Therapy’s role in Chronic

Pain Relief and

Modulation
By Amia Gaines
 FOUR MAJOR TYPES OF PAIN:
1. Nociceptive Pain: Usually from general tissue
damage.
Examples: arthritic pain, mechanical back pain, post
surgical pain
2. Inflammatory Pain: An abnormal inflammatory
response prompted by the immune system.

Define Pain… Examples: Gout, rheumatoid arthritis.

3. Neuropathic Pain: Pain caused by nerve irritation.
Examples: transverse myelitis, neuropathy
(CIDP/GBS), radicular pain, trigeminal neuralgia
4. Functional Pain (idiopathic pain): Pain that we can’t
identify the exact origin
Examples: fibromyalgia, irritable bowel syndrome.
 ..but is that all
• The International Society for Pain defines pain as, “an unpleasant sensory and
emotional experience associated with, or resembling that associated with, actual or
potential tissue damage”
• This indicates pain is equally a biological and emotional problem since the limbic
system is integral in the pain process
• Chronic Pain: Body undergoes neurobiological, psychological, and social changes that
cause pain to no longer be directly indicative of tissue damage.
• Now the body is inconsistent in is indication of tissue damage. Pain may present
due to disease progression or may be due to sensitization.
 • Biomedical Model: Original Medical Model: Is the
current and dominant approach. If focuses on
abnormal cellular activity as the basis for any
injury, illness, or disability.
• This model believes there is an identifiable
pathology to every presentation of pain or

Biomedical vs. dysfunction.

• This poses a problem with pain conditions
[Edgerton et al]
Biopsychosocial • Biopsychosocial Model:
• “The biopsychosocial model acknowledges
Model of Health the patient as a whole, their social, cultural
and environmental context that shapes an
individual’s response to illness, in essence a
patient-centered healthcare system.”
[Sanders et al]
• World Health Organization’s International
Classification of Function, disability and
Health (WHO ICF)
 • Elderly
• Pain may be perceived as normal aspect of
aging. [ Patel et al]
• Alternately, patients may be viewed as
malingerers [Herr et al]

Chronic Pain in • Prior literature suggests that back pain in

older adults is neither inevitable nor should
it go untreated [Makris et al]
Underserviced • Patients may also be fearful [Makris et al]

Populations
 • POC
• Pain is a personal experience however it’s filtered
through the lens of culture.
• A person's culture determines how they perceive,

Chronic Pain in experience and communicate pain. [Patel et al]

• Extravagant vs. stoic/ down-playing pain

Underserviced • Individuals who don’t speak English as first

language are less likely to report pain [Edgerton
et al]
Populations • Black and Hispanic patients are more likely to be
under-treated for pain across in emergent, acute,
and long-term care facilities “ [Bonham et al]
• More responsive to pain from the same culture
and can misunderstand other cultures. [Giger et
al]
So what can we do?

• Identify
• Acknowledge
• Educate
• Adjust
Identify Pain Type
• It is important to know the type of pain to know the appropriate response. [Edgerton
et al]
• Also evaluate for red flags of progression of condition or new concern
• Acute Pain
• Provocation and Palliation
• Quality/Quantity
• Region/Radiation
• Severity Scale
• Timing:
• Acute pain, can become chronic pain through a process called sensitization.
 • Temporary Pain Modulation Alterations>> Permanent
[Bushnell et al, Yang et al]
• A tumultuous emotional state i.e increased panic,
fear, anxiety, mood, pain catastrophizing, stress
management etc increase the perception of pain
[Edgerton et al]
Acknowledge • Observing another person in pain primes our own
pain centers to be more reactive

Issues, • Attention to pain engages and primes

• Structural Changes in pain modulatory systems
often occurs from chronic pain
Concerns and • Grey matter loss in dorsal lateral tract occurs
(pain and temperature regulation)

Changes • Descending pain modulation pathways can

prime or desensitize lower pain receptors.
• Neurochemistry changes (excitatory
neurotransmitters can be upregulated)
• Decrease in opioid receptor bindings
 • Chronic pain requires reconceptualization of pain (i.e earning
about avoidance, catastrophizing, maladaptive thoughts etc.)
• Teach patient’s fear of pain intensifies perception of pain

Educate • Alternatively, pain relief is boosted in placebo analgesia if

a patient believes pain relief is possible [Bushnell et al]

Patients • Encourage patient to switch locus of control internally

• Promote patient independence and involvement in
therapy
• Bring patient’s attention to uplifting or engaging topics
• Remind patients of improvements to help them recongnize
symptom modification.
• Educate patients on exercise induced analgesia
• Resistance training is linked with improved health in
geriatric populations [Edgerton et al]
 Move patient to quiet, or controlled
environments

Make
Use calming tone/voice
Possible
Adjustments
[Edgerton et Hands on manipulation helps desensitize
nervous system
al]
Utilize thermal modalities when
appropriate
 Kudos
• Promoting Function and
Movement
• Activity combats
sensitization, improves
function and helps
release endorphins
• Empathize and make individual
efforts to be attentive to
patient needs, and pain levels

Improvements
• Continue improving industry wide CEUs
for CBT based interventions to allow EBP
when addressing pain modulation during
therapy.
• Help patients learn and practices
tactics that will allow them an
active roll in their own pain

Kudos and Improvements modulation

• Industry wide CEUs on biases in
underserviced populations
 Hopeful endeavors
• Research into the placebo affect
of analgesia [Farre et al]
• Long Term Opioid Usage
(sensitization, addiction) [Edgerton
In the et al]
future… • Advancements and action steps
in research for biopsychosocial
model application in PT/OT/ST
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causes and solutions to the disparities in pain treatment. J Law Med Ethics. 2001
Spring;29(1):52-68. doi: 10.1111/j.1748-720x.2001.tb00039.x. PMID: 11521272.
3. Bushnell MC, Ceko M, Low LA. Cognitive and emotional control of pain and its
disruption in chronic pain. Nat Rev Neurosci. 2013;14(7):502-511.
doi:10.1038/nrn3516
4. Edgerton, K, Hall, J, Bland, MK, Marshall, B, Hulla, R, Gatchel, RJ. A physical
therapist’s role in pain management: A biopsychosocial perspective. J Appl

Resources 5.
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Published 2013 Feb 19. doi:10.1186/1471-2474-14-65
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Questions