- Email: [email protected]
Physical therapy for chronic pain conditions—A novel approach using mind–body connection
Techniques in Regional Anesthesia and Pain Management (2011) 15, 51-54
Physical therapy for chronic pain conditions—A novel approach using mind– body connection Ann Marie Wenzel, PT Fairview Pain Management Centre, Minneapolis, Minnesota. KEYWORDS: Physical therapy; Chronic pain; Body awareness; Self care
The treatment of chronic pain conditions continue to present a challenge to the medical field. Physical therapy treatment needs to approach the management of chronic pain differently than the approach used to resolve acute pain. Patients with chronic pain often have many factors that have perpetuated the pain condition. These factors, as well as pain itself, influence their ability to reactivate and perform functional daily activities. Physical therapists can begin to address some of the factors, including fear and deconditioning, by building confidence and body awareness in a self-care model including a slow graduated reactivation program. There is evidence that patients with chronic pain conditions have altered motor control that may be influencing reoccurrences and possible flares of pain condition. Guiding patients through ritualistic body awareness and posture corrections and gentle reactivation activity may be 1 way to improve motor control and build the patient’s confidence to make decisions about daily activity based on knowledge of their body not based on fear of movement or reinjury. © 2011 Elsevier Inc. All rights reserved.
Physical therapy is a common treatment used for the management of patients with chronic pain. For orthopedic pain, such as low back or neck pain, the physical therapist uses their skills of assessment to develop a treatment program that may include manual techniques, modalities, and a home exercise program that is intended to fix or control the mechanical dysfunctions assessed in their evaluation. In the realm of acute care this plan of care is often successful. When patients present with chronic musculoskeletal pain, this medical model is often too simplistic to make the changes needed for the patient to realize a change in their pain experience or improvement in their function. In the biomedical model the goal is to effectively cure the mechanical dysfunction that is causing the patient’s pain. This will often fail in patients with chronic pain conditions because it fails to observe or recognize the complex factors that contribute to the patient’s pain experience and the influences that exist that perpetuate the pain
Address reprint requests and correspondence: Ann Marie Wenzel, PT, Fairview Pain Management Centre, 606 24th Avenue S, Minneapolis, MN 55454. E-mail address: [email protected].
1084-208X/$ -see front matter © 2011 Elsevier Inc. All rights reserved. doi:10.1053/j.trap.2011.06.001
condition.1 Addressing a patient with a chronic pain condition with the same approach as a patient who has an acute pain conditions will often lead to frustrations and feelings of failure for both the patient and the therapist. Patients with chronic pain conditions often complain that physical therapy is too aggressive or too painful, which leads to distrust of physical therapy and reinforces the belief that activity and exercise are not helpful for their pain condition. Short-term success using passive modalities or manual treatments can reinforce their dependence with the medical field and can limit their focus on self-care and selfmanagement of the pain over the long term. The goal of this article is to recognize a bio-psycho-social approach for physical therapy, and to organize a protocol with a mind⫺body focus that can be used in an independent outpatient physical therapy setting.
The protocol setup, body awareness, self-care, reactivation A physical therapist needs to take a different approach when treating patients with chronic pain vs acute pain. The focus
52
Techniques in Regional Anesthesia and Pain Management, Vol 15, No 2, April 2011
and goals of the physical therapy intervention need to be clearly defined and understood by both the practitioner as well as the patient. The focus on assessment for mechanical dysfunction and fixing that dysfunction will fail. Successful physical therapy treatments for patients with chronic pain must take into account psychosocial influences, fear avoidance behaviors, mood such as anxiety and depression, and the influence on activity muscle patterns and behavioral habits. A more comprehensive approach must be used. A treatment approach should include training of body awareness, and instruction in self-care in addition to reactivation exercises. The initial assessment is the first opportunity the physical therapist has to connect the patients with their physical sensations. Through the use of the visual assessment, the therapist and patient can discover postural habits, clenching patterns, and protective patterns, used by the patient at rest and during functional activities. Quite often the patient and physical therapist are both focused on the findings in the painful area. When the patient’s condition has become chronic, the emphasis needs to be on the whole patient. It is extremely important for the physical therapist to guild the patient through visual assessment of the whole body. Through verbal cues, mirrors, and gentle repositioning, the patient can begin to connect to physical sensations such as posture corrections, tension reduction, and general relaxation. This assessment and education can be done without eliciting a pain response. Patients with chronic pain conditions can have difficulty tolerating the evaluation techniques used to assess acute pain conditions. The therapist should assess if the patient has high levels of fear or distrust and take this into consideration when performing their evaluation. Building trust with the patient is an important step on the initial visit, and allowing the patient to perform activities they feel comfortable with can reduce fear and protective behaviors. The assessment of gait patterns, transfer techniques, sitting or standing postures can demonstrate a significant amount of useful information about their movement patterns, weakness, and flexibility. Observing habitual movements, clenching patterns, breathing patterns, speech patterns, and pain behavior can give valuable information about the patient’s protective patterns in response to the pain experience.2 This information is invaluable for both the therapist and the patient. A good visual assessment can be shared with the patient and can be used to begin the first steps of body awareness development.
Body awareness Body awareness can be defined as the consciousness of our somatic sensations. The patient should be made aware of their own movement patterns, habitual postures, and clenching patterns so they can begin to develop a relationship with their bodies as it exists now. Guiding the patient to connect
to their physical sensations instead of just the pain experience can help them begin to make decisions based on what they feel in their body instead of basing all of their decisions on pain and the fear of reinjury. Instructing patients to begin to focus on the muscle tension or tightness, postural strain, and their breathing patterns can lead to a greater overall awareness. Patients with chronic pain frequently present with faulty movement patterns, muscle inhibition, and general deconditioning due to the length of time they have had the pain condition.3 Avoidance behaviors and inactivity are tools patients commonly use to control their pain experience. This behavior leads to a disruption in mind⫺body connection. When the mind⫺body connection is disrupted, the patient may maintain dysfunctional alignments and movement patterns for long periods, resulting in muscle tightness or myofascial syndromes that can lead to increased pain and discomfort. By focusing on the patient’s mind⫺body connection through practiced body awareness, the patient can begin to establish a more true relationship with their body throughout the day. The patient can begin to change the protective or overused muscle patterns that have helped sustain mechanical dysfunctions that have contributed to the maintenance of their pain condition and their difficulty with return to functional enjoyable daily activities.4 The information from the visual assessment can be relayed to the patient though a variety of techniques. One effective way is the use of ritualistic posture correction on various levels of physical support including sitting, standing, and supine with knees bent. In sitting, one begins with the patient’s somatic awareness of their breathing to decrease the protective state as well as a way to cue a relaxation response naturally. The step begins with verbal cues including, “breathe slowly and comfortably, feel your feet flat on the ground, sit back, feel both hips in the chair equally, allow your shoulders to drop and feel your head balance on your shoulders.” It is also important to cue habitual jaw unclenching in this position. Pain makes it difficult for the patient to recognize their own postural tension or poor alignment; using a more neutral joint such as the jaw can begin to help the patient recognize the difference between clenching and relaxation in a simplistic manner. The neutral standing position is an effective body awareness exercise just to begin to connect the patient with their common patterns of muscle overuse. The cues are simple, “feet are flat with equal weight on both feet, arms dangle at your side with shoulders and chest relaxed, head is balanced on your shoulders, practice a diaphragmatic breath as you let you jaw relax.” The key component here is to begin to introduce diaphragmatic breathing as an active part of their day. Using a mirror in this position can be very helpful especially for patients to recognize postural deviations and to make the experience more meaningful and personal for the patient. Patients can become connected to somatic sensations of elevated shoulders, a clenched jaw, forward head,
Wenzel
Physical Therapy for Chronic Pain Conditions
or increased lumbar lordosis fairly easily, which can lead to self-correction and a stronger mind⫺body connection. Another postural alignment for somatic education is the supine hook lying or knees bent position. In hook lying the cues used again are ritualistic and simplistic, “feel your back against the table, is it relaxed, feel your chest and shoulders, are they open and relaxed, is your head resting on the pillow, is your jaw relaxed.” Quite often the patient will lie down maintaining their faulty posture patterns and is unaware of the deviations from a more neutral supine position. This is where the physical therapist can help the patient connect to somatic sensations such as tightness and tension, using gentle pectoral stretching and again guiding them in diaphragmatic breathing and helping them recognize lower back relaxation, or assessing for pelvic rotations. Once a patient has been instructed in neutral posture correction and body awareness training, there needs to be an emphasis on practicing these positions regularly during the day as a form of self-care.
Self-care The second emphasis in the physical therapy treatment of patients with chronic pain conditions is self-care. Self-care is the practice of consistent attention and active participation in the care of the body. Habit reversal is a key practice tool. Habit reversal is the practice of changing habitual body patterns such as reversal of jaw clenching, correcting postural deviations, and beginning diaphragmatic breathing practices for the reversal of muscle tension. If the patient is instructed in body awareness, they can often understand the concept of overuse and underuse of muscle groups and are willing to use habit reversal movement patterns during the day. This is especially true if the new movement pattern helps them tolerate activity better with a reduced pain experience. As a patient begins to become more engaged in the process of habit reversal, they can often express to the therapist what they are learning and experiencing in their own bodies. The therapist can help guild them to understand how taking breaks, pacing activity, changing positions, or using better body mechanics can help them manage sensations while still performing their daily activity. This growing knowledge and mind⫺body connection increases their confidence with what they are feeling and can promote increased activity. This can encourage patients to begin using their bodies and to change faulty movement patterns that have contributed, and possibly perpetuated, the chronic pain condition.
Reactivation As patients begin to develop improved body awareness with the practice of self-care and habit reversal, they gain the confidence they need to begin to increase their daily activ-
53 ity. Reactivation is a slow gradual process that is best achieved while taking into account the patient’s goals and interests. Reactivation should include components of functional strengthening, flexibility, and aerobic conditioning. During reconditioning efforts, old beliefs and fears of injury can arise. Just increasing mobility produces sensations that patients might find dangerous. They have tried to avoid those sensations over the duration of their chronic pain condition. Breaking down traditional exercise regimens used in traditional physical therapy treatment, into small building blocks, can encourage confidence, knowledge, and understanding when beginning the reconditioning program.5 The stretching program needs to begin in the neutral postures they began to use for body awareness training and self-care development. Cervical range of motion, back stretching, as well as lower extremity stretching, all need to be done with attention to the patient’s tension level, breathing, and postural alignment. Instructing the patient to relax a muscle before they stretch it can improve their tolerance for the stretch as well as their awareness of how tense and tight they are holding that muscle. If they are going to make any changes in their flexibility, they need to develop an understanding that a relaxed muscle stretches better then a muscle they are holding tense. Strengthening can begin with an organized plan of functional upper and lower body strengthening that addresses the patient’s weakness noted in the evaluation. The focus here should be consistency and instructing the patient to begin slowly, advancing as tolerated over an extended period. To help them correct dysfunctional compensatory movement patterns, the physical therapist assists the patient in experiencing core recruitment during neutral posture and then during functional and strengthening activities. Once a patient achieves a balanced alignment, they can be instructed to recruit their core muscles, while performing functional movement such as sit to stand, stair climbing, lifting and carrying and reaching, or performing specific exercises such as squats, scaption, wall pushups, and upper body weight lifting exercises. It is especially helpful at this time to correlate the exercise movement patterns with movement patterns they can use for daily activity. Helping the patient use these new movement patterns during their daily activity serves to establish muscle memory and promotes consistency and adherence to the therapy program outside of the therapy visits. As patients begin to reactivate, they develop an understanding how weaknesses, postural deviations, and immobility have affected their daily activity, body mechanics, and general endurance. An aerobic program is essential when treating a patient with a chronic pain condition. A walking program can often be a good place to start because of the functional nature of the activity as well as the connection it has with the goal of greater life participation. It is important to not assume the patient’s walking tolerance. Evaluating their initial walking endurance is essential. Patients with chronic pain are not always aware of their level of deconditioning. Helping them attain a baseline, then instructing them on a gradual, con-
54
Techniques in Regional Anesthesia and Pain Management, Vol 15, No 2, April 2011
sistent increase in time or distance is important. Reconnecting to posture, core recruitment and habit reversal during their walking program can help them correct poor gait patterns and pain behaviors they have developed as compensatory measures against the pain. Progression in any part of the reactivation portion of the program can be difficult and slow. The emphasis on consistency and making small goals of improved flexibility and endurance can help the patient maintain focus. Reconnecting to the patient’s initial physical activity goals can be helpful for motivation. It is important to recognize that the progression of the patient’s program is often influenced by psychosocial factors. Mood disruption such as depression and anxiety, fear of pain or altered sensations, and low motivation for change are just a few influences on how fast a patient can make meaningful changes in the body awareness, self-care, and reactivation program. Outlining concrete goals is important for both the patient and the therapist. The goals for the reconditioning program, including strength, endurance, and flexibility, at first should be about consistency and slowly building tolerance. Goals for body awareness and self-care should emphasize the importance of the patient’s understanding of how postural strain, muscle tension, and flexibility affects their pain sensations, function mobility, and body mechanics with everyday activity. It should be the therapist’s goal to make it clear to the patient that their old beliefs and old movement patterns can be affecting their pain experience and are no longer helpful. Overall the main goal should be to help the patient attain a more manageable pain experience with increased life enjoyment through knowledge, understanding, and caring for their body.
Conclusions There are 3 areas that can be looked at as key components for physical therapists who are involved in the care of
patients with chronic pain: the visual and physical assessment with patient education of body awareness, instructing the patient to begin self-care practices including habit reversal, and development of a tolerable and appropriate reconditioning program. Chronic pain conditions are difficult to treat. The progress can be slow and is influenced by many complex factors. It is important for the therapist, and the patients they are working with, to recognize goals from the beginning. If either person’s focus is to fix or cure the medical condition, the results can be frustration and feelings of failure. This can be compounded if the patient has experienced multiple physical therapy interventions over a period with no relief. From the beginning of treatment, the emphasis needs to be on caring for the body as a whole and focusing on functional realistic goals. Building confidence with small successes in self-care and increased mobility can promote the return to active participation in their lives.
References 1. Metcalf DHH: Measurements of outcomes in general practice, in Hopkins A, Costain D (eds): The Outcomes of Medical Care. Oxford, The Royal College of Physicians of London, 1990, pp 93-104 2. Hodges PW, Moseley GL: Pain and motor control of the lumbopelvic region: effect and possible mechanisms. J Electromyogr Kinesiol 13: 361-370, 2003 3. Holtermann A, Grönlund C, Roeleveld K, et al: The relation between neuromuscular control and pain intensity in fibromyalgia. J Electromyogr Kinesiol 21:519-524, 2011 4. Boudreau SA, Farina D, Falla D: The role of motor learning and neuroplasticity in designing rehabilitation approaches for musculoskeletal pain disorders. Man Ther 15:410-414, 2010 5. Sullivan MJ, Adams H, Rhodenizer T, et al: A psychosocial risk factor⫺targeted intervention for the prevention of chronic pain and disability following whiplash injury. Phys Ther 86:8-18, 2006
Physical therapy for chronic pain conditions—A novel approach using mind– body connection Ann Marie Wenzel, PT Fairview Pain Management Centre, Minneapolis, Minnesota. KEYWORDS: Physical therapy; Chronic pain; Body awareness; Self care
The treatment of chronic pain conditions continue to present a challenge to the medical field. Physical therapy treatment needs to approach the management of chronic pain differently than the approach used to resolve acute pain. Patients with chronic pain often have many factors that have perpetuated the pain condition. These factors, as well as pain itself, influence their ability to reactivate and perform functional daily activities. Physical therapists can begin to address some of the factors, including fear and deconditioning, by building confidence and body awareness in a self-care model including a slow graduated reactivation program. There is evidence that patients with chronic pain conditions have altered motor control that may be influencing reoccurrences and possible flares of pain condition. Guiding patients through ritualistic body awareness and posture corrections and gentle reactivation activity may be 1 way to improve motor control and build the patient’s confidence to make decisions about daily activity based on knowledge of their body not based on fear of movement or reinjury. © 2011 Elsevier Inc. All rights reserved.
Physical therapy is a common treatment used for the management of patients with chronic pain. For orthopedic pain, such as low back or neck pain, the physical therapist uses their skills of assessment to develop a treatment program that may include manual techniques, modalities, and a home exercise program that is intended to fix or control the mechanical dysfunctions assessed in their evaluation. In the realm of acute care this plan of care is often successful. When patients present with chronic musculoskeletal pain, this medical model is often too simplistic to make the changes needed for the patient to realize a change in their pain experience or improvement in their function. In the biomedical model the goal is to effectively cure the mechanical dysfunction that is causing the patient’s pain. This will often fail in patients with chronic pain conditions because it fails to observe or recognize the complex factors that contribute to the patient’s pain experience and the influences that exist that perpetuate the pain
Address reprint requests and correspondence: Ann Marie Wenzel, PT, Fairview Pain Management Centre, 606 24th Avenue S, Minneapolis, MN 55454. E-mail address: [email protected].
1084-208X/$ -see front matter © 2011 Elsevier Inc. All rights reserved. doi:10.1053/j.trap.2011.06.001
condition.1 Addressing a patient with a chronic pain condition with the same approach as a patient who has an acute pain conditions will often lead to frustrations and feelings of failure for both the patient and the therapist. Patients with chronic pain conditions often complain that physical therapy is too aggressive or too painful, which leads to distrust of physical therapy and reinforces the belief that activity and exercise are not helpful for their pain condition. Short-term success using passive modalities or manual treatments can reinforce their dependence with the medical field and can limit their focus on self-care and selfmanagement of the pain over the long term. The goal of this article is to recognize a bio-psycho-social approach for physical therapy, and to organize a protocol with a mind⫺body focus that can be used in an independent outpatient physical therapy setting.
The protocol setup, body awareness, self-care, reactivation A physical therapist needs to take a different approach when treating patients with chronic pain vs acute pain. The focus
52
Techniques in Regional Anesthesia and Pain Management, Vol 15, No 2, April 2011
and goals of the physical therapy intervention need to be clearly defined and understood by both the practitioner as well as the patient. The focus on assessment for mechanical dysfunction and fixing that dysfunction will fail. Successful physical therapy treatments for patients with chronic pain must take into account psychosocial influences, fear avoidance behaviors, mood such as anxiety and depression, and the influence on activity muscle patterns and behavioral habits. A more comprehensive approach must be used. A treatment approach should include training of body awareness, and instruction in self-care in addition to reactivation exercises. The initial assessment is the first opportunity the physical therapist has to connect the patients with their physical sensations. Through the use of the visual assessment, the therapist and patient can discover postural habits, clenching patterns, and protective patterns, used by the patient at rest and during functional activities. Quite often the patient and physical therapist are both focused on the findings in the painful area. When the patient’s condition has become chronic, the emphasis needs to be on the whole patient. It is extremely important for the physical therapist to guild the patient through visual assessment of the whole body. Through verbal cues, mirrors, and gentle repositioning, the patient can begin to connect to physical sensations such as posture corrections, tension reduction, and general relaxation. This assessment and education can be done without eliciting a pain response. Patients with chronic pain conditions can have difficulty tolerating the evaluation techniques used to assess acute pain conditions. The therapist should assess if the patient has high levels of fear or distrust and take this into consideration when performing their evaluation. Building trust with the patient is an important step on the initial visit, and allowing the patient to perform activities they feel comfortable with can reduce fear and protective behaviors. The assessment of gait patterns, transfer techniques, sitting or standing postures can demonstrate a significant amount of useful information about their movement patterns, weakness, and flexibility. Observing habitual movements, clenching patterns, breathing patterns, speech patterns, and pain behavior can give valuable information about the patient’s protective patterns in response to the pain experience.2 This information is invaluable for both the therapist and the patient. A good visual assessment can be shared with the patient and can be used to begin the first steps of body awareness development.
Body awareness Body awareness can be defined as the consciousness of our somatic sensations. The patient should be made aware of their own movement patterns, habitual postures, and clenching patterns so they can begin to develop a relationship with their bodies as it exists now. Guiding the patient to connect
to their physical sensations instead of just the pain experience can help them begin to make decisions based on what they feel in their body instead of basing all of their decisions on pain and the fear of reinjury. Instructing patients to begin to focus on the muscle tension or tightness, postural strain, and their breathing patterns can lead to a greater overall awareness. Patients with chronic pain frequently present with faulty movement patterns, muscle inhibition, and general deconditioning due to the length of time they have had the pain condition.3 Avoidance behaviors and inactivity are tools patients commonly use to control their pain experience. This behavior leads to a disruption in mind⫺body connection. When the mind⫺body connection is disrupted, the patient may maintain dysfunctional alignments and movement patterns for long periods, resulting in muscle tightness or myofascial syndromes that can lead to increased pain and discomfort. By focusing on the patient’s mind⫺body connection through practiced body awareness, the patient can begin to establish a more true relationship with their body throughout the day. The patient can begin to change the protective or overused muscle patterns that have helped sustain mechanical dysfunctions that have contributed to the maintenance of their pain condition and their difficulty with return to functional enjoyable daily activities.4 The information from the visual assessment can be relayed to the patient though a variety of techniques. One effective way is the use of ritualistic posture correction on various levels of physical support including sitting, standing, and supine with knees bent. In sitting, one begins with the patient’s somatic awareness of their breathing to decrease the protective state as well as a way to cue a relaxation response naturally. The step begins with verbal cues including, “breathe slowly and comfortably, feel your feet flat on the ground, sit back, feel both hips in the chair equally, allow your shoulders to drop and feel your head balance on your shoulders.” It is also important to cue habitual jaw unclenching in this position. Pain makes it difficult for the patient to recognize their own postural tension or poor alignment; using a more neutral joint such as the jaw can begin to help the patient recognize the difference between clenching and relaxation in a simplistic manner. The neutral standing position is an effective body awareness exercise just to begin to connect the patient with their common patterns of muscle overuse. The cues are simple, “feet are flat with equal weight on both feet, arms dangle at your side with shoulders and chest relaxed, head is balanced on your shoulders, practice a diaphragmatic breath as you let you jaw relax.” The key component here is to begin to introduce diaphragmatic breathing as an active part of their day. Using a mirror in this position can be very helpful especially for patients to recognize postural deviations and to make the experience more meaningful and personal for the patient. Patients can become connected to somatic sensations of elevated shoulders, a clenched jaw, forward head,
Wenzel
Physical Therapy for Chronic Pain Conditions
or increased lumbar lordosis fairly easily, which can lead to self-correction and a stronger mind⫺body connection. Another postural alignment for somatic education is the supine hook lying or knees bent position. In hook lying the cues used again are ritualistic and simplistic, “feel your back against the table, is it relaxed, feel your chest and shoulders, are they open and relaxed, is your head resting on the pillow, is your jaw relaxed.” Quite often the patient will lie down maintaining their faulty posture patterns and is unaware of the deviations from a more neutral supine position. This is where the physical therapist can help the patient connect to somatic sensations such as tightness and tension, using gentle pectoral stretching and again guiding them in diaphragmatic breathing and helping them recognize lower back relaxation, or assessing for pelvic rotations. Once a patient has been instructed in neutral posture correction and body awareness training, there needs to be an emphasis on practicing these positions regularly during the day as a form of self-care.
Self-care The second emphasis in the physical therapy treatment of patients with chronic pain conditions is self-care. Self-care is the practice of consistent attention and active participation in the care of the body. Habit reversal is a key practice tool. Habit reversal is the practice of changing habitual body patterns such as reversal of jaw clenching, correcting postural deviations, and beginning diaphragmatic breathing practices for the reversal of muscle tension. If the patient is instructed in body awareness, they can often understand the concept of overuse and underuse of muscle groups and are willing to use habit reversal movement patterns during the day. This is especially true if the new movement pattern helps them tolerate activity better with a reduced pain experience. As a patient begins to become more engaged in the process of habit reversal, they can often express to the therapist what they are learning and experiencing in their own bodies. The therapist can help guild them to understand how taking breaks, pacing activity, changing positions, or using better body mechanics can help them manage sensations while still performing their daily activity. This growing knowledge and mind⫺body connection increases their confidence with what they are feeling and can promote increased activity. This can encourage patients to begin using their bodies and to change faulty movement patterns that have contributed, and possibly perpetuated, the chronic pain condition.
Reactivation As patients begin to develop improved body awareness with the practice of self-care and habit reversal, they gain the confidence they need to begin to increase their daily activ-
53 ity. Reactivation is a slow gradual process that is best achieved while taking into account the patient’s goals and interests. Reactivation should include components of functional strengthening, flexibility, and aerobic conditioning. During reconditioning efforts, old beliefs and fears of injury can arise. Just increasing mobility produces sensations that patients might find dangerous. They have tried to avoid those sensations over the duration of their chronic pain condition. Breaking down traditional exercise regimens used in traditional physical therapy treatment, into small building blocks, can encourage confidence, knowledge, and understanding when beginning the reconditioning program.5 The stretching program needs to begin in the neutral postures they began to use for body awareness training and self-care development. Cervical range of motion, back stretching, as well as lower extremity stretching, all need to be done with attention to the patient’s tension level, breathing, and postural alignment. Instructing the patient to relax a muscle before they stretch it can improve their tolerance for the stretch as well as their awareness of how tense and tight they are holding that muscle. If they are going to make any changes in their flexibility, they need to develop an understanding that a relaxed muscle stretches better then a muscle they are holding tense. Strengthening can begin with an organized plan of functional upper and lower body strengthening that addresses the patient’s weakness noted in the evaluation. The focus here should be consistency and instructing the patient to begin slowly, advancing as tolerated over an extended period. To help them correct dysfunctional compensatory movement patterns, the physical therapist assists the patient in experiencing core recruitment during neutral posture and then during functional and strengthening activities. Once a patient achieves a balanced alignment, they can be instructed to recruit their core muscles, while performing functional movement such as sit to stand, stair climbing, lifting and carrying and reaching, or performing specific exercises such as squats, scaption, wall pushups, and upper body weight lifting exercises. It is especially helpful at this time to correlate the exercise movement patterns with movement patterns they can use for daily activity. Helping the patient use these new movement patterns during their daily activity serves to establish muscle memory and promotes consistency and adherence to the therapy program outside of the therapy visits. As patients begin to reactivate, they develop an understanding how weaknesses, postural deviations, and immobility have affected their daily activity, body mechanics, and general endurance. An aerobic program is essential when treating a patient with a chronic pain condition. A walking program can often be a good place to start because of the functional nature of the activity as well as the connection it has with the goal of greater life participation. It is important to not assume the patient’s walking tolerance. Evaluating their initial walking endurance is essential. Patients with chronic pain are not always aware of their level of deconditioning. Helping them attain a baseline, then instructing them on a gradual, con-
54
Techniques in Regional Anesthesia and Pain Management, Vol 15, No 2, April 2011
sistent increase in time or distance is important. Reconnecting to posture, core recruitment and habit reversal during their walking program can help them correct poor gait patterns and pain behaviors they have developed as compensatory measures against the pain. Progression in any part of the reactivation portion of the program can be difficult and slow. The emphasis on consistency and making small goals of improved flexibility and endurance can help the patient maintain focus. Reconnecting to the patient’s initial physical activity goals can be helpful for motivation. It is important to recognize that the progression of the patient’s program is often influenced by psychosocial factors. Mood disruption such as depression and anxiety, fear of pain or altered sensations, and low motivation for change are just a few influences on how fast a patient can make meaningful changes in the body awareness, self-care, and reactivation program. Outlining concrete goals is important for both the patient and the therapist. The goals for the reconditioning program, including strength, endurance, and flexibility, at first should be about consistency and slowly building tolerance. Goals for body awareness and self-care should emphasize the importance of the patient’s understanding of how postural strain, muscle tension, and flexibility affects their pain sensations, function mobility, and body mechanics with everyday activity. It should be the therapist’s goal to make it clear to the patient that their old beliefs and old movement patterns can be affecting their pain experience and are no longer helpful. Overall the main goal should be to help the patient attain a more manageable pain experience with increased life enjoyment through knowledge, understanding, and caring for their body.
Conclusions There are 3 areas that can be looked at as key components for physical therapists who are involved in the care of
patients with chronic pain: the visual and physical assessment with patient education of body awareness, instructing the patient to begin self-care practices including habit reversal, and development of a tolerable and appropriate reconditioning program. Chronic pain conditions are difficult to treat. The progress can be slow and is influenced by many complex factors. It is important for the therapist, and the patients they are working with, to recognize goals from the beginning. If either person’s focus is to fix or cure the medical condition, the results can be frustration and feelings of failure. This can be compounded if the patient has experienced multiple physical therapy interventions over a period with no relief. From the beginning of treatment, the emphasis needs to be on caring for the body as a whole and focusing on functional realistic goals. Building confidence with small successes in self-care and increased mobility can promote the return to active participation in their lives.
References 1. Metcalf DHH: Measurements of outcomes in general practice, in Hopkins A, Costain D (eds): The Outcomes of Medical Care. Oxford, The Royal College of Physicians of London, 1990, pp 93-104 2. Hodges PW, Moseley GL: Pain and motor control of the lumbopelvic region: effect and possible mechanisms. J Electromyogr Kinesiol 13: 361-370, 2003 3. Holtermann A, Grönlund C, Roeleveld K, et al: The relation between neuromuscular control and pain intensity in fibromyalgia. J Electromyogr Kinesiol 21:519-524, 2011 4. Boudreau SA, Farina D, Falla D: The role of motor learning and neuroplasticity in designing rehabilitation approaches for musculoskeletal pain disorders. Man Ther 15:410-414, 2010 5. Sullivan MJ, Adams H, Rhodenizer T, et al: A psychosocial risk factor⫺targeted intervention for the prevention of chronic pain and disability following whiplash injury. Phys Ther 86:8-18, 2006