4.
Chronic vs. Acute Pain
To understand the difference between chronic and acute pain, one must first understand what pain is. Pain is a sign that damage or a threat of damage has happened. The way pain manifests is different for each person, so the best judge of pain is yourself. Pain in general can be divided into two categories: chronic and acute. Chronic pain is a type of pain that is ongoing and can continue even if an injury or sickness has been treated. Conversely, acute pain often has a specific cause and is felt suddenly and immediately.
One goal of a physical therapist is to help patients understand and manage their chronic pain or completely treat their acute pain symptoms. This research has provided a necessary introduction and insight into a prominent subject in the physical therapy field. In this section of my Capstone ePortfolio, you can read more about chronic and acute pain, their sources, and their treatments. Below is a breakdown of this section:
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Chronic Pain: What is it and how is it treated?
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Acute Pain: What is it and how is it treated?
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Adult vs. Pediatric Care: How does the approach differ?
Chronic Pain
What is chronic pain?
Chronic pain is pain that persists with or without an origin and may continue even after an injury or illness is treated. It is traditionally categorized into two categories, with a recent addition of a third category within the past few years. These chronic pain categories are:
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Nociceptive pain
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Neuropathic pain
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Nociplastic pain
Sources of Chronic Pain
Nociceptive Pain
Nociceptive pain is described as “pain that arises from actual or threatened damage to non-neural tissue and is due to the activation of nociceptors” (Bonezzi et al, 2020, pp. S5). It is the most common form of chronic pain and can be divided into somatic and visceral pain categories. Somatic pain is either superficial or deep pain that originates in the peripheral tissues, such as skin, muscle, and bone, while visceral pain originates within the abdomen or a specific organ.
Whether somatic or peripheral, nociceptive pain can feel sharp, aching, or throbbing. Some examples of nociceptive pain:
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Bruises
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Burns
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Cuts
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Fractures or broken bones
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Muscle strains or tears
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Joint damage, like arthritis or sprains
Neuropathic Pain
Neuropathic pain can be described as “pain caused by a lesion or disease of the somatosensory nervous system” (Bonezzi et al, 2020, pp. S5). Neuropathic Pain can be challenging to treat sometimes and requires a different method of therapy compared to nociceptive pain. This type of pain can be generalized or localized. Examples of neuropathic pain may come from chemotherapy induced peripheral neuropathy or HIV associated neuropathy.
Nociplastic Pain
Nociplastic pain, the most recent addition to the categorization of chronic pain, may be described as “pain that arises from altered nociception despite no clear evidence of actual or threatened tissue damage causing the activation of peripheral nociceptors or evidence for disease or lesion of the somatosensory system causing the pain” (Bonezzi et al, 2020, pp. S5). In short, nociplastic pain introduces a category of chronic pain that includes all that might not fit into the first two categories.
Nociplastic pain is a form of primary pain. Primary pain is defined as “pain in one or more anatomical regions that:
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Persists for more than 3 months
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Is associated with significant emotional distress
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And has symptoms that are not better accounted for by another diagnosis” (Bonezzi et al, 2020, pp. S6).
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Some examples of nociplastic pain include fibromyalgia, irritable bowel syndrome (IBS), and nonspecific chronic low back pain.
Ramifications of Chronic Pain
Chronic pain can vary in severity. In mild cases, chronic pain can be more of an annoyance than a health concern. In more severe cases, chronic pain can be so painful that it may be immobilizing, which can put one out of work and cause a myriad of other stresses on the mind and body. Chronic pain may also cause emotional distress in the form of depression, anger, and anxiety.
Treatment for Chronic Pain
Physical Therapy Treatment
According to the Center for Substance Abuse Treatment, 2012, chronic pain treatment is often with neurological or orthopedic physical therapists. Treatment uses a variety of hands-on techniques to help improve a patient's range of motion, strength, and overall functioning. With chronic pain, there is often no obvious treatment or cure, so many of the approaches used by physical therapists focus on improving function of the area to make daily tasks easier and less painful.
Aside from hands-on techniques, physical therapists may also encourage patients to complete therapeutic exercises and movements to improve their balance, flexibility, and strength. These exercises can be done under the supervision of a physical therapist and at home to continue treatment when outside the clinic. Below is a video demonstration from the Athletico YouTube page on thoracic spinal manipulation. Go to minute 2:36 to see the exercise demonstrated that can be done at home to stretch and practice range of motion for the thoracic area of the back, whether that is to manage back pain or to prevent it during movement.
Pharmaceutical Treatment
While a physical therapist cannot prescribe any medications, they may suggest the use of acetaminophen for occasional pain management. Chronic pain may also be managed with non-steroidal anti-inflammatory drugs (NSAIDs). Very rarely are opioids used for chronic pain treatment and management due to their potential for adverse side effects. If clinicians do prescribe opioids for pain management, they tend to:
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Look for opioids with minimal reward when effective
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Avoid supratherapeutic doses
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Prescribe slow-onset opioids with prolonged duration of action if they are high potency
Acute Pain
What is acute pain?
Acute pain is often more simple than chronic pain and is caused by something specific and may be felt suddenly and immediately. According to the Cleveland Clinic, acute pain does not last long and eventually goes away with or without treatment, depending on the origin of the pain.
Sources of Acute Pain
Usually, acute pain has a more obvious origin than chronic pain does and it is often associated with a particular illness or injury. Acute pain may be the result of:
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Surgery
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Broken bones
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Pulled muscle
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Illness
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Trauma
Ramifications of Acute Pain
Because acute pain does not last much longer than a few months, there are not often long-term pain symptoms associated, which can dampen any negative social, emotional, or professional ramifications. If recovering from a particular injury or illness, recovery may put an individual out of work or their specific sport, which can cause various levels of emotional distress.
Depending on the origin of pain, patient history, and swiftness and efficacy of treatment, acute pain may transition into chronic pain.
Treatment for Acute Pain
Physical Therapy Treatment
Just as with chronic pain, physical therapists may use a hands-on approach to treat acute pain symptoms. This may include massaging the area of pain, which is a good option for post-operative pain, and spinal manipulation techniques for acute back pain. Heat therapy is also an effective form of acute back pain management. Outside of hands-on therapies, a physical therapist might prescribe regular exercise and various mobilization exercises to strengthen muscles; this approach is used for acute neck pain and preventative measures to avoid development of chronic pain symptoms. (Chou et al, 2020)
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Below are two separate videos: one demonstrating a hands-on approach for a post-operative hip and/or knee surgery patient, while the other shows mobilization exercises for tennis elbow, which can be an acute injury if it occurs with trauma or it may become chronic.
Post Hip and/or Knee Surgery
Tennis Elbow
Pharmaceutical Treatment
NSAIDs are also a form of pharmaceutical treatment for acute pain that are often effective for surgical pain. Opioids are not very effective for acute pain and are usually more effective for neuropathic chronic pain, and as with chronic pain management, opioids are not often relied upon by clinicians because of their potential for adverse side effects, such as:
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Nausea
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Dizziness
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Somnolence
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Physical therapists are not licensed to prescribe medication, but can recommend pain reducing medicine, such as acetaminophen, in the short term. A physical therapist may also be in contact with the patient's primary care physician to discuss their treatment plan and any checkpoints the patient should hit along the way to recovery. These checkpoints may include specific dates to ween off any medication they were prescribed, as well as physical checkpoints, perhaps regarding their range of motion post-surgery.
Adult vs. Pediatric: A Different Approach?
The content below came from an interview about the difference in approach between adult and pediatric patients conducted between myself and Dr. Brad Penning, DPT, at Indiana Physical Therapy in Avon
All patients are different in what kind of treatment they require and which exercises and movements they will best respond to. This difference is seen especially between adult patients and pediatric patients. Regardless of age, it is important to make sure therapy exercises are kept relatively interesting and do not become monotonous for the patient. With adults, they may have a better understanding of why they are receiving physical therapy, so even the more boring exercises are seen as valuable to their health and recovery, making the patient more likely to complete the exercise whether it is entertaining or not. With children, however, they may not always understand the importance of their physical therapy treatments and they may become resistant to the less engaging exercises, even if they are effective.
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From Dr. Penning's experience, and mine as I shadowed him, it is helpful to turn the exercises into some sort of game or competition to keep the pediatric patients entertained and engaged in their treatment. It is also helpful when a particular goal is set for the patient, which gives them direction and motivation to achieve that goal. One way we navigated this obstacle during my time shadowing was to keep the younger patients focused by using an "exercise wheel" that they could spin to determine which exercise they would do next. This little game gave them some control over their therapy appointment and got them to actually complete the effective exercises that would improve their health. One option on the "exercise wheel" was kickball, where one patient would balance herself on one foot on a foam mat and kick a yoga ball with the other foot; this worked on her strength and balance in her bowed right leg. A couple of the other options were mostly just for fun, but gave the patient a chance to take a quick break before returning to their therapy.
Patient education is also key; it is very important with younger patients to educate their parents or guardians so that strong habits and intentional movements are encouraged when the child is not in therapy. For example, with the pediatric patient who had a bowed right leg, it was crucial to explain to her parent any at-home exercises that she could do to continue her progress and work on her gait. Education for caretakers is also important for geriatric patients so that certain hands-on, therapeutic movements can be done at home. One geriatric patient that I observed would often bring his daughter who cared for him. During his sessions, Dr. Penning would walk the daughter through certain shoulder mobilization movements that she could do for her father at home to further improve his recovery process after a fall he had. Educating the patient and their parent, guardian, or care taker can only benefit their treatment.
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Whether the patient is a child or an adult, mixing up their treatment exercises each session will keep them engaged in their recovery, which can improve their health and ensure that their appointments do not become repetitive and their health does not plateau prematurely.