Move Forward Guide
Physical Therapist's Guide to
Chronic Pain Syndromes
Chronic pain is a condition that occurs when the brain concludes there is a threat to a person's well-being based on the many signals it receives from the body. This condition can and often does occur independently of any actual body tissue damage (due to injury or illness), and beyond normal tissue healing time.
It is estimated that 116 million Americans have chronic pain each year. The cost in the United States is $560–$635 billion annually for medical treatment, lost work time, and lost wages.
The causes of chronic pain vary widely. While any condition can lead to chronic pain, there are certain medical conditions more likely to cause chronic pain. These include:
- Diabetes Mellitus
- Limb amputation
- Reflex Sympathetic Dystrophy
Some diseases, such as cancer and arthritis, cause ongoing pain. With chronic pain, however, pain is created in the nervous system even after physical tissues have healed.
Chronic pain affects each person experiencing it differently. In some cases, chronic pain can lead to decreased activity levels, job loss, or financial difficulties, as well as anxiety, depression, and disability. Physical therapists work together with chronic pain patients to lessen their pain, and restore their activity to the highest possible levels. With treatment, the negative effects of chronic pain can be reduced.
What Is Chronic Pain?
Pain is an unpleasant sensation that we usually associate with injury or tissue damage, but can actually be present in the absence of tissue damage as well. Pain can be acute or chronic.
Acute pain lasts for a short time – up to 12 weeks. It is a warning that tissue damage has occurred or may occur, or to help us prevent injury or disease. For instance, if we touch a hot stove, the body sends a danger message to the brain that there is a threat to tissues in order to prevent further injury. A sore foot can signal a need to change your footwear. In some cases, the danger messages may be due to some disease process, and your brain may interpret those messages as pain. This can cause you to seek medical attention – diagnosis and treatment – for what may be a serious condition. Signaling pain in this manner is the body's way of protecting us and is a good thing.
Chronic pain is any discomfort or unpleasant sensation that lasts for more than 3 months – or beyond an expected normal healing time. Often, those who have chronic pain believe they have an ongoing disease or that their body has not healed, when this may not be the case. Chronic pain is likely not warning you of possible injury or danger; instead, the pain centers in the brain may be causing you to hurt even though there are no new causes of pain occurring in the body. Anyone can develop chronic pain, at any age. The brain changes in chronic pain:
- When you are injured or develop a painful disease, nerves send information from the problem area to the brain.
- The brain analyzes this information coming from the body to determine if there is a threat to the body and whether action needs to be taken to prevent harm.
- When pain is constant or chronic, the brain and nervous system go on "high alert," becoming more sensitive.
- Cells that conduct sensation in the nervous system can also become more sensitive when on high alert, making it easier for the brain to interpret these sensations as a threat and thus cause you to have more pain. These changes in the brain and central nervous system induce and maintain chronic pain symptoms.
- When pain is chronic: Pain sensations are activated in the brain; The brain continues to interpret all sensations from the problem areas as danger, even when there is no more tissue damage occuring. This makes it easier for the pain centers in the brain to activate; Pain messages come from many different areas of the brain – areas that may control fight or fear reactions, movement, emotions, problem-solving, and learning. In fact, almost any system of the body can be affected by chronic pain.
- The brain and nervous system continue reacting by causing you to continue to be in pain. This process increases sensations, emotions, or thoughts about the problem area. At this point, any sensory input can activate the pain centers. Even thinking about it, or reading the word pain can trigger pain sensations. The pain is in the brain: In order to protect you, the brain is making the decision to increase the alert level for sensations you feel.
How Does it Feel?
How chronic pain feels varies with each individual; it is very personal. How often it occurs, how severe it is, or how long it lasts is not predictable from one person to another.
Common complaints related to chronic pain include:
- It may seem as if "everything hurts, everywhere."
- There may be sudden stabs of pain.
- It may seem as if the pain "has a mind of its own."
- You feel symptoms even if you are not doing anything to cause them.
- It feels worse when you think about it.
- It feels worse when you experience upsetting circumstances in your life.
- You may feel more anxious and depressed.
- You may feel your symptoms spread from one area to another area.
- You may feel fatigued, and afraid to do your normal activities.
These complaints are common when you have chronic pain. However, it does not necessarily mean that your physical condition is worsening; it may just mean that your system has become more sensitive.
Signs and Symptoms
Research finds the following signs may be associated with a chronic pain syndrome:
Fearfulness. It is easy to begin to fear increased pain when you have a chronic pain condition. As a result, you may begin to avoid activity. You may find that you rely more on family members to help with daily functions.
Body stiffness when you try to become more active. Stiffness may make you feel as if your body is less able to perform daily activities.
Deconditioning. Not moving your body results in less tolerance when you want to become more active. If you are inactive for a long time, muscles weaken and shrink from not being used. This can also increase your risk of falling.
Decreased circulation. Lack of activity decreases the circulation of much-needed blood to your cells. Tissues in your body may not get as much oxygen as they need. As a result, they may not be as healthy as they can be. This can cause you to feel fatigued, and lack energy.
Weight gain and/or a worsening of other conditions. Decreased activity can lead to unwanted weight gain. Added pounds and inactivity can aggravate symptoms of other conditions such as diabetes and high blood pressure. Chronic pain conditions are also commonly associated with feelings of anxiety or depression.
Increased use of medication. Chronic pain patients can have the tendency to increase their medication over time to seek relief.
Individual behaviors can include:
- Seeking out of many different doctors or health care providers and facilities to find relief.
- Difficulties with job performance. Some people with chronic pain even seek work disability.
- Avoidance of social situations or family members.
- When pain is ongoing, you may find you have feelings of bitterness, frustration, or depression. Some people report they have thoughts of suicide. If you are having these feelings, tell your doctor. This is important, so that you can get appropriate medications to help you feel better.
How Is It Diagnosed?
Your physical therapist will perform a thorough evaluation. He or she will:
- Ask specific questions about your past and present health and use of medication.
- Ask about your symptoms: their location, intensity, how and when the pain occurs, and other questions, to form a clear picture of your individual situation.
- Ask you to fill out pain and function questionnaires, to understand how the pain is affecting your daily life.
- Perform tests and movements with you. The tests help to identify problems with posture, flexibility, muscle strength, joint mobility, and movement. Special tests help to rule out any serious health problem such as pressure on a nerve or an underlying disease.
- Observe how you use your body for home, work, and social/leisure activities. This information helps your therapist prescribe a program that will boost your quality of life, and get you moving your best.
Imaging tests such as x-rays, computed tomography (CT) scans, and magnetic resonance imaging (MRI) are often not helpful for diagnosing the cause of chronic pain. However, if your physical therapist suspects that your pain might be caused by any serious underlying condition, he or she will refer you to your physician for evaluation.
Your physical therapist will work with your physician to provide the best diagnosis and treatment for your chronic pain.
How Can a Physical Therapist Help?
Your physical therapist will work with you to educate you on chronic pain, find solutions to improve your quality of life, and get you moving again! He or she will help you improve movement, teach you pain management strategies, and, in many cases, reduce your pain.
Not all chronic pain is the same. Your therapist will evaluate your clinical examination and test results and design an individualized treatment plan that fits you best.
Physical therapy treatments may include:
Education to improve your knowledge and understanding of chronic pain -- how it occurs, and what you can do about it. Your therapist will teach you how to manage your pain and help you work toward performing your normal daily activities again.
Strengthening and flexibility exercises to help you move more easily with less discomfort. Your therapist will design a program of graded exercises for you -- movements that are gradually increased according to your abilities. Graded exercises help you improve your coordination and movement, reducing the stress and strain on your body, and decreasing your pain. Carefully introducing a graded exercise program will help train your brain to sense the problem area in your body without increasing its danger messages.
Manual therapy, which consists of specific, gentle, hands-on techniques that may be used to manipulate or mobilize tight joint structures and soft tissues. Manual therapy is used to increase movement (range of motion), improve the quality of the tissues, and reduce pain.
Posture awareness and body mechanics instruction to help improve your posture and movement. This training helps you use your body more efficiently while performing activities and even when you are resting. Your therapist will help you adjust your movement at work, or when performing chores or recreational activities, to reduce your pain and increase your ability to function.
The use of ice, heat, or electrical stimulation has not been found to be helpful with chronic pain. Your physical therapist, however, will determine if any of these treatments could benefit your unique condition.
Can this Injury or Condition be Prevented?
Research shows that treating pain as soon as possible helps to prevent chronic pain. Don't ignore pain. Serious pain or pain that does not get better as expected should be treated.
Your physical therapist will work with you to develop strategies to prevent chronic pain, such as:
- Keeping up with your normal activities as much as possible.
- Avoiding bed rest. Long periods of bed rest will not improve your pain and may make it worse. Prolonged bed rest puts you at risk of other complications as well, including increased muscle weakness, bone loss, weight gain, and poor circulation.
- Improving posture. Your therapist will help you adjust your posture so your body can work at optimal efficiency to reduce joint stress and help to reduce your symptoms.
- Performing exercises to improve and restore your sense of the involved body area. Your therapist will also teach you exercises to restore movement (range of motion), mobilize nervous tissue (main component of nervous system), and rebuild your strength for performing routine daily activities.
- Introducing meditation, relaxation, and imagery exercises to help reduce stress and muscle tension.
- Learning fully about your condition. This will help you better understand what is occurring in your body, so you don't worry about every new ache, pain, or symptom.
- Maintaining healthy activity levels and improving your overall health.
Real Life Experiences
Helen is a 44-year-old woman who has been experiencing low back pain for the past 4 years. She first noticed the pain after she lifted a heavy object. Helen didn't seek help for her pain when it first occurred; it has now become a chronic pain condition. She has had to quit her job.
Helen lives alone in her apartment. She worries about paying her rent and no longer goes out except to keep her medical appointments.
Helen finally seeks help for her chronic pain, and is referred to an orthopedic physical therapist specializing in low back pain.
Helen reports her symptoms as aching and burning in her low back that spread to her right outer thigh. The symptoms are present constantly, even at rest. The pain interferes with all of her activities. It makes her afraid to perform simple tasks like bending and lifting, walking more than a short distance, or even standing for short periods of time. She has difficulty sleeping, and wakes up throughout the night. Her doctors have tried a number of medications to ease her pain without much success.
Helen's physical therapist performs an evaluation and notes that Helen has poor posture, and weakness in her hip and trunk muscles. Helen is also fearful of moving or of being touched during the exam. Her therapist performs specific tests to rule out any serious underlying condition, and finds none.
Over the course of treatment, Helen's therapist educates her about how the pain system works, and how the brain and central nervous system can create chronic pain. They discuss ways to help cope with the problem with imagery and relaxation exercises. Helen also learns how inactivity and fearfulness can feed into the pain symptoms. Her therapist encourages her to begin more activity. The therapist shows her better ways to use her body with less stress and strain with daily activity.
Helen begins to participate in more of her normal daily activities. She learns that it is possible if she balances the activity with short rest periods to control her symptoms. As she begins to prepare some meals for herself and to do some light housekeeping, she realizes she can live a fuller life without increasing her back pain. Helen also needs to learn exercises to improve her conditioning. After years of inactivity, she feels tightness and a lack of strength when she tries to be active. Her therapist prescribes exercises specifically to address Helen's flexibility and strength issues, and her goals to walk, stand, and sleep with less pain. She is given specific exercises to mobilize the nervous system to improve its health and aid it in becoming less sensitive. Helen also performs exercises that help the brain to recognize the involved areas of her body better and become less sensitive to changes. The exercises are gradually increased as Helen's condition improves.
After achieving her physical therapy goals, Helen can tolerate movement much better, and has lost her fear of being touched. She is sleeping better, and is able to walk with improved posture. She also walks for longer distances without increasing her symptoms, and has resumed going to her local church for Sunday services. Helen plans to continue her exercise and treatment program at home and to get a new job.
This story was based on a real-life case. Your case may be different. Your physical therapist will tailor a treatment program to your specific case.
What Kind of Physical Therapist Do I Need?
All physical therapists are prepared through education and clinical experience to treat a variety of conditions or injuries.
You can find physical therapists that have these and other credentials by using Find a PT, the online tool built by the American Physical Therapy Association to help you search for physical therapists with specific clinical expertise in your geographic area.
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 with chronic pain.
- During your first visit with the physical therapist, be prepared to describe your symptoms in as much detail as possible, and report activities that make your symptoms worse.
The American Physical Therapy Association (APTA) believes that consumers should have access to information that could help them make health care decisions and also prepare them for their visit with their health care provider.
The following articles provide some of the best scientific evidence related to physical therapy treatment of chronic pain. The articles report recent research and give an overview of the standards of practice both in the United States and internationally. The article titles are linked either to a PubMed* abstract of the article or to free full text, so that you can read it or print out a copy to bring with you to your health care provider.
Rundell SD, Davenport TE. Patient education based on principles of cognitive behavioral therapy for a patient with persistent low back pain: a case report. J Orthop Sports Phys Ther. 2010:40:494–501. Article Summary on PubMed.
Doidge N. The Brain That Changes Itself. New York, NY: Penguin Books; 2007. Product Summary.
Moseley L. Painful Yarns: Metaphors and Stories to Help Understand the Biology of Pain. Canberra, Australia: Dancing Giraffe Press; 2007. Product Summary.
Butler DS, Moseley L. Explain Pain. Adelaide City West, South Australia: Noigroup Publications; 2003. Product Summary.
Jull GA, Soderlund A, Stemper BD, et al. Toward optimal early management after whiplash injury to lessen the rate of transition to chronicity: discussion paper 5. Spine (Phila Pa 1976). 2011;36(25 Suppl):S335–S342. Article Summary on PubMed.
*PubMed is a free online resource developed by the National Center for Biotechnology Information (NCBI). PubMed contains millions of citations to biomedical literature, including citations in the National Library of Medicine’s MEDLINE database.
Acknowledgements: Mary Kay Zane, PT, OCS