January 22, 2019

Pain may start with an injury but linger longer than it should. Physical therapy for chronic pain management can go beyond exercising injured tissue.


Pain is tricky.

It gives us a warning if we have an injury, the classic example being touching a hot stove. Injuries usually will heal within a few weeks, but sometimes pain lingers for much longer and can be more difficult to treat. Pain lasting more than 12 weeks is considered chronic.

The United States has an epidemic of chronic pain. In 2016, about 20 percent of American adults experienced the discomfort, according to a report from the National Institutes of Health. That report describes the challenges that come with it: “Chronic pain has been linked to restricted mobility, opioid dependency, anxiety, depression and reduced quality of life, and it contributes to an estimated $560 billion annually in direct medical costs, lost productivity and disability programs in the United States.”

Traditional strategies for chronic pain management include medication, physical therapy and/or surgery. However, those tactics don’t always help. At Vanderbilt Orthopedics’ Cool Springs, Tennessee, location, physical therapist Flavio Silva explains that chronic pain patients usually will respond to exercises together with cognitive behavioral therapy, which addresses mental and emotional factors that can contribute to symptoms.


How pain becomes chronic

Most injuries heal within weeks or months, so pain should fade. But sometimes, due to different mechanisms, pain-perception patterns stick in the brain long term. In this way, chronic pain management becomes more mental than physical.

The brain receives and reacts to information from chemical messages sent between neurons, effectively memorizing neural patterns that happen frequently or carry great emotional weight. Initially, a pain signal is a warning of danger or threat. If the pain lasts for too long, it causes changes within your central nervous system that may be unrelated to the initial injury. As Silva said, “Your body starts to identify things that shouldn’t be harmful as harmful” – such as a new movement, activity or even a minor twinge that’s recovered from past injury. Pain signals can fire regularly in the brain even when there’s nothing physically wrong. Current research has shown that certain factors such as anxiety, stress or lack of sleep intensify the pain.

When people develop chronic pain, they naturally pay attention to it, Silva said: “They wake up in the morning thinking about how much they’re hurting. They go the whole day thinking about how much they’re hurting. They go to bed at night thinking about how much they’re hurting. And then they can’t sleep, because they’re thinking about how much they’re hurting.”

This attention further reinforces the neural patterns of chronic pain. A cycle develops: pain, stress, fear, poor sleep and therefore more pain. People with chronic pain are at higher risk of depression than people without chronic pain, and depression, in turn, can worsen pain.


How to manage chronic pain

There are many strategies, some unconventional, for managing and recovering from chronic pain. Silva’s physical therapy practice includes educating clients about regular exercise, a big factor.

Pain can scare people out of physical activity because they worry it will make it worse. But a lack of activity stiffens joints and reduces range of motion, causing more discomfort. Exercise also provides many other benefits that go beyond mobility. It improves people’s confidence and prevents the fear of movement that is common with chronic pain.

“I’ve had patients come in, saying, ‘My doctor told me not to bend forward.’ And it’s been five years of not bending forward,” said Silva. “You need to be able to bend forward. It’s part of your life.”

Physical therapy strengthens injured or weakened muscles and joints. The key for exercising with chronic pain is to start with exercises patients can tolerate without discomfort or fear. As they gain strength, better mobility and confidence, they can move without triggering debilitating pain and can progress to more demanding activities.

For chronic pain patients, exercises should be goal-driven. Some patients might simply want to climb stairs pain-free, while others aim for a triathlon. The program should work around the patient’s short-term goals and help build toward long-term ones, Silva said. Each time a patient reaches a small goal, the patient gains confidence and feels encouraged to take on more challenges.

“We want them to continue some sort of active lifestyle that will gradually challenge those tissues without producing symptoms,” Silva said. “With a graded approach, most patients will be able to handle any tasks as they are prepared for them.”


Some other strategies to discuss during physical therapy visits:

  • Pain science: Understanding why you hurt and what you can do for it brings many benefits.
  • Sleep: Sleep deprivation worsens pain, so improving “sleep hygiene” is crucial.
  • Mindfulness: Becoming aware of fearful, negative thoughts and learning to redirect attention away from pain can minimize it. For example, “meditation is very beneficial for chronic pain patients,” Silva said. “There’s significant research that shows positive effects.”
  • Reducing stress: Stress exacerbates pain, so finding ways to manage it can help reduce pain.
  • Managing “central sensitization”: Silva gives patients research-based questionnaires evaluating central sensitization – when the central nervous system has become so sensitive to stress and danger signals that the brain triggers pain and inflammation. Silva described the wide range of symptoms that can result: “You’re having problems with sleep — GI (digestive) problems — problems with headaches. You may have TMJ (jaw joint) pain. You have fibromyalgia.”

It’s not “all in your head.”

“Your body is reacting. Your body is wired to feel certain things,” Silva said. “Unfortunately, some of those connections get a little muddled and confused, and your body starts to see things that are supposed to be not threatening as threatening. And you develop more pain.”

Most people agree that stress can cause headaches or stomachaches. Most of Silva’s patients accept that stress, fear and poor sleep can perpetuate pain. They’re willing to adopt these mind-body strategies, he said — and those that do usually recover better than other patients with chronic pain.

Older man, seen from behind, stretching his triceps.

Need help?

If you are dealing with an injury, facing surgery or coping with chronic pain, Vanderbilt Orthopaedics offers a full spectrum of care. Our specialists work with you from evaluation and “prehab” through physical therapy and, if needed, surgery. We’ll help you get back to doing the things you love, pain-free. To make an appointment, call 615-936-7846.

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