Be mindful of the mind: Understanding the brain’s role in chronic pain

June 11th, 2019
By: Content Staff

To address a patient’s chronic pain effectively, you need to understand his whole story. That’s the message from Leonard Van Gelder, who recently founded the physical therapy practice Dynamic Movement and Recovery in Grand Rapids, Mich., after training as a therapeutic pain specialist through the International Spine and Pain Institute.

Van Gelder pointed to one patient who came to him complaining of rheumatoid arthritis and fibromyalgia. The patient’s pain had worsened over time and even led to a brief hospital stay, Van Gelder told PT in Motion, a publication of the American Physical Therapy Association.

After several PT sessions, the patient began opening up to Van Gelder about how the management team at her job had created a high-pressure environment that was causing her tremendous stress, Van Gelder told PT in Motion. Their discussions ultimately led the patient to seek out another job, a decision that led to “profound improvements in her ability to function and be productive,” Van Gelder told the website.

For Van Gelder, the experience was proof that while it’s important to understand the biology of pain and how it works, the key to treatment is to see "how the patient's life, history, and social and mental health all play into the bigger picture," he told PT in Motion.

Mark Shepherd, assistant director of the Orthopaedic Manual Physical Therapy Fellowship at Bellin College, offered PT in Motion the following best practices for treating patients with chronic pain.

  • Create a welcoming and trusting environment. Many new patients complaining of persistent pain have already seen other providers but have not gotten the care they needed. By telling new patients that he believes them when they speak of their chronic pain, Shepherd hopes to earn their trust and instill confidence in them that this time will be different.
  • Determine whether the patient belongs in your clinic. If a patient appears to have a musculoskeletal condition such as persistent lower back pain, make sure the problem doesn’t stem from another kind of physical ailment, such as a spinal cord condition or cancer, or a mental-health condition, such as anxiety or depression. "You have to know when it's best to make a referral," Shepherd told PT in Motion.
  • Empower patients to help themselves at home. When Shepherd is performing manual therapy on patients, he immediately checks to see what changes occurred with that approach and then teaches patients how to do those things for themselves at home. Doing this addresses one major criticism of manual therapy – that it is passive, with the PT doing the work and the patient just trying to “will the pain away,” Shepherd told PT in Motion.
  • Shepherd told the website that for every three patients he sees, only one typically will experience a "true turnaround" to the point of being able to function as he did before pain emerged. But PTs can increase their patients’ odds of success by using a combination of patient education about pain, exercises and graded motor imagery.

    Carolyn McManus, a staff PT at Swedish Medical Center in Seattle, said told PT in Motion that she typically sees patients for two to six visits and usually begins with basic pain education.

    "The mechanisms that give rise to acute pain are different from those that give rise to chronic pain," McManus, president of the APTA Academy of Orthopaedic Physical Therapy's Pain Special Interest Group, told the website. "It can be helpful to patients to understand that the sensitivity of their nervous system can contribute to a chronic pain condition."

    McManus tells patients that persistent pain is not necessarily related to any kind of physical injury. "The metaphor I like to use is the fire alarm system in our building,” she told PT in Motion. “It usually would take a fire to set off the alarm, but if the wires are too sensitive, that alarm might be triggered by overly warm temperatures." For patients with chronic pain, McManus said, their alarms are going off without any fire. "They experience pain, but there may not be any tissue damage. The problem is in the wiring."

    McManus told PT in Motion that once patients understand that pain doesn't necessarily indicate a physical problem, they typically are less frightened by their pain. She then teaches them breathing exercises and the practice of body awareness, or calm observation of whether their body is tense or relaxed. The goal is to help the patient self-regulate his reaction to stress, she told PT in Motion.

    "The motto of one woman I worked with became, 'If I stay calm, my nerves stay calm,' ” McManus told PT in Motion.

    Van Gelder said the key is for pain-focused PT to look at the patient’s body from a behavioral standpoint "beyond the biology about which we've been so thoroughly educated – and you're trying to understand how people's thoughts and feelings influence and affect their pain," he told PT in Motion.

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