Volume VI, No. 3,
Physical Therapy for Chronic Pain Historically, the management of disease, injury, and even childbirth involved long periods of hospitalization, bed rest, and convalescence. Health care practitioners used a narrow disease/impairment-based model in which patients were passive recipients of care. Physical therapists working within such a "rest for recovery" framework developed skills and techniques of which many were passive, some were modality-based, and most were lengthy. Health care has changed in recent decades. Early activity for recovery of function is now encouraged, and the impairment model has broadened to include psychosocial components. A multidisciplinary team approach now includes the patient as an educated and active participant, and physical therapy treatments emphasize activity. The therapist's role has changed from healer to helper. Therapists help patients address and overcome physical and psychological obstacles, return to activities, and achieve personal goals. Recognition of a broad biopsychosocial model of health (and illness) and the positive role of activity in health and healing, emphasis on function rather than impairment, and reliance upon clinical evidence have transformed physical therapists' practice. Recognition of a broad biopsychosocial model of health (and illness) and the positive role of activity in health and healing, emphasis on function rather than impairment, and reliance upon clinical evidence have transformed physical therapists' practice. Adoption of cognitive and behavioral principles and time limited, goal-oriented rehabilitation has changed the assessment, management, and evaluation of outcome for patients with chronic pain. A patient-centered rehabilitative approach that emphasizes restoration of normal movement and function incorporates physical therapy as a vital component of the collaborative approach required for effective pain management. This article addresses the physical therapist's role in the rehabilitation of patients with chronic pain. Assessment
Jette et al.1 identified reduction in patients' pain report and improvement in physical functioning as primary goals of physical therapy. Yet pain reduction, however desirable, may not always be feasible for patients with chronic pain. Management then aims to improve physical function and reduce disability. Assessment includes clinicians' measures of physical function and patients' reports of disability. Physical therapy clinical assessment has traditionally relied on clinical tests of impairment. These tests correlate poorly with patients' pain and dysfunction, especially in the case of chronic pain2,3. Standardized tests of muscle strength and range of motion in isolation lack sensitivity, specificity, and responsiveness4. Complex and expensive isoinertial and isokinetic devices measure strength, and range and velocity of motion reliably, but performance of chronic pain patients may be erratic5 because of psychological factors such as fear of injury and low perceived self-efficacy. Moreover, specialized testing with these devices does not simulate everyday activities. The best performance testing is quick, simple, and meaningful to both patient and practitioner. Clinician Measured Function. Measured performance tests are best when quick, simple, and meaningful to both patient and practitioner. Those that use minimal (if any) special equipment, are inexpensive, and test functions of everyday life compromised by chronic pain have been adopted in clinical practice. Patients with pain tend to move more slowly than pain-free persons, generate less force during muscle testing, and may have poor endurance during exercise. Therefore timed tasks and measures of increased loading of joints and muscles generally discriminate between those with and those without painful conditions6,7. The physical performance battery (PPB)7 measures time taken and distance reached or walked during a set of tasks. The PPB was developed for use in persons with low back pain. It has demonstrated good intra- and inter-rater reliability and stability over time, and differentiates patients from pain-free controls. Self-report of disability correlates with most of the PPB measures, but measures of pain and PPB measures are less closely linked. The assessment battery of Harding et al.8 for use in a diverse chronic pain population detects change following pain management. Self Report of Function. Self-report questionnaires may be generic or condition-specific, and they may vary from long and comprehensive (e.g., Sickness Impact Profile9) to short and specific (e.g., Roland and Morris Disability Questionnaire for low back pain10). The latter are more frequently used in physical therapy. Self-report provides insights into patients' self-perception and may flag problems overlooked on clinical testing. However, there may be differences between how patients function and how they believe they function11. Thus directly observable, quantifiable tests of physical function are useful to complement patient reports. The Patient Persons with chronic pain may be severely incapacitated and physically deconditioned. Deconditioned individuals function at a level close to their maximum capacity. They
have less energy available and use it less efficiently. Their energy is spent getting through the day, meaning that they have little in reserve for recreation or emergencies. Some patients with chronic pain report levels of activity that fluctuate dramatically, as governed by pain. The overactivity-rest cycle12 is characterized by perseverance with activity until increasing pain prevents further participation. The person then rests completely until the pain subsides or frustration with inactivity stimulates resumption of activity. The person then again perseveres until increasing pain prevents further activity. Intolerance of physical activity and/or deconditioning are problems for many patients. A causal directional relationship is assumed between pain, decreased activity, and deconditioning despite little empirical support. Evidence supports the notion that patients with chronic pain are not physically fit. However, the problem of physical deconditioning in patients with pain must be considered within the broader social context. The majority of all persons in industrialized societies -- not just those disabled by pain -- are physically deconditioned. According to the 1996 U.S. Surgeon General's report, 60% of Americans are not regularly active, and 25% are not active at all. Nevertheless, the relatively low level of fitness among chronic pain patients suggests that even a small reduction in normal activity can have profoundly negative effects. Chronically reduced activity compounds the negative consequences of pain -- physically, psychologically, and socially. Activity is part of normal, healthy, everyday life, and all cells of the body undergo mechanical deformation and metabolic adaptation in response to activity-evoked mechanical stress. Inactivity deprives tissues of this stimulation and can have generalized negative effects. A detailed discussion of physiological mechanisms in deconditioning is beyond the scope of this paper; however, several key factors deserve mention. Patients with pain perceive an equivalent level of exertion at a significantly lower level of performance, because of both central (cardiorespiratory) and peripheral (muscle strength and recruitment) factors. Deconditioned individuals have a reduction in cardiorespiratory endurance and experience dyspnea and fatigue earlier during aerobic exercise. Their heart rates are elevated at rest and increase markedly during submaximal levels of exercise. With inactivity, skeletal muscles atrophy. Immobilization and bed rest produce a disproportionate loss of Type I muscle fibers. Loss of muscle strength and endurance with inactivity is due to loss of muscle mass, decreased ability to use energy substrates efficiently, decreased neuromuscular transmission, and decreased efficiency in muscle fiber recruitment. Patients with pain perceive an equivalent level of exertion at a significantly lower level of performance, a finding accounted for by both central (cardiorespiratory) and peripheral (muscle strength and recruitment) factors. Inactivity also deprives bones, joint cartilage, and connective tissue of the mechanical stress necessary to maintain tensile and compressive strength and elasticity. Evidence is building that motor control and proprioceptive efficiency are altered, balance is compromised, and reaction times are slower in persons who are unfit or have pain.
Further work is needed to investigate the presumed detrimental effects of the poor static posture that often accompanies deconditioning. This may have an effect, via neural overstretch and/or neurovascular constriction, upon neuronal axoplasmic transport of trophic substances to target collagenous tissues in the periphery. The precise roles of nociceptive input or perceived pain in physiological deconditioning, muscle activity, motor control, and balance reactions are incompletely investigated. Rehabilitation Rehabilitation strategies must be individualized to optimize improvement in physical function. Activity, activity-related goal setting, and pacing of activity play key roles in the rehabilitation of patients with chronic pain. Activity, activity-related goal setting, and pacing of activity play key roles in the rehabilitation of patients with chronic pain. Many problems associated with deconditioning are reversible through general and specific exercise regimens. For example, aerobic training improves aerobic fitness (maximal oxygen consumption, VO2max)13-16. The relevance of an improvement in VO2max to a patient's pain and physical function is not always apparent. However, the fact that improvement in overall physical function is linked with improvement in psychosocial function and mood17 is clearly relevant to patients. Exercise regimens should be regular, and gradually increase in duration and intensity. Adherence is greatest with exercises that are easily incorporated into a patient's routine. Patients are also more likely to participate in exercises or activities that they find interesting, especially if others are involved. Patients require good information to assist them in making choices, overcoming unhelpful beliefs, and modifying behavior (such as increasing activity and exercise). Many patients with chronic pain have concerns that inhibit physical rehabilitation. These include: •
Lack of a diagnosis or failure to understand or address the meaning of explanations given, such as "no observable abnormality," "degenerative condition," or "wear and tear." Inability to relate a tissue- or system-based diagnosis to multifactorial causation and secondary effects over time, pain extent and severity, pain continuance, physical effects, and life disruption. Misunderstanding brought about by myths about pain, the workings of the nervous system, and the influence of psychological factors.
Two skills essential for successful rehabilitation are self-pacing during activity and setting appropriate and achievable goals. Pacing and goal setting in physical therapy seek to even out the activity peaks and troughs controlled by pain so as to achieve a moderate activity-rest cycle12. Appropriate pacing requires that daily activities be regulated and
structured. Gradual, controlled increases in general activity level will avert triggering sudden increases of pain that lead to reduction of activity. Activities are paced by timing and/or the introduction of exercise quotas interspersed with periods of rest or a different activity12, 18, 19. Appropriate goal setting is another important skill that patients usually must learn. Establishing specific, challenging but attainable goals can actually facilitate task performance20. In contrast, poor task performance, decreased motivation, and a sense of failure can result from repeatedly failing to achieve unrealistic goals. Task performance results from meeting expectations of efficacy and outcome21. Efficacy expectation is the belief that one has the ability to perform an action that leads to a specific outcome. Outcome expectation is the belief that a specific outcome can be achieved as a result of a specific behavior. Efficacy expectations may be the most potent determinants of change during rehabilitation. Increased self-efficacy is closely linked to successful rehabilitation. Positive outcome is defined as increased activity, improved coping, and reduced pain behavior22, 23. Confidence is often low when tackling new goals or returning to previously abandoned activities. To increase confidence, patients need to attempt something previously feared, achieve it, and recognize it as their own achievement. Thus, persistent goal attainment will reinforce self-efficacy and lead to a perception of mastery over the problem and the task. Activity goals should be set in three separate domains. The physical domain is the exercise program the patient follows and includes the number of exercises to be performed, the duration of exercise, and the level of difficulty. The functional domain involves tasks of everyday living such as housework or hobbies. The social domain relates to pleasurable social activities (e.g., visiting friends, going to church or the movies, going for a walk). Goals must be personally relevant, interesting, measurable, and achievable. Goal setting should be a matter of negotiation between the patient and the therapist. The use of goal-setting charts is essential. Patients set a target for activities each week, record their achievements on the chart, note the nature of any difficulties and how these will be tackled next time, and make other comments. For example, they may comment on their performance or on the appropriateness of the goals they had set. In this manner they can monitor their progress and improve their accuracy in goal setting Relapse Management It is almost inevitable that a patient with chronic pain will experience an exacerbation of the pain problem at some time. Relapse may be due to an individual physical event or it may result from cumulative physical and psychological stresses that challenge patients' coping resources. The physical therapist can help to identify situations that are challenging and develop strategies to cope with them. Strategies may include setting criteria to visit health professionals, to use pain medication, or to briefly rest and relax.
Plans for resumption of activity following such an exacerbation are critical. Even if it does not cover all eventualities, having an action plan in readiness for exacerbations can help the patient retain a sense of control. An exacerbation should never be taken as failure or as evidence of patients' inability to manage the condition. It is a challenge to self-management, not the end of it. Moreover, should specific treatment be required (e.g., manipulation, mobilization, or trigger point therapy), it must be time-limited and presented to patients as a short-term measure that can assist in a crisis as they resume self-management. For chronic pain sufferers the process of rehabilitation to a life less dominated by pain can be long and complex. Rehabilitation involves overcoming physical and psychological obstacles. Physical therapists are important to pain management. They help patients address obstacles to rehabilitation and to use information, and provide helpful feedback and reinforcement to guide efforts toward a return to activities and achievement of valued personal goals. Physical therapists have incorporated cognitive and behavioral principles into rehabilitation and use a comprehensive biopsychosocial model of pain management that is patient-centered, time-limited, and goal-oriented24-26 . Their rehabilitative approach and fundamental concern with restoration of movement and function make physical therapists essential to the collaborative approach required for effective pain management. An exacerbation should never be taken as failure or as evidence of patients' inability to manage the condition. It is a challenge to self-management, not the end of it. Their rehabilitative approach and focus upon restoration of movement and function make physical therapists essential to the collaborative approach required for effective pain management. Vicki R. Harding, MCSP INPUT, St. Thomas' Hospital, London, UK Maureen J. Simmonds, PhD MCSP Department of Physical Therapy, Texas Woman's University, Houston, Texas, USA Paul J. Watson, MSc MCSP Department of Behavioural Medicine, Hope Hospital, Salford, UK References 1. Jette AM et al. Phys Ther 1994; 74:101-115. 2. Waddell G. Spine 1987; 12:632-644. 3. Turk DC et al. J Rheumatol 1996; 23:1255-1262. 4. Nelson RM. NIOSH Low Back Atlas of Standardized Tests and Measures. Springfield VA:
National Technical Information Service, 1988. 5. Newton M et al. Spine 1993; 18:812-824. 6. Simmonds MJ, Claveau Y. Physiotherapy Theory and Practice 1997; 13:53-65. 7. Simmonds MJ et al. Spine 1998; 23:2412-2421. 8. Harding VR et al. Pain 1994; 58:367-375. 9. Bergner Met al. Med Care 1981, 19:787-805. 10. Roland M, Morris R. Spine 1983; 8:141-144. 11. Fordyce WE et al. In: France RD, Krishnan KRR (Eds). Chronic Pain. Washington: American Psychiatric Press, 1984, pp 317-413. 12. Gil KM et al. In: France RD, Krishnan KRR (Eds). Chronic Pain. Washington: American Psychiatric Press, 1988. 13. Davis V et al. Arch Phys Med Rehabil 1992, 73:726-729. 14. Lindstrom SJ et al. Phys Ther 1992; 72:279-290. 15. Brennan GP et al. Spine 1994, 19:735-739. 16. Martin L et al. J Rheumatol 1996; 23(6):1050-1053. 17. Simmonds MJ et al. Disabil Rehabil 1996; 18:(4):161-168. 18. Fordyce WE. Behavioral methods for chronic pain and illness. St. Louis: CV Mosby, 1976. 19. Keefe FJ et al. In: Gatchel RM, Turk DC (Eds). Psychological approaches to pain management. New York: Guilford Press, 1996. 20. Locke EA. Organizational Behavior and Human Performance 1967; 3:157-189. 21. Bandura A. Psychol Rev 1977; 84:191-215. 22. Bucklew SP et al. Pain 1994; 59:377-384. 23. Burckhardt CS et al. J Rheumatol 1994; 21(4):714-720 24. Wittink H, Michel TH (Eds). Chronic pain management for physical therapists. Boston: Butterworth-Heinemann, 1997. 25. Gifford L (Ed). Topical Issues in Pain: Physiotherapy Pain Association Yearbook 1998-1999. Falmouth: NOI Press, 1998. 26. Harding VR. In: Pitt-Brooke J (Ed). Rehabilitation of Movement: Theoretical Basis of Clinical Practice. London: WB Saunders, 1998. IASP was founded in 1973 as a nonprofit organization to foster and encourage research on pain mechanisms and pain syndromes, and to help improve the care of patients with acute and chronic pain. IASP brings together scientists, physicians, dentists, nurses, psychologists, physical therapists, and other health professionals who have an interest in pain research and treatment. Information about membership, books, meetings, etc., is available from the address below or on the IASP web page: www.halcyon.com/iasp. Free copies of back issues of this newsletter are available on the IASP web page. Disclaimer: Timely topics in pain research and treatment have been selected for publication but the information provided and opinions expressed have not involved any verification of the findings, conclusions, and opinions by IASP. Thus, opinions expressed in Pain: Clinical Updates do not necessarily reflect those of IASP or of the Officers or Councillors. No responsibility is assumed by IASP for any injury and/or damage to persons or property as a matter of product liability, negligence, or from any use of any methods, products, instruction, or ideas contained in the material herein. Because of the rapid advances in the medical sciences, the publisher recommends that there should be independent verification of diagnoses and drug dosages. EDITORIAL BOARD Editor-in-Chief: Daniel B. Carr, MD, Internal Medicine, Endocrinology, Anesthesiology, USA Advisory Board: Lar Arendt-Nielsen, PhD, Neurophysiology, Denmark Kay Brune, MD, Pharmacology, Germany James R. Fricton, DDS, MS, Dentistry, Orofacial Pain, USA Victoria R. Harding, MCSP, SRP, GradDipPhys, Physical Therapy, United Kingdom Alejandro R. Jadad, MD, PhD, Anesthesiology, Evidence-Based Medicine and Consumer Issues, Canada
Irena Madjar, RGON, PhD, Nursing, Australia Patricia A. McGrath, PhD, Psychology, Pediatric Pain, Canada Bengt H. Sjolund, MD, PhD, Neurosurgery, Rehabilitation, Sweden Masaya Tohyama, MD, PhD, Molecular Biology, Japan Production Editor: Leslie N. Bond Copyright © 1999, International Association for the Study of Pain®. All rights reserved. ISSN 1083-0707.