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    Move Forward Guide

    Physical Therapist's Guide to Pain

    The International Association for the Study of Pain has defined pain as "an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage." This definition indicates that pain may result from actual injury to a tissue (ie, bone, muscle, tendon) or the perceived threat of injury to a tissue. Whether actual tissue damage or perceived threat of injury has occurred, people will experience pain as real.


     

    Understanding Pain

    Pain is one of the most common symptoms that lead a person to seek the help of a physical therapist or other health care professional. Physical therapists are experts in the management of pain. 

    Successful management of pain relies on an understanding of why someone feels pain. Although much is still being discovered about the sensation of pain, our understanding of how and why pain exists has changed over the past several decade.

    A New Understanding of Pain

    Pain was once thought to be an indicator of injury to body tissue; it is now known that pain also can be a warning signal designed to alert us to potential damage and to protect us from injury. As a result of this new understanding, we now know that feeling pain does not necessarily mean a physical injury has occurred

    When a tissue is injured or the potential for injury occurs (such as with an ankle sprain), special nerves called nociceptors send information toward the brain to warn of damage. The body responds in order to minimize damage (ie, sends pain signals to make sure the person doesn’t step on the affected foot), and to begin the healing process (ie, produces swelling to bring healing cells to the area). 

    However, we now know that injury-warning pain signals can increase or decrease based on specific situations. For example, if you sprain your ankle while trying to get out of a burning building, you may not be aware of your injury until you are safe, because the warning signals are overridden for a more important reason: survival. Science has shown that this decision to rank the importance of warning signals occurs in the brain, which has led to the conclusion that the sensation of pain is triggered by, and occurs in, the brain.

    Science has also shown that no two human brains are alike. Therefore, it follows that each person’s pain experience will be unique—influenced by specific situations such as the one described above, as well as by a range of other factors that make each person’s life unique. These factors can include life experiences over time, psychological histories, living and work environments, and even the social structures in which we live. These past experiences can help to decrease pain in life-threatening situations, but can also increase pain in people with persistent or chronic pain.

    Major Implications for Pain Management

    The recent shift in the understanding of pain has several major implications. First, it changes the way a physical therapist may approach your care. In the past, many health care fields focused treatment on the healing of damaged tissue. Although this approach helped many people who had experienced an injury, others reported pain that lasted well beyond the time necessary for tissue to heal.

    Based on the new evidence regarding pain, physical therapists are today using methods of treatment and of managing pain that do not solely focus on injured tissue, but also address other factors such as environment, stress, psychology, and social considerations that may be influencing the amount of pain experienced. This “brain and body” approach to the management of pain is an important shift that has occurred in response to the new and evolving understanding of the purpose and nature of pain.

    Pain and Opioids

    The misuse of opioids has become a public health emergency in the United States and beyond. The origins of the current crisis date back to the late 1990s, when the medical community had no evidence of the addictive properties of opioid-based pain-relief medications. As medical providers began to prescribe opioids more frequently, because they successfully eased pain in many patients, evidence of addiction began to surface.

    In response to the crisis, measures including better addiction prevention, treatment, and recovery services, better data, better pain management, better targeting of overdose-reversing drugs, and better research have been implemented. The crisis will likely have its solution in new approaches to the treatment and management of pain. Physical therapy is proving to be one of the safest methods of treating and managing pain.

    For more resources on pain, and on the use of opioids for pain management, visit this website’s Health Center on Pain and our Health Center on Avoiding Opioid Use for Pain Management.

     

    How Does it Feel?

    We often use different terms to describe pain, such as sharp, burning, stabbing, or aching, but it is hard to know if you feel pain the same way your friends or family feel it. Not only is your experience of pain unique to you, it can change from day to day and situation to situation. Research shows that pain can be modified and can change for a number of reasons.

    The latest science tells us 2 important facts:

    1. The amount or intensity of the pain you feel is not an indication of the amount or seriousness of a possible injury. In fact, there may be no injury present.
    2. The experience of pain can change; the pain felt today does not necessarily have to be the pain felt tomorrow.
     

    Signs and Symptoms

    The unique nature of your pain may give your physical therapist some insight into why you are experiencing it. Traditionally, the amount of time a person has been experiencing pain is an important indicator. Acute (recently acquired) pain and chronic (ongoing longer-term) pain are not the same things.

    • Acute pain is most often reflective of actual tissue injury or damage.
    • Chronic pain is less frequently related to tissue injury or damage and is instead linked to other factors such as chronic inflammation, changes in nerve sensitivity, emotions, prior traumatic injury, and changes that occur in the brain.

    The following is a general description of the signs and symptoms you might experience with each of the types of pain you feel. However, it is important to note that, although these terms help medical professionals categorize pain, they do not describe the mechanisms causing pain.

    Signs and Symptoms of Acute Pain

    If your pain is acute, you may feel it:

    • For less than 3 months
    • Locally at an injured area
    • Accompanied by swelling, warmth, and redness in the injured area
    • Related to an injury or specific event
    • Increase when the injured tissue is provoked or compromised, and decrease when the factor causing the pain is removed; example: If you have a swollen or injured tendon in your shoulder, you may experience pain when moving your arm overhead. When you move the arm back down, unloading the tendon, the pain often resolves or at least significantly lessens.

    Signs and Symptoms of Chronic Pain

    If you are experiencing chronic pain, you may feel:

    • Pain that lasts longer than 3 months
    • Current pain that is not the result of tissue damage or injury
    • Widespread pain
    • Pain that is often unpredictable and cannot be consistently related to a specific motion or activity
    • Hypersensitivity to even the slightest pain triggers
    • Pain accompanied by psychological factors such as depression, fear, or anxiety
     

    How Is It Diagnosed?

    Unlike other diseases or health-related problems, there is no one method to diagnose pain. Your physical therapist will ask questions to determine whether a specific physical problem is causing your pain. Your physical therapist may ask:

    • How long have you had pain?
    • How did it start?
    • Where is the pain located?
    • When do you experience the pain?
    • What types of activities bring it on?
    • How long does it take for it to go away?
    • What does the pain “feel” like?
    • What can make the pain feel better (lessen)?
    • On a scale of 0 to 10, can you rate how much pain you are currently experiencing?
    • What do you think is causing the pain?
    • What is your past medical history?

    Your physical therapist also may ask you to fill out a questionnaire to pinpoint how the pain may be affecting your daily life.

    Imaging tests, such as X-rays, computed tomography (CT) scans, and magnetic resonance imaging (MRI) may be needed to rule out any underlying medical condition that is contributing to your pain. Your physical therapist will refer you to other medical professionals for these assessments. NOTE: The findings of these tests cannot indicate how much pain an individual is experiencing. 

     

    How Can a Physical Therapist Help?

    Once your condition has been diagnosed, your physical therapist will work with you to develop a treatment plan to help address your pain.

    Treatment for Acute Pain

    If you have acute pain, your physical therapist will help identify the injured tissue (eg, bone, muscle, tendon) and devise treatments to help promote healing and reduce stress on the injured area.

    Your physical therapist will offer guidance as to how to safely return to your normal activities without further damaging the injured tissue. Research demonstrates that people who return to their normal daily activities more quickly following injury recover faster and have fewer long-term problems than people who do not return to activity in a timely manner.

    Your physical therapist may help you identify positions that hurt and positions that do not hurt, and provide treatment and exercises to help the injured tissue move more efficiently. Physical therapists are movement experts.

    Treatment for Chronic Pain

    If you have chronic pain, your physical therapist can help you identify factors that may be leading to the prolonged pain. These factors may include faulty movement patterns, muscle weakness, areas of stiffness that prevent normal motion, previous injury and past events that may be contributing to your pain, fear, negative emotions, and other behaviors or social factors that can lead to long-term pain.

    Your physical therapist will design a treatment program to fit your specific needs, which may include manual (hands-on) therapy, and gentle exercises to relieve pain.

    Your treatment may emphasize education about the latest findings regarding pain, in addition to healing exercises and manual therapy. Research has demonstrated that positive changes occur in the brain after patients are educated about the purpose and causes of pain.

    Treatment Techniques

    Because the mechanisms of pain vary, each approach to care will also vary. Treatments are likely to include a combination of the following, depending on your unique needs:

    Manual therapy. Manual therapy consists of specific, hands-on techniques that may be used to manipulate or mobilize joints and muscles. Manual therapy is often used in conjunction with other activities to increase movement, and has been shown to reduce pain. Some physical therapists have additional certifications that identify them as having advanced training in this type of therapy.

    Movement and exercise. Moving more and exercising can often be a great strategy to lessen pain. Studies have found that those who exercise on a regular basis experience less pain. Your physical therapist will help identify specific movements that will help reduce your symptoms.

    Modalities. Your physical therapist will be able to determine whether the use of modalities such as ice, heat, or electrical stimulation applied to specific areas will benefit your unique condition.

    Graded exposure. Because emotions such as fear are often associated with pain, your physical therapist may slowly introduce movement and activity back into your life. Graded exposure may involve visualizing movement followed by slowly and safely beginning to move in ways that are pain free, to start the process of returning to normal activities. This type of approach has been shown to help reduce pain and restore the ability to perform everyday activities.

    Psychologically informed physical therapy. Research consistently demonstrates that pain is closely tied to, and is influenced by, psychological factors such as fear, anxiety, and depression. Addressing these factors has been shown to help reduce the amount of pain a person is experiencing. If you have chronic pain, your physical therapist will work with you to address factors like these that may be contributing to your pain.

    Home program. Your physical therapist will help you develop a home program that is individualized to your specific needs and requirements. Research shows that the positive relationship between you and your physical therapist, focused on your well-being, is an important factor in your recovery process.

     

    Can this Injury or Condition be Prevented?

    Pain is a normal and natural part of life. It is a protective mechanism designed to help us survive. Without it, we would not be able to respond to a threat or injury. Pain cannot be prevented—nor should it be. The key to management of pain is to stop the progression of pain from the normal, acute pain that warns us of damage and helps us to protect and heal an injured tissue, to a chronic type of pain that prevents us from doing the things we love to do.

    Your physical therapist will work with you to develop strategies to better understand and manage your pain. Some points to remember about dealing with pain are:

    Education is key. When we understand what pain is, we can use it to better guide our movements and activities.

    Bed rest may not always be helpful. Despite what we once thought, long periods of bed rest (more than a day or two) may actually make your pain worse and lead to other medical complications. Your physical therapist can work with you to develop safe levels of activity to help treat your condition.

    Regular exercise is important. Routine exercise provides a lot of benefits, such as improving the conditioning of the nervous system, which is responsible for sending pain messages.

    Relaxation and imagery exercises can help. We often experience things that can trigger pain (ie, a stressful day, loud noises, an uncomfortable situation). Your physical therapist will teach you ways to relax your body, which can help calm down the nervous system.

     

    Real Life Experiences

    Alan is a 28-year-old window washer who enjoys rock climbing on the weekends. While at work recently, Alan lost his footing and fell off of the window scaffolding supporting him. He sustained fractures to his right leg, right collarbone, and right forearm. Alan was hospitalized for more than a month, undergoing surgeries to fix his fractured bones.

    Surprisingly, when Alan met his physical therapist following his surgeries, he said he had experienced very little pain throughout his entire ordeal. He denied taking any medications for pain and reported he was excited to begin physical therapy because he wanted to return to rock climbing. His physical therapist noted that Alan had a relatively high pain-tolerance level.

    On his first day of treatment, Alan took a seat in the clinic next to James, a 40-year-old accountant who had recently sustained a mild ankle sprain at work. In contrast to Alan, James had been feeling a lot of pain since the injury. He reported that his ankle hurt every time he took a step, and often rated the pain as a 10 on a scale of 0 to 10. James said his pain kept him from doing many things he used to enjoy doing, like shooting baskets at the local basketball court.

    Alan’s physical therapist also treated James. She noted that James had a relatively low pain-tolerance level. She also was able to assess each of their responses to activity, and designed individualized treatment programs to help Alan and James achieve their specific goals based on their physical and psychological conditions.

    In Alan’s case, the physical therapist carefully designed a program to restore his lost motion, while integrating activities that would help him safely return to rock climbing as soon as possible, but not too soon.

    She educated James about his pain threshold, and performed gentle manual-therapy techniques to decrease his pain prior to his performance of physical activities.

    Despite the difference in pain levels experienced by Alan and James, both did well with a personalized course of physical therapy. The approach to care differed because of the degree of pain they each experienced. With careful attention from their physical therapist, and individualized treatment plans carefully designed to safely restore their function, both completed their rehabilitation and reached their goals of returning to healthy, productive lives.

    This story highlights the individualized experience of pain. Your case may be different. Your physical therapist will tailor a treatment program to your specific needs.

     

    What Kind of Physical Therapist Do I Need?

    Physical therapists receive more pain education than almost all other health care providers. As a profession, physical therapists are also at the leading edge of pain research, determining its causes and how to best manage it. Physical therapists are pain experts prepared through education and experience to help you manage your pain. When seeking the help of a physical therapist, you may want to consider:

    • A physical therapist who is a board-certified clinical specialist, or has completed a residency or fellowship in physical therapy. This physical therapist has advanced knowledge, experience, and skills that may apply to your condition.
    • A physical therapist who understands that pain may be influenced by a multitude of variables, and who has advanced training in the science and management of pain.

    You can find physical therapists who 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 are 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 painful conditions.
    • During your first visit with the physical therapist, be prepared to describe your symptoms in as much detail as possible. Keeping a journal highlighting when you experience pain will help the physical therapist identify the best approach to your rehabilitation.

     

     

    Further Reading

    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 readings and videos provide some additional resources related to physical therapy treatment of pain.

    US Department of Health and Human Services. What is the US opioid epidemic? Accessed June 25, 2018.

    US Department of Health and Human Services. Help, resources, and information: national opioids crisis. Accessed June 25, 2018.

    Kim HJ, Yang GS, Greenspan JD, et al. Racial and ethnic differences in experimental pain sensitivity: systematic review and meta-analysis. Pain. 2017;158(2):194–211. Article Summary in PubMed

    Lefebvre JC, Jensen MP, Trant DA. The effects of manipulating worry and happiness on the experience of acute pain and worry about pain. Cognit Ther Res. 2017;41(5):787–798. Article Summary on Publisher Website.

    López-de-Uralde-Villanueva I, Muñoz-García D, Gil-Martínez A, et al. A systematic review and meta-analysis on the effectiveness of graded activity and graded exposure for chronic nonspecific low back pain. Pain Med. 2016;17(1):172–188. Free Article

    Louw A, Zimney K, Puentedura EJ, Diener I. The efficacy of pain neuroscience education on musculoskeletal pain: a systematic review of the literature. Physiother Theory Pract. 2016;32(5):332–355. Article Summary in PubMed.

    Khatib Y, Madan A, Naylor JM, Harris IA. Do psychological factors predict poor outcome in patients undergoing TKA? A systematic review. Clin Orthop Relat Res. 2015;473(8):2630–2638. Free Article

    O'Connor SR, Tully MA, Ryan B, et al. Walking exercise for chronic musculoskeletal pain: systematic review and meta-analysis [published correction in: Arch Phys Med Rehabil. 2015;96(6):1182]. Arch Phys Med Rehabil. 2015;96(4):724–734. Free Article

    O'Sullivan K, Dankaerts W, O'Sullivan L, O'Sullivan PB. Cognitive functional therapy for disabling nonspecific chronic low back pain: multiple case-cohort study. Phys Ther. 2015;95(11):1478–1488. Free Article.

    Voogt L, de Vries J, Meeus M, Struyf F, Meuffels D, Nijs J. Analgesic effects of manual therapy in patients with musculoskeletal pain: a systematic review. Man Ther. 2015;20(2):250–256. Article Summary in PubMed.

    Moseley GL, Butler DS. Fifteen years of explaining pain: the past, present, and future. J Pain. 2015;16(9):807–813. Article Summary in PubMed.

    Carroll LJ, Ferrari R, Cassidy JD, Côté P. Coping and recovery in whiplash-associated disorders: early use of passive coping strategies is associated with slower recovery of neck pain and pain-related disability. Clin J Pain. 2014;30(1):1–8. Article Summary in PubMed

    Fuentes J, Armijo-Olivo S, Funabashi M, et al. Enhanced therapeutic alliance modulates pain intensity and muscle pain sensitivity in patients with chronic low back pain: an experimental controlled study. Phys Ther. 2014;94(4):477–489. Free Article

    Martini M, Pérez Marcos D, Sanchez-Vives MV. What color is my arm? Changes in skin color of an embodied virtual arm modulates pain threshold. Front Hum Neurosci. 2013;7:438. Free Article

    Butler DS, Moseley GL. Explain Pain. 2nd ed. Adelaide, Australia: Noigroup Publications; 2013.

    Racine M, Tousignant-Laflamme Y, Kloda LA, Dion D, Dupuis G, Choinière M. A systematic literature review of 10 years of research on sex/gender and experimental pain perception; part 1: are there really differences between women and men? Pain. 2012;153(3):602–618. Article Summary in PubMed.

    Louw A, Diener I, Butler DS, Puentedura EJ. The effect of neuroscience education on pain, disability, anxiety, and stress in chronic musculoskeletal pain. Arch Phys Med Rehabil. 2011;92(12):2041–2056. Article Summary in PubMed

    Revised by Derrick Sueki, PT, DPT, PhD. Authored by Joseph Brence, PT, DPT, COMT, DAC. Reviewed by the MoveForwardPT.com editorial board.


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