Moving on to Movement in Patients with Chronic Joint Pain
Meeus.M, Nijs J, Van Wilgen P, Noten, SGoubert D and Huijnen I. Pain Vol XXIV. No 1 March 2016. IASP
As the International Association for the Study of Pain, IASP, focuses on 2016 as the Year Against Pain in the Joints, these Dutch and Belgian authors’ article published in the Journal, Pain, sheds light on how best to introduce exercise and physical activity into treatment for chronic joint pain. Below is a simplified summary or you may prefer to read the full article. It helps to explain why we osteopaths go to the lengths that we do with whole person assessment and detailed exercise prescriptions to support our treatment.
There are many varied causes and presentations of chronic joint pain from rheumatoid and osteoarthritis, to fibromyalgia, frozen shoulder, low back and neck pain. There are many treatment options from medication, to surgery and manual therapies. The evidence for all of these modalities is limited, but the one that is always appropriate is physical activity and exercise. Clinicians struggle to implement exercise due to several barriers.
The first point to make is that when health people exercise, generally their pain sensitivity reduces. When people with chronic pain conditions exercise the outcome is more varied from decreasing pain sensitivity to increasing pain sensitivity. One certainty about chronic pain is that it is unique for each and every patient. Although exercise induced hypersensitivity only lasts for a limited time it can have a negative impact on patients perceptions and beliefs about pain mechanisms and determine future exercise behaviour. They think they are causing more damage, even though this is not usually the case.
Pain can be driven by signals from nerves around joints called nociceptors. We sometimes refer to this as mechanical pain and is often associated with inflammation. At other times a nerve may actually be directly irritated or damaged producing neuropathic pain. If either of these types of signalling are prolonged over time the central nervous system (brain) becomes over sensitised which has two negative effects; 1. Pain sensitivity in heightened and 2. The normal healthy ability of the brain to regulate pain intensity down is diminished. This is called central sensitisation and much has been written recently about neuroplasticity. Just as this sensitivity can be turned up, it can also be turned down. That is our aim! It is important to identify which of the three mechanisms of pain production are in play or how they are influencing each other in a pain matrix which is specific to the individual person. All of the complex contributors need to be identified and managed.
So the important starting point is for the clinician to conduct a thorough biopsychosocial (whole person) assessment of the patient presenting with chronic or persistent pain. This takes time and the patient has to answer questions and possibly complete questionnaires on things that may not at first seem relevant to the painful joint in question.
Next it is important that the patient is well informed about the basics of pain neurophysiology. Unfortunately many peoples pain is made worse by poor perceptions or beliefs about pain mechanisms. The most common myth is that “hurt = harm”. When we are well informed, understand the process of the way forward and have a clear set of strategies we are more able to return to functioning at the activities that we have been unable to perform due to pain. This includes returning to work, sport and leisure activities or just being able to move around home and perform domestic duties.
Each individual person requires a tailored plan that suits their nature, condition, resources and goals. Their specific barriers need to be addressed. Persistent pain has more than one. This includes patient specific barriers, environmental barriers and health care delivery barriers. There needs to be a balance of general and specific exercise. A level of supervision and review of activity and exercise is essential. So while it is clear that we need to “get the patient moving”, the “how” is complex and unique for each person. This will involve setting baselines, gradually pacing up activity levels appropriately towards goals set by the patient. We also need to be prepared for set-backs which are common.
The authors address different clinical approaches required to help patients that are more stoic, “persisters” and those that are “avoiders” of exercise for whatever reason.
While we often tend to focus on the importance of functional movement and exercise on the muscles and joints; what is at least as important in the benefit to the “plastic” nervous system and brain. That means the nervous system needs to experience functional, efficient movement and to be re-programmed back to healthy, adaptive beliefs and behaviour around movement. Then the brain functions as a healthy person again where exercise reduces pain sensitivity, builds strength and stability of the joints and modulates pain down rather than up!
Patients are often seeking a magic bullet. When it comes to chronic pain it is a complex collaborative process between clinician(s) and patient. There are usually several aspects to unpack along the journey.
Summarised by Michael Mulholland. DO MSc Med (Pain Management) Osteopath.