Persistent pain is a newer term being used in place of “chronic pain.” Nearly all of the physical therapists at Alpine Physical Therapy took part in the 6th annual Montana Pain Initiative Conference, a two-day conference held at the University of Montana on May 30th and 31st. This year’s conference was titled “Treating Pain: Neuroplasticity and Team Care in an Evolving Healthcare System.” Resultantly, we thought it would be appropriate to include a recent literature review on the topic. It’s a bit lengthier than most of our blog posts, but it’s well worth the read.
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Chronic pain is constant pain that lasts long after the expected time frame of healing. For instance, if you roll your ankle you would expect that ankle to be painful for the length of time that it takes for the ligaments and tendons to heal—say a week or so depending on the extent of the sprain. If there was an underlying chronic, or persistent pain, component then your ankle might still hurt six months after the injury, long after the actual tissue damage has corrected itself.

To understand why the pain that people feel is very real we need to look at how we actually feel pain. For 400 years the medical model for understanding pain was simple: when you step in a flame the sensors in your feet feel the pain and a pain signal is sent via nerves to your brain which shouts Tissue is being damaged! Move your foot! Then in the 1960s this model was proven to be much more complicated. Instead of one continuous pathway (foot to brain), there is a pathway going up with three junctions (at your limb, at your spine, and in your brain) and a pathway going down with the same junctions. Each of these junctions interprets pain and can do so in multiple ways via pain sensors.

At the level of your limbs there are two types of pain sensors, which are then further divided into sub categories. Each of these categories is responsible for a different type of pain detection such as hot or sharp. They also each transmit signals to the spine at varying speeds. This explains why when you accidentally touch something hot you quickly pull back your hand but when your leg falls asleep from sitting you do not notice for a while. To make things more complicated, one category of these pain sensors (known as C fibers) sends signals very slowly with generalized information in regards to pain location and are extra sensitive to inflammatory chemicals that your body creates to help to heal itself. As an example, C fibers are responsible for that achy pain you might have after rolling your ankle; the pain is in your foot and a little up your calf even though the tissue damage might only be at the outside of your ankle. Luckily, C-fibers respond well to NSAIDs like ibuprofen so you take a few of these and the pain signals being sent from your ankle to your brain are quieted as the inflammation decreases.

Pain sensors at the next level, your spine, are more complicated. The sensors here are the go-between from your limbs to your central nervous system (think brain and spinal cord). The caveat is these pain sensors can be ignored by your brain. For instance, if you are in a house fire you grab your baby and run out of the house before you realize that your arm is burned. Your arm is obviously hurt, but you didn’t feel it at the time because of your brain sending a message down to your spine pain receptors saying, Override, there are more important matters at hand!

The highest levels of pain sensors are in your brain in multiple locations. At each of these locations pain is controlled by complex relationships between emotions, brain chemicals, and the nerve matrix itself. Your brain determines what pain you acknowledge and what pain you ignore.

Remember that there are three levels of pain sensors going in both directions? If our brains responded to all of the pain sensors signals at all three levels imagine how much information that would be. A key piece to a healthy pain response is for our brain to recognize which signals are important to acknowledge and which ones we should ignore. Or, which signals are telling us that there is actual tissue damage occurring, and which ones are simply saying, this surface is lukewarm.

In people with persistent or chronic pain, their pain response system at one of those three levels has lost the ability to send accurate signals or ignore signals all together. In other words, the communication lines are crossed and even though there is no tissue damage occurring that person is feeling very real pain. Psychotherapy, relaxation techniques, and rehabilitation (physical therapy or occupational therapy) to down-train the hypersensitivity of the pain sensors are all ways the muddled pain system can be addressed without drugs at the brain level and are often rather effective since the brain is the control center of the pain itself.

Drug management of chronic pain is complicated and controversial. NSAIDs (i.e. ibuprofen), aspirin and acetaminophen (i.e. Tylenol) have mixed effects for treating chronic pain depending on pain location. Long-term use of NSAIDs can cause issues in your stomach and intestines. Opiates and opioids (most commonly morphine) has been the standard drug prescribed. This drug class acts at all three levels of pain sensors. The catch is three fold: you develop a dependency, require higher and higher doses, and suffer side effects as a result. Long-term use studies (>6 months) show that opiates lose their effectiveness over time so it is not recommended to take them long term.

More promising are drugs that address the pain at the control center itself: your brain. These drugs include:
1. Anticonvulsants (i.e. gabapentin and carbamazepine)
2. Antidepressants (which low doses address both depression as well as diminish the pain signals being sent)
3. Tramadol (acts similarly to anticonvulsants and antidepressants but can cause many of the same side effects as opiates).
4. Muscle relaxants (i.e. cyclobenzaprine, tizanidine, both which do not have evidence to support the effectiveness of long term use)
More location specific treatments include creams or patches placed on your skin at the pain location such as lidocaine or NSAID patches.

Moderate evidence exists for non-invasive treatment strategies, which include transcutaneous electrical nerve stimulation (TENS) (this confuses your pain sensors and decreases pain by wearing sticky pads with mild current flowing to your skin), hot or cold packs, and acupuncture. Spinal injections or nerve blocks are yet another way to help to manage pain but have mixed results as well.

However, no matter what drug options are used, it should be noted that the most effective way to treat persistent pain is in utilizing multiple approaches and calling on a team of health care providers to help to restore a person’s overall function.
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Reference:
Richard L. Uhl, MD, et al. Management of Chronic Musculoskeletal Pain. In Journal of American Academy of Orthopedic Surgery. February 2014. Vol 22, No 2. Pp 101-110.

Alpine Director, Sam Schmidt, MPT, offered the Balance Body University Pilates Reformer I workshop last month.

Alpine Physical Therapy has consistently built a strong presence with its integration of Pilates and Reformer use as a rehabilitation tool, especially to address low back and neck pain.Thus, it is no surprise that five of Alpine’s PTs took this Reformer Level 1 course to understand and learn how to best use the Pilates method for helping patients get better, faster.

The Reformer allows many patients, who otherwise are limited by pain, to relearn optimal and pain-free movement and build a foundation of core strength and coordination for long-term fitness and functional goals.

Alpine PT has partnered with Balanced Body University (www.Pilates.com) to become one of the nation’s leaders in rehabilitation mind body corrective movement. The success of this program is seen and heard from the many Alpine patients that have re-established optimal function and achieved a pain-free life again!
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For more information on Pilates at Alpine, visit our clinic webpage by clicking here.

Fit to Fight is excited to show Missoula how we are “stronger than cancer” at Relay for Life. We are looking for Fit To Fight alumni and supporters to join our team. Relay for Life will take place Friday, June 20th at 6pm and run through 9 am Saturday, June 21st at Big Sky High School in Missoula. We would love to have you come show your support for the cancer community and help us spread the word about Fit to Fight.

There will be lots of fun activities for the whole family. If you would like to participate in the activities but do not want to join the team, we would love to have you stop by and show your support.

Event schedule:

Friday, June 20th
5pm – Survivor and Caregiver reception
7pm – Opening Ceremony and Survivor lap
10:30- Luminaria Ceremony

Saturday, June 21st
9am – Closing Ceremony

If you would like to join our team, walk the survivor lap or would like more information please contact:

Emily Melton
Outreach Coordinator
406-750-0943
emily.fittofightmt@gmail.com

To donate to our team click here.
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To contact Emily Melton, call 406-750-0943, or email her at emily.fittofightmt@gmail.com.

“Fit To Fight and UM PT researchers demonstrate the benefits of exercise for quality of life for those fighting cancer. This spring the UM Physical Therapy School led an introductory study on analyzing the outcomes and benefits from an organized exercise program for cancer fighters. The study concluded that ‘Subjects with cancer and cancer survivors demonstrated significant improvement in sit-to-stand and in the number of days that they report feeling healthy’.”

Help The PEAK Health and Wellness Center and Alpine Physical Therapy support this great non-profit by donating to www.FitToFightMT.org today!

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Abstract Proof
CONTROL ID: 2019899
TITLE: ASSESSING OUTCOME MEASURES AND OUTCOMES OF AN EXERCISE PROGRAM FOR CANCER SURVIVORS: A PILOT STUDY.
PRESENTATION TYPE: Poster
CURRENT SECTION: Oncology

Author Details
AUTHORS (LAST NAME, FIRST NAME): Ikeda, Elizabeth R.1; Sweeney, Josie1; Schmidt, Samantha S.2
INSTITUTIONS (ALL): 1. School of Physical Therapy and Rehabilitation Science, Univ Montana, Missoula, MT, United States.
2. Alpine Physical Therapy, Missoula, MT, United States.

Abstract

ABSTRACT BODY:
Purpose/Hypothesis : Cancer and cancer treatment can adversely affect physical and emotional well-being. There is some evidence that exercise may be beneficial in improving function, strength, and longevity in patients with cancer. Purposes of this study were to: 1) Assess participants’ outcomes in exercise tolerance, strength, balance, function, and quality of life after an eight week program and 2) determine the appropriateness of chosen outcome measures.

Number of Subjects : The subjects were 5 women and 2 men, mean age 58.14 years, who had active cancer, ongoing treatment for cancer, or had completed treatment for cancer.

Materials/Methods : Pre and post testing consisted of; the modified Naughton treadmill test, the four stage balance test, a timed sit to stand test (STS), the CDC Health Quality of Life test (HQOL), and the Outpatient Physical Therapy Improvement in Movement Assessment Log (OPTIMAL). Examiners and exercise leaders were physical therapists, exercise physiologists, physical therapy students and exercise physiology students and were educated in the administration of the tests. The eight week program met twice weekly with group and individualized training consisting of stretching, relaxation, resistive exercise and endurance exercise. Subjects were given a membership to a local athletic club to encourage exercise between sessions.

Results : The subjects attended an average of 12 sessions (range of 8-15). There were no adverse effects of testing or exercise reported by the subjects or staff. Ordinal level data was analyzed by Repeated Measures ANOVA and the Wilcoxon Signed-Ranks Test was used for nominal level data. There was a significant improvement in sit-to-stand (p=.028). There was a significant difference in the HQOL Symptom Module question 5; “During the last 30 days, for about how many days have you felt VERY HEALTHYAND FULL OF ENERGY?”, (p=.004) Pre-test average for question 5 was 5.3 days and post program average was 18.7 days. Six of the seven subjects improved in the Modified Naughton test. All subjects improved in most items in the OPTIMAL and HQOL tests. At the pre-test, all subjects were able to complete the 4 stage balance test without difficulty so an alternative post-test was conducted and this data was not analyzed.

Conclusions : Subjects with cancer and cancer survivors demonstrated significant improvement in sit-to-stand and in the number of days that they report feeling healthy. In this preliminary data, improvements were seen in all tests. Additional subjects will be recruited from this program that is scheduled three times per year. Outcome measures were satisfactory with the exception of the balance test, thus a different measure will be used in future testing.

Clinical Relevance : After an eight week exercise program, all subjects, including one terminally ill subject, more than doubled the number of days that they report feeling “very healthy and full of energy”. In addition to physical outcome measures, quality of life measures are important to attain a comprehensive assessment in this population.
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KEYWORDS: cancer, exercise, quality of life.

Special thanks to star physical therapist Antara Quiñones for providing this write up on a recent article from the Journal of Hand Surgery.

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Mallet finger typically occurs with “jamming your finger”, like hitting a basketball with a straight finger, forcing it to bend when not expected.  If the tendon that attaches near the base of your fingernail is unable to withstand this sudden force, it “avulses” or rips out of the bone creating a droopy fingertip.  Unless this tendon is reattached somehow, you will never be able to straighten the tip of your finger again. Typically, this does not interfere with your ability to do things.

People seek treatment because they are more concerned about how their finger looks.  A small percentage of mallet finger injuries can progress to a “swan neck deformity” where the tip of your finger is stuck pointing down and the middle knuckle is hyperextended in the opposite direction. This does interfere with finger function and treatment is typically necessary.

Treatment options for mallet finger vary depending on the length of time after injury that the droopy finger shows up (its not always immediate).  Treatment is deemed successful if there is little or no “extensor tendon lag,” meaning you are able to straighten your finger fully.

The most conservative treatment option is long term splinting.  This involves wearing a specially made finger brace that holds your finger in a neutral position in hopes that the tendon will reattach via scar tissue.  This can be anywhere from 6 to 14 weeks.  Most patients see acceptable success with splinting alone–their finger tip may be not quite straight but less noticeably bent–and do not seek further treatment.

Surgery is the next step if splinting does not work.  However, recent review of the literature suggests that despite many different applications of surgical procedures, results are relatively no better than splinting alone.

Authors of this literature review concluded that splinting should be the primary treatment for a mallet finger, especially if it has been longer than 4 weeks since the injury.  Their reasoning being that splinting is just as effective as surgery, a mallet finger typically does not interfere with day to day life, and is corrected typically for aesthetic purposes only.

Nina Suh, MD, Scott W. Wolfe, MD. Soft Tissue Mallet Finger Injuries With Delayed Treatment. In Journal of Hand Surgery. September, 2013. Vol 38A. Pp. 1803-1805.
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For more information on this topic visit our clinic resource pages by clicking here.

Dennis McCrea, PT, will be representing Alpine Physical Therapy in this year’s Missoula Marathon. As part of Dennis’ marathon training he will be writing a three-part blog post. This first part is about why he decided to run the marathon (see below). The second will be about his training and the third about his race experience. Thanks, Dennis. We’re all pulling for you here at Alpine PT!

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Why run the Marathon? The question is always “Why”, especially from both family and friends when they hear that I am training for the upcoming Missoula Marathon. I suppose it’s also a question I ask myself, especially on longer runs. Yet I never really have a good answer and frankly don’t know that there is one for me.

When I was in my 20’s I ran a lot of long distances just for the fun of it, but over time I gradually got away from doing that as life got busy or I found other interests.

So now at 61 years of age I was curious to see if I could run those longer distances again, so I added this notion of running a marathon on my Bucket List. My aim with this year’s Marathon is that I complete it so that I can take it off the My Bucket List!
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Right before the question of Why? is the statement “I hear you are going to run the Missoula Marathon.” My response is, I am training to run the marathon and hopefully, health permitting, I will run and complete the marathon on my 62 birthday.

So the journey has begun, and I will see how well my body holds up as the miles pile up on a body that already has a lot of miles on it. I will keep you posted!
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Dennis McCrea, PT

Special thanks to star Alpine physical therapist Brace Hayden, DPT,  for providing this write up on a recent article from Spine.

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There is no arguing that low back pain is an illness that burdens a large percentage of Americans. Sadly, centuries of folk cures and decades of research have fallen short predict reduce the prevalence of low back pain. Modern medicine has dramatically improved the health and livelihood in many arenas, but back pain remains an age-old, expensive, debilitating and frustrating… pain.

The average person with back pain and the American health care reform analyst are equally interested in sorting the worthwhile from the worthless treatments for reducing the duration and frequency of back pain episodes. Comparative effectiveness research hopes to shed light on what services should be recommended and reimbursed by insurance carriers.  For example, the Cochrane Collaboration, another meta-analysis think tank, in 2010 looked at fifty studies on chiropractic treatments on low back pain and found muddled results across years of research.

. . . there is . . no evidence to support or refute that combined chiropractic interventions provide a clinically meaningful advantage over other treatments for pain or disability in . . . low back pain Future research is very likely to change the estimate of (the) effect and our confidence in the results.

Double doctor, J. Michael Menke, a doctor of chiropractic and PhD academic out of the International Medical University in Kuala Lumpur, Malaysia, found very little supportive evidence in his meta-analyses on comparative effectiveness of various manual therapies in his review of the existing literature.  “A comparative effectiveness meta-analysis” was performed to compare the relative effectiveness of various spinal manipulation treatments (from the ancient bonesetter to the modern back cracker), medical management (READ: drugs, injections, etc), physical therapy, and exercise for acute (less than a month) and chronic (more than 3 months) nonsurgical management of low back pain.

The good news is most pain originating from the muscles and joint in the human body is ‘self-limiting’, meaning slowing down, protecting your injury, and letting the body heal will often suffice. Research supports the notion that sixty to seventy percent of acute low back pain settles in six weeks without any medical treatment. Chronic low back pain sufferers get better in a year without treatment 40 to 70 percent of the time.  Pain whether short-term or long-term is indubitably unpleasant, so why suffer any longer than you have to if effective treatment is available.

This study looked at 56 spinal manipulation studies published between 1974 and 2010 and classified them into six different treatment categories. The categories included: 95 spinal manipulation studies, 31 exercise studies, 51 physical therapy/physiotherapy modalities (for example, ultrasound, electrical stimulation, and hot packs) studies, 40 usual medical care studies, and 40 control group studies of subjects that received no treatment. The results found a 96 percent relative improvement in the first 6 weeks across acute back pain studies was unrelated to treatment. Thus the “carry on with your life” control group and the various treatment groups were nearly equal in settling their acute pain. The chronic pain comparison analyses found that 32 percent of the various treatment studies could claim improved outcomes. The balance of the percentage of claimed improvement in the chronic pain comparison analyses can be attributed to everything else (letting the injury run its course). Looking at the printed boxplots of the 6 treatment categories effect sizes attributable to the passage of time alone, the three largest effect sizes were in the exercise group, then the spinal manipulation group, then the modality group.

This study also examined which spinal manipulation treatment provider did the best job for improving chronic back pain. It was determined in the comparison that getting your spine manipulated in the first 6 weeks has little influence on the outcome of shortening the duration of your acute pain. Five types of spinal manipulation providers (osteopaths, physical therapists, chiropractors, allopathic medical physicians, and bonesetters) were compared.  Spinal manipulation by a physical therapist was found to be most effective, and most variable, in treating both acute and chronic back pain.

In the 36 years and 8,400 patients subjected to comparative spinal manipulation studies research cost from $32 to $80 million. Menke’s comparative analysis makes the bold assertion that ‘equivocal outcomes are unacceptable for this investment’, and funding more research on the topic should be stopped.  It stands to reason, that inadequate analytics and methodology throughout the studies could be part of the problem. The take home message was that all of the compared treatments for acute and chronic low back pain are hard to quantify when looking at their relative effectiveness versus letting the injury run its course.
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J. Michael Menke, DC, PhD.  Do manual therapies help low back Pain? A comparative effectiveness meta-analysis. Spine. April 1, 2014. Volume 39 , Number 7. pp.  e463-e472.