High impact chronic pain, defined as persistent pain with “substantial restriction of participation in work, social, and self-care activities for six months or more” (1), of nonmalignant origin has been an enormous burden on the quality of life of an individual and society. Chronic pain not only impacts physical limitations, but may likely effects emotional, social, vocational, recreational and legal aspects of someone’s life. Therefore, unimodal or singular treatment options such as pharmacological intervention, injections, surgery, physical therapy or spinal cord stimulators are not as individually effective in improving suffering and restoring a normal lifestyle for people with chronic pain when compared to multimodal approaches (2,3). Consequently, integrated and multidisciplinary approaches have shown to be superior in the successful treatment of chronic pain patients (2,3). We, as physical therapists, are part of one of such multiple disciplinary team at Henry Ford Health in Detroit, Michigan.
What is the Multidisciplinary Pain (MDP) Clinic and How does the current MDP work?
The MDP clinic offers longitudinal, patient-centered care where patients are evaluated and treated by a team of providers which include a pain physician, pain psychologist, physical therapist and nurse practitioner. The MDP clinic at Henry Ford Health is unique in the way that patients are treated in an outpatient setting over the course of a lifetime, while other MDP clinics are often intensive, partial inpatient programs that are several weeks long without long term follow-up.
Once selected and referred to the program, an ample amount of time is dedicated to listening to the patient’s story to allow them to feel heard and provide a non-judgmental, supportive patient-provider relationship toward the path of recovery and functional independence. Our treatment is focused on behavioral changes through shared decision-making process. At the first MDP visit, patients are asked to identify at least one functional goal (using the SMART principle, achievable by the next MDP visit in 6-8 weeks. Based on the evaluation and patient needs, individuals are referred to other providers such as a nutritionist, massage therapist, physical therapist, neurologist and so forth. If needed, appropriate lab work or diagnostic testing is ordered. At the next visit, the patient’s self-selected goal is reviewed. At every visit, the patient is asked to make a new functional goal or continue working on an earlier goal with team members providing necessary recommendations. Outside of regular visits, there is frequent communication between providers and patients to fulfill other concerns. This goal-based, longitudinal and collaborative team approach shifts the focus away from pain and pain-related behavior towards functional restoration and independence.
What is the role of PT and current barriers for PT in treating chronic pain
Apart from a multidisciplinary collaboration, chronic pain is addressable within physical therapy. However, many physical therapists perceive barriers and challenges implementing a biopsychosocial treatment model with their patients with chronic pain (5,6). There is often a feeling of insufficient training and skill using this novel approach, which requires a change in thinking from traditional biomedical intervention. In fact, ninety percent of providers, including psychologists, nurses and physicians do not have thorough training to properly address chronic pain (6). A recent survey of doctoral PT programs was found to have poor awareness of chronic pain intervention (7). Due to these issues, there is a sense of frustration, reluctance and dissatisfaction among PTs treating patients with chronic pain resulting in reliance on outdated practice with poor outcomes.
Now that we appreciate the pitfalls of the current model of treatment, how can we improve our existing practice to address the critical needs of patients with chronic pain?
Approaching this patient population in PT
As chronic pain is multi-dimensional in terms of life impact (8), best management is achieved by using a multimodal approach (9). It can be challenging to address chronic pain issues within physical therapy, and it is not always clear where to start. Chronic pain patients can often feel frustrated by lack of progress using a traditional biomechanical approach to pain management. Feeling unprepared to work with the multifaceted nature of chronic pain, therapists may not be aware of methods to integrate a biopsychosocial model into their interventions (8). Additionally, physical therapists may feel that the psychosocial domain is outside their scope of practice and does not fit within the established professional role (4). Reframing concepts can answer the need to address both the behavioral and emotional sequelae of long-standing chronic pain that act as barriers to restoring function (7). This is where physical therapists and assistants have a great advantage over all health care professionals. We are perfectly positioned to help this refractory population due to our special skill of being educators and having ample one-on-one time with our patients. Our expectations will need some modification which is a simple enough thing to achieve life changing outcomes that are rewarding to both patient and clinician.
So, how does evidence-based care look for high-impact chronic pain? There is such a strong need for improved interventions for chronic pain that the American Physical Therapy Association adopted guidelines and competencies in 2018 emphasizing the biopsychosocial model within a multidisciplinary model (10). Our first step is to educate ourselves that chronic pain comes more from the central nervous system with a de-emphasis on tissue damage and injury as the source of chronic pain. e. Reconceptualizing how the pain system works helps change pain beliefs, decreases fear of movement, and reduces catastrophization (11). We know gentle low-level exercise is great for improving function and addressing nociplastic (pain without the presence of tissue damage), nociceptive, and neuropathic pain. People who are in pain can be reluctant to move, so physical therapists can pair what we already know is beneficial alongside education using simple terms, images, examples, and metaphors (10). Valuable tools include questionnaires to identify pain beliefs such as the Pain Catastrophization Scale or the Tampa Scale of Kinesiophobia. Do not be afraid to address negative lifestyle behaviors that additionally sensitize the nervous system. Help integrate new supportive behaviors surrounding pain such as meditation, relaxed diaphragmatic breathing, and self-reassurance. Limit passive care and empower patients to address their own needs and minimize reliance on others (10). These skills work together to calm a sensitized nervous system to improve independent pain management and function. The last step is to coordinate care with your team. Share your experience with referring providers, coworkers, and other disciplines (11). Consider referring to an interdisciplinary pain clinic that can help support your excellent work and refer to other disciplines judiciously, but liberally.
This blog was meant to provide you a glimpse of how PT can play a critical role in restoring function of patients with chronic pain. But there is much more that needs to be done to update our skills and improve ourselves. If any help is needed, you have suggestions, or just want to talk or share, please reach out to Karnik Shah (email@example.com) &/or Andrea Sherman (firstname.lastname@example.org).
Karnik Shah is a passionate and caring person, who enjoys treating patients with various musculoskeletal and neurological injuries. He specializes in treating patients with chronic pain syndrome. Karnik Shah graduated with a bachelor’s degree in physical therapy from SBB college of Physiotherapy, Gujarat, India. He pursued his Master in Exercise Science from Oakland University, Michigan, USA. Furthermore, he completed his second master’s in public health with focus on health behavior and health education. Karnik is curious and fascinated by how an individual’s behavior, attitude and beliefs can impact their health simultaneously considering the socio-demographic factor influencing one’s health outcome. His passion for psychology pushed him to get certified as Cognitive Behavioral Therapist. He combines principles of behavioral health, psychology, and various manual therapy skills to improve the quality of lives of his patients.
In his personal life, Karnik enjoys playing sports like cricket, pickleball and volleyball. He loves hiking and traveling to different places. To keep mental peace, he meditates every day and enjoys cooking for relaxation. He also loves reading books and enjoys history.
Andrea K. Sherman is an outpatient physical therapist who works closely with chronic pain patients and those with craniofacial pain. She was introduced to management of chronic pain while a PT student at Wayne State University in Detroit, MI. Andrea honed her skills and love for patients with chronic, refractory craniofacial pain while working for Michigan Head-Pain & Neurologic Institute in Ann Arbor, MI. After taking a position at Henry Ford Health, she has been grateful to continue learning methods to address and coordinate evidence-based care relating to individual with high-impact chronic pain as member of the multidisciplinary chronic pain clinic. Andrea enjoys knitting, all things outdoors, and adventures with her puppy, Pippa.
- Department of Health and Human Services: National Pain Strategy: A Comprehensive Population Health Strategy for Pain. Available at: https://iprcc.nih.gov/docs/ HHSNational_Pain_Strategy.pdf Accessed on Dec 28th, 2022
- Turk DC. Clinical effectiveness and cost-effectiveness of treatments for patients with chronic pain. Clin J Pain. 2002. 18:355-365
- Cowell, I., O'Sullivan, P., O'Sullivan, K., Poyton, R., McGregor, A., & Murtagh, G. (2018). Perceptions of physiotherapists towards the management of non-specific chronic low back pain from a biopsychosocial perspective: a qualitative study. Musculoskeletal Science and Practice, 38, 113-119.
- Sanders, T., Foster, N. E., Bishop, A., & Ong, B. N. (2013). Biopsychosocial care and the physiotherapy encounter: physiotherapists’ accounts of back pain consultations. BMC musculoskeletal disorders, 14(1), 1-10.
- Holopainen, R., Simpson, P., Piirainen, A., Karppinen, J., Schütze, R., Smith, A., ... & Kent, P. (2020). Physiotherapists' perceptions of learning and implementing a biopsychosocial intervention to treat musculoskeletal pain conditions: a systematic review and metasynthesis of qualitative studies Pain, 161(6), 1150-1168.
- Bement, Marie K. Hoeger, and Kathleen A. Sluka. "The current state of physical therapy pain curricula in the United States: a faculty survey." The Journal of Pain 16.2 (2015): 144-152.
- Caneiro, J. P., et al. "Process of change in pain-related fear: clinical insights from a single case report of persistent back pain managed with cognitive functional therapy." Journal of Orthopaedic & Sports Physical Therapy 47.9 (2017): 637-651.
- Cohen SP, Vase L, Hooten WM. Chronic pain: an update on burden, best practices, and new advances. Lancet. 2021 May 29;397(10289):2082-2097. doi: 10.1016/S0140-6736(21)00393- PMID: 34062143.
- Louw A, Sluka KA, Nijs J, Courtney CA, Zimney K. Revisiting the Provision of Pain Neuroscience Education: An Adjunct Intervention for Patients but a Primary Focus of Clinician Education. J Orthop Sports Phys Ther. 2021 Feb;51(2):57-59. doi: 10.2519/jospt.2021.9804. Epub 2020 Oct 19. PMID: 33076759.
- Hernández-Sánchez S, Poveda-Pagán EJ, Toledo-Marhuenda JV, Lozano-Quijada C. Dealing with Chronic Pain: Tips to Teach Undergraduate Health Sciences Students. J Pain Res. 2022 Oct 18;15:3223-3232. doi: 10.2147/JPR.S377124. PMID: 36281308; PMCID: PMC9587724.
- Hernández-Sánchez S, Poveda-Pagán EJ, Toledo-Marhuenda JV, Lozano-Quijada C. Dealing with Chronic Pain: Tips to Teach Undergraduate Health Sciences Students. J Pain Res. 2022 Oct 18;15:3223-3232. doi: 10.2147/JPR.S377124. PMID: 36281308; PMCID: PMC9587724
Great article! Motivates me to want to learn/re-learn more on this topic. Thank you!