Chronic Pain Management: When to Call in a Physical Therapist

The number of people living with chronic pain has lingered at 20%, or approximately 51.6 million people, for several years. About 7%, or 17.1 million, of those people further live with high-impact chronic pain, the type that leads to a substantial reduction in daily activities.¹

The CDC looked at pain by body site, reporting, in order of frequency, back, lower limb, upper limb, head, abdomen, genitals, pelvis, and tooth.² Trying to fit in the latest CME on all types of pain management and keep patients moving – the number one recommended treatment – despite that pain is difficult, with too many patients and not enough minutes in an office visit.

Once medical issues are cleared, physicians might consider calling in a physical therapist.

Physical Therapy Services Underused

In fact, physical therapy remains underutilized, according to a report published this year in the Journal for Nurse Practitioners by Nunez-Gaunaurd and Goldin.³ The need for such services is expected to increase given the combined effects of the aging population, despite lifespan decreases, and the prevalence of chronic diseases marked by pain.^4,5

According to the American Physical Therapy Association (APTA), more physical therapists are needed as well. As of 2019, there were 312,716 licensed physical therapists in the US, along with 127,750 licensed PT assistants. That works out to 95 PTs per 100,000 population and 39 PT assistants per 100,000.⁶

The strongest evidence for how physical therapy can help is with low back pain, said Colleen Louw, MPT, a spokesperson for APTA who was in clinical practice for 28 years. She is now the program director for therapeutic pain specialist certification for Evidence in Motion, a post-professional educational company.

In their overview on underused physical therapy in primary care settings, Nunez-Gaunaurd and Goldin pointed out several areas in which PT could be used more, including low back pain, migraines, pelvic floor and functional incontinence conditions, and rehabilitation from cancer.³

Cost-Effectiveness

In a separate APTA report issued in September, the association incorporated reviews of clinical research, modeling of health economics, and subject matter expertise to analyze how the long-lasting quality of life improvement from PT could lead to economic benefits.⁷ The report focused on eight conditions: knee OA, carpal tunnel, low back pain, stress urinary incontinence, tennis elbow, vascular claudication, cancer rehab, and fall prevention. Findings showed that the use of physical therapy was linked with a net economic benefit to the health system when compared to alternative types of care.

For carpel tunnel, for example, the study compared an average physical therapy intervention (per episode of care/per person) to surgery and found a net benefit of $39,533.

Active Approach is Key to Pain Reduction

When used, it’s important that physical therapy provides an active versus passive approach to the pain, advises Don L. Goldenberg, MD, a rheumatologist, professor emeritus at Tufts University and affiliate faculty at Oregon Health & Science University, Portland.

His approach for pain management, he said, is to push active approaches. In looking at research about physical therapy for various conditions, Dr. Goldenberg noted, we have to remember that most physical therapy programs don’t extend beyond a few months, so the research may not fully capture all the benefits.

“I think everyone agrees that there aren’t many chronic pain conditions that we should not be using activity and exercise as an early component to treatment.” Long gone, Dr. Goldenberg added, are the days when a week or two of bedrest was advised for low back pain. Other chronic pain conditions, such as headache, pelvic pain, and fibromyalgia, also have been shown to improve with exercise and activity, he said.

Evidence further suggests that exercise therapy, a major part of PT, for hip or knee osteoarthritis reduces pain and improves functioning right after treatment for up to 6 months.⁸ Exercise therapy has also been shown to help physical function and well-being in fibromyalgia and to help support and complement medication migraine management.⁹Last but not least, PT can help mitigate the functional decline often experienced by individuals with cancer.¹⁰

Referring a patient for physical therapy for chronic pain is different than referring after, say, a knee replacement, Dr. Goldenberg clarified. The goal for the former, he said, should be to focus on “changing a patient’s life view on activity and exercise, and making a long-term commitment to that.”

How to Forge the Physician-PT Relationship

For community-based physicians, ‘’the issue now is they are so overwhelmed there is such a small amount of time to give to people,” Dr. Goldenberg said. While doctors know it’s important to educate patients about their pain condition and how to get and keep moving, the time crunch often means they simply refer the patient out to PT, he said.

“It would be ideal to have a little more input [to give to] the PT on what the doctor wants this patient to get [out of it],” Dr. Goldenberg explained. The physicians should discuss in some detail with the physical therapist what they see as the issue and their goals for the patient, with regular check-ins to adjust care as needed.

“I think we work better as partners,” added Louw. “The more communication a PT and physician have with each other, the better for the patient.” Although direct access to physical therapy is possible in nearly all states now, according to Louw, a majority of PT patients are still referred by their physicians.

She suggests physicians refer to PT sooner rather than later. It’s important for physicians to know, she said, that “We also are trained on how to clear out medical conditions. We call them red flags. In our evaluation, if we find any red flags, the first person we call is the doctor.”