Introduction
Chronic pain is defined as persistent or recurrent pain lasting longer than 3-6 months that continues beyond the usual healing time for an injury or illness. It can arise from an initial injury, such as a back sprain, or exist without a clear cause. Chronic pain affects over 50 million Americans and is the leading cause of long-term disability.
Physical therapy plays a key role in the management of chronic pain through a combination of modalities, therapeutic exercises, manual techniques, and patient education. The goal of physical therapy is to reduce pain, improve physical functioning, increase activity tolerance, and teach self-management skills. This enables patients to better manage symptoms and improve quality of life.
This article provides an overview of how physical therapy can help manage chronic pain. It covers common assessments, treatment modalities and techniques, therapeutic exercises, self-care strategies, and how physical therapists work with other healthcare providers for interdisciplinary chronic pain care. The focus is on evidence-based physical therapy interventions for adults living with persistent pain.
Causes and Symptoms of Chronic Pain
Chronic pain is defined as pain that persists for 12 weeks or longer, even after an injury or illness has healed. It can have a major impact on a person's quality of life. Chronic pain differs from acute pain in that it persists over time and is generally more complex to treat.
Some of the most common causes of chronic pain include:
Osteoarthritis - Breakdown of cartilage causes joint pain and stiffness. It often affects the back, knees, hips, hands and feet.
Fibromyalgia - A disorder characterized by widespread muscle pain and tenderness. It may be related to problems with how the brain processes pain signals.
Neuropathic pain - Caused by damage or disease affecting the somatosensory nervous system. This includes conditions like diabetic neuropathy, postherpetic neuralgia and sciatica.
Lower back pain - Muscle strains and sprains, spinal abnormalities, bone disease and nerve compression can lead to ongoing back pain. It is one of the most common chronic pain conditions.
Some common symptoms of chronic pain include:
Persistent aching, burning, throbbing or stabbing pain that ranges from mild to severe and does not go away over time.
Joint stiffness, reduced flexibility and range of motion.
Difficulty with physical activities due to pain and mobility issues.
Sleep disturbances like insomnia due to nighttime pain.
Fatigue, low energy levels and weakness.
Emotional distress - chronic pain can lead to anxiety, depression, irritability and lack of motivation.
Unlike acute pain after an injury, chronic pain persists over time even after any disease or injury has healed. It may not have a specific cause and can continue due to complex changes within the nervous system. Treatment needs to address both the physical pain and its emotional effects.
Relieving Chronic Pain With Physical Therapy Goals
Physical therapy plays an important role in managing chronic pain through movement-based interventions. The main goals of physical therapy for chronic pain include:
Reduce pain - Physical therapists use various modalities like heat, ice, electrical stimulation, massage, and others to help decrease pain levels and provide temporary relief. Certain exercises and techniques can also help reduce musculoskeletal pain over time.
Improve function - Restricted mobility and problems with daily activities are common with chronic pain. Physical therapists prescribe specialized stretching, strengthening, and low-impact aerobic exercises to improve flexibility, range of motion, core stability, posture, strength, and endurance. This helps improve physical function and activity tolerance.
Improve quality of life - Chronic pain can greatly impact mental health and participation in work, social activities, and relationships. By reducing pain, improving sleep, increasing fitness, and setting achievable goals, physical therapy aims to enhance overall well-being and quality of life.
Prevent disability - Untreated chronic pain can worsen over time and lead to long-term disability. Physical therapy helps prevent muscle atrophy and weakness through exercise. It also teaches people how to properly move and lift while avoiding further injury. This helps reduce the disabling effects of chronic pain.
Physical Therapy Assessments
A physical therapist will start by taking a detailed medical history and performing a thorough physical exam to understand the patient's condition. This helps identify the source of pain, determine what movements or positions provoke or relieve pain, and assess the patient's range of motion, strength, balance, and mobility.
Some key aspects of the assessment include:
Medical history - The therapist will ask about the onset, location, severity, quality, and duration of pain symptoms. They'll also gather information on any previous treatments, medications, imaging or laboratory tests, and comorbidities.
Physical exam - The therapist will check posture, palpate areas of pain, and observe movements. They may check reflexes, sensation, coordination, flexibility, and joint function. This identifies movement compensations, impairments, or dysfunctions contributing to pain.
Functional assessment - The patient will be asked to perform various functional tasks while the therapist observes. This could include simple motions like bending, lifting, reaching, or household chores to assess specific limitations.
Range of motion testing - The therapist will check joint range of motion, both actively and passively, to identify restricted movements. Goniometers precisely measure joint angles.
Muscle strength testing - Manual muscle testing or handheld dynamometers determine weakness or imbalances in muscle groups that could contribute to pain or dysfunction.
Additional testing - If needed, additional tests may assess posture, gait, ergonomics, weight-bearing capability, or the impact of specific movements on symptoms.
The comprehensive assessment informs the design of an individualized treatment plan. It also provides objective baseline measurements for comparison throughout treatment to quantify progress.
Physical Therapy Modalities
Physical therapists may use various modalities as part of a chronic pain treatment plan. These modalities can help relieve pain, improve range of motion, and prepare the body for other treatments. Some common modalities used in chronic pain physical therapy include:
Heat/Cold Therapies
Heat therapies involve applying heat to the affected area, often through hot packs, warm compresses, or hydrotherapy. Heat helps relax muscles and increase blood flow. It can help reduce pain and stiffness.
Cold therapies like ice packs or cold compresses constrict blood vessels and numb nerve endings. This reduces inflammation, swelling, and spasms. Cold therapy may temporarily relieve chronic pain.
Transcutaneous Electrical Nerve Stimulation (TENS)
TENS uses a small device to deliver electrical impulses through electrodes on the skin. This stimulates nerves and may interfere with pain signals. TENS may provide temporary pain relief.
Ultrasound
Ultrasound uses high-frequency soundwaves directed at the painful area. This increases blood flow and tissue relaxation. Ultrasound may help reduce muscle spasms, joint stiffness, and chronic pain.
Iontophoresis
Iontophoresis uses a weak electrical current to deliver anti-inflammatory medications through the skin. This may help treat inflammation that contributes to chronic pain.
Massage
Massage techniques like effleurage and petrissage can help relax muscles, improve circulation, increase joint mobility, and provide pain relief. Massage may be used along with other modalities.
These physical therapy modalities are often used along with exercises, manual therapy, and education to provide a comprehensive treatment approach for chronic pain management.
Therapeutic Exercises
Therapeutic exercises are an essential part of physical therapy for chronic pain management. Under the supervision of a physical therapist, patients will perform various exercises to help restore strength, mobility, balance, and coordination.
Common therapeutic exercises include:
Stretching
Gentle stretching can help relax tense muscles, improve flexibility, and reduce stiffness. Stretches should be held for 30 seconds and repeated 2-4 times. Care should be taken not to overstretch. Examples of stretching exercises include:
Hamstring stretch
Calf stretch
Upper back stretch
Neck stretches
Strengthening
Targeted strengthening exercises help build up muscles that have become weak or deconditioned from chronic pain and reduced activity. This helps support the spine and joints. Strengthening is done progressively using bodyweight, resistance bands, or light weights. Examples include:
Bridge exercise
Wall push ups
Resisted knee extensions
Shoulder raises
Aerobic
Low-impact aerobic exercise increases heart rate, improves cardiovascular fitness, and releases endorphins for pain relief. Options like walking, cycling, or swimming are recommended over high-impact activities.
Balance
Balance exercises like tandem stance and single leg stands help improve proprioception, coordination, and stability. This reduces risk of falls.
Posture
Postural exercises strengthen core muscles to support proper spine alignment and reduce strain. Common posture exercises include chin tucks and wall angels.
Coordination
Coordination exercises challenge motor skills and brain-body connection. Examples are balance boards, catching a ball, or sequenced movements.
Physical therapists design an exercise program tailored to each patient's needs and functional limitations. The key is starting low, setting realistic goals, pacing activity, and progressing gradually over time. Therapeutic exercise is essential for managing chronic pain.
Manual Therapy
Manual therapy techniques are often used by physical therapists to help treat chronic pain. These hands-on techniques can help relax muscles, improve joint mobility, decrease pain, and promote overall healing. Common manual therapy techniques include:
Soft Tissue Mobilization
Soft tissue mobilization involves the physical therapist using their hands to massage, rub, and manipulate soft tissues like muscles and fascia. The goal is to relax the tissues, increase blood flow, decrease muscle tension, and mobilize scar tissue. Techniques like myofascial release, massage, and trigger point therapy are examples of soft tissue mobilization. These can be helpful for releasing myofascial tightness that contributes to pain.
Joint Mobilization
Joint mobilization involves the physical therapist using hands-on techniques to manipulate joints in a gentle, oscillating way. This can help restore normal joint mobility and take tension off structures like ligaments, tendons, and joint capsules that may be contributing to pain. Mobilization is very hands on but less aggressive than manipulation or adjustments.
Muscle Energy Techniques
These techniques use gentle muscle contractions and stretching to mobilize joints and relax muscles. The patient will contract specific muscles against resistance from the physical therapist, followed by gentle stretching in the barrier direction. This sequence helps muscles relax and allows for improved range of motion. Muscle energy techniques can help reduce muscle and joint restrictions and pain.
Manual therapy requires specialized training and skill. When performed by a knowledgeable physical therapist, these hands-on techniques can provide pain relief, improved mobility, decreased muscle tension, and promote healing. They are often used in conjunction with therapeutic exercises and other modalities as part of a comprehensive chronic pain physical therapy program.
Self-Management Techniques
In addition to exercises and modalities performed during physical therapy sessions, patients with chronic pain can benefit greatly from continuing self-management techniques at home. These techniques aim to provide patients with coping strategies and a sense of control over their pain.
Patient Education
Educating patients is a critical component of physical therapy for chronic pain. Therapists will explain the nature of chronic pain and set realistic expectations for management rather than complete elimination. They will teach patients how to properly pace activities, relax through pain flares, and use other coping strategies. Patients who understand their condition and treatment plan often experience less anxiety and improved outcomes.
Pacing
Pacing involves balancing rest and activity to avoid overexertion. Patients learn to break tasks into smaller parts and take breaks as needed. This helps prevent pain from intensifying and allows patients to maintain a steady activity level. Therapists can collaborate with patients to set a sustainable pace tailored to the patient's needs and abilities.
Relaxation Techniques
Relaxation techniques such as diaphragmatic breathing, progressive muscle relaxation, and guided imagery can help patients better manage pain episodes. These techniques are focused on releasing muscle tension and anxiety. Patients can practice them at home to achieve a relaxed state that minimizes pain perception. Therapists may recommend audio recordings or phone apps to guide relaxation exercises.
Coping Strategies
Cognitive behavioral therapy techniques can provide patients with positive coping strategies. For example, patients may learn to challenge negative thoughts, stay focused in the present moment, and distract themselves from pain through engaging activities. Support groups can also help patients connect with others facing chronic pain and learn new management approaches.
Interdisciplinary Care
Physical therapists often work with other healthcare professionals as part of a collaborative, interdisciplinary approach to chronic pain management. This may include:
Doctors (general practitioner, psychiatrist, pain specialist, etc.): Doctors can prescribe medications and order imaging or other tests to help determine an underlying cause for chronic pain. They may also refer patients to physical therapy. Physical therapists share updates on the patient's progress and provide recommendations.
Mental health professionals (psychologists, therapists, counselors): Chronic pain can lead to depression, anxiety, stress and other mental health issues. Mental health professionals evaluate psychological factors related to pain and provide counseling, cognitive behavioral therapy and other treatments. This is complementary to the physical rehabilitation from a physical therapist.
Dietitians: Dietitians can recommend anti-inflammatory diets and ensure patients are getting proper nutrition to help in the healing and recovery process.
Occupational therapists: Occupational therapists help patients perform daily activities through modifications and adaptive techniques or devices. They may collaborate with physical therapists on improving function and developing pain coping strategies.
Massage therapists: Massage can help relieve muscle tension and spasms related to chronic pain. Massage therapists may work alongside physical therapists to relax the muscles and increase range of motion.
An interdisciplinary approach allows various experts to work together to address the physical, psychological and lifestyle factors related to chronic pain. This comprehensive team effort often provides better outcomes compared to any single treatment approach alone.
Conclusion
Physical therapy plays a crucial role in the management of chronic pain. By utilizing various treatment techniques and modalities, physical therapists aim to reduce pain, improve function, increase mobility, and enhance quality of life.
Some of the key benefits of physical therapy for chronic pain include:
Provides personalized treatment plans tailored to each patient's specific needs and goals. Physical therapists evaluate each individual and design programs accordingly.
Focuses on treating the underlying causes of pain through hands-on techniques, exercise therapy, and patient education. This helps address problems directly rather than just masking symptoms.
Aims to empower patients to self-manage their condition. Physical therapists teach patients exercises, postural techniques, and pain coping strategies they can continue using independently long-term.
Takes a whole-body approach to healing. Physical therapists don't just look at the site of pain but also assess how other joints, muscles, nerves may contribute to symptoms.
Promotes an active, multimodal approach to pain relief. Rather than relying solely on medications or injections, physical therapy utilizes movement and exercise as core components of care.
Provides a customized home exercise program for patients to follow. Staying active is key to managing chronic pain effectively.
In summary, physical therapy is an integral part of chronic pain treatment and management. By taking a holistic, individualized approach, physical therapists can help patients experiencing chronic pain improve function, increase activity levels, and enhance overall health and wellbeing.