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Physical Therapy for Chronic Pain

It is estimated that about 100 million people in America are living with chronic pain. Chronic pain can interfere with your day-to-day work and recreational activities, and it may have a profound effect on your ability to concentrate, relax, and enjoy life.

There are a multitude of treatments available for chronic pain: medication, massage, exercise, acupuncture, and a host of other treatments. Physical Therapy (PT) for chronic pain is also an option, and it may help you manage your pain and regain your normal mobility.

If you have chronic pain, working with a physical therapist can help your pain go away, and your therapist can give you strategies to keep the pain away. So, what does physical therapy for chronic pain look and feel like, and what can you expect from PT for chronic pain?

What Is Chronic Pain?

The simple definition of chronic pain is pain that has been present for greater than 12 weeks.

However, it can be more complex than that, and the best way to understand chronic pain is to learn about its cousin: acute pain. Acute pain is pain that comes on suddenly and lasts for a few weeks. Typically, acute pain is caused by some traumatic event that injures your body’s tissues.

If you smash your thumb with a hammer, for instance, this causes acute pain. The pain is sudden and severe, and you can easily discern the cause of it. Your thumb becomes red, swollen, and painful. Over the course of a few weeks, however, the pain goes away as your thumb heals.

Now imagine that you smash your thumb with a hammer again. Your thumb becomes red, swollen, and painful. This time imagine your thumb pain continues long after the signs of injury have gone away. The tissues are clearly healed, but your thumb still hurts. When you try to move your hand, the pain increases. This is chronic pain.

Chronic pain can be confusing, and it can prevent you from moving normally and concentrating on your daily activities. Plus, dealing with chronic pain can leave you and your doctor perplexed.

Often, pain occurs when there is little or no tissue damage. Why is the pain lasting long after the tissues are healed? Why are medicines not effective in treating your pain? Is there something really wrong? These questions may be difficult to answer and finding the best treatment for your chronic pain may be equally difficult.

Treatments Types

There are many different treatments available for chronic pain. Finding the best one for you can take a little trial and error.

  • Physical therapy (PT)
  • Medication (oral or injected)
  • Supplements and natural remedies
  • Chiropractic care
  • Massage
  • Acupuncture
  • Exercise
  • Meditation
  • Cognitive behavioral therapy (CBT)

There are likely more items to add to this list, and you may find one remedy helpful while another may not be effective for your pain at all. Physical therapy may be an option to treat your chronic pain and working with a physical therapist has been shown to help chronic pain sufferers improve their function while decreasing or eliminating their pain.

What to Expect

When attending physical therapy for chronic pain, your first session will be an initial evaluation. During this session, you will meet your physical therapist and discuss your condition.

Your therapist should ask questions about your pain and how it behaves. Is your pain present constantly or intermittently, and how does it affect your life? What makes it better or worse? Your physical therapist should also ask about any previous treatments you have received and the effect those treatments have had.

He/she might do a review of your overall medical history and will perform various tests and measures to get a sense of any impairments that may be contributing to your pain, including:

  • Range of motion
  • Posture
  • Strength
  • Balance
  • Endurance

Some of these tests may increase your pain, while others may cause your pain to decrease. Be sure to communicate with your physical therapist how you are feeling and how sensations are changing during your evaluation.

Once your PT evaluation is complete, your physical therapist should work with you to develop realistic and attainable goals for therapy. Goals may include pain relief, extended range of motion, increased strength and improved functional mobility. Your goals should be personal and should give you a road map to follow during your rehabilitation program. Finally, your treatment can begin.

PT Treatments

When you attend physical therapy for chronic pain, you may experience various treatments that may be used to decrease pain, improve your mobility, and help you fully function. Common treatments used by physical therapists for chronic pain patients include:

  • Exercise: Exercise should be your main PT tool in the treatment of chronic pain because it can help your body improve strength and mobility. Think of exercise as a feedback loop. Your brain moves your body, so exercise is output coming from your brain. When you can move with little or no pain, you are reinforcing to your brain that the movement is not going to hurt. This positive feedback allows you to move more with less pain. So while you are getting stronger and improving mobility, you are also training your sensitive nervous system to trust that the movement is safe.
  • Ultrasound: Ultrasound is a deep heating modality that you may encounter while in PT. It is applied to your skin and as your body’s tissues are heated, it is thought that this improves circulation and blood flow. It is important to note that ultrasound has not been proven to be an effective treatment for chronic pain. Still, you may encounter this treatment during your PT sessions.
  • TENS and Electrical Stimulation: Transcutaneous electrical nerve stimulation (TENS) is a therapeutic modality that uses electricity to decrease pain signals coming from your body to your brain.
  • Massage: Some physical therapists employ massage techniques to decrease pain by improving muscular blood flow and relieving tightness.
  • Dry Needling: Dry needling is a newer treatment employed by some physical therapists to decrease painful muscle knots and trigger points. This treatment involves using small needles (such as acupuncture needles) to pierce muscle tissue and knots, relieving the pain in these spots.
  • Heat or Ice: Modalities like heat and ice are often used by PTs to help decrease pain and inflammation. These treatments have not been proven to be effective with patients dealing with chronic pain, but they are often used as adjunct treatments during your PT sessions.
  • Pain Neuroscience Education (PNE): New research indicates that teaching patients about their pain and why it is happening can have a positive effect on their rehab. Your physical therapist may spend time teaching you about why you have pain, how your pain might behave, and things you can do to take control of your pain.

Each of these treatments is designed to achieve a specific goal. It is important that you discuss with your physical therapist the intent of the treatment, so you know what to expect.

Finding What Works

Some Treatments Not Proven Effective

Some PT treatments for chronic pain are based on theoretical models and have not been proven to be effective for pain. Does this mean that they will not be effective for you? No. It simply means that in studies of large groups of people with similar characteristics, some treatments have not been proven to work. Understanding the research can help you make informed decisions about your care.

Some treatments that may not be as effective for chronic pain include ultrasound, TENS, or heat and ice.

A meta-analysis (study examining conclusions of many different studies) concluded that ultrasound was not effective for chronic low back pain (LBP) when compared to exercise alone or a placebo (fake treatment). The authors concluded: “No high-quality evidence was found to support the use of ultrasound for improving pain or quality of life in patients with non‐specific chronic LBP.” Another meta-analysis of the use of massage for chronic pain concluded that patients may report a 20 to 80 percent reduction in pain after a massage, but that these reductions are temporary. Massage, however, may help improve the mobility of tissues and feelings of well-being. Dry needling studies show similar results, and both heat and ice are shown to give slight short-term relief of pain.

Treatments Proven to Be Effective

Exercise has been proven to be effective for chronic pain. Pain neuroscience education (PNE) or learning about pain and how it affects your body, has also been shown to offer long-term benefits with pain reduction and improved mobility.

Research published in the Archives of Physical Medicine and Rehabilitation showed that a graded walking program can have a positive effect on patients with chronic pain. However, one important caveat of the study was that adherence to an exercise and a walking program can be difficult. Still, finding ways to maintain walking and exercising is important. (Your PT can help with this.)

In addition, neuroscience pain expert Adriaan Louw has found that learning about pain through pain neuroscience education (PNE) can improve symptoms, mobility, and feelings of psychological well-being in people with chronic pain.

Overall, passive treatments like heat, ice, or massage may feel good. However, if you want to take control of your pain, more active treatments like exercise and learning about your pain are recommended.

The most important thing to remember is that your pain is personal. Your physical therapist can work with you to find specific things that can help you move better and feel better.

If you have chronic pain, you may find that it is difficult to function well. Managing your pain can be challenging, as there are many different options for you, all with varying degrees of effectiveness. Physical therapy, with a focus on exercise and pain neuroscience education, can be an effective way to decrease your pain and improve your mobility.

Physical Therapist’s Guide to Knee Pain

Knee pain can be caused by disease or injury. Among American adults, approximately 25% have experienced knee pain affecting the function of the knee. The prevalence of knee pain has increased over the past 20 years, with osteoarthritis being the most common cause in individuals over the age of 50. Knee pain that is caused by injury is most often associated with knee cartilage tears. Knee injuries can occur as the result of a direct blow or sudden movement that strains the knee beyond its normal range of movement. Knee pain can cause difficulty performing activities such as walking, rising from a chair, climbing stairs, or playing sports. Physical therapists are specially trained to help diagnose and treat knee pain, and help individuals return to their normal activities without pain or limitation.

What is Knee Pain?

The knee joint is a hinge joint that connects the tibia (shin bone), and the femur (thigh bone) at the patella (kneecap). There are 4 main ligaments that support the knee joint. They are the anterior cruciate ligament (ACL); posterior cruciate ligament (PCL); medial collateral ligament (MCL); and lateral collateral ligament (LCL). There are also 2 rings of cartilage that act as shock absorbers in the knee, called the medial and lateral meniscus.

The most common cause of knee pain is osteoarthritis, a condition that occurs when the cartilage that protects the inside surfaces of the tibia and femur bones called articular cartilage gradually wears away, resulting in pain and swelling in the knee.

How Does it Feel?

Knee pain can occur suddenly for no apparent reason or develop slowly, as the result of repetitive trauma. Knee pain occurs in different parts of the knee, depending on what structures in the knee are involved. Below is a general breakdown of the areas in which knee pain may occur and the structures of the knee that may be involved:

  • Anterior knee pain, also referred to as patellofemoral pain, is pain around the kneecap (patella) in front of the knee, caused when the kneecap shifts out of position. This condition commonly affects younger females and may be due to overuse injury. Pain often occurs when performing activities like squats or stair-climbing.
  • Lateral knee pain is pain that occurs on the outside of the knee. It is a type of overuse injury that commonly occurs in runners when the tendon called the iliotibial band (ITB) becomes irritated. Pain is often felt when performing activities such as climbing stairs, or when walking or running.
  • Medial knee pain is pain that occurs along the inside of the knee when the MCL or the medial meniscus become irritated due to direct injury or overuse. Pain is felt when squatting, walking up or down an incline, or going downstairs.
  • Pain caused by a ligament tear may result from a direct blow to the knee, or when twisting or pivoting the knee while the foot is planted on the ground. Immediate pain and swelling usually occur, and the knee may feel unstable—like it will “give out”—when an individual attempt to put weight on the involved leg.
  • Pain caused by osteoarthritis may occur anywhere in the knee where cartilage has broken down. This type of knee pain may begin as mild and progressively worsen. It can become increasingly difficult to walk long distances, fully bend and straighten the knee, climb stairs, or squat to sit in a chair. The knee also may swell intermittently with increased activity. 

 

How Is It Diagnosed?

Your physical therapist will make a diagnosis based on your symptoms, medical history, and a thorough examination. Your physician may order an X-ray and magnetic resonance imaging (MRI) to complete the diagnosis.

Your physical therapist will perform an evaluation that will start with discussing your medical history and your symptoms. Your therapist will ask questions to determine where your pain is located, if you sustained any trauma or injury to the knee, and what functional daily activities are painful or difficult for you to perform. Your physical therapist will perform tests to find out if you have:

  • Limited range of motion in the knee.
  • Pain in the knee with certain movements.
  • Weakness in the muscles around your hip, knee, or ankle.
  • Limited flexibility in your hip, knee, or ankle.
  • Difficulty walking.
  • Difficulty performing activities, such as rising from a chair or climbing stairs.
  • Problems with your balance or coordination.
  • Difficulty controlling the knee during certain activities.
  • Difficulty performing specific sports activities (for athletes). 

 

How Can a Physical Therapist Help?

Based on the findings of your evaluation, your physical therapist will develop a customized rehabilitation program to ensure a safe return to your desired activities. Some general treatment techniques may include:

  • Pain management.  Your physical therapist may provide treatments using different “modalities” such as ice, heat, ultrasound, or electrical stimulation to help decrease pain and swelling.
  • Manual therapy.  Your therapist will apply manual (hands-on) therapy to gently guide movement of the knee area to restore joint and tissue mobility.
  • Therapeutic exercises. Your physical therapist will prescribe specific strengthening, flexibility, and endurance exercises to address your specific needs and goals.
  • Functional exercises. You will learn individualized exercises designed to help you return to your home, work, and sport activities. These also may include balance and coordination exercises.
  • Self-care instruction.  Your physical therapist will teach you ways to manage your pain at home and design a safe and effective home-exercise program based on your specific condition, which you can continue long after your formal physical therapy sessions have ended. You also will learn how to avoid placing unnecessary forces on the knee during your daily activities for years to come. 

 

How Can a Physical Therapist Help Before & After Surgery?

Your physical therapist, in consultation with your surgeon, will be able to tell you how much activity you can do depending on the type of knee surgery (such as total knee replacement) you undergo. Your therapist and surgeon also might have you participate in physical therapy prior to surgery to increase your strength and motion. This can sometimes help with recovery after surgery.

Following surgery, your physical therapist will design a personalized rehabilitation program for you and help you gain the strength, movement, and endurance you need to return to performing the daily activities you did before.

Can this Injury or Condition be Prevented?

To help reduce knee pain, it is important to maintain a healthy lifestyle, perform regular safe exercise, get adequate rest, and eat healthy foods. Weight management is important for maintaining healthy knee function, as increased body weight puts extra pressure on all the joints, including the knees. Ideally, individuals of all ages should regularly perform some form of flexibility, strength, and heart-conditioning exercises.

It also is important for athletes to perform appropriate warm-up exercises and stretches on a daily basis and before beginning physical activity.

CAUTION: If any exercise or activity provokes knee pain, seek professional help before the symptoms worsen. 

What Kind of Physical Therapist Do I Need?

All physical therapists are prepared through education and experience to treat knee pain. However, you may want to consider:

  • A physical therapist who is experienced in treating people with knee pain. Some physical therapists have a practice with an orthopedic and sports medicine focus.
  • A physical therapist who is a board-certified clinical specialist or who completed a residency or fellowship in orthopedic, manual, or sports physical therapy. This therapist has advanced knowledge, experience, and skills that may apply to your condition.

General tips when you’re looking for a physical therapist (or any other health care provider):

  • Get recommendations from family and friends or from other health care providers.
  • When you contact a physical therapy clinic for an appointment, ask about the physical therapists’ experience in helping people who have underlying knee pain.
  • During your first visit with the physical therapist, be prepared to describe your symptoms in as much detail as possible, and say what makes your symptoms worse. 

Start Your Year With an Annual Movement Screen

Your car needs regular maintenance, so you probably have a mechanic. Your eyes and teeth are important, so you see your optometrist and dentist regularly. You get an annual physical from your family physician. You might even be getting ready to see your accountant to get your yearly income tax done. What about your physical therapist? Do you and your family have one? If not, you should. Your body is a lot like your car. It’s got multiple systems, all of which are complex, and all of which have to be working well for it to function. Physical therapists are experts in maintaining, diagnosing, and treating the movement system. Like the braking or ignition system in a car, most people only think of the movement system when it’s not working the way it should.

DON’T NEGLECT YOUR MOVEMENT SYSTEM

Similar to the systems in your car, problems with your movement system are much easier to deal with if they’re caught and treated early. This prevents small issues from becoming larger ones. For example, if you have a little bit of weakness, and balance that’s not quite up to par, improving those early could prevent a sprained ankle, or a fall and a broken wrist.
An annual movement screen from your physical therapist can find small issues that you may not have noticed with your strength, balance, flexibility, or coordination. Many of these minor issues can be fixed with a few exercises at home, or with just a few visits.

WHAT TO EXPECT

A screen of your movement system is quick and easy. Your annual visit may include:
● A history of your injuries, as well as a health history
● Assessment of your strength, balance, flexibility, etc.
● A review of your movement goals (do you want to run a marathon? Get on and off the floor easily playing with your grand kids?)
● A review and update of your exercise program

Physical Therapy and Low Back Pain

Back Pain

At any given time, about 25% of people in the United States report having low back pain within the past 3 months. In most cases, low back pain is mild and disappears on its own. For some people, back pain can return or hang on, leading to a decrease in quality of life, or even to disability.
If your low back pain is accompanied by the following symptoms, you should visit your local emergency department immediately:
• Loss of bowel or bladder control
• Numbness in the groin or inner thigh

There are 3 different types of low back pain:
• Acute – pain lasting less than 3 months
• Recurrent – acute symptoms come back
• Chronic – pain lasting longer than 3 months.

ARSO therapists can teach you how to use the following strategies to prevent back pain:
• Use good body positioning at work, home, or during leisure activities.
• Keep the load close to your body during lifting.
• Ask for help before lifting heavy objects.
• Maintain a regular physical fitness regimen—staying active can help to prevent injuries.

Not all low back pain is the same, so your physical therapist will design an individualized treatment plan for your specific back problem. Treatments may include:
• Manual therapy
• Specific strengthening and flexibility exercises
• Education
• Training for proper lifting, bending, and sitting; for doing chores both at work and in the home; and for proper sleeping positions
• Assistance in creating a safe and effective physical activity program
• Use of ice or heat treatments or electrical stimulation to help relieve pain

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