The objectives for rehabilitation in musculoskeletal medicine is to restore a patient to their former capacity by therapeutic means or to improve physical function so they can return to meaningful and constructive activity. For acute pain management with moderate limitations to functional activity, a therapist can follow a relatively linear process of assessing for any major health concerns and then safely treat and guide the patient to their desired level of recovery.
The majority of musculoskeletal concerns RMTs encounter are relatively benign and will resolve on their own. A majority of spinal pain presentations are not a medical emergency and with time they will subside with simple advice and self-management suggestions.[i] Two questions to consider; if most musculoskeletal complaints are not a major concern, then why does approximately 20% of Canada’s population live with persistent pain.[ii] Why, when patients have received treatments from numerous healthcare providers (HCPs) is their suffering and quality of life still negatively impacted?
Educational limitations for treating persistent pain
Principles of effective persistent pain management are often absent within manual therapy training. Primary RMT education emphasizes tissue-based treatment interventions with focus on correcting anatomical dysfunctions. Musculoskeletal (MSK) assessments are used to identify areas of pain and dysfunction and then specific manual and movement interventions are applied in an effort to correct these perceived problems. Unfortunately, the longer someone experiences pain, the less valid standard MSK assessments and treatments become.
The standard biomechanical process of assessment, treatment and management when treating a patient who lives with disabling persistent pain is often unhelpful because it misses the entirety of the person’s experience. Adopting a more encompassing biopsychosocial (BPS) conceptual framework changes clinical reasoning and decision making to deliver more effective evidence informed treatments. Changing to a BPS framework becomes increasingly important with presentations of persisting pain after standard orthopaedic assessment and treatment protocols are followed and symptomatic changes, or quality of life improvements are absent or minimal.
Adopting a new narrative around pain
Pain is a strong sensory experience and massage can help to temporarily decrease pain sensitivity. To achieve better rehabilitation outcomes requires expanding thinking from pain as a single sensory experience and understanding what that experience means to the person and how it is impacting their quality of life. Reconceptualizing the therapeutic narrative from fixing anatomical and movement dysfunctions to evidence informed BPS management strategies needs to be the established norm for allied health providers. To assess and reason in a BPS framework requires a solid foundation in understanding the complexities of pain. Foundational pain knowledge simplifies treatments by providing a better understanding of the person’s experience, it promotes better communication, and empowers people to take a more active role in their recovery.
Research does not support the fixing of painful problems with aggressive interventions like surgery or injections. [iii] Patient centred shared decision making and interdisciplinary care has the strongest evidence for managing persistent pain. [iv] Passive interventions like massage, joint mobilization, acupuncture or electrical modalities can help manage symptoms. There is only anecdotal evidence to suggest these results on their own can provide anything more than short term analgesia. Placing these interventions into perspective highlights their effectiveness as an adjunct to coincide with more evidence informed treatment options.
A core competency for RMTs is to adopt an evidence-based practice. HCPs have an ethical obligation to assess current evidence and adopt into practice to the best of their ability. The RMT culture and treatment environment is different from other HCPs. RMTs spend significantly more time with their patients which creates the opportunity to establish a profound therapeutic alliance. This can facilitate a path of self-efficacy and meaningful recovery and guide the patient away from searches for a quick cure through intervention shopping.
For persistent pain populations, the focus for rehabilitation should be on using psychosocially informed self-management strategies. A psychologically informed practice is a logical extension of an evidence-based practice (EBP) framework. RMTs need to be aware of psychosocial factors and how these can influence patients’ barriers and facilitators to recovery. Pain catastrophizing, unhelpful beliefs and fears about the body and encouraging healthy behaviours around pain and function are all achievable clinical objectives that RMTs can influence. This does not mean RMTs need to be trained as counsellors or social workers. There is inherent value in understanding the basic impacts of psychosocial factors and how RMTs can effectively influence those to aid in recovery while staying within scope of practice. Psychosocial influences can be a significant predictor to treatment outcomes. Ignoring psychosocial factors to health leaves HCPs incomplete in optimum management of persistent pain presentations. This goes against the core principles of what HCP’s are supposed to do, help patients using current best evidence, combined with personal experiences and patient values.
Rehabilitation basics for persistent pain populations
By reconceptualizing the meaning of persistent pain and aligning treatment and management principles with similar frameworks to how other chronic health conditions are managed could have a positive effect on reducing health care utilization, improve workplace productivity, and establish a better quality of life.
Rehabilitation of the persistent pain patient should focus on self-management, lifestyle alterations, social engagement and exercise. These strategies increase the likelihood for functional improvements and better quality of life. Similar approaches are successfully used in the management of diabetes, respiratory illnesses, heart disease and autoimmune diseases. Moving the focus towards management of symptoms and not chasing to fix them, the persistent pain patient increases their chance at accomplishing meaningful quality of life improvements.
By following the research, it becomes more evident that what is manually done ‘to’ the patient is of minor importance to overall outcomes. The therapeutic relationship developed, the patient’s narrative, their thoughts, beliefs and perceived control for managing symptoms, has an effect greater than any manual intervention. Touch is therapeutic, it feels good, that is the foundation of the RMT profession. Being more effective in rehabilitating the persistent pain patient requires the re-focusing of treatment objectives to concentrate on understanding what the pain experience means to the patient and looking to achieve specific, measurable and reasonable functional improvements that are consistent with their personal objectives.
[i] O’Sullivan, P., Caneiro, J., O’Sullivan, K., & Okeefe, M. (2016). Unravelling the complexity of low back pain. Journal of Orthopaedic Sports Physical Therapy. 46(11), 932-937.
[ii] Schopflocher, D., Jovey, R., & Taenzer, P. (2011). The prevalence of chronic pain in Canada. Pain Research and Management 16(6), 445‐450.
[iii] Mailis, A., & Taenzer, P. (2012). Evidence based guideline for neuropathic pain interventional treatments: Spinal cord stimulation, intravenous infusions, epidural injections and nerve blocks. Pain Research and Management, 17(3), 150-158.
[iv] Chou, R., Loeser, J., Owens, D., Rosenquist, R., … Wall, E. (2009). Interventional therapies, surgery, and interdisciplinary rehabilitation for low back pain: An evidence based clinical practice guideline for the American Pain Society. Spine 34(10), 1066-1077.