Untangling pain sensitivity management
In the fifth instalment of our pain sensitivity series, Darren Beales FACP and Tim Mitchell FACP consider pain sensitivity management and the benefits of collaboration with specialist physiotherapists.
Pain sensitivity management isn’t easy but it’s important to get it right.
The approach a physiotherapist takes to managing pain sensitivity has a significant impact on their patient’s understanding of their own condition and on the effectiveness of any treatments prescribed.
The unknowing therapist
How often do you see your physiotherapist?
Patient: ‘Twice per week.’
What treatment are they providing you?
Patient: ‘They massage my back and use needles.’
And how do you feel after this?
Patient: ‘Well, I am extremely sore after the session and have to go home and rest for the remainder of the day.’
Does the soreness settle quickly?
Patient: ‘It usually takes a good one to two days to settle, but I feel a bit better before the next appointment.’
By ‘better’, do you mean improved?
Patient: ‘No, no. I just feel that the aggravation in my back from the treatment has settled.’
Do you think this is helping you then?
Patient: ‘It must be—right?’
This is a story we hear frequently from patients when there is significant pain sensitivity associated with their presentation.
In this example, the physiotherapist has not recognised pain sensitivity.
Look back to our patient with allodynia.
This is probably not a person who is going to manage well with ‘standard’ treatment such as massage, manual therapy or dry needling.
They possibly won’t cope well with ‘standard’ stretching or strengthening either.
The first tip for management here is that you have to recognise when pain sensitivity is a significant issue.
The good intentions therapist
What has your physiotherapist told you is the problem?
Patient: ‘They tested my knee with ice and told me it was really sensitive.
'They said that my knee muscles were very weak and that I needed to get in the gym and get stronger.’
How do you go in the gym?
Patient: ‘I manage about five minutes on the exercise bike, but it is really sore.
'I have some squatting exercises but I can only manage six repetitions and have to stop because of the pain.
'I do some arm exercises, which go okay.
'I then do some lunges.
'I have a lot of pain about halfway down, but the physiotherapist tells me that “pain does not mean danger” and has me go right down to the ground.
'We tried some single-leg balance but I couldn’t do it because of the pain.’
How do you feel after?
Patient: ‘I have to go home and lie down for two hours before I can even try to get dinner ready.’
How many times per week do you go to the gym then?
Patient: ‘Once per week.’
Do you have home exercises?
Patient: ‘I was given squats and lunges for home, but they are just too painful and I don’t do them.’
Pain sensitivity has been recognised in the patient profile here.
But the gym strengthening program has not been modified according to the behaviour of the pain sensitivity.
Yes, there is pain sensitivity, but pushing through it just because it does not signify tissue damage does not work for this person.
Trying to push through pain sensitivity often results in further wind-up of the nociceptive system, not positive adaption.
Exercise is important but it must be individually tailored.
Reduced range of motion in the exercises, reducing the amount of weight-bearing load and/or working in a circuit-based manner are potential strategies that may counter undesirable nervous system wind-up and facilitate more consistent engagement in exercise.
How much pain is enough, or too much, when pain sensitivity is a significant factor?
There is no single answer.
Perhaps a logical approach might be for the pain increase to be tolerable to the individual and to settle within a time frame that does not deter them from continuing the program (you work this out through shared decision-making).
General exercise (to potentially wind down the nervous system) might be much more effective than highly specific exercise targeting particular impairments of minimal consequence in the grand scheme of the patient’s presentation when there is significant pain sensitivity.
The educating therapist
What do you understand is going on with your body?
Patient: ‘The therapist has told me that pain does not equal damage.
'They said that all pain comes from the brain.
'That the nerves become sensitised.’
Did this make sense to you?
Patient: ‘Well, I don’t think the pain is in my head.
'I can feel the pain in my back.
'I feel it when I move.
'I know there is something wrong in my back.’
There could be a lot to unpack here.
Let’s try to summarise a few points.
Education has been provided.
It might have been very reasonable in terms of the messages delivered.
But what message has been taken on by the patient?
Possibly not the intended one.
Checking the patient’s understanding of their condition by asking them to explain it in their own words will provide insight into how they have interpreted what they’ve been told.
Patient: ‘One therapist told me the pain was in my head.
'The pain specialist told me I have neuropathic pain, that the nerve is a problem.
'The GP told me not to worry about my scans, that I have just become really sensitive.
'To be honest, I am totally confused and don’t know what to believe.’
These three healthcare practitioners could all be working off the same page, but using different descriptions and terminology for the same presentation.
The patient is confused.
If there was consistency in the way the message was delivered, significant strides could be taken in patient understanding.
There is a broader health system issue at play here, but are there ways you could influence this?
Consider making your education about pain sensitivity personally meaningful to the patient.
Hours of pain education might be useful for some people, though for many a short, personally meaningful explanation may suffice.
The collaborating therapist
What do you understand is going on with your body?
Patient: ‘My physiotherapist tested me and worked out that my nervous system is very sensitive.
'They used a toothpick, a tissue and some ice.
'They explained to me how this could result in the burning pain and tingling I get through my whole arm.
'How it might be causing the shooting pain I get at night for no reason.
'I was so relieved when they worked this out because finally I could understand what was going on.
'We have stepped back on some initial exercises, which were just too painful to do.
'The new exercises are better.
'But the therapist said I should come here so we can get some additional guidance about my rehabilitation plan.’
Patients with pain sensitivity as a significant contributing factor can be inherently complex.
This might be the perfect time for a therapist to reach out for assistance by engaging in a model of collaborative care.
In this case, collaboration might include reinforcing and validating what the treating physiotherapist has explained to the patient.
It may include additional advice about modification and progression of exercise-based management.
It might mean adding desensitisation activities to the program and might flag the need for medication review with the GP.
The specialist physiotherapist should collaborate with the treating physiotherapist to guide management planning.
After returning to the treating therapist for four to six weeks, the patient may then come back for further specialist review and collaboration.
Our experience is that collaborative care of this nature is an overwhelming positive experience for the treating physiotherapist, the patient and the specialist.
See Table 1 for triggers for potential referral for specialist physiotherapist engagement.
Patient: ‘I am glad my physio sent me to see you to confirm what the problem is and now I can go back with confidence and work with them on my recovery.’
Like to hear Tim and Darren casually chat about the management of pain sensitivity for musculoskeletal conditions? Click here.
Looking for case studies that consider pain sensitivity? Click here for Beales et al. ‘Masterclass: A pragmatic approach to pain sensitivity in people with musculoskeletal disorders and implications for clinical management for musculoskeletal clinicians.’ Musculoskeletal Science and Practice, 2021. DOI: 10.1016/j.msksp.2020.102221
Click here for the Musculoskeletal Clinical Translation Framework, 2023.
Want to get help from a physiotherapist colleague? Click here for ‘Stepped care for musculoskeletal pain is ineffective: a model for utilisation of specialist physiotherapists in primary healthcare management.’ Australian Journal of Primary Health, 2021. doi.org/10.1071/PY21006
Like something short and fun? (Tim and Darren again.) Click here.
>> Darren Beales FACP is a Specialist Musculoskeletal Physiotherapist (as awarded by the Australian College of Physiotherapists in 2008) and a director at Pain Options in Perth, WA. As a senior research fellow at Curtin University, Darren is undertaking broad research into clinical pain, from the mechanistic understanding of clinical pain to efforts to enhance the management of persistent pain and implementation of knowledge into practice.
>> Tim Mitchell FACP is a Specialist Musculoskeletal Physiotherapist (as awarded by the Australian College of Physiotherapists in 2007) and a director of Pain Options. Tim has completed a PhD in the area of low back pain and has a special interest in the translation of logical reasoning into clinical practice. He holds positions with the Australian Physiotherapy Council and the Australian College of Physiotherapists.
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