How physiotherapy can help those experiencing persistent pain
By Matt Forster, Titled Pain Physiotherapist
Pain is a complex and distressing human experience. Pain experts have defined it as a distressing experience associated with actual or potential tissue damage with sensory, emotional, cognitive, and social components.
As a physiotherapist, I often see the emotional and social effects pain can have. The story below illustrates one example of how chronic pain can affect multiple aspects of our lives and how modern pain science can help treat it.
Nathan (patient name changed) is 39 and strained his back moving pallets on the family pineapple farm on the Sunshine Coast. He had just taken over running the farm from his father. Six months later, Nathan had persistent pain. He was managing the farm, but mainly from the office and couldn’t do any manual work or operate any machinery. He wanted to be a “hands on” farmer and work with the staff. He felt depressed, had gained weight, and had trouble sleeping. He felt that he had let his dad down and wouldn’t be able to run the farm like his old man had.
Nathan had been told that he may have to learn to live with his pain. However, a physiotherapist with knowledge about modern pain science helped Nathan identify which mechanisms were contributing to his pain:
- Structural mechanisms – Nathan was initially correctly diagnosed with a musculoskeletal strain, which can cause acute (short term) pain. He went on to have a MRI scan which showed a mild broad-based disc bulge. However, scans often reveal “age-related pathology” which in Nathan’s case, may not have been caused by the injury. This strain will take six to twelve weeks to heal, and the disc bulge will likely remain unchanged during this time. There may be stiffness and weakness in the tissues after the healing timeframe ends.
- Nerve function mechanisms – The perception of pain requires information to be transmitted from the injured area via nerves to the brain (no brain, no pain). The functioning of the nerve system can vary. In some pain conditions, known as nociplastic pain, the sensitivity of the nerves near the injury can increase, and nerve transmission becomes more efficient. With this nociplastic pain, movements that are not dangerous and potentially helpful to the tissues, will be felt as significantly more painful than expected.
- Psychological mechanisms – By definition, pain is an emotional experience. Modern brain scanning techniques have shown that multiple regions of the brain process information about pain. The limbic system, which is in part responsible for processing of our emotions, is active when people are in pain. Pain can be associated with mental health conditions such as depression and stress. In Nathan’s case, he is fearful about further injury, anxious, depressed, and concerned his pain will continue. He became hypervigilant, avoided movements he feared might harm his back, and lost confidence in his back. This impacted on his family life, his work life, his relationships and his participation in hobbies and sports.
- Movement mechanisms– Due to the initial injury, Nathan lost mobility and strength in the injured area. After receiving the results of his scan, he became worried and fearful of his back, and start moving less in an attempt to avoid further injury. He felt stiffness and tension in his muscles due to trying to keep his back supported. He felt pains in other areas, changed how he got up and down from a chair, and noticed an occasional limp. These abnormal movements can end up actually contributing to ongoing pain, rather that helping to prevent further injury.
- Health and lifestyle mechanisms – Six months down the track, Nathan has stopped exercising, can’t drive the tractor, is staying in the office, and lying down a few times a day. He is having trouble sleeping at night, feeling depressed and not seeing his mates on the weekend. He has lost interest in restoring his ‘74 Harley and can’t see himself recovering.
Nathan’s case is not extreme or unusual. There are many Nathans out there, and it is important to recognise that his pain is not “all in his head”. However, there are multiple mechanisms contributing to ongoing pain. If treatment focusses solely on the disc bulge visible on his scan, the outcome for Nathan will not likely be optimal.
Fortunately, Nathan has a great physiotherapist who has been able to identify all these mechanisms and together, they developed a rehabilitation plan. The physiotherapist has a framework to help guide Nathan’s recovery. One framework, developed by researcher Dr Bronwyn Thompson, describes three components:
- Making sense – Nathan’s physiotherapist was able to explain stiffness and weakness after the lumbar strain, that his disc bulge was not a major factor, and how his nerve sensitivity caused some increased perception of pain. Nathan was reassured that he was safe to move and would not cause more damage.
- Deciding – Nathan identified some goals he wanted to achieve. He wanted to help with harvesting, do more work on the Harley, and help out with his daughter’s basketball coaching. He decided to talk to his GP to try to reduce his pain medications. With the physiotherapist’s help, an exercise rehabilitation program was set up and Nathan started walking each day with his dog.
- Flexibly persisting – Nathan steadily made progress, but it was not a straight-line recovery. There were a few flare-ups along the way, some from trying too much too soon (movement factors), but others due to stress and anxiety related to the farm (psychosocial factors). He found that a bad sleep led to worse pain the next day (lifestyle factors). Some psychology treatment was recommended and Nathan found that learning some strategies to manage anxiety, improve his sleep and actively relax his muscles was very helpful to manage his symptoms and for his recovery.
Recovering from persistent pain is challenging. Finding the right physiotherapist who can work alongside patients to understand their individual pain mechanisms and provide a structured treatment framework is crucial to successful recovery. Nathan is now back on the farm harvesting pineapples again and taking his Harley for a cruise in the hinterland on the weekend.
If you or someone you know needs help with chronic or persistent pain, contact your local physiotherapist by clicking here or contact Matt Forster at Pace It Physio, Consultant physiotherapist at Allsports Forest Lake, Entire Health North Lakes, Parkwood via email: firstname.lastname@example.org
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Lennox Thompson, B., Gage, J., & Kirk, R. (2020). Living well with chronic pain: a classical grounded theory. Disability and rehabilitation, 42(8), 1141-1152.
Edwards, R. R., Dworkin, R. H., Sullivan, M. D., Turk, D. C., & Wasan, A. D. (2016). The role of psychosocial processes in the development and maintenance of chronic pain. The Journal of Pain, 17(9), T70-T92.