There is a war on opioids. Opioids are prescription medications for pain management, which also happen to be highly addictive.

With celebrities like Macklemore and John Oliver covering this topic, the opioid epidemic has made it to the national stage. In a timely and strategic response, the American Physical Therapy Association (APTA) launched a campaign, #choosePT and #getPT1st, to showcase that physical therapists should be the practitioners of choice when it comes to the treatment of chronic pain.

Though I agree that physical therapists can be effective agents for chronic pain, I’m not confident that the majority of physical therapists are properly equipped and educated to treat chronic pain. The campaign can be misleading.

Misconception regarding the role of Opioids

There is a place for opioids and a place for physical therapy when treating different types of pain. As Kory Zimney PT, DPT explains, “The use of opioid medication is very different when using it for acute/nociceptive pain compared to more chronic pain. The use of opioids in the acute situation may be very valuable in reducing acute pain thus helping with the war on chronic pain.” 

Zimney warns his readers to not choose between the two camps. It should be clear that physical therapy can be effective for chronic pain, however physical therapy is not indicated to extinguish a drug addiction. We can help with the public health problem by providing proper physical therapeutic intervention to acute injuries to prevent the formation of chronic pain, and we can also be a first line intervention for diagnosed chronic pain before drug prescription.

It is easy to interpret the hashtag as ALL opioids are bad and that physical therapy is good for ALL pains. What needs to be understood is that opioids are often ineffective for chronic pain. Prescription of these pharmaceuticals to individuals with chronic pain can easily lead to the toxic addiction associated with the opioid epidemic. Unfortunately, as explained by Sean Blanda here, social media and mainstream media helps garner this black and white perspective of who is right and who is wrong.

We need to make sure that the message we deliver to patients and the public is not one that “opioids are bad”. Instead “improper use of opioids is bad”. Many times opioids can and should be a part of a comprehensive multidisciplinary biopsychosocial plan to help those with pain.
— Kory Zimney PT, DPT

After understanding why physical therapy may be more effective than opioids for chronic pain, HOW can physical therapy be the treatment of choice? Are physical therapists properly educated on how to treat chronic pain?

Why #choose us, when many physical therapists are not versed in how chronic pain works?

How much do you actually know about pain? Take this quick quiz designed by Rajam Roose HHP that highlights evidence based facts on pain.

An article published by the Journal of Pain in 2014 reveals the current state of pain education in physical therapy schools. The average American physical therapy student currently receives 31 hours during their doctoral education with a mode of 10 hours (range of 5 to 115 hours). This may seem to be plenty of hours, but the authors admit that their “survey was not designed… to assess the quality of pain education.”

The criteria to show whether pain is covered in school did not include how pain can be explained to patients nor the mechanisms of chronic pain. Their results showed that, in terms of the physiology, most programs cover pain pathways in the lectures. Also, the majority of the time in lecture was spent on interventions. For all we know, explaining “pain fibers” and pain-gate theory may be as far as the material covers in terms of underlying mechanisms for pain. This is insufficient for understanding chronic pain. The authors report that programs stated that “pain science” is taught throughout the entire curriculum, which makes sense, but discussion about the subjective pain scales and questionnaires are sufficient to validate this claim.

The most important point I took from this article was that less than 50% of the participating schools (over 130 programs) were aware of International Association for the Study of Pain (IASP) guidelines and the Institute of Medicine's (IOM) report on pain. These are foundational published material that addresses the lack of pain education in healthcare, providing baseline understanding of how pain can develop, yet most schools are not even aware of their existences. Education about pain in physical therapy may be more present in programs now, but the quality of the education is unknown.

Current physical therapists are not comfortable treating chronic pain

In the same article referred to above, research from 1991 reported that 91% of orthopedic physical therapists were reluctant to work with patients with chronic pain because they weren’t comfortable with their knowledge on the subject. This is a problem, but that was 1991, there must be improvement right?

It turns out many physical therapists are still uncomfortable with dealing with chronic pain. In terms of chronic low back pain, this article published by Pain-Ed, led by Peter O’Sullivan Dip Physio, Post Grad Dip Manip Ther, PhD, FACP, APAM summarizes a 2015 systematic review done by a team of leading pain researchers explaining how “physiotherapists perceived that neither their initial training, nor currently available professional development training, instilled them with the requisite skills and confidence to successfully address and treat the multidimensional pain presentations seen in LBP.” This is the current state of our profession.

So what do we do? Is chronic pain within our scope?

Of course it is! We need to become more knowledgeable in pain science education, the evidence supporting it, and its application to each unique chronic pain presentation.

Before considering a continuing education course, it needs to be known that the internet provides many resources to develop a solid foundation to pain science. I’m definitely far from an expert, but I am becoming more and more comfortable with understanding and explaining pain through the blogs, research, forums, books, and podcasts provided by the actual experts. Here are two great articles to help start and establish a basic understanding of pain and how it can be applied clinically.

An Introduction To Therapeutic Neuroscience Education 
Understanding Pain

Physical therapists are in an ideal position to help those with chronic pain. The evidence supports our role in chronic pain. Here is a small sample of the great evidence out there.

The clinical application of teaching people about pain.
Exercise interventions for the treatment of chronic low back pain: a systematic review and meta-analysis of randomised controlled trials.
An update of stabilisation exercises for low back pain: a systematic review with meta-analysis. 
Consensus at last! Long-term results of all randomized controlled trials show that fusion is no better than non-operative care in improving pain and disability in chronic low back pain.
Cognitive functional approach to manage low back pain in male adolescent rowers: a randomised controlled trial

Cory Blickenstaff PT, MS, OCS and Sandy Hilton PT, DPTon the Pain and Sensitivity Podcast, talk about how physical therapists are in a favorable position to treat chronic pain because people seek pain relief under the assumption there is something anatomically incorrect in their body. As movement therapists, we can provide first-line strategies to improve their daily lives by helping them understand their perception of pain and threat through explanation and exposure to movements. Both Dr. Hilton and Dr. Blickenstaff emphasized that if the patient’s complaints do not relate to movement or function, they need to be referred out to receive proper interventions from specialists like a psychologist.

Patients don’t need to understand pain science to get relief from a practitioner who does.
— Eric Kruger PT, DPT, PhD

If we’re going to be #chosenfirst, we need to #understandpainfirst. The non-specific/placebo effects of most (if not all) of our passive interventions and emphasis on pathoanatomical origins are not enough to treat chronic pain. Since the curriculum in schools are still behind on providing this material, we need to be proactive in our own education and take advantage of the material provided by the experts on pain science and education. Until we as therapists understand how pain works, we cannot zealously sway the public away from opioids toward our profession. If this lack of knowledge is not addressed, we will perpetuate the provision of a service that does not address this population's chronic pain.

Image Credit: Aches and Pains by Louis Gifford