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8 Articles in Volume 16, Issue #8
Genetic Testing in Pain Medicine—The Future Is Coming
Genetic Factors in Fibromyalgia and Chronic Widespread Pain
IV Treatment of Centralized Pain and Headache
Low Back Pain and Osteopathic Manipulative Medicine: A Trend in Pain Management
Clinician as Patient: What I Learned About the Role of Physical Therapy in Pain Management
Mental Health & Vocational Rehabilitation: Information for Pain Management
Neuroinflammation and Peripheral Inflammation—A Big Difference
Letters to the Editor: Genetic Testing

Clinician as Patient: What I Learned About the Role of Physical Therapy in Pain Management

After injuring his low back, Kern A. Olson, PhD, interviews Brad G. Simpson, DPT, CSCS, COMT, FAAOMPT, his physical therapist at The KOR Physical Therapy, an ATI Company.

This past winter I experienced an acute back injury that resulted in severe low back pain. It was difficult to stand or walk without pain. At first I thought the cause was back strain or muscle spasm. But since I was also experiencing radiating pain into my right hip, I was suspicious.

I was scheduled to leave for Southern California for a month of sun and golf, so I thought a little rest in a long car trip would help. With the help of ibuprofen and stretching, I made it from Portland to Palm Springs. However, my back pain was not getting better.

Brad G. Simpson, DPT, and Kern Olson, PhD, enjoying a round of golf.

I then went to the Eisenhower Immediate Care Center where I met a wonderful physician by the name of Denny Mauricio, MD. After his careful assessment, he prescribed tramadol (50 mg, 3 times a day), and carisoprodol (Soma) at bedtime to help with sleep. In addition, he administered an intramuscular shot of the nonsteroidal anti-inflammatory agent ketorolac (Toradol), with a referral to the Eisenhower Medical Center for a lumbar magnetic resonance imaging (MRI). I scheduled a follow-up for the next week, where I learned the results of my MRI. The results were remarkable for degenerative lumbar disc disease plus 3 bulging discs at L3/4, L4/5, and L5/S1. The L4/5 disc bulge was the most significant, which explained the radiating pain into my right hip.

It was an awkward situation since my time in Palm Springs was limited, but Dr. Mauricio agreed to see me weekly for my ketorolac injections. Over the next 3 weeks, I tried to practice what I preach, which involved relaxation exercises and stretches in the hot tub, but no golf. Toward the end of 3 weeks, my pain started to subside, so I headed home to Portland to rain and cold weather, which did not help.

When I got home, I scheduled a visit with Ruhul Desi, MD, an interventional radiologist who runs a clinic called Restore PDX. I wanted him to look at my MRI and give me his opinion. He recommended physical therapy and referred me to an excellent physical therapist by the name of Brad Simpson, DPT.

I worked with Brad for 12 weeks, 2 times per week. At the end of 12 weeks of therapy, my back pain had subsided from severe (range of 8/10 on a visual analog scale) to mild (2/10) and I started playing golf and tennis again. I still do my stretches and I am limiting my swing in both golf and tennis, but it feels good to be back in the game!

Over the course of my rehabilitation, I considered a surgical consult, but my common sense said to hold off and trust my body to repair itself with the help of physical therapy.

I have always been a strong supporter of physical therapy, going back to my time at Oregon Health & Science University (OHSU), where we had a dedicated physical therapist in our pain management program who evaluated every referral. I knew right away that Brad was very knowledgeable, so I asked him if he would be willing to be interviewed. Below is my conversation with Dr. Simpson on the role of physical therapy in the management of pain.

Q: What made you want to become a physical therapist?

Dr. Simpson: I knew in high school that I wanted to be in a profession where I could help people. I shadowed various health care professions, and felt physical therapy was the best fit for me. It seemed to be a well-respected profession that was growing due to an aging population. Physical therapy is truly a positive profession, in that we have the benefit of seeing people “get better” every day. I can help the small population whom I feel I am not helping to get better get to other health care professionals in the hope of getting them on the right path toward improvement. Our mission is to help maximize people’s potential, which is an amazing goal to strive for every day. 

Q: Talk about your background, experience, and education, and how your experience has changed in the past few years.

Dr. Simpson: I graduated from Oregon State University in 2002, with a Bachelor of Science in Exercise & Sports Science. I received my Doctorate of Physical Therapy (DPT) from Pacific University in 2005. Since the start of my career, I have been fortunate to have brilliant mentors who taught me to continue learning, and to always ask the question “Why?” with patients.

For example, after examining a person with insidious-onset left-sided knee pain, I would be challenged by mentors with questions such as, “Why did this happen to his left side, not his right side?” Early on, I was educated as to the benefits of residency or fellowship, and was introduced to the North American Institute of Orthopedic Manual Physical Therapy (NAIOMT), which is where I completed my manual therapy fellowship in 2012. I successfully completed all the requirements of the NAIOMT clinical fellowship program in 2012, and received my COMT, which is a Certified Orthopaedic Manipulative Therapist. I also received the designation of Fellow (FAAOMPT) through the American Academy of Orthopaedic Manual Physical Therapists (AAOMPT) in 2012. I am also a CSCS, which is a Certified Strength and Conditioning Specialist.

Throughout my career, it has been interesting to see how some people improve and others have a more difficult time rehabilitating from what seems to be the same condition. For the majority of my career, I worked in a clinic that attracted a high percentage of complex, chronic pain patients, and I began adopting a more biopsychosocial model for treating clients.

When a person becomes injured, the fear-avoidance model (FAM) suggests there are 2 paths a patient’s recovery process can take, depending on psychological factors such as negative affect, threatening illness information, pain catastrophizing, fear of pain, and pain anxiety. If these variables are not present, normal recovery takes place. If they are present, there is a higher likelihood of fear-avoidance behaviors, which may lead toward chronic musculoskeletal pain syndromes.

Although there are biological dysfunctions that need to be addressed, there are also psychosocial aspects that may be affecting the patient’s ability to properly heal. Unless these barriers to successful rehabilitation are addressed, the patient will likely not improve, or may struggle with long-term success.  

Another main concept emphasized through my fellowship was foundation building. It was stressed that “good physical therapists do the simple things well.” In addressing patients with chronic pain, this concept helped when I realized these patients were simply not managing well. They have no foundation to build their recovery on; therefore, they continue to hit a wall every time they try to progress. I began helping them form foundations, normalizing their “normal” prior to progressing their home program.

The patient’s home exercise adherence is stressed early on in treatment. Part of the success of home-program compliance is educating the patient on the reason behind each exercise and its role in helping him progress in therapy. I think we blame the patient too often for failing to comply with the home program. Most patients truly want to get better; they take time out of their day seeking medical care for their condition, which is a big deal. So, when they come in saying they are noncompliant with their home program, I try to take an outsider’s view of what I may have missed that may be leading towards this compliance issue. I ask myself questions like: Is the program appropriate? Have I educated the patient about its importance to his body’s healing? Or have I addressed the patient’s barriers to success (such as work, home life, etc) that may be affecting his ability to perform the exercises as prescribed? One of the great things about the physical therapy profession is that we have the time to spend with patients to figure out what these barriers to success may be. If a patient has difficulty with compliance, I discuss with him that this may change the timeframe of how long it will take for him to get better. I still emphasize that he is going to get better, but that it may just take a little more time.

The body is so good at compensating when it is in pain; that is part of our survival. If those compensation patterns are not addressed and improved, it does not matter what we do with that patient, his pain is likely going to come back. So with every patient, both acute and chronic, I look first to normalize patterns, to get their life functioning more normally, prior to implementing a larger-scale home program. Then we have something to build on. If we hit a wall later in rehab, we have something to fall back on. The patient’s fear stays low, knowing he has an independent way to manage the pain to get back toward his baseline, which is empowering.

Q: Explain how access to physical therapy has changed.

Dr. Simpson: Every physical therapy-accredited school in the US is now a DPT program, which was the Vision 2020 goal of the American Physical Therapy Association (APTA) in 2000. This became a focus as the APTA was lobbying for patients to be able to see physical therapists through direct access, or without the need for a physician referral. Now, every state in the US has at least some form of direct access.1

Q: Talk about your initial evaluation. What do you look for? And do you approach chronic and acute pain differently?

Dr. Simpson: During my initial evaluation, the first thing I do is look at the patient chart, giving me an idea of gender, age, location of pain, duration of symptoms, and any other information available, such as Fear-Avoidance Belief Questionnaire score (FABQ).2 Even before greeting the patient, I begin building hypotheses that I will look to confirm or negate with the examination.

On the first day, I spend a good portion of the evaluation talking to patients (face to face, not with my back to them or looking at my computer screen) and hearing what they think is going on. If I get a sense the patient has apprehensions about physical therapy, or high fear along with chronic pain, I may not perform much objective assessment on the first day.

If this patient appears to be an appropriate candidate for therapy, I may go right into pain education and how I plan to address his case. I would discuss how we will do more assessing in future visits and continue to look at things depending on how he responds to the treatment. The last thing I want to do is put a chronic pain patient in more pain until he has bought in to therapy and trusts me as someone who is going to help him improve. This is different than someone who has low fear and acute symptoms. With them, I can go right into the objective examination and possibly treat them with more manual therapy or physical treatment without going into as much detail on pain education.

Q: What is the most prevalent pain condition that is referred for physical therapy?  

Dr. Simpson: Low back pain is a societal epidemic that is poorly managed, as evidenced by the extreme amount of money spent treating it in the US annually. Most low back pain is chronic (meaning it comes and goes [flares], but never really goes away), and of US adults reporting pain, the highest percentage (28.1%) report low back pain.3

Without taking a biopsychosocial approach to its management, I feel the lower back is a difficult region to treat with long-term success. The likelihood is that, even if the person’s painful episode goes away (which it likely will), there is a large chance that the pain will come back at some point in the future. People with low back pain need to be educated about their back, how to make improvements themselves to minimize future episodes, and how to self-manage their pain when it does occur in the future. Though future low back pain is likely imminent, how the person responds to it, how often it recurs, how quickly it resolves, and the ability to continue improving over the long term, can all be affected by how a painful episode is conservatively managed.

Q: What are the signs that a patient who has acute symptoms may be at risk of becoming a chronic pain patient?

Dr. Simpson: I look at the FABQ patients fill out to see where they lie on the scale—that tells me how they perceive their pain, how fearful they are about resuming their activities, and what their perceptions are about their likelihood of getting better. Pain fear has been shown to be a significant predictor of pain intensity.4 The FABQ has been shown to be a reliable tool for identifying individuals who are likely going to take longer to improve, or who will have a hard time getting back to their normal activities because of fear and anxiety about their pain.2

The FABQ also can be used with a patient who has chronic symptoms; if he or she scores high, I make sure we focus the education on chronic pain to help decrease his or her fear and anxiety. If the patient’s condition is acute, and he or she scores high on the FABQ, fear/anxiety may contribute to that person becoming a chronic pain patient, so I make sure we also address chronic pain with this person.

I pay attention to various “yellow flag” responses during the interview process. Chronic pain patients may state that everything hurts and no position provides comfort. Or they state they have had multiple practitioners treat the same condition, with numerous tests completed, tried various medications, and/or tried other procedures—all without helping. The more the patient has had done, the more passive procedures that have not changed the course of treatment, the more concerned I am. When nothing helps, it tells me the patient has poor self-management of his symptoms. Also, if the patient indicates his painful part is a person with a name, or if a patient references their pain as a he or she, those are not normal responses.

Some other yellow flags during the interview can present during a carefully taken medical history—the patient’s   past history of pain, how it was treated, how long it took to get better, what he did to improve, and his feelings toward those previous injuries. These answers may give insight into the patient’s  current condition, and how his body likely will respond to the pain.

Q: Do you address ergonomics with chronic pain patients?

Dr. Simpson: I address ergonomics with anyone who performs the same thing over and over in their job, or who stays in 1 position for long periods, which seems to be most people. Frequently, I hear patients state their pain gets worse during work, or as the week goes on, and is better during the weekends and vacations. Those statements are clues that ergonomics needs to be addressed.

Simply put, ergonomics is the art of finding the ideal position for your body and building your environment around that ideal. Too often, people are forced to mold themselves to an environment that is not ideal for them and, over time, their body begins to hurt because of it.  

During the interview, I always ask patients what makes their pain feel better or worse. Musculoskeletal pain has a mechanical nature to it—certain activities affect it differently. I have noticed a trend with chronic pain patients. They commonly state that various activities do make them feel better, such as pulling their shoulder blades back, stretching their arms up and overhead, or getting up and walking around, to name just a few. When asked what prompted them to do that “feel-good” activity, they would tell me it was due to pain.

This is where I feel people can fall into problems. If your body waits for “pain,” you have waited too long to make your correction. People without chronic pain also frequently report that they shift and stretch throughout the day. The difference between the 2 groups, however, is that people without pain don’t typically realize they are doing it. Their bodies are aware of their position, and spending too much time in 1 position gets their bodies to move subconsciously. Chronic pain patients, by contrast, focus on the pain and react to it by moving—instead of being proactive and learning how to respond to a position instead of waiting until pain worsens. This is the hard part, as this proactive approach toward change takes thousands of repetitions and a lot of mental focus. It is changing a mindset from one focusing on pain to one recognizing position.

Chronic pain is literally a state where you are always in a fight-or-flight mode. Patients need to learn how to get out of the fight and begin letting their bodies relax. Think of the people you see fidgeting all the time. When I see this, it is likely due to something hurting. Fidgeting is an attempt to get comfortable. But it is not solving anything. What do people do after they fidget? They go right back to the same position that caused them to feel like they needed to fidget in the first place. The next time they want to fidget, I tell them to correct their posture, to relax, and to breathe comfortably. When they want to fidget again, I tell them to correct the posture again and work on relaxed breathing. Throughout the day, patients should stretch, take frequent breaks, and build an environment suitable for pain-free work. A frequent goal for patients is to come back saying they feel they do not need to fidget as often anymore.

Years ago, I designed an example of a bell curve that I show to chronic pain patients. It depicts where I hope they will get to over time (Figure 1). Rather than being the patient shown on the bottom of the curve—focusing on “pain” and reacting to pain with extreme measures before going right back to the positions that bother them—I want their bodies to be sensitive to “position,“ which is the example at the top of the bell curve. Feel-good postures are great to have in your tool belt, and using them as you need to is healthy.

Q: What are you looking for to show signs of early progress with chronic pain patients?

Dr. Simpson: I first look for a change in how a patient describes his or her painful condition. Not to sound cliché, but I want a patient telling me what he or she can do, instead of just focusing on what he or she cannot do—that is progress.

For example, a patient initially states his or her pain is 8/10. If you only ask him or her what his or her pain level is, this person may state at future visits that his or her pain is still 8/10. But if you focus on function and what he or she can do (exercise, walking the dog, making the bed), this person may have a pain that indeed spikes to 8/10, but he or she is able to get the pain down by doing “x” now. If the pain was present 50% of the day, for example, now it may be present only 30% of the day, which is an improvement.

In addition, I rarely use the word “pain” when speaking with chronic pain patients. I ask patients, “How’s your exercises?” instead of “How’s your pain?” Other examples are, “How have things been since our last visit?” or “How is traction appearing to help?” At the onset of treatment, many patients are not aware that certain things help them feel better; they just think everything hurts. And no matter how I try to direct a conversation, they always bring the talk back to their pain. So starting to have them focus on things that feel better helps them realize there is hope, and begins getting them to focus on something other than pain. As treatment progresses, I look for these patients to use the word “pain” less often.

Q: How do you communicate with other providers who are treating these patients with chronic pain?

Dr. Simpson: I try to keep open communication lines with my referring providers, mostly regarding chronic pain patients. These patients have frequent follow-ups with the other providers, and it is important we are all using the same language, have the same goals, and are being told the same things by the patients. I want to understand the physician’s medication plans for both the short term and long term, and how those are being monitored. Chronic pain patients frequently come in on multiple medications to help manage the pain the physician is addressing. My input on how PT is being tolerated may help determine how the physician tapers, or changes, the patient’s medications.

Last updated on: October 17, 2016
Continue Reading:
Neuroinflammation and Peripheral Inflammation—A Big Difference

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