Beware of Irrational Exuberance of #physicaltherapy for Chronic Pain

       “What is true isn’t always popular, and what is popular isn’t always true” ……Howard Cosell

In the past few weeks, my travels have included conversations with many PT’s who are very excited about the recent CDC guidelines on prescribing opioids for chronic pain.  The suggestion that physical therapy is the right and correct replacement while encouraging is an illusion at this stage.  As I pointed out in my last post, in 1998 there were over a thousand multi disciplinary clinics practicing a biopsychosocial approach to chronic pain and likely having great outcomes. Within 7 years, this was reduced to approximately 75 locations. Why? Payor policy.  Just because we have CDC guidelines now, doesn’t mean this trend will quickly reverse. In fact, here are just a few reasons:

Insurance companies:  Payor’s are not motivated to expand reimbursement policy under any circumstances. It is just easier for a payor to justify paying less for something  than to pay for something that is likely better but involves more services-after all they are motivated to save employers money remember? Chronic pain patients will always be cumbersome to a primary care practice such that a “new, non addicting” pharmacologic agent will likely continue to be the treatment of choice (medical marijuana?) rather than a significant rise in physical therapy and other services.

Marketing outpacing training:  A sudden rise in multidisciplinary clinics with physical therapy as its core will crop up and will be more marketing than substance. We are already seeing PT wannabe groups sending few PT’s to weekend pain science seminars and now suddenly all of their clinics are fully “certified” in pain science.  Tell tale sign of this will be a temporary rise in PT referrals to “pain PT specialists” that may get less than stellar results due to inadequate training and thus do more harm than good for our cause.

Opportunistic physicians.  There are a number of physician types-anesthesiologists, internal medicine, physical medicine pain specialists, and neurosurgeons that are also seeing the CDC guidelines as an opportunity to expand the breadth and depth of their services.


In my view, for physical therapy to have any success, we have to admit treating chronic pain is not at this time an entry level competency. A shift in emphasis from manual skills to tacit knowledge skills will have to take center stage. A broad acceptance and understanding of social neuroscience,  cognitive behavioral techniques, appropriate use of meditation, and in particular communication skills will need significant enhancement and emphasis. This is not to suggest that manual skills are unimportant but we have to rely more on “neck up” skills in order to maximize our opportunity afforded by the CDC guidelines. The numbers of patients with chronic pain are rising to epidemic proportions and we have to be able to access more than 7% like we do in low back pain. The challenge is on-will we rise up, collaborate with other professionals, or will chronic pain clinics simply be the work hardening centers of this decade?

Thomas Frieden, the director for the CDC was thoughtful in his words on the day of the release of the CDC guidelines, “When Opiates are used, start low and go slow” he advised.  Perhaps as PT’s we should also heed this great advice if we are to have long term, sustainable impact on patients with chronic pain that need us.




11 responses to “Beware of Irrational Exuberance of #physicaltherapy for Chronic Pain

  1. Tracy Sher says:

    Great points! Another piece we are already seeing and will continue to see: ONLY “neck up” brain/pain treatment without any regard to validating the peripheral site of pain or assessing it.

    Patients are coming in saying things such as “they are supposed to be a top PT specialist in pain. They didn’t even look at my abdomen, but just said your brain is telling you that you have pain.” These specialists are forgetting that the patient still needs validation, a listening ear and a physical exam (Yes, we know the brain controls ultimate output).

    The pendulum has swing so far into the psychosocial /neuroscience sphere with some professionals. They know a lot, but are missing the mark of being effective and connecting with patients in a therapeutic way.

    1. Larry says:

      Great point!

      1. Debbie Cohen says:

        Excellent, Tracy! I would add that treating the problem in the periphery is important because the fact that all pain is produced by the brain does not negate the fact that peripheral pathology exists. In addition to our clients’ understanding of the neurobiological basis of pain, our assessment and manual treatment skills go a long way – along with the client’s own self care – in order to decrease nociceptive input and give the central pain patterns a rest.

  2. Kory Zimney says:

    Only comment is to echo the quote: “if we are so good why are our patients doing so bad”. Having spent almost the last 10 years trying to understand just a little more about pain to help my patients and share whatever little knowledge I have picked up with other therapists, has left me seeing many times how poorly I myself and others are doing. Pain especially persistent pain is amazingly complex. Unfortunately many times the more complex we make the treatment and the explanation of why someone still hurts seems often times to make it worse, especially over time. I believe the more simple we can keep the treatment and explanation by helping someone change to more “well behaviors” the better chance we have to help. Even at that we need to understand and accept how difficult and complex treating someone with persistent pain is. Both the patient and I the therapist will need amazing patience and persistence.

  3. Selena Horner says:

    If we focus on having people see a physical therapist within the first 14 of experiencing pain, there may be substanitially less people adding to growth in the current persistent pain bucket. Of course we need to help those currently in the persistent pain category, but going forward we need to focus on shrinking growth into that area.

    1. Larry says:

      Selena, you are correct but that is akin to saying if the population watches what they eat and exercises we won’t have obesity long term-what are the odds of that? There is no evidence for any near term decline in chronic pain.

      1. Selena Horner says:

        When it comes to pain, it’s an issue of the right professional treating the person at the right time. Chronic pain is big business. Patients aren’t being advised to see a physical therapist soon enough. The more people who have pain in the early stage who see a physical therapist will impact the number of individuals experiencing chronic pain (which cuts into the profits of Dx testing, pharmaceuticals, PM&R docs and their procedures).

  4. Ray VanWye says:

    I found this very interesting:
    “A shift in emphasis from manual skills to tacit knowledge skills will have to take center stage. A broad acceptance and understanding of social neuroscience, cognitive behavioral techniques, appropriate use of meditation, and in particular communication skills will need significant enhancement and emphasis.”

    In 10 years as a physical therapist I have seen a shift in my approach from a very procedural to being more present to the individual’s needs. I think in some ways my own personal challenges have given me a better understanding of how to care for someone. I believe the knowledge and skills I possess can demonstrate that I know what I am doing, but I also think my patients need to FEEL that I am right there with them during their tough times.

    1. Sam Peck says:

      A therapeutic bond helps give patient validation and builds trust in your treatment, definitely helps promote patient participation and a positive outcome. I am currently starting a chronic pain/brain over pain course. Thanks for sharing

  5. D Cordel says:

    In regards to this not being among the skills of an entry level DPT: agreed. I am steeped in pain science research, and engage in discussion with other clinicians and patients about pain every single day, and it feels like I can hardly get a grasp of any single concept. I am definitely better at this stuff than I was before really diving in, so diving in without the learning of the material beforehand would have been detrimental for my practice, undoubtedly. That being said, for those that have a vested interest in this, and have dedicated lots of time and effort to training on it; be rationally exuberant. We absolutely can help. For you private sector folks, you just have to figure out how to do it notwithstanding the evils of third party payers.

  6. charles says:

    Let me tell you what none of you awesome PTs are getting–largely because you live in this golly gee world that doesn’t remotely resemble reality.
    First, before you start your diatribe of knee jerk snarl of “well maybe it is just your technique that doesn’t work” I will tell you that I have heavy training in many philosophies–mobilizations (maitland/mulligan) fascia release (barnes) and positional realignment. And I have 20 years in the field. And I know countless other “gurus” who chronic pain patients wail that “he/she is the ONLY one who can help me.”
    And they aren’t helped. Not in anything outside of short term. Brilliant or not there is no therapist that can point to success with chronic pain–because largely it is one of two things–an offbeat diagnosis such as polymyalgia rheumatica or the more likely reason—poor lifestyle. You can’t solve either. I am in the process right now of imploring insurance companies to greatly reduce reimbursements to my own profession where the chronic pain patient who never leaves PT cannot be solved. Regardless of your GROC scores or whatnot—at the end of the day that patient continues to return. I’ve heard and watched all the rhetoric and seen all the research—even the great Carol Courtney—and she has nothing but short term results.
    You are a charlatan profession now because you have made this patient your cash cow. You cannot help the obese. Or the sedentary. Or the chronic anxiety patient. But you keep taking them back–over and over as if THIS time you will have a different result than LAST time. If you had any integrity you would write that “Order is inappropriate–patient just seen recently for exact same diagnosis.” But you don’t. You keep these patients cycling in and out of the clinic continuously. That’s why your profession is a joke now–you made it that way. Third party payers aren’t the evils as one comment above stated–you are–the provider who doesn’t live in reality. We are wasting billions in healthcare in PT for zero long term results–minus the patient who actually changes his lifestyle. And my profession is a criminal in the heist of these billions.

    Ok go ahead and start the snarl–I’ve heard it all before from the therapists who keep taking the same patients back over and over.

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