Persistent Pain: An Independent Disease State?

I recently began reading C.S. Lewis' The Problem of Pain. As with many of Lewis' writings, it is remarkable in both it's depth and simplicity. So many questions arise when it comes to the issue of pain, particularly for this therapist. Because I don't like weak links, I figured I'd better start looking for answers!

One aspect of a good question is that it often gives rise to more even better and more clinically relevant questions. Many physical therapists (myself included) emerge from entry-level training with a rather unsophisticated understanding of pain. We are more apt to enter the workforce with a strong understanding of pathoanatomy and biomechanics as it pertains to movement. If our goal is for our profession to evolve into becoming entry-level providers, we should have no tolerance for blind spots.

In the coming weeks, I will be incorporating the rather complex subject of pain as it pertains to common orthopedic conditions we encounter. More importantly, I will place emphasis on relevance to both assessment and treatment. I hope you will get as much out of the articles as I have in researching them. Mercifully, the topics will appease those of you with an appetite for physiology versus psychology.

Today's article comes from the Journal of Pain and Symptom Management on the issue of persistent pain and is truly an eye-opening read. Based on our study of pathophysiology, the concept of persistent or chronic pain doesn't always connect with our understanding of the inflammatory process. While there is clearly an inflammatory component to the acute pain our patients' experience, the relationship between tissue damage and persistent pain becomes much less clear in more.

The review provides evidence for "independent, pain-perpetuating pathophysiologic changes that occur after, or in the absence of, acute painful conditions or concomitant painful conditions." The review's author, anesthesiologist Michael Cousins, makes a very strong argument for persistent pain as a distinct pathological entity warranting specific attention from diagnosis through management. Cousins' contention is that failure to acknowledge the distinct physiology of persistent pain is likely to result in suboptimal care.

Contrary to much of the cognitive-behavioral pain literature I've tried to choke down over the years, this article provides the reader with some pretty significant pathophysiology supporting the concept of persistent pain as a distinct entity. I was particularly impressed with the physiology of peripheral sensitization, spinal cord events, and central nervous system changes that result from persistent pain. There is a relatively brief discussion of psychologic and environmental contributors,but the weight of the article is devoted to the biologic processes behind persistent pain.

Pain is not something orthopedic therapists may find particularly interesting or even relevant to their daily practice. The "no pain no gain" philosophy does have its time and place. However, what if there is a better way? I have no illusions of becoming the next pain-guru nor will I turn this into another freaky pain-blog, but I think we can take our practice to the next level by improving our understanding of pain in an orthopedic setting.


COUSINS, M. (2007). Persistent Pain: A Disease Entity. Journal of Pain and Symptom Management, 33(2), S4-S10. DOI: 10.1016/j.jpainsymman.2006.09.007

The Pelvic Floor and an Unexpected Lesson...

It's been six months since starting this blog and I'm amazed what the process has taught me to this point. Sitting down in front of a computer has given me numerous opportunities to learn more about our profession, enhance my clinical skill, and in this case, grow up a little.

If you know me personally, I tend to be a pretty fun-loving and somewhat irreverent guy who is prone to cracking wise about a variety of topics. In most settings, this characteristic is simply what makes me "me". In the context of a public discussion on a physical therapy website, it could transform "me" into a bit of a jerk.

I recently made a pretty insensitive comment regarding pelvic pain on the Rehab Edge forums. I won't delete the post as accountability and transparency is something I believe in and don't think running away from what I said is the right approach. In response to my comments, two ladies associated with a blog called Pelvic Pain Matters descended upon me with what turned out to be understandable mix of outrage and disappointment.

With a strange sense that I really might have stepped in it with my comments, I ran them by my wife, mother, and academic mentor from physical therapy school. The result of my informal poll was unanimous and a bit humbling: I was a total jerk for what I said. Not the easiest things to hear from three people who you respect and admire, but the consensus struck a chord nonetheless.

Pelvic floor dysfunction is not an area I have previously held any interest in addressing as a orthopedic clinician. In fact, it is not likely to ever be an area I develop a strong skill set in assessing or managing. However, it is worth noting that pelvic floor dysfunction is a distinct clinical issue that can be present in a broader population than I had previously understood.

JOSPT: Lumbopelvic dysfunction, Incontinence, and the use of Rehabilitative Ultrasound

In keeping with the theme of this blog, today's entry comes to us from JOSPT on the topic of lumbopelvic dysfunction and stress urinary incontinence. The paper is a case study on a 35 y/o female soldier presenting with stress urinary incontinence and left buttock pain. These symptoms were limiting her tolerance for physical activity necessary to complete basic training.

The study's authors utilized a multimodal approach to managing what was determined to be an SIJ dysfunction coupled with active pelvic floor insufficiency contributing to stress incontinence. Of particular focus in the study was the use of rehabilitative ultrasound as a biofeedback device to retrain the pelvic floor musculature.

At a six-week follow up, the patient had no subjective or objective signs of SIJ dysfunction or stress urinary incontinence. This allowed her to complete all the requirements of basic training without limitation. A six month telephone follow up was equally positive with no evidence of lumbopelvic dysfunction or incontinence.

What can this study tell the orthopedic therapist?

While I wasn't bowled over with the methodology or outcomes of this particular study, I did learn quite a bit regarding pelvic floor dysfunction. Firstly, I discovered just how prevalent pelvic floor pain and/or dysfunction can be in both men and women. Secondly, I got a better appreciation for the biomechanics of the pelvic floor and its possible role in low back pain. Lastly, I gained an appreciation for another clinical syndrome physical therapists may be able to benefit.

What has this process taught me?

Well...that remains to be seen! Some might say you can take the boy out of the locker room but it's hard to take the locker room out of the boy. I might agree with this statement. However, there comes a time when us boys have to realize we are professionals and people do read what we say on blogs and internet forums. I make no guarantees of future perfection. In fact, I'm more prepared to guarantee future imperfection. That doesn't mean I can't grow up along the way. Have a great day.

Painter, E.E. (2007). Lumbopelvic Dysfunction and Stress Urinary Incontinence: A Case Report Applying Rehabilitative Ultrasound Imaging. Journal of Orthopaedic and Sports Physical Therapy DOI: 10.2519/jospt.2007.2538

Imaging and Shoulder Pain: Why we don't treat MRIs....

How many of us have heard patients tell us they'll be relieved if they could just get an MRI to "tell them what's wrong."? I'll be the first to admit I too jumped on this bandwagon early in my career. I was very eager to see an individuals MRI report to correlate their clinical symptoms. You've heard me quote a wise old PT friend of mine who said "We don't treat MRIs". Well RV, this one goes out to you. ;)

This fascination with "seeing" what's wrong has lost a bit of its luster as I've read some very interesting reports on the lack of agreement between MR and clinical presentations. We've seen this phenomenon in low back and shoulder pain where imaging studies don't necessarily correlate with the patients clinical presentation.

It'd been a while since I've seen a good study on this topic so I figured I'd look up what the American Journal of Roentgenology had to say on the issue. The article takes a whopping 1079 consecutive patients referred for shoulder MRI. The subjects were asked to complete validated shoulder questionnaires regarding pain and disability. These were correlated with the radiologists' MR findings.

What did the authors conclude?

• MRI is highly accurate at detecting the presence of a partial or full-thickness rotator cuff lesion.



• There was no relationship between pain or disability with the size or location of the rotator cuff tear.



• Rotator cuff lesions may be thought of as a natural correlate of aging



• It is not clearly identified why some rotator cuff lesions are symptomatic while others are "silent"



• Factors such as bursitis, capsuloligamentous lesions, or cartilage lesions may confound the findings of MRI as they pertain to the rotator cuff



• There may be "no relationship between rotator cuff tear size and the inflammatory reaction responsible for the pain and disability, like low back pain is unrelated to the size of disc herniations."

What are the author's recommendations?

• "Despite the absence of correlation between the size of the rotator cuff tears and the level of disability,MRI provides important data that may affect the management of rotator cuff lesions and should be performed before rehabilitation or surgery."

Really AJR? Let me make sure I understand. There is little to no correlation between imaging and symptoms, yet folks should go ahead and get the MRI anyway? Even before rehab? That's a hard one to swallow. In his defense of the study's author, the investigation took place in France within a socialized health care system where utilization would doubtless be far different from ours.

Regardless of the author's curious conclusion, the study is an honest representation of how limited the value of MRI can be for common musculoskeletal complaints. It also underscores the importance for physical therapists not to get too caught up in hounding the referring physician for the MRI report.

Treat the patient, not the report!

Krief, O.P. (2006). Shoulder Pain and Disability: Comparison with MR Findings. American Journal of Roentgenology, 186(5), 1234-1239. DOI: 10.2214/AJR.04.1766