The final part of my Pain series had intended to look at the current management approaches for persistent pain. I thought about this and decided against it. Why? Well teaching you to suck eggs is not the way. I could offer the same as everyone else - solutions, guidance, strategies to empower you, to aid in the management of pain which has, in part, been highlighted in this pain series journey, but I won’t. Instead I’ll share my thoughts on physiotherapy and how new evidence is paving to what I believe could be a more refined direction for Physiotherapy……

I will start by saying there are a lot of blogs/websites out there that all talk about approaches to pain management, so is there any point in telling you again what you may have already read? Instead a list of recommended blog/websites are displayed at the bottom of this post.

I also feel it is pertinent to point out that the amount of evidence that is published every day/week/month is at an alarming rate! Clinicians are having a tough time keeping up. When I joined twitter this year it overwhelmed me, but i’m glad I did join because I am informed about evidence, I learn to critique what is out there, challenge clinicians and help me identify the direction my profession is heading. If you haven’t joined twitter I suggest you do! Interestingly by the time I publish this post the information that I want to share will probably be out of date! Ok perhaps not but you catch my drift…..

What I will share with you are my discoveries and thoughts on why physiotherapy needs to change that a holistic approach to pain management and overall health and well-being needs to be considered now more than ever, and that interdisciplinary team working is fundamental to the future of front line healthcare. Dave Nicholls has eloquently explained this in his post on connectivity and physiotherapy (here). There are diseases such as persistent pain, obesity, diabetes at epidemic proportions that are associated with a host of other problems, mental health issues, cardio-vascular disease, financial constraints, social isolation. These are continuing to grow at unprecedented rates and our current system is failing us. All these topics are beyond the scope of this post but they are all pertinent towards patient centered care as many patients are at increased risk of morbidity.

This blog post was not intended to get all philosophical about physio, however I can’t talk about the future of physio without getting all philosophical, it is fundamental to our professional existence. So if you will permit me, I will now have a wee rant.

A wee rant….

Historically (may make a few heads roll with this!!) physio’s have jumped on bandwagons as nicely pointed out by Adam Meakins here, and I wonder why that is? Is it insecurity in our profession? Is it our need to prove ourselves? Is it to stamp out Dogma? Do we actually know ourselves what we do? If we are not jumping on pain management; and I love pain management we are releasing trigger points (sorry Adam Meakins) or using fancy coloured tape or performing the latest and greatest manual therapy technique or a new gadget that you can sit on to challenge your balance. The latest one looks discerningly phalic! (Bronnie Thomson’s blog explains!) We have always advocated exercise yes but we have jumped onto individual treatments a lot such as Electrotherapy (little bit of exercise), Manual Therapy (little bit of exercise) Acupuncture (little bit of exercise) and other fancy treatment techniques (little bit of exercise) that are all…..well….not really providing the long term outcomes we are so desperately looking for (reference, reference, reference, reference). Exercise has always appeared to come last despite the fact that a lot of evidence suggests it’s just as good as the passive treatments and it has a host of other health benefits. (reference, reference, reference, reference, reference).

In fact at physiotherapy school exercise was covered in, I recall, one or two seminars and when I joined the NHS the majority of the time I used exercises as part of my treatment, the irony!!?? I wonder if we had embraced and understood exercise better would we have consolidated our knowledge of manual therapies and exercise = clinical reasoning. I guess the great thing that we have is our ability to critically think, to clinically reason and use our diagnostic skills, which should set us apart from the crowd i.e. strength & conditioning coaches, Personal Trainers etc. However it seems it doesn’t and there is a fine line where those boundaries are being crossed at the potential risk of causing harm to patients and even losing our identity. Before you all jump at me saying I have a good relationship with the aforementioned, I salute you, I hope you know it’s reciprocal and I’m not talking about you per se I’m talking about the standing of our profession. So why do I think this? Possible reasons are because of dogma and reductionism within medicine which has filtered into our profession or perhaps not truly identifying our place (The CynicalPT does a good job of explaining)….. So indirectly I’m saying maybe it’s our fault… perhaps it is insecurity within our profession. Of course I am open to scrutiny and to be told what on earth am I talking about?? It generates discussion.

So I propose this….

Physiotherapists working as triage providers to specialties in healthcare. Physiotherapists would still have their special interests, their extended scopes, the evidence that I will highlight in this post suggests there is more scope for specialism and diversity. I’m just saying let’s be a lot more holistic/diverse in the right way without the need for an association, or perhaps one(s) that unite us all i.e. the neuromusculoskeletal alliance is a nice example. As front line practitioners physiotherapists can be and offer so much more. We are one of the few professions that are front-line, have a direct link within the medical system, is focused towards health promotion and has such a close association with GPs. We could facilitate and consolidate their workload.

So let’s get back to my thoughts on best management and where we can go in terms of providing a more holistic approach to healthcare. I like to think I read quite a bit, some would argue too much #geeknerd. Significant advances in health science are identifying strong evidence to support specific approaches to pain management from an individual perspective. These approaches have been around for years and are a large part of our everyday lives. So what are they? I hear you cry! Well my thoughts are..? 5 components that encompass total health. This includes exercise, diet, sleep, mindfulness and stress management. An umbrella term would be optimal health. Pretty obvious huh? Those of you that are already doing this, great! Keep it going! What I do ask is why then are the most obvious things the hardest to change?

I’ve said it all the way through my pain series and i’ll say it again, Pain is extremely complex. The management of pain cannot be discussed or treated through dualism, although that is how many of us manage it. We take a pill to help block the signals that may be associated or that deliver the messages that may be interpreted by your brain as pain, we expect the passive treatment blocks the signals that may contribute to pain but why do we persist in taking them when they do not resolve the issue. Why use a passive process to facilitate an active one? I know I know it’s easy to pop a pill, but let me share a revelation with you. In the United States alone, in the last 10 years, there has been a significant increase in pain-killing medication prescription for persistent pain problems such as low back pain, headaches and other persistent pain states (reference). This has resulted in medication abuse concurrently creating an increase in overdose numbers. Studies have shown that pain killing medication is no better than placebo when treating something like low back pain highlighting that a one size fits all approach to pain treatment is not efficacious (reference, reference). When you step into the realms of the Brain, pain is many things; contextual, implicit, attentional, physical, behavioral, Pain treatment cannot be considered as something separate to treat. Its integration is part of every aspect of overall health and well-being. Dualism is not the way.

So in the hope that you all haven’t switched off (perhaps you should all put the kettle on and make a fresh cup of tea) let me take you through my thoughts of the triage service that should be more cemented in physiotherapy practice. In fact most probably do this everyday but don’t realize they are doing it.

The 5 points of Health and Wellness

The following pathway is based on a biopsychsocial model, I will provide a small excerpt of each, explain how they are all integrated and how physiotherapy can be influential to all the components. Medicine has created a reductionist perspective of the human body. We all know that each system integrates with the other. So we should be advocating it more in our clinical practice.

Diet

We all know that our diet is important. What we put in our mouths are part of the building blocks to our physiology (sunlight, fresh air etc also have their place). Physiotherapists are exposed to acute injuries everyday. I don’t know many physiotherapists that offer appropriate dietary advice to facilitate and promote tissue healing. A lot of studies are highlighting the negative effects certain foods and dietary habits have on tissue healing and health (reference, reference, reference , reference). Diabetes and obesity have a significant impact on tissue healing. The high concentrations of sugar in our food cause an increased risk of obesity and diabetes and recent studies have shown other alarming effects such as changes in cortical brain matter (reference, reference, reference). The majority of these issues come as a result of increased carbohydrate consumption in the diet (reference). Recent studies suggest that we can obtain the sufficient amount of energy we require from fat and protein as opposed to the previous recommendations of eating carbohydrate for energy provision (reference).

It’s not all bad news there are some interesting studies out there that propose the following:

Omega 3 fatty acids to help with neuropathic pain (reference)

Vitamin B-12 to help with nerve regeneration (reference)

How a tart juice and certain fruit can alleviate the symptoms of muscle soreness (reference, reference)

The importance of protein in the diet and it’s consumption (reference, reference)

I’m not asking you to perform skin-fold tests and measure blood sugar levels leave that to the experts! However telling our patients ‘to lose weight’ is completely unhelpful! Physiotherapists providing simple dietary advice particularly towards tissue healing in injuries can facilitate and support nutritionists and dietitians in making an impact on changing eating habits and reducing morbidity in our aging population.

Sleep

We all know sleep is important but why is it important? A lot more research is investigating the importance of sleep. One particularly interesting study found that sleep clears metabolites from the brain (reference). During our waking hours the brain uses up a 1/4 of the bodies entire energy supply, toxins build up in the brain like any other cell in the body through metabolic exchange. In the body the lymphatic system clears metabolites out of the cells which are then expelled out of our body. There is no lymphatic system in the brain so the brain uses cerebral spinal fluid to clear the toxins that build up in the brain and yep you guessed it this process only happens during sleep. Think of it as a detoxification process that happens whilst you are asleep. The less sleep you get the more this important process is impaired, which can increase your risk of pain and neurological disorders as studies have shown (reference, reference, reference).

The sleeping brain performing its cleaning chores

Sleep is also important for tissue recovery there are studies that highlight the importance of sleep for the prevention and recovery of injury (reference, reference). On average we are sleeping a lot less due to our busy lifestyles. Those that suffer with persistent pain get even less sleep feeding into the perpetual cycle of persistent pain states. Studies have shown that getting less than 6 hours sleep increases tissue sensitivity increasing your risk of suffering with persistent pain states such as back and neck pain (reference, reference). So sleep is pretty important. When we are in pain it can be difficult to sleep so it is best to discuss with your health professional on best tips for sleep hygiene.

Mindfulness

We’ve all done mental rehearsal. At some point we have all imagined ourselves on a beach with a margarita cocktail to get away from a stressful situation or practiced going through the route of the half marathon or run in our heads. Studies over the last 10 years have shown that the same neural networks light up when you think about an action or movement as when actually perform the movement (reference, reference, reference, reference). We’ve all experienced anxiety for example the wobbly tooth that is painful we find ourselves in this perpetual cycle of checking the tooth again and again re-enforcing our anxiety and increasing our pain. We then become hyper-vigilant of it and we shy away from touching it. Persistent back pain can be appreciated in the same way instead the anxiety we experience is associated with pain and fear which prevents us from moving. The NOI Group in Australia are doing some great work with graded motor imagery, laterality recognition and mirror therapy for the treatment of persistent pain states.

I’m not suggesting that we all meditate and say ahhhhmmmmm. I’m suggesting that we educate our patients in simple ways such as providing a simple understanding of pain science, encouraging them to be more mindful about the activity or exercise they have been asked to do, making the connection between mind and body. Our understanding of the mind-body connection through neuroscience and pain studies suggest that we need to ditch the dualistic approach to treating patients (that’s throughout medicine) and treat the patient not the pathology. Physiotherapists are becoming more experienced in rehabilitation techniques that encompass a cognitive behavioral approach. As pain science tells us, our thoughts, beliefs, behavior and emotions have a significant impact on our pain experiences.

Exercise

I’m thinking do I really need to talk about this? It should be a no brainer? I won’t discuss this at length as I expect all Physios to have an understanding of its benefits. However, we are still not getting enough exercise in our lives or we are not balancing it out with our lifestyle or perhaps we need to think about different ways to encourage our patients to exercise. There is no excuse to not encourage injured patients to gently exercise. Going for walks or cycling on a stationary bike whilst recovering from a shoulder injury or wrist injury, performing upper body exercises when you are recovering from a lower limb injury. When we are injured our body enters a catabolic state (breakdown) the longer we rest and offload our tissues the more this process perpetuates. Placing your body in an anabolic state (buildup) facilitates injury recovery and releases lots of happy hormones to promote recovery (reference, reference). I also refer you to Karim Khan’s Mechanotransduction paper which explains how our body is an active machine down to the cellular level. Why we would want to use a passive process (pills, manual therapy, acupuncture) to stimulate an active one doesn’t really sit with me (reference). Yet not to sound like a hypocrite I do still use them but to a lesser degree.

Stress Management

Do we all view stress as a bad thing? Is exercise a bad thing? Would you class exercise as a form of stress? Interestingly studies have shown that if we perceive stress as having a negative effect on our body it increases our risk of morbidity such as heart disease (reference, reference, reference). Stress is related to the flight or fight response. During the stress response we receive an injection of adrenalin and cortisol into our blood stream, thus having an effect on our physiology such as speeding up our heart rate and breathing, increasing our muscle tone and increasing our alertness. So it prepares us to take action.

However when is stress advantageous to us? Consider the context of these two scenarios.

Scenario 1:- If you are stuck in a traffic jam needing to get to an important meeting is there any reason to experience a stress response? Yes the meeting might be important but this is stress affecting you in a negative way. The traffic Jam clears you rush to your meeting but now you are all flustered and struggle to get your words out and your point across. Then you blame the traffic for making you late and a cascade of events occurs. Probably best to reschedule the meeting? Ok not always an ideal situation but the outcome may be different when you are more calm and focused. Was stress helpful in this situation? The physiological responses were the same but the context changed your perception of the outcome.

Scenario 2:- You are getting ready for a big race you are competing against a personal best or other runners. Adrenalin and Cortisol are released to bring the same changes to your body systems as previously mentioned. However this time the context of the situation is different. You have physically and mentally prepared well, you have been injury free up to the race deadline and you have improved your time in training runs. Everything has gone well in the run up to the race. You complete the race, beat some other runners and improve your personal best! This is stress affecting you in a positive way you feel great, you are on top of the world and you share your success with friends and family who congratulate you.

So stress can affect us in many different ways. It’s the same physiological responses to a situation but the context of the experience has an affect in a very different way. Persistent pain states can increase our stress levels and stress can increase our pain - a perpetuating cycle. Have strategies in place such as activity pacing and planning, pacing and prioritizing our daily routine can help in reducing stress levels. This is not only effective for people suffering from persistent pain states but also effective for acute injury management.

Summary

So if you worked it out you can see that all these components tie into each other really well. Like our body systems they are all integrated. One will complement the other. The suggestion of this model is not to negate a physiotherapists desire to move into a specialism, I love tendinopathy rehab. It identifies the need to provide a more holistic approach to our front line service, with the right integrated care pathways. Physiotherapists can utilize other health professionals to provide patient centered care and begin delivering the appropriate strategies to patients first hand thus facilitating appropriate referral to a specialist provider (psychologist, nutritionist, sleep coach, ESP physiotherapist, integrated care nurse). Integrated care pathways utilizing the expertise of several clinicians providing a holistic approach to persistent pain have been shown to be very beneficial to restoring function (reference, reference, reference).

So why are we not integrating our healthcare system more, promoting collaborative care? I understand that bio-medicine favours reductionism, the body broken up into separate parts, so the entire healthcare system appears to have to abide by this system. However this does not promote efficient and integrated care pathways. The continued emergence of quality research into the areas that I have highlighted will require more of an integrated approach to health care in the future. Why not start now!

Do you have any comments you would like to make, post away here or on twitter! If you want any tips on sleep hygiene, diet, mindfulness, stress management and exercise then please don’t hesitate to get in touch. I can help or I can point you in the right direction.

Thanks again for reading

TNP

 

Recommended websites for learning about Pain

www.bodyinmind.org

www.noijam.com

www.pain-ed.com

Blogs to learn about pain/health/philosophy

www.healthskills.wordpress.com

http://breakingmuscle.com/

http://criticalphysio.me/

Recommended Podcasts for everything related to Health

www.chewshealth.co.uk/