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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.
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- 1. Physiotherapy for non-cancerchronic 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-cancerchronic 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-cancerchronic 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 caseof persistent pain…
- 5. A typical caseof 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 caseof 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 Practicein 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 aboutpersistent 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
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- 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 opportunityto 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 opportunityto 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 opportunityto 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
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- 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… “Heis certainly barking up the wrong tree.” 1. Pain = Damage/Injury 2. Scans can identify pain source 3. Pain due to weakness, tightness, poor ‘control’
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- 20. Evaluation process inPT • 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 inPT • 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-physicalAgents Exercise Manual TherapyActive Passive
- 23. Physiotherapy Modalities Education Electro-physicalAgents Exercise Manual Therapy • Traction • Heat/cold • TENS • Ultrasound Active Passive
- 24. Physiotherapy Modalities Education Electro-physicalAgents Exercise Manual Therapy • Traction • Heat/cold • TENS • Ultrasound • Massage • Joint Manipulation • Stretching Active Passive
- 25. Physiotherapy Modalities Education Electro-physicalAgents Exercise Manual Therapy • Traction • Heat/cold • TENS • Ultrasound • Massage • Joint Manipulation • Stretching • Aerobic • Strengthening • Graded functional rehabilitation Active Passive
- 26. Physiotherapy Modalities Education Electro-physicalAgents 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-physicalAgents 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)
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- 34. LBP 1. The biomedicalmodel of LBP is greatly challenged
- 35. LBP 1. The biomedicalmodel of LBP is greatly challenged 2. No management approach is clearly superior
- 36. LBP 1. The biomedicalmodel 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 biomedicalmodel 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 biomedicalmodel 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 biomedicalmodel 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
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- 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 methodologicalshortcomings 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 methodologicalshortcomings 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 methodologicalshortcomings 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 exerciseprogramme 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 exerciseprogramme 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.
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- 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 ScreeningTool © Keele University 01/08/07 Funded by Arthritis Research UK
- 56. STarT Back ScreeningTool © Keele University 01/08/07 Funded by Arthritis Research UK
- 57. STarT Back ScreeningTool © Keele University 01/08/07 Funded by Arthritis Research UK
- 58. STarT Back ScreeningTool © Keele University 01/08/07 Funded by Arthritis Research UK Advice + Analgesia
- 59. STarT Back ScreeningTool © Keele University 01/08/07 Funded by Arthritis Research UK Advice + Analgesia Physiotherapy
- 60. STarT Back ScreeningTool © Keele University 01/08/07 Funded by Arthritis Research UK Advice + Analgesia Physiotherapy Multi-disciplinary Approach
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- 62. What should wedo? A cognitive-functional approach!
- 63. What can westart doing today?
- 64. What can westart 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 westart 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! ! !
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- 67. • Red flagsruled out PT referral.
- 68. • Red flagsruled out • Pain affects ADL PT referral.
- 69. • Red flagsruled out • Pain affects ADL • 'Recovered' from recent injury but unsure of appropriate level of physical activity PT referral.
- 70. • Red flagsruled out • Pain affects ADL • 'Recovered' from recent injury but unsure of appropriate level of physical activity • Dysfunctional pain, eg, Fibromyalgia PT referral.
- 71. • Red flagsruled 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.
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