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How physical therapy addresses pain

Meet Mark Denesha, ex-military turned Physical Therapist and owner of Forever Forward - a mobile clinic for orthopedic injuries, post-ops recovery and sport-specific training. We sat with Mark to hear about his journey in becoming a Physical therapist.


Welcome back Mark. Let's talk about pain. Is it right to say that pain is the common denominator in physical therapy?

Definitely! Most people come to physical therapy because they are in pain and it has become too much for them to manage on their own. Pain is a warning sign that something is wrong and it is important to get rid of the stimuli causing it. Most of the time that's nociceptive pain. However, there is also neuropathic pain, where the tissues may be healed but the person is still experiencing pain. This is when it becomes trickier to treat and manage the symptoms. You have to become creative and focus first on managing then on healing.

Do you think neuropathic pain is on the rise?

It's a possibility that the global state of anxiety and the decrease in activity due to the pandemic have caused an increase in people reporting neuropathic pain. In fact I have seen a number of people in the past year with neuropathic symptoms that may be related to COVID. Mind you that includes people who have chosen to limit social contact during the pandemic and delayed seeking physical therapy, which led to their symptoms worsening.

Are you saying that time is of the essence when it comes to physical therapy?

It's important to seek physical therapy as soon as possible when experiencing pain, as the longer you wait, the more problematic it becomes. Generally, the quicker you can start addressing the pain, the better the outcomes will be.

You mentioned neuropathic and nociceptive pain. Is that how you categorize pain?

Pain can be categorized as neuropathic or nociceptive, and acute or chronic. Chronic pain is generally defined as lasting 3 months or more. Sometimes people experience a combination of both neuropathic and nociceptive pain, and this can be difficult to manage. For example, one patient may be in for a chronic hip pain, but also have an acute injury, such as a broken toe, which must be worked around. That's another reason why you don't want to wait when you start experiencing pain. It can be cumulative making it trickier to deal with.

How do you diagnose pain?

When diagnosing pain, I take into account the patient's age, history, and physical assessment. I ask questions about the timeline of the pain, and then use that information to determine the most likely cause. For example, if the patient is 21 years old, I would expect an acute injury such as a muscle tear, labral tear, or muscle strain. On the other hand, if the patient is 87 years old, I would look for bursitis, radicular symptoms from the lower back, glute tendinopathy, or arthritis. After gathering the subjective information, I then assess the patient's range of motion, strength, and perform any necessary special tests to complete the diagnosis.

And how do you evaluate a patient's pain?

When evaluating a patient's pain, I use the Visual Analog Scale (VAS) which is a standard scale of zero to ten. To help patients understand the scale, I might ask them to compare their pain to something like a punch in the arm (2 or 3) or being hit by a car (10). If a patient tells me they almost called the ER because of their pain, then I know it's a 10.

Have you noticed a cultural aspect to reporting pain? Would you say some people are more honest when reporting it?

Sure, there is a cultural factor at play when it comes to pain. However I'm not sure if 'honest' is the right word to use here. I think 'accurate' might be better. For instance, I have noticed that people who participate in contact sports have a higher threshold for pain and a better understanding of the difference between pain and injury. For example, an athlete might know if their hamstring pain is due to overworking or a complete tear, whereas someone who went ice skating recreationally may not be able to tell them apart and their pain levels will be much different too.

Can you explain more this distinction between pain and injury?

There is a distinction between pain and injury. Pain is something that can be felt, like if you punch someone in the arm, it will hurt, but it is not an injury. Injury is more serious and requires medical attention. People who are more body aware, like athletes for instance, can tell the difference between pain and injury. Depending on the situation, different treatments are needed. Pain can still be treated, but if there are any red flags, like a potential fracture or a low back pain that doesn't go away, loss of sleep, weight loss, then it is more than just pain and medical attention is needed.

Have you had any of such red flags recently?

I recently haven't had any major red flags, but in the past I have encountered a few. For example, an older woman had a history of cancer and had experienced extreme weight loss and back pain over the past month, which was concerning. It was clear that she needed to get checked out. Another example is if someone is having altered sensation, muscle weakness, or other neurological symptoms, they should see a neurologist.

With all this in mind, where do you see physical therapy being most effective?

In my experience, physical therapy is most effective for acute and post-operative conditions, such as total knee replacements. Physical therapists are particularly well-equipped to handle post-operative precautions, strengthening, and movement. But there is way more. Truth is, our profession is so broad that it can be difficult for people to understand all that we can do. That might think of other profession first. For example, if someone has back pain, they may first think of a chiropractor. However we are not the same as personal trainers or chiropractors, and our governing body, the APTA, has made this clear.

What would you tell someone experiencing pain?

I would tell someone experiencing pain and considering coming to see me to stop waiting and get in now. The sooner we address it, the better. I'm confident that they can get better. Physical therapy should be the first stop. They don't need a referral. I mean, you can go see your doctor if you're really worried. But 9 times out of 10 he or she will suggest shots. Some sort of injection which only provides a temporary relief. Instead, I want to empower patients by teaching them strategies and breathing techniques to be more confident and not catastrophize. At the very least, they will get stronger, more mobile, and more flexible. Best case scenario, they won't experience pain anymore.

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