GPs and physiotherapists: Teaming up to fight chronic pain

National Pain Week has been designed to shine a spotlight on the needs of people who are experiencing chronic pain. That pain experience is very complex and different for everyone, presenting an inextricable entanglement of body and mind.
 
‘Our perception of pain can depend on its context,’ Dianne Wilson, Chair of the Australian Physiotherapy Association’s National Pain Group, told newsGP.
 
‘For example, the footballer who feels no pain when he is kicking a goal, but realises later he sprained his ankle taking the mark. Even acute pain can be out of proportion to actual tissue damage, such as the pain from a paper cut.’
 
Sometimes, pain can go on so long it becomes chronic, and may even continue after its original, physical cause has been resolved.
 
‘Pain is now viewed as part of the body’s protective or alarm mechanism, when the brain interprets messages from the body and our environment and prompts behavioural change to protect us from damage or injury,’ Ms Wilson said.
 
‘Sometimes it is no longer an accurate reflection of tissue damage, but rather a sign that the alarm system has become overactive.’
 
This type of pain is known as neuropathic pain because it is the result of a complex process in which new pathways are created in the brain.
 
‘The pain has wound up inside the patient’s neural system and they are actually perceiving a neuropathy, the pain’s memory of itself,’ Dr Milana Votrubec, GP and Chair of the RACGP Pain Management Specific Interests network, told newsGP.
 
Dr Votrubec has had plenty of direct experience with this phenomenon in her work as a doctor.
 
‘I work with a group in a private hospital that has an out-patients rehab unit where I get called to see knee-replacement patients with nice scars that are all clean and healed, and yet they still complain about the burning pain,’ she explained.
 
Prescription opioids seemed to present an effective approach to the problem of chronic pain back in the late 1990s. But the resulting rise in opioid addiction and overdose deaths within Australia have led healthcare professionals away from drugs and towards a more holistic approach to pain management.
 
‘Opioids are totally inappropriate for neuropathic pain – patients keep needing more because they become tolerant,’ Dr Votrubec said.
 
‘Opioids also have their own problems, not just addiction, but constipation and other things – basically they don’t really agree with a lot of people. You’re sort of trading off one problem for another.’
 
Instead of drugs, Dr Votrubec advocates interdisciplinary teamwork between GPs and physiotherapists, because physiotherapists can get patients moving again and help them push through the physical barriers of chronic pain.
 
‘Once [patients with pain] start using their muscles, they’re actually doing a lot better; they’re improving the circulation and also improving their ability to enjoy life – sitting around immobile is no fun,’ she said.
 
Physiotherapists can also assist with providing education for patients experiencing chronic pain, and can also address and untangle its physical and psychological components.
 
‘This knowledge can change patient beliefs that pain and tissue damage are always related, thus decreasing some of the associated threat of pain,’ Ms Wilson said.
 
‘Physiotherapists working in this area can also deliver screening tools that recognise psychological factors impacting on the pain experience, and refer on to psychologists or GPs for appropriate management.
 
‘Exercise programs will improve strength and cardiovascular fitness as well as decrease the sensitivity of the body’s alarm system. Goal-setting using SMART goals is important in helping the patient regain full function and return to work where appropriate.’
 
Ms Wilson believes that a relationship and exchange of information between a patient’s GP and physiotherapist is very beneficial for patient outcomes, and may even prevent acute pain from developing into chronic pain.
 
‘Early recognition of at-risk patients by GPs is vital, and … consistent and accurate information between health providers is important to reduce patients’ fear about the pain and uncertainty about the prognosis,’ she said.
 
‘Reassurance from both parties about the normal nature of pain and healing, along with the use of non-threatening language – for example, “normal wear for your age” – when interpreting radiology can all help.
 
‘As pain becomes chronic, ongoing communication between GPs and physiotherapists can instil a patient with confidence, especially when the patient is reluctant to increase their activity. And recognition of active self-management in a biopsychosocial approach, rather than a reliance on passive modalities like drugs, can be encouraged by both parties.’
 
Dr Votrubec agrees that a GP–physiotherapist relationship is helpful to patients with chronic and neuropathic pain, and encourages GPs to get to know the physiotherapists in their area.
 
‘The first thing a GP can do is establish a relationship with a physiotherapist, to have someone out there in physio land who’s willing to take the time and have the patience to work with these patients to encourage them to get moving rather than doing things to them,’ she said.
 
‘A physiotherapist who is going to help their patients move, that’s absolutely critical to the management of people who are beset with persistent chronic pain.’

Chronic-pain Opioids Pain-management Physiotherapy