by Patti J. Brown, M.D.
Physical Medicine and Rehabilitation
Medical Director, HealthSouth Reading
The treatment of chronic pain has been a hot topic lately due to the opioid crisis our country is presently facing. As a physical medicine and rehabilitation specialist my interest in treatment of chronic pain has been long-standing. PM and R specialists have been trained in alternatives to opioids in the treatment of pain. When I started in practice in the 90s our rehab hospital had a multidisciplinary pain clinic based on non-narcotic approaches to pain. However, around that time the media and pharmaceutical companies started touting pain relief at all costs. It is my opinion that this approach is responsible for the crisis we are now facing. For that reason I was anxious to write this review article on a comprehensive treatment approach to chronic pain.
Chronic pain is among the most common reasons persons seek medical attention. It is reported by 20 to 50 percent of patients seen in primary care. Ten to 15 percent of the working population is affected by back pain each year.
Acute pain can be linked to a precipitating event. It may be accompanied by anxiety, anger and requires a temporary lifestyle adjustment. Acute pain has a high rate of successful cure. It is generally self limiting.
Treat acute pain aggressively, the longer pain persists, the less likely complete resolution becomes. Patients must be educated on preventative measures.
Address pain relief through modalities – RICE. Rest, ice, compression and elevation. Regain normal muscle length through range of motion. Address gradual muscle strengthening and exercise.
Chronic pain is persistent pain that lasts greater than six months. Complications of chronic pain are physical, psychological, and environmental.
Secondary physical pain develops due to inactivity. Patients develop decreased range of motion, myofacial pain and weakness due to deconditioning. Patients develop weight gain. They may develop drug dependency.
Psychological complications of chronic pain include depression, sexual dysfunction and marital stress.
Environmental complications of chronic pain include lost working days, decreased productivity, and escalating costs of workers compensation.
The characteristics of chronic pain patients is a person with low level of activity, high demand for medication, high verbalization of pain and inability to work. These patients are best approached in a multidisciplinary model.
The multidisciplinary approach includes a rehabilitation specialist for a clinical evaluation, psychologist for depression and motivation, interventionist for procedures and physical therapy for modalities and exercise. Occupational therapy should be available to address function and daily activities.
Treatment goals should be to teach patients to control or cope with the pain, improve their quality of life, improve functional capabilities, decrease dependence on drugs, decrease visits to physicians, increase physical activity and return to employment.
This pain treatment approach begins with patient education. Empower patients. Make them active participants in their own treatment program. Help patients understand what is causing the pain. Give them the appropriate tools – heat, ice, range of motion, non- narcotoic medication to deal with exacerbations. Instruct patients in a home exercise program. Instruct patients in proper body mechanics.
Physical modalities should be used in the acute phase and for exacerbations. They should be used in combination with active exercise.
Examples of physical modalities includes cold therapy which decreases pain, decreases muscle spasm and decreases inflammation. Heat therapy increases blood flow and decreases inflammation. Deep heat therapy such as ultrasound is used to decrease inflammation and increase range of motion.
Sensory modulation such as TENS, acupuncture and contrast baths utilizes the Gate theory, which is activation of large afferent fibers to inhibit the transmission of painful impulses.
Assistive devices can be used to support and decrease stress to the affected area. Orthoses such as casts, splints and braces can be used. Gait aids such as canes, crutches, and walkers can be used but only temporarily. The eventual goal should be restoring range of motion and function.
In the multidisciplinary approach, the patient should be instructed in behavioral and self regulation techniques. These include relaxation methods, such as breathing, meditation, yoga, and self hypnosis. Coping skills such as distraction and imagery can be used. Biofeedback can be a useful adjunct. Biofeedback involves using a relaxation technique to modify a physiologic parameter such as heart rate or breathing.
Therapeutic exercise is an important adjunct in pain therapy and should be used judiciously in acute pain. With acute pain and exacerbations rest should be limited to a very few days. Isometric exercises can be performed with range of motion to the point of pain. Range of motion and flexibility is addressed as inflammation subsides. Strengthening and aerobic exercise is added as pain improves.
Chronic pain developes in part due to immobilization and deconditioning. Work through pain slowly to achieve increasing goals.
Non narcotic pharmacologic interventions should be addressed. Adjuvant analgesics are drugs primarily approved for treatment of conditions other than pain but act as analgesics in selected circustances. Antidepressants work on serotonin and norepinephrine pathways, increase pain thresholds, improve sleep, improve mood and alter perception of pain. Anticonvulsants work by stabilizing neuronal membranes. Anti-inflammatories, muscle relaxants and scheduled analgesics can be used.
Invasive techniques include joint or soft tissue injections with corticosteroids and local anesthetics. Nerve blocks can be used and are most successful when followed by therapy. Trigger point injections address myofascial pain. Injections should be followed by routine, regular stretching. Epidural blocks are steroid injections into the epidural space close to the nerve root, often a series of three, several weeks apart. Neuroablation such as rhyzotomy and cordotomy are reserved for severe cases.
Modulating techniques are available such as implantation of drug infusion systems such as intrathecal morphine pump and chronic stimulators such as dorsal column stimulator.
Chronic pain is a difficult area of medicine. However, it is also an important one, due to the enormous consequences for the quality of patients lives. Patients appreciate when physicians listen attentively to their symptoms and make sincere efforts to intervene in ways that improve their quality of life. The physical medicine approach is a multi-disciplinary approach with a goal of decreasing dependence on narcotic medications. Goals should be — give patients control, improve function and improve quality of life.
Robinson James P. Chronic Pain.
Phys Med Rehabil Clin N Am 18 (2007)761-783