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, etc) or the potential for injury to a tissue. Whether actual or potential damage has occurred, however, people will experience pain as real.
Pain is one of the most common symptoms that may lead someone to seek the help of a physical therapist or other health care professional.
Over the past decade, our understanding of how and why pain exists has changed. While pain was once thought to originate at the level of the tissues (eg, if a knee was injured, pain signals originated at the level of the knee), it is now believed that pain is not perceived until the brain concludes there is a potential threat to those tissues. Today’s findings suggest that if a knee is injured, danger signals originate at the level of the knee, these signals are relayed to the brain, and the brain determines if it needs to respond by sending an output of pain. This response is individual—what causes 1 person’s brain to respond, may not cause another’s to do so. This response is based on many different variables.
The recent shift in the understanding of pain has several major implications. First, it changes the way a physical therapist may approach your care. While many health care fields used to focus on the treatment of individual tissues, many physical therapists are beginning to use a “bio-psycho-social” model of pain treatment. In this approach, physical therapists do not solely focus on the tissues of the body (bio), but they also account for psychological and social factors that may be influencing the amount of pain you experience. If you hurt your knee at work, for example, a physical therapist may incorporate different aspects of your work into your rehabilitation. Your physical therapist may design exercises that replicate the positions you assume during a workday or the tasks you perform at work, such as lifting crates, or climbing a ladder. Your physical therapist will also talk to you about any fears that you may have about movement, and help give you the confidence to move safely again.
Second, it can have a wide economic impact. In 2010, it was estimated that the United States spent between $500 billion and $635 billion on the treatment of pain. To put these numbers in perspective, that same year $309 billion was spent treating heart disease, $243 billion was spent treating cancer, and $188 billion was spent treating diabetes. We are spending an enormous amount of money on the treatment of pain, but these numbers could decrease as we better understand why pain occurs.
How Does it Feel?
Pain is a completely individualized experience. We often use different terms to describe it, but it is hard to know if you feel pain the same way as your friends or family feel pain. Some people talk about having a high or low tolerance to pain, but because pain is such a subjective experience, science has not developed accurate ways to measure pain tolerance.
Currently, there are 2 ways your physical therapist may categorize your pain:
1. The most standard classification of pain is time-based:
Acute (pain experienced for less than 3 months)
Chronic (pain experienced for more than 3 months)
While these terms help us categorize pain, they do not describe the mechanisms causing your pain.
2. The second classification of pain is based on the likely triggering mechanism:
Nociceptive triggers result inpain that is localized to an area of injury or dysfunction. The pain is often aggravated or eased by certain movements or positions, which demonstrates that the pain has a clear mechanical nature.
Peripheral neuropathic-induced pain occurs with a history of injury, disease, or mechanical compromise to a nerve. Pain is generally experienced due to damage or disease of neural (nerve) tissue.
Central sensitization results in pain that is disproportionate to the nature or extent of the injury or disease. The pain is usually nonmechanical and unpredictable in response to factors that usually aggravate or decrease pain.
Research has indicated pain may also result in the following deficits:
Fear avoidance – an avoidance of movements or activities because of a belief about the potential negative consequences of those movements or activities (eg, My work might harm my back).
Catastrophizing – an exaggerated, negative orientation toward pain (eg, “Because of this pain, I feel I cannot go on”).
Kinesiophobia – a fear of moving or exercising (eg, I am afraid to return to exercising).
Inability to move as freely as usual
Difficulty performing daily activities
Signs and Symptoms
We all experience pain differently; the nature of your pain may give your physical therapist some insight into the contributing mechanism. The following is a general description of the different types of pain experienced:
Acute pain, often from a nociceptive mechanism, generally results in discomfort locally at the injured tissue. This pain will increase when the injured tissue is provoked or compromised, and will decrease when the trigger is removed. For example, if you have a swollen or injured tendon in your shoulder, you may experience pain when moving your arm overhead. That is because the tendon can get stretched, pinched, or compressed during the movement. When you move the arm back down, unloading the tendon, the pain often resolves or at least significantly lessens. A physical therapist will 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.
Chronic pain, often from a central sensitization mechanism, results in widespread pain that is often unpredictable. Individuals experiencing it may be hypersensitive to even the slightest triggers. Chronic pain often is related to psychological factors, and has been identified as a characteristic of chronic low back pain, chronic fatigue syndrome, whiplash, TMJ disorder, rheumatoid arthritis, osteoarthritis, and fibromyalgia. The approach to care for chronic pain is often less aggressive because of its unpredictability, and treatment often emphasizes education in addition to exercise and manual therapy. A physical therapist is well equipped to assess and treat disorders resulting in pain.
How Is It Diagnosed?
Your physical therapist will ask you questions as well as perform tests to better understand what may be causing your pain. Your physical therapist may ask:
Where is the pain located?
When do you experience the pain?
What types of activities bring it on, and when provoked, how long does it take to go away?
What does the pain “feel” like?
On a scale of 0 to 10, can you rate how much pain you are currently experiencing (as well as the best and worst pain you have felt in the past 24 hours)?
What do you think is causing the pain?
In addition, your physical therapist may ask you to fill out a questionnaire to better understand 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.
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.
Because the mechanisms of pain vary, each approach to care will also vary. That being said, there is evidence to suggest that simply understanding pain through educational means, such as reading this guide, may result in reduced symptoms. (Know pain equals know gain!)
In addition, physical therapy treatments may include:
Manual therapy. Manual therapy consists of specific, hands-on techniques that may be used to manipulate or mobilize your skin, bones, and soft tissues. Manual therapy is often used in conjunction with other activities to increase movement and reduce pain. Some physical therapists have additional certifications that identify them as having advanced training in this type of therapy.
Movement and strengthening exercises. Moving and exercising can often be a great strategy to lessen 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 will benefit your unique condition.
Can this Injury or Condition be Prevented?
Pain is a symptom that all healthy human beings experience at some point in their lives. The sensation of pain is necessary for survival; if we did not experience it, we would not know that we were injured or unwell.
However, the degree of pain experienced does not always match the degree of injury (ie, minor injuries may cause extreme pain, and vice versa).
Your physical therapist will work with you to develop strategies to better understand and manage your pain. Some points to remember:
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 2) 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, etc). A physical therapist will help you learn ways to relax the body, which can often calm down the nervous system.
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Real Life Experiences
Alan is a 28-year-old window washer who has not been able to work for the past month, due to the injuries he suffered after falling off window scaffolding. Alan sustained several fractures in his right leg, right collar bone, right forearm, and skull. He has been hospitalized for these injuries for more than a month, receiving multiple 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 whole ordeal. He denied taking any medications for pain, and reported he was excited to begin physical therapy because he wanted to return to his favorite hobby, rock climbing.
On his first day of treatment, Alan took a seat in the clinic next to Alice, who had recently sustained a mild ankle sprain at work. In contrast to Alan, Alice had been feeling a lot of pain since her injury. She reported that her ankle hurt every time she took a step, and often rated the pain as a 10 on a scale of 0 to 10. She reported her pain kept her from doing many things she used to enjoy doing.
The physical therapist was able to assess Alan’s and Alice’s responses to activity, and designed individual treatment plans to help them achieve their goals. In Alan’s case, the physical therapist carefully designed a program to restore his lost motion, while integrating activities that would help him return to rock climbing. In Alice’s case, the physical therapist educated her about pain, and performed gentle manual interventions to decrease her pain prior to performing physical activities.
Despite the variation in pain levels experienced, both of these individuals did well with a personalized course of physical therapy. The approach to care differed because of the degree of pain they each experienced, but 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?
All physical therapists are prepared through education and experience to treat conditions that carry the symptom of pain. However, when seeking a provider, you may want to consider:
A physical therapist who is a board-certified clinical specialist, or who completed a residency or fellowship in physical therapy. This therapist has advanced knowledge, experience, and skills that may apply to your condition.
A physical therapist who is well-versed in the bio-psycho-social model of care, and understands that pain may be influenced by a multitude of variables.
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.
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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 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.
Lin CW, McAuley JH, Macedo L, et al. Relationship between physical activity and disability in low back pain: a systematic review and meta-analysis. Pain. 2011;152(3):607-613. Article Summary on PubMed.
Koes BW, van Tulder M, Lin CW, et al. An updated overview of clinical guidelines for the management of non-specific low back pain in primary care. Eur Spine J. 2010;19(12):2075-2094. Free Article.
Leaver AM, Refshauge KM, Maher CG, McAuley JH. Conservative interventions provide short-term relief for non-specific neck pain: a systematic review. J Physiother. 2010;56(2):73-85. Free Article.
Moseley L. Painful Yarns: Metaphors and Stories to Help Understand the Biology of Pain. Canberra, Australia: Dancing Giraffe Press; 2007.
Moseley GL, Nicholas MK, Hodges PW. A randomized controlled trial of intensive neurophysiology education in chronic low back pain. Clin J Pain. 2004;20(5):324-330. Article Summary on PubMed.
Wand BM, Bird C, McAuley JH, et al. Early intervention for the management of acute low back pain: a single-blind randomized controlled trial of biopsychosocial education, manual therapy, and exercise. Spine (Phila Pa 1976). 2004;29(21):2350-2356. Article Summary on PubMed.
Butler DS, Moseley L. Explain Pain. Adelaide City West, South Australia: Noigroup Publications; 2003.
Dr Lorimer Moseley. TED lecture explaining why things hurt.
*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.
Authored by Joseph Brence, PT, DPT, COMT, DAC. Reviewed by the MoveForwardPT.com editorial board.
Physical Therapist’s Guide to Pain