Not all individuals will require the same level of detail of information or level of care. The clinician takes into consideration the combination of factors affecting the patient, and develops an individualized treatment plan. For example, one individual may present with shoulder pain but their assessment reveals multiple yellow flags, related to work environment, family responsibilities, and job security. Another individual may present with fibromyalgia, but there are few flags - they have a supportive work and a stable family and social environment.
Biological factors such as central sensitization, psychological factors such as anxiety, depression and insomnia, in combination with the patient’s social and environmental context contribute to the individual’s experience of pain. Although physiotherapists may feel reluctant to address psychological, social, and environmental aspects of care9, an effective plan of care must include addressing the factors hypothesized to impact the experience. Biological, psychological and social factors coincide and interact. Thus, addressing just one aspect is unlikely to facilitate progress toward the patient’s goals related to pain reduction or management and function.
Incorporating the biopsychosocial approach may require a shift in perspective and review of personal beliefs. Along with focused professional development activities such as courses, journal reviews and professional collaboration, clinicians review their personal beliefs and attitudes to understand any influence on their practice.45 This may be done through self-assessment by completing patient assessment tools such as the Pain Catastrophizing Scale or the Tampa Kinesiophobia Scale. Self-assessment enables the clinician to have greater understanding of their own personal beliefs and to recognize any potential impact this may have on client outcomes in this population.46
There are three basic foundational components of physiotherapy treatment and/or management for individuals experiencing chronic/persistent pain. These components address chronic pain that is influenced by biological factors such as CS and primarily psychological yellow flags:
- Improving function, activity, and overall quality of life
- Promoting self-management (self-efficacy)
These treatments and management principles are fundamental and are relatively basic competencies. There are additional professional development opportunities available that will broaden and deepen the physiotherapist’s treatment repertoire in the management of patients with chronic pain.
Additional resources provided at the end of the document
Education addresses any assessment findings related to biological factors such as central sensitization, and/or psychosocial factors such as maladaptive thoughts or beliefs. For example, fear-avoidance beliefs (i.e., pain is a sign of tissue damage, activity is dangerous).
Education interventions can be discrete or intensive depending on the extent the assessment reveals that the patient holds maladaptive beliefs about pain. In the case where the assessment does not reveal maladaptive beliefs, education will not be intensive and typically involves reassurance and encouragement to remain active. In contrast, when beliefs are maladaptive (e.g., pain is a sign of tissue damage, fear of movement, pain catastrophizing), Pain Neurophysiology Education (PNE) is an important first step.
PNE for patients with chronic/persistent pain addresses the physiology of pain, in contrast to the biomedical approach (in which education focuses on anatomy and biomechanics). The goal for PNE is to help the patient to:
- Revise their understanding of pain, to recognize and accept that their pain experience is not tied to actual or potential injury/harm
- Increase/improve physical activity and function based on that understanding
- Promote self-management, including setting goals
PNE is an effective tool. Research shows that patients retained the knowledge they gained from a single session of PNE for as long as three months.47 Recent research showed success in this approach as part of a tailored physiotherapy program in persons with chronic pain who were considered “hard to reach” because of other comorbidities.48
PNE can alter a patient’s pain perceptions and health status, and is most effective when it is delivered in a one-to-one format. It should be tailored to the individual, and presented in combination with written materials the patient can review in the non-clinical environment.13 As part of the educational process, patients are encouraged to discuss the application of PNE principles to daily activity.
PNE is ongoing throughout treatment. Optimally, it is first taught/explained in a manner that encourages questions and ongoing discussion (e.g., based on the patient’s responses to the Neurophysiology of Pain Questionnaire) and reinforced throughout overall treatment in further discussions with the patient, relating all treatment to the goals of PNE.
Components of PNE
The level and detail of PNE is geared to the individual, based on assessment findings (e.g., barriers – sleep pattern, medications, literacy, co-morbidities). Additional detail and information can be added as treatment progresses and the level of discussion changes.
The key components of PNE are:49
- Learning about pain is therapy – when you understand why you hurt, you hurt less
- Pain is normal, personal and always real – pain is a response to what your brain judges to be threatening
- There are danger sensors, not pain sensors
- Pain and tissue damage can each exist in the absence of the other
- Pain depends on the balance between factors that threaten the body and those that promote safety
- Pain relies on context (e.g., senses, beliefs, etc)
- Our nervous system can adapt to become more, or less, sensitive
- Active treatment strategies promote recovery
Personalize PNE to the individual and their situation – use examples and metaphors that will make sense to the patient and help them integrate the PNE messages.
The following are useful teaching resources for PNE
Clinician resources for PNE
Nijs J, van Wilgen C, van Oosterwijck J, van Ittersum M, Meeus M. How to explain central sensitization to patients with unexplained chronic musculoskeletal pain: Practice guidelines. Man Ther 2011 16(5):413-48 DOI:10.1016/j.math.2011.04.005 ( free access)
Louw A, Diener I, Butler D, Puedentura E The Effect of Neuroscience Education on Pain, Disability, Anxiety and Stress in Chronic Musculoskeletal Pain Arch Phys Med Rehab 2011;92:2041-56. DOI: 10.1016/j.apmr.2011.07.198 (Open Access)
Louw A, Zimney K, O’Hotto C, Hilton S. The clinical application of teaching people about pain, 2016 Physiotherapy Theory and Practice 32:5, 385-395. DOI: 10.1080/09593985.2016.1194652 0.1016/j.apmr.2011.07.198
The self-management component addresses assessment findings related to factors (biological and psychosocial) that limit the patient’s confidence in actively managing pain autonomously.
Self-management fosters the individual’s autonomy. Three of the primary principles in chronic disease self management may be applied to individuals living with chronic pain:
- Acknowledgment that one may have to live with the condition
- Positively managing the condition
- Optimizing physical and emotional health to minimize the effects of the condition
The following websites provide useful, accessible information for both patients and health-care professionals on self-management.
- Better choices, Better Health
- Pain BC Information for health professionals and patients (self-management)
- Life is Now provides information and resources for people living with chronic pain, health professionals, and others who work with this population
Pacing and planning programs help teach strategies for being active without triggering pain. A useful guide to pacing and planning can be found at Chronic Pain Australia. An important aspect of self-management is setting realistic, practical goals with the patient that are achievable and that the patient can see as success. Two tools that will assist this process are the Patient Specific Functional Scale and the Canadian Occupational Performance Measure.
Improving Function and Activity
Strategies to improve function and activity address assessment findings for biological factors such as central sensitization and deconditioning, as well as for psychological factors such as maladaptive thoughts or beliefs. For example, fear-avoidance beliefs (i.e., pain is a sign of tissue damage, activity is dangerous).
Individuals experiencing chronic/persistent pain adopt various coping strategies that may or may not be adaptive depending on their personal circumstances, such as avoidance of movement (fear), persistence (no pain no gain), or a combination, in which some activities are seen as potentially painful and avoided, while other activities are completed regardless of pain.14
While there are numerous exercise approaches to increase function and activity, graded activity is a simple approach used to gradually acclimatize the patient to activity. It is a useful strategy for patients fearful of movement, but may also be incorporated into management of patients demonstrating central sensitization or peripheral neuropathy.
To use the graded activity process:
- Select a meaningful activity
- Measure the tolerance to that activity (time/distance before pain increases 2 points on the 0-10 pain intensity scale) – for example: when starting a walk at 4/10 pain, how long before pain intensity rises to 6/10
- Negotiate a starting point below the activity tolerance (e.g., 50-75% of tolerance)
- Each week, gradually increase activity (10-25%)
- Recommend an activity range to enable some flexibility based on how one feels that day (e.g. on a good day, activity could be at the higher end of the range; when on a bad day, activity would be at the lower end of the range).
In some centres, as an example, patients are instructed to grade their daily activity level as “red, green or yellow light days.” Together with the physiotherapist, the patient has identified a range of exercise or activity that corresponds to each colour. Each day, they choose the level of exercise or activity that corresponds to the colour of the light that day.
Note: Some patients may modify a specific movement or range to maintain or continue a function or activity. This is not the same as fear-avoidance behaviour.
Other exercise approaches such as graded exposure and cognitive functional therapy are options that the reader should consider to add to future professional development activities.
Graded exposure is similar to graded activity, except its focus is the hierarchy of fear and maladaptive beliefs, and treatment progression is based on these levels. Its application in physiotherapy as a strategy to reduce pain-related fear in patients with chronic low back pain.50
Cognitive Functional Therapy (CFT) targets the patient’s fears, beliefs and behaviours or activities associated with pain. It incorporates motivational interviewing and graduated strategies to restore normal movement and activity. It is effective in the management of non-specific chronic low back pain.51
Relaxation and Mindfulness
Relaxation and mindfulness techniques address assessment findings for biological factors such as central sensitization and de-conditioning, as well as any psychological factors such as maladaptive thoughts or beliefs. For example, fear-avoidance beliefs (i.e., pain is a sign of tissue damage, activity is dangerous).
When prescribing exercises and activity, it is common to focus on increasing activity or strength, however; relaxation can be included as a key part of an activity plan in chronic pain management. Relaxation techniques, such as mindfulness, may be incorporated within the chronic pain program, whether by a physiotherapist with training in techniques or through referral to another health professional.
There is evidence that relaxation can reduce pain in both acute and chronic pain, although the benefit may not be long-term.52 Examples of relaxation techniques include progressive muscle relaxation, guided imagery, meditation, yoga and deep or tactical breathing in a restful position.
Mindfulness techniques have been shown to improve psychological measures and physical function.53
Appropriate exercise prescription is an important component of optimizing function and mobility in people with chronic pain. For some, earlier steps may be required (e.g., PNE, GMA) before getting to specific exercise prescription, while for others education and exercise can occur concurrently.
When prescribing a formal exercise program, it is important to find a starting point that the patient is comfortable with, not the level that the physiotherapist expects or has determined. The goal for an exercise program is to have consensus on a baseline for building a program and that the patient achieves and sees success. As with any intervention, however, it is important to prescribe exercise in accordance with the findings of the assessment for each particular patient.
While exercise has been shown to have powerful analgesic (pain relieving) effects for most healthy people, a subset of those with chronic pain may in fact show the opposite effect where their pain increases as a result of exercise, a phenomenon termed exercise-induced hyperalgesia. Clinicians should be aware of this phenomenon and plan treatments accordingly, possibly starting with education and graded activity before formal exercise prescription.
If a structured exercise program is not the patient’s preference, consider other activities – e.g., pole walking, dancing, Tai Chi, or Qi Gong – which will have a different connotation to the patient. Culturally competent exercise and activity prescription should consider both individual and family-oriented activities.
Disturbed Sleep Patterns
Sleep disturbance is a common symptom in patients with chronic pain, and research shows that sleep and pain may have a bidirectional reciprocal relationship.54 If the assessment has identified that the patient is experiencing sleep disturbances, a more detailed sleep assessment is warranted. Available assessment tools include:
In addition, asking the patient to keep a sleep diary may help to better understand their sleep patterns.
Incorporating the principles of sleep hygiene within treatment, including a discussion of resting positions, can assist the patient in obtaining more restful sleep and may help reduce pain.56
In the event that assessment indicates that the disturbed sleep patterns are significant or the interventions are not effective, the clinician may consult or collaborate with other health-care providers experienced in the area, and/or refer the patient to their physician or a sleep clinic.
Strategies for Managing Patients who Demonstrate Maladaptive Patterns or Behaviours
On occasion, there will be a patient whose patterns of behaviour, mood and/or social interactions are barriers to successful treatment outcomes. Once the therapist recognizes these patterns, they may be able to adjust their treatment approach to mitigate their effect. Below are general descriptors of three types of behaviours that are barriers to successful outcomes, along with strategies to consider for a management approach.
Patient behaviour: The patient consistently attempts to exert power over perceived authority figures, positions themself as morally correct and/or polarizes helpers as either “villains” or “heroes.”
Strategies the clinician may consider:
- First, recognize that your actions have not precipitated the behaviour
- Maintain a frank, confident manner
- Manage expectations - don’t give guarantees or other promises
- Outline treatment process and expectations, including discharge criteria
- Avoid language that prompts acceptance or rejection of ideas – e.g., “One possibility is...”
- Help identify triggers for behaviour – recent disappointment, personal loss
- Understand that this patient may see therapeutic relationship as contractual – e.g., giving physiotherapist praise is a strategy, or, they may end it when it no longer has value to them
Patient behaviour: The patient is constantly in crisis but is inflexible about solutions, has unrealistic expectations for others, and is very “touchy” or reactive.
Strategies the clinician may consider:
- Be clear and specific in all communication – a vague comment or response may trigger anxiety
- Continue to provide clear descriptions of therapeutic goals (e.g., function, quality of life) – their coping strategies may have been overwhelmed by the stress associated with a having a disability
- Acknowledge their challenges – recognize their concerns and expectations
- Clarify the roles and responsibilities for both patient and physiotherapist – maintain boundaries
- Emphasize the patient’s responsibility to do their own work
- Set clear rules for treatment length, targets, attendance
- This client may also have difficulty terminating a therapeutic relationship and perceive discharge as rejection. Consider framing discharge as their positive achievement (i.e., graduation)
- Use “I” language – avoid “you” comments to decrease any defensiveness (e.g., “I think this may have contributed” ... not “You should have realized”)
Patient behaviour: The patient consistently complains about their situation, but does nothing to change, frequently changes topic/complaint, avoids issues, convinces others they “deserve” to be helped and/or that they are helpless regardless of what they do.
Strategies for the clinician to consider:
- Avoid treatment positioning in which you are above or looking down at patient – try to be at eye level
- Set good boundaries so you do not overextend yourself. Be collaborative, but not overly sympathetic
- Help them understand responsibility for activity outcome – don’t “rescue”
- Refrain from critical comments – this may provoke strong negative emotions
- Maintain professional boundaries – anticipate statements that challenge your professional abilities or appear to blame physiotherapist/treatment for pain (e.g., “Let’s go back over the past few days. Can you think of anything that may have brought this on?”)
- Recognize that the behaviour may be masking fear/terror the patient is trying to hide
Manual Therapy and Modalities
Manual therapy and modalities are interventions that are generally more effective in the management of mechanical/nociceptive pain and are thought to help modulate that component of chronic pain.57 They can be adjuncts in the management of chronic pain,58 as outlined within this resource but are not the primary focus of treatment.
Medications used in Management of Chronic Pain
Optimal care includes awareness of the medications used in chronic pain management and their potential side effects. Familiarity with these medications can assist the physiotherapist in planning their PNE, treatment progress, and in monitoring outcomes.
Medications are catalysts or complementary to care and affect a patient’s quality of life (QoL). For example, inadequate sleep can affect QoL, and have a negative impact on mental health. Familiarity with the medication(s) prescribed for the patient will enable the physiotherapist to ask the physician about the medication’s potential effect on sleep and whether a change in dosage or medication is warranted.
Clinicians are encouraged to become familiar with the common medications used in chronic pain management, including their generic and branded names, their mechanism of action (in broad terms), usual dosing strategies, and potential side effects. These include common opioids, pregabalin and gabapentin, tricyclics, and selective norepinephrine or serotonin reuptake inhibitors. Constipation, sleep disturbance, shakiness (tremor), dry mouth, lethargy, and even opioid-induced hyperalgesia (a paradoxical increase in pain sensitivity some people will experience while taking opioids) are important side effects of which clinicians should be aware when developing treatment plans.
It is also recommended that clinicians become familiar with the definitions and clinical manifestations of tolerance, physical dependence, psychological dependence (addiction), and pseudo-addiction to help themselves and their patients work through their concerns about use of these drugs and to advocate appropriately on their patient’s behalf.