Behind the Book

We asked the editor for her thoughts on this important new book.
Q: The book includes an overview of the basic science of pain. Does this information fill a gap in the standard education of the physical therapist?
A: The basic science mechanisms of pain presented in this book expand on the normal education physical therapists receive on pain mechanisms. The book describes the standard pathways for transmission of nociceptive information in the periphery through to the cortex, which is normally included in physical therapy education. This information is expanded to describe the neurotransmitters and receptors involved in nociceptive transmission peripherally, as well as centrally. In addition, we describe the neuroplastic changes that occur in the peripheral and central nervous systems as a result of tissue damage, termed peripheral and central sensitization. We further emphasize how these basic science mechanisms underlie clinical pain manifestations, such as referred pain, hyperalgesia, and allodynia.
Q: Physical therapy has traditionally been involved in increasing functional ability and movement. Do physical therapy techniques directly relieve pain as well?
A: The overall goals of physical therapy are to improve functional ability and movement. These goals can be met by directly addressing muscle and joint function, as with exercise and manual therapy, but also indirectly by relieving pain, as with TENS. Several physical therapy techniques can directly relieve pain by activating inhibitory mechanisms within the nervous system. These include exercise, TENS, and joint manipulation. The neurobiological mechanisms by which these techniques relieve pain are outlined in specific chapters.
Q: What are some of the ways described in this book in which physical therapists can help patients with chronic pain to improve their quality of life?
A: The management of chronic pain is difficult for all clinicians. This book provides the evidence that will allow the therapist to make an educated choice about treatment. The philosophy we present involves understanding potential mechanisms that underlie findings in the assessment of patients, and understanding the mechanisms by which physical therapy treatments work. For example, if a patient has significant central sensitization as a result of a pain condition, therapies designed to reduce central sensitization should be the first choice. These treatments could be ones aimed at activating the descending inhibitory system, such as TENS or exercise. The book also supports a multidisciplinary approach to the management of chronic pain that can be delivered in collaboration with a team that includes physicians, nurses, and psychologists. This team approach addresses the multidisciplinary nature of pain to reduce the sensory as well as the affective dimension of pain.
Q: Which is more valuable for the patient with acute or chronic pain: hands-on therapy or education on self-care?
A: There is no single technique that is more valuable for a person with acute or chronic pain. However, the philosophy of the physical therapy profession, and for the physical therapy management of pain, is to give patients the tools to help manage the pain on their own. This approach includes education on self-care and on appropriate exercise programs for a given condition. Making the patient an active participant in the care process through education and exercise is particularly important for those with chronic pain. Hands-on therapy can be a valuable addition that can reduce functional limitations and pain to allow the patient to progress through an active exercise program.
Q: You and your contributors have reviewed the evidence base for many techniques used today in physical therapy practice. In general, how well are these methods supported by high-quality evidence? Were there any surprises?
A: There were few surprises in the findings, with the level of support varying depending on the pain condition and the treatment itself. There is very strong high-quality evidence to support the use of exercise in the treatment of almost all pain conditions. For other treatments, evidence is beginning to emerge, with higher-quality trials being published on a variety of pain conditions. There are several newer studies supporting manual therapy techniques for musculoskeletal pain conditions, as well as two relatively new meta-analyses to support the use of TENS for postoperative pain and for chronic musculoskeletal pain. Studies on the efficacy of physical therapy treatment can be difficult to design due to the inability to provide an adequate placebo. For example, how do you provide an adequate placebo for a hot pack or for exercise? These types of problems will always be inherent in the experimental design of true randomized double-blind placebo-controlled trials for many physical therapy treatments.
Q: What is the applicability of physical therapy for pain relief in developing countries and low-resource settings?
A: Physical therapy is extremely applicable in developing countries and low-resource settings. Most therapies are inexpensive, and those with the strongest efficacy, such as exercise, are among the most inexpensive and easy to administer. Exercise and manual therapy techniques for the management of chronic pain do not require special equipment and can be performed in almost any setting. The principles of physical therapy are clearly to use education and exercise to improve function, which can be done in any setting.
Q: What is your philosophy regarding the interdisciplinary management of pain, and what is the physical therapist’s role in a treatment team?
A: Interdisciplinary management, particularly for chronic pain, has good evidence to support its efficacy and appears to produce greater effects than treatment by a sole practitioner. Interdisciplinary pain management should be considered for every chronic pain patient. The physical therapist plays a vital role in this team by helping patients become active participants in their recovery, and by emphasizing an approach that will improve function.
Q: What are some important research areas for the future of physical therapy management of pain?
A: Numerous research areas present themselves at both the basic science and clinical level for physical therapy management of pain. I believe we need to continue to expand our understanding of the mechanisms by which physical therapy treatments, such as exercise or manual therapy, relieve pain. One of our weakest databases involves the use of physical therapy for neuropathic pain and complex regional pain syndromes, and thus high-quality randomized controlled trials are needed. We also need to begin examining, in high-quality trials, the effectiveness of our treatments not only on resting pain, but also on other outcomes that are clinically relevant, such as function, pain with function, quality of life, and return to work. Lastly, combinations of treatments, either more than one physical therapy treatment or a pharmacological treatment and a physical therapy treatment, should be explored for enhanced efficacy. This issue is particularly relevant because most patients do not receive only one treatment at a time.
Q: Who should buy this book?
A: This book is designed for physical therapy students in a professional degree program and can serve as a textbook for a course on pain management for physical therapists. It is also appropriate for practicing physical therapists who actively treat people with acute and chronic pain, and for those in other areas of rehabilitation, such as physiatrists, osteopaths, and occupational therapists. The book would also be useful for any health professional with an interest in an interdisciplinary approach to pain management.