In the very early years of my career (many moons ago), I was called to see Ms. E., a delightful 75 year old woman who had slipped in her apartment and had fractured a couple of ribs. The daughter had brought her in our emergency with excruciating pain and she was admitted for pain control.
However, 2 weeks later, she was still laying in a hospital bed in significant pain despite the pain medications. Since Ms. E. adamantly refused to get out of bed complaining of serious pain – my colleague- her attending physician, asked for my help.
When I got to her room I sat by her bedside after introducing myself and I started chatting with her about a couple of photos on her night table. She explained that they were her grandchildren, the apple(s) of her eye. She spoke of how much she missed them, and tearfully, spoke of how much she wanted to get better so that she could return home and be re-united with them.
At that moment I took the opportunity to tell her that if she were to start walking this would speed her recovery and her return home to the family. She resisted. “What about if I fall again” she asked. “You won’t” I assured her, “because we will be holding you”. With my encouragement and the help of a nurse she was able to stand on her feet, despite the face that she was shaky and weak from the prolonged bed rest. Leaning on ours arm, she took a few steps with us while I distracted her by talking about her family. It was not much, just to the door and back, but she did it without one complaining of her pain. When I pointed this out to her she looked puzzled and surprised. Then I explained that maybe she was afraid that getting up would bring on her pain, but that her body had been healing and that it was her fear of movement and fear of pain that had held her captive in her bed.
The rest is history. Later the same afternoon we brought in the hospital physiotherapist who took on the rest of her rehabilitation recovery by assisting her with walking and moving around. Ms. E’s recovery progressed so fast that in a week she was ready to return home to her family, walking on her own two feet.
I have asked my colleague, Dr. Judith Hunter, a physiotherapist and researcher, to describe to you, the readers, what physiotherapists do. Here is what she told me:
Physical therapists, also called physiotherapists, are licensed health care professionals, concerned with physical function, movement, and physical potential. When starting physical therapy, you must decide what you want to accomplish. The goals you set must be important to you, realistic and attainable and your physical therapist will develop an appropriate treatment program to help you achieve those goals. Your therapist may also interact other health professionals, and perhaps your family, caregivers, or your community.
Movement is the key tool for physical therapists. Improving her ability to move helped Ms. E., manage her pain and improve her ability to function. It is interesting to note that people in pain move differently than people who do not suffer from pain. In some cases muscle fatigue, reduced function of a muscle or group of muscles, or even neurological problems, change the way one moves. Normal movements usually occur in “patterns”. For example: when you walk there is a certain way one foot advances in front of the other while your arms swing. Different conditions may affect patterns of movements and make a person less capable to adapt to normal changes that occur as one moves across different types of surfaces and through different postures.
Muscle and joint pain changes how the brain controls movement. The nervous system is wired so that the muscles will respond to an acute stimulus by moving you away from the stimulus and protecting you from receiving additional painful stimuli from the same source. So we are wired to learn “how to avoid pain”.
Physical types of therapies are non-pharmacologic and non-medicinal. Physical treatments include therapeutic exercise, hydrotherapy, light, heat, cold, massage, and electricity. There are many physical modalities such as ice or heat, (TENS), acupuncture, manual therapies including mobilization, manipulation and massage. These modalities in themselves do NOT constitute physical therapy. Just like medications, these modalities are “passive” (which means someone else or something else is doing things for you). Some may help with short-term relief of pain. In isolation, however, they are not considered “Physical Therapy” for chronic pain.
However, exercise (active therapy that you do yourself) is the key to rehabilitation. Muscles attached to sore joints lose about 50% of their strength. Muscle atrophy (wasting) and changes to muscle composition with prolonged immobility also contribute to reduced strength and fitness. Many people with chronic pain have out-of-shape (de-conditioned) muscles. Many also have poor endurance. Supervised exercise can help improve circulation, muscle tone, tissue healing, and endurance.
Muscle weakness and change in the brain’s control of movement means you may use abnormal protective responses or abnormal muscle movements. These can lead to overuse and sprains in initially unaffected areas of the body.
In addition, many people who suffer from chronic pain have a more sensitive nervous systems and in this case even some normal movements may increase pain. This in turn leads to the patient avoiding these movements and learning subconsciously to fear them (exactly like Ms. E). Avoiding certain movements may help when pain is acute, as this protects the tissues from further harm. However, when pain persists, activity avoidance becomes maladaptive (that means it does not serve a useful purpose) leading to a cycle of muscle de-conditioning and loss of range of motion, reduced capacity for physical activity and subsequent disability. More importantly, when you experience this loss of function, your body and mind has learned to interpret it as pain or problems in the tissues, but in many cases, this is due to “maladaptive learning” within your nervous system.
The physical therapist will either:
- Carefully expose you to movements and movement patterns that you have avoided due to fear of (re)injury;
- Teach you how to strengthen and stretch the muscles accompanied by specific training in affected movement patterns;
- Teach you to recognize abnormal movement patterns, and how to correct these patterns;
- Make you understand the difference between “hurt” (my muscles are painful) versus “harm” (I may damage my body);
- Learn about how motor control and movement affect pain;
- Use physical strategies like ice, heat, massage, acupuncture and TENS to improve your ability to exercise or manual therapy and/or acupuncture to manage occasional muscle or joint dysfunctions as you move forward in your exercise or increased movement;
- Learn to choose activities and exercises that will help you improve mood, sleep, pain, and your daily function.
Now, next time your doctor suggest you “need physiotherapy”, you will really understand what to expect from yourself and a good physiotherapist.
Angela Mailis Gagnon, MD, MSc, FRCPC(PhysMed)
Director, Comprehensive Pain Program,
Senior Investigator, Krembil Neuroscience Centre
Toronto Western Hospital,
Chair ACTION Ontario www.actionontario.ca