This document summarizes a presentation on physiotherapy for non-cancer chronic pain. It discusses that physiotherapy aims to restore and promote optimal physical function and quality of life for those with persistent pain. It provides an overview of evaluation processes in physiotherapy and various treatment modalities. It also summarizes evidence on approaches for common persistent pain conditions like low back pain, whiplash associated disorder, and osteoarthritis. Screening tools for risk of long-term disability are also briefly covered.

1. Physiotherapy for
non-cancer chronic pain
Pain Forum Singapore 2014
Lian Guojie
M Clin Physio(Curtin) Dip Phys(NYP)
Member of IASP
Senior Physiotherapist
Singapore General Hospital

2. Physiotherapy for
non-cancer chronic pain
Pain Forum Singapore 2014
Lian Guojie
M Clin Physio(Curtin) Dip Phys(NYP)
Member of IASP
Senior Physiotherapist
Singapore General Hospital

3. Physiotherapy for
non-cancer chronic pain
Pain Forum Singapore 2014
Lian Guojie
M Clin Physio(Curtin) Dip Phys(NYP)
Member of IASP
Senior Physiotherapist
Singapore General Hospital
persistent

4. A typical case of persistent pain…

5. A typical case of persistent pain…
Why hasn't my whiplash
resolve after 9 months?
!
Do I need an MRI?
!
Maybe an operation will
solve this...
!
Now it spreads to my
back too!

6. A typical case of persistent pain…
Why hasn't my whiplash
resolve after 9 months?
!
Do I need an MRI?
!
Maybe an operation will
solve this...
!
Now it spreads to my
back too!
Okay, my doctor said my
discs are 'done', but I'm not
a suitable candidate for
surgery.
!
Will activity make my
condition worse?
!
Will I recover?
!
Can I still function in my
job?
!

7. Principles of Physiotherapy
Practice in Persistent Pain
To restore and promote optimal physical
function and improved quality of life.
Although the goal is pain relief, this may be
minimal or impossible. However, physical
function and quality of life my be greatly
improved.

8. Topics
• Facts about persistent pain all healthcare providers
should know
• 3 commonest non-cancer persistent pain disorders
• The evidence behind physiotherapy management
• Current guidelines to manage persistent pain
disorders

9. Do you know…

11. Lifestyle
Patho-anatomical
Physical
Nervous system
Cognitive
Genetic/familial
Social
Gatchel, R.J., Peng, Y.B., Peters, M.L., et al. (2007). The biopsychosocial approach to chronic pain: scientific advances
and future directions. Psychol Bull, 133, 581–624.
What
underlies
the
person
with
persistent
pain?

12. Lifestyle
Patho-anatomical
Physical
Nervous system
Cognitive
Genetic/familial
Social
Gatchel, R.J., Peng, Y.B., Peters, M.L., et al. (2007). The biopsychosocial approach to chronic pain: scientific advances
and future directions. Psychol Bull, 133, 581–624.
What
underlies
the
person
with
persistent
pain?

13. Clinical consultations provide an
opportunity to have long-term positive
influences on patient beliefs1,2.
1Darlow, B. et al. (2013). The Enduring Impact of What Clinicians Say to People With Low Back Pain. Ann Fam Med,
527-534. doi:10.1370/afm.1518.
!
2Pincus. T. et al. (2013). Cognitive and affective reassurance and patient outcomes in primary care: A systematic review.
PAIN, (154), 2407-2416. doi: http://dx.doi.org/10.1016/j.pain.2013,07.019

14. Clinical consultations provide an
opportunity to have long-term positive
influences on patient beliefs1,2.
1Darlow, B. et al. (2013). The Enduring Impact of What Clinicians Say to People With Low Back Pain. Ann Fam Med,
527-534. doi:10.1370/afm.1518.
!
2Pincus. T. et al. (2013). Cognitive and affective reassurance and patient outcomes in primary care: A systematic review.
PAIN, (154), 2407-2416. doi: http://dx.doi.org/10.1016/j.pain.2013,07.019
Lin IB, O’Sullivan PB, Coffin JA, et al. Disabling chronic low back pain as an iatrogenic disorder: a qualitative study in
Aboriginal Australians. BMJ Open 2013;3:e002654. doi:10.1136/bmjopen-2013-002654

15. Clinical consultations provide an
opportunity to have long-term positive
influences on patient beliefs1,2.
1Darlow, B. et al. (2013). The Enduring Impact of What Clinicians Say to People With Low Back Pain. Ann Fam Med,
527-534. doi:10.1370/afm.1518.
!
2Pincus. T. et al. (2013). Cognitive and affective reassurance and patient outcomes in primary care: A systematic review.
PAIN, (154), 2407-2416. doi: http://dx.doi.org/10.1016/j.pain.2013,07.019
Lin IB, O’Sullivan PB, Coffin JA, et al. Disabling chronic low back pain as an iatrogenic disorder: a qualitative study in
Aboriginal Australians. BMJ Open 2013;3:e002654. doi:10.1136/bmjopen-2013-002654

16. How we think
traditionally…

17. How we think
traditionally…
1. Pain = Damage/Injury
2. Scans can identify pain source
3. Pain due to weakness,
tightness, poor ‘control’

18. How we think
traditionally…
“He is certainly
barking up the wrong tree.”
1. Pain = Damage/Injury
2. Scans can identify pain source
3. Pain due to weakness,
tightness, poor ‘control’

19. Physiotherapy
Management

20. Evaluation process in PT
• Pain history!
• The context (what happened/
MOI)!
• Pain area!
• Pain behaviour!
• Pain stage!
• Level of disability!
• Coping strategies!
• Beliefs, values!
• Psycho-social factors!
• Lifestyle factors!
• Goal setting!
• Screening / radiology!

21. Evaluation process in PT
• Pain history!
• The context (what happened/
MOI)!
• Pain area!
• Pain behaviour!
• Pain stage!
• Level of disability!
• Coping strategies!
• Beliefs, values!
• Psycho-social factors!
• Lifestyle factors!
• Goal setting!
• Screening / radiology!
•Impairments
•Functional limitations
•Disabilities
•Changes in physical
function

22. Physiotherapy Modalities
Education Electro-physical Agents
Exercise Manual TherapyActive Passive

23. Physiotherapy Modalities
Education Electro-physical Agents
Exercise Manual Therapy
• Traction
• Heat/cold
• TENS
• Ultrasound
Active Passive

24. Physiotherapy Modalities
Education Electro-physical Agents
Exercise Manual Therapy
• Traction
• Heat/cold
• TENS
• Ultrasound
• Massage
• Joint Manipulation
• Stretching
Active Passive

25. Physiotherapy Modalities
Education Electro-physical Agents
Exercise Manual Therapy
• Traction
• Heat/cold
• TENS
• Ultrasound
• Massage
• Joint Manipulation
• Stretching
• Aerobic
• Strengthening
• Graded functional rehabilitation
Active Passive

26. Physiotherapy Modalities
Education Electro-physical Agents
Exercise Manual Therapy
• Neuroscience Education
• Cognitive Behavioural Therapy
• Self-reading
• Traction
• Heat/cold
• TENS
• Ultrasound
• Massage
• Joint Manipulation
• Stretching
• Aerobic
• Strengthening
• Graded functional rehabilitation
Active Passive

27. Physiotherapy Modalities
Education Electro-physical Agents
Exercise Manual Therapy
• Neuroscience Education
• Cognitive Behavioural Therapy
• Self-reading
• Traction
• Heat/cold
• TENS
• Ultrasound
• Massage
• Joint Manipulation
• Stretching
• Aerobic
• Strengthening
• Graded functional rehabilitation
Active Passive
for persistent pain (when used alone)

32. LBP

33. LBP

34. LBP
1. The biomedical model of LBP is greatly challenged

35. LBP
1. The biomedical model of LBP is greatly challenged
2. No management approach is clearly superior

36. LBP
1. The biomedical model of LBP is greatly challenged
2. No management approach is clearly superior
3. NSCLBP patients often report conflicting diagnoses, failed
treatments, lost hope, ongoing suffering

37. LBP
1. The biomedical model of LBP is greatly challenged
2. No management approach is clearly superior
3. NSCLBP patients often report conflicting diagnoses, failed
treatments, lost hope, ongoing suffering
4. NSCLBP is multidimensional, where disability is more
closely associated with cognitive/behavioural aspects of
pain rather than sensory/biomedical ones

38. LBP
1. The biomedical model of LBP is greatly challenged
2. No management approach is clearly superior
3. NSCLBP patients often report conflicting diagnoses, failed
treatments, lost hope, ongoing suffering
4. NSCLBP is multidimensional, where disability is more
closely associated with cognitive/behavioural aspects of
pain rather than sensory/biomedical ones
5. Positive outcomes are best predicted by changes to the
cognitive/beliefs

39. LBP
1. The biomedical model of LBP is greatly challenged
2. No management approach is clearly superior
3. NSCLBP patients often report conflicting diagnoses, failed
treatments, lost hope, ongoing suffering
4. NSCLBP is multidimensional, where disability is more
closely associated with cognitive/behavioural aspects of
pain rather than sensory/biomedical ones
5. Positive outcomes are best predicted by changes to the
cognitive/beliefs
6. Evidence supports sub-grouping them for treatment

40. LBP

41. LBP

42. LBP
Cognitive Functional
Therapy
(CFT)
n = 62

43. LBP
Cognitive Functional
Therapy
(CFT)
n = 62
VS

44. LBP
Cognitive Functional
Therapy
(CFT)
n = 62
Manual Therapy &
Exercise
(Usual Care)
n = 59
VS

45. LBP
Cognitive Functional
Therapy
(CFT)
n = 62
Manual Therapy &
Exercise
(Usual Care)
n = 59
CFT group displayed significantly better short & long
term outcomes in:
• Pain
• Disability scores
• Patient satisfaction
VS

46. WAD
Teasell. R. W., McClure J. A., Walton D., et al. (2010). A research synthesis of therapeutic interventions for
whiplash-associated disorder (WAD): Part 4 – noninvasive interventions for chronic WAD. Pain Res Manage,
15(5), 313-322.

47. WAD
Despite recurring methodological shortcomings in the research
studies, it appears that exercise programs provided during the
chronic phase of WAD are effective in relieving pain, although
it does not appear that these gains are maintained over the
long term.
Teasell. R. W., McClure J. A., Walton D., et al. (2010). A research synthesis of therapeutic interventions for
whiplash-associated disorder (WAD): Part 4 – noninvasive interventions for chronic WAD. Pain Res Manage,
15(5), 313-322.

48. WAD
Despite recurring methodological shortcomings in the research
studies, it appears that exercise programs provided during the
chronic phase of WAD are effective in relieving pain, although
it does not appear that these gains are maintained over the
long term.
Teasell. R. W., McClure J. A., Walton D., et al. (2010). A research synthesis of therapeutic interventions for
whiplash-associated disorder (WAD): Part 4 – noninvasive interventions for chronic WAD. Pain Res Manage,
15(5), 313-322.

49. WAD
Despite recurring methodological shortcomings in the research
studies, it appears that exercise programs provided during the
chronic phase of WAD are effective in relieving pain, although
it does not appear that these gains are maintained over the
long term.
While there is some evidence regarding the relative
effectiveness and potential benefits of specific exercise
protocols, further research is needed before any definitive
conclusions can be drawn.
Teasell. R. W., McClure J. A., Walton D., et al. (2010). A research synthesis of therapeutic interventions for
whiplash-associated disorder (WAD): Part 4 – noninvasive interventions for chronic WAD. Pain Res Manage,
15(5), 313-322.

50. Comprehensive physiotherapy exercise programme
or advice for chronic whiplash (PROMISE): a
pragmatic randomised controlled trial.
WAD
Education &
support!
(1 session)
Comprehensive PT!
(20 sessions)VS
Michaleff Z. A., Maher C. G., Lin C. W., Rebbeck T., Jull G., Latimer J., Connelly L., Sterling M. (2014).
Lancet. Jul 12;384(9938):133-41. doi: 10.1016/S0140-6736(14)60457-8. Epub 2014 Apr 4.

51. Comprehensive physiotherapy exercise programme
or advice for chronic whiplash (PROMISE): a
pragmatic randomised controlled trial.
WAD
Education &
support!
(1 session)
Comprehensive PT!
(20 sessions)
No difference!
VS
Michaleff Z. A., Maher C. G., Lin C. W., Rebbeck T., Jull G., Latimer J., Connelly L., Sterling M. (2014).
Lancet. Jul 12;384(9938):133-41. doi: 10.1016/S0140-6736(14)60457-8. Epub 2014 Apr 4.

52. OA
• OARSI recommends1: PT referral,
undertake/continue regular exercise, lose
weight, use of walking aid
!
• Overwhelming evidence that exercise is
beneficial for pain2
!
• Aerobic or quadriceps strengthening are
equally effective3
!
• All physical therapies improve pain and
function4
1 Zhang W, Moskowitz W, Nuki G, Abramson S, Altman RD, Arden N, et al. OARSI recommendations for the management of hip and knee osteoarthritis, Part II:
OARSI evidence-based, expert consensus guidelines. Osteoarthritis Cartilage. 2008; 16: 137-162.
!2 Fransen M, McConnell S. Exercise for osteoarthritis of the knee. Cochrane Database Syst Rev. 2008;(4): CD004376.
!3 Roddy E, Zhang W, Doherty M. Aerobic walking or strengthening exercise for osteoarthritis of the knee? A systematic review. Ann Rheum Dis. 2005;64(4):544-8.
!4 Jamtvedt G, Dahm KT, Christle A, Moe RH, Haavardsholm E, Holm I, et al. Physical therapy interventions for patients with osteoarthritis of the knee: an overview
of systematic reviews. Phys Ther. 2008;88(1):123-36. Epub 2007 Nov 6.

53. Screening tools

54. Orebro Musculoskeletal Pain
Questionnaire (OMPSQ)
• Determines long term disability, risk of failure of
returning to work due to musculoskeletal pain
• Long1 (20 Qns) and short2 (10 Qns) forms available
• English and Mandarin available
1. Linton SJ, Boersma K. (2003). Early identification of patients at risk of developing a persistent back problem: the
predictive validity of the Örebro Muscuoloskeletal Pain Questionnaire. Clin J Pain,19: 80-86.
!
2. Linton, S. J., Nicholas, M., MacDonald, S. (2011). Development of a Short Form of the Örebro Musculoskeletal
Pain Screening Questionnaire. Spine, 36, 1891–1895. doi: 10.1097/BRS.0b013e3181f8f775

55. STarT Back Screening Tool
© Keele University 01/08/07
Funded by Arthritis Research UK

56. STarT Back Screening Tool
© Keele University 01/08/07
Funded by Arthritis Research UK

57. STarT Back Screening Tool
© Keele University 01/08/07
Funded by Arthritis Research UK

58. STarT Back Screening Tool
© Keele University 01/08/07
Funded by Arthritis Research UK
Advice + Analgesia

59. STarT Back Screening Tool
© Keele University 01/08/07
Funded by Arthritis Research UK
Advice + Analgesia
Physiotherapy

60. STarT Back Screening Tool
© Keele University 01/08/07
Funded by Arthritis Research UK
Advice + Analgesia
Physiotherapy
Multi-disciplinary
Approach

61. What should we do?

62. What should we do?
A cognitive-functional approach!

63. What can we start doing today?

64. What can we start doing today?
!
Doctor mentioned that I
have age-appropriate
changes seen on my MRI
and sinister causes were
ruled out.
!
He have reassured me that
they are unlikely sources
of my ongoing pain.
!

65. What can we start doing today?
!
Doctor mentioned that I
have age-appropriate
changes seen on my MRI
and sinister causes were
ruled out.
!
He have reassured me that
they are unlikely sources
of my ongoing pain.
!
!
!
He encouraged me to start
a graded physical therapy
program to get well again.
!
I feel more confident in my
recovery now!
!
!

66. PT referral.

67. • Red flags ruled out
PT referral.

68. • Red flags ruled out
• Pain affects ADL
PT referral.

69. • Red flags ruled out
• Pain affects ADL
• 'Recovered' from recent injury but unsure of
appropriate level of physical activity
PT referral.

70. • Red flags ruled out
• Pain affects ADL
• 'Recovered' from recent injury but unsure of
appropriate level of physical activity
• Dysfunctional pain, eg, Fibromyalgia
PT referral.

71. • Red flags ruled out
• Pain affects ADL
• 'Recovered' from recent injury but unsure of
appropriate level of physical activity
• Dysfunctional pain, eg, Fibromyalgia
• Anxiety, stress disorders
PT referral.

72. In summary...

73. In summary...

74. In summary...

75. In summary...

76. In summary...

77. In summary...