Pain Management with Physical Therapy

Written by: Ben Boyle, PT, DPT, FAAOMPT

Ben Boyle is the chief clinical affairs officer at IRG Physical & Hand Therapy, with over 16 years of experience in a variety of clinical settings. He is also actively involved in government affairs and advocacy efforts for the profession.  

The COVID-19 crisis has had rapid, sustained and devastating impacts on our health, the economy and our social networks – particularly in the United States, where government, public health agencies and the healthcare community has struggled to contain the immediate and long-term consequences of the coronavirus. Of concern to public health officials and healthcare providers alike is the collision of an ongoing national epidemic, the opioid crisis and the largest global pandemic of a generation, which is causing significant health, economic and societal consequences.

In the late 1990s, pharmaceutical companies made a big push into the musculoskeletal and orthopedic markets by reassuring healthcare providers that patients would not become addicted to opioid pain relievers, if they were prescribed for conditions within these designations. The resulting increase in prescription opioid medications led to widespread misuse of both prescription and non-prescription opioids, due to the highly addictive nature of these drugs.  Consequently, the rise in opioid misuse for chronic orthopedic and musculoskeletal conditions has had devastating consequences.  Currently, the number of people misusing opioid medication in the U.S. tops 10 million, and the resulting epidemic has led to over 130 deaths per day, with over 2 million people developing opioid use disorder.

 The American Medical Association reports a 42 percent increase in opioid related overdoses during the COVID-19 pandemic.  Additionally, the British Medical Journal reports a substantial increase in chronic neuro-musculoskeletal pain diagnoses and symptom exacerbations during the COVID-19 pandemic.  This is likely due to the fact that chronic pain and opioid use disorders share similar etiologies and risk factors.  There is strong evidence that both disorders have biopsychosocial risk factors including depression, anxiety, stress, social isolation and economic despair, along with the presence of multiple co-morbidities, nutritional deficits and persistent sleep disorders - all of which are undoubtedly exacerbated during the COVID-19 pandemic. 

Limited access to multidisciplinary and effective treatments for chronic pain and opioid use are undoubtedly fueling the significant increase in cases during the pandemic.  One of the best choices for treating chronic pain and preventing opioid use is physical therapy. A large study in 2018 found that early physical therapy for pain significantly reduced an individual’s chances of future opioid use. 

Chronic pain that often leads to opioid abuse is fundamentally different then acute pain associated with an acute injury, such as a muscle strain. Chronic pain affects each person differently, and arises when all of our stressors exceed our perceived ability to adapt. This helps explain why common events throughout the current pandemic, such as job loss, stress, anxiety, financial difficulties and fear, coincide with a substantial increase in chronic pain and opioid or substance abuse. 

Anyone can develop chronic pain at any age. Emerging evidence demonstrates that the brain undergoes significant changes when dealing with this type of pain. In scenarios of chronic pain, the brain will analyze information coming from the nerves in the body to determine if there is a threat to the body, and whether action needs to be taken to prevent harm. When these signals are constant or chronic, the brain and nervous system go on “high alert,” becoming more sensitive.  Additionally, cells that conduct sensation in the nervous system become more sensitive when on high alert, making it easier for the brain to interpret sensations as a threat, causing more pain.  Pain becomes chronic when the brain continues to interpret all sensations from the problem area as danger, even when there is no more tissue damage. The sustained activation by the brain and nervous system increases sensations, emotions and thoughts about the problem area.  Eventually, any sensory input can activate pain centers, causing activity avoidance, fearfulness, body stiffness, deconditioning, decreased circulation and worsening of other health conditions. 

Physical therapists are excellent healthcare providers to help patients manage and treat chronic pain, and reduce the need for pharmacological intervention.  Physical therapists have the opportunity to spend a significant amount of time with patients, allowing them to build trusting relationships and educate on pain control. There is a significant amount of emerging research suggesting that when patients with chronic pain are educated on the cause and mechanisms of their pain in a manner that they understand, they experience less anxiety about movement and their pain in general.  Physical therapy has been shown to be effective at controlling pain and decreasing opioid use by increasing muscular strength and mobility, and improving postural awareness and body mechanics.  This has been shown to not only reduce immediate pain levels, but also stimulate a re-wiring of the brain and nervous system to decrease an individual’s perception of pain. 

Access to safe and effective non-pharmacological methods for treating chronic pain, such as physical therapy, will be essential to simultaneously navigating the U.S. opioid crisis and the COVID-19 pandemic. It will also take coordinated and innovative efforts from providers, local government and insurers to facilitate the delivery of these essential services. An example of this is the rapid expansion of telehealth and at home or on-site services, to overcome restrictions on social interaction, travel and exposure, and the delivery of these critical services to patients in need.

The ongoing opioid crisis and worldwide pandemic will continue to provide unique challenges to maintaining health and wellness. However, the physical therapy community continues to innovate during these unprecedented times, to deliver uninterrupted, high-quality care to those most in-need within our communities.