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Chronic Pain and the Benefits of Physical Therapy
For our community activity we chose to go to Sports & Wellness Physical
Therapy on Higuera Street. We interviewed the owner, Doug Johnson and gained insight
on his background, advice for the younger community, and what exactly it is that he does
there and how it relates to seniors. Doug’s main focuses include post surgical
rehabilitation, injury rehabilitation and prevention, back and neck care, and some sports
related injuries. Doug’s wife, Lisa Story, also works with many of the patients that come
in for physical therapy as a health coach and focuses on nutrition and dietary needs,
lifestyle management, and she also mentoring and encouraging a holistic lifestyle;
unfortunately we did not get the opportunity to meet with her. When asking Doug about
the patients he sees, interestingly enough he explained that a majority of his clientele are
seniors with joint related problems and dealing with chronic pain. We chose this
particular agency because our career goals both fall along the lines of sports medicine and
sports nutrition. Although many of the clients that come in for physical therapy at Sports
& Wellness Physical Therapy did not suffer from a sports related injury, a majority are
seen due to post surgical rehabilitation or chronic pain. With such an outstanding number
of patients being seen at this facility for chronic pain, we realized how much of an issue it
truly was in that such a high number of people suffer from it and search for a
non-invasive treatment method. We chose to learn more about chronic pain and how
exactly physical therapy can help prevent, treat, and heal it.
Chronic pain affects 100 million Americans - that's more than cancer, diabetes
and heart disease combined. Chronic pain can be defined as pain lasting for more than 12
consecutive weeks, and it can be compared to acute pain (NIH). Acute pain is a normal
sensation that alerts us to possible injury, whereas chronic pain persists for a longer
period of time. Chronic pain can arise from different injuries, such as sports injuries, neck
and back injuries, etc., or there could be an ongoing cause, such as an illness. There also
may be no clear cause of the pain. Other health problems can accompany chronic pain,
such as fatigue, sleep disturbance, decreased appetite and mood changes. While there are
a lot of symptoms to pain, there unfortunately is no test that can measure and locate pain
with precision(NIH). Pain is a very personal, subjective experience. Health professionals
rely on the patient’s own description of the type and location of pain. There are a few
different risk factors associated with chronic pain, and they can be broken down into
three categories. Dispositional, situational and exposures (Fillingim). Dispositional risk
factors could be genetics, demographics, personality or depression, situational could be
stress, mood/coping, or transient biological processes, and exposures could be
trauma/injury, stressors/occupation, or smoking/diet. The development of chronic pain
from acute pain occurs in discrete, pathophysiological steps involving multiple signaling
pathways (Voscopoulos).
Treatment for chronic pain can come in many different forms. The first form of
treatment to consider for chronic is pharmaceutical. As of 2009, the American Geriatrics
Society (AGS) updated their guidelines for the Pharmacological Management for
Persistent Pain in Older Adults. The current guidelines were aiming to update the
evidence from the 2002 guideline and provide new recommendations regarding the use of
newer pharmacological approaches to manage persistent pain in the older population.
AGS reported difficulty prescribing pain medication to older adults because often times
the older population under report pain, or concurrent illnesses and multiple health
problems make it difficult to prescribe medication (AGS). The older population is also
more likely to experience medication related side effects. Before prescribing medication,
clinicians will perform an evaluation of pain which relies on the patients on report which
includes an assessment of the intensity and evaluation of the effect of pain on their daily
functions. Positive outcome of medication is maximized when the clinician is
knowledgeable about the drugs they are prescribing, monitor the patient regularly for
adverse effects. With older patients optimal dosage and common side effects are difficult
to predict. It is often best to start with a lower dosage of medication and steadily increase
and also increase the number of reassessments of the dosage to find the optimum dosage
for maximum pain relief (AGS). For the older population, the least invasive method of
drug administration is most often times preferred. For many patients the combination of
pharmacological and non-pharmacological strategies seems to work the best to maximize
their pain relief. One of the most effective non-pharmacological interventions is physical
therapy. Combinations of drugs might be necessary to reach the desired end point. Some
of the most well known or common drugs used for treatment of chronic of persistent pain
include: acetaminophen (Tylenol), celecoxib ( Celebrex), ibuprofen, opioids such as
hydrocodone, oxycontin, and morphine.
The second type of treatment to discuss is surgical. According to both the
American College of Rheumatology (ACR) and the American Association of
Neurological Surgeons (AANS), surgery is often only recommended to those who have
already undergone non-surgical treatment and found it to have been unsuccessful and still
suffer from chronic pain. The most common form of surgery for chronic pain is joint
replacement in either the hips or knees. It is so common that in 2003 ACR found that
418,000 total knee replacements and over 220,000 hip replacements were performed in
the United States (ACR). Since surgical techniques and new implant materials have been
developed, total joint replacement has been found to be one of the most reliable and
durable procedures of any medicine. Joint replacement surgery is the removal of worn
cartilage from around the joint, followed by the resurfacing of the joint with a metal and
plastic replacement implant that looks and functions almost identically to the normal
joint. Total joint replacement is first diagnosed by chronic pain due to arthritis, and can
be confirmed with a simple x-ray of the area with the damaged cartilage (ACR). Mild
arthritis is not enough to qualify for total joint replacement surgery; severe arthritis
caused by osteoarthritis, rheumatoid arthritis, other inflammatory joint problems, and
previous joint injuries or fractures are typically conditions which qualify someone for
total joint replacement. Other qualifications for surgery include sufficient health in order
to ensure a safe surgery, proper reaction to anesthesia, and ability to undergo
post-surgical rehabilitation associated with the surgery. Once surgery has been
completed, certain types of physical activity may be resumed. It is best to avoid an
overload of activities that involve heavy lifting, running, and jumping. Encouraged
exercises and activities include swimming, water aerobics, walking, biking, low impact
aerobics, golf, or tennis. Very few patients have seen any significant restrictions to their
normal, everyday activities after having undergone total joint replacement of the knee or
hip (ACR).
Another option for surgical treatment of chronic pain is neurosurgery.
Neurosurgery focuses less on the musculoskeletal pathway and more on the nervous
system. According to the American Association of Neurological surgeons there are
several different types of neurosurgery offered to treat chronic pain, but the similarity
they all share is the attempt to lessen the pain signaling from nerves throughout the body
to the brain. The first type of surgery is decompression. The process involves
microsurgical exposure of the nerve root, and finding a blood vessel near it that is
compressing, or putting pressure on the nerve. The blood vessel is then moved to lessen
the sensitivity of the nerve, and hopefully let the nerve recover to a normal pain free
condition. The next type of surgery offered by the AANS is radiofrequency rhizotomy.
The procedure involves treating the nervous tissue with heat. This treatment can be used
on anything from the trigeminal nerve in the head, or to any area of the three areas of the
spine - cervical, thoracic, or lumbar. Another type of rhizotomy is glycerol rhizotomy.
This involves injecting glycerol through a needle into the area where the nerve divides
into three main branches. The goal of this procedure is to selectively damage the nerve in
order to interfere with transmission to the brain of pain signals as stated by the AANS.
Stereotactic radiation is a procedure where radiation is aimed precisely at an appropriate
target. Because of radiation exposure, with time a lesion in the nerve will form and the
blockage interrupts transmission of pain signals to the brain. The last two types of
neurosurgery available for the treatment of chronic pain are spinal cord stimulation and
deep brain stimulation. Spinal cord stimulation delivers low-voltage electrical currents
continuously to affected areas of the spinal cord in order to block the sensation of pain
from ever reaching the brain. Rather than stimulating the area of pain itself, its possible to
stimulate the final destination of pain processing through deep brain stimulation, or
DBS. DBS involves the placement of a very thin electrode to specific parts of the brain
that are involved with the processing of pain signals. DBS delivers a continuous electrical
pulse, and is shown by the AANS to be the most effective treatment of intractable chronic
back pain. Similarly to the total joint replacement surgeries or any surgery, it is important
to evaluate the patient’s age, medical condition, and symptoms before any of the
procedures can be fully considered.
Some of the major downsides to pharmaceutical treatment or invasive surgical
procedures is that these approaches can be very costly, cause medication dependence and
potential abuse, and may even be associated with serious side effects (Crawford).
Although many of these treatments aim to reduce the pain the patients feels and improve
function so they can resume day-to-day activities, One of the major options for treatment
is physical therapy. According to the American Physical Therapy Association, physical
therapy plays a vital role in helping patients manage and overcome chronic pain. Physical
therapists administer treatments that include strengthening and flexibility exercises,
manual therapy, posture awareness, and body mechanics instruction. By using a “go low
and slow” method, physical therapists are able to gradually increase the intensity of
active exercises. Physical therapists can also help the patient to understand the underlying
cause of their pain. One way this is achieved is by educating their patients about how
brain and central nervous system hypersensitivity contribute to their chronic pain. By
encouraging patients to never give up, they can learn that chronic pain does not need to
be a way of life. (Brown 2013).
Just this year, the American Academy of Pain Medicine (AAPM) published an
article called Physically Oriented Therapies for the Self-Management of Chronic Pain
Symptoms. The study performed was a systematic review of existing research regarding
the comparison of active self-care complementary and integrative medicine (ACT-SIM)
therapies to traditional approaches to treating chronic pain. ACT-SIM considers the
holistic interplay of biological, psychological, and social/cultural factors within an
individual may be more effective treatment options according to the AAPM. For the
study, database searches yielded 2,771 articles to be reviewed. The first type of treatment
to be reviewed was acupressure, which is a type of musculoskeletal manipulation.
Acupressure is a traditional Eastern concept which is aimed at restoring healing and
balance to the body’s channels of energy in order to promote relaxation, wellness, and
disease treatment. Similar to acupuncture, acupressure targets those same acupuncture
points just with pressure instead of needles (Crawford). The study was aimed towards
individuals suffering from chronic pain of the lower back and chronic headache. Out of a
total of 303 participants, it was found that acupressure was more effective in treating the
chronic pain than the administration of a muscle relaxant, and there were no adverse
effects to be found. The second type of ACT-SIM therapy was self-correcting exercises.
It is the self care form of manipulation therapies that include stretches and flexibility
exercises. There were forms where a medical provider would assign a functionally
oriented diagnosis and facilitates the development of an exercise program for the patient.
The exercises could be facilitated by doctors of chiropractic medicine of osteopathic
medicine, or physical therapists. This particular treatment strategy was aimed at
individuals suffering from chronic lower back pain but could also be applied to other
musculoskeletal pain conditions. Out of all the studies examined, it was found there was
no significant difference in reported pain after treatment using self-correcting exercise in
comparison to traditional surgical or pharmacological treatment (Crawford). For both
acupressure and self-correcting exercises, no adverse effects were observed and the panel
of experts reviewing the research found that these therapies empowered the patients and
gave them the sense of control over his or her condition, it decreased their reliance on
provider-dependent care, and therefore improved chronic pain management outcomes.
While the decided that more research was needed in order to fully understand the efficacy
of those modalities as self-care practices, but they claim there are numerous conditions
that these forms of physically oriented therapies could be well suited to treat (Crawford).
The targeted system when dealing with treatment for chronic pain through
physical therapy is the musculoskeletal system. The skeletal system includes the bones of
the skeleton and the cartilages, ligaments, and other connective tissue that stabilize or
connect the bones. In addition to supporting the weight of the body, bones work together
with muscles to maintain body position and to produce controlled, precise movements
(AAOS). Without the skeleton to pull against, contracting muscle fibers could not make
us sit, stand, walk, or run. The causes of musculoskeletal pain are varied. Muscle tissue
can be damaged with the wear and tear of daily activities. Trauma to an area, such as
jerking movements, auto accidents, falls, fractures, sprains, etc., can cause
musculoskeletal pain. Other causes of pain can include postural strain, repetitive
movements, overuse, and prolonged immobilization. When physical therapist target the
musculoskeletal system to treat chronic pain, they can focus on strengthening the
surrounding muscles (AAOS). This helps to reduce stress in the surrounding joints.
Strong muscles will also absorb shock, which would result in fewer injuries.
There are many questions out there to see if physical therapy alone can help heal a
person without the need for surgery. Thankfully, there was a study done that tested these
questions. A multi-center, randomized, controlled trial was conducted that involved
symptomatic patients, 45 years of age or older, with a meniscal tear and evidence of
mild-to-moderate osteoarthritis on imaging (Katz). Meniscal tears are among the most
common knee injuries. The meniscus is made up of two wedge-shaped pieces of cartilage
that act as "shock absorbers" between the femur and the tibia. They are tough and rubbery
to help cushion the joint and keep it stable. Unfortunately, there are many ways the
meniscus can tear. One example of how the meniscus can is tear is by suddenly twisting
the knee while the foot is planted on the ground. Common tears include longitudinal,
parrot-beak, flap, bucket handle, and mixed/complex (AAOS). Older people are more
likely to have degenerative meniscal tears because cartilage weakens and wears thin over
time. Aged, worn tissue is more prone to tears. Just an awkward twist when getting up
from a chair may be enough to cause a tear, if the menisci have weakened with age.
Along with weakened cartilage leading to meniscal tears, osteoarthritis has been shown to
have a negative effect on seniors and their joints. Osteoarthritis is one of the most
common forms of arthritis. It is a chronic condition in which the material that cushions
the joints, called cartilage, breaks down. This causes the bones to rub against each other,
causing stiffness, pain and loss of joint movement. Osteoarthritis in the knee is frequently
associated with small degenerative meniscal tears and vice versa. Many people with knee
osteoarthritis and a meniscal tear may be able to avoid surgery and achieve comparable
relief from physical therapy. By randomly assigning the 351 patients to either receive
surgery and go to postoperative physical therapy or just to a standardized
physical-therapy regimen (with the option to cross over to surgery at the discretion of the
patient and surgeon), the questions could be answered. The patients were evaluated at 6
and 12 months. At the end of the trial, it was shown that there were no significant
differences in the magnitude of improvement in functional status and pain after 6 and 12
months between patients assigned to arthroscopic partial meniscectomy with
postoperative physical therapy and patients assigned to a standardized physical-therapy
regimen (Katz).
From clinical trials to detailed research, physical therapy has been shown to be an
excellent way to heal a person suffering from chronic pain. People should not have to
suffer from chronic pain.
References
Johnson, Doug. Personal Interview. 16 April 2014
“Chronic Pain: Symptoms, Diagnosis, & Treatment.” National Institute of Health Medline
Plus. 2011. Web. 30 May 2014.
Fillingim, R. “Genetic and Non-Genetic Risk Factors for Development of Chronic Pain.”
Initiative on Methods, Measurement, and Pain Assessment in Clinical Trials. 2009. Web.
30 May 2014.
Voscopoulos, C. “When does acute pain become chronic?” British Journal of
Anaesthesia. 2010. Web. 30 May 2014.
Radcliff, S., Addleman, K. “Pharmacological Management of Persistent Pain in Older
Persons.” American Geriatrics Society on the Pharmacological Management of Pain in
Older Persons. 2009. Web. 31 May 2014.
Kraay, M. “Joint Surgery.” American College of Rheumatology. 2013. Web. 29 May
2014
“Patient Information Chronic Pain.” American Association of Neurological Surgeons. 2005.
Web. 30 May 2014
Brown, L. “Manage Chronic Pain With the Help of a Physical Therapist.” American
Physical Therapy Association. 2013. Web. 28 May 2014.
Crawford, C., Lee, C., May, T. “Physically Oriented Therapies for the Self- Management
of Chronic Pain Symptoms.” American Academy of Pain Medicine. 2014. Web. 30 May
2014
“Meniscal Tears.” American Academy of Orthopaedic Surgeons. March 2014. Web. 30
May 2014.
Katz, J. “Surgery versus Physical Therapy for a Meniscal Tear and Osteoarthritis.” The
New England Journal of Medicine. May 2013. Web. 25 May 2014.