Decreasing Chronic Pain

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One hundred million adults in America suffer from chronic pain. This is greater than the number of individuals affected by diabetes, cancer, and heart disease combined! The evidence on chronic pain and what decreases symptoms or improves outcomes for this population is plentiful. However, clear and decisive answers on what should be done to decrease chronic pain have not been found. The research is indicating that a multimodal approach is required to treat each patient individually with their personal beliefs, goals, and expectations.

There has been one modality that repeatedly decreases symptoms – EXERCISE! Research has found that adults who participate in higher levels of physical activity have more effective pain modulation. In fact, exercise can decrease the perception of pain even if you are not exercising the painful region. Say that you have low back pain and decide to go ride a recumbent bike. Your back is supported so the bike riding does not increase your symptoms AND your leg movement helps to decrease you perception of pain. (In addition, you burn calories, improve heart health, and release endorphins which are all good things.) This is called exercise induced hypoalgesia and has been shown to affect a multitude of chronic pain conditions. Five systematic reviews concluded that walking improved pain for individuals with chronic musculoskeletal pain, low back pain, knee osteoarthritis, and intermittent claudication.
Now, you may have tried exercise for your chronic pain and found that it increased symptoms. There is one caveat found in the literature – not all exercise is created equally. Some conditions respond better to cardiovascular exercise while others have been shown to improve with strengthening. Understanding the original source of pain generation as well as the current systems affected by chronic pain are all important in designing an optimal exercise program. If you have any questions regarding the optimum exercise for you, please feel free to contact us here at Physical Therapy for everybody at (360)367-0970 or amykonvalinpt@gmail.com.

Education & Self-Management of Pain

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The research indicates what Physical Therapists have long known – education is the key to rehabilitation! Education becomes even more important as we discuss chronic pain. Every PT has stories of patients they were able to treat quickly, who had good long term results. We thrive on those patients and we are just as happy as they are with their results! But when patients have struggled with a chronic condition for years, they tend to develop abnormal motor patterns (see previous post) and poor pain responses. Therefore, most chronic pain patients have better long term outcomes with education along the way to help them manage their symptoms through the years.|

Education is key and commonly termed “explaining pain”. This is incredibly important in chronic pain since the nervous system pathways that maintain chronic pain do not function in a way that we commonly understand. Acute pain indicates tissue injury and is the body’s response to protect the damaged tissue. With chronic pain the nervous system is no longer responding to acute injury and the “protection” it offers is no longer helpful, but detrimental to healing. Therefore, it is important to gain an understanding of how pain is produced, why pain can persist when tissues are healed, and how pain can be seen as a truly biopsychosocial phenomenon.

Self-management plans are implemented to help each patient achieve THEIR goals. These plans help to give each patient control over their pain and over their ability to return to their chosen activities in life. Although these plans are always patient specific, they generally include several of the same ingredients. First, reasonable goals and timelines for achieving them need to be established. Next, graded exposure and pacing are implemented to optimize sleep (because when you are sleeping is when you are healing!). Targeting stress reduction and finding useful strategies for relaxation for each patient is key to decreasing the load on the nervous system. Another component is helping each person find ways to modulate their own pain which may include use of heat and/or cold therapy at home.

Chronic pain requires a health care ally to walk with you and find the strategies that work best for YOUR body. If we can help you, please feel free to contact us at (360)367-0970 or amykonvalinpt@gmail.com.

To brace your abs or not to brace your abs?

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As we are talking about chronic pain in this series of blog articles, it is critical to talk about how our body chooses to move in response to pain.  Let’s take an example of a sprained ankle.  When someone sprains their ankle they may start to walk with their foot turned out to the side.  This is a conscious or subconscious effort to protect the ligaments that have been damaged on the outside of the ankle.  However, this can cause more pain up the chain – in the knee, hip, low back, or even the shoulder.  What starts out as a movement pattern to protect an injured area turns into a movement pattern that causes pain in other places of the body.

Currently, we have four hypotheses to explain why these motor strategies occur.  The Suboptimal Tissue-Loading Hypothesis states that we tend to change our movement patterns over time due to habit or energy minimization.  Over time this suboptimal loading causes pain because it exceeds the tissue tolerance.  The Pain/Injury Interference/Inaccuracy Hypothesis describes altered movement patterns in response to a real or perceived threat of injury.  The Protective Response Hypothesis describes a change in the nervous system to remove or reduce the threat of pain which changes the motor behavior.  While the Conditioned Response Hypothesis states that pain may be experienced in association with movement in the absence of nociceptive discharge due to pain “memories”.  These four hypotheses often interact with each other and each person can move through different theories as they progress through an injury.

Understanding these hypotheses and how they are affecting an individual are critical to the rehabilitation of an injury.  Each motor strategy has a unique treatment regimen for optimal results.  We can help you to understand where your body is and develop a program to improve motor strategies to assure complete healing.  Please contact us at (360)367-0970 or amykonvalinpt@gmail.com for more information.

Explaining Chronic Pain

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Chronic pain involves changes in the peripheral nervous system (PNS) which conveys nociceptive information to the central nervous system (CNS).  Over time, changes occur in the CNS that can cause continuation of the nociceptive information – even if the original stimulus has been removed!  For instance, say someone has a very painful ulcer on their calf.  The doctor sees the infection is spreading and must amputate the leg to save the person’s life.  After the amputation, the patient continues to report pain in the calf from the ulcer.  This is called phantom limb pain.  Let’s work through the process of how phantom limb pain (and chronic pain) occurs.

A-delta and C fibers are nociceptor unencapsulated receptors (free nerve endings) that respond to noxious stimuli.  Noxious stimuli is an actual or potential tissue injury that is likely to cause pain.  Nociceptors convert mechanical, thermal, and chemical energy into electrical signals and carry this information to the CNS.  Mechanical energy can include compression or tension.  Thermal energy includes heat which is caused by inflammation.  While chemical energy is a response to the chemicals in the body.  The nociceptors are found in/around most tissue including skin, muscle, tendons, joint structures, periosteum, intervertebral disks, and within peripheral nerves.

Nociceptors can begin to have increased responsiveness, which is termed peripheral sensitization.  Sensitization of a neuron is characterized by increased spontaneous activity, a decrease in threshold of response to noxious stimuli, an increase in responsiveness to the same noxious stimuli, and/or an increase in receptive field size.  So, what a normal nerve might perceive as slightly painful a sensitized nerve may perceive as excruciatingly painful.

Nociceptors then send their information up to the CNS:

  • Creating a reflexive response that is coordinated within the spinal cord to withdraw the body from the painful stimulus (i.e. pulling your hand away from a hot stove)
  • Ascending nociceptive pathways which take the information up to the brain to be further processed and may trigger
  • Descending facilitatory pathways which increase the nociceptive response and can cause referred pain, secondary hyperalgesia, and contralateral hyperalgesia or
  • Descending inhibitory pathways which decrease the nociceptive response

More recently, researchers have found glial cells in the CNS which also play a critical role in the processing of nociceptive information.  Research indicates that glial cells can release anti-inflammatory factors that help to restore normal nociceptive processing.  However, they also release a variety of substances that facilitate nociceptive information.  Therefore, glial cells play an important role in both the facilitation and inhibition of nociceptive information in the CNS.

Are you completely confused with all of this and questioning how it applies to your chronic pain?  Hold tight – the next blog posts discuss this in further detail regarding specific diagnosis.  Or, if you would like to understand more about the pathways involved in chronic pain, please feel free to contact Amy at Physical Therapy for EveryBODY at (360)367-0970 or amykonvalinpt@gmail.com.  I am passionate about education and would be happy to have a phone conversation with you!

Acute versus Chronic Pain

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The International Association for the Study of Pain (IASP) defines pain as an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage. By this definition, pain does not HAVE to be associated with observable tissue damage or have a detectable underlying cause.

Pain is subjective.

If described by the patient – pain IS real.

Now, before you shoot the messenger here, let me explain the point of this blog series I am starting. An updated version of “Mechanisms and Management of Pain for the Physical Therapist” was recently released. As I was reading it I thought to myself “Are we using the proper vocabulary to explain chronic pain to our patients?” Why is this important, you ask. Because chronic pain works through a different mechanism than acute pain. And, the pain cycle we describe in the clinic tends to focus on acute pain. Which confuses people because they assume pain MUST be associated with tissue damage and we know that is false. So, it’s time to clear up the confusion!

Acute pain is a direct result of tissue damage and IS a symptom. When you sprain you ankle and the ligaments are overstretched, acute pain tells you to take it easy on the ankle and give it a chance to heal. This is a useful function of pain! Acute pain usually responds well and quickly to treatment including pain free movement, ice, and nonsteroidal anti-inflammatory drugs.

On the other hand, chronic pain is not protective and does not serve a biological purpose. Pain is defined as chronic if: 1) it outlasts normal tissue healing time, 2) the impairment is greater than would be expected from the physical findings or injury, and/or 3) pain occurs in the absence of identifiable tissue damage. In VERY general terms, chronic pain is pain that has lasted more than 3-6 months. However, you must take into consideration if the initial injury was properly diagnosed/treated in the first place, if the condition has been given enough time to heal, or if an athlete is constantly reinjuring the same tissues.

If YOU need help understanding YOUR pain, please feel free to contact us here at Physical Therapy for everybody at (360)367-0970 or amykonvalinpt@gmail.com.

Hip Osteoarthritis – New Clinical Practice Guideline

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Physical Therapy utilizes art and science to create a specific program for restoration of each patient’s physical function.  Later blog articles will focus on the ART while this article is focusing on the SCIENCE.  Physical Therapists are passionate about finding, confirming, and using optimal treatment strategies for their patients.  We are greatly indebted to the researchers who dedicate their lives to helping us in that pursuit.

The Journal of Orthopaedic and Sports Physical Therapy (JOSPT) is one of my “go to” journals for good, sound research.  In June 2017 they published a new Clinical Practice Guideline for Hip Osteoarthritis.  What does that mean for you, the person living with hip osteoarthritis?  That means that a bunch of really smart people combed through all the research and made recommendations for people like me to use when helping the most important people involved – our patients!  And, here is what they said…

How do we diagnose Hip Osteoarthritis?  Adults over the age of 50 with moderate anterior or lateral hip pain during weight-bearing activities, morning stiffness less than 1 hour duration after waking, hip internal rotation (IR) range of motion less than 24 degrees or IR and flexion 15 degrees less than non-painful side, and/or increased hip pain associated with passive hip internal rotation.  What is hip internal rotation?  Lie on your back with one knee and same hip bent to 90 degrees.  While maintaining this hip and knee position, try to bring your foot out to the side.  Compare the motion to the other side.

What tests and measures should be included in the evaluation?  You should be assessed for physical function measures, balance performance/risk of falls assessment, active range of motion for the hip, and muscle strength.

How should we treat Hip Osteoarthritis?  Manual therapy should be used to improve hip mobility.  This should be followed up with flexibility, strengthening, and endurance exercises to address impairments in hip range of motion, specific muscle weakness, and limited muscle flexibility.  Patients should receive education on activity modification, exercise, weight reduction when overweight, and methods of unloading the arthritic joints.  Bracing should be used as a last resort if these forms of treatment are not effective.

If you have any questions regarding these recommendations, please feel free to contact us here at Physical Therapy for Everybody – amykonvalinpt@gmail.com or (360)367-0970.  If you would like to read the complete article:

http://www.jospt.org/doi/full/10.2519/jospt.2017.0301

Hip and Knee Osteoarthritis in Younger People (yeah, that means YOU!)

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Hip and Knee Osteoarthritis Affects Younger People, Too
Ackerman, I., Kemp, J. Crossley, K., Culvenor, A., Hinman, R.
Journal of Orthopaedic and Sports Physical Therapy, February 2017, p 67-79.

This Clinical Commentary focused on evidence-based assessment and management approaches for “younger individuals” defined as those less than 40-45 years old.
Why is this important? Hip and knee osteoarthritis (OA) at younger ages has a significant impact on psychosocial well-being and work capacity. People who are affected by OA in their 40’s have decreased exercise tolerance to maintain a healthy weight and active lifestyle. It may further decrease work tolerance for jobs involving high labor which has the potential to decrease available work force for these jobs as well as limiting future job potential for those affected.
Why is this happening? Key risk factors for accelerated development of knee OA are obesity and a history of traumatic knee injury. Traumatic knee injury included anterior cruciate ligament (ACL) rupture and/or meniscal tears. Even more troubling was that having ACL reconstruction surgery “does not appear to prevent future onset of knee OA”. The bright spot in this research was that long distance running in youth did NOT seem to increase the risk of hip and knee OA later in life!
Should I ask my MD for imaging on my painful knee and hips? This commentary stated that imaging should be reserved for those with atypical signs and symptoms that “may indicate diagnoses other than OA”.
What can I do for my youth with knee and/or hip pain? The top recommendations were therapist-prescribed exercise programs to address impairments, specific activity modification, disease-related education, and weight control or weight loss (if applicable). There are specific exercises which have been proven to decrease stress to the hips and knees that can help young athletes. Also, strengthening exercises can help to “protect” the joint for athletes to decrease the risk for ACL rupture or meniscal tears.
What if I am a “younger person” showing signs of hip and/or knee OA? Physical therapy should focus on a specific patient-centered history, comprehensive evaluation including joint mobility, muscle strength, and performance-based measures, and outcome measures to assess symptoms and function over time.
The key “take away” from this article was the importance of early intervention to decrease progression of OA and allow people to maintain their desired level of activity through their lifetime. If you have any questions regarding OA, hip and/or knee pain, please feel free to contact us here at Physical Therapy for EveryBODY at amykonvalinpt@gmail.com or (360)367-0970.

The Importance of Education

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When on a family vacation, my sacroiliac joint (near the tailbone) went out of place causing extreme pain down my right leg every time I stepped on my right foot. Which is a challenge when you are spending your days and nights walking around theme parks! During a meal break in the middle of our day, I spent several hours stretching and performing joint mobilization to alleviate the symptoms. That night, I carefully positioned myself while sleeping to ensure that the joint had a chance to relax and “get back into position”. And it worked! The next morning I woke up with minor soreness that wore off while we were walking around the amusement park. Score one for self-care techniques!

You may be thinking, “Well, that’s great, Amy, but I don’t have your knowledge to take care of myself when I am traveling!” So let me tell you about a patient who was traveling overseas on a 3 week tour of Europe. This patient had been pain free for over a year but had all of her symptoms come back one morning while traveling. She had to miss the scheduled tours that day and was concerned about her ability to even complete the trip! While she was in her hotel room, she remembered all the exercises and self-care techniques we had worked on during her treatment time. She started at the beginning and worked her way to the end of her exercise progression all in one day! The next day she woke up, felt fine, and had no further problems for the rest of her trip! This is the long term success that I strive for with each of my patients.

Physical Therapy is intended to facilitate healing through the use of hands on techniques, a personalized home exercise program, and large amounts of education specific to each patient’s needs. At least, this is the definition we use here at Physical Therapy for EveryBODY. We believe that each body is unique and each person can be helped through a process of learning how to restore optimal health to return them to their optimal lifestyle. That may be walking, yoga, marathons, being a super parent, or finally getting your splits! Each body is unique, each person has a distinct learning pattern, and everybody has their own goals. Call us and learn more about how we can help your body to reach the goals your mind sets! www.physicaltherapyforeverybody.com or E-mail at amykonvalinpt@gmail.com or feel free to call us at (360)367-0970.

Why Use a Cash Based Model?

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Why did I choose a cash based Physical Therapy model for PT4EB? One reason:

QUALITY OF CARE FOR EACH PATIENT BASED ON THEIR NEEDS

PT4EB utilizes knowledge, experience, research, and patient preference to determine specific treatment plans to return each body to optimum performance. I do realize that is a hefty mission statement that may seemed filled with “buzz words” to sound good. Let’s break it down:

Knowledge – Amy is the only Physical Therapist with a PhD in Orthopedic Manual Physical Therapy in the Maple Valley, Covington, Black Diamond, Kent, and Renton area.

Experience – 16+ years of clinical experience in outpatient physical therapy with years of emphasis on military personnel/dependents and pediatrics.
Research – Writing your own dissertation helps one to understand and interpret the current research available.

Patient Preference – It doesn’t matter how good your treatment plan is if your patient doesn’t agree it is the right strategy for their body. Therefore, we discuss your treatment plan and come to an agreement of what works best for YOUR body.

The current insurance based model of physical therapy creates an emphasis on getting patients in and out as quickly as possible for each treatment session while performing the maximum number of treatment sessions that insurance allows. Physical Therapy Assistants (trained, 2 year degree program) as well as Physical Therapy Aides/Techs (on the job training) are utilized to move patients through their program which works well if patients are progressing on schedule through their treatment. But, Assistants and Aides are not able to make changes to the treatment plan set out by the Physical Therapist causing some patients to get “stuck” on a treatment plan until their next scheduled visit with their Physical Therapist.

I have obtained optimum patient outcomes with a one-on-one based treatment plan that allows one hour for each treatment session. Each session begins with a review of how the patient responded to the last treatment session and how their body is feeling now. Manual treatment is applied to restore normal joint motion, decrease muscle tension, improve fascial mobility, and retrain muscle coordination. The treatment is often concluded with a review and modification of the home exercise program to continue until the next visit. This is a very active treatment approach that requires complete patient participation in providing honest feedback, implementing changes to daily routine, and performing their home exercise program as prescribed.

Patients are usually seen once per week or even every other week as opposed to 2-3 times a week at a more traditional Physical Therapy clinic. This is to allow time for the body to respond to the treatment and eliminate any possible soreness or fatigue from the treatment. It also allows patients to try their home exercise program and see the effects the exercise has on their symptoms. Patients tend to require fewer visits which may decrease the cost of treatment. The following table provides a comparison of a cash based PT model versus a more traditional PT model.

Cost per visit

Cash Based                                                Traditional PT
Cost per visits                            $125       Co-pay                                             $40
Number of visits                              4        Number of visits                                12
Total Cost                                  $500        Total Cost                                      $480
Time Spent with PT                    240        (15 minutes per visit)                       180
Cost per Minute                       $2.08         Cost per Minute                           $2.67

As a patient, it is important to remember that insurances do vary. Some patients have a high deductible and will be responsible for their entire PT bill – even if they go to a traditional PT clinic that bills insurance. A cash based model allows patients to fully understand their costs up front and not be surprised by a large bill three months after treatment. All patients are provided with a superbill at the end of their treatment session that has the ICD-10 and treatment codes they can submit to their insurance for reimbursement. Of course, the time taken from work or school to attend 12 treatment sessions versus 4 treatment session also must be taken into the accounting for each patient.
If you are looking for improved outcomes in a shorter amount of time, I recommend a model that focuses on the quality of care versus the quantity of patients seen.

My Valentine’s Day Present from the American College of Physicians

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American College of Physicians Issues Guideline for Treating Nonradicular Low Back Pain

Be still my heart! The America College of Physicians (ACP) decided to give Physical Therapists (and other “alternative” treatment options) a HUGE Valentine’s Day present by issuing new guidelines for the treatment of nonradicular low back pain.
Okay, did I lose you at “nonradicular”? That just means low back pain that is in your back and does NOT radiate down to your leg! Radicular low back pain is pain that begins in your back AND radiates down your leg. Radicular low back pain is caused by a pinched nerve in your lower back and there are different treatment recommendations for that!
The ACP did a comprehensive review of the literature and concluded that acute low back pain (lasting less than 4 weeks) and subacute low back pain (4-12 weeks) are best treated by heat, massage, acupuncture, or spinal manipulation. While heat can be done at home and acupuncture must be delivered by an acupuncturist, the terms “massage” and “spinal manipulation” as they are defined in this guideline are treatments delivered here at Physical Therapy for Everybody. Two out of four options found in one location! For patients with chronic low back pain (longer than 12 weeks) the ACP recommended exercise, multidisciplinary rehabilitation, acupuncture, and mindfulness-based stress reduction. Again, “exercise” and part of the “multidisciplinary rehabilitation” are also treatments delivered here at Physical Therapy for Everybody. You can receive the manual treatment and exercise treatment recommended by the ACP in one place by one person!
On the pharmacological side, acetaminophen was not effective versus placebo, NSAIDs are first line therapy drugs, tramadol or duloxetine are second line therapy drugs, and opioids are the last treatment option, which is only used for patients who have failed other therapies.
And surgery? Forget about it, says the ACP. There is no research to prove that surgery decreases low back pain.
So, if you have low back pain that does NOT radiate down to your leg, the ACP (which probably includes YOUR doctor) recommend that you see a Physical Therapist (or an acupuncturist if you prefer the non exercise route). Want to read more? Please visit:
https://www.acponline.org/acp-newsroom/american-college-of-physicians-issues-guideline-for-treating-nonradicular-low-back-pain