic Manual Physical Therapy Fellowship at Bellin College and an as-needed therapist at 2 clinics in the Baltimore area. He completed the same ISPI therapeutic pain specialist program as did Van Gelder and is an occasional teacher for the institute.

    "When I see someone who is dealing with persistent pain, the first thing I try to do is create a welcoming and trusting environment," Shepherd says. Many of his patients have seen other providers, and "while some may have been great and helpful in some way, others may have scared them or not given them the care they needed." With those experiences imprinted on their memories, Shepherd says, patients often are skeptical that he'll be any different. "I immediately let them know that I believe them—that they don't have to prove to me that they're in pain. I also reassure them that I care, and that I want them to trust me."

    From there, Shepherd says, his job is to make sure that the patient belongs in his clinic. "Sometimes it initially seems as if they have a musculoskeletal condition—such as persistent low back pain—but then you see that it may be something else, like a spinal cord condition or cancer." Likewise, he'll sometimes meet patients who are dealing with severe depression or anxiety, and he will realize there's more to their pain than was first apparent. "You have to know when it's best to make a referral," he says.

    For individuals he does think he can help, Shepherd employs patient empowerment. "There is a lot of criticism around manual therapy being passive, with the clinician doing something to the patient, skillfully trying to 'will' the pain away." At least some of the criticism is warranted, Shepherd says. "When we're doing those passive treatments, we may not be helping patients overcome their pain through their own strength and abilities. So, if I'm doing anything hands-on, I'll immediately check and see what changes occurred with that approach. And then I teach patients how to do those things on their own at home."

    One of his patients, Shepherd recalls, had chronic regional pain syndrome (CRPS). She had been engaged in her work in a director-level position that involved presenting at conferences. But she had developed significant pain in her lower extremity that didn't let her bear weight on her ankle or foot. Shepherd worked with her for several months, he says, first educating her "on what pain is and why her body was responding the way it was, then letting her know that she wasn't alone—that this wasn't normal but that it does happen."

    He then began a process known as graded motor imagery and eventually went on to use graded exposure to increase her tolerance for activities that caused her pain. "Instead of doing 3 sets of 15 reps of a given activity, we used a time-contingent approach," he explains. "We'd say, 'Okay, you can tolerate 30 seconds of this. Now let's try to do several sets of 30 seconds and see how that goes.'" He also incorporated exercises designed to improve her function so that she could, for example, commute to work by train, walk up and down stairs, and maneuver around people.

    Shepherd estimates that for every 3 patients he sees, 1 experiences a "true turnaround" to the point of being able to function as they did before pain. Those odds can be difficult to accept, he admits, but patients like the one with CRPS help him focus on trying what he can. "She had essentially a full recovery, with no major flair-ups," he notes. "She's working again, traveling abroad, hiking, and doing the things she loves."

    "Rewiring" the Brain For Success

    Patient success stories are something that Adriaan Louw, PT, PhD, likes to keep in mind as he goes about his work. Louw, who cofounded ISPI in 2005 and now is the organization's chief executive officer, also owns Ortho Spine and Pain Clinic in Story City, Iowa.

    Many of his patients are young children, he reports, including one he saw recently who came to him following arthroscopic surgery on her left knee. "Unfortunately, her knee became super-sensitive to the point that she wouldn't let anything touch that leg," he says. When she first arrived at his clinic, she wore sweatpants that had been cut to shorts-length on her affected side, Louw recalls. His intervention, as with most of his pain patients, involved a combination of patient education, exercises, and graded motor imagery.

    "What worked well for this individual was having her sit on the treatment table with a long mirror between her legs that let her see her right knee projected on her left side." When he touched her unaffected right leg, he explains, she'd look in the mirror and have the impression that he actually was working on her left leg—and that it didn't hurt at all. "It's basically rewiring the brain to say, 'Hey, I'm going to be okay.'"

    Louw gave that patient's mother an inexpensive mirror so that she and her daughter could practice the exercise at home. Over time, the girl's condition improved to the point that she had normal sensitivity in the affected knee. One of the keys to her rehabilitation—and a technique Louw uses for many of his patients—involved touching the sensitive area, once she allowed him to do so, with varying levels of force and stimulation.

    "Every patient is different," he notes, "but we know that when we hurt and we don't move—as when our arm is in a cast or a brace—the inherent mapping in our brain is altered very quickly." Pain specialists refer to that alteration as "smudging," Louw explains. They often try to treat it through "sensory discrimination," in which the skin is touched in different places with different objects—something sharp followed by something dull, for example—and patients are asked to discern what they feel. "It teaches that map in the brain to work again," he says, "and gradually sensitivity eases and the pain goes down."

    Van Gelder is familiar with how "brain remapping" can get patients back on their feet. And he encourages other PTs to learn similar pain-management strategies to use in their own practice. His advice? "The most important thing to realize in this work is that you're still doing what you know best as a PT. It's hands-on. It's exercise prescription. And it's analyzing movement and trying to improve function."

    However, he adds, pain-focused physical therapy looks at the physical body from a behavioral standpoint—"beyond the biology about which we've been so thoroughly educated—and you're trying to understand how people's thoughts and feelings influence and affect their pain."

    Yes, Van Gelder says, it does take training and continuing education to become adept at pain management as a PT. And success with individual patients often requires collaboration with other professionals, including social workers and psychologists. But that "journey," as he describes it, and the work that's required, is well worth it in the end. "You may not be able to help every patient, but you can make a difference for those you can."

    Chris Hayhurst is a freelance writer.

    #ChoosePT and Other APTA Pain Initiatives

    "Whether or not pain and its treatment is your niche, it's an area in which all PTs should try to improve," says Hadiya Green Guerrero, PT, DPT, senior practice specialist at APTA. The opioid crisis in particular has made clear the importance of PTs establishing themselves as leaders in nonpharmacological pain management, she says.

    "It's not that physical therapy always should be a substitute for opioids or that therapy can absolve people of all pain," Guerrero says, "but, as movement specialists and experts on neuromusculoskeletal conditions, PTs should have a place at the table in these discussions."

    APTA in 2016 unveiled #ChoosePT, a broad public relations effort to educate consumers about the opioid epidemic and urge them to choose physical therapy to manage pain without the risks of opioids. Housed at MoveForwardPT.com/ChoosePT, the campaign includes national online advertising, TV and radio public service announcements, and other targeted advertising and media outreach.

    The #ChoosePT campaign website includes facts about pain and the opioid epidemic, tips for avoiding chronic pain, and a toolkit with downloadable graphics and other materials to extend the campaign's reach.

    APTA continues to develop initiatives designed to raise awareness of physical therapy's potential role in managing pain. Last year, for example, as part of #ChoosePT, the association published a white paper, "Beyond Opioids: How Physical Therapy Can Transform Pain Management to Improve Health." The document argues that stemming the opioid epidemic will require both multidisciplinary collaboration and a commitment to interventions targeting the causes of pain.

    APTA also has published a chart that people can use to assess the severity and impact of their pain (and to determine whether physical therapy might provide the best treatment). It's also developing a pain-focused toolkit that's intended to help clinical professionals in all areas of health care "know who they should refer to and for what," Guerrero says.

    Other association initiatives in the works include a pain "triage tree" that, like the toolkit, will help PTs determine when to treat or refer; resources for therapists interested in advocating for change in pain-related legislation in their local areas; and an effort to bring more pain-management coursework to the curricula of accredited physical therapy education programs.

    And then there's the APTA Academy of Orthopaedic Physical Therapy's Pain Special Interest Group (P-SIG). According to Carolyn McManus, PT, MPT, MA, P-SIG's president, the group's goals include promoting the role of PTs in clinical pain management, expanding opportunities for pain-related continuing education, and serving as a resource for current research on pain. P-SIG currently is open only to academy members, but plans are under way to change that. "It's not just orthopedic patients who are coming in with issues related to pain. We're aware of that, and we realize that P-SIG could be an important resource for any physical therapist," McManus says.

    Stopping Pain in its Tracks

    According to Carol Courtney, PT, PhD, a professor of physical therapy and human movement sciences at Northwestern University in Chicago, current curricular guidelines for DPT programs call for a "mechanisms-based approach" to pain management, meaning that PTs should choose interventions to address aberrant pain mechanisms they have identified during the examination process. "We have certain mechanisms that always are at work that inhibit our experience of pain," she explains. "When those mechanisms are impaired—that's when we experience pain at a higher level or intensity."

    Pain mechanisms, as described in a May 2018 article in PTJ (Physical Therapy), include nociceptive, central, neuropathic, psychosocial, and movement system processes.1 Poor sleep can prevent these mechanisms from functioning properly, Courtney notes, as can lack of exercise. "If you tear a ligament, it's going to hurt. You're going to experience acute pain. The pain mechanisms approach says, 'Let's make sure you can still do things such as sleep and exercise to try to prevent that transition to chronic pain.'"

    The good news for PTs and their patients, Courtney says, is that this is the kind of work at which the profession excels. "Prescribing exercise while treating the injured knee, or whatever the peripheral driver of that pain happens to be? That is the physical therapist's bread and butter."

    References

    1. Chimenti RL, Frey-Law LA, Sluka KA. A mechanism-based approach to physical therapist management of pain. Phys Ther. 2018;98(5):302-314.

    Resources

    APTA

    Other Organizations


    Comments

    It's interesting that physical therapy seems to be looking at the "neuroscience of pain" and biopsychosocial approaches as new concepts but these viewpoints are really nothing new and have been utilized in a variety of forms by people like Emil Coue, Milton Erickson, Raymond Burnap (DIOBA), and many others starting at least a century ago (and more) and proceeding up to modern times. Then there are the truly unique approaches such as John Iam's Pain Reflex Release Technology (PRRT) where one can quickly inhibit nociceptive reflexes. I've had a number of patients with pain lasting up to decades have the pain vanish in less than a minute with this approach. How about APTA doing an article on him and his methodology?
    Posted by Brian Miller -> =KX[> on 4/30/2019 9:15:33 PM
    Physical therapists should treat the "whole" patient. Unfortunately, billing codes, access restrictions and scope of practice are still issues today for many interventions. For example: I do not recall ever getting reimbursed for billing "patient education" even though we had a code. Of course, patient education is a misnomer as you cannot educate the unwilling, skeptical or biased, therefore, first, a detailed biopsychosocial-spiritual and cognitive- behavioral approach that includes assessing past experience, current beliefs, perceived barriers, supports for success, and incremental goals is required. What do you bill this under if it is not completed in the eval? Then, regardless of other PT interventions, these folks need wellness and lifestyle interventions which PTs are well qualified to provide in both group and individual sessions, but we cannot usually get reimbursed for this. Improving lifestyle choices may be the most important component of chronic disease, including pain, management. These folks need to move from passive care to active self-care and many with chronic pain and comorbid mental health conditions must be coached to be successful, yet most of us can only do this cash pay in many cases. When there is less scope and practice restriction we will finally bend the chronic disease, cost curve down, improve peoples quality of life and lessen their pain, or improve their skills in self-care. Too bad my 30 year P.T. career has passed with these and other limits still on our access and scope because we have so much to offer.
    Posted by John Lesh on 5/1/2019 5:11:11 PM
    I truly appreciate the insight and knowledge presented in this article. Education is perhaps the most important part of the treatment we can give.
    Posted by Brandon Tutt -> DIU\>M on 5/6/2019 1:02:53 PM
    How about billing neuromuscular re-education for Therapeutic Neuroscience Education? Also consider billing therapeutic activities when discussing coping mechanisms for ADLs like walking, household chores, bending, lifting, reaching? Thoughts?
    Posted by Anthony Pazzaglia -> >HX`DN on 5/23/2019 8:29:04 PM
    I 100% agree with the article but it is also missing some very important factors when it comes to chronic pain. The past few years I’ve been the director of human performance in the military special operations community and have had the pleasure of working with sports dietitians and psychologists. I always knew that sleep and diet were important but I never grasped how extremely important they are when dealing with pain and recovery until recently. As physical therapists I believe we really need to address this more with our patients. Now, I always start with making sure that their vitamin D levels are adequate, which can have a huge impact, and then I address exercise, diet, and sleep. I know it’s hard to change a patients diet/lifestyle but it isn’t that difficult to convince them to take Omega 3s (in sufficient quantity) which can also make a big difference in pain. As physical therapists please don’t ignore these critical elements with all of your patients, especially ones dealing with chronic pain.
    Posted by NATHAN Shepard on 5/24/2019 12:20:46 PM
    This is nonsense. The major problem with the chronic pain patient is the chronic lifestyle problem. Obesity, sedentary lifestyle and chronic anxiety, not to mention terrible diet are the main contributors of chronic pain. Fibromyalgia doesn't exist as a disease--poor lifestyle exists. Yes there are physiological changes in the nerve fibers with centralization--and they are caused by poor lifestyle. This is the problem with my profession and why physical therapy is becoming more of a charlatan profession--and I've been in for twenty years now and can tell you what the patient was like twenty years ago versus the majority of patients that exist today. The problem, our problem, is we are a profession that does not live in reality. You don't solve the chronic patient outside of short term results. Regardless of your GROC or LE functional scales at discharge---the chronic pain patient keeps coming back. The chronic pain patient is now the main cash cow of physical therapy. I am actually in the process of sending letters to the major insurance companies to advise to greatly reduce physical therapy reimbursement for chronic pain--for not one of you, brilliant or not, can show me the chronic pain patient that got better long term--unless that patient changed his lifestyle, which isn't in the hands of PT. My profession is nothing short of guilty of the heist of billions in reimbursement for no results whatsoever. And this sort of discussion above is exactly what the problem is--inability to recognize the universe known as reality.
    Posted by charles on 8/14/2019 7:51:44 PM

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