It started with a simple sprain: After visiting the emergency room, Allison*, 13, was sent home with the assurance that her ankle injury was minor and would improve soon. But she didn’t get better. Soon, her ankle had swollen and when mild throbbing became a searing pain, she had difficulty walking. By the time Allison was referred to physical therapist Annie Burke-Doe, MPT, PhD, the assistant program director of the Doctor of Physical Therapy (DPT) program on the San Marcos campus, she couldn’t stand to be touched below her knee. What had begun as an ordinary acute injury had transformed into debilitating chronic pain.
Unfortunately, this is an example of a challenge many clinicians feel uncomfortable addressing. In fact, according to a survey by the American Physical Therapy Association, just 4% of outpatient orthopedic physical therapists said they felt prepared to treat patients in chronic pain. It’s disappointing to learn, because physical therapists—and their occupational therapist peers—are uniquely qualified to care for patients with acute and chronic pain.
With this in mind, Burke-Doe and 11 colleagues at the university formed what’s become affectionately known as the Pain Pack— an interdisciplinary team of faculty members dedicated to improving students’ knowledge of pain by revising the university’s curriculum. Their initial research may also aid practicing clinicians—as well as patients themselves. Here, we share key takeaways you may begin applying today.
Understanding an Epidemic
Most of us have experienced acute pain at some point, usually in the form of a sudden injury such as a fracture, burn or sprain, or following surgery. Acute pain isn’t necessarily a bad thing. “Some pain can be protective,” explains Burke-Doe. “It allows damaged tissues to heal.” It’s also self-limited, typically easing as time passes and the body heals.
Chronic pain—which lasts longer than 12 weeks and affects some 25 million Americans— is quite different. While there’s still much we don’t know about it, chronic pain often occurs in concert with conditions that affect bones, joints, or muscles, such as arthritis, fibromyalgia, and certain autoimmune conditions. Migraines, lower back problems, shingles, and even irritable bowel syndrome can also cause chronic pain.
What’s more, some cases of chronic pain have their roots in acute injuries that haven’t been treated properly or promptly. For Burke- Doe’s patient Allison, misdiagnosis and under-treatment of a minor sprain set the stage for an excruciating affliction that persisted for more than a year. “If we don’t take the time to evaluate and treat acute pain,” Burke-Doe explains, “it can get much worse.”
While the exact process is still unclear, we know that pain appears to modify the way the central nervous system works, turning a simple injury into long-standing pain, a phenomenon known as central sensitization.
Stress and other negative emotions may exacerbate pain in some situations, says Terri Roberts, OTD, a core faculty member in the Master of Occupational Therapy (MOT) program. “There’s a psychology to pain,” she explains.
“We can manifest worries and fears about injuries: ‘When will I feel better? Will I be able to return to work? When can I play with my kids again?’ That can actually make pain worse.”
Such was the case with Roberts’ patient Mary*, a nurse who hurt her wrist during a fall at work. Though the injury itself was minor—comprehensive diagnostic tests showed no lasting injury—she was incapacitated, her hand clenched into a tight fist, she had intense pain, difficulty sleeping, driving, and couldn’t meet daily responsibilities. A series of conversations with Roberts revealed that Mary was worried about her livelihood but also harbored negative feelings about her stressful nursing job. It wasn’t that she was avoiding work responsibilities—her pain and clenched fist were very real.
“Understanding the emotional side of pain and helping patients unravel emotional troubles often is the key to healing,” Roberts says.
When pain becomes chronic, patients are often prescribed powerful medications with a potential for addiction and accidental overdose. The Centers for Disease Control and Prevention found that sales of prescription opioids in this country nearly quadrupled from 1999 to 2014, despite a much smaller increase—from 25 to 40 percent—in the amount of pain Americans reported during emergency room visits.
It’s a problem clinical instructor Jim Mathews, DPT, sees firsthand in his own practice, where his patient population is heavily comprised of arthritic elderly immigrants from the former Soviet Union. “These folks tend to be very stoic and they don’t like to talk about pain,” he explains. “As a result, they often end up overmedicated just so they can go about their day.”
An Individual Approach
While opioids can have a place in pain management, they aren’t the only—or the best—option. In fact, research has shown that patients who are weaned off opioid drugs and undergo interdisciplinary non-drug programs that include modalities such as physical and occupational therapy actually experience less pain and better function than they did while on these medications.
The truth is, physical and occupational therapists are perfectly suited to treat the full spectrum of pain. It starts with a careful evaluation of the problem. “We can ask patients what the pain feels like—is it aching, throbbing, sharp?” explains Burke-Doe. “But it’s often difficult for them to put into words.” Instead, she suggests that clinicians delve deeper, asking patients how pain affects their lives. “Ask them to rank their pain on a scale of zero to ten,” she advises. “The key for practitioners is to listen and not put words in patients’ mouths.”
Patients themselves can also help improve the process. “I ask my patients to keep a pain journal that tracks their symptoms and possible triggers,” says Mathews. “The brain is very good at worsening pain. Not only can journaling help patients better understand and describe how their body feels, it can also help them reduce medication use by tracking how they feel as they decrease their dose over time.”
Above all, the patient always comes first. “It’s important to tailor treatments to the individual and their unique needs,” explains Burke-Doe. While the ultimate goal is always to reduce pain and improve function, people often respond best to specific objectives. “We can say that exercise will help someone feel better,” she says. “But it’s usually more effective to work with patients to come up with small, achievable milestones. It’s about what they need, not what we want to impose on them.”
One patient might want to walk his daughter down the aisle at her wedding without pain, for example, while another might want to kneel comfortably to weed her garden. Likewise, Mathews often works with patients to set a goal of decreasing medication use, performing manual therapies on them, and referring them to clinicians in other fields when necessary. Indeed, optimal treatment of pain requires an interdisciplinary team approach that includes not just physical or occupational therapists, but also physicians, pain specialists, nurses, social workers, therapists, and even practitioners of complementary and alternative medicine.
Working as part of such a team is critical to success. “It’s humbling to realize that we can’t—and shouldn’t—always treat pain in a vacuum,” says Burke-Doe. That means recognizing what you do and don’t know, and seeking out experts in other disciplines for help. Pursuing continuing education opportunities, such as those offered by the university, can be instrumental in gaining new knowledge and skills, and can help position physical and occupational therapists as leaders in the field of pain management. Staying current in the field helps practitioners remain creative and flexible as well.
For Burke-Doe, being creative meant literally drawing on the small section of Allison’s leg that could be touched without pain and then brainstorming exercises to increase joint mobility. It took more than a year for the teen to fully heal, but today she’s able to enjoy a normal life, pain-free.
Back at her own practice, Roberts performed a variety of treatments, including activity modification and pain management strategies to help Mary get full use of her hand again—but the real treatment came, Roberts says, “from understanding the client’s fears and anxiety. Empowering the patient to make necessary changes in her work environment addressed the psychosocial factors that can worsen pain.
“At first she seemed resistant to making any big life changes,” Roberts continues. “But as treatment continued and Mary started making steady, positive lifestyle adjustments, her clenched fist began to subside. And a few months after finding a new job, Mary’s hand pain resolved and motion was completely restored. “She was sleeping better, fully engaged in nursing, and enjoying life with her family again,” Roberts shares.
Outcomes like these are what the Pain Pack hopes will inspire physical and occupational therapists to embrace the skills they have already mastered and seek out even more skills to assist them in treating patients with chronic pain. “Pain is such an explosive word with many facets,” says Roberts. “Practitioners should seek to truly understand its complexity to be even more effective in helping patients.”
*Names have been changed to protect individuals’ privacy.
Meet The Pain Pack
Faculty on the San Marcos campus who are contributing to the project, regularly publishing and presenting while working to revamp the curriculum, include:
- Annie Burke-Doe, PT, MPT, PhD
- Anna Edwards, PT, MA, MBA, ACCE
- Christopher Ingstad, PT, DPT, MTC, ATC
- Christopher Ivey, PT, MPT, OCS, SCS, ATAC, MS
- Kristen Johnson, PT, EdD, MS, NCS
- Steve Lasiovich, PT, DPT, CPed
- Ellen Lowe, PT, PhD, MHS
- Jim Mathews, PT, DPT, MBA, BS, GCS
- Susan McNulty, OTD, OTR/L
- Terri Roberts, OTD, OTR/L
- Kayla Smith, PT, DSc, OCS, COMT
- Jon Warren, MHSC, PGD Sports Med, Dip MT, MNZCP