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6 Articles in this Series
Where Are We With a National Pain Strategy?
Prevalence of Growth Hormone Deficiency in Fibromyalgia
The Perfect Storm: Chronic Pain, Inflammation, and Dysfunctional Sleep
Ketamine and Pyschotherapy Effective for Management of CRPS and PTSD
Using a Multimodal Approach to Physical Therapy for Chronic Pain
Combining Noninvasive Brain Stimulation Therapies for CRPS

Using a Multimodal Approach to Physical Therapy for Chronic Pain

Physical therapists are encouraged to expand their horizons beyond biomechanical treatments.

Interview with John E. Garzione, PT, DPT

Physical therapists can encounter serious challenges in assessing and treating patients suffering from chronic pain. However, physical therapists may not be utilizing all the treatment options available to them.   

Cognitive behavioral therapy (CBT) is a form of psychotherapy shown to improve patients’ perception of pain, self-efficacy, sleep, and overall quality of life.1,2,3 While CBT may not be a panacea for all patients, it could be an aspect of treatment that physical therapists have overlooked when they've assessed chronic pain patients from strictly a biomechanical perspective.

Based in out-patient physical therapy center based in Norwich, New York, John E. Garzione, PT, DPT, owner of Chenango Therapeutics, suggested that incorporating CBT into a physical therapy setting may be a key component to ensure the best patient outcome.4 During his presentation at AIPM, "Musculoskelatal Pain: Is the issue in the tissue?," Dr. Garzione suggested that physical therapists refer patients who are suffering from recalcitrant pain to CBT therapists to help facilitate greater progress toward a pain free state.4

“Those of us who deal with chronic pain have realized that with just straight physical therapy, there’s something missing,” Dr. Garzione told Practical Pain Management. For the past 43 years, he has been treating patients with a variety of pain conditions and has achieved better success by utilizing a more multimodal approach to managing his chronic pain patients.

“We've tried to incorporate as much cognitive therapy as we can within the physical therapy treatment setting,"4 said Dr. Garzione. If it’s somebody who needs more intense cognitive therapy, I will certainly send the person to somebody else who is more skilled at it, who just does cognitive therapy.” 

CBT Adds to PT for Patients With Complex Chronic Pain Issues

In presenting at the 2016 Academy of Integrative Pain Medicine annual meeting, Dr. Garzione described a patient case example that reflected the benefits of multimodal care at his practice in Norwich.4 A middle-aged woman presenting with chronic headache and neck and cervical pain was having significant issues getting enough sleep and performing daily tasks, like writing or turning her head while driving.

Getting as many details as possible about a patient’s background is essential in better understanding the patient's situation. “[Patient] history is extremely important,” said Dr. Garzione, "but not all physical therapists may realize this includes social history in addition to the physical exam."4

The patient—divorced and fired from her last 2 jobs—had suffered a motor vehicle collision 9 years prior. The patient even reported she had been the victim of sexual assault by a relative when she was only 9 years old. In addition, the patient was taking multiple medications, including escitalopram, buspirone, tramadol, and simvastatin.

Despite the fact, she was taking more than 1 medication for anxiety and depressive symptoms, the patient only recently had scheduled an appointment with a counselor for the first time.

“A lot of times people come in [to the PT session] and they say ‘Should I go to a counselor?’ or ‘I made an appointment with a therapist, should I keep it?’"

To this patient, Dr. Garzione responded, "Not only should you keep the appointment with the counselor, you should also get with a psychiatrist to consider some medication adjustments.”

Dr. Garzione’s treatment plan for the patient included psychological counseling for anger management from a qualified social worker and psychiatric care for the patient’s anxiety and depression, with medication adjustments to be made in coordination with the counselor and physical therapist.4

Local heating and healing modalities also were performed on the cervical to thoracic spine to increase scar extensibility and to improve the tissue perfusion and blood flow.4 Modalities included:

  • Iontophoresis using salicylate/iodex
  • Ultrasound therapy (1.0 W/mc2 continuous for 10 minutes to the cervical spine)
  • Laser therapy
  • Soft tissue mobilization
  • Spinal range of motion exercises
  • Isometric exercises for spinal muscles
  • Associative Awareness Techniques (AAT)

However, magnetic resonance imaging (MRI) revealed that even though the patient did have scar tissue in her paraspinal muscles, the patient’s chronic pain could not have been explained away biomechanically.4

“The MRI showed that with the pain that she had, there was really just some mild tissue problems going on, but nothing that indicated the patient required surgical intervention. That was not really the major issue,” said Dr. Garzione.

By using this multimodal, multidisciplinary approach, the patient enjoyed noticeable improvements after 3 months of physical therapy sessions, showing more strength, greater range of motion, and improved posture, reduced muscle hypertonus, and increased ability to turn her head when backing up her car.

Putting Patients First With Multimodal Management

Unfortunately, opening up a dialogue with chronic pain patients that reaches past the physical aspects of their pain may be a challenge. Patients can be forgetful or even secretive about their general medical history, let alone significant personal trauma and diagnosed or undiagnosed psychological issues.

Overcoming the barriers of communication could be particularly difficult for physical therapists.4 Many physical therapists practice in centers with just one large room, where patients are examined on adjacent tables.The lack of privacy may make it difficult for physical therapists to pivot their dialogue with patients to more sensitive or personal questions. This is why our clinic utilizes separate rooms for evaluating patients, according to Dr. Garzione.

However, given the right circumstances or the right approach, physical therapists surprisingly may find their patients are willing to share more personal details, especially if patients think it will help with their pain.

“When I do an evaluation with a patient, it’s a one-on-one. Sometimes during the evaluation, we don’t pull out a lot of the past traumas, but as they get comfortable with us and as they know that they can talk, a lot of people become more than willing to open up with us in that way,"4 said Dr. Garzione.

“The whole question is: Do we treat the mind or do we treat the body? And the best approach is—we should treat both,” concluded Dr. Garzione.


  1. Ehde DM, Dillworth TM, Turner JA. Cognitive behavioral therapy for individuals with chronic pain: efficacy, innovations, and directions for research. Am Psychol. 2014;69(2):153-166.
  2. Knoerl R, Lavoie Smith EM, Weisberg J. Chronic pain and cognitive behavioral therapy: an integrative review. West J Nurs Res. 2016;38(5):596-628.
  3. Tang NK. Cognitive-behavioral therapy for sleep abnormalities of chronic pain patients. Curr Rheumatol Rep. 2009;11(6):451-460.
  4. Garzione JE. Musculoskeletal pain: is the tissue the issue? A physical therapy perspective. Presentation at: Academy of Integrative Pain Medicine 27th annual Meeting; September 21-25, 2016; San Antonio, TX.   
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