The San Diego Pain Summit #sdpain brought together over 120 clinicians from eight countries. Largely made up of physiotherapist’s with a special interest in pain, it was also well represented my massage therapists, Feldenkrais practitioners, exercise practitioners and even an osteopath or two. The first event of its kind in the world, it was wonderfully put together, blending science and clinical concepts.

With my pain training coming out of Sydney University medical school, my usual ‘pain gang’ are largely medically orientated bunch, and I frequently feel that I’m having to defend my position as a manual therapist working with a chronic pain population, particularly because osteopaths are often seen as very manual technique orientated. At #sdpain it was affirming to be surrounded by people who were working in the field of chronic pain as manual therapists, confidently applying approaches such as pain education, graded movement approaches and lo and behold, manual therapy, with good clinical outcomes. I felt very at home!

Lorimer Moseley kicked off proceedings on day one with his witty, funny, engaging and incredibly relevant science and clinical information. The idolisation of the man by the group at large was evident by their engagement, the lines of people afterwards to ‘pick his brains’ and the subsequent frequent references to him and his work by virtually all of the speakers that followed. It sometimes felt like a weekend of worship at the altar of Explain Pain.

And rightly so. Moseley and his equally charming co-author, David Butler, literally ‘wrote the book’ and in doing so, started a revolution that has had a massive, world wide influence on our understanding and treatment of chronic pain, particularly in the world of manual therapy. They have lead the charge with innovative research and accessible courses showing how to apply the research clinically.

For practitioners engaging with their material, opening this Pandoras box can be both exciting and terrifying, and for many, the truth that lies in the science can make it prohibitively scary to engage with (as discussed here earlier and here by Jason Silvernail). Explain Pain helps make the transition from the dark side of a biomechanical model to the more widely excepted biopsychosocial model as pain free(??) as possible.

Jason Silvernail followed Lorimer with a beautiful, big picture overview of how getting practitioners both medical and manual, as well as society as a whole, to shift their understanding of pain, is it tough but worthwhile pursuit.

Cory Blickenstaff demonstrated how teaching patients to move within pain free ranges can help to reassure their sensitised nervous systems that movement doesn’t need to be a frightening experience.

On the final day, Eric Kruger, a US physical therapist doing a PhD in psychology at the University of New Mexico, presented ‘Pain in the face of uncertainty’. Listening to him speak, I had an urge to start high-fiving people around me, not unlike the first time I listened to Peter O’Sullivan on this pod cast whilst I was doing the grocery shopping at Coles one Sunday! He focussed around why our patient’s uncertainty about their predicament largely drives their feelings of helplessness and frustration, and how reassurance, rapport and a listening ear are more valuable than we can often imagine. He emphasised that allowing patients to express their pain is important and validating. He also strongly advocated setting expectations of flare-ups as being a normal part of the rehab process, which helps the patient to stick with the treatment approach when that inevitable first flareup occurs, rather than walking away and seeing their treatment experience as yet another failed treatment.

All of the other speakers were fantastic, and the similar themes, language and approaches that were consistently coming across in their respective modalities were reassuring. It continually demonstrated a baseline understanding that all of the speakers were operating from – that of a biopsychosocial approach played out in daily practice with every patient who walks in the door.

From a social perspective, the conference for me has been a hit! I have made many wonderful connections and have enjoyed my time in San Diego. I hope to be able to return next year and can’t recommend it highly enough.

Headaches and migraines are debilitating and costly. For people who suffer with them, it is understandable that they will want to try anything that might work. An easy fix would be lovely and pursing this is an understandably tempting option. Like most other chronic conditions however, the magic silver bullet to reduce the problem is rarely going to come from a single modality treatment such as medication or manual therapy.
Getting patients to acknowledge that there might be a mind body connection in something like back pain might be tricky. We might be able to see that there are some obvious contributors and getting that message across to the patient can be a tough but important step in making progress. However headaches is an obvious one isn’t it? It is a metaphor for stress, we even have a label for one of the more common headaches – tension type headache. It’s not always an easy sell to get this one acknowledged either. Patients will often insist that if they could just get rid of the headache, their problems would be easier to tackle or wouldn’t exist. I have been guilty of this myself – so focused on a tension headache being the cause of my heightened stress levels, chasing the quick fix with the idea that taking the headache away is the number one priority. In effect – not being able to see the wood for the trees and that the heightened stress levels are majorly contributing to the headache situation. In my case, it has sometimes taken a treating practitioner to point out this situation to me. Once this has been pointed and I have acknowledged that indeed, I am under the pump and need to address the situation, the headaches invariably go. Nothing like a personal foray into pain to help boost a practitioner’s empathy and understanding!
The science is increasingly telling the story that a bigger picture approach is the key to getting good reductions in frequency and severity of chronic headaches, as well as improving the functional losses that often accompany headaches, such as days off work.

Cognitive behavioural approaches to headaches are well represented in the literature and are acknowledged by the pain community as relatively low cost, low side effect treatment for tension type headaches and migraines.(1) A study by Paul Martin and colleagues in 2007 took 51 headache and migraine suffers and allocated them into a cognitive behavioural therapy (CBT) group, a biofeedback group and a control group. The CBT group had 8, 1 hour sessions and the intervention was found to reduce headaches an average of 68% following treatment. This was compared to a 56% reduction in the biofeedback group and 20% reduction in the control group. Furthermore, in the CBT group, the headaches continued to decrease to a 12 month follow up, whereas the other groups did not. The CBT group also had a 70% reduction in medication use.(2)

Mindfulness based approaches work really well in the chronic pain setting as part of a bigger picture approach(3). A recent study published in the Clinical Journal of Pain, looked at applying Mindfulness-based stress reduction in combination with CBT approaches in treating chronic headaches. The study demonstrated that the approach gave good outcomes for pain acceptance, pain catastrophising and helped to reduce pain interference (or functional losses to due pain). This was a pilot study but showed some very promising results. (4)

Exercise approaches for tension headache and migraine have been shown to be helpful and regular exercise is often recommended in migraine treatment. For a small proportion of the migraine population however, exercise can act, or be perceived to act as a trigger for a migraine, perhaps making them avoid exercise. A study published in Cephalgia in 2011, compared three groups of intervention for migraine sufferers – an exercise group, a medication group (Topirimate –a prophylactic medication for migraine) and a relaxation group. Good reductions in migraine frequency were seen in all three groups with no statistically significant difference between them. The exercise used was a 40 minute session of indoor cycling three times a week. Of that 40 minutes, 15 minutes was a warm up, 20 minutes was the main exercise component and 5 minutes was a cool down. It terms of risks versus benefits, this shows huge potential as it is easy to implement and has virtually no side effects, compared to some of the mild side effects seen with the medication group.(5)

So whilst we might not be able to make a big impact on these types of headaches with our hands in the longer term, we can certainly be incorporating these approaches in our practice, even if it is in the form of case management – where we oversee the treatment approaches and refer to appropriate practitioners. Alternatively you may be able to implement exercise approaches either within your clinic or together with the patient as a home exercise program. Starting patients on mindfulness meditation is a no-brainer and essentially is a free kick at goal for the results you can achieve versus the effort and cost to implement it. You can use something like the smiling mind app and website to help get things going.

You may be able to refer your patient to a psychologist for some cognitive behavioural therapy.  Our listening ears and a good referral base of practitioners in this case are the thing that is most likely going to give good outcomes for the patient. The impact that this can have should not be underestimated.

1. Rains, J., Penzien, D., McCrory, D., & Gray, R. (2005). Behavioural treatment: History, review of the empirical literature and methodological critique. Headache, 45(Suppl.2), S92-109.
2. Martin, P., Forsyth, M., & Reece, J. (2007). Cognitive-behavioural therapy versus temporal pulse amplitude biofeedback training for recurrent headache. Behavior Therapy, 38, 350-363.
3. Mars, T., & Abbey, H. (2010). Mindfulness meditation practice as a healthcare intervention: A systematic review. International Journal of Osteopathic Medicine. 13(2), 55-66.
4. Day, M., Thorn, B., Ward, C., Rubin, N., Hickman, S., Scogin, F., & Kilgo, G. (2014). Mindfulness-based cognitive therapy for the treatment of headache pain. A pilot study. Clinical Journal of Pain, 30(2), 152-161.
5. Varkey,E., Cider, A., Carlsson, J., & Linde, M. (2011). Exercise as migraine prophylaxis: A randomized study using relaxation and topirimate as controls. Cephalgia. 31(14), 1428-1438.

I seem to be seeing my fair share of patients presenting with headaches at the moment – this last week roughly half of my clinic time has spent working with patients presenting with a headache on its own, or in combination with other musculoskeletal complaints. There are a couple of things that I feel are important for breaking a headache cycle –
• The person needs to acknowledge a connection between their emotions/stress levels/current situation and how that is contributing to their headache
• They need to have some level of “body awareness” – to be able to tune into where they are holding tension in their body (jaw, shoulders, upper neck etc) and be therefore able to consciously relax that area.

Creating awareness around these areas can be a difficult task – some people walk in the door and are already on board with the ideas, telling you that things have worsened since circumstances have changed such as increased work hours or a stressful situation has reared its head. For other people, I sometimes feel like I am bashing my own head against the wall trying to get these concepts across – particularly for those who have some strongly entrenched ideas around the neck being the cause of their headache. These patients are often stuck in passive mode, believing that it is the practitioners’ job to take the headache away for them. They tend to have a cause and effect understanding about their headache which usually goes along the lines of “my neck is out/tight/sore and therefore I have a headache”. But the reality is, as discussed last time, a true cervicogenic headache is actually not that common. We will often be seeing patients with a tension type headache, who are also experiencing concurrent upper cervical pain, due to the way that the information from the head and neck are processed in the brain, particularly at the trigeminocervical nucleus.

One patient summed up the attitude that I felt I had been dealing with all week – “I haven’t got time for a headache”. A busy, self employed designer, working to some pretty tight deadlines, doing 15 hour days at the computer, sleeping in the spare room so as not to wake her partner when the insomnia was bad…………. You know the story! It took three weeks of both her GP and I saying the same things before if finally sunk in and she made some changes – we need to address the mechanical factors (time and posture at the desk), the stress levels (do your daily mindfulness exercises, make that appointment with the psychologist you have been saying you will do, schedule some down time into the diary) and for goodness sake, get some exercise! The absurdity of that statement and ironic laughs that followed probably helped to put it all into perspective for her.

So what does the literature tell us about treatment of headaches, particularly the persistent ones?
As discussed previously, a true cervicogenic headache will tend to respond fairly well to manual therapy and manipulation approaches as well as exercise approaches. A study done by Jull in 2002 (1) demonstrated that in a group of 200 subjects with a diagnosed cervicogenic headache (change in cervical range of motion, reduced control of craniocervical flexion muscles and pain on palpation of C0-C4) significant reductions in headache frequency and intensity were see in in both musculoskeletal therapy groups and specific muscle exercise therapy groups when compared to the control group. Furthermore, combining both exercise and manual therapy gave good relief to 10% more people than in the single intervention groups. Similarly a study by Haas in 2010 (2) demonstrated good reduction in cervicogenic headaches with weekly cervical manipulation, however doubling the number of treatments to two per week gave no further significant improvements.

In treating migraine headaches there is limited high quality data available regarding manual therapy interventions. Some lower quality studies demonstrated that manipulation was as effective as Amytriptyline (an older style antidepressant, often used in low doses for chronic conditions like migraine) in preventing onset of migraine. Another showed that mobilisation of the neck would have an effect on reducing migraines, but manipulation was no more effective than the mobilisation (3).

Several review articles (4,5) tell us that manual therapy is not effective for treating tension type headaches, however both reviews acknowledge that the studies included were of poor quality and therefore drawing solid conclusions about this is not possible. The tricky bit probably lies in the difficulty in accurately diagnosing a headache, given that frequently there are overlapping features of several types of headaches. See here for a reminder on the clinical features of the different types of common headaches. The answer to whether manual therapy is always the way forward is therefore going to be along the lines of how we answer this question for most chronic conditions – probably not on its own, but in conjunction with other approaches there is certainly a strong justification for its use. Manual therapists are going to be well placed to put together a management program that can combine these approaches and manage their implementation.

Mindfulness exercises, psychological approaches and exercises approaches are fairly well represented in the literature and show some really promising results in the treatment of a variety of different types of headaches, including migraines. Next time we will look at what these approaches are and how you can start using some of them in your private practice.

1. Jull, G., Trott, P., Potter, H., Zito, G., Niere, K., Shirley, D., Emberson, J., Marschner, I., & Richardson, C. (2002). A randomized controlled trial of exercise and manipulative therapy for cervicogenic headache. Spine, 1:27(17), 1835-43.

2. Haas, M., Spegman, A., Peterson, D., Aickin, M & Vavrek, N. (2010). Dose-Response and Efficacy of Spinal Manipulation for Chronic Cervicogenic Headache: A Pilot Randomized controlled Trial. Spine, 10(2), 117.

3. Posadzki, P., & Ernst, E. (2011). Spinal Manipulation: an update of a systematic review of systematic reviews. New Zealand Medical Journal 12:124(1340), 55-71.

4. Bronfort,G., Haas, M., Evans, R., Leininger, B., & Triano, J. (2010). Effectiveness of manual therapies: The UK evidence report. Journal of Chiropractic and Osteopathy. 25, 18.

5. Fernandez-de-Las-Pena, C., Alonso-Blanco, C., Cuadrado, M., Miangolarra, J., Barriga, F & Pareja, J. (2006). Are manual therapies effective in reducing pain from tension-type headache?:a systematic review. Clinical Journal of Pain, 22(3), 278-85.

Headaches are frequent causes for presentations at most manual therapy clinics.  Headaches can be debilitating, annoying and all encompassing, be they migraine, tension type headaches, cervicogenic  or the less common autonomic cephalgias such as cluster headaches (sometimes called suicide headaches). People will frequently seek out manual therapy because when their head hurts, they also will tend to have neck pain.  Studies tell us that 64-70% of people with headache and migraine will also have neck pain ¹.

Is the neck the cause of the headache?

In some cases, yes.  In reality though, cervicogenic headaches actually make up a fairly small proportion (18%) of the headache sufferer population ².  To be classified as a cervicogenic headache (and be therefore most likely to respond to manual therapy) the headache must be precipitated by neck movements or postures and/or pressure over the upper cervical/ occipital regions, have restriction in neck ROM and have weakness in the deep cervical flexors.  Cervicogenic headaches are also typically side dominant and don’t throb³.

Typically, manual therapists tend to place a lot of emphasis for diagnosis of a cervicogenic headache on the ability to reproduce the headache with palpation of the upper cervical region.  However this is a bit of an erroneous test because we know that almost 100% of patients with either a tension type headache or a migraine will also get reproduction of their headache with palpation of the upper cervicals⁴.   This is most likely due to the phenomenon of convergence at the Trigeminocervical nucleus(TCN) , where information from both the upper three cervical vertebra and the trigeminal nerve feed into the same region in the brain.  Like other types of convergence or referred pain, the brain can’t figure out where the pain is coming from and so both can tend to be painful.  In the chronic headache sufferer, the TCN undergoes central sensitisation processes, making it more likely to interpret and pass on information of a painful nature.

The literature tells us that physical treatment for headaches tends to only give sustained benefit to those people who genuinely fall into the cervicogenic headache category ⁵ .  However, as practitioners we have all seen instances when some level of relief from manual therapy has been achieved for a headache that falls outside of these categories, including for those suffering from tension type headaches.  In these instances, we are probably having a modulatory effect on the TCN.

As an occasional tension headache sufferer, I would argue that any benefit that can be achieved from manual therapy for a non cervicogenic headache  is  fantastic and is worth pursuing – with the caveat that both the practitioner and patient understand the context of use – to provide temporary relief as part of a bigger picture of treatment.  We should not be suggesting that we can comprehensively treat all types of headaches using manual therapy alone.  As in all chronic conditions, passive approaches such as this are not the answer.

The literature is very good at telling us what doesn’t work for a particular condition, and headaches are no different in this instance.  In the next blog post we will look at some of the approaches that are known to have an effect on headache frequency, intensity and medication use.  Surely all this research has to be good for something!

 

1. Blau, J., MacGregor, E. (1994). Headache and the neck.  Headache, 35(2), 104-106.
2. Nilsson, N. (1995). The prevalence of cervicogenic headache in a random population sample of 20-59 year olds. Spine, 1:20 (17) 1884-1888.
3. Hall, T., Briffa, K., & Hoppa, D. (2008). Clinical evaluation of cervicogenic headache: A clinical perspective. The Journal of Manual and Manipulative Therapy, 16(2) 73-80.
4. Watson, D., & Drummond, D. (2012). Headache pain referral during examination of the neck in migraine and tension-type headache. Headache, 52(8), 1226-35
5. Bronfort,G., Haas, M., Evans, R., Leininger, B., & Triano, J. (2010). Effectiveness of manual therapies: The UK evidence report. Journal of Chiropractic and Osteopathy. 25, 18.

Exercise is an essential part of any rehabilitation approach to chronic pain. 

Our clinical experience as well as the literature tells us that it works ^1,2.

Further to this, there doesn’t seem to be much evidence to tell us which exercise works best – whether we choose motor control type exercises, graded strength based approaches or even aerobic exercises. Regardless of what exercise you choose, you are likely to see improvement in pain and function ³.

Start With Success

When we are setting someone up with an exercise program as part of a management program, it is incredibly important that we put a lot of effort into making sure that the program is going to be ongoing. 

In the event that they don’t stick with the exercise program and stop doing it before it can start to have the anticipated positive effects, the take home message for the patient is “exercise doesn’t work for my pain”.  

It becomes for them yet another failed treatment and can feed into the cycle of hopelessness that many chronic pain suffers experience.  By having a half-hearted go at exercise and failing, it may have inadvertently done more harm than good.

Engage Your Patients

Research tells us that adherence to home exercise programs on the whole is an uphill battle, with up to 70% of patient not engaging in prescribed home exercises ⁴.

Efforts to increase compliance such as involving the patient in the planning and goal setting process, formally establishing motivation and compliance, exploring the patient’s beliefs about exercise and pain, planning for and troubleshooting obstacles and setbacks and regular follow ups to check compliance have been shown to dramatically improve adherence to exercise programs ⁴.

Teamwork Makes The Dream Work

For people who haven’t got a strong exercise history, starting out with a high level of support is going to mean better adherence in both the short and long term.

Telling someone to start exercising, without much guidance or support is likely to last about two weeks – until the rain, cold, dark, sickness, increased pain or countless other obstacles rear their ugly head. 

Your Guide To Success

Specifically, to increase your chances of getting an exercise program to stick the following can be helpful:

• Establish motivation – why are you here? What do you want to get out of this?
• What do you enjoy doing? What fits in with your lifestyle? What are you likely to stick with?
• What do you understand about your pain and how exercise effects it and vice versa?
• Try to make sure the exercise is scheduled, especially for the first few months. This might mean that the person attends a class, personal training session, clinical pilates, small group training, bootcamp, crossfit etc. When it is scheduled into their diary and they are expected to attend, the chances of them turning up are greater.  This is often even further evident when there is a financial commitment attached to that session (ie. they still pay for the session in the event they don’t turn up!). If the sessions are not as individualised as something like a personal training session, getting them to create a diary entry for something like a gym class is the next best thing.
• Having a high level of supervision, particularly in the early phases can be really helpful in building confidence. This is particularly important when there is a level of fear avoidance.  If there is someone qualified who can confidently say to the client that the exercise they are doing is safe and won’t be causing damage, they are more likely to engage in the exercise even if there is some pain associated.   There is also greater chance that the exercises will be appropriately progressed and therefore you will see better results.
• For people who are struggling to see the value in, or are unable to afford these types of highly supervised sessions on an ongoing basis, I often suggest that they start with a period of 8-12 weeks on such a program and then review it. More often than not, when the review time comes around, they have seen the value in the sessions and the results that are happening. They will often be happy to continue because they are enjoying the progress they are making.  If they choose not to keep going, you have at least got a level of habit, some confidence and success, to keep going on a slightly less supervised program.
• Making a fairly direct referral to the exercise practitioner also helps with the uptake of your suggestion. If you are referring to someone that you know and trust, and can help the person to facilitate contact with that person, you can help smooth the way to the start of their journey.  When they are aware that you trust the practitioner, they will have a greater level of confidence in them too.  This works particularly well when you have your rehab options “in-house” but can also work  with some well established local networks.

Upcoming Seminars

Check out our upcoming events for details on future seminars and workshops that cover topics like goal setting and pain education.

References

1. Van Middelkoop, M., Rubinstein, S., Verhagen, A., Ostelo, R., Koes, B., & van Tulder, M. (2010). Exercise therapy for chronic nonspecific low back pain. Best Practice and Research Clinical Rheumatology, 24, 193-204
2. Hayden, J., van Tulder, M., Malmivaara, A., et al. (2005) Exercise therapy for treatment of non-specific low back pain.  Cochrane Database Syst Rev, (3). CD000335
3. Gazzi Macedo, L., Latimer, J., Maher, C., et al.(2012). Effect of motor control exercises versus graded activity in patients with nonspecific low back pain: A randomized controlled trial.  Physical Therapy, 92 (3), 363-377.
4. Beinart, N., Goodchild, C., Weinman, J., Ayis, S., & Godfrey, (2013). Individual and intervention-related factors associated with adherence to home exercise in chronic low back pain: a systematic review.  The Spine Journal, 13, 1940-1950.

Manual therapy is not effective in the long term in treating chronic pain^1,2.  It’s the elephant in the room that is harder for some practitioners to acknowledge than others.  Is it the fear that this science might make manual practitioners obsolete in managing these patients, that makes it easier to ignore or dismiss than engage with?

 

Some manual practitioners might have difficulty engaging with pain science because they are quietly thinking “but what I do works – I make people feel better”.  And there is a reason that they think this – a lot of the time, patients will get a level of pain relief from manual therapy.  Practitioners will hear it day in and day out – “it feels a lot easier/more free/less painful” after a treatment.  It affirms that what we do is hitting the spot and having an effect…….. but the problem is, if we continue with this model of care in the chronic pain setting, we will be having this conversation over and over and over because the relief that people feel in this situation is overwhelmingly going to be temporary.

The temptation for manual practitioners delving into pain science might be to disengage with the material all together – “you can’t measure what we do,” “I am confident that I am making a difference,” “my patients tell me it helps them,” or “perhaps what you do doesn’t work, but I practice this particular stream of manual therapy techniques and I fix people with chronic pain.

 

In order for us to get good acceptance of pain science in manual therapies, we need to make sure that our approaches don’t throw the baby out with the bath water – manual therapy can still have a place in the chronic pain setting, it just has to be used in a very defined context that is understood by both the practitioner and the patient.  We also need to offer manual therapists some really good options for how to incorporate an understanding of pain physiology into their practice.  There are plenty of “non hands on” evidence based approaches that demonstrate good clinical outcomes,  that can be used in private practices such as osteopathic, physiotherapy, myotherapy or massage practices. These might include exercise, mindfulness, pain education and cognitive behavioural therapy (CBT) approaches.  Up-skilling manual therapists in these approaches makes a lot of sense – who else has good palpation and assessment skills, an opportunity to create good rapport with patients due to the nature of our longer consultations and a solid health sciences background?

 

I firmly believe that active approaches are the way forward in both the acute and chronic setting.  However I still use my hands on skills every day in practice.

 

• Being able to reproduce a patient’s pain in an initial consultation during the examination process demonstrates to the patient that you have listened to their story and that you believe that their pain is real.  This is very important if you are including, or the patient has been exposed to pain education material that tells a story of central sensitisation.  One of goals of pain education is to help the patient to separate out the sensation of pain and the idea that the pain is representative of tissue damage.  We teach that the mechanisms perpetuating the pain are located not so much in the original tissue, but in the central nervous system, and if we are not careful, we can convey the idea that the pain is not real.

 

• Having a good idea of where and how the pain can be reproduced gives us a “yard stick”.  We can get the patient to engage in active approaches and demonstrate to them how these can improve the level of pain provoked on palpation or with other examination techniques, thereby reinforcing that these approaches are effective.

 

• When you are starting movement based approaches or starting a chronic pain management program that removes or reduces some of the “crutches” that people have been using, (including the reduction of opioids), patients are likely to experience times of increased pain, often for several weeks before the introduced approaches start to have an effect.  This can reduce the patient’s acceptance of the outlined management and they can potentially fall off the wagon.  If manual therapy had worked for them in the past in temporarily reducing their pain, then using it in the short term as the program is getting started is probably justified, as long as both practitioner and patient know that that is the context it is being used in and that the expectation is that over a period of time it will be reduced or stopped.

 

• No matter how well we try to educate our patients, reframe our management approaches and attempt to get the patient to embrace active approaches, there are some that are going to be resentful in coming to see a manual therapist without receiving manual therapy.  This is particularly prominent in patients who have attended other practitioners of  your particular profession or even other practitioners in the clinic and long held that  expectation. There is probably a case to be argued that refusing to treat these patients with any manual therapy will result in them leaving the clinic and searching for the next practitioner/therapy/intervention that is going “cure” their pain.  In these cases perhaps a softly softly approach might work better- a combination of gradually introducing pain concepts and active approaches  whilst gradually reducing their reliance on manual therapy.  We know that these patients are particularly vulnerable to anyone who offers them a quick fix – it could be argued that even though it doesn’t fall strictly within the bounds of an evidence based approach at the outset, if you are moving them in the right direction, it is a better outcome than losing them to the expensive miracle healer around the corner.

 

What do you think?  Should we interpret evidence in a black and white manner or is there room to read between the lines?  Is any form of manual therapy in the chronic setting to be avoided altogether because it sends the wrong message to the patient?   Are there other aspects of using manual therapy in chronic settings that might be considered helpful?  Discussion and comments welcome.

 

 

1. Rubinstein, S., van Middelkoop, M., Assendelft, W., de Boer, M.,& van Tulder, M. 2011. Spinal Manipulative Therapy for Chronic Low-Back Pain: An Update of a Cochrane Review. Spine 36,13

1. Loeser, J. & Turk, D. (2001). Multidiciplinary pain management.  In Loeser J (3^rd ed., pp2069-2080).  Philadelphia:Lippincott.  Bonica’s Management of Pain.       Williams and  Wilkins.

A young regular client comes in to see you with knee pain that has come on after she started riding her bike more often and began an exercise class that included a bit of running.  You examine her and decide that she has a mild patella tracking issue that is causing a touch of patello-femoral pain.  It should respond to your management plan – some strengthening, a bit of stretching and some manual therapy.  No problems!  She does well on the plan and returns a week later reporting a 50% decrease in her symptoms and seems happy.  The following week however, she offers to fill in for a friend’s futsal team and plays not one but two games in the middle of the week.  Her knee pain returns as does the swelling.  Your reassure her and explain that you are confident that the backward step is explained by the excessive overloading of the tissues and that once this flare up settles she will continue to improve on the course of treatment you had initially outlined.

However……  she seems to be having a minor meltdown about the knee situation.  She is crying and doesn’t seem to believe what you have to say.  She is anxious to get the manual therapy started.  While she is on the table you ask her what it is about the situation that she is most worried about.  She gathers her thoughts and tells you:

• I have had such an awful time with my back pain (that you have treated her for over the years) and it has dominated my life. I am worried that my knee will not get better and I will need to constantly be stopping doing what I enjoy doing and will need to be spending money on treatment all the time
• I am angry that I can’t do the things that I want to do. I should be able to play game of soccer with my mates.
• My cousin has been diagnosed with rheumatoid arthritis. She was really fit and healthy and now she can’t run or do much.  I am worried that I am going to end up like her.

She also tells you that she has been under a lot of stress with a deadline at work and hasn’t slept well for about a week.  She is exhausted.  You decide to address her concerns and help her to identify how real the thoughts around her knee are, and if they are unhelpful and likely to be hindering her recovery.  Using open ended questions you begin to tease out a more balanced view of the situation:

• How has your back been lately? I thought you felt that you were getting on top of it a bit more?
  • She replies “That is true. I haven’t really felt it much in the past few months and it has been even better since I started bootcamp” 
• If your back got better with our plan of attack, what do you think is likely to happen with the knee?
  • “It would probably keep getting better like it had been doing. I guess I just got a bit carried away and was having too much fun with the soccer and I overdid it” 
• You had been building up your running and exercise tolerance beautifully in the last few months. You probably would have been fine to start back at soccer once the knee had settled a bit more, but a gradual approach might have been a bit better.  Do you think your expectations weren’t matching up to the actual picture of your current fitness and injury level?
  • “I guess so. I have always been pretty competitive and been tempted to push through. I probably shouldn’t feel angry about it because it was a bit of a silly thing to do”
• You mentioned your cousin a few weeks ago. It obviously a really stressful thing to watch her going through.  What makes you think you will end up like her?
  • “It’s genetic isn’t it? I am worried that it might be the cause of my knee pain.  But I googled it doesn’t really sound like what I have got going on.  I think I am just really upset about seeing it stop her.”
• In this case “google doctor” is probably right. You don’t have any other signs or symptoms that might indicate that you have rheumatoid arthritis.   Also, based on what I have observed with your knee and what you have told me, I am confident that our initial diagnosis still fits.  Does that make you feel a little easier about those fears?
  • “Yes, I think I knew that but it is nice to hear it. I am just so tired I feel like I can’t think straight!”
• Yes, a lack of sleep certainly can cloud our ability to see the issues clearly

 

If you enjoy spending time chatting with clients during consultations, it is likely that you have had many conversations like this in your work.  You are probably using some principles from a cognitive behavioural therapy model (CBT) in situations like this nearly every day.

Following the treatment, it is really likely that this person will stand up and feel an awful lot better and it is unlikely that your magic hands are the prime cause of the improvement.  Addressing the  emotional distress components of a pain experience is a really powerful clinical tool.  It is even better if you can encourage the person to challenge their unhelpful thoughts themselves in their everyday lives as it means that when the same thoughts pop up again later and causes them to feel those uncomfortable emotions (anger, fear, panic) they can negate or rationalise the thoughts that are underpinning those emotions.  This approach is in line with CBT models of treatment, often employed by psychologists.

CBT works with people to recognise the connections between the emotions, behaviours, thoughts and physical reactions that all occur in response to a situation.  It aims to give a person the skills to be able to solve their own problems and to manage their own psychological responses to situations.  It is accessible, easy to understand and it works for many conditions including anxiety, depression, sleep disturbance to mention a few.  With regards to chronic pain, it has been shown to help increase functional activity, reduce medication use, and improve mood ¹.   Used on its own it is unlikely to have a lasting impact for the patient in chronic pain²,  however in combination with exercise approaches it produces superior outcomes ³.   Which makes sense – if you can address the unhelpful thoughts that are preventing someone from engaging in movement or rehabilitation approaches and reduce distress about their condition, they will often do better.

Some of the CBT principles don’t have to be done as formally as a structured therapeutic program psychologists are likely to employ – you can (and probably already do) use the approach more informally by helping patients to challenge unhelpful thoughts about their conditions.  In fact, as a practitioner who knows a lot about musculoskeletal problems, you are well placed to help them gain a better understanding and perspective of their condition.  Having said that, formal instruction around skills that  patients can practice in their everyday lives is an empowering tool for them and satisfying for clinician’s who can make a real difference to their patient’s quality of life.     Studies have also shown that with appropriate training in CBT techniques, other allied health professionals, besides psychologists, can get good results when using this approach with chronic pain patients ⁴.  As always, it is important to know the boundaries of your scope of practice and refer on to a clinical psychologist if your patient is presenting with wider ranging psychological problems then a specific chronic pain issue.  However if your goal is to help a patient to address unhelpful thoughts around their pain or musculoskeletal condition specifically, with  training, mentoring/supervision and wide reading on the topic, you can easily start to incorporate some of these skills into your practice.

Beyond Mechanical Pain will be running workshops in 2015, which will teach health practitioners practical CBT skills.  Our Clinical Neuropsychologist Dr Joanne Sherry will be teaching these components of the workshops.  The day long workshop will also teach skills around how to deliver pain education to clients and  mindfulness based approaches for pain.  Places will be limited.  To register your interest email [email protected]

 

 

 

1. William, A., Eccleston, C. & Morley, S. (2012). Psychological therapies for management of chronic pain (excluding headache) in adults. Cochrane Database Systems Review, Nov14.
2. Ostelo, R., Van Tulder, M., Vlaeyen, J., Linton, S., Moreley, S., & Assendelft, W. (2005). Behavioural treatment for chronic low back pain, Cochrane Database Systems Review, CDOO2014
3. Vibe Fersum, K., O’Sullivan, P., Skouen, J., Smith, A., & Kvale, A. (2013). Efficacy of classification-based  cognitive functional therapy in patients with non-specific chronic low back pain: A randomized controlled trial.  European Journal of Pain. 17,6, 916-928.
4. Woby, S., Roach, N., Urmston, M., &  Watson,P. (2008). Outcome following a  physiotherapist-led intervention for chronic low back pain: the important role of cognitive processes. Physiotherapy, 94, 115-124.

 

 

Switching a patient from a predominantly passive approach to an active approach can be a tricky proposition.  Generally, if someone is used to coming in for manual treatment and has not been using active approaches to address their pain, there is always going to be an element of “handing over their health” to the practitioner – that is, that there is an undertone in that consultation, that to a certain degree, the practitioner is responsible for the outcomes of the treatment and the progression of the pain state.  When things go wrong (flare ups) or improvement in pain scores aren’t being seen, it is easy for the patient to think that the fault lies with the practitioner – are they withholding treatments that were previously effective in the earlier days of treatment, are they doing the techniques wrong – too hard, too soft, in the wrong place and so on? Unfortunately, this is the nature of passive approaches – the patient is relying on something or someone to take the pain away from them.  Not only is this disempowering for the patient, but it puts a lot of pressure on the practitioner.

With a little knowledge about pain science and the changes that occur in central sensitisation, we know that we can’t make the chronic pain sufferer’s pain go away by massaging, stretching or manipulating the tissues that were initially causing the symptoms.  In the chronic pain patient, the tissue causing the symptoms (in this case –perpetuating the pain) is the central nervous system.  Its plastic nature means that the changes that have occurred to create the persisting pain state, can potentially be changed back. To effectively tackle this though, we know we need to take a broader approach and include education, stress reduction, movement rehabilitation and thought based approaches as well as manual therapy in the right context.

How do we make this switch, when the therapeutic relationship has been established with a passive basis for some time?  This is tough situation and one that doesn’t always have good outcomes.  If we suddenly want to introduce exercise, pacing, thought challenging and other self management strategies  into our management of a chronic pain situation, where the patient has long been relying on the practitioner to do the work for them, it can upset the status quo.  Frequently patients can feel that the practitioner is no longer “there for them”  or can even feel that they no longer care about the person’s pain – because ultimately, making that switch from passive to active is removing the responsibility for the outcomes, from the practitioner to the patient – handing them back their health.

To give this process the best possible chance of happening effectively there are a few things to keep in mind:

• Sometimes it can be easier to refer to the patient to another practitioner within the clinic or to someone you know will work using a biopsychosocial approach. This has the advantage that you can separate your approach from the next practitioner’s approach and the patient can start afresh.  It is really helpful if you can set up their expectations for the new approach, mainly with the idea that there will be exercise involved and a lot more talking about the understanding of their condition and less hands on therapy.  This sets up for movement rehab approaches, education and cognitive behavioural therapy (CBT) approaches.  If the patient goes along expecting these approaches, the subsequent practitioner is more likely to be able to successfully integrate them.
• If you can’t refer on due to a lack of appropriate practitioners or because the patient is not keen to see anyone else, then start with good pain education. Set aside up to an hour and let the patient know that most of that time will be spent talking.  Explain, using as many resources as you can, the basics of pain physiology and the changes that occur from acute situations to chronic situations.  This will help to explain why passive approaches haven’t been effective at resolving the situation and can help underpin why you feel active approaches will give better outcomes.  You might be surprised at the level of information they can take on board.  You can back up this session by loaning a book with similar information such as Explain Pain ¹ or Manage Your Pain ² and asking them to read it as homework.   This video by the Hunter Integrated Pain Services team can also be helpful  : https://www.youtube.com/watch?v=4b8oB757DKc
• You can then take a gently – gently approach and begin to add active approaches. You could start by switching manual therapy sessions to exercise or stretching based sessions within your rooms.  You could add homework exercises and work up to a level of supported external exercises such as personal training, pilates or yoga.  Add some mindfulness training to their homework and you are well on your way.
• You can still use manual therapy as part of the process. We know that it makes people feel better, and even if those effects are only temporary we can take advantage of them – The feel-good factor following manual therapy can boost morale and make people feel a bit more positive about their situation.  Additionally if you improve the function of a joint or region by increasing it’s range of motion or decreasing the pain associated with movement you can hopefully get better engagement with movement based approaches.  You just need to make sure that the patient understands the purpose of the treatment is for those reasons and is not aiming to be curative.

 

1. Butler, D & Moseley, L. (2003) Explain Pain. NOI Group Publishing, Adelaide
2. Nicholas, M., Siddal, P., Tonkin, L., & Beeston L. (2002) Manage Your Pain: Practical and Positive Ways of Adapting to Chronic Pain, 3^rd Harper Collins.

For the person who has had pain for a long time, particularly when they have been on “the search” – for the right practitioner, therapy or intervention that holds the magic bullet to cure their pain, setting goals that are reasonable can be the first hurdle to overcome.

A Common Clinical Tale

Recently I treated a young girl who has had various longstanding painful conditions.

She worked in a manual job that she enjoyed and two of these conditions had begun following incidents at work.  She left one job after feeling that her bosses and work colleagues were turning on her.  It was a traumatic experience and one that she felt both angry and sad about.

In her subsequent job she  also had a minor injury and was starting to recognise some of the same patterns that had occurred at her last job – she felt like she was being excluded by co-workers and that there was a general lack of support offered to her regarding working around her injuries and concerns by management.

She was no longer really enjoying going to work, despite still really loving the actual manual work and the satisfaction that came with completing a job well.

A Common Clinical Challenge

With a long history of relying on manual therapy (weekly treatments for many years covered by 3^rd party insurance), and a strongly held belief that she was entitled to a cure because the initial injury was not her fault, we started our pain education sessions with a lot of discussion around reasonable expectations and goals.

She had several “ah –ha” moments following pain physiology explanations and was engaged with the material, remarking that it both fitted with her situation and that it made a lot of sense.

Her level of insight into her condition was very high and she was quite open to digging into her understanding of her condition in subsequent cognitive behavioural therapy sessions, coming up with the ideas that her anger at both workplaces had been contributing to creating the conflict.

She also felt that once she had thought things through, the bosses weren’t really responsible for her recovery or happiness at work.  She challenged the idea that she held that they didn’t care about her, by reflecting on the fact that they were very busy and didn’t tend to have a great deal of contact with the workers.  Therefore the lack of care that she perceived probably wasn’t deliberate on their part.  This lead to a realization on her part that punishing the bosses and the company by taking days off work probably wasn’t going to achieve the outcome she wanted!

Setting Goals to Move Forward

We know these are really important factors in the success of return to work following an injury – if workers feel well supported they will tend to do better¹.

It would be great if we could encourage all workplaces to embrace this understanding – but failing that, it can be helpful to work with the patient about their understanding of the situation.

After two sessions (2 x 1  hour sessions on pain education,  goal setting, flare up management and thought challenging) we had come up with some more reasonable goals that were based more around function rather that curing her pain.

Some of these included goals around work – like getting her to challenge her thoughts at the time of deciding to take a day off work.  Other goals included reading the book:  Manage your Pain² to reinforce some of the pain principles that we had discussed.

She was feeling a lot better about her situation and this was reflected in a fairly dramatic improvement in her Pain Catastrophizing Scale(PCS) scores.   She was also taking less days off work and going to the gym more often.  Her pain levels were still up and down but overall she was reporting feeling a bit better.

A Successful Outcome?

Evaluating success in cases like this are not as black and white as they might be in acute cases. 

Complete relief from pain does occur sometimes, but this is not really backed up by the literature, which tells us that while good functional outcomes can be achieved and distress and medication usage can all be reduced, significant reductions in pain scores are not always easy to come by³.

Having said that, these figures are mostly coming from Interdisciplinary pain clinics, whose patients have been in pain an average of 7  years prior to presentation⁴ and are likely to be more disabled and unemployed than patients that we might see in a private practice setting. Therefore we would hope to be seeing some good reductions in pain scores at least some of the time.

In the case of this young girl, my benchmarks for success were based around keeping her in paid employment and managing the falls off the wagon, which have so far occurred twice since our initial goal setting sessions.

These temporary backward steps were always likely to occur as she had some big yellow flags from the outset and breaking those long held beliefs was going to be tough at times.

For her, knowing that her GP, psychologist and myself were all on the same page about the situation was helpful for her and enabled her to bounce back from the minor setbacks.

Upcoming Seminars

Check out our upcoming events for details on future seminars and workshops that cover topics like goal setting and pain education.

References

1. W Shaw, C Main & V Johnston, “Addressing occupational factors in the management of low back pain: implications for physical therapist practice. [Review]” Physical Therapy,  91(5) (2011), 777-89.
2. Michael Nicholas, Allan Molloy, Lois Tonks & Lee Beeston, “Manage Your Pain: Practical and Positive Ways of Adapting to Chronic Pain”, 3^rd (2012), Harper Collins
3. Dennis Turk, “Clinical effectiveness and cost-effectiveness of treatments for patients with chronic pain”  Clinical Journal of Pain, 18, (2002), 355-365.
4. H Davies, T Crombie, J Brown & C Martin, “Diminishing returns or appropriate treatment strategy? An analysis of short term outcomes after pain clinic treatment”, Pain, 70 (1997), 203-208.

 

When a person who has had persisting pain for a period of time commences any form of exercise as part of a rehabilitation program, it is likely that they will experience periods of increased pain or acute flare ups.  This is because they are likely to have some level of central sensitisation that will tend to lower their threshold for pain signals to be sent to, and interpreted by the brain as a pain experience.  Additionally their descending modulatory systems (such as the GABA, serotonin and a-adrenergic systems), that would normally suppress information of a less threatening nature are likely to be severely inhibited, therefore allowing the brain to be bombarded with pain signals that ordinarily wouldn’t make it through.  However, even when a healthy person starts a movement program that they haven’t previously done, they are likely to experience some level of discomfort or even temporary pain as their body adjusts to the new movement and loading patterns being asked of it.

When starting someone on a movement program who has chronic pain, it is important to explain this concept to them.  In the process of educating them and forewarning them of the possibility of increased pain in the initial phases, we are helping to set their expectations and therefore reduce their levels of distress in the event that they do have a flare up.  It helps to normalise the situation and “normal” reduces fear.

Movement is an essential part of any program help people with chronic pain move to a better functional state. Combined with other active modalities such as stretching, modulation of activities, thought management (such as cognitive behavioural therapy) and returning to work, we are likely to see much better outcomes than those we would expect when patients continue with passive modalities such as manual therapy or medication ¹.

Here are a few steps to help set up expectations for a movement program:

1. Start with solid pain education including pathophysiological changes that occur in peripheral nerve tissues, the spinal cord and brain in persisting pain states. This helps to underpin your management which is going to involve normal movement to hopefully reverse some of these changes.  It helps with the uptake of the exercise and other components.
2. Include in your education the concept of flare ups and expectations that they might occur
3. Further diffuse the fear associated with the potential for flare ups by arming the patient with a series of pain breaks. These are techniques and tools that they can use to temporarily reduce pain levels.  Pain breaks may reduce pain scores enough to make the person feel more positive, move better and reduce some of the accompanying muscular tension that tends to go hand in hand with higher levels of pain.  In some cases the pain break allows the nervous system to take a moment of rest and can break or reduce the pain cycle.  Pain breaks might include:

• Very hot shower over the affected area for a period of time (make sure to warn the person not to burn themselves)
• TENs machine for 20-30 minutes
• Series of exercises or stretches
• Medication that has been prescribed for breakthrough pain
• Cognitive Behavioural Therapy worksheets
• Mindfulness meditation
• Manual therapy

As some of the above pain breaks could be considered passive interventions, it is important that you explain the context that they will be used in – that is that they are short term interventions used to break the pain cycle – not something that is aiming to be curative or used in the long term.  They help to improve function in the short term so that progress can continue through to the longer term.

 

1. Lynn Snow-Turek, Margaret Norris & Gabriel Tan, “Active and passive coping strategies in chronic pain patients” Pain, 64 (1996): 455-462.