March 2004

The Pain Fighters

By Michele B. Nicosia, PT, MSM

Chronic pain is defined as pain that lasts more than 3 months. Approximately 86 million Americans are affected to some degree by pain that impacts their quality of life and affects their families. Costs in lost productivity, sick time, and direct and indirect medical expenses are estimated to be about $90 billion annually.¹

The physical therapists, physicians, and psychologists at St Louis Behavioral Medicine Institute (SLBMI) know the many facets of chronic pain, and understand the severity of its impact on lives. Experiencing pain for up to 168 hours each week, possibly for years on end, severely impacts a person’s quality of life. A person who cannot walk, dress, or prepare meals without pain cannot perform more strenuous work. Such unremitting, unmanageable pain can seem overwhelming when there is no sign of relief.

From the beginning
The SLBMI Pain Management Program began in 1979, making it an early leader in the field of pain management. The pioneers of this program recognized from the start that a multidisciplinary approach was integral to effectively treating chronic pain. Clients receive coordinated holistic pain management services and specific practical information to help reduce pain with normal daily activities. All treatments begin with comprehensive medical, physical, and psychological evaluations. Using a multidisciplinary approach, the clinicians treat the whole person by addressing medical and physical problems, as well as social, emotional, spiritual, and occupational issues. The medical evaluation begins with a thorough history and physical examination, plus appropriate tests and laboratory work to rule out specific diagnoses. If indicated, the patient may receive trigger point injections and/or nerve blocks, as well as adjustment of current medications. Most important, the patient needs to be educated. “The multidisciplinary team approach is the most effective method of addressing the various life factors that contribute to pain,” says William D. Richardson, MD, internist and medical director of pain management at SLBMI. “Being part of a pain management program helps the patient become educated in realistic techniques for managing pain, even if the pain cannot be totally eradicated. Many conditions (like arthritis) cannot be cured, but the pain and associated problems can be managed more effectively. Having the entire pain management team at the same facility, able to communicate easily with other team members, allows for more effective management of any problems.”

A thorough evaluation
Managing chronic conditions requires identifying the many reasons for the onset and continuation of pain. SLBMI focuses on breaking the vicious cycle of pain, depression, tension, and musculoskeletal problems, recognizing that this cycle can be exacerbated by muscle imbalance, poor posture, poor mechanics, and lifestyle issues. It is our experience that the human body does not wake up one day and arbitrarily decide to experience severe pain. It actually forgives a lot of abuse before it starts sending pain telegrams to get attention and help.

For this reason, thorough physical therapy evaluations begin at the feet and end with the head, looking at alignment as well as body mechanics. Flat feet cause more than foot problems; they promote valgus knee position, affect vastus medialis function and can cause pelvic shift in several planes. Pelvic obliquities produce knee and hip stresses, functional scoliosis, paraspinal muscle imbalance, and even stress headaches. Weak abdominal muscles, pelvic obliquities, and sacroiliac dysfunctions are contributory culprits for a multitude of painful conditions, from back pain to osteoarthritis. I hate to see joints replaced without first correcting the dysfunctional mechanics that caused the original wear and tear. The improper alignment and dysfunctional mechanics remain, and will cause early failure of the replacement joint. Trying to correct those problems when the patient is in pain after surgery does not work as well.

Prolonged poor sitting posture can result in forward head and shoulders, tight cervicothoracic muscles, extensor weakness, and axioscapular muscle dysfunction. Ultimately, this may lead to upper quadrant problems like headaches, cervical arthritis, temporomandibular dysfunction, and overuse conditions like rotator cuff problems, epicondylitis, and carpal tunnel syndrome. Scapulohumeral function and extensor strength are critical, but neglected, elements of upper quadrant problems. These conditions cannot be fully resolved unless the dysfunctions are identified and the patient is trained to use proper mechanics with all activities.

We try to stress this concept to clients and professionals, that our bodies are the physical reflection of our postural habits, physical demands, and injuries. The longer we have any problem, the more our body adjusts to it, accepting the changes as “normal.” However, improper body alignment and function cause progressive damage to muscles, bones, joints, and nerves. Uncorrected problems get worse over time, affecting more parts of the body and increasing pain. When a house is damaged by an earthquake, the foundation cannot be neglected when the upper levels are repaired. Similarly, effective therapeutic intervention requires attention to body symmetry and functional mechanics from the ground up.

Getting past bad habits
However, no matter how good the therapy program, the body quickly tries to revert to bad habits, bad postures, muscle imbalance, and dysfunctions, which cause pain levels to increase. Patients will say, “I felt good for a few hours, then the pain came back.” The therapy was effective; now it is up to the client to keep that good feeling for as long as possible, frequently reminding the body of correct position and mechanics. Each tight muscle must be gently stretched once every 1 to 2 hours, teaching it to remain lengthened and in proper alignment during all daily activities. Vigorous stretching is counterproductive, and stretching done only a few times daily will not adequately change muscle memory. With proper stretching, pain should gradually decrease. The patient may still have more pain in the morning due to lack of directed exercise during the night, but each morning should be less painful as the musculoskeletal problems resolve.

Stabilizing the pelvis with daily activities is the next step. The therapist should assess pelvic stability with bed mobility, transfers, walking, steps, squats and “driving,” so the patient knows how often to normalize the pelvis with each activity. Clients must understand that even sleep movements can cause that all-important pelvis to shift out of alignment; they must do appropriate corrective exercises before walking, even to the bathroom. Driving a car (especially one with an automatic transmission) produces strain on the right pelvis and thigh, which must be corrected before walking again.

When increased pain indicates probable pelvic shift, corrective exercises should be performed immediately. Doing these gentle pelvic corrections often throughout the day will quickly lengthen and strengthen muscles and control pelvic instability, possibly allowing reduction of corrections within a week.

Maintaining normal pelvic position during activities is the function of abdominal muscles, which hold the posterior pelvic tilt against the combined antagonistic pull of rectus femoris, lumbosacral, and quadratus lumborum muscles (major culprits in lumbar hyperextension and pelvic anterior rotation). Using the abdominals effectively during standing, walking, going up and down steps, and other activities decreases back pain, reduces pelvic instability, and strengthens muscles more quickly.

The patient should be taught to isolate and properly contract three specific sets of muscles critical to good posture: the abdominal, sternocleidomastoid, and trapezius muscles. Gently contracting and using these muscles during activities will cause reciprocal inhibition of the tight hyper-reactive antagonists. Using these muscles encourages good functional mechanics with all daily activities, and eliminates bad habits that may still feel right.

“Most traditional PT programs focus treatment on the painful areas, instead of on the whole person. Our approach to PT identifies all sources of dysfunction possibly affecting the area of pain and treats accordingly,” says SLBMI physical therapist Trisha A. Becker, PT, MHS, OCS. “We use manual techniques and muscle imbalance exercises to improve function, activities of daily living, and work tasks. We encourage active participation of the patient in their rehabilitation, and promote patient responsibility in healing and pain control. “I have had great success with this treatment approach, resulting in decreased chronic pain, case closure, and return to work with relatively fewer visits than with the traditional physical therapy model.”

Psychological and Lifestyle Issues
Many clients who seek treatment have discovered that medicines they take to control pain actually rebound on them, worsening the symptoms and possibly causing drug dependency or even addiction. The physician may need to change or reduce their medications, so they must be taught nondrug techniques to manage their pain. The psychologists educate them in stress management skills, helping them integrate this information into a healthy reduced-stress lifestyle. Sessions may be individual or involve partners and family members to enhance outcomes.

SLBMI psychologist Hermann Witte, PhD, teaches many pain control techniques—biobehavioral, biofeedback, relaxation, and some nontraditional approaches to relax hypertonic muscles. He recognizes that “pain may feel like a single phenomenon, something that is beyond one’s control but, in fact, has multiple causes, many of which are well controllable. Among those controllable causes are factors that the pain patient may not even be aware of, namely excessive muscle tension, impaired breathing, depression, and smoking.”

The entire pain management team teaches and reinforces alternative ways of controlling pain: acupressure to trigger points, gentle stretching of painful muscles, use of cold, relaxation techniques, and deep breathing to oxygenate affected areas. The clinicians at SLBMI strongly encourage increasing protein intake and decreasing carbohydrates; this approach repeatedly has proved beneficial for general pain, headaches, acid reflux, weight control, diabetes, and hyper/hypoglycemic rebound. Other lifestyle changes may be indicated, including improving fluid intake and nutrition; reducing or ceasing smoking to improve blood flow; improving quality and quantity of sleep for healing; and moderating exercise and activities by working smarter not harder. Using these techniques can reduce pain levels, often dramatically, although pain levels and muscle tone in smokers are highly resistant to change.

Psychologist Ryan Niemiec, PsyD, stresses the body-mind connection and psychosomatic considerations. “Common emotional reactions to pain include depression, anxiety, and anger, but usually one emotion dominates,” he says. “Emotional stress can cause symptoms to worsen. Thoughts, feelings, and behaviors can make pain worse, keep the pain from decreasing, or contribute to return of pain symptoms. Learning ways to manage these powerful emotions can have a tremendously positive effect on pain. Understanding what drives our behavioral patterns, and learning to respond in new ways, are helpful in managing pain.”

Long-term help
Pain management specialists must see themselves as guides who direct clients through unfamiliar territory, because they cannot provide supervision every minute of the day. Out-of-town clients require intensive daily sessions to achieve quick results, but local clients initially have one or two sessions per week with each specialist, decreasing as their status improves. Since patients normally are seen for only a few of the 168 hours in each week, they must assume responsibility for their own care and progress. They must control their pain, not let their pain control them. Along the way, regular assessment of their pain, problems, work demands, and exercise programs must continue, with clinicians providing practical suggestions and help as needed.

As patients are able to control pain and show improvement in the identified problem areas, they can reduce treatment frequency. However, regular physician appointments should continue even after psychological and physical therapy treatments terminate, in order to evaluate how well the patient is managing their long-term self-care. Follow-up appointments with physical therapists and psychologists may be scheduled periodically to determine additional corrections and interventions as needed.

Michele B. Nicosia, PT, MSM, has more than 30 years of clinical experience in every medical setting; she has worked in pain management for 10 years and is an independent contractor at St Louis Behavioral Medicine Institute, St Louis. She may be contacted by email: Michele@slbmi.com. Information about the institute is available at www.slbmi.com.

1. What is chronic pain, American Chronic Pain Association. Available at: www.theacpa.org. Accessed January 12, 2004.