Why Chronic Pain is Such a Pain and What Physical Therapy Can Do About It

More than 50 million people in the U.S. suffer from chronic pain according to The Centers for Disease Control and Prevention, and 7.4 percent or 3.4 million of them say it interferes with their daily lives and work.

To understand chronic pain, let’s start with a simple explanation of the mechanism of pain. Pain occurs when the brain receives signals that a disease or injury is threatening a person’s wellbeing. The brain signals the runner to get off the sprained ankle.  It’s a good thing.

With chronic pain, though, the brain may interpret a signal as a danger when none exists. The brain and nervous system can activate the pain centers even when there is no tissue damage.

Patients describe chronic pain in all kinds of ways.  Some hurt all over; other people describe sharp stabs in specific places. Some people feel worse when they think about it, others feel symptoms when they’re not doing anything to cause them, and still others get pain when experiencing an emotional upheaval. Chronic pain wears patients down causing them to feel anxious, fatigued, and depressed.

On top of that, stiffness and deconditioning can be associated with chronic pain. The patient doesn’t feel like moving around and that lack of activity decreases circulation and contributes to a loss of strength and joint mobility.

Studies and practitioners agree that early physical therapy is best for all kinds of reasons, including preventing chronic pain and steering patients away from opioids. However, injured workers who have chronic pain, even those who have been in pain for months or years, can still benefit from physical therapy.

Each person experiences pain differently, so customized, patient-centric treatment plans work best. They should start with a consultation to discuss the injury, the pain and its effect on the injured worker’s lifestyle and ability to perform their job duties.  An initial consult may also reveal barriers to recovery like pain avoidance or secondary gain issues. When these barriers are documented in the clinical records, adjusters can allocate resources to address the psychosocial factors.   

While rehabilitation programs are customized for the condition and return-to-work goals, most include:

Exercise

Physical therapy combines strength, mobility, and flexibility exercises so patients can move with less discomfort. With chronic pain patients, this is usually a tiered program designed to train the brain to sense the problem area without sending danger messages. Depending on the condition, gentle hands-on manual therapy is also used to manipulate and mobilize tight joints and soft tissues to increase range of motion, improve tissue quality and reduce pain.

Therapists teach injured workers how to self-manage chronic pain through stretches and exercises and help set expectations of how they can live with and manage the pain, their overall health, and activities, including workplace responsibilities. Some meditation and relaxation techniques may also be introduced to help reduce stress and muscle tension. 

Education

Teaching patients how chronic pain works helps keep them from stressing over every new symptom.  Through understanding basic body mechanics, being aware of posture, and learning how to move efficiently, patients can reduce stress on their joints and lessen pain symptoms.

It also helps for patients to understand the concept of pain memory. Sometimes when injured workers return to the scene of the accident or put normal stress on the tissue, they feel pain and assume they’ve reinjured themselves. This can be pain memory, rather than an actual injury.  Like any other memory, it can be replaced by other thoughts and activity.

Telerehab with its instructional videos has delivered another aid for chronic pain patients.  They can use these videos after therapy ends to recall stretches and exercises and remember exactly how to do them.  Technology also enables therapists to zoom into people’s workstations and make ergonomic recommendations, such as raising a computer screen or changing a seat height to accommodate a pain point.

How is the Therapy Different?

The main difference for chronic pain patients is shifting the balance of education and exercise.  Picture an old-fashioned scale with exercise on one side and education on the other.  When an injury is recent, exercise and manual treatment weigh much more than education. The physical therapy focuses on restoring strength and mobility and getting out of pain. Education plays a role, but it really takes center stage when working with chronic pain patients.

When pain goes on a long time, the body develops workarounds for coping with it. Posture changes, muscles tighten, and limps, slumps, and trigger points develop. People tend to lie around more and self-medicate. Some exercise heavily, but not correctly.  Patients need to learn new ways to move efficiently. Their exercises and stretches may differ from those of a newly injured person so they can correct these adaptions. 

Their physical therapist will assess their rehabilitation potential and help them set reasonable goals for recovering mobility, strength, and function along with realistic expectations for eliminating or managing pain. Some people will not be able to become 100 percent pain free and that’s a tough thing to accept. 

Yet, there are hundreds of pain relief strategies and many people who have suffered from chronic pain for years do eliminate most of their pain.  Ergonomic and environmental pain-management techniques include such things as keeping eye glass prescriptions up to date, making sure the pillow is right and that the posture is correct. Certain stretches, exercises, and breathing and meditation exercises help people release muscle tension.  And a physical therapist can help injured employees find the techniques that work best for them.

Keep in mind that the margin of error that can set off pain in a chronic-pain patient is smaller than in a newly injured one. A lot of education and self-acceptance on the part of the patient has to take place. 

What about Return to Work & Chronic Pain?

A survey of employers and employees with chronic pain published in BMC Musculoskeletal Disorders examined barriers to having employees with chronic pain return to work. Both employers and workers worried about the chronic pain sufferers’ ability to fulfill their job duties and the resentment it could cause colleagues who had to pick up the slack.

Of course, physical job demands play into this discussion, but workplace changes could address some of these concerns.  Part-time duties, standing desks, and working from home so the employee can lie down occasionally, and staggering work hours come to mind. Interestingly, employers and employees agreed that a lack of confidence was a return-to-work barrier.

On the flip side, successfully completing work assignments can build confidence and some patients report less pain when they’re working, so more effort should be taken to facilitate return to work with this population. 

People – being individual as they are – respond differently to treatment – and this is true of those in chronic pain.  There are fantastic success stories of chronic-pain patients who have taken large doses of opioids for years and have physical therapy and are able taper off medication and overcome pain with the right exercise regimen.  Others learn how to mitigate pain, live with their physical limitations, and improve their quality of life with physical therapy.  And sadly, there are those with too much tissue damage or who are unwilling or unable to improve.

While early physical therapy is the gold standard, physical therapy is beneficial at any stage of recovery and should definitely be considered for injured employees who have chronic pain.  As a claim progresses, things change.  Injured workers who couldn’t accept that they would always have some level of pain may now be ready to learn how to manage their pain and reduce their medications. It’s worth the time to review your files to see who is ready to challenge themselves so they can feel and function better. 

By Brian Peers

Brian Peers is a licensed physical therapist and serves as MedRisk’s Vice President of Clinical Services and Provider Management.  He is responsible for overseeing and ensuring the quality of MedRisk’s centralized telerehabilitation services, as well as MedRisk’s platinum grade clinical review and peer-to peer provider coaching program. He is board certified as an orthopedic clinical specialist and is recognized as an expert in rehabilitation of the injured worker.  Prior to joining MedRisk, Dr. Peers was the owner and operator of an interdisciplinary rehab practice and has held faculty appointments at multiple physical therapy education programs.  He has also served as an injury prevention consultant for multiple large corporations and the United States Department of Defense.  Dr. Peers holds a Bachelor’s and Master’s degree from St. Francis University and a Doctorate from the University of St. Augustine.

Link to study:  https://bmcmusculoskeletdisord.biomedcentral.com/track/pdf/10.1186/s12891-019-2877-5.pdf

Share This Article: