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Physiotherapy maximizes activity, improves quality of life and promotes self-management for people with chronic pain.

What is chronic pain?

Chronic, persistent or long-term pain is pain continuing beyond 3 months or after healing is complete.(1) Affecting adults and children, it may arise from tissue damage or inflammation or have no identified cause. It can affect a specific body area (e.g. Complex Regional Pain Syndrome, low back pain (LBP), pelvic pain) or be widespread (e.g. fibromyalgia). Chronic pain is a complex condition with physical, social and psychological components, which can lead to disability, loss of independence and poor quality of life (QoL).(2)

Physiotherapy

Physiotherapy in hospitals, clinics and the community aims to achieve healthy levels of activity and self-management for people with chronic pain.(3) Clinical and cost-effectiveness evidence supports using a cognitive behavioural approach addressing both physical limitations and people’s beliefs about, and understanding of, their condition.(4) People with multiple health issues or whose pain is causing significant physical, psychological or social problems may require management by a multidisciplinary pain service.

Physiotherpists can help identify reasons for lack of progress in rehabilitation, such as fear avoidance of movement or unhelpful patterns of over - and under - activity. 

One in five Canadians live with chronic pain. (13)

GP referral to services for advice and exercise improves outcomes and is cost effective.(5) Using a risk-stratification tool and providing risk-matched treatment improves the condition, shortens time off work, reduces sickness certification and health-care costs.(6) 

Manual therapy or acupuncture may produce short term benefit,(7) but evidence supports the use of active treatments such as therapeutic exercise.(5) Multidisciplinary pain management programs (PMP)(8) including physiotherapy(9) are an effective intervention for people with chronic pain(3)(8) and cost-saving compared to physiotherapy alone.(10) Physiotherapy supports and enables people with chronic pain to remain in or return to work.(3) Mindfulness(11) and acceptance & commitment therapy (ACT) have been shown to be as effective as cognitive behavioural therapy (CBT) and are used in some centres.(12) Physiotherapists signpost people to online and community resources to support ongoing self-management.(3) 

Significant impact

  • Chronic pain is one of the most common conditions  seen in primary care.(14)
  • 10% of all disabilities in Canada are pain related.(16)
  • One in six Canadians (15+) use prescription opiods to control pain.(17)
  • 40% of patients on a wait list for treatment were unable to return to work due to chronic pain.(18)(20)
  • Over 1/3 of Canadians with chronic pain have back pain.(15)

​Cost of chronic pain

  • Chronic pain costs society more than heart disease, cancer and HIV combined.(21) 
  • Total cost of chronic pain in Canada is estimated at $37 billion annually.(19)

Case Study

At the multidisciplinary Calgary Chronic Pain Centre (CPC), physiotherapists  are part of the teams that treat individuals with chronic musculoskeletal, headache and pelvic pain. They assess and treat their patients individually, using a combination of therapeutic exercise and other interventions to target each  individual's needs. They link with community providers to enhance continuity of care, and offer public lectures on chronic pain management.  Physiotherapists at CPC also assist in the screening, education and use  of implanted neuromodulation devices used in the management of chronic pain.

A 2014 report demonstrated that a flexible format, interdisciplinary treatment and rehabilitation program at CPC was effective in the treatment of chronic daily headache.(22)

Conclusion

Chronic pain can impact significantly upon physical, emotional and social wellbeing. Physiotherapy utilizing a broad scope of practice can safely and cost-effectively support and guide people with long term pain towards the best possible quality of life.

References

  1. Merskey H, Bogduk N, editors. Classification of chronic pain. 2nd Rev ed. Seattle: IASP Press; 1994 (Rev 2011-2). URL: http://www.iasp-pain.org/PublicationsNews/Content.aspx? ItemNumber=1673&navItemNumber=677
  2. Breivik H, Collett B, Ventafridda V, et al. Survey of chronic pain in Europe: Prevalence, impact on daily life, and treatment. European journal of pain (London, England). 2006;10(4):287-333.
  3. Scottish Intercollegiate Guidelines Network Management of chronic pain (SIGN 136). Edinburgh: Scottish Intercollegiate Guidelines Network; 2013. URL: http://www.sign.ac.uk/guidelines/fulltext/136/index.html
  4. Moseley GL. Evidence for a direct relationship between cognitive and physical change during an education intervention in people with chronic low back pain. European journal of pain (London, England). 2004 Feb;8(1):39-45.
  5. Lin CW HM, Maher CG, Machado LA, van Tulder MW,. Cost-effectiveness of general practice care for low back pain: a systematic review European spine journal : official publication of the European Spine Society, the European Spinal Deformity Society, and the European Section of the Cervical Spine Research Society. 2011;20(7):1012-23.
  6. Foster NE, Mullis R, Hill JC, et al. Effect of stratified care for low back pain in family practice (IMPaCT Back): A prospective population-based sequential comparison. Ann Fam Med 2014;12(2):102-11.
  7. Hopton A, MacPherson H. Acupuncture for chronic pain: is acupuncture more than an effective placebo? A systematic review of pooled data from meta-analyses. Pain Practice. 2010;10(2):94-102.
  8. British Pain Society. Guidelines for pain management programmes for adults: an evidencebased review prepared on behalf of the British Pain Society. London: British Pain Society; 2013. URL: http://www.britishpainsociety.org/pub_professional.htm
  9. Scascighini L, Toma V, Dober-Spielmann S, et al. Multidisciplinary treatment for chronic pain: a systematic review of interventions and outcomes. Rheumatology. 2008 May;47(5):670-8. URL: http://rheumatology.oxfordjournals.org/content/47/5.toc
  10. Critchley DJ, Ratcliffe J, Noonan S, et al. Effectiveness and cost-effectiveness of three types of physiotherapy used to reduce chronic low back pain disability: a pragmatic randomized trial with economic evaluation. Spine. 2007;32(14):1474-81.
  11. Chiesa A, Serretti A. Mindfulness-based interventions for chronic pain: a systematic review of the evidence. Journal of alternative and complementary medicine (New York, NY). 2011 Jan;17(1):83-93.
  12. Wetherell JL, Afari N, Rutledge T, et al. A randomized, controlled trial of acceptance and commitment therapy and cognitive-behavioral therapy for chronic pain. Pain. 2011 Sep;152(9):2098-10
  13. Position paper 2013,  Pain Society of Alberta, http://painsocietyofalberta.org/position-papers/D Schopflocher, P Taenzer, R Jovey. The prevalence of chronic pain in Canada. Pain Res Manage 2011;16(6):445-450.
  14. Canadian Institute for Health Information, A Snapshot of Health Care in Canada as Demonstrated by Top 10 Lists, 2011 (Ottawa, Ont.: CIHI, 2012)  https://secure.cihi.ca/free_products/Top10ReportEN-Web.pdf 
  15. D Schopflocher, P Taenzer, R Jovey. The prevalence of chronic pain in Canada. Pain Res Manage 2011;16(6):445-450
  16. Statistics Canada A profile of persons with disabilities among Canadians aged 15 years or older, 2012  http://www.statcan.gc.ca/pub/89-654-x/89-654-x2015001-eng.htm#a1
  17. Canadian Alcohol and Drug Use Monitoring Survey 2012 http://www.hc-sc.gc.ca/hc-ps/drugs-drogues/stat/_2012/summary-sommaire-eng.php#s5
  18. M Chonière et al, The Canadian  STOP PAIN project part 1: Who are the patients on the waitlists of multidisciplinary pain treatment facilities? Can J Anesth/J Can Anesth (2010) 57:539–548
  19.  J Khan, M Gill, P Seth, H Clarke Chronic Pain: an Overview McMaster University Medical Journal vol.9 no 12 2012
  20. L Lalonde et al, Costs of moderate to severe chronic pain in primary care clinics - a study of the ACCORD program, Journal of Pain Research 2014:7 389-403
  21. Phillips, C. J. and D. Schopflocher (2008). The Economics of Chronic Pain. Health Policy Perspectives on Chronic  Pain. S. Rashiq, P. Taenzer and D. Schopflocher. UK, Wiley Press
  22. Barton PM et al, A flexible format interdisciplinary treatment and rehabilitation program for
    chronic daily headache: patient clinical features, resource utilization and outcomes. Headache
    2014; 54:1320-1336

Acknowledgement

Adapted and used with permission of the Chartered Society of Physiotherapy.