The chronic pain client can be a challenge to treat even for the most knowledgeable clinician.
To this day, not only the patient, but also the providers are asking the questions 1) which is the best approach to treating the chronic pain patient: physical therapy or interventional management? 2) what is the best conservative management strategy for treating the chronic pain sufferer? and 3) what does the evidence say?
Numerous studies have shown that the optimal outcomes can be achieved with a multidisciplinary approach to management (1,2). It generally takes a ‘perfect storm’ to place an individual in their current chronic pain condition, meaning that biological/mechanical, social/relational, and psychological/emotional factors all play a role in the initiation or perpetuation of the painful condition(s). Offering treatment that is sequential (first physical therapy, then acupuncture, then interventional management, for instance) rarely, if ever, effectively addresses this very complicated challenge. Rather, simultaneous treatments and attending to what is known to enhance a treatment outcome will offer the greatest opportunity for success.
Such an approach can involve various professional disciplines, such as pain physicians, physical therapists, massage therapists and acupuncturists (to name a few). Each health care provider has the ability to not only employ tools specific to their profession, but additionally to make use of several facets important to the healing process that can be optimized in the local treatment environment (3)(4)(5). In the attainment of functional goals, three important strategies should be applied in the management of clients with chronic pain: (a) reduction of peripheral nociceptive input; (6–11), (b) improvement of central sensitization; and (c) treatment of negative affect, particularly depression (12).
For decades, patients – and clinicians – have searched for the ‘silver bullet,’ or a management approach that would finally and comprehensively ensure patient recovery. For example, clinicians first leaned on traditional physical therapy and then gravitated to rehabilitation based on a sports medicine model; with either, patients’ symptoms often worsened (13–17). Moreover, physical therapy has evolved from the utilization of only exercise, to the addition of application of modalities, to hands-on treatment, to a purely verbal ‘Explain Pain’, to a generalized biopsychosocial treatment paradigm individualized to the client (3,18). Each of these tools are valuable, but insufficient when used in isolation in the management of clients with chronic pain. Not only the plan of care but also the environment in which those treatments are carried out (from clinical setting to the type of music (19)(20)) play an important role in optimizing improvement.
As Bonakdar stated “When assessing pain, it is important to understand the physical and functional limitations that may be imposed. Equally paramount is appreciating and approaching the profound social, psychological, neurologic, and metabolic shifts that occur. This understanding as well as incorporating proper diet, activity, behavioral support, and patient activation as key components of treatment is essential in improving quality of life in those with pain.”(21)
Have you ever asked your client: ‘what does your client feel is wrong and what do they feel that they need to get better?’ How do you decide what or how much to provide? It is all part of being comprehensive and complete as a clinician. What is your art behind the science and clinical reasoning in patient care… Are you offering complete care in your clinical practice?
- Akyüz G, Özkök Ö. Evidence based rehabilitation in chronic pain syndromes. Aǧrı Ağrı Derneği’nin Yayın organıdır = J Turkish Soc Algol [Internet]. 2012;24(3):97–103. Available from: http://www.ncbi.nlm.nih.gov/pubmed/22865515
- Guzman J, Esmail R. Multidisciplinary bio-psycho-social rehabilitation for chronic low-back pain. Cochrane Database Syst Rev [Internet]. 2002;(1). Available from: http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD000963/full
- Scott JG, Scott RG, Miller WL, Stange KC, Crabtree BF. Healing relationships and the existential philosophy of Martin Buber. Philos ethics, Humanit Med [Internet]. 2009;4(1):11. Available from: http://peh-med.biomedcentral.com/articles/10.1186/1747-5341-4-11
- Iyendo TO, Uwajeh PC, Ikenna ES. The therapeutic impacts of environmental design interventions on wellness in clinical settings: A narrative review. Complement Ther Clin Pract [Internet]. 2016;24:174–88. Available from: http://dx.doi.org/10.1016/j.ctcp.2016.06.008
- Karnik M, Printz B, Finkel J. A Hospital ’ s Contemporary Art Collection : 2014;7(3):60–77.
- Schaible HG, Grubb BD. Afferent and spinal mechanisms of joint pain. Pain. 1993;55(1):5–54.
- Loeser JD, Melzack R. Pain : an overview. 1999;353:1607–9.
- Wright a. Recent concepts in the neurophysiology of pain. Man Ther. 1999;4(4):196–202.
- Baker K. Recent advances in the neurophysiology of chronic pain. Emerg Med Australas [Internet]. 2005;17(1):65–72. Available from: http://www.ncbi.nlm.nih.gov/pubmed/15675907
- Nie H, Graven-Nielsen T, Arendt-Nielsen L. Spatial and temporal summation of pain evoked by mechanical pressure stimulation. Eur J Pain. 2009;13(6):592–9.
- (Karin) Swart C.M.A. CMA, Stins JF, Beek PJ. Cortical changes in complex regional pain syndrome (CRPS). Eur J Pain [Internet]. 2009;13(9):902–7. Available from: http://dx.doi.org/10.1016/j.ejpain.2008.11.010
- Staud R. Future perspectives: pathogenesis of chronic muscle pain. Best Pract Res Clin Rheumatol. 2007;21(3):581–96.
- Järvholm U, Styf J, Suurkula M, Herberts P. Intramuscular pressure and muscle blood flow in supraspinatus. Eur J Appl Physiol Occup Physiol. 1988;58(3):219–24.
- Strobel ES, Krapf M, Suckfill M, Bruckle W, Fleckenstein W, Muller W. Tissue oxygen measurement and31P magnetic resonance spectroscopy in patients with muscle tension and fibromyalgia. Rheumatol Int. 1997;16(5):175–80.
- Maekawa K, Clark GT, Kuboki T. Intramuscular hypoperfusion, adrenergic receptors, and chronic muscle pain. J Pain [Internet]. 2002;3(4):251–60. Available from: http://linkinghub.elsevier.com/retrieve/pii/S152659000200010X
- Gallagher AM, Coldrick AR, Hedge B, Weir WRC, White PD. Is the chronic fatigue syndrome an exercise phobia? A case control study. J Psychosom Res. 2005;58(4):367–73.
- Wasenius N, Karapalo T, Sjögren T, Pekkonen M, Mälkiä E. Physical dose of therapeutic exercises in institutional neck rehabilitation. J Rehabil Med. 2013;45(3):300–7.
- Brunner E, De Herdt A, Minguet P, Baldew S-S, Probst M. Can cognitive behavioural therapy based strategies be integrated into physiotherapy for the prevention of chronic low back pain? A systematic review. Disabil Rehabil [Internet]. 2013;35(1):1–10. Available from: http://www.ncbi.nlm.nih.gov/pubmed/22607157
- Blödt S, Pach D, Roll S, Witt CM. Effectiveness of app-based relaxation for patients with chronic low back pain (Relaxback) and chronic neck pain (Relaxneck): study protocol for two randomized pragmatic trials. Trials [Internet]. 2014;15(1):490. Available from: http://trialsjournal.biomedcentral.com/articles/10.1186/1745-6215-15-490
- Kwekkeboom KL, Gretarsdottir E. Systematic review of relaxation interventions for pain. J Nurs Scholarsh. 2006;38(3):269–77.
21. Bonakdar RA. Integrative Pain Management. Med Clin North Am. 2017;101(5):987–1004.