Pain: retraining mind & brain (FS-20)

Exercise therapy for chronic pain: retraining mind & brain

Jo Nijs (Belgium), Rob Smeets (Netherlands), Mark Bishop (United States of America), Niamh Moloney (Australia)

Focused symposium

Saturday 2 May 2015, 08:30-10:00, Hall 406

Exercise therapy for chronic pain: retraining mind & brain

Nijs J. 1,2,3, Smeets R. 4,5, Bishop M. 6, Moloney N. 7

1Vrije Universiteit Brussel, Physiotherapy and Rehabilitation Sciences, Brussels, Belgium, 2University Hospital Brussels, Department of physiotherapy, Brussels, Belgium, 3Pain in Motion research group, www.paininmotion.be, Brussels, Belgium, 4Maastricht University Medical Centre, Department of Rehabilitation Medicine, Maastricht, Netherlands, 5Adelante Centre of Expertise in Rehabiliation Medicine, Hoensbroek, Netherlands, 6University of Florida, Department of Physical Therapy, Gainesville, United States of America, 7The University of Sydney, Discipline of Physiotherapy, Faculty of Health Sciences, Sydney, Australia

Learning objectives

  1. Evaluate and modify ongoing current exercise paradigms salient to the patient with a chronic pain condition;
  2. Apply evidence-based guidelines for chronic pain management to physical therapy practice;
  3. Devise an effective exercise program to remediate pain that engages the patient and considers cognitive/affective/emotive aspects of the pain experience;

Description

Chronic pain remains a challenging issue for clinicians and researchers. Over the past decades, scientific understanding of chronic pain has increased substantially. It has now become clear that chronic pain represents a biopsychosocial problem, with maladaptive changes in the central nervous system, musculoskeletal system and at the cognitive level. Exercise interventions are commonly recommended and used for the management of individuals with chronic pain conditions. Exercise is an effective treatment for various chronic pain disorders, including fibromyalgia, chronic neck pain, osteoarthritis, rheumatoid arthritis and chronic low back pain. Although the clinical benefits of exercise therapy in these populations are well established (i.e. evidence based), clinicians struggle applying science in daily physical therapy practice.

At the cognitive level, pain catastrophizing and fear-avoidance beliefs are often present in chronic pain patients, and can be addressed by applying cognitive exercise therapy (e.g. graded exercise therapy, graded activity and graded exposure in vivo). Excessively elevated fear-avoidance beliefs, both in patients and treating physical therapists, have a negative impact on chronic pain outcomes as they delay recovery and increase disability. Reductions in maladaptive pain cognitions, especially pain catastrophising and fear-avoidance beliefs, as well as increased pain self-efficacy beliefs, have been established as key contributors to positive outcome in exercise therapy programs for chronic pain. Such maladaptive cognitive factors are typically addressed in comprehensive exercise therapy programs that include not only exercise but also pain neuroscience education, stress management, and activity self-management. These include fear-avoidance beliefs- and catastrophizing-reducing information, pain and fear desensitizing treatments along with counseling.

In addition, increasing evidence supports the role of adherence to exercise interventions and non-specific factors for determining outcome. Research findings have taught us that patient expectations are an important and 'overlooked' determinant for predicting clinical outcome in chronic pain treatment. Symposium participants will learn how to address patient expectations for care in individually-tailored exercise therapy for chronic pain patients.

Within the context of the management of chronic pain, it is crucial to consider the concept of pain mechanisms, including aspects like central sensitization and dysfunctional endogenous analgesia in response to exercise as seen in some chronic pain populations. Hence, in patients with chronic pain and central sensitization it seems rational to target therapies at the brain rather than muscles, joints or cardiovascular system. More precisely, modern pain neuroscience calls for treatment strategies aiming at decreasing the sensitivity of the central nervous system (i.e. desensitizing therapies). The brain of chronic pain patients has typically acquired a protective pain memory. For movements that once provoked pain, this implies protective behaviours like antalgic postures, antalgic movement patterns (including altered motor control) and avoidance of such movements (fear of movement). Even preparing for such 'dangerous' movements is enough for the brain to activate its fear-memory network and hence to produce pain (without nociception) and apply an altered (protective) motor control strategy. Exercise therapy can address this by applying the 'exposure without danger' principle. The symposium participants will learn how to apply the principle to physical therapy for patients with chronic pain, including those with work-related musculoskeletal disorders, low back pain, neck pain, shoulder pain, etc.

Implications / Conclusions

Physical therapy for patients with chronic pain should include exercise therapy tailored to the patient's preferences, needs, pain cognitions, musculoskeletal and central nervous system dysfunctions. A broad biopsychosocial view is required for applying effective exercise therapy for patients with chronic pain, and can be provided in primary, secondary or tertiary care. This accounts for physical therapists working in the field of musculoskeletal pain, neurology, pediatrics, internal medicine and geriatrics.

Keywords

Therapy; Exercise; Pain

Funding acknowledgements

Mark Bishop receives funding from the National Institute of Arthritis and Musculoskeletal and Skin Diseases and the National Center for Complementary and Alternative Medicine, USA.

Relevance to WCPT and expected audience

Regardless of the setting in which physical therapists work, primary, secondary or tertiary care, they are confronted with chronic pain. This accounts for physical therapists working in the field of musculoskeletal pain (e.g. osteoarthritis, spinal pain, lateral epicondylalgia, headache), neurology (e.g. neuropathic pain, pain in Parkinson disease, Multiple Sclerosis and stroke), pediatrics, internal medicine (e.g. cancer pain) and geriatrics. The physical therapy profession has a long history of applying successful exercise interventions for (pain) patients.

Target audience

The target audience includes practitioners, educators, and researchers mainly, and to a lesser extent managers and policy makers.